Most tobacco use begins during youth and young adulthood.1 Recent declines in prevalence of cigarette smoking among youth have coincided with increased use of e-cigarettes and hookahs.2 Although flavors other than menthol are prohibited in cigarettes in the United States,3 flavored noncigarette tobacco products are widely available and may appeal to youth. We examined flavored tobacco use among a nationally representative sample of US youth.
The Population Assessment of Tobacco and Health (PATH) Study is a household-based, nationally representative, longitudinal cohort study of 45 971 adults and youth (12-17 years) in the United States. We analyzed youth data from wave 1, collected September 2013 through December 2014 (the survey is available in the eAppendix in the Supplement). Among youth within participating households (weighted household screener rate, 54%), 78.4% participated in an audio computer-assisted interview. Nonresponse analysis showed few differences with referent national surveys.4 Survey weights were adjusted for nonresponse.
Parents and emancipated youth provided written informed consent, whereas youth assented to participate. Further details regarding the study methods are available.4 The study was conducted by Westat and approved by the Westat institutional review board.
Youth responded to questions about ever and past 30-day use of tobacco products including cigarettes, e-cigarettes, hookahs, cigars (traditional cigars, cigarillos, filtered cigars), pipe tobacco, all types of smokeless tobacco, dissolvable tobacco, bidis, and kreteks. For each product ever used, youth endorsed whether the first product they used was flavored (eg, “Was the first e-cigarette you used flavored to taste like menthol, mint, clove, spice, candy, fruit, chocolate, alcohol [such as wine or cognac], or other sweets?”). Users of noncigarette products reported any past 30-day use of a flavored product. Past 30-day noncigarette tobacco users also reported reasons for product use, including “(It) comes in flavors I like,” for each product. Past 30-day cigarette smokers reported smoking cigarettes flavored to taste like menthol or mint.
We used SAS version 9.3 (SAS Institute Inc) survey procedures to account for weighting and calculated proportions with 95% confidence intervals for all measures. Estimates from denominators of fewer than 50 users are suppressed; estimates with relative standard errors greater than 30% are flagged.
Of the 13 651 youth enrolled and included in this analysis, 51.3% were male, 54.5% non-Hispanic white, 13.7% non-Hispanic black, and 22.5% Hispanic. Mean respondent age was 14.5 (SD, 0.02) years. Table 1 summarizes ever and past 30-day use of flavored tobacco products. The majority of youth ever-users reported that the first product they had used was flavored, including 88.7% of ever hookah users, 81.0% of ever e-cigarette users, 65.4% of ever users of any cigar type, and 50.1% of ever cigarette smokers. For past 30-day youth tobacco use, the overall proportion of flavored product use was 79.8% (95% CI, 77.3%-82.3%) among users of any product and 89.0% among hookah users, 85.3% among e-cigarette users, 71.7% among users of any cigar type, and 59.5% among cigarette smokers.
Table 2 presents leading reasons for use among past 30-day noncigarette tobacco users. Youth consistently reported product flavoring as a reason for use across all product types, including e-cigarettes (81.5%), hookahs (78.9%), cigars (73.8%), smokeless tobacco (69.3%), and snus pouches (67.2%).
Among a survey of youth aged 12 to 17 years, the majority who self-reported ever experimenting with tobacco started with a flavored product, and most current youth tobacco users reported use of flavored products. This study extends a recent national report5 on youth use of flavored tobacco products by examining first use of flavored product among ever users by products and flavorings as a reason for noncigarette tobacco use. Consistent with national school-based estimates,5 this study confirms widespread appeal of flavored products among youth tobacco users. In addition to continued proven tobacco control and prevention strategies, efforts to decrease use of flavored tobacco products among youth should be considered.1
Study limitations include potential difficulty with recall because youth often experiment with many products. This cross-sectional analysis does not allow direct estimation of flavoring’s role in initiation of tobacco use among youth. In addition, there are mode differences in household- vs school-based youth tobacco surveys.6 Data from future PATH Study waves can provide information on tobacco use trajectories following experimentation with flavored compared with nonflavored products.
Corresponding Author: Bridget K. Ambrose, PhD, MPH, Office of Science, Center for Tobacco Products, US Food and Drug Administration, 10903 New Hampshire Ave, Bldg 75, Room 4432, Silver Spring, MD, 20993 (firstname.lastname@example.org).
Published Online: October 26, 2015. doi:10.1001/jama.2015.13802.
Author Contributions: Drs Ambrose and Day had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Ambrose, Conway, Borek, Hyland, Villanti.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Ambrose.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Day, Rostron.
Administrative, technical or material support: Ambrose, Borek, Villanti.
Study supervision: Conway, Borek, Hyland.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: Funded by the National Institute on Drug Abuse (NIDA), National Institutes of Health, and the US Food and Drug Administration (FDA), Department of Health and Human Services, under contract HHSN271201100027C.
Role of the Funders/Sponsors: Staff from the NIDA and the FDA contributed to the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and the decision to submit the manuscript for publication. The NIDA and the FDA were not directly involved in the collection of study data.
Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily represent the views, official policy, or position of the US Department of Health and Human Services or any of its affiliated institutions or agencies.
Additional Contributions: We thank David Maklan, PhD, and Charles Carusi, PhD, from Westat Inc for contributions to study design and supervision, as well as data acquisition. We also thank Kristie Taylor, PhD, from Westat Inc for contributions to the study design and analytic support. Drs Maklan, Carusi, and Taylor received compensation for their contributions to the PATH Study.
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