Flavored Tobacco Product Use among Youth and Young Adults:
What if Flavors Didn’t Exist?
Melissa B. Harrell, PhD, MPH,
Associate Professor, University of Texas Health Science Center School of Public Health in Austin,
Michael & Susan Dell Center for Healthy Living, Austin, TX
Alexandra Loukas, PhD,
Professor, Department of Kinesiology & Health Education, University of Texas at Austin, Austin,
TX
Christian D. Jackson, MS,
Statistician, University of Texas Health Science Center School of Public Health in Austin, Michael
& Susan Dell Center for Healthy Living, Austin, TX
C. Nathan Marti, PhD, and
Statistical Consultant, Department of Kinesiology & Health Education, University of Texas at
Austin, Austin, TX
Cheryl L. Perry, PhD
Professor & Regional Dean, University of Texas Health Science Center School of Public Health in
Austin, Michael & Susan Dell Center for Healthy Living, Austin, TX
Abstract
Objective—We aimed to determine the potential for reductions in the prevalence of young
people’s e-cigarette and tobacco use if characterizing flavors were not present.
Methods—Two parallel cross-sectional surveys of 2483 youth (TATAMS: Texas Adolescent
Tobacco and Marketing Surveillance System) and 4326 young adults (M-PACT: Marketing and
Promotions across Colleges in Texas) in Texas (Houston, Dallas/Ft. Worth, San Antonio, Austin).
Current use of e-cigarettes and other tobacco (cigarettes, cigar products, hookah, smokeless
tobacco). Users were asked: “When you use [product], do you usually use any of the following
flavors?” Flavored product users were asked: “Would you continue using [product] if it were not
flavored?”
Results—Over 80% of youth and young adult tobacco users reported using flavored tobacco.
Three-fourths of flavored product users said they would no longer use the product if it was not
Correspondence Dr Harrell; Melissa.B.Harrell@uth.tmc.edu.
Human Subjects Statement
The Institutional Review Board at University of Texas’ Health Science Center, Houston approved all protocols specific to TATAMS
(HSC-SPH-13-0377). The University of Texas at Austin’s Institutional Review Board approved all protocols for M-PACT
(2013-06-0034).
Conflict of Interest Statement
These authors have no conflicts of interest to disclose.
HHS Public Access
Author manuscript
Tob Regul Sci
. Author manuscript; available in PMC 2018 April 01.
Published in final edited form as:
Tob Regul Sci
. 2017 April ; 3(2): 168–173. doi:10.18001/TRS.3.2.4.
Author Manuscript Author Manuscript Author Manuscript Author Manuscript
flavored. This was highest for e-cigarettes and hookah and lowest for cigarettes. Few demographic
differences in findings were observed.
Conclusions—Restricting flavors in tobacco products would not eradicate e-cigarette or other
tobacco use among young people, but the potential for substantial reductions in the prevalence of
young people’s e-cigarette and other tobacco use seems high if flavors were removed.
Keywords
youth; young adults; tobacco product flavors; tobacco use reduction
Flavored tobacco products, including menthol cigarettes, candy flavored e-cigarettes, and
other flavored products like grape cigars, are widely available. For example, there are more
than 7500 characterizing flavors available on the market for e-cigarettes, alone.
1–3
With the
exception of some e-cigarettes that are nicotine-free, all of these products contain nicotine
and so are of particular concern to the well-being of young people, because nicotine is
addictive.
4,5
Characterizing flavors also present their own unique health risks.
6,7
There is concern that characterizing flavors may be contributing to observed increases in
some types of tobacco product use among young people.
2,3
All characterizing flavors except
menthol were banned from conventional cigarettes in 2009 to reduce youth smoking, as
flavored cigarettes were particularly attractive to young smokers and often used as a starter
product.
8
Data from the National Youth Tobacco Survey (NYTS)
9
as well as the Population
Assessment of Tobacco and Health (PATH)
10
suggest flavored tobacco products remain
appealing to young people. The prevalence of flavored tobacco use among youth varied
between 60% and 85% in these national studies from 2014.
7,8
Removing or restricting characterizing flavors in these products may be helpful to prevent
the onset and decrease tobacco use among young people, as use of these products often
begins in adolescence or young adulthood.
1
However, it remains unknown whether
removing characterizing flavors from these products would lead to reductions in the
prevalence of their use. Therefore, we sought to determine the potential for reductions in the
prevalence of young people’s tobacco use if characterizing flavors were not present. We
examined preferences for flavored e-cigarette and other tobacco products (cigarettes, cigar
products, hookah, smokeless tobacco) in 2 large, representative samples of youth and young
adults residing in major metropolitan areas of Texas. Importantly, we asked users if they
would continue their tobacco use if characterizing flavors were not present.
METHODS
Data are derived from 2, cross-sectional parallel studies of youth (12–17 years old) and
young adults (18–29 years old) living in the 5 counties surrounding the 4 largest
metropolitan areas in Texas (Houston, Dallas/Fort Worth, San Antonio, Austin). The Texas
Adolescent Tobacco and Marketing Surveillance System (TATAMS) surveyed 6
th
, 8
th
, and
10
th
grade students (n = 2483; weighted N = 461,069; 61% response rate; 49% female and
54.5% Hispanic, 18.2% non-Hispanic white, 17.6% non-Hispanic black) enrolled in 79
participating schools. The Marketing and Promotions Across Colleges in Texas project (M-
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PACT) surveyed students in 2-year and 4-year colleges (N = 4326; 79% response rate;
63.4% female and 36.3% non-Hispanic white, 31.1% Hispanic, 8.1% non-Hispanic black,
16.9% Asian). More details about the study designs employed in each study, including
eligibility criteria, are presented elsewhere.
11,12
Active, informed consent was obtained from
both parents and students in TATAMS and from young adults in M-PACT.
Students were asked about their past 30-day use of tobacco products, including cigarettes, e-
cigarettes, cigars (little filtered cigars, cigarillos, large cigars), hookah, and smokeless
tobacco. Each item was asked separately and pictures, product descriptions, and exemplar
brands were included with each measure.
13
For each product they reported using, students
were asked if the product was typically flavored (eg, “When you use [tobacco product], do
you usually use any of the following flavors?”). Flavor options varied by product and could
include menthol/mint, candy, fruit, coffee, alcohol, spice, or other. Then, if students reported
the use of a flavored product, they were asked if they would still use the product if it were
not flavored (eg, “Would you continue using [tobacco product] if it were not flavored?”).
All responses were dichotomized in analyses so that any flavor for a product was coded as
“flavored product use” vs “unflavored product use.” For “any product use,” responses were
coded yes if any flavored product use was endorsed across all of the products considered.
Prevalence estimates and 95% confidence intervals were calculated for all measures.
Estimates from denominators of less than 20 users are suppressed; this only affected youth
smokeless tobacco use. All TATAMS analyses were weighted to account for the complex
survey design, so as to generalize back to the population from which the sample was drawn.
M-PACT analyses were not weighted, as this was not necessary, given the study’s design.
11
Missing data did not exceed 5% for any variable. Two-sided chi-square tests were used to
test for differences between subgroups (sex and school/age level), such that differences were
statistically significant if the p-value was < .05. Non-overlapping confidence intervals
provided evidence for significant differences between tobacco products.
RESULTS
Among those who had used any tobacco product in the past 30 days, flavored tobacco use
was high for both youth (89%) and young adults (83%). This finding was reasonably robust
across tobacco products and subgroups (Table 1). The use of flavored e-cigarettes and
hookah was most common (> 90% of past 30-day users), whereas the use of menthol
cigarettes was least prevalent and significantly lower than any other product (eg, 41% of past
30-day young adult users). No differences in flavored product use by sex or school level
were observed for youth (all p > .05). Among young adults, the use of menthol cigarettes
and flavored cigar products was significantly more prevalent among females compared to
males (p < .05 both), while the use of any tobacco product was significantly higher for 18–
24 year-olds compared to 25–29 year-olds (p < .01).
The majority of past 30-day e-cigarette and tobacco product users reported they would
not
use the product if it were not flavored, including 84% of youth and 76% of young adult past
30-day users of any flavored product (Table 1). More than 3 out of every 4 youth- (78%) and
young adult- (74%) flavored e-cigarette users said that they would
not
use an e-cigarette if it
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was not available in a flavored form (eg, candy, fruit, mint/menthol, etc.). For youth, no
statistically significant differences in preferences for flavored product use were observed by
sex or school level. Significantly more young adult females than males reported that they
would
not
use the product if it were not flavored, for e-cigarettes (77% vs 69%, p = .03),
cigar products (65% vs 48%, p = .02), and smokeless tobacco (87% vs 53%, p = .03), and
any tobacco use (87% vs 53%, p = .03). However, no differences in their preferences for
flavored product use by age were noted for young adults (all p > .05).
DISCUSSION
Our results add to the body of literature showing flavored tobacco product use is high
appeals to both youth
9,10,14–16
and young adults.
16,17
More than 4 out of every 5 past 30-
day e-cigarette or tobacco users in our studies from Texas reported using a flavored product.
This finding was consistent by sex and school level for youth, and only a few differences
were noted for young adults, with females and 18–24 year-old current users reporting more
flavored product use than males and 25–29 year-olds. These findings differ from those for
older adults (≥ 30 years old), for whom flavored tobacco product use is lower.
16
Although
youth often start their tobacco use with flavored products,
10
this study reinforces that use of
flavored tobacco products among current users after initiation and experimentation is also
high.
Our study builds upon previous ones by reporting on the potential for reductions in e-
cigarette and other tobacco product use, if characterizing flavors were no longer available.
The possibilities are apparent in these data. Overall, three-fourths of youth and young adult
current users said they would
no longer use
the product if it was
not
flavored. This is not a
small minority of users, so the potential for reductions in the prevalence of young people’s
use seems high if flavors were restricted or removed. Given these results, these reductions
would be expected to impact adolescent boys and girls across middle school and high school
in Texas about equally. However, restricting or removing flavors may have a larger impact
on young adult female than male e-cigarette and other tobacco product use. These findings
corroborate the tobacco industry’s research that female cigarette preferences are strongly
influenced by taste, enjoyment, and aroma,
18
and extend it by indicating that removal of
flavors may result in reductions in the prevalence of use.
With the exception of menthol, flavored cigarettes have been banned from the market since
2009.
19
Presently, it is estimated that there are more than 7500 types of e-cigarette flavors
available on the market.
20
Notably, the use of other flavored tobacco products, like e-
cigarettes, was much higher in this study, compared to use of menthol cigarettes. For
example, 96% of young adult e-cigarette users reported using a flavored e-cigarette,
compared to 41% of young adult cigarette smokers who smoked menthol cigarettes. Thus,
simply applying the same type of regulation (ie, restricting availability to a single flavor, like
menthol) to e-cigarettes and other tobacco products could lead to reductions in their use,
though the largest impact would be expected if all characterizing flavors were entirely
removed from the manufacturing process of all tobacco products.
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Limitations include the study’s reliance on school-going participants, who might not
generalize to out-of-school youth or young adults, and cross-sectional analyses that do not
allow for direct estimation of the role that flavors have in initiation or cessation among
young people. Future research should explore the latter more fully. Although these data are
based on self-report, behavioral intentions do predict future tobacco use behaviors among
both youth and young adults;
23–25
therefore, our findings should prove useful to informing
future regulations on the use or sale of flavored tobacco products. Previously published
research specific to menthol cigarettes suggests that many menthol smokers, including
young adults, support a ban on the use of this characterizing flavor in this product and would
try to quit if such a ban were put into place.
26–28
Our findings may not generalize beyond metropolitan areas of Texas; however, because they
are among the top 5 fastest growing metropolitan areas in the United States,
17
they may
serve as an indicator, demographically-speaking, for the state of the nation to come.
Approximately 10% of the nation’s children under the age of 18 years old live in Tex-as;
29
the state is also home to 8% of the US Hispanic population, with about one in 6 Hispanic
youth in the US living in Texas.
30,31
In 2013, Texas ranked first among all states for tobacco
company expenditures on marketing at $636 million.
32
In the same year, the state spent only
2.4% of US Centers for Disease Control and Prevention’s recommended spending for
tobacco prevention programs, thereby ranking among the lowest nationwide.
33
Thus, our
findings are potentially applicable to the future demographics of the US, and provide some
insights on a large percentage of the nation’s young people.
IMPLICATIONS FOR TOBACCO REGULATION
Given our findings, restricting or eliminating characterizing flavors in tobacco products
during the manufacturing process, which the US Food and Drug Administration (FDA) has
the authority to regulate, could substantially reduce the prevalence of tobacco use among
youth and young adults for many types of tobacco products. However, the implementation of
a policy like this would not completely eradicate tobacco use among young people. Among
these young adults in Texas, for example, 27% of e-cigarette users and 56% of cigarette
smokers said they would
not
discontinue the product if it were not flavored; among these
youth in Texas, 22% and 46.1% of e-cigarette users and cigarette smokers, respectively, said
the same. Yet, this approach could be an important element of comprehensive tobacco
control by reducing the appeal of tobacco products for a large proportion of young people.
Alternatively, the sale of flavored tobacco products, which the FDA also has the authority to
regulate, could be restricted to prohibit uptake, like actions taken in New York City and
Chicago.
9,21,22
Acknowledgments
MH led the development of the manuscript, which included obtaining funding for the study, conceptualizing the
study, and drafting the manuscript. AL and CP also obtained funding for the study and revised the manuscript for
important intellectual content. NM and CJ analyzed the data and revised the manuscript for important intellectual
content.
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