Flavors of e-Cigarettes Used by Youths in the United States
Leventhal, Adam M., Richard A. Miech, Jessica Barrington-Trimis, Lloyd Johnston, Patrick M. O'Malley, and Megan E. Patrick. 2019. "Flavors of e-Cigarettes Used by Youths in the United States." JAMA, 322(21): 2132-2134.
Adolescent e-cigarette use has increased substantially since 2016.1 To counteract such trends, public health agencies are considering regulatory restrictions of e-cigarettes in flavors popular among youths.2,3 Whether certain flavors warrant inclusion or exemption from regulatory policies is unclear because recent estimates of the specific e-cigarette flavors adolescents use are lacking.
The myriad e-cigarette products available has complicated flavor preference research. JUUL's e-cigarette product, which has 8 flavor options, constituted 75% of all US e-cigarette sales in late 2018.4 This study estimated the prevalence of JUUL e-cigarette flavors used among US youths in 2019.
The Monitoring the Future (MTF) study surveyed nationally representative samples of US 8th-grade (response rate, 87%), 10th-grade (86%), and 12th-grade (80%) students from February 13 to June 3, 2019.1 By design, every student had a 1-in-3 probability of being randomly assigned a module containing JUUL questions presented via tablet accompanied by pictures of JUUL devices. Weighted prevalences (with 95% CIs) of responses to "Which JUUL flavor do you use most often?" (forced-choice options; see Figure) were analyzed among past 30-day JUUL users by grade and further stratified by past 30-day use frequency (<20 vs ≥20 days). Analyses used Stata MP version 15.1 software (StataCorp) with "svy:" commands to account for MTF's complex sampling design. The University of Michigan Institutional Review Board approved the study. Informed consent (active or passive, per school policy) was obtained from parents for students younger than 18 years and from students aged 18 years or older.
Among all 42 531 MTF respondents, 14 191 (33.36%) were administered the JUUL module, of whom 18.8% reported past 30-day vaping of any nicotine product and 12.6% reported using JUUL (7% in 8th grade, 15% in 10th grade, and 16% in 12th grade). The analytic sample included 1739 past 30-day JUUL users with flavor preference data (50% female; 5.0% black; 11.3% Hispanic; 2.3% Asian; 63.9% white; and 17.6% other race/ethnicity).
Among 8th-grade past 30-day JUUL users (n = 330), the flavors most often used were mango (33.5%; 95% CI, 28.7%-38.7%), mint (29.2%; 95% CI, 22.7%-36.8%), fruit (16.0%; 95% CI, 12.1%-20.9%), and other (14.8%; 95% CI, 9.4%-22.6%) (Figure). In 10th grade (n = 719), mint (43.5%; 95% CI, 37.1%-50.1%), mango (27.3%; 95% CI, 23.1%-31.9%), fruit (10.8%; 95% CI, 8.1%-14.1%), and other (8.4%; 95% CI, 5.2%-13.4%) flavors were most popular. In 12th grade (n = 690), mint (47.1%; 95% CI, 41.5%-52.8%), mango (23.8%; 95% CI, 18.8%-29.7%), fruit (8.6%; 95% CI, 6.0%-12.0%), and other (6.0%; 95% CI, 4.3%-8.4%) flavors were most popular. In all grades, remaining flavors had prevalences less than 6.0%, including tobacco-related flavors (<2.0%) (Figure). Flavor preferences were generally similar across youths who used JUUL on 20 or more vs fewer than 20 days in the past month, although the relative popularity of the mint flavor was more pronounced among more frequent users (Table).
In this sample of US youths who self-reported using JUUL e-cigarettes in 2019, mint was the most popular flavor in 12th and 10th grades and the second most popular in 8th grade. The 2015-2016 Population Assessment of Tobacco and Health (PATH) study found that among US youths who used a single flavor of e-cigarettes in the past 30 days, 10.8% reported using mint or menthol.5 In both 2015-2016 PATH youths5 and the current sample, tobacco-related e-cigarette flavors were unpopular and fruit-related flavors were popular.
Study limitations include generalizability only to JUUL users, lack of assessment of additional flavors used other than respondents' first-choice preferences, potential for reporting error, and that youths who dropped out or were absent from school were not surveyed.
The US Food and Drug Administration is considering regulatory restrictions on the sale of flavored e-cigarettes but does not currently have any policies that prohibit sales of flavored e-cigarettes. Some local municipalities have prohibited sales of e-cigarettes in flavors other than mint, menthol, and tobacco or prohibited sales of all nontobacco flavors.3 JUUL voluntarily suspended sales of their product in flavors other than tobacco, menthol, or mint by some retailers.6 The current findings raise uncertainty whether regulations or sales suspensions that exempt mint flavors are optimal strategies for reducing youth e-cigarette use.
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