The study, conducted by researchers at the University of North Carolina at Chapel Hill and published in the British Medical Journal Open, is a systematic review of all peer-reviewed scientific literature published on e-cigarette use behaviors and perceptions through March 2018. The researchers reviewed 51 articles, including 17 published before 2016 and 34 published between 2016 and 2018. First author Clare Meernik, MPH, is a doctoral student of epidemiology at the UNC Gillings School of Global Public Health.
The researchers found several key takeaways:
- Five studies indicate that non-menthol flavors — particularly fruit and candy flavors — decrease the perception that e-cigarettes are harmful.
- Six studies indicate that flavors make youth and young adults more willing to try e-cigarettes.
- Seven studies showed that flavors increase product appeal among adults.
- Five studies revealed that flavors are a primary reason adults use e-cigarettes.
- Six studies showed that the role of flavored e-cigarettes in stopping traditional cigarette smoking among adults is unclear.
- One study showed that youth who use flavored e-cigarettes were less likely to quit tobacco products.
“Consistent evidence shows that flavors attract both youth and adults to use e-cigarettes,” said Adam Goldstein, MD, MPH, a professor of family medicine and member of UNC’s Lineberger Comprehensive Cancer Center. “Given the fact that nicotine is highly addictive and can affect brain development — as well as these clear findings that the impact of flavors on youth is strong and consistent — we believe that banning non-menthol flavors in e-cigarettes will help reduce the epidemic of youth e-cigarette use.”
Most e-cigarettes contain nicotine, and most include at least one of about 7,000 e-cigarette flavors available for purchase, such as blueberry cheesecake, mango, cinnamon, sweet milk and lemon crumble cake. Many flavors are named for candy or sweets — such as gummy bear, cookies ‘n cream and cotton candy — that appeal more to younger e-cigarette users.
Studies over the past five years have shown a steady rise in vaping among youth, with a 2019 study finding that about 28% of young people in the United States currently use e-cigarettes.
“Many studies we reviewed showed that flavors were particularly appealing to youth and were cited as a primary reason for use among this age group,” said lead author Hannah Baker, MPH, a research associate with both the UNC Department of Family Medicine and UNC Lineberger. “The use of e-cigarettes among youth may be a gateway to future cigarette use, and nicotine is especially harmful to developing adolescent brains. These facts, along with biomedical research linking vaping to multiple adverse health effects, make the recent precipitous increase in e-cigarette use among youth particularly alarming.”
Baker added: “Our synthesis of evidence regarding the role of non-menthol flavors in e-cigarettes on product perceptions and use is particularly relevant to the Food and Drug Administration’s recently proposed policy framework that seeks to place additional regulations on the sale of non-menthol flavored e-cigarettes to youth.”
The other authors of this paper are Sarah Kowitt, PhD, a Gillings School alumna and postdoctoral research associate with UNC Lineberger, and Leah Ranney, PhD, assistant professor of family medicine and director of the UNC Tobacco Prevention and Evaluation Program.
