Reactions to hypothetical flavor bans among current users of flavored e-cigarettes

Abstract

Banning flavors in e-cigarettes and other tobacco products may decrease their use. To examine how current users of flavored e-cigarettes might react to a ban on flavored e-cigarettes when: (i) menthol flavor is banned together with other flavors, or (ii) this ban on e-cigarettes is combined with a ban on menthol cigarettes and flavored cigars. A national cross-sectional survey of 2,347 current users of flavored e-cigarettes was conducted in May 2022. For each hypothetical ban scenario, respondents reported if they would quit all tobacco product use, continue to use e-cigarettes with no flavor or flavors that were not banned, or switch to alternative tobacco products. Multinomial logistic regressions were used to estimate the associations between responses and ban scenarios, adjusting for tobacco use and demographic variables.

If e-cigarettes with any flavors except menthol and tobacco were banned, the majority of current e-cigarette users would keep using e-cigarettes with no flavor or tobacco and menthol flavor. When menthol flavor was added to a ban, a greater proportion of respondents would quit all tobacco use; however, more would also switch to cigarettes or cigars. When menthol cigarettes and flavored cigars were added to a ban, those who used menthol flavor only would be less likely to switch to cigarettes and cigars.

Among current e-cigarette users, the harm reduction (i.e., from quitting all use) from a ban on flavored e-cigarettes, particularly if menthol is also banned, may be outweighed by the harm increases (i.e., switching to cigarettes or cigars, or other products that are more harmful than using e-cigarettes). A concurrent ban on menthol cigarettes and flavored cigars would secure more certain net reductions to public health harms from e-cigarette use and smoking.

INTRODUCTION

The use of flavors in tobacco products is a public health concern. Flavors such as menthol, fruits, and candy promote the initiation of tobacco use, particularly among youth and young adults, increase nicotine dependence, and hinder cessation among current users [1–6]. Since 2009, all characterizing flavors except menthol have been banned from cigarettes in the USA. Recently, some U.S. states and municipalities have banned certain flavors in various tobacco products, with some banning all added flavors in e-cigarettes, and some banning menthol-flavored cigarettes [7]. At the federal level, in 2020, the FDA initiated a policy to take off the market all capsule or cartridge-based e-cigarettes with flavors other than menthol or tobacco. FDA is currently evaluating e-cigarette companies’ “pre-market” tobacco product applications to determine which, if any, flavored e-cigarettes will be allowed to stay on or re-enter the market, and, so far, has only allowed tobacco-flavored e-cigarettes. It is not yet clear if menthol e-cigarettes will be allowed. In April 2022, FDA issued proposed rules to prohibit menthol in cigarettes and characterizing flavors in cigars, but whether or when any related final rules will be issued is unclear [8].

Banning menthol flavor in cigarettes or flavored cigars reduces smoking substantially, both by reducing initiation and increasing quitting success among current smokers [9–11]. However, in response to bans of e-cigarette flavors, users of e-cigarettes with banned flavors must choose between trying to quit all use (reducing harm), using e-cigarettes with no or permitted flavors, or switching to other tobacco products such as cigarettes or cigars (increasing harm).

This study aimed to examine how users of flavored e-cigarettes who do not currently smoke or use other tobacco products might react to a ban on flavored e-cigarettes with two considerations. First, should menthol flavor be banned in e-cigarettes together with other flavors? If menthol flavor is banned, among those who would switch to menthol e-cigarettes otherwise, some may quit all tobacco use but some may switch to smoking. Compared with using e-cigarettes, the former is with health benefits but the latter results in harm and risk. Second, how current users of e-cigarettes who do not smoke, may respond to a ban on flavored e-cigarettes differently when the ban is combined with a ban on menthol cigarettes and flavored cigars compared with not? it is plausible that without menthol cigarettes and flavored cigars as optional alternatives, current users of flavored e-cigarettes may be more likely to quit all tobacco use rather than switch to smoking cigarettes and cigars.

METHODS

Data were collected in May 2022 on Amazon Mechanical Turk [12]. Eligible respondents were adults who currently used flavored e-cigarettes at least once a week in the past 30 days and did not use any other tobacco or nicotine product, including cigarettes and cigars. Besides demographics, we collected respondents’ e-cigarette use status (intention to quit, use frequency, history, flavors, and devices), and whether they were former or never smokers of cigarettes or cigars. For e-cigarette devices, respondents were asked to choose the device that they typically used from four categories: (i) disposable e-cigarettes; (ii) tanks, or vape pens; (iii) mods, or advanced personal vaporizers; and (iv) rechargeable ­e-cigarettes (e.g., Juul). Brief descriptions and pictures were provided for all devices.

For each relevant ban scenario, we asked respondents, under the assumption that the banned products could not be obtained anywhere, whether they would quit all tobacco and nicotine product use, continue to use non-flavored e-cigarettes or e-cigarettes with flavors that were not banned, or switch to alternative products that were still legally available, including: (i) cigarettes or cigars; (ii) hookah or waterpipe; (iii) heated tobacco products; and (iv) other products such as smokeless or dissolvable tobacco products.

We examined four ban scenarios with two considerations: (i) whether menthol flavor is banned together with other flavors in e-cigarettes or not, and (ii) whether flavor ban on e-cigarettes is combined with a ban on menthol cigarettes and flavored cigars or not. The four ban scenarios were:

• E1 is the base scenario and only bans e-cigarettes with any flavors except menthol.

• E2: E1 plus a ban on menthol e-cigarettes.

• EC1: E1 plus a ban on menthol cigarettes and flavored cigars.

• EC2: E1 plus a ban on both menthol e-cigarettes, menthol cigarettes, and flavored cigars.

Respondents were categorized into three groups according to the flavors they used: (i) both menthol and other flavors such as fruit or candy; (ii) other flavors but not menthol; and (iii) menthol but not other flavors. We did not consider tobacco to be a flavor of e-cigarettes in this study. Thus, the participants could have concurrently used tobacco and non-flavored e-cigarettes. It should be noted that for the respondents who used menthol but not other flavors, only scenarios E2 and EC2 were relevant.

We first summarized participants’ responses to each relevant ban scenario, stratified by three flavor groups. Second, for each of the three flavor groups, a separate multinomial logistic regression (PROC LOGISTIC in SAS, version 9.4) was conducted to estimate the associations between their responses to various ban scenarios, with an adjustment of demographic and tobacco use variables. The responses were categorized into three outcomes: using e-cigarettes was the reference outcome and the other two outcomes included quitting all tobacco use and switching to any alternative products (e.g., hookah, heated tobacco products, smokeless or dissolvable tobacco products). All regression models adjusted for respondents’ demographic characteristics and tobacco use variables.

RESULTS

Respondents’ demographics and tobacco use status are shown in Table 1. Compared with the US general population, the respondents were younger, with a lower proportion of Blacks and Asians, and were more highly educated. The majority of respondents used e-cigarettes daily, had some intention to quit e-cigarettes, with an e-cigarette use history of one to 5 years, and were former smokers of cigarettes or cigars. The three flavor groups were significantly different across most characteristics according to the results of Chi-square tests. Particularly, compared with the other two groups, the group who used both menthol and other flavors was more likely to use tobacco or non-flavored e-cigarettes concurrently.

As Table 2 shows, overall, responses to various ban scenarios were roughly similar among respondents who used other flavors, either with or without menthol flavor but different from respondents who used menthol flavor only. Compared with the other two groups, respondents who used menthol only were less likely to quit all tobacco use and much more likely to switch to cigarettes and cigars. For example, under scenario E2, among respondents who used menthol only, 8.4% would quit all tobacco and nicotine use and 38.9% would switch to cigarettes or cigars while the corresponding percentages were 16.8% and 19.2% among respondents who used flavors other than menthol. For respondents who used menthol only, responses to scenarios E2 and EC2 were roughly similar except when menthol cigarettes and flavored cigars were not available together with menthol cigarettes, fewer participants indicated they would switch to cigarettes and cigars while more would switch to other tobacco and nicotine products. For users of other flavors, either with ­menthol or not, when more flavored products were banned, the proportion quitting all use also increased, but the proportion who would switch to cigarettes and cigars also increased.

Table 3 displays how responses differed under the different ban options. Respondents who used both menthol and other flavors and those who used other flavors only were similar; that is, if menthol e-cigarettes were banned, respondents would be more likely to quit all use, and also more likely to switch to any alternative products including cigarettes and cigars, compared with if menthol e-cigarettes were not banned. Concurrent bans on menthol cigarettes and flavored cigars did not significantly change these two groups’ responses, except that respondents who used only flavors other than menthol were more likely to quit all use when the flavors were banned for cigarettes and cigars. For respondents who used menthol only, when menthol cigarettes and flavored cigars were banned, the respondents did not change their likelihood of quitting all tobacco use and switching to any alternative products including cigarettes and cigars.

As Table 4 showed, males, Hispanics, those with a bachelor’s degree or higher educational attainment, those with no intention to quit using e-cigarettes, those who used e-cigarettes daily, used tobacco or non-flavored e-cigarettes concurrently, and those who obtained e-cigarettes either from the Internet or through friends, and former smokers were less likely to quit all tobacco use than their counterparts. Compared with their counterparts, respondents with higher educational attainment, with some intention to quit e-cigarette use, those who used e-cigarettes less frequent than daily, those who did not obtain e-cigarettes through the Internet, and former smokers were also more likely to switch to alternative products. Compared with those who used disposable e-cigarettes, respondents who used tanks, mods, or rechargeable devices were more likely to switch to alternative products. Compared with respondents who use both menthol and other flavors, those who use menthol only were less likely to quit all tobacco use and more likely to switch to alternative tobacco products.

DISCUSSION

First, our results showed that if e-cigarettes with any flavors except menthol or tobacco were banned, the majority of current e-cigarette users would keep using e-cigarettes with menthol or tobacco flavors, or unflavored. When menthol was included in the e-cigarette flavor ban, a greater ­proportion of respondents indicated they would quit all tobacco use; however, more would also switch to cigarettes or cigars, or other products as an alternative. This result indicates that among current e-cigarette users, the harm reduction resulting from a ban on flavored e-cigarettes (i.e., from quitting all use), ­particularly when menthol is banned, may be outweighed by harm increases (i.e., from switching to cigarettes or cigars).

Second, when menthol cigarettes and flavored cigars were added to a menthol-including ban of flavored e-cigarettes, a significant proportion of respondents who used menthol but not other flavors would switch to products other than e-cigarettes, cigarettes, or cigars. Respondents who used other flavors, either with together with menthol or not, were less sensitive to a ban on menthol cigarettes and flavored cigars. This findings indicate that for respondents who used menthol flavor only, menthol cigarettes and flavored cigars are attractive alternatives for them and banning menthol cigarettes and flavored cigars may have additional value for this group.

Consistent with expectations, “heavy” users of e-cigarettes (e.g., daily use and no intention to quit) indicated they would be more likely to keep using e-cigarettes in response to the flavor bans. Users of disposable e-cigarettes would be less likely to switch to other products than those used tanks, vape pens, mods, or rechargeable e-cigarettes, and this may be because users of disposable e-cigarettes were less additive or dependent to tobacco products than those who used more complicated types.

It should be noted that our large sample was not representative of the U.S. population although recruited nationally, and some groups including young adults and people with high educational attainment were overrepresented. Also, our estimation of people’s reaction to flavor bans was based on an assumption that under nationwide flavor bans, the banned products could not be obtained readily through illegal sales.

Overall, our results suggest that it is possible that banning menthol e-cigarettes, along with all other non-tobacco added e-cigarette flavors, could result, on balance, with increased rather than reduced harm among current users of flavored e-cigarettes. However, more users who use only menthol-flavored e-cigarettes would likely quit all use instead of switching to smoking if the e-cigarette flavor ban were combined with a ban of menthol cigarettes and flavored cigars.

Funding

This research was supported by the National Institute of Drug Abuse (R03DA048460) and by the National Cancer Institute and FDA Center for Tobacco Products (U54CA229974). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.

Compliance with Ethical Standards

Conflict of Interest: The authors have no financial conflicts of interest

Human Rights: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Institutional Review Board at the University of Memphis approved this study.

Informed Consent: “Informed consent was obtained from all individual participants included in the study.

Welfare of Animals: This article does not contain any studies with animals performed by any of the authors.

Transparency Statements: This study was not formally registered. The analysis plan was not formally pre-registered. De-identified data from this study are not available in an a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author. Analytic code used to conduct the analyses presented in this study are not available in a public archive. They may be available by emailing the corresponding author. Materials used to conduct the study are not publically available.

References