Fruit ecigs most popular first flavor, but kids who start with menthol/mint more likely to still be vaping as young adults

Jim Sargent, Jessica Barrington-Trimis and their colleagues at Dartmouth, USC, and other institutions just published an important study highlighting the importance of menthol/mint to long-term nicotine dependence among young adult e-cig users.

Their paper, “First E-Cigarette Flavor and Device Type Used: Associations With Vaping Persistence, Frequency, and Dependence in Young Adults,” used data from the USC Happiness and Health Study that originally recruited ninth grade students in 2013 in Los Angeles County, CA then followed them forward in time.  The data for this study were collected October 2018 and November 2019 when the respondents were an average of 19.7 years old.  They collected data on current vaping and measures of addiction and asked respondents what flavor and device type they started with.

Recollection of first flavor was consistent with what is already well-documents: most kids started with fruit/sweet (71%) compared to 19% who started with menthol/mint, and 10% with tobacco/flavorless/other.   This result would seem to support the FDA’s current practice of banning flavors other than tobacco and but raises more questions about a likely FDA decision to give menthol a pass.

But the longer-term results are very different.  The kids who recollected starting with menthol/mint were more likely to still be vaping years later.

Specifically, the authors found:

Seventy-nine percent of those beginning with menthol/mint first flavor were past 30-day vapers at the time of survey during young adulthood, compared to 52% for those beginning with tobacco/flavorless/other and 54% who first used fruit/sweet (Figure 1A [in their paper, reproduced above]).  Among past 30-day vapers, those reporting menthol/mint as first flavor (Figure 1B [reproduced above]) reported almost double the mean days vaped (Mean: 6.9[95% CI = 4.2 to 11.3]) as compared to tobacco/other flavors (Mean: 3.3[95% CI = 1.7 to 6.4]), with first fruit/sweet falling in between (Mean: 4.5[95% CI = 2.9 to 7.1]). In the multivariable covariate-adjusted analysis (Table 2 [in their paper]), menthol/mint versus tobacco/other flavor use was significantly associated with both a greater likelihood of any past 30-day vaping (AOR: 2.22[95% CI = 1.16 to 4.25]) and higher vaping frequency among past 30-day vapers (ARR = 2.12 [1.27, 3.56]). Fruit/sweet versus tobacco/other was not significantly associated with past-30-day vaping odds or frequency. [emphasis added]

More of the youth who started with mint/menthol (46%) reported at least one dependence symptom 5 or 6 years later, compared to 22% beginning with tobacco/flavorless/other flavors and 24% for those starting fruit/sweet.  In the multivariable analysis that controlled for a range of demographic and other risk factors, menthol/mint (vs. tobacco/other) first flavor was associated with a higher likelihood of experiencing at least one dependence symptoms.  In contrast, fruit/sweet flavor was not associated with dependence symptom status.

The bottom line according to the authors:

young adults who initiated e-cigarette use with menthol/mint flavors, as compared to tobacco and other non-sweet/fruit flavors or flavorless products, had higher odds of continued and more frequent e-cigarette use, and greater nicotine dependence.

This paper provides important evidence that the FDA (and other regulators) need to look beyond the fact that fruit flavor ecigs are most common among youth and recognize that to prevent long terms addiction FDA needs to ban menthol/mint e-cigarettes.

This paper also supports comprehensive local and state bans on sales of all flavored tobacco products, including menthol/mint. 

(The paper also looks at first device type, but given  the rapidly evolving technology, that is probably less important than the menthol results.)

Here is the abstract:

Introduction: Type of e-cigarette flavoring and device during first use might differentiate later e-cigarette use and dependence. This retrospective cross-sectional study examined associations of recalled first nicotine vaping device and flavor used with current vaping frequency/dependence.

Aims and methods: A young adult cohort from Los Angeles, California, USA completed web-based surveys (N = 2553). Using cross-sectional data from 971 reporting ever vaping nicotine, multivariable hurdle regressions tested associations between recalled first flavor (fruit/sweet, menthol/mint, other) and device (Juul, disposable, mod, box, pod, pen, other) vaped with past-30-day vaping status (yes/no) and frequency (1-30 days), and with any vaping dependence symptoms (yes/no) and count (1-10 symptoms).

Results: The most common first-flavor was sweet (71%); the most common first-device was a vape pen (37%), then Juul (22%). First-flavor of mint/menthol (vs. other; adjusted odds ratio [AOR]: 2.22[95% CI = 1.16 to 4.25]), and first-device mod (AOR = 2.40[95% CI = 1.34 to 4.31]) and non-Juul pod (2.64[95% CI = 1.41 to 4.92]) (vs. pen) were associated with past-30-day vaping, and twice as many vaping days (adjusted rate ratios [ARRs] range: 1.96-2.12; ps < .05). First flavor of mint/menthol (vs. other; AOR: 1.95[95% CI = 1.003 to 3.79) and first device mod, box, non-Juul pod, and other (AORs range: 2.36-4.01; ps < .05) were associated with nicotine dependence. First device Juul, mod, box, and non-Juul pod were also associated with more dependence symptoms (ARRs range:1.38-1.59; ps < .05). 

Conclusions: Exposure to mint/menthol and certain devices (mod, box, Juul, and non-Juul pods) at first e-cigarette use may be associated with more frequent e-cigarette use and nicotine dependence symptoms in young adulthood. Mint/menthol and certain devices warrant consideration in regulation of e-cigarettes based on product characteristics. 

Implications: Characteristics (flavor and device type) of first e-cigarette product used were associated with higher usage and more dependence. Pending replication with prospective designs, the findings suggest certain flavors (mint/menthol) and devices (pods, mods) merit consideration in regulation because of their possible link with continued use and dependence among young people.

The full citation is:  Sargent JD, Stoolmiller M, Dai H, Barrington-Trimis JL, McConnell R, Audrain-McGovern J, Leventhal AM. First E-Cigarette Flavor and Device Type Used: Associations With Vaping Persistence, Frequency, and Dependence in Young Adults. Nicotine Tob Res. 2022 Feb 14;24(3):380-387. doi: 10.1093/ntr/ntab172. PMID: 34460934; PMCID: PMC8842392.  It is available here.