ENDS Flavors

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• This page will attempt to address the following questions:

FAQ: Why are flavored ENDS products important to people who smoke?

FAQ: Why are flavored ENDS products important to people trying to prevent relapse to smoking?

FAQ: Do flavors entice youth to illegally use ENDS products?

FAQ: When comparing continuum of risk, how do flavored ENDS products compare to smoking?

FAQ: Are the flavors a threat to public health?

FAQ: Are there any unintended consequences to banning flavored ENDS products?

Public Health Advantages - Studies / Papers

2018: A QUESTION OF TASTE: THE PUBLIC HEALTH CASE FOR E-CIGARETTE FLAVORS

• The available evidence on flavored e-cigarettes suggests that flavors in and of themselves are not especially appealing to non-smoking adults or adolescents. There is, however, a substantial and growing literature on how and why these products appeal to smoking adults and their potential to help consumers switch from smoking to less-harmful vaping.
• Any policy that harms the exclusive makers of reduced-risk products such as e-cigarettes more than the makers of traditional cigarettes is not in the interests of public health.
• Report Author (55 pages): Guy Bentley

2016: Cigarette smoking and electronic cigarette vaping patterns as a function of e-cigarette flavourings

• The findings suggest that adoption of e-cigarettes in smokers may influence smoking rates of people who smoke.
• E-cigarette vaping rates are influenced by flavorings by people transitioning from smoking.
• These findings have implications for the utility of e-cigarettes as a nicotine replacement device and for the regulation of e-cigarettes for harm reduction.
• PDF Version
• Citation: Litt MD, Duffy V, Oncken C. Cigarette smoking and electronic cigarette vaping patterns as a function of e-cigarette flavourings, Tobacco Control 2016;25:ii67-ii72.
• Acknowledgement: Support for this project was provided by Grant 1 R01 DA036492 from the National Institute on Drug Abuse, and in part by General Clinical Research Center Grant M01-RR06192 from the National Institutes of Health.

Regulations or Unintended Consequences - Studies / Papers

2020: Association of vaping‐related lung injuries with rates of e‐cigarette and cannabis use across US states

• Policymakers should proceed with caution when considering bans on flavored nicotine e‐liquids: restricting legal sales may push some vapers towards illicit sources, user‐modified e‐liquids (e.g. to add flavoring) or even conventional cigarette use. Given EVALI’s potential lethality and a myriad of work suggesting that conventional cigarette use is probably far more dangerous than vaping nicotine, these outcomes could be disastrous for public health. There is no link between nicotine liquids and EVALI. It appears to have come from illicit cannabis products.
• Link above is to the PDF version
• Citation: Friedman, A. S. (2020). Association of Vaping‐related Lung Injuries with Rates of E‐cigarette and Cannabis Use across US States. Addiction. doi:10.1111/add.15235
• Acknowledgement: Research reported in this publication was supported by grant number 3U54DA036151‐08S2 from the National Institute On Drug Abuse of the National Institutes of Health and FDA Center for Tobacco Products (CTP).

2020: The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults

• Among the 18–24 age group, there was a significant increase in cigarette smoking.
• Cigarette smoking increased among 25–34 years old.
• Banning flavors in e-cigarettes can push some e-cigarette users to turn to cigarette smoking and could prompt some youth to initiate into smoking instead of e-cigarette use.
• The proportions of e-cigarettes, cigarettes, and cigars obtained over the internet increased after the ban, and the proportions obtained from retailers outside of San Francisco also increased overall.
• PDF Version
• Citation: Yang, Y., Lindblom, E. N., Salloum, R. G., & Ward, K. D. (2020). The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults. Addictive Behaviors Reports, 11, 100273. doi:10.1016/j.abrep.2020.100273
• Acknowledgement: This research was supported by the National Institute of Drug Abuse of the National Institutes of Health (R03DA048460).

2019: Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users

• Our results regarding anticipated reactions to FDA e-cigarette flavor regulation suggest complexities such that the benefits and risks of flavor ban need to be carefully evaluated.
• A majority anticipated that they would personally attempt to circumvent potential FDA regulations of e-cigarettes by obtaining e-cigarette flavors from various illicit sources (e.g., Internet orders from foreign countries) or even self-making flavors.
• The use of flavoring agents purchased from unregulated sources could lead to additional unanticipated toxicities.
• It is also concerning that some established e-cigarette users believed that they would return to cigarette smoking if nontobacco e-cigarette flavors were banned. Thus, for adult e-cigarette users who use certain flavors to facilitate smoking cessation or reduction, banning all nontobacco flavors could precipitate relapse to smoking.
• PDF Version
• Citation: Ann Am Thorac Soc Vol 17, No 5, pp 573–581, May 2020, Copyright © 2020 by the American Thoracic Society, DOI: 10.1513/AnnalsATS.201906-472OC
• Acknowledgement: Supported by the National Institute on Drug Abuse of the National Institutes of Health (NIH) and the Center for Tobacco Products of the U.S. Food and Drug Administration (FDA) (P50-DA-036107) for the Penn State Tobacco Center of Regulatory Science.

2018 Patterns of flavored e-cigarette use among adults vapers in the United States: an internet survey

• Survey results submitted to the FDA
• In conclusion, this cross-sectional study of a very large sample of adult US e-cigarette users, most of which were former smokers, identified the importance of non-tobacco flavors in e-cigarette use initiation and sustained use, and their contribution to smoking cessation and relapse prevention. *This information should be considered by regulators in order to avoid unintentional adverse effects of over-restrictive regulation on e-cigarette flavors.
• PDF Version
• Citation: Konstantinos Farsalinos, MD, MPH, Christopher Russell, PhD, George Lagoumintzis, PhD, Konstantinos Poulas, Submitted to: Docket No. FDA-2017 N-6565 for “Regulation of Flavors in Tobacco Products.”

2018: Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment

• A ban on flavoured e-cigarettes would likely increase the choice of cigarettes in smokers, the more harmful way of obtaining nicotine.
• PDF Version
• Citation:Buckell J, Marti J, Sindelar JLShould flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experimentTobacco Control 2019;28:168-175.
• Acknowledgement: Research reported in this publication was supported by grant number P50DA036151 from the National Institute on Drug Abuse (NIDA) and FDA Center for Tobacco Products (CTP).

Relapse Prevention or Long Term Abstinence - Studies / Papers

2020: Reported patterns of vaping to support long-term abstinence from smoking: a cross-sectional survey of a convenience sample of vapers

• Qualitative research suggests e-cigarettes can meet many of the needs of ex-smokers by substituting physical, psychological, social, cultural and identity-related aspects of tobacco addiction.
• According to a time-series analysis of data from the Smoking Toolkit study, in which repeated cross-sectional surveys are conducted with a representative sample of households in England, increasing prevalence of e-cigarette use in current smokers was predictive of higher success rates of quit attempts.
• Most participants were self-reported long-term abstinent smokers (86.3%).
• Those who start on a low self-reported nicotine e-liquid concentration (strength) will be more likely to relapse to tobacco smoking than those starting on a higher nicotine e-liquid, after controlling for cigarettes per day (CPD) before cessation.
• Results suggest a change in flavor choices over the course of vaping initiation and uptake. There was a reduction in the proportion of people using a tobacco flavor, and increase in the proportion using a fruit/sweet/food flavor, from initial to current flavor choice
• According to the 2017 ASH-A survey, among current users, fruit flavors were the most popular.
• PDF Version
• Citation: Gentry, S.V., Ward, E., Dawkins, L. et al. Reported patterns of vaping to support long-term abstinence from smoking: a cross-sectional survey of a convenience sample of vapers. Harm Reduct J 17, 70 (2020). doi:10.1186/s12954-020-00418-8
• Acknowledgement: This research was funded by Cancer Research UK (CRUK), Grant Number C54889/A22732.

Smoking Cessation - Studies / Papers

2020: Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation

• Adults who began vaping nontobacco-flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors.
• Banning flavors altogether may be too blunt an instrument for the current problem (youth use of vapor products).
• PDF Version
• Citation: Friedman, A. S., & Xu, S. (2020). Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation. JAMA Network Open, 3(6), e203826. doi:10.1001/jamanetworkopen.2020.3826
• Acknowledgment: : Ms Xu was supported by a T32 National Research Service Award from the Agency for Healthcare Research and Quality (HS017589).

2019: The role of flavors in vaping initiation and satisfaction among U.S. adults

• Most common reasons for vaping initiation were as an alternative to cigarettes (43.7%) and because respondents viewed e-cigarettes as less harmful than other tobacco products (31.2%). Flavor was the third most commonly reported reason.
• Satisfaction among those who bought flavored e-liquid was higher than those who did not buy flavored e-liquid.
• PDF Version
• Citation: Landry, R. L., Groom, A. L., Vu, T.-H. T., Stokes, A. C., Berry, K. M., Kesh, A., … Payne, T. J. (2019). The role of flavors in vaping initiation and satisfaction among U.S. adults. Addictive Behaviors, 106077. doi:10.1016/j.addbeh.2019.106077
• This research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) and the FDA Center for Tobacco Products (CTP) under Awards P50HL120163 and U54HL120163.

2019 Vaping patterns, nicotine dependence and reasons for vaping among American Indian dual users of cigarettes and electronic cigarettes

• The ten-item Penn State Dependence Index (PSDI) suggested greater dependence on smoking than vaping
• The most common reasons for vaping were to reduce smoking (79%), enjoyment of flavors (78%), and ability to vape where smoking is not allowed (73%). Perceptions of less harm to others (69%) or to self were the next most common (65%). Fewer than half used ECs to reduce stress, for affordability, or because others used them.
• PDF Version
• Citation: Rhoades DA, Comiford AL, Dvorak JD, Ding K, Hopkins M, Spicer P, Wagener TL, Doescher MP. Vaping patterns, nicotine dependence and reasons for vaping among American Indian dual users of cigarettes and electronic cigarettes. BMC Public Health. 2019 Sep 2;19(1):1211. doi: 10.1186/s12889-019-7523-5. PMID: 31477072; PMCID: PMC6721166.
• Acknowledgement: Grants from the National Cancer Institute of the National Institutes of Health (P20CA202921 to University of Oklahoma, and 5P20CA202923 to Cherokee Nation) supported this study.

2017 Differences between Dual Users and Switchers Center around Vaping Behavior and Its Experiences Rather than Beliefs and Attitudes

• To the extent that dual users substantially lower the number of cigarettes, they will reduce health risks from smoking. However, from a medical point of view, exclusive vaping is preferable to dual use;
• Differences between dual users and switchers center around variables proximal to the vaping behavior and its experienced effects rather than hinging on more general vaping-related beliefs and attitudes.
• After e-cig initiation, dual users decreased tobacco consumption by 82% and were low-to-moderately cigarette dependent.
• The two groups (dual users and switchers) reported mostly using a flavor other than tobacco.
• PDF Version
• Citation: Adriaens K, Van Gucht D, Baeyens F. Differences between Dual Users and Switchers Center around Vaping Behavior and Its Experiences Rather than Beliefs and Attitudes. Int J Environ Res Public Health. 2017 Dec 23;15(1):12. doi: 10.3390/ijerph15010012. PMID: 29295483; PMCID: PMC5800112.

2015: Preferred Flavors and Reasons for E-cigarette Use and Discontinued Use Among Never, Current, and Former Smokers

• Never users had significantly lower prevalence of use of alcohol, marijuana, and other tobacco products (take less risks).
• The most commonly reported reasons for e-cigarette use were “they might be less harmful than cigarettes” (77%); “they don’t smell” (77%); “they help people quit smoking” (66%); and “they cost less than other forms of tobacco” (62%); these reasons were more frequently endorsed by former smokers.
• Among current e-cigarette users, the most commonly used flavor was fruit flavors (67%)
• Over 90% of former cigarette smokers who were current e-cigarette users reported using e-cigarettes to quit smoking.
• Over half of never smokers who are former e-cigarette users said they did not recently use e-cigarettes because they “just don’t think about it”, possibly indicating that addiction did not play a role in their use.
• PDF Version
• Citation: Berg CJ. Preferred flavors and reasons for e-cigarette use and discontinued use among never, current, and former smokers. Int J Public Health. 2016 Mar;61(2):225-36. doi: 10.1007/s00038-015-0764-x. Epub 2015 Nov 18. PMID: 26582009; PMCID: PMC4808473.
• Acknowledgement: This research was supported by the National Cancer Institute (1K07CA139114-01A1; PI: Berg) and the Georgia Cancer Coalition (PI: Berg).

2013: Impact of Flavour Variability on Electronic Cigarette Use Experience: An Internet Survey

• 4,618 participants were included in the analysis, with 4,515 reporting current smoking status (current vs. former smokers).
• More than 90% were former smokers. The mean age was 40 years
• At the time of participation, most commonly used flavors were fruits, followed by sweets.
• Most participants (68.3%) were switching between flavours on a daily basis or within the day, with former smokers switching more frequently. More than half of the study sample mentioned that they like the variety of flavours and that the taste gets blunt from long-term use of the same flavour. The average score for importance of flavours variability in reducing or quitting smoking was 4 (“very important”). Finally, the majority of participants stated that restricting variability of flavours would make the EC experience less enjoyable while almost half of them answered that it would increase craving for tobacco cigarettes and would make reducing or completely substituting smoking less likely.
• The results of this survey indicate that EC liquid flavourings play a major role in the overall experience of dedicated users and support the hypothesis that they are important contributors in reducing or eliminating smoking consumption.
• PDF Version
• Citation: Farsalinos, K., Romagna, G., Tsiapras, D., Kyrzopoulos, S., Spyrou, A., & Voudris, V. (2013). Impact of Flavour Variability on Electronic Cigarette Use Experience: An Internet Survey. International Journal of Environmental Research and Public Health, 10(12), 7272–7282. doi:10.3390/ijerph10127272
• Acknowledgement: No funding was received for this study.

Use of Flavors (Youth to Sr. Citizens) - Studies / Papers

2020: Choice and variety-seeking of e-liquids and flavour (flavor) categories by New Zealand smokers using an electronic cigarette: a longitudinal study

• Variety-seeking behaviour (behavior) was common and typically reported within the first 12 weeks of participants’ e-cigarette-assisted attempt to transition away from smoking.
• Policies allowing diverse e-liquid flavours at specialist stores could support users’ variety-seeking and potentially create opportunities to couple e-liquid purchasing occasions with cessation advice during the first months of a transition attempt.
• (Link above is to the PDF version)
• Citation: Mei-Ling Blank, MPH, Janet Hoek, PhD, Choice and variety-seeking of e-liquids and flavour categories by New Zealand smokers using an electronic cigarette: a longitudinal study, Nicotine & Tobacco Research, , ntaa248, doi:10.1093/ntr/ntaa248
• Acknowledgement: Royal Society of New Zealand Marsden Fund Grant (17-UOO-129) to Janet Hoek (PI), Mei-Ling Blank (AI), Tamlin Conner (AI), Shelagh Ferguson (AI), and Lee Thompson (AI). Both authors are members of ASPIRE 2025, a research collaboration working to achieve the New Zealand Government's Smokefree 2025 goal.

2018: Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA

• Adult frequent e-cigarette users in the USA who have completely switched from smoking cigarettes to using e-cigarettes are increasingly likely to have initiated e-cigarette use with non-tobacco flavors and to have transitioned from tobacco to non-tobacco flavors over time. Restricting access to non-tobacco e-cigarette flavors may discourage smokers from attempting to switch to e-cigarettes.
• PDF Version
• Citation: Russell C, McKeganey N, Dickson T, Nides M. Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. 2018 Jun 28;15(1):33. doi: 10.1186/s12954-018-0238-6. PMID: 29954412; PMCID: PMC6022703.
• Acknowledgements: The authors are grateful to Julie Woessner and Alex Clark (Consumer Advocates for Smoke-free Alternatives Association), Stefan Didak and Danielle Bloss (Not Blowing Smoke), Gregory Conley (American Vaping Association), Cynthia Cabrera (Cating Group), and the Board of the Smoke-Free Alternatives Trade Association, without whose assistance this study would not have been possible. Fontem Ventures, a company that makes e-cigarettes, and a wholly owned subsidiary of Imperial Brands PLC provided funding for this study.

2015: The Impact of Flavor Descriptors on Nonsmoking Teens’ and Adult Smokers’ Interest in Electronic Cigarettes

• Nonsmoking teens’ interest in e-cigarettes was very low.
• Adult smokers’ interest was significantly higher overall and for each flavor.
• Teen interest did not vary by flavor, but adult interest did.
• Past-30-day adult e-cigarette users had the greatest interest in e-cigarettes, and their interest was most affected by flavor.
• Nonsmoking teens who had never tried e-cigarettes had the lowest interest in flavors, followed by adults who had never tried e-cigarettes
• PDF Version
• Citation: Saul Shiffman, PhD, Mark A Sembower, MS, Janine L Pillitteri, PhD, Karen K Gerlach, PhD, MPH, Joseph G Gitchell, BA, The Impact of Flavor Descriptors on Nonsmoking Teens’ and Adult Smokers’ Interest in Electronic Cigarettes, Nicotine & Tobacco Research, Volume 17, Issue 10, October 2015, Pages 1255–1262, doi: 10.1093/ntr/ntu333
• Acknowledgement: This work was supported by NJOY, a company that markets electronic cigarettes, but does not make or sell any combustible tobacco products. All authors work for Pinney Associates and provide consulting services to GlaxoSmithKline Consumer Healthcare on their stop-smoking medications and to NJOY, Inc. on electronic nicotine delivery systems (ENDS). SS and JGG also own an interest in a novel nicotine medication in development. The study sponsor was involved in discussion of the study design, but had no role in study execution, data collection, data analysis, or writing of the manuscript, nor did the sponsor review the manuscript prior to submission.

2013: Adolescent Males' Awareness of and Willingness to Try Electronic Cigarettes

• Only two participants (< 1%) had previously tried e-cigarettes.
• Among those who had not tried e-cigarettes, most (67%) had heard of them. Awareness was higher among older and non-Hispanic adolescents.
• Nearly 1 in 5 (18%) participants were willing to try either a plain or flavored e-cigarette, but willingness to try plain versus flavored varieties did not differ.
• Smokers were more willing to try any e-cigarette than nonsmokers.
• Nonsmokers who had more negative beliefs about the typical smoker were less willing to try e-cigarettes.
• PDF Version
• Citation: Pepper, J. K., Reiter, P. L., McRee, A.-L., Cameron, L. D., Gilkey, M. B., & Brewer, N. T. (2013). Adolescent Males’ Awareness of and Willingness to Try Electronic Cigarettes. Journal of Adolescent Health, 52(2), 144–150. doi:10.1016/j.jadohealth.2012.09.014
• Acknowledgement: : Support for this study was provided by the American Cancer Society (MSRG-06-259-01-CPPB), the Cancer Control Education Program at UNC Lineberger Comprehensive Cancer Center (R25 CA57726), the National Institutes of Health (P50CA105632 and P30CA016058), and a

Youth - Studies / Papers

2020: Report Summary: Perverse Psychology How Anti-Vaping Campaigners Created the Youth Vaping “Epidemic”

• It is reasonable for anti-tobacco advocates to worry about youth experimentation with nicotine, but the evidence is clear that their interventions have backfired and made the problem worse. Their attempts to dissuade teenagers from vaping increased their awareness of the behavior, made it more attractive, and convinced them that everyone around them was doing it.
• Anti-tobacco advocates argue that the government can end the “epidemic” by raising the minimum tobacco age to 21, banning non-tobacco e-cigarette flavors, and increasing funding for anti-vaping education. But, as this paper has demonstrated, these measures will not only fail, they will actually make matters worse by increasing the coolness of vaping and youth attraction to it.
• Teen vaping did not escalate despite the increased anti-vaping messaging. Adolescents’ curiosity and subsequent experimentation with vaping rose because of anti-vaping messaging.
• PDF of Full report

2020: Paper: Intended and Unintended Effects of Banning Menthol Cigarettes

• Menthol bans significantly increased non-menthol cigarette smoking among youths, resulting in no overall net change in youth smoking rates.
• Menthol bans shifted smokers’ cigarette purchases away from grocery stores and gas stations to First Nations reserves (where the menthol bans do not bind).
• PDF Full Paper

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