Flavor Inconsistencies between Flavored Tobacco Products among US Adults Liane M. Schneller, PhD, MS Irfan Rahman, PhD Dongmei Li, PhD Scott McIntosh, PhD Zahíra Quiñones Tavárez, MD Richard J. O’Connor, PhD Maciej L. Goniewicz, PhD, PharmD Deborah J. Ossip, PhD Amanda J. Quisenberry, PhD Zidian Xie, PhD Objective: Banning flavors in some tobacco products, while allowing them in others, may shift consumer preferences towards products in which flavors are still allowed. In this study, we exam- ine flavor popularity and inconsistencies in flavor preference across non-cigarette tobacco prod- ucts among US adults. Methods: We used data from the Population Assessment of Tobacco and Health Study Wave 3 to assess the prevalence of flavor preference for users of non-cigarette to- bacco products (N = 9037), as well as flavor inconsistencies between products among polyusers (N = 3183). Results: Most users of flavored tobacco products reported using one flavor category per product. Fruit and tobacco were among the most commonly used flavor categories of ENDS, hookah, traditional cigars, and cigarillo/filtered cigars. Menthol/mint was the most common fla- vor among snus/smokeless users. Polyusers of ENDS and traditional cigars had the largest incon- sistency, where about 68%-76% used different flavors across products. Conversely, polyusers of traditional cigars and cigarillos/filtered cigars had the lowest inconsistency (25%-28%).Conclu - sions: Flavor preferences differed according to product, suggesting that consumers are not like- ly to switch across products to maintain a flavor preference. Future research should assess flavor preferences prospectively to improve understanding of the potential benefits of flavor bans. Key words: flavored tobacco products; electronic nicotine delivery systems (ENDS); cigars; hookah; smokeless tobacco; tobacco polyusers Am J Health Behav.™ 2020;44(5):617-630 DOI: doi.org/10.5993/AJHB.44.5.6 haracterizing flavors, excluding tobacco and May 2016,2 this policy was not immediately ex- menthol, were banned in cigarettes by the tended to currently marketed other non-cigarette United States (US) Food and Drug Ad- tobacco products. However, some states (eg, New Cministration (FDA) following the Family Smoking Jersey, New York, and Rhode Island) and localities Prevention and Tobacco Control Act of 2009.1 Al- (eg, Chicago, and Santa Clara County) did ban though the FDA now has the authority to ban char- characterizing flavors in electronic nicotine deliv- acterizing flavors in non-cigarette tobacco products ery systems (ENDS).3-8 Furthermore, following the marketed in the US as per the Deeming Rule of spike in cases of lung injury and deaths associated Liane M. Schneller, Postdoctoral Fellow, the Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY. Dongmei Li, Associate Professor, the Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY. Zahíra Qui- ñones Tavárez, Doctorate Student, Translational Biomedical Science, University of Rochester Medical Center, Rochester, NY. Maciej L. Goniewicz, Associate Professor of Oncology, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY. Amanda J. Quisenberry, Assistant Professor of Oncology, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY. Zidian Xie, Senior Analyst and Programmer, the Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY. Irfan Rahman, Professor, Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY. Scott McIntosh, Associate Professor, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY. Richard J. O’Connor, Professor of Oncology, Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY. Deborah J. Ossip, Professor, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY. Correspondence Dr Schneller; [email protected] Am J Health Behav.™ 2020;44(5):617-630 617 Flavor Inconsistencies between Flavored Tobacco Products among US Adults with the use of ENDS,9 several states and locali- cigars (3.9%), ENDS (3.2%), smokeless tobacco ties have issued emergency rules banning the sale (2.4%), and the use of regular pipe, water pipe of flavored ENDS.10 The has FDA prioritized the or hookah (1.0%).36 Although any form of flavor enforcement of the sale of flavored cartridge-based ban is likely implemented to reduce appeal and, ENDS, except tobacco or menthol, while leaving therefore, overall prevalence of use, the ban on fla- other ENDS and flavored tobacco products alone vored cartridge-based ENDS may not result in a to ensure that manufacturers are taking the proper change in ENDS use, but rather a shift in the type precautions to minimize youth access.11 of ENDS device used (eg, open, modifiable ENDS Flavors are added to tobacco products, in part, devices). In the event of a more intense ban on all to mask the harsh taste of tobacco or nicotine.12-17 flavored ENDS, the market share of tobacco use This facilitates consumer initiation and continua- may shift to other products that are still available in tion of tobacco use.12-17 It has been reported that flavors (eg, cigars or smokeless tobacco). flavored tobacco products are viewed as more fa- The availability of flavored tobacco products is vorable than unflavored products, as they increase known to be a top reason for using non-cigarette satisfaction, create a better feel and taste, and allow tobacco products.31,37,38 The flavor additives used consumers to customize their experience.18-20 Previ- in various tobacco products could differ in qual- ous studies have shown that young adult ENDS us- ity; hookah tobacco may be flavored with natural ers (generally 18-30 years of age) are more attracted additives, such as fruit and honey, whereas e-liquid to sweet flavors (eg, fruit and candy).21-26 Similar may be artificially flavored. The quality of flavor patterns can be seen among adult vapers, although additives in various tobacco products could alter more bitter flavors (eg, menthol/mint27 and to- the sensory perception among consumers, and bacco12-17) are also common among adults,28,29 es- therefore, alter flavor preference between tobacco pecially smokers.26 ENDS, however, are not the products. In the event of a partial flavor ban, such only tobacco products that are available in flavors. as the ban of flavored cartridge-based ENDS, the ENDS, as well as smokeless tobacco, hookah, and observation of shifts in the tobacco market is likely. cigarillos/cigars are available in flavors. In 2013- Although we would expect a reduction in the prev- 2014, more than 50% of adults reported trying fla- alence of use,39,40 the use of other tobacco products vored hookah or snus before the age of 18 years.30 that are still available in flavors could also be ex- First time use of a flavored cigar, especially cigaril- pected,39,41-43 which would continue to pose a risk los and filtered cigars, was also prevalent among the to the public health.44 Therefore, understanding youth and young adult population.30,31 Further- consistencies in flavor preference across products more, about 60% of current cigarillo and filtered may portend switching to another product with a cigar users reported using a flavored product.32 It comparable flavor rather than remaining loyal to has been shown that sweeter flavors, such as fruit, the current product. To our knowledge, the flavor candy/other sweets, chocolate or alcohol-flavors, preference across various tobacco products and are popular among young adult hookah and cigar among polytobacco users has not been assessed be- users,33,34 whereas mint flavored snus is preferred by yond flavor use among cigarette and ENDS users.45 combustible cigarette smokers.35 Using data from Wave 3 (W3) of the Population Public health officials continue to gather data Assessment of Tobacco and Health (PATH) Study, on the use of flavored tobacco products to deter- the purpose of this study was to: (1) examine the mine if the flavor ban should be extended beyond popularity of flavors among exclusive and poly- that of flavored cartridge-based ENDS. However, tobacco users of various type of flavored tobacco the ban on flavored cartridge-based ENDS or the products, and (2) analyze inconsistencies in flavor implementation of any extension to this ban will preference among polytobacco users of different likely alter the tobacco market share. As of 2018, types of flavored tobacco products in the US. about 49.1 million or 19.7% of US adults reported currently using any tobacco products.36 Cigarettes METHODS were the most prevalent tobacco product used with Study Design and Population 13.7% of US adults using cigarettes followed by The PATH Study is a nationally representative, 618 Schneller et al longitudinal cohort study of tobacco use and its sweets, or some other flavor. Participants who re- health effects among non-institutionalized adults ported using traditional cigars, cigarillos, filtered and youth in the US, through the National Insti- cigars, or hookah could choose from menthol/ tute of Health and the FDA. Data from W3 of the mint, clove/spice, fruit, chocolate, an alcoholic PATH Study were collected between October 19, drink, candy/other sweets, or some other flavor. Fi- 2015 and October 23, 2016 among 28,148 adult nally, those who reported using snus or smokeless and 13,651 youth respondents. More informa- tobacco could choose menthol/mint, wintergreen/ tion about the PATH Study design and methods spearmint/frost, clove/spice, fruit, chocolate, alco- can be found elsewhere.46 This analysis provides holic drinks, candy/other sweets, or some other fla- W3 cross-sectional estimates from 9037 adult fla- vor. Tobacco flavor was offered only explicitly as a vored tobacco users. Analyses were done to assess flavor option among those who used an ENDS as the popularity of flavors of various non-cigarette the other tobacco products are by default tobacco tobacco products, as well as inconsistencies in pre- flavored.