More evidence to support eliminating flavors to reduce youth cigarette and e-cigarette use

Two recent papers demonstrate that flavors are an important reason that kids use cigarettes and e-cigarettes, supporting the importance of the kind of comprehensive ban on selling all flavored tobacco products, including menthol, that San Francisco passed and this is under assault by RJ Reynolds.
 
Charles J. Courtemanche and colleagues published “ Influence of the Flavored Cigarette Ban on Adolescent Tobacco Use” in American Journal of Preventive Medicine in which they analyzed data from the National Youth Tobacco Survey between 1999 and 2013.  They found that following the ban on characterizing flavors in cigarettes included in the 2009 Family Smoking Prevention and Tobacco Control Act was followed by a substantial drop in the probability of youth being smokers and the number  of cigarettes smoked.
 
The law exempted menthol in cigarettes and all other tobacco products (except smokeless).  Courtemanche and colleagues found big increases in use of these products (by 34-55%, depending on the product), which indicates that kids were substituting these other products for flavored cigarettes.
 
M.B. Harrell and colleagues published “Flavored e-cigarette use: Characterizing youth, young adult, and adult users” in Preventive Medicine Reports.  They found that “[m]ost e-cigarette users said their first and “usual” e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide.  Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes.”
 
They also found that “[a]mong adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.”  There was not an explicit analysis of the association between use of flavors and being a former smoker.
 
These two papers, taken together, provide consistent support for the conclusion that comprehensive flavor bans will lower youth smoking and e-cigarette use.   They also highlight the problems created by the fact that the Obama Administration blocked the FDA from dealing with flavors, including menthol, in e-cigarettes, little cigars, and other tobacco products.  While the Trump Administration is allowing the FDA to open a rulemaking process on flavors, any meaningful action is years away and uncertain at best.
 
This reality reinforces the importance of local action to prohibit the sales of these products, particularly defending the San Francisco ordinance and winning passage of similar comprehensive ordinances elsewhere.  They also show that, from its perspective of sellers of Newport, the leading menthol cigarette, RJ Reynolds was making a rational business decision to invest nearly $700,000 (so far) to try and block the San Francisco ordinance as a way to discourage action elsewhere.
 
Here are the full citations and abstracts:
 
Courtemanche, Charles J. et al.  Influence of the Flavored Cigarette Ban on Adolescent Tobacco Use.          American Journal of Preventive Medicine 2017; 52(5):e139 - e146
 
Introduction.  This paper estimated the association between the U.S. Food and Drug Administration’s 2009 ban on flavored cigarettes (which did not apply to menthol cigarettes or tobacco products besides cigarettes) and adolescents’ tobacco use.
Methods.  Regression modeling was used to evaluate tobacco use before and after the ban. The analyses controlled for a quadratic time trend, demographic variables, prices of cigarettes and other tobacco products, and teenage unemployment rate. Data from the 1999–2013 National Youth Tobacco Surveys were collected and analyzed in 2016. The sample included 197,834 middle and high schoolers. Outcomes were past 30–day cigarette use; cigarettes smoked in the past 30 days among smokers; rate of menthol cigarette use among smokers; and past 30–day use of cigars, smokeless tobacco, pipes, any tobacco products besides cigarettes, and any tobacco products including cigarettes.
Results.  Banning flavored cigarettes was associated with reductions in the probability of being a cigarette smoker (17%, p<0.001) and cigarettes smoked by smokers (58%, p=0.005). However, the ban was positively associated with the use by smokers of menthol cigarettes (45%, p<0.001), cigars (34%, p<0.001), and pipes (55%, p<0.001), implying substitution toward the remaining legal flavored tobacco products. Despite increases in some forms of tobacco, overall there was a 6% (p<0.001) reduction in the probability of using any tobacco.
Conclusions.  The results suggest the 2009 flavored cigarette ban did achieve its objective of reducing adolescent tobacco use, but effects were likely diminished by the continued availability of menthol cigarettes and other flavored tobacco products.
 
MB. Harrell, et al.  Flavored e-cigarette use: Characterizing youth, young adult, and adult users.  Prev Med Rep. 2017; 5: 33–40.  Published online 2016 Nov 11. doi:  10.1016/j.pmedr.2016.11.001 PMCID: PMC5121224
The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12–17 years old), young adults (18–29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014–2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and “usual” e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.