Patterns of flavored e-cigarette use among adults vapers in the United States: an online cross-sectional survey of 69,233 participants

doi:10.21203/rs.3.rs-2658498/v1

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Research Article

Patterns of flavored e-cigarette use among adults vapers in the United States: an online cross-sectional survey of 69,233 participants

https://doi.org/10.21203/rs.3.rs-2658498/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 14 Oct, 2023

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Background.

Flavored e-cigarettes remain a controversial topic with regulators planning or already implementing restrictions worldwide. In this study we examined patterns of flavors use in e-cigarettes among a convenience sample of US adult vapers.

Methods.

Participants aged ≥ 18 years who reported ever using an e-cigarette were included in the study (N = 69233) and responded to an online questionnaire. Their smoking status was recorded as well as patterns of flavors use at e-cigarette use initiation, at the time of the survey and at the time of smoking cessation (for former smokers who were using e-cigarettes at the time of quitting).

Results.

The most popular flavors at e-cigarette use initiation were fruit (82.8%), followed by dessert/pastry/bakery (68.6%) and candy/chocolate/sweet (52.2%). Slightly higher prevalence was observed in never compared to current and former smokers for fruit and dessert/pastry/bakery. Tobacco flavors were used by 20.8% of the participants and was by far least prevalent among never smokers. Similar patterns were observed with participants’choices at the time of the survey, but tobacco flavors use was substantially reduced (7.7%). Only 2.1% reported tobacco as the single most often used flavor. The most prevalent flavor at the time of quitting smoking was again fruit (83.3%), followed by dessert/pastry/bakery (68.0%) and candy/chocolate/sweet (44.5%). These flavors were considered the most helpful for quitting smoking. Tobacco flavor use at the time of smoking cessation was reported by 15.0% while 9.3% considered it helpful for quitting smoking.

Conclusion.

Non-tobacco flavors were popular among the US adult vapers who participated to the study, and were popular choices at the time of quitting smoking for former smokers. Tobacco flavors use prevalence was low and was further reduced over time. Regulators should consider the flavors choice of adult consumers, especially those who quit smoking, when preparing legislation on flavored e-cigarettes.

Electronic cigarettes (e-cigarettes) have been marketed in recent years as alternative to smoking products and have rapidly grown in popularity in several countries including the United States (US) [1–3]. Nationally-representative population surveys suggest that they are the most popular smoking cessation aid in the US [4, 5]. E-cigarettes consist mainly of a battery and an atomizer where liquid is stored and gets evaporated by energy supplied to an electrical resistance. The liquid contains mainly propylene glycol and glycerol, with the option to include nicotine. A major characteristic of the e-cigarette market is the availability of a variety of flavorings in e-liquids. Besides tobacco-like flavors, consumers can choose flavors consisting of fruits, sweets, drinks and beverages and many more. An estimated 7700 unique e-liquid flavors were identified in 2014 [6] and it is very likely that the number has further increased in recent years. Evidence from cross-sectional surveys of dedicated e-cigarette users suggests that smokers tend to initiate e-cigarette use with tobacco-flavored e-cigarettes but transition to exclusive or predominant use of non-tobacco flavored products—particularly fruit, sweet, and dessert flavors—with increased frequency and duration of e-cigarette use [3, 7, 8]. Former-smoking e-cigarette users report that switching between flavors within the same day is common and that regular use of multiple e-liquid flavors was associated with significantly higher odds of having quit smoking, with fruit and sweet flavors being the most popular choices among established long-term vapers [8].

The availability of so many different flavorings has been criticized by authorities stating that there is a potential to attract youngsters. This could potentially habituate youth to the effects of nicotine and, in turn, youth who would not have smoked in the absence of flavored e-cigarettes will “graduate” to use more harmful combustible tobacco products that deliver nicotine more efficiently [9]. Studies have shown that the majority of youth and young adults who have ever tried an e-cigarette started their use with fruit or sweet flavors rather than a tobacco flavor, while rates of use of flavored tobacco products are higher among youth and young adults than among older adults [7, 10, 11]. Regulatory authorities have tried to address these concerns, mainly by discussing about flavors restrictions or bans. In the United States (US), particularly after the acute lung disease outbreak in 2019 (named EVALI), several states introduced flavors bans for e-cigarettes, despite the fact that this outbreak was most likely related to illicit to tetrahydrocannabinol oil use rather than flavored nicotine e-cigarettes [12, 13]. In Europe, there are also discussions about flavors restrictions in the upcoming Tobacco Products Directive.

Understanding the patterns of flavors use among adults is important since any overly-restrictive regulatory decisions (e.g. a ban on popular flavors) could have unintended consequences among established adult vapers who may have reduced or quit smoking with the help of e-cigarettes. Risk reduction in smokers who quit by switching to e-cigarettes is one of the determinants of the public health impact of e-cigarettes [14]. Therefore, any regulatory framework should consider the balance between protecting population subgroups from unintended and undesired use and causing harm to people who use e-cigarettes as smoking substitutes.

The main purpose of this study was to analyze the patterns of flavored e-cigarette use in a large sample of dedicated adult e-cigarette users residing in the US. Additionally, the study focused on comparing flavors use between current-smoking e-cigarette users (dual users) and former-smoking e-cigarette users and on specifically examining patterns of flavors use among former-smoking e-cigarette users at the time they had quit smoking.

Study sample and online platform

The study sample consisted of individuals aged 18 and older living in the US who have ever used an e-cigarette (even a single puff). Participants were invited to complete an online questionnaire that was available through Dacima Survey software (Dacima, Montreal, Quebec, Canada). Of note, this tool is FDA 21 CFR Part 11 compliant (https://www.dacimasoftware.com/healthcare/dacima-survey-a-web-survey-software-that-is-fda-21cfr-part-11-compliant/). Before entering the main survey questionnaire, participants had to read an informed consent form and check that they agreed to participate. The informed consent presented the purpose of the survey, the names and contact details of the study investigators, information about who was eligible to take part and how survey data would be used, assurances of participant anonymity and confidentiality. Subsequently, participants were asked if they were permanent residents of the US, their age and if they had ever used an e-cigarette (even once or twice). Participants satisfying these inclusion criteria (adults, permanent residents of the US and having used an e-cigarette) were directed to the main questionnaire. No financial or other incentive was offered in exchange for participation. The study was approved by the ethics committee of the University of Patras in Greece.

The questionnaire was open for participation from April 3rd to May 2nd, 2018. No personal identifying details were collected, besides the usual demographic information collected in any type of cross-sectional survey (see Results section). The IP address was recorded with the sole purpose of removing double entries.

Questionnaire design

The questionnaire assessed in detail the past and current smoking status of participants. Participants were defined as current smokers if they were smoking in the past 30 days. Former smokers were defined as people who had ever smoked (even 1 or 2 puffs) but had not smoked in the past 30 days. Never smokers were those who responded that they had never smoked a tobacco cigarette.

All participants were by definition ever e-cigarette users. The patterns of use and reasons for e-cigarette use initiation were recorded. Specifically, the age at e-cigarette use initiation, regular e-cigarette and daily e-cigarette use was recorded. Additionally, participants were asked to report whether they used e-cigarettes at the time of the survey every day, some days or not at all. A specific question among former smokers examined whether they were using e-cigarettes at the time of quitting smoking by asking “Thinking back to when you quit smoking cigarettes completely, were you using an e-cigarette/ vaping device…”, with response options being “Every day”, “Some days” and “Not at all”. This question was considered important to more reliably identify former smokers who had quit smoking with the help of e-cigarettes. Questions about e-cigarette flavors use were asked in 3 sections, addressing 3 different periods: A. At the time of e-cigarette use initiation; B. At the time of survey participation; C. At the time of quitting smoking. The latter was recorded only for former smokers who responded that they were using e-cigarettes at the time of quitting. At all time-points, participants were asked to report all types of flavors regularly used but also the single flavor most often used.

Statistical analysis

Descriptive analysis was performed with the data presented as median and interquartile range (IQR) for continuous variables and proportions (%), number (n) and 95% confidence intervals (95%CI) for categorical variables. Comparisons between smoking groups were performed using cross-tabulations and chi-square tests with z-test to compare column proportions with Bonferroni correction. Paired comparisons in flavors use between different time points (e-cigarette use initiation and survey time points) were examined using non-parametric paired samples test (McNemar test). All analyses were performed with commercially available software (SPSS v. 22, Chicago IL, USA) and a p value of < 0.05 was considered statistically significant.

Descriptive analysis for all participants

After removing double entries through the IP address, the study sample consisted of 69233 adult e-cigarette users living in the US. The reported residence state of participants is presented in Supplementary Table 1. Only 0.7% (n = 506) did not report their residence state (missing data). Participant demographics are presented in Table 1.

Table 1

Participant demographics (n = 69,233)
	Mean (SD) / % (n)
Age	34.6 (11.6)
Gender
Male	72.4% (50157)
Female	26.5% (18341)
Marital status
Married	40.6% (28077)
Never married	44.9% (31066)
Divorced	11.2% (7733)
Separated	2.2% (1506)
Widowed	0.9% (611)
Employment status
Not currently working for pay	16.9% (11691)
Full-time working, at least 35h/week	70.8% (48999)
Part-time working, 15-34h/week	9.9% (6823)
Part-time working, < 15h/week	2.1% (1461)
Education
Less than high school	0.9% (622)
Some high school, no diploma	4.0% (2784)
General Education Diploma (GED)	7.6% (5249)
High school graduate—diploma	25.3% (17491)
Some college but no degree	32.9% (22811)
Associate degree—occupational/vocational	9.4% (6521)
Associate degree—academic program	5.5% (3830)
Bachelor’s degree (ex: BA, AB, BS)	10.0% (6937)
Master’s degree (ex: MA, MS, MEng,Med, MSW)	2.1% (1484)
Professional school degree (ex: MD,DDS, DVM, JD)	0.5% (354)
Doctorate degree (ex: PhD, EdD)	0.3% (219)
Currently enrolled in a degree program
Yes	9.6% (6663)
No	85.8% (59398)
Household income per 12 months
Less than $10,000	6.7% (4652)
$10,000 to $14,999	6.2% (4305)
$15,000 to $24,999	10.9% (7547)
$25,000 to $34,999	13.1% (9055)
$35,000 to $49,999	15.7% (10882)
$50,000 to $74,999	18.3% (12694)
$75,000 to $99,999	10.4% (7216)
$100,000 to $149,999	8.6% (5931)
$150,000 to $199,999	2.5% (1735)
$200,000 or more	2.0% (1361)

The smoking history of participants is presented in Fig. 1. Almost 95% of participants reported being ever (current or former) smokers. The majority had quit smoking, while 61% of current smokers were occasional smokers (smoking on some days). Notably, 68.2% of all participants reported having quit smoking > 12 months ago, while 13.1% had quit within the past 12 months before survey participation. The median time since quitting smoking for all former smokers was 36 months (IQR: 23–61 months). Only 5.2% of the study sample reported being never smokers. The vast majority of former smokers (91.8% of all former smokers, 74.6% of the study sample) reported using e-cigarettes at the time of smoking cessation. The median age of first e-cigarette use was 28 (21–37) years while the age of initiating regular e-cigarette use was 29 (22–38) years. Almost all participants (98.9%) were using e-cigarettes in the past 30 days at the time of the survey, with most (93.5% of the whole sample) using them every day.

Table 2 presents the e-cigarette equipment and flavors used by the participants at e-cigarette use initiation. Most participants initiated e-cigarette use with advanced devices (variable voltage/wattage) or eGO-style batteries. A small minority used first generation (cigarette-like, “ciga-like”) devices. The most popular nicotine concentration at initiation was 1–6 mg/mL followed by 18–24 mg/mL. For most participants, it was easy to find the flavors of preference at e-cigarette use initiation, which is expected considering the unrestricted large variability available until now. Participants were asked to report all different flavors that they were using regularly, but they were also subsequently asked to report the single most regularly used flavor. The most popular flavors were fruit and dessert/pastry/bakery, while only approximately 20% reported using tobacco flavors. Similarly, fruit and dessert/pastry/bakery were the most popular single flavors used most often at e-cigarette use initiation.

Table 2

E-cigarette equipment and flavors use at e-cigarette use initiation (n = 69233).
	%	95% CI	N
First device used
Disposable	8.1%	7.8–8.3%	5635
Rechargeable ciga-like with prefilled cartridges	17.5%	17.2–17.8%	12135
eGo-style	32.5%	32.2–32.8%	22477
Pod mod	1.2%	1.1–1.3%	811
Mechanical device	3.7%	3.6–3.8%	2544
Variable voltage/wattage (advanced personal vaporizer)	35.6%	35.2–36.0%	24657
Something else	1.4%	1.3–1.5%	974
Initial nicotine concentration
0 mg/mL	4.1%	4.0-4.2%	2827
1–6 mg/mL	38.1%	37.7–38.5%	26411
7–12 mg/mL	17.5%	17.2–17.8%	12117
13–17 mg/mL	4.5%	4.3–4.7%	3083
18–24 mg/mL	26.1%	25.8–26.4%	18088
25–49 mg/mL	3.3%	3.2–3.4%	2294
50 mg/mL or more	0.6%	0.5–0.7%	402
How difficult was it to find the flavor you likes at e-cigarette use initiation?
Very difficult	3.1%	3.0-3.2%	2133
Difficult	9.9%	9.7–10.1%	6836
Neither easy nor difficult	21.8%	21.5–22.1%	15078
Easy	27.1%	26.8–27.4%	18742
Very easy	38.2%	37.8–38.6%	26444
Initial flavors choices (used regularly)
Tobacco	20.8%	20.5–21.1%	14373
Menthol	21.9%	21.6–22.2%	15133
Mint/wintergreen	13.8%	13.5–14.1%	9581
Fruit	82.8%	82.5–83.1%	57320
Dessert/pastry/bakery	68.6%	68.3–68.9%	47509
Candy/chocolate/sweet	52.2%	51.8–52.6%	36160
Spice	12.5%	12.2–12.7%	8659
Coffee	26.4%	26.1–26.7%	18306
Alcohol/cocktail	7.5%	7.3–7.7%	5211
Non alcoholic/non coffee drink	18.7%	18.4–19.0%	12980
Unflavored	1.0%	0.9–1.1%	715
Other	17.3%	17.0-17.6%	12006
Single flavor used most often at e-cigarette use initiation
Tobacco	7.7%	7.5–7.9%	5301
Menthol	6.3%	6.1–6.5%	4382
Mint/wintergreen	1.9%	1.8-2.0%	1306
Fruit	48.5%	48.1–48.9%	33574
Dessert/pastry/bakery	25.8%	25.5–26.1%	17872
Candy/chocolate/sweet	4.1%	39.5–42.5%	2823
Spice	1.0%	0.9–1.1%	726
Coffee	2.3%	2.2–2.4%	1570
Alcohol/cocktail	0.3%	0.3–0.3%	220
Non alcoholic/non coffee drink	1.1%	1.0-1.2%	779
Unflavored	0.1%	0.1–0.1%	89
Other	0.9%	0.8-1.0%	591

Table 3 presents the e-cigarette equipment and flavors used by the participants at the time of survey participation. E-cigarette use initiation was reported at 4 years (IQR: 2–6 years) before survey participation, while regular use was reported for 3 years (IQR: 2–5 years). The patterns of equipment use were for the most part similar to the data at e-cigarette use initiation. Even more participants were using advanced devices (variable voltage/wattage) at the time of survey participation. Use of disposable or rechargeable first generation devices was rare. By far the most popular nicotine concentration was 1–6 mg/mL (more than twice the use rate at e-cigarette use initiation), which is compatible with the well-documented gradual transition to lower nicotine concentration over time. The most popular flavors were again fruit and dessert/pastry/bakery. Use of tobacco flavors was by far less prevalent compared to e-cigarette use initiation, both as a flavor used regularly and as a single most often used flavor. Only 2.1% of participants reported that the single most often used flavor at the time of survey participation was a tobacco flavor, compared to 7.7% at use initiation. Many participants reported using multiple flavors within the same day.

Table 3

E-cigarette equipment and flavors use at the time of the survey (n = 69233).
	%	95% CI	N
Device used
Disposable	0.2%	0.2–0.2%	155
Rechargeable ciga-like with prefilled cartridges	3.1%	3.0-3.2%	2179
eGo-style	3.5%	3.4–3.6%	2409
Pod mod	3.0%	2.9–3.1%	2059
Mechanical device	10.7%	10.5–10.9%	7388
Variable voltage/wattage (advanced personal vaporizer)	76.7%	76.4–77.0%	53128
Something else	1.5%	1.4–1.6%	1011
Nicotine concentration
0 mg/mL	6.2%	6.0-6.4%	4258
1–6 mg/mL	82.4%	82.1–82.7%	57057
7–12 mg/mL	4.7%	4.5–4.9%	3238
13–17 mg/mL	0.8%	0.7–0.9%	561
18–24 mg/mL	1.7%	1.6–1.8%	1172
25–49 mg/mL	1.3%	1.2–1.4%	928
50 mg/mL or more	1.1%	1.0-1.2%	762
Flavors choices (used regularly)
Tobacco	7.8%	7.6-8.0%	5395
Menthol	13.3%	13.0-13.6%	9217
Mint/wintergreen	9.6%	9.4–9.8%	6616
Fruit	83.0%	82.7–83.3%	57447
Dessert/pastry/bakery	70.5%	70.2–70.8%	48823
Candy/chocolate/sweet	46.3%	45.9–46.7%	32064
Spice	9.2%	9.0-9.4%	6394
Coffee	19.3%	19.0-19.6%	13385
Alcohol/cocktail	6.9%	6.7–7.1%	4746
Non alcoholic/non coffee drink	13.5%	13.2–13.8%	9368
Unflavored	0.9%	0.8-1.0%	630
Other	11.5%	11.2–11.7%	7945
Single flavor used most often
Tobacco	2.1%	2.0-2.2%	1481
Menthol	2.5%	2.4–2.6%	1734
Mint/wintergreen	1.2%	1.1–1.3%	862
Fruit	49.0%	48.6–49.4%	33893
Dessert/pastry/bakery	35.3%	34.9–35.7%	24436
Candy/chocolate/sweet	4.4%	4.2–4.6%	3062
Spice	0.6%	0.5–0.7%	389
Coffee	1.3%	1.2–1.4%	903
Alcohol/cocktail	0.3%	0.3–0.3%	206
Non alcoholic/non coffee drink	0.8%	0.7–0.9%	552
Unflavored	0.2%	0.2–0.2%	131
Other	1.0%	0.9–1.1%	680
Frequency of using different flavors
Use multiple flavors in the same day	42.0%	41.6–42.4%	29112
Change flavors every 2–3 days	21.1%	20.8–21.4%	14574
Change flavors every 4–5 days	6.7%	6.5–6.9%	4642
Change flavors every week	9.4%	9.2–9.6%	6474
Change flavors every 2 weeks	8.2%	8.0-8.4%	5701
Change flavors every month	11.3%	11.1–11.5%	7826

Flavors and device choice according to the smoking status

Figure 2 presents the choice of flavors at e-cigarette use initiation according to the smoking status at the time of survey participation. For all groups, fruit flavors were the most popular, followed by dessert/pastry/bakery and candy/chocolate/sweet flavors. Statistically significant differences were found for all flavors besides mint-wintergreen. Never smokers were more likely to initiate e-cigarette use with fruit and candy/chocolate/sweet compared to current and former smokers, but the differences were small. For fruit flavors, no statistically significant difference was found between never and former smokers. Tobacco flavors were more prevalent among current compared to former and never smokers, and were least prevalent among never smokers (less than half the rate of current and former smokers).

Figure 3 shows the device choice at the time of survey participation according to the smoking status. Small but statistically significant differences were found between groups. Advanced devices were by far the more popular overall, but were statistically less prevalent among never compared to former and current smokers. Disposables or rechargeable ciga-like devices were rarely used at the time of survey participation.

Figure 4 presents the choice of flavors at the time of survey participation according to the smoking status. Again, fruit flavors were the most popular, followed by dessert/pastry/bakery and candy/chocolate/sweet flavors. Tobacco flavors prevalence was substantially lower compared to the period of e-cigarette use initiation for all groups. Dessert/pastry/bakery and candy/chocolate/sweet flavors were more prevalent among former compared to current and never smokers.

Figure 5 presents the choice of the single most often used flavor at the time of survey participation according to the smoking status at the time of survey participation. Fruit flavors were the most popular, followed by dessert/pastry/bakery. Never smokers were more likely to use fruit flavors compared to current and former smokers, but former smokers were more likely to use dessert/pastry/bakery compared to the other groups. Minimal use of tobacco flavors was observed in all groups, with current smokers being more likely to use them compared to former and never smokers.

Former smokers who were using e-cigarettes at the time of quitting

A sub-analysis of the survey focused on former smokers who were using e-cigarettes at the time of smoking cessation. They represented 74.6% of the study sample (n = 51,641, Fig. 1).

Table 4 presents the e-cigarette use patterns, equipment and flavors used by this subgroup of study participants at the time of quitting smoking. From all former smokers, 8.3% reported that they were not using e-cigarettes at the time of quitting; they were excluded from the present analysis. The vast majority of the former smokers analyzed reported that they would definitely or probably still be smoking today if they had never started using e-cigarettes. The majority were using advanced e-cigarette devices. The most popular nicotine concentration at the time of quitting was 1–6 mg/mL, followed by 18–24 mg/mL. The vast majority considered finding the flavor of preference as an extremely or very important factor in their attempt to quit smoking, and identified fruit, dessert/pastry/bakery and candy/chocolate/sweet as the flavors that were particularly helpful for quitting smoking. The most popular flavor choices at the time of quitting smoking were fruit flavors, followed by dessert/pastry/bakery. Only 15% of participants were using tobacco flavors. Fruit and dessert/pastry/bakery and candy/chocolate/sweet flavors were considered particularly helpful to avoid relapse to smoking, with only 7.3% considering that tobacco flavors could have such a role.

Table 4

E-cigarette use patterns, equipment and flavors use by former smokers at the time of quitting smoking (n = 51,641).
	%	95% CI	n
At the time of quitting smoking, were you using e-cigarettes: (1)
Every day	85.1%	84.8–85.4%	47933
Some days	6.6%	6.4–6.8%	3708
Not at all (2)	8.3%	8.1–8.5%	4659
If you had never started using e-cigarettes, would you still be smoking today?
Definitely yes	72.2%	71.8–72.6%	37265
Probably yes	23.9%	23.5–24.3%	12359
Probably no	1.7%	1.6–1.8%	881
Definitely no	2.2%	2.1–2.3%	1136
Device used at time of quitting smoking
Disposable	1.9%	1.8-2.0%	1005
Rechargeable ciga-like with prefilled cartridges	9.8%	9.5–10.1%	5044
eGo-style	26.8%	26.4–27.2%	13827
Pod mod	1.2%	1.1–1.3%	625
Mechanical device	5.2%	5.0-5.4%	2666
Variable voltage/wattage (advanced personal vaporizer)	54.4%	54.0-54.8%	28081
Something else	0.8%	0.7–0.9%	393
Nicotine concentration at time of quitting smoking
0 mg/mL	1.5%	1.4–1.6%	798
1–6 mg/mL	46.9%	46.5–47.3%	24220
7–12 mg/mL	19.3%	19.0-19.6%	9973
13–17 mg/mL	4.2%	4.0-4.4%	2161
18–24 mg/mL	23.1%	22.7–23.5%	11927
25–49 mg/mL	2.7%	2.6–2.8%	1418
50 mg/mL or more	0.7%	0.6–0.8%	365
How important was finding an e-cigarette/e-liquid flavor you liked in your attempt to quit smoking?
Extremely important	69.7%	69.3–70.1%	35979
Very important	17.6%	17.3–17.9%	9070
Important	8.7%	8.5–8.9%	4508
Slightly important	3.1%	3.0-3.2%	1579
Not important	1.0%	0.9–1.1%	505
Flavors choices (used regularly) at time of quitting smoking
Tobacco	15.0%	14.7–15.3%	7763
Menthol	18.2%	17.9–18.5%	9394
Mint/wintergreen	11.5%	11.2–11.8%	5934
Fruit	83.3%	83.0-83.6%	43012
Dessert/pastry/bakery	68.0%	67.6–68.4%	35106
Candy/chocolate/sweet	44.5%	44.1–44.9%	22986
Spice	9.6%	9.3–9.9%	4951
Coffee	19.9%	19.6–20.2%	10298
Alcohol/cocktail	5.9%	5.7–6.1%	3050
Non alcoholic/non coffee drink	13.1%	12.8–13.4%	6766
Unflavored	0.7%	0.6–0.8%	349
Other	9.2%	9.0-9.4%	4761
Single flavor used most often at time of quitting smoking
Tobacco	5.1%	4.9–5.3%	2617
Menthol	4.7%	4.5–4.9%	2430
Mint/wintergreen	1.6%	1.5–1.7%	841
Fruit	49.3%	48.9–49.7%	25483
Dessert/pastry/bakery	30.3%	29.9–30.7%	15657
Candy/chocolate/sweet	4.1%	3.9–4.3%	2105
Spice	1.1%	1.0-1.2%	593
Coffee	1.8%	1.7–1.9%	953
Alcohol/cocktail	0.3%	0.3–0.3%	142
Non alcoholic/non coffee drink	0.9%	0.8-1.0%	476
Unflavored	0.1%	0.1–0.1%	40
Other	0.6%	0.5–0.7%	304
Flavors choices that were particularly helpful for quitting smoking
Tobacco	9.3%	9.0-9.6%	4813
Menthol	11.7%	11.4–12.0%	6020
Mint/wintergreen	7.4%	7.2–7.6%	3820
Fruit	60.8%	60.4–61.2%	31393
Dessert/pastry/bakery	48.9%	48.5–49.3%	25277
Candy/chocolate/sweet	29.7%	29.3–30.1%	15327
Spice	7.1%	6.9–7.3%	3649
Coffee	13.9%	13.6–14.2%	7201
Alcohol/cocktail	4.7%	4.5–4.9%	2438
Non alcoholic/non coffee drink	9.6%	9.3–9.9%	4943
Unflavored	0.5%	0.4–0.6%	264
Other	8.0%	7.8–8.3%	4130
Flavors choices that were particularly helpful to avoid relapse to smoking
Tobacco	7.3%	7.1–7.5%	3792
Menthol	11.5%	11.2–11.8%	5925
Mint/wintergreen	8.8%	8.6-9.0%	4525
Fruit	72.1%	71.7–72.5%	37244
Dessert/pastry/bakery	61.9%	61.5–62.3%	31958
Candy/chocolate/sweet	40.6%	40.2–41.0%	20981
Spice	9.2%	9.0-9.4%	4735
Coffee	19.1%	18.8–19.4%	9857
Alcohol/cocktail	6.6%	6.4–6.8%	3425
Non alcoholic/non coffee drink	12.9%	12.6–13.2%	6641
Unflavored	0.7%	0.6–0.8%	363
Other	9.3%	9.0-9.6%	4816

(1) Data on participants who were using e-cigarettes every day or on some days when quitting smoking are presented in the rest of the table.

(2) These participants were excluded from the rest of the analysis in the present table.

Figure 6 presents the transition in flavors choice from e-cigarette use initiation to the time of survey participation by former smokers who were using e-cigarettes at the time of quitting smoking. A small increase in prevalence of fruit and dessert/pastry/bakery use was observed over time, which were the most popular choices. A substantial decrease in the use of tobacco flavors to almost 1/3rd the use rate at e-cigarette use initiation was also reported.

Figure 7 shows the single most often used flavor at the time of survey participation by former smokers who were using e-cigarettes at the time of quitting smoking. Again, fruit flavors were the most popular, followed by dessert/pastry/bakery. Use of tobacco flavors was rare.

This study represents the largest survey ever performed on e-cigarette use in terms of sample size, with almost 70,000 participants. The main findings were that non-tobacco flavors, especially fruit and dessert/pastry/bakery flavors, were the most prevalent choices of the established, dedicated adult US e-cigarette users who participated in this study. These flavors were particularly popular not only during long-term e-cigarette use but also at the period of e-cigarette use initiation. Additionally, they were popular at the time of smoking cessation among former smokers. Fruit and dessert/pastry/bakery flavors were also considered particularly important in their effort to quit smoking and to prevent relapse to smoking. Tobacco flavors were generally used by a minority of the study participants, and their use prevalence decreased substantially over time.

The patterns of e-cigarette flavors use observed herein are in agreement with a cross-sectional study examining the responses of more than 20,000 participants from the US [15].Additionally, a recent longitudinal study examined changes in flavor use patterns in long-term e-cigarette users over a period of 5 years, and found a transition to sweet flavors with a significant reduction in the use of tobacco, menthol and mint flavors [16]. Importantly, almost all participants in that study were using more than one flavor on a regular basis, while only 11.2% reported that tobacco was their preferred flavor. Multiple flavor use has been observed since the early days of e-cigarettes [8]. This may be related to olfactory fatigue that is observed when the same flavor is used for prolonged time [8, 17] or due to a significant decrease in pleasantness with time even when the odor is initially pleasant [18].

Limited data exist on the issue of flavors choice by former smokers who used e-cigarettes to quit. In this study, we examined the patterns of flavors use at the time of smoking cessation among the former smokers who were using e-cigarettes at that time. Non-tobacco flavors were the predominant choice at the time of smoking cessation, and they were considered particularly helpful both for quitting smoking and to prevent relapse. A longitudinal study examining factors associated with past 30-day abstinence from cigarette smoking among people buying an e-cigarette found that non-tobacco flavors users were 30% more likely to report smoking abstinence compared to those using tobacco flavor [19]. Data from the 2018–2019 Tobacco Use Supplement-Current Population Survey (TUS-CPS) survey showed that smokers who used e-cigarettes with nontobacco flavors were more likely to make a quit attempt and to successfully quit compared to those exclusively using non-flavored or tobacco-flavored e-cigarettes [20]. An analysis of the waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study focusing on young adults reported that e-cigarette users with one and multiple non-tobacco/non-menthol flavors were more likely to have reduced or quit smoking over the past year compared to non-e-cigarette users [21]. Another analysis of waves 1 to 4 of the PATH survey found that vaping nontobacco flavors was no more associated with youth smoking initiation than vaping tobacco-flavors but was associated with increased adult smoking cessation [22]. A study following-up 886 dual users for 2 years (from 2016 to 2018) reported that use of fruit and other sweet flavored e-liquids is positively related to smokers' transition away from cigarettes compared to users of tobacco flavors [23]. Finally, a recent systematic review concluded that the availability of a variety of flavors in e-cigarettes might facilitate complete substitution for cigarettes, because it is an important factor in e-cigarette appeal among smokers [24].

While our data and the above-mentioned studies raise the possibility that non-tobacco flavors may have a role in smoking cessation, the evidence on the association between flavored e-cigarettes and smoking relapse is even scarcer. Herein we found that the vast majority of participants considered fruit and dessert/pastry/bakery and candy/chocolate/sweet flavors as important to avoid relapse. It is unclear whether this represents a way to be distracted from the tobacco flavor in order to reduce smoking craving, or that they just don’t need the tobacco flavors any more but feel the desire to experiment with new flavors [8]. It may also be the result of an aversion to the flavor of tobacco over time or an improvement in taste function after smoking cessation, with the latter being verified in the clinical setting [25–27]. Interestingly, while flavors such as candy or fruits were associated with greater rates of enjoyment compared to tobacco flavors and more satisfaction compared to smoking, those using tobacco flavors were more likely than those using candy or unflavored products to vape in order to avoid relapse to smoking [28]. However, this study was performed in recent quitters (who had quit smoking in the last 2 years), and it is unclear whether the findings could be applicable to longer-term former smokers as those in our study sample. Understanding the effect of flavors on smoking relapse is expected to be complex due to the observed transition in flavors use over time, poly-flavor use and perhaps interindividual characteristics in personal preference that may affect flavors choices.

Regulatory concerns over e-cigarette flavors emerge from evidence that youth may be more likely to use non-tobacco flavors [29, 30], although it is unclear if this is linked to subsequent smoking uptake [22, 30]. However, any regulation on e-cigarette flavors should consider the balance between protecting from unintended use by some population subgroups (e.g. by adolescents or never smokers) and avoiding adverse effects and potential harm to other subgroups (e.g. by preventing smokers from switching to e-cigarettes in a harm reduction approach to quitting smoking). Our data raise the possibility that an overly-restrictive regulation, such as banning the sales of specific flavor groups (especially fruit and dessert/pastry/bakery flavors), might have unintended consequences, preventing smokers from switching to e-cigarette use and/or increasing the relapse rate among former smokers who have managed to quit with the help of e-cigarettes. Due to the harm reduction potential and possible health benefits of switching from smoking to e-cigarette use, any regulatory decisions will be much more complex compared to similar past decisions on the ban of flavors in tobacco cigarettes. Therefore, more evidence is needed in order to clarify the role of flavors in smoking cessation and relapse prevention, and regulators should be careful in striking the right balance in order to avoid unintended adverse public health effects.

A major limitation of the study is the cross-sectional design and the recruitment of a convenience sample of dedicated e-cigarette users. The sample was not representative of the general US adult population and the study was not designed or intended to estimate the population prevalence or frequency of e-cigarette flavors use. The flavor preferences and patterns of e-cigarette use reported by the present sample of dedicated e-cigarette users may more closely represent those who exclusively use e-cigarettes on a daily basis rather than the majority who experiment or use e-cigarettes occasionally. Still, this survey presents the patterns of use of a very large sample of adult US e-cigarette users, most of which self-reported that they were successful in quitting smoking with the help of e-cigarettes. While flavors seem to play an important role in their smoking cessation attempt, it should be mentioned that other characteristics, such as the more prevalent use of advanced e-cigarette devices compared to ciga-likes or pod systems, may also contribute to a successful quit attempt. Major developments in e-cigarette products, such as the marketing of nicotine salts and higher nicotine concentrations were not covered by this study. Additionally, participants were asked about past flavors choices, which may introduce some recall bias. Finally, the findings in this study are not necessarily applicable to European e-cigarette users or users in other regions, and more studies are needed to examine the patterns of flavors use in different populations.

In conclusion, this cross-sectional study of a very large sample of adult US e-cigarette users, most of whom were former smokers, identified the importance of non-tobacco flavors in e-cigarette use initiation and sustained use, and their potential 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.

Contributions. KF and CR conceptualized the study; KF, CR, GL and AB prepared the study protocol and questionnaire design; KF, and KP led the data analysis; KF, CR, RP, and GL contributed to the interpretation of the analysis. KF and CR were involved in drafting the initial paper for submission; RP, KP, AB made critical contributions and revisions to the paper; all authors agreed to the final version submitted for publication and agreed to be accountable for all aspects of the work. All authors read and approved the final manuscript.
Funding: No funding was provided for this study.

Conflict of interest statement. KF, GL, and AB have nothing to report for the past 5 years. CR reports that, in the past three years, his employer, Russell Burnett Research & Consultancy Ltd, has received funding from e‑cigarette/tobacco product manufacturers to conduct behavioral research on population use, use intentions, and perceptions of e‑cigarettes/vaping products, and on the effects of e‑cigarette use/vaping on population use of other tobacco products. KP has received service grants and research funding from a number of Vaping Companies. He is the Head of the Institute of Research and Innovations, which has received a grant from the Foundation for a Smoke Free World. RP is full tenured professor of Internal Medicine at the University of Catania (Italy) and Medical Director of the Institute for Internal Medicine and Clinical Immunology at the same University. He has received grants from U-BIOPRED and AIR-PROM, Integral Rheumatology & Immunology Specialists Network (IRIS), Foundation for a Smoke Free World, Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A/S, Sandoz, Merk Sharp & Dohme, Boehringer Ingelheim, Novartis, Arbi Group Srl., Duska Therapeutics, Forest Laboratories and Ministero dell Universita’ e della Ricerca (MUR) Bando PNRR 3277/2021 (CUP E63C22000900006) and 341/2022 (CUP E63C22002080006), funded by NextGenerationEU, the European Union (EU) economic recovery package. He is founder of the Center for Tobacco Prevention and Treatment (CPCT) at the University of Catania and of the Center of Excellence for the Acceleration of Harm Reduction at the same university. He receives consultancy fees from Pfizer, Boehringer Ingel- heim, Duska Therapeutics, Forest Laboratories, CV Therapeutics, and Sermo Inc. He is being paid textbook royalties from Elsevier. He is also involved in a patent application for ECLAT Srl. He is a pro bono scientific advisor for Lega Italiana Anti Fumo (LIAF) and the International Network of Nicotine Consumers Organizations (INNCO); and he is Chair of the European Technical Committee for Standardization on “Requirements and test methods for emissions of electronic cigarettes” (CEN/TC 437; WG4).

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Competing interest reported. KF, GL, and AB have nothing to report for the past 5 years. CR reports that, in the past three years, his employer, Russell Burnett Research & Consultancy Ltd, has received funding from e‑cigarette/tobacco product manufacturers to conduct behavioral research on population use, use intentions, and perceptions of e‑cigarettes/vaping products, and on the effects of e‑cigarette use/vaping on population use of other tobacco products. KP has received service grants and research funding from a number of Vaping Companies. He is the Head of the Institute of Research and Innovations, which has received a grant from the Foundation for a Smoke Free World. RP is full tenured professor of Internal Medicine at the University of Catania (Italy) and Medical Director of the Institute for Internal Medicine and Clinical Immunology at the same University. He has received grants from U-BIOPRED and AIR-PROM, Integral Rheumatology & Immunology Specialists Network (IRIS), Foundation for a Smoke Free World, Pfizer, GlaxoSmithKline, CV Therapeutics, NeuroSearch A/S, Sandoz, Merk Sharp & Dohme, Boehringer Ingelheim, Novartis, Arbi Group Srl., Duska Therapeutics, Forest Laboratories and Ministero dell Universita’ e della Ricerca (MUR) Bando PNRR 3277/2021 (CUP E63C22000900006) and 341/2022 (CUP E63C22002080006), funded by NextGenerationEU, the European Union (EU) economic recovery package. He is founder of the Center for Tobacco Prevention and Treatment (CPCT) at the University of Catania and of the Center of Excellence for the Acceleration of Harm Reduction at the same university. He receives consultancy fees from Pfizer, Boehringer Ingelheim, Duska Therapeutics, Forest Laboratories, CV Therapeutics, and Sermo Inc. He is being paid textbook royalties from Elsevier. He is also involved in a patent application for ECLAT Srl. He is a pro bono scientific advisor for Lega Italiana Anti Fumo (LIAF) and the International Network of Nicotine Consumers Organizations (INNCO); and he is Chair of the European Technical Committee for Standardization on “Requirements and test methods for emissions of electronic cigarettes” (CEN/TC 437; WG4).

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Patterns of flavored e-cigarette use among adults vapers in the United States: an online cross-sectional survey of 69,233 participants

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Flavors and device choice according to the smoking status

Former smokers who were using e-cigarettes at the time of quitting

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