Stanford adolescent medicine expert Bonnie Halpern-Felsher, PhD, is worried that flavored vape and e-cigarette products are a gateway to nicotine use for young people.
"So far, all the research on adolescents and young adults is showing that today's youth are not starting with cigarettes," she told me recently. "Young people just have very negative opinions of cigarettes and no intentions of using them. But they have more favorable perceptions of e-cigarettes."
That seems to be especially true of flavored e-cigarettes and vape pods, according to a paper that Halpern-Felsher's team just published in the Journal of Adolescent Health. In a survey of 365 California young adults, a large majority of those who used these products had started their nicotine habits with flavored options that tasted like mint, fruit or candy.
The data was collected before the Food and Drug Administration proposed new rules limiting which flavored vape and e-cigarette products can be sold and where, Halpern-Felsher noted. The FDA has suggested that sales of most flavored nicotine products should be allowed only in adults-only venues, although they suggest that tobacco, mint and menthol flavors could still be sold anywhere traditional cigarettes are available. At present, teens can still easily purchase all flavors of these products, except in a few cities, such as San Francisco, that have enacted flavor bans.
In the study, the researchers asked the young adults -- who were mostly college students, all 18 or older -- if they had ever used pod-based products such as Juul, other e-cigarettes, hookah, or cigars/cigarillos. Those who said yes answered questions about whether they had started their nicotine use with flavored products, which flavors they tried first, and whether they stuck with their original flavor choice over time.
Most respondents said they began with flavored nicotine products, including 72% of pod-based e-cigarette users, 85% of users of other e-cigarettes, 80% percent of hookah users and 33% percent of cigar/cigarillo users. Fruit, mint and menthol were the most common starting flavors, and fruit, mint, menthol and candy flavors were the most popular overall. About half of users stuck to a single flavor over time.
Given the popularity of mint and menthol flavors among young adults, these should not receive special treatment in new regulations, according to the study's authors. "Collectively, the evidence points to needed regulation of all flavored tobacco products, including mint and menthol," they write. "By eliminating the sale of all flavored tobacco, these products will be less appealing to youth and young adults."
It's worth noting that another recent Stanford study raised concerns about the cardiovascular effects of flavored nicotine products. That research showed that e-cigarette flavoring liquids damage human blood vessel cells grown in a lab, even if nicotine was absent.
When we talked, I also asked Halpern-Felsher about her perspective on the trend of rising e-cigarette use in youth.
"I really thought, five years ago, that we'd made such a dent in youth tobacco use that I would be able to move my research to other problems in adolescent health, things like marijuana and opioid use, or reproductive health and sexual behavior," she said. "We are so much going back to square one, with nicotine use rates for these products close to what we saw decades ago for cigarettes, and the industry is taking a page out of Big Tobacco 1.0. It's very, very frustrating."
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