- Email: [email protected]
WITHDRAWN: Flavored Tobacco Use is Associated with Dual and Poly Tobacco Use among Adolescents
Addictive Behaviors 92 (2019) 84–88
Contents lists available at ScienceDirect
Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
Short Communication
Flavored tobacco use is associated with dual and poly tobacco use among adolescents
T
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Dale S. Manteya, , Onyinye Omega-Njemnobia, LaTrice Montgomeryb a b
University of Texas School of Public Health, 1616 Guadalupe, Suite 6.300, Austin, TX 78701, USA University of Cincinnati College of Medicine, Addiction Sciences Division, Department of Psychiatry & Behavioral Neuroscience, USA
H I GH L IG H T S
majority of adolescent tobacco users reported using flavors (73.2%) • The of all adolescent tobacco users used 2 or more tobacco products • Half • Flavored tobacco users had greater odds of using multiple tobacco products
A B S T R A C T
Objectives: This study examines the relationships between flavored tobacco use and single, dual, and poly tobacco product use, among adolescents. Given the increased use of flavored tobacco products, it is vital to understand if flavored products are associated with dual and poly tobacco product use. Methods: Data were obtained from the 2017 National Youth Tobacco Survey. Participants were 2329 adolescent past 30-day tobacco users. Multivariable multinomial logistic regression models were used to assess the relationship between flavored tobacco use and past 30-day single, dual, and poly (three or more) tobacco product use. Two analyses were conducted using different categories as referent groups to allow for a comprehensive examination of the relationship between all groups. Covariates included sex, grade level, and race/ethnicity. Results: Approximately half of all adolescent tobacco users (48.6%) reported use of more than one product. The majority of adolescent tobacco users reported using flavors (73.2%). Flavored tobacco use was significantly correlated with a greater risk of dual (RRR: 2.26) and poly (RRR: 5.76) tobacco use, relative to single product use, controlling for covariates. Similarly, flavored tobacco use was significantly correlated with a greater risk of poly (RRR: 2.54) tobacco use, relative to dual tobacco use, controlling for covariates. Conclusions: A positive relationship was observed for flavored tobacco use and multiple tobacco product use. Findings suggest the need to consider stronger regulations of flavored tobacco products. Similarly, as most adolescent tobacco users reported using flavors, findings suggest the need to emphasize flavored tobacco use in prevention and education programs.
1. Introduction In 2017, approximately 2.4% of middle school and 9.2% of high school students reported use of two or more tobacco products in the past 30-days (Wang et al., 2018). Electronic cigarettes (e-cigarettes) and combustible cigarettes are the most commonly used tobacco products among youth (Wang et al., 2018). National data from 2014 revealed 63.7% of e-cigarette users and 80.4% of conventional cigarette smokers used at least one other tobacco product (Mantey et al., 2018). Multiple tobacco use among youth is concerning as this behavior is associated with an increased risk for nicotine dependence and longterm tobacco use into adulthood (U.S. Department of Health and Human Services, 2000). Given the prevalence and long-term
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epidemiological concerns of multiple tobacco use among youth, understanding correlates of multiple tobacco use is of public health significance. Several risk factors for multiple tobacco use have been identified. For example, alcohol and marijuana use are associated with greater risks of multiple tobacco use among youth (Creamer et al., 2016). Similarly, research suggest tobacco marketing exposure may be associated with greater risks of using two or more tobacco products (Mantey et al., 2018). Recent research suggests there may be differences between users of two tobacco products (i.e., dual users) and three or more tobacco products (i.e., poly users) (Cooper et al., 2016; Soneji et al., 2016; Little et al., 2016; Ali et al., 2016). Specifically, socio-demographic factors (e.g., sex, race/ethnicity), psychosocial variables (e.g.,
Corresponding author. E-mail address: [email protected] (D.S. Mantey).
https://doi.org/10.1016/j.addbeh.2018.12.028 Received 30 October 2018; Received in revised form 18 December 2018; Accepted 21 December 2018 Available online 27 December 2018 0306-4603/ © 2018 Elsevier Ltd. All rights reserved.
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students in the United States. A stratified, three-stage cluster sample design was used to obtain the representative sample of this dataset from 185 schools (National Youth Tobacco Survey (NYTS), 2017). The 2017 NYTS surveyed 17,872 participants. This study examined participants that self-reported use of any tobacco product(s) in the past 30-days (n = 2578). This study excluded incomplete cases (n = 179; 6.9%). A total of 2399 adolescents were eligible for participation. However, a small number of eligible participants (n = 70; 2.9%) were excluded due to inconsistent responses. These criteria resulted in a final sample size of 2329.
harm perceptions, sensation seeking), and tobacco use profile (e.g., nicotine dependence, age of initiation) may all influence the number of tobacco products used by adolescents (Cooper et al., 2016; Soneji et al., 2016; Little et al., 2016; Ali et al., 2016). As such, research should examine risk factors for multiple tobacco use in general, as well as across dual and poly tobacco users. Flavored tobacco use is a potential risk factor for multiple tobacco use. Research has consistently shown flavors increase the appeal of tobacco products among young people (Corey et al., 2015; Villanti et al., 2017; Minaker & Ahmed, 2014; Courtemanche et al., 2016; King et al., 2014; Ambrose et al., 2015; Osman et al., 2018). For instance, among tobacco users ages 12–29 years old, 80% used flavored products (Harrell et al., 2017a) and 75% of these flavored tobacco users would not use tobacco if flavors were not available (Harrell et al., 2017a). While one study has examined correlates of single, dual, and poly flavored tobacco use among adolescents (Dai, 2018), to our knowledge, no studies have directly examined the relationship between flavors and multiple tobacco use. Along with increasing the appeal of tobacco use, flavors improve the experience of tobacco use, particularly among novice users (Nonnemaker et al., 2013). Specifically, flavored tobacco products such as e-cigarettes (Mantey et al., 2017), hookah (Mantey et al., 2017), and menthol cigarettes (Nonnemaker et al., 2013) increase positive (e.g., euphoria, relaxation) and decrease negative (e.g., nausea, coughing) subjective experiences among novice users. Positive subjective experiences are associated with initiation and sustained cigarette smoking (Nonnemaker et al., 2013; Mantey et al., 2017; Ursprung et al., 2011; Klein et al., 2013; Zabor et al., 2013) and negative subjective experiences may be associated with reduced odds of sustained cigarette smoking (Nonnemaker et al., 2013; Mantey et al., 2017; Ursprung et al., 2011; Klein et al., 2013; Zabor et al., 2013); this relationship has not been extensively examined across non-cigarette tobacco products (e.g., e-cigarettes, hookah, cigars). The combination of increased appeal and improved experiences highlight the possibility of flavors contributing to multiple tobacco use. With the exception of conventional cigarettes, which are restricted to menthol, there are currently no regulations on flavored tobacco (Food and Drug Administration & HHS, 2016). There are an estimated 7500 e-cigarette flavors (Zhu et al., 2014) with fruit, candy, and dessert being the most popular among youth (Harrell et al., 2017a; Harrell et al., 2017b). Similarly, sale of flavored cigar products increased 50% from 2008 to 2015 and account for > 52.1% of all cigar sales in the United States (Delnevo et al., 2017; Kuiper et al., 2018). Furthermore, the number of cigar flavors available more than doubled from 2008 (108) to 2015 (250) (Delnevo et al., 2017; Kuiper et al., 2018).Similar trends in availability and sales of flavored products have been observed for smokeless tobacco (Delnevo et al., 2012; Kuiper et al., 2017). This study aims to examine the association between flavored tobacco use and multiple tobacco product use among a nationally representative sample of adolescent tobacco users. This study has three hypotheses. First, we hypothesize flavored tobacco use will be associated with greater risks of dual product use, relative to single tobacco product use. Second, we hypothesize flavored tobacco use will be associated with greater risks of poly tobacco use, relative to single tobacco product use. Third, we hypothesize flavored tobacco use will be associated with greater risks of poly tobacco use, relative to dual tobacco product use. Understanding the relationship between flavors and multiple tobacco use among youth will help inform public health research and policy.
2.2. Procedure NYTS sample procedures are probabilistic and conducted without replacement at all stages. The first stage was to select primary sampling units within each stratum, then schools within each primary sampling unit, followed by classes within each school. Participation was voluntary and confidential for students and schools. Details of the sample procedures for the 2017 NYTS are available elsewhere (National Youth Tobacco Survey (NYTS), 2017). 2.3 Measures. 2.3.1 Single, Dual, and Poly Tobacco Use: Tobacco use was assessed for 9 products: cigarettes, electronic cigarettes (e-cigarettes), hookah, cigar products (i.e., cigars; cigarillos; little cigars), smokeless tobacco, snus, pipe tobacco, bidis, and dissolvable tobacco. Use for each tobacco product was assessed individual through the following question: “During the past 30-days, on how many days did you use [product]?” Participants that reported use of a no tobacco products in the past 30days were excluded from the analysis. Participants that reported use of one tobacco product were considered “single product users” (coded as 0). Participants that reported use two tobacco products were considered “dual tobacco users” (coded as 1). Participants that reported use of three or more tobacco products were considered “poly tobacco users” (coded as 2). 2.3.2 Flavored Tobacco Use: Flavored tobacco use was assessed through several questions. First, cigarette smoker were asked “Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?” Next, participants were asked: “Which of the following tobacco products that you used in the past 30 days were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate or any other flavors? (Select one or more)” Possible products included e-cigarettes, hookah, cigars/cigarillos/little cigars, smokeless tobacco, snus, pipe tobacco, bidis, and dissolvable tobacco. Participants that reported any use of flavored tobacco were considered “flavor users” (coded as 1). Participants that reported no use of flavors for tobacco products were considered “non-flavor users” (coded as 0). 2.3.3 Covariates: This analysis included several variables as covariates. Grade was categorized as middle (coded as 0) and high school (coded as 1). Race/ethnicity was categorized as: white, non-Hispanic (coded as 0); black, non-Hispanic (coded as 1); Hispanic/Latino (coded as 2); and “other” (coded as 3). For this analysis, “other” consisted of non-Hispanic/Asian, multiracial, and any other race. Sex is a biologically dichotomous variable. Males were the referent group (coded as 0) and females were the comparison group (coded as 1). 2.4 Statistical Analyses. Data were weighted to be representative of US middle and high school students and to adjust for nonresponse and probability of selection. Prior to testing study hypotheses, chi-squared analyses were used to compare flavor tobacco use and tobacco use category by sociodemographic variables. Next, two multivariate multinomial logistic regression models were used to examine the association of flavored tobacco use and number of tobacco products used, controlling for grade level, race/ethnicity, and sex. For these multivariate multinomial logistic regression models, number of tobacco products was categorized as single tobacco product use, dual tobacco product use, and poly (i.e.,
2. MATRIALS and methods 2.1. Study sample This study analyzed data from the 2017 National Youth Tobacco Survey (NYTS), a representative sample of middle and high school 85
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3 or more) tobacco product use. The first model was used to test hypotheses one and two. In this model, single tobacco product use served as the referent outcome. The second model was used to test hypothesis three. In this model, dual tobacco product use served as the referent outcome. All analyses were conducted using STATA 14.2 (College Station, TX).
Table 2 Multinomial logistic regression models of flavored tobacco use and number of tobacco products used in the past 30-days (NYTS, 2017; n = 2329).
3. Results 3.1. Descriptive statistics
Single users as referent Flavored tobacco usec Dual users as referent Flavored tobacco usec
Overall, 51.5% used one product, 20.7% used two products, and 27.9% used three or more products. Among all tobacco users, 72.4% reported using flavors. However, flavored tobacco use was substantially greater among dual (78.2%) and poly (90.1%) tobacco users, relative to single product users (60.4%). Flavored tobacco use prevalence differed significantly by race (p ≤.001), with non-Hispanic whites having the greatest prevalence (76.8%) followed by Hispanic/Latinos (70.8%). Flavored tobacco use did not differ by sex (p = .363) or grade level (p = .061). Single, dual, and poly tobacco use prevalence differed significantly by race (p = .018). Single product use prevalence was greatest among non-Hispanic blacks (64.1%). Dual product use was greatest among non-Hispanic whites (22.0%). Poly tobacco use was greatest among Hispanic/Latinos (30.9%). Single, dual, and poly tobacco use prevalence did not differ statistically by sex (p = .060) or grade level (p = .492). Descriptive statistics are available in Table 1.
Single usersa (n = 1206)b
Dual usersa (n = 484)b
Poly usersa (n = 639)b
Relative risk ratio 95% confidence Interval
Relative risk ratio 95% confidence Interval
Relative risk ratio 95% confidence Interval
1.00 (Ref)
2.28⁎⁎⁎ (1.59–3.26)
5.76⁎⁎⁎ (4.10–8.10)
–
1.00 (Ref)
2.53⁎⁎⁎ (1.62–3.95)
All models adjusted for grade level, sex, and race/ethnicity; Bold indicates statistical significance. a Corresponds to the number of tobacco products used in past 30-days. b Unweighted sample size. c Reported use of menthol or other flavors for one or more tobacco products. ⁎⁎⁎ p < .001.
tobacco product use, controlling for covariates. Furthermore, flavored tobacco use was associated with an increased relative risk of poly tobacco product use of 2.53 (1.62–3.95), relative to dual tobacco product use, controlling for covariates.
3.2. Study hypotheses 4. Discussion As seen in Table 2, flavored tobacco use was associated with an increased relative risk of dual tobacco product use of 2.28 (1.59–3.26), relative to single tobacco product use, controlling for covariates. Similarly, flavored tobacco use was associated with an increased relative risk of poly tobacco product use of 5.76 (4.10–8.10), relative to single
This study found flavored tobacco use was associated with increased risk of multiple tobacco use. Specifically, flavored tobacco users were more likely to be dual and poly tobacco users, relative to single tobacco product users. Similarly, flavored tobacco users were more likely to be
Table 1 Descriptive statistics by tobacco use category (NYTS 2017, n = 2329). Flavored tobacco usea (n = 2329)
Percent of sample Sex Male (n = 1298)c Female (n = 1031)c Grade Middle School (n = 476)c High School (n = 1853)c Race/ethnicity Non-Hispanic White (n = 1137)c African American (n = 319)c Hispanic/Latino (n = 635)c Other (n = 238)c,d Flavored tobacco use No (n = 706)c Yes (n = 1, 623)c
Tobacco use categories (n = 2329)
No (n = 706)c
Yes (n = 1623)c
Single usersb (n = 1206)c
Dual usersb (n = 484)c
Poly usersb (n = 639)c
27.6%
72.4%
51.5%
20.7%
27.9%
26.7% 28.8%
73.3% 71.2%
50.6% 52.7%
19.3% 22.5%
30.1% 24.9%
χ2 (1,N = 2329) = 9.4; p = .363
χ2 (2,N = 2329) = 66.2; p = .060
32.3% 26.6%
55.3% 50.6%
67.7% 73.4%
18.7% 21.1%
χ2 (1,N = 2329) = 44.0 p = .061
χ2 (2,N = 2329) = 23.8; p = .492
23.2% 46.6% 29.2% 33.3%
49.1% 64.1% 49.5% 59.3%
76.8% 53.4% 70.8% 66.7%
22.0% 18.2% 19.7% 17.0%
χ2 (3,N = 2329) = 425.7; p < .001
χ2 (6,N = 2329) = 195.9; p = .018
– – –
39.6% 21.8% 60.4% 78.2% χ2 (2,N = 2329) = 1496.3; p ≤.001
a
26.0% 28.3%
28.9% 17.8% 30.9% 23.8%
9.9% 90.1%
Corresponds to the number of tobacco products used in past 30-days. Unweighted sample size. c These rows reflect proportion of entire sub-sample (i.e., tobacco use category). d “Other” is where a response was “Asian, non-Hispanic”, “American Indian/Alaska Native, non-Hispanic;” or “native Hawaiian and other Pacific Islanders, nonHispanic”. b
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examination of the role of flavors on multiple tobacco use.
poly tobacco users, relative to dual poly users. To our knowledge, this is the first study to examine this association among a nationally representative sample of adolescent tobacco users. This study furthers the understanding of the role flavored tobacco play in adolescent tobacco use behaviors. This study has several implications. From a regulatory perspective, this study adds to existing research that suggest the need to consider restricting or eliminating flavored tobacco products as a method of reducing adolescent tobacco use. Specifically, flavors have been shown to increase the appeal of tobacco use among youth (Corey et al., 2015; Villanti et al., 2017; Minaker & Ahmed, 2014; Courtemanche et al., 2016; King et al., 2014; Ambrose et al., 2015; Osman et al., 2018; Harrell et al., 2017a; Harrell et al., 2017b),improve the experience of tobacco use among novice users (Nonnemaker et al., 2013; Mantey et al., 2017), and result in greater nicotine dependence and sustained use into adulthood (U.S. Department of Health and Human Services, 2000). Similarly, younger tobacco users have repeatedly cited the importance of flavors for initiation and continued use of tobacco products (Corey et al., 2015; Villanti et al., 2017; Minaker & Ahmed, 2014; Courtemanche et al., 2016; King et al., 2014; Ambrose et al., 2015; Osman et al., 2018; Harrell et al., 2017a; Harrell et al., 2017b). The Food and Drug Administration holds regulatory authority over tobacco flavors (Food and Drug Administration & HHS, 2016). However, flavors among non-cigarette tobacco products remain entirely unregulated (Food and Drug Administration & HHS, 2016). Given the association between flavored tobacco and multiple tobacco use observed in this study, as well as the known association between flavored tobacco use and nicotine dependence (U.S. Department of Health and Human Services, 2000; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012), long-term tobacco use (U.S. Department of Health and Human Services, 2000; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012), evidence is mounting to suggest regulating tobacco flavorings may result in a meaningful reduction of adolescent tobacco use. This study also has public health implications. Specifically, findings suggest there is an association between tobacco flavors and multiple tobacco use. Given the public health consequences of multiple tobacco use, such as nicotine dependence (Creamer et al., 2016; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012) and long-term tobacco use (Creamer et al., 2016; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012), these findings suggests a new public health risk associated with flavored tobacco use. However, longitudinal research is needed to further examine the relationship between flavors and multiple tobacco use. This study has several limitations. First, the presented data are cross-sectional and thus causal inferences cannot be drawn. Second, all data are self-report and thus subject to recall bias. Third, flavored tobacco use is likely more nuanced than the measures this study allowed. For example, adolescent cigarette smokers may smoke both menthol and non-menthol cigarettes. Further, multiple tobacco users may concurrently use both flavored and non-flavored tobacco products. Future research is needed to examine the diverse use, and robust available, of flavored tobacco.
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5. Conclusion Despite these limitations, this study expands the literature base by examining the relationship between two growing issues in adolescent tobacco use: flavors and multiple product use. This cross-sectional study provides the statistical evidence to support the need for longitudinal 87
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Contents lists available at ScienceDirect
Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
Short Communication
Flavored tobacco use is associated with dual and poly tobacco use among adolescents
T
⁎
Dale S. Manteya, , Onyinye Omega-Njemnobia, LaTrice Montgomeryb a b
University of Texas School of Public Health, 1616 Guadalupe, Suite 6.300, Austin, TX 78701, USA University of Cincinnati College of Medicine, Addiction Sciences Division, Department of Psychiatry & Behavioral Neuroscience, USA
H I GH L IG H T S
majority of adolescent tobacco users reported using flavors (73.2%) • The of all adolescent tobacco users used 2 or more tobacco products • Half • Flavored tobacco users had greater odds of using multiple tobacco products
A B S T R A C T
Objectives: This study examines the relationships between flavored tobacco use and single, dual, and poly tobacco product use, among adolescents. Given the increased use of flavored tobacco products, it is vital to understand if flavored products are associated with dual and poly tobacco product use. Methods: Data were obtained from the 2017 National Youth Tobacco Survey. Participants were 2329 adolescent past 30-day tobacco users. Multivariable multinomial logistic regression models were used to assess the relationship between flavored tobacco use and past 30-day single, dual, and poly (three or more) tobacco product use. Two analyses were conducted using different categories as referent groups to allow for a comprehensive examination of the relationship between all groups. Covariates included sex, grade level, and race/ethnicity. Results: Approximately half of all adolescent tobacco users (48.6%) reported use of more than one product. The majority of adolescent tobacco users reported using flavors (73.2%). Flavored tobacco use was significantly correlated with a greater risk of dual (RRR: 2.26) and poly (RRR: 5.76) tobacco use, relative to single product use, controlling for covariates. Similarly, flavored tobacco use was significantly correlated with a greater risk of poly (RRR: 2.54) tobacco use, relative to dual tobacco use, controlling for covariates. Conclusions: A positive relationship was observed for flavored tobacco use and multiple tobacco product use. Findings suggest the need to consider stronger regulations of flavored tobacco products. Similarly, as most adolescent tobacco users reported using flavors, findings suggest the need to emphasize flavored tobacco use in prevention and education programs.
1. Introduction In 2017, approximately 2.4% of middle school and 9.2% of high school students reported use of two or more tobacco products in the past 30-days (Wang et al., 2018). Electronic cigarettes (e-cigarettes) and combustible cigarettes are the most commonly used tobacco products among youth (Wang et al., 2018). National data from 2014 revealed 63.7% of e-cigarette users and 80.4% of conventional cigarette smokers used at least one other tobacco product (Mantey et al., 2018). Multiple tobacco use among youth is concerning as this behavior is associated with an increased risk for nicotine dependence and longterm tobacco use into adulthood (U.S. Department of Health and Human Services, 2000). Given the prevalence and long-term
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epidemiological concerns of multiple tobacco use among youth, understanding correlates of multiple tobacco use is of public health significance. Several risk factors for multiple tobacco use have been identified. For example, alcohol and marijuana use are associated with greater risks of multiple tobacco use among youth (Creamer et al., 2016). Similarly, research suggest tobacco marketing exposure may be associated with greater risks of using two or more tobacco products (Mantey et al., 2018). Recent research suggests there may be differences between users of two tobacco products (i.e., dual users) and three or more tobacco products (i.e., poly users) (Cooper et al., 2016; Soneji et al., 2016; Little et al., 2016; Ali et al., 2016). Specifically, socio-demographic factors (e.g., sex, race/ethnicity), psychosocial variables (e.g.,
Corresponding author. E-mail address: [email protected] (D.S. Mantey).
https://doi.org/10.1016/j.addbeh.2018.12.028 Received 30 October 2018; Received in revised form 18 December 2018; Accepted 21 December 2018 Available online 27 December 2018 0306-4603/ © 2018 Elsevier Ltd. All rights reserved.
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students in the United States. A stratified, three-stage cluster sample design was used to obtain the representative sample of this dataset from 185 schools (National Youth Tobacco Survey (NYTS), 2017). The 2017 NYTS surveyed 17,872 participants. This study examined participants that self-reported use of any tobacco product(s) in the past 30-days (n = 2578). This study excluded incomplete cases (n = 179; 6.9%). A total of 2399 adolescents were eligible for participation. However, a small number of eligible participants (n = 70; 2.9%) were excluded due to inconsistent responses. These criteria resulted in a final sample size of 2329.
harm perceptions, sensation seeking), and tobacco use profile (e.g., nicotine dependence, age of initiation) may all influence the number of tobacco products used by adolescents (Cooper et al., 2016; Soneji et al., 2016; Little et al., 2016; Ali et al., 2016). As such, research should examine risk factors for multiple tobacco use in general, as well as across dual and poly tobacco users. Flavored tobacco use is a potential risk factor for multiple tobacco use. Research has consistently shown flavors increase the appeal of tobacco products among young people (Corey et al., 2015; Villanti et al., 2017; Minaker & Ahmed, 2014; Courtemanche et al., 2016; King et al., 2014; Ambrose et al., 2015; Osman et al., 2018). For instance, among tobacco users ages 12–29 years old, 80% used flavored products (Harrell et al., 2017a) and 75% of these flavored tobacco users would not use tobacco if flavors were not available (Harrell et al., 2017a). While one study has examined correlates of single, dual, and poly flavored tobacco use among adolescents (Dai, 2018), to our knowledge, no studies have directly examined the relationship between flavors and multiple tobacco use. Along with increasing the appeal of tobacco use, flavors improve the experience of tobacco use, particularly among novice users (Nonnemaker et al., 2013). Specifically, flavored tobacco products such as e-cigarettes (Mantey et al., 2017), hookah (Mantey et al., 2017), and menthol cigarettes (Nonnemaker et al., 2013) increase positive (e.g., euphoria, relaxation) and decrease negative (e.g., nausea, coughing) subjective experiences among novice users. Positive subjective experiences are associated with initiation and sustained cigarette smoking (Nonnemaker et al., 2013; Mantey et al., 2017; Ursprung et al., 2011; Klein et al., 2013; Zabor et al., 2013) and negative subjective experiences may be associated with reduced odds of sustained cigarette smoking (Nonnemaker et al., 2013; Mantey et al., 2017; Ursprung et al., 2011; Klein et al., 2013; Zabor et al., 2013); this relationship has not been extensively examined across non-cigarette tobacco products (e.g., e-cigarettes, hookah, cigars). The combination of increased appeal and improved experiences highlight the possibility of flavors contributing to multiple tobacco use. With the exception of conventional cigarettes, which are restricted to menthol, there are currently no regulations on flavored tobacco (Food and Drug Administration & HHS, 2016). There are an estimated 7500 e-cigarette flavors (Zhu et al., 2014) with fruit, candy, and dessert being the most popular among youth (Harrell et al., 2017a; Harrell et al., 2017b). Similarly, sale of flavored cigar products increased 50% from 2008 to 2015 and account for > 52.1% of all cigar sales in the United States (Delnevo et al., 2017; Kuiper et al., 2018). Furthermore, the number of cigar flavors available more than doubled from 2008 (108) to 2015 (250) (Delnevo et al., 2017; Kuiper et al., 2018).Similar trends in availability and sales of flavored products have been observed for smokeless tobacco (Delnevo et al., 2012; Kuiper et al., 2017). This study aims to examine the association between flavored tobacco use and multiple tobacco product use among a nationally representative sample of adolescent tobacco users. This study has three hypotheses. First, we hypothesize flavored tobacco use will be associated with greater risks of dual product use, relative to single tobacco product use. Second, we hypothesize flavored tobacco use will be associated with greater risks of poly tobacco use, relative to single tobacco product use. Third, we hypothesize flavored tobacco use will be associated with greater risks of poly tobacco use, relative to dual tobacco product use. Understanding the relationship between flavors and multiple tobacco use among youth will help inform public health research and policy.
2.2. Procedure NYTS sample procedures are probabilistic and conducted without replacement at all stages. The first stage was to select primary sampling units within each stratum, then schools within each primary sampling unit, followed by classes within each school. Participation was voluntary and confidential for students and schools. Details of the sample procedures for the 2017 NYTS are available elsewhere (National Youth Tobacco Survey (NYTS), 2017). 2.3 Measures. 2.3.1 Single, Dual, and Poly Tobacco Use: Tobacco use was assessed for 9 products: cigarettes, electronic cigarettes (e-cigarettes), hookah, cigar products (i.e., cigars; cigarillos; little cigars), smokeless tobacco, snus, pipe tobacco, bidis, and dissolvable tobacco. Use for each tobacco product was assessed individual through the following question: “During the past 30-days, on how many days did you use [product]?” Participants that reported use of a no tobacco products in the past 30days were excluded from the analysis. Participants that reported use of one tobacco product were considered “single product users” (coded as 0). Participants that reported use two tobacco products were considered “dual tobacco users” (coded as 1). Participants that reported use of three or more tobacco products were considered “poly tobacco users” (coded as 2). 2.3.2 Flavored Tobacco Use: Flavored tobacco use was assessed through several questions. First, cigarette smoker were asked “Menthol cigarettes are cigarettes that taste like mint. During the past 30 days, were the cigarettes that you usually smoked menthol?” Next, participants were asked: “Which of the following tobacco products that you used in the past 30 days were flavored to taste like menthol (mint), alcohol (wine, cognac), candy, fruit, chocolate or any other flavors? (Select one or more)” Possible products included e-cigarettes, hookah, cigars/cigarillos/little cigars, smokeless tobacco, snus, pipe tobacco, bidis, and dissolvable tobacco. Participants that reported any use of flavored tobacco were considered “flavor users” (coded as 1). Participants that reported no use of flavors for tobacco products were considered “non-flavor users” (coded as 0). 2.3.3 Covariates: This analysis included several variables as covariates. Grade was categorized as middle (coded as 0) and high school (coded as 1). Race/ethnicity was categorized as: white, non-Hispanic (coded as 0); black, non-Hispanic (coded as 1); Hispanic/Latino (coded as 2); and “other” (coded as 3). For this analysis, “other” consisted of non-Hispanic/Asian, multiracial, and any other race. Sex is a biologically dichotomous variable. Males were the referent group (coded as 0) and females were the comparison group (coded as 1). 2.4 Statistical Analyses. Data were weighted to be representative of US middle and high school students and to adjust for nonresponse and probability of selection. Prior to testing study hypotheses, chi-squared analyses were used to compare flavor tobacco use and tobacco use category by sociodemographic variables. Next, two multivariate multinomial logistic regression models were used to examine the association of flavored tobacco use and number of tobacco products used, controlling for grade level, race/ethnicity, and sex. For these multivariate multinomial logistic regression models, number of tobacco products was categorized as single tobacco product use, dual tobacco product use, and poly (i.e.,
2. MATRIALS and methods 2.1. Study sample This study analyzed data from the 2017 National Youth Tobacco Survey (NYTS), a representative sample of middle and high school 85
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3 or more) tobacco product use. The first model was used to test hypotheses one and two. In this model, single tobacco product use served as the referent outcome. The second model was used to test hypothesis three. In this model, dual tobacco product use served as the referent outcome. All analyses were conducted using STATA 14.2 (College Station, TX).
Table 2 Multinomial logistic regression models of flavored tobacco use and number of tobacco products used in the past 30-days (NYTS, 2017; n = 2329).
3. Results 3.1. Descriptive statistics
Single users as referent Flavored tobacco usec Dual users as referent Flavored tobacco usec
Overall, 51.5% used one product, 20.7% used two products, and 27.9% used three or more products. Among all tobacco users, 72.4% reported using flavors. However, flavored tobacco use was substantially greater among dual (78.2%) and poly (90.1%) tobacco users, relative to single product users (60.4%). Flavored tobacco use prevalence differed significantly by race (p ≤.001), with non-Hispanic whites having the greatest prevalence (76.8%) followed by Hispanic/Latinos (70.8%). Flavored tobacco use did not differ by sex (p = .363) or grade level (p = .061). Single, dual, and poly tobacco use prevalence differed significantly by race (p = .018). Single product use prevalence was greatest among non-Hispanic blacks (64.1%). Dual product use was greatest among non-Hispanic whites (22.0%). Poly tobacco use was greatest among Hispanic/Latinos (30.9%). Single, dual, and poly tobacco use prevalence did not differ statistically by sex (p = .060) or grade level (p = .492). Descriptive statistics are available in Table 1.
Single usersa (n = 1206)b
Dual usersa (n = 484)b
Poly usersa (n = 639)b
Relative risk ratio 95% confidence Interval
Relative risk ratio 95% confidence Interval
Relative risk ratio 95% confidence Interval
1.00 (Ref)
2.28⁎⁎⁎ (1.59–3.26)
5.76⁎⁎⁎ (4.10–8.10)
–
1.00 (Ref)
2.53⁎⁎⁎ (1.62–3.95)
All models adjusted for grade level, sex, and race/ethnicity; Bold indicates statistical significance. a Corresponds to the number of tobacco products used in past 30-days. b Unweighted sample size. c Reported use of menthol or other flavors for one or more tobacco products. ⁎⁎⁎ p < .001.
tobacco product use, controlling for covariates. Furthermore, flavored tobacco use was associated with an increased relative risk of poly tobacco product use of 2.53 (1.62–3.95), relative to dual tobacco product use, controlling for covariates.
3.2. Study hypotheses 4. Discussion As seen in Table 2, flavored tobacco use was associated with an increased relative risk of dual tobacco product use of 2.28 (1.59–3.26), relative to single tobacco product use, controlling for covariates. Similarly, flavored tobacco use was associated with an increased relative risk of poly tobacco product use of 5.76 (4.10–8.10), relative to single
This study found flavored tobacco use was associated with increased risk of multiple tobacco use. Specifically, flavored tobacco users were more likely to be dual and poly tobacco users, relative to single tobacco product users. Similarly, flavored tobacco users were more likely to be
Table 1 Descriptive statistics by tobacco use category (NYTS 2017, n = 2329). Flavored tobacco usea (n = 2329)
Percent of sample Sex Male (n = 1298)c Female (n = 1031)c Grade Middle School (n = 476)c High School (n = 1853)c Race/ethnicity Non-Hispanic White (n = 1137)c African American (n = 319)c Hispanic/Latino (n = 635)c Other (n = 238)c,d Flavored tobacco use No (n = 706)c Yes (n = 1, 623)c
Tobacco use categories (n = 2329)
No (n = 706)c
Yes (n = 1623)c
Single usersb (n = 1206)c
Dual usersb (n = 484)c
Poly usersb (n = 639)c
27.6%
72.4%
51.5%
20.7%
27.9%
26.7% 28.8%
73.3% 71.2%
50.6% 52.7%
19.3% 22.5%
30.1% 24.9%
χ2 (1,N = 2329) = 9.4; p = .363
χ2 (2,N = 2329) = 66.2; p = .060
32.3% 26.6%
55.3% 50.6%
67.7% 73.4%
18.7% 21.1%
χ2 (1,N = 2329) = 44.0 p = .061
χ2 (2,N = 2329) = 23.8; p = .492
23.2% 46.6% 29.2% 33.3%
49.1% 64.1% 49.5% 59.3%
76.8% 53.4% 70.8% 66.7%
22.0% 18.2% 19.7% 17.0%
χ2 (3,N = 2329) = 425.7; p < .001
χ2 (6,N = 2329) = 195.9; p = .018
– – –
39.6% 21.8% 60.4% 78.2% χ2 (2,N = 2329) = 1496.3; p ≤.001
a
26.0% 28.3%
28.9% 17.8% 30.9% 23.8%
9.9% 90.1%
Corresponds to the number of tobacco products used in past 30-days. Unweighted sample size. c These rows reflect proportion of entire sub-sample (i.e., tobacco use category). d “Other” is where a response was “Asian, non-Hispanic”, “American Indian/Alaska Native, non-Hispanic;” or “native Hawaiian and other Pacific Islanders, nonHispanic”. b
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examination of the role of flavors on multiple tobacco use.
poly tobacco users, relative to dual poly users. To our knowledge, this is the first study to examine this association among a nationally representative sample of adolescent tobacco users. This study furthers the understanding of the role flavored tobacco play in adolescent tobacco use behaviors. This study has several implications. From a regulatory perspective, this study adds to existing research that suggest the need to consider restricting or eliminating flavored tobacco products as a method of reducing adolescent tobacco use. Specifically, flavors have been shown to increase the appeal of tobacco use among youth (Corey et al., 2015; Villanti et al., 2017; Minaker & Ahmed, 2014; Courtemanche et al., 2016; King et al., 2014; Ambrose et al., 2015; Osman et al., 2018; Harrell et al., 2017a; Harrell et al., 2017b),improve the experience of tobacco use among novice users (Nonnemaker et al., 2013; Mantey et al., 2017), and result in greater nicotine dependence and sustained use into adulthood (U.S. Department of Health and Human Services, 2000). Similarly, younger tobacco users have repeatedly cited the importance of flavors for initiation and continued use of tobacco products (Corey et al., 2015; Villanti et al., 2017; Minaker & Ahmed, 2014; Courtemanche et al., 2016; King et al., 2014; Ambrose et al., 2015; Osman et al., 2018; Harrell et al., 2017a; Harrell et al., 2017b). The Food and Drug Administration holds regulatory authority over tobacco flavors (Food and Drug Administration & HHS, 2016). However, flavors among non-cigarette tobacco products remain entirely unregulated (Food and Drug Administration & HHS, 2016). Given the association between flavored tobacco and multiple tobacco use observed in this study, as well as the known association between flavored tobacco use and nicotine dependence (U.S. Department of Health and Human Services, 2000; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012), long-term tobacco use (U.S. Department of Health and Human Services, 2000; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012), evidence is mounting to suggest regulating tobacco flavorings may result in a meaningful reduction of adolescent tobacco use. This study also has public health implications. Specifically, findings suggest there is an association between tobacco flavors and multiple tobacco use. Given the public health consequences of multiple tobacco use, such as nicotine dependence (Creamer et al., 2016; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012) and long-term tobacco use (Creamer et al., 2016; United States. Public Health Service. Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (U.S.). Office on Smoking and Health, 2012), these findings suggests a new public health risk associated with flavored tobacco use. However, longitudinal research is needed to further examine the relationship between flavors and multiple tobacco use. This study has several limitations. First, the presented data are cross-sectional and thus causal inferences cannot be drawn. Second, all data are self-report and thus subject to recall bias. Third, flavored tobacco use is likely more nuanced than the measures this study allowed. For example, adolescent cigarette smokers may smoke both menthol and non-menthol cigarettes. Further, multiple tobacco users may concurrently use both flavored and non-flavored tobacco products. Future research is needed to examine the diverse use, and robust available, of flavored tobacco.
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5. Conclusion Despite these limitations, this study expands the literature base by examining the relationship between two growing issues in adolescent tobacco use: flavors and multiple product use. This cross-sectional study provides the statistical evidence to support the need for longitudinal 87
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