Correlations Between Flavored E‐Cigarette Use and Tobacco and Substance Use Among US Youth, 2021 to 2023

Policy Points Menthol‐flavored e‐cigarettes are disproportionately used by youth who co‐use other substances; allowing menthol sales may undermine efforts to reduce poly‐tobacco and poly‐substance use. Fruit/ice‐fruit flavors are most common among lower‐risk youth (those not engaged in other substance use), and banning these flavors could help prevent nicotine initiation. Because nearly all youth who vape use non–tobacco‐flavored e‐cigarettes, comprehensive policies that eliminate access to all non–tobacco‐flavored e‐cigarettes, including menthol, may be more effective than selective bans. Stronger enforcement and broader flavor restrictions could help prevent initiation and reduce sustained use, particularly among youth who co‐use menthol‐flavored e‐cigarettes and other substances. Context The specific nontobacco e‐cigarette flavors used by US youth who exclusively vape e‐cigarettes compared with youth who engage in poly‐tobacco or poly‐substance use can help identify the populations most likely to be impacted by e‐cigarette flavor policies. This study examines correlations between e‐cigarette flavor use and past 30‐day tobacco and substance use among US youth who vape. Methods We analyzed the Monitoring the Future survey data (2021–2023), a nationally representative annual study of US eighth, tenth, and 12th graders. Among 14,675 participants who vaped nicotine in the past year, we assessed their most frequently used e‐cigarette flavor: fruit/ice‐fruit, menthol, mint, sweet, tobacco, or unflavored. Log‐binomial regression models estimated adjusted prevalence ratios (APRs) for correlations between e‐cigarette flavor use and past 30‐day tobacco and substance use, adjusting for sociodemographic characteristics and e‐cigarette use. Findings Few youth predominately vaped tobacco‐flavored (1.3%) or unflavored (3.6%) e‐cigarettes, regardless of whether they did or did not use other tobacco products or nontobacco substances. Menthol‐flavored (12.1%) e‐cigarette use was correlated with past 30‐day cigarette (APR 1.53, 95% CI 1.29‐1.81), smokeless tobacco (APR 1.53, 95% CI 1.24‐1.89), cigars/hookah tobacco products (APR 1.51, 95% CI 1.13‐2.02), and alcohol (APR 1.16, 95% CI 1.02‐1.32) use. In contrast, fruit/ice‐fruit–flavored (72.3%) e‐cigarettes were less commonly used among youth who smoked cigarettes (APR 0.83, 95% CI 0.76‐0.90), used smokeless tobacco (APR 0.83, 95% CI 0.75‐0.91), or reported noncannabis illicit drug use (APR 0.89, 95% CI 0.80‐0.98). Conclusions Closing federal regulatory loopholes and implementing state and local bans on all non–tobacco‐flavored e‐cigarettes may support efforts to reduce youth nicotine uptake. Policies that limit access and sales to menthol‐flavored e‐cigarettes could be particularly relevant for youth at risk of poly‐tobacco or poly‐substance use.