Association of Flavored Tobacco Use With Tobacco Initiation and Subsequent Use Among US Youth and Adults, 2013-2015

Importance: Flavors in tobacco products may appeal to young and inexperienced users. Objective: To examine among youth (aged 12-17 years), young adults (aged 18-24 years), and adults (aged ≥25 years) the prevalence of first use of flavored tobacco products among new tobacco users and the association between first flavored use of a given tobacco product and tobacco use 1 year later, including progression of tobacco use. Design, Setting, and Participants: This cohort study represents a longitudinal analysis of data from the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative study with data collected in 2013 to 2014 (wave 1) and 2014 to 2015 (wave 2). Participants were noninstitutionalized individuals, including 11 996 youth and 26 447 adults, in selected households who participated in both waves of the PATH Study. Data analysis was conducted from July 2016 to June 2019. Main Outcomes and Measures: Prevalence of tobacco product use at wave 2. Results: The mean (SE) age of the participants was 14.5 (0.0) years for youth, 21.1 (0.0) years for young adults, and 50.3 (0.0) for adults. Most youth (71.9%; 95% CI, 69.7%-74.0%) and young adults (57.6%; 95% CI, 54.9%-60.3%) who were new users of tobacco products over the 10- to 13-month follow-up period used flavored products. First use of a menthol or mint or other flavored cigarette documented at wave 1 was positively associated with past 12-month and past 30-day cigarette use in all age groups at wave 2 compared with first use of a nonflavored cigarette (youth, flavored cigarette, past 12-month use adjusted prevalence ratio aPR, 1.14 95% CI, 1.05-1.25 and past 30-day use aPR, 1.15 95% CI, 1.00-1.31; youth, menthol or mint cigarette, past 12-month use aPR, 1.18 95% CI, 1.08-1.29 and past 30-day use aPR, 1.19 95% CI, 1.04-1.37; young adult, flavored cigarette, past 12-month use aPR, 1.09 95% CI, 1.04-1.15 and past 30-day use aPR, 1.13 95% CI, 1.06-1.21; young adult menthol or mint cigarette, past 12-month use aPR, 1.10 95% CI, 1.05-1.16 and past 30-day use aPR, 1.15 95% CI, 1.07-1.23; adult flavored cigarette, past 12-month use aPR, 1.10 95% CI, 1.05-1.15 and past 30-day use aPR, 1.09 95% CI, 1.04-1.14; adult menthol or mint cigarette, past 12-month use aPR, 1.13 95% CI, 1.08-1.18 and past 30-day use aPR, 1.12 95% CI, 1.07-1.17). Among young adults, first use of flavored e-cigarettes (aPR, 2.05; 95% CI, 1.61-2.61), any cigars (aPR, 1.60; 95% CI, 1.26-2.02), cigarillos (aPR, 1.49; 95% CI, 1.08-2.05), filtered cigars (aPR, 3.69; 95% CI, 2.08-6.57), hookah (aPR, 1.91; 95% CI, 1.23-2.98), and any smokeless tobacco (aPR, 1.54; 95% CI, 1.08-2.20) was prospectively associated with current regular use of those products at wave 2 compared with first nonflavored use. Among adults aged 25 years and older, first use of flavored e-cigarettes (aPR, 1.60; 95% CI, 1.41-1.82), any cigars (aPR, 1.56; 95% CI, 1.29-1.87), cigarillos (aPR, 1.29; 95% CI, 1.01-1.64), filtered cigars (aPR, 1.79; 95% CI, 1.25-2.54), hookah (aPR, 5.66; 95% CI, 2.04-15.71), and any smokeless tobacco (aPR, 1.55; 95% CI, 1.32-1.82) was prospectively associated with current regular use of those products at wave 2 compared with first nonflavored use. Conclusions and Relevance: In this longitudinal cohort study, flavors in tobacco products were associated with youth and young adult tobacco experimentation. First use of a flavored tobacco product may place youth, young adults, and adults at risk of subsequent tobacco use.