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.

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.

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.

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).

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.