Higher nicotine levels in fruit-, menthol-, and mint-flavored e-cigarettes is tied to greater nicotine dependence

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Emerging Tobacco Products

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Young people who vaped fruit-, menthol-, and mint-flavored e-cigarettes with higher nicotine concentrations had greater nicotine dependence compared to those who used e-cigarettes with lower nicotine levels, according to new Truth Initiative research published in Substance Use and Misuse. Using higher nicotine concentrations with these flavored e-cigarettes were also tied to higher frequency of vaping and lower likelihood of intentions to quit vaping.

The study is the first to investigate associations between flavors, nicotine concentration, and nicotine dependence among e-cigarette users, and highlights the immediate need to further understand the role these characteristics play in nicotine dependence. Given the rapid evolution of e-cigarette products and their availability in youth-appealing flavors and high nicotine levels, findings also call for comprehensive regulation of flavors, nicotine concentrations, and other characteristics to fully protect young people from nicotine addiction.

Higher nicotine levels are tied to nicotine dependence

Included in the analyses are 1,430 young people between the ages of 15-24 who owned and used e-cigarettes in the past month. These survey respondents were asked about which flavor and nicotine levels they used most often in fall 2020. Nicotine dependence was measured by asking how soon they vaped after waking up.

Results show that young e-cigarette users who vaped products containing higher levels of nicotine were more dependent on nicotine. Those who used the highest nicotine concentrations (5% or more) were nearly twice as likely to vape within half an hour of waking up compared to those who used nicotine concentrations between 0 and 2.9%.

Similarly, for those who vaped fruit, mint, and menthol flavors, the prevalence of vaping within half an hour of waking gradually increased as nicotine concentration increased. Users who vaped tobacco flavors saw a decrease in prevalence of vaping within half an hour of waking as nicotine concentration increased.

Higher nicotine levels are tied to greater vaping frequency

Higher nicotine concentrations were also associated with greater frequency of e-cigarette use and lower intentions to quit vaping.

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Most (71.5%) e-cigarette users vaping nicotine concentrations 5% or above and over half (51.5%) of those using concentrations between 3% and 4.9% reported vaping at least 10 out of the past 30 days. These rates of frequent vaping are higher than the roughly third (36.2%) of e-cigarette users using lower nicotine concentrations (0 to 2.9%) who reported vaping at least 10 out of the past 30 days. The majority of e-cigarette users (60.8%) who used products with 0 to 2.9% nicotine concentration reported intentions to quit within a year, compared to less than half (46.8%) of those using nicotine concentrations of 5% or greater.

High nicotine-containing e-cigarettes became a rising concern in 2015 when JUUL debuted with pods that contained 5% nicotine. Products with more than 5% nicotine concentration accounted for just 0.7% of the market share in 2015. Three years later, they represented more than two-thirds — 67.2% — of the market. Following this market trend, the average nicotine concentration in e-cigarettes sold in U.S. retailers more than doubled in five years, according to a study by Truth Initiative and Centers for Disease Control and Prevention researchers. The study found that the average nicotine concentration in e-cigarette products increased from 2.10% to 4.34% between 2013 and 2018, a 106.7% increase.

The role of flavors in youth e-cigarette use

Research shows that both adolescents and adults prefer sweet, menthol, and fruit flavors. Prior studies suggest that adolescents are more likely to vape flavored e-cigarettes, which can function as a gateway to other nicotine-containing products and a lifetime of addiction. Because of their role as an on-ramp to tobacco for adolescents who haven’t previously used tobacco and a potential off-ramp for smokers already addicted to nicotine, flavored e-cigarettes are caught at the crux of the concept of harm reduction, the principle of providing evidence-based, lower harm alternatives for those who do not quit harmful substances. Truth Initiative stands behind the idea that a genuine harm reduction approach requires measured and careful deployment of nicotine alternatives that are tightly focused on helping smokers who otherwise would not quit smoking cigarettes.

The flavored policy landscape continues to evolve

The findings highlight the need to better understand the role e-cigarette product features, like flavors and nicotine concentration, play in nicotine dependence, especially given piecemeal U.S. policies governing flavored tobacco. A total of 338 U.S. jurisdictions restrict flavored tobacco in some form, according to Truth Initiative’s most recent update on local flavored policies. Out of the 338 jurisdictions, 205 and three tribes prohibit flavors such as fruit, candy, alcohol, or dessert, but don’t ban menthol flavors, while 124 prohibit the sale of all flavors – including menthol – across all products.

The national policy landscape around flavors is changing. In 2020, the Food and Drug Administration (FDA) provided guidance on flavored e-cigarettes which allowed for certain flavored products to remain widely available across the country. Now, the FDA is reviewing applications permitting the sale of e-cigarettes, while the most popular brands remain on the market. The FDA is approaching the one-year mark from its April 2021 announcement that it would begin the process within the year for rulemaking to prohibit the sale of menthol cigarettes and all flavored cigars.

“Although the FDA has provided some guidance on restricting fruit and mint flavors in e-cigarettes, results from this study suggest that comprehensive e-cigarette product regulation of all flavors, including menthol, as well as reducing nicotine concentration will help to reduce the risk for nicotine dependence among our young people,” the authors write.