Associations of Flavored e-Cigarette Uptake With Subsequent Smoking Initiation and Cessation

JAMA Netw Open. 2020 Jun 1;3(6):e203826. doi: 10.1001/jamanetworkopen.2020.3826.


Importance: Several states have banned sales of flavored e-cigarettes, but evidence on the association between vaping flavors and subsequent smoking initiation and cessation is limited.

Objective: To evaluate whether new uptake of flavored e-cigarettes is more strongly associated with subsequent smoking initiation and cessation than uptake of unflavored e-cigarettes, separately for youths (12-17 years), emerging adults (18-24 years), and prime-age adults (25-54 years).

Design, setting, and participants: This cohort study conducted secondary data analyses of longitudinal survey data from waves 1 to 4 of the Population Assessment of Tobacco and Health Study (collected from 2013 to 2018). The analytic sample was limited to 17 929 respondents aged 12 to 54 years at wave 1 who completed at least 3 consecutive waves of the survey and did not use e-cigarettes at baseline. Data were collected from 2013 to 2018 and analyzed in February 2020.

Exposures: Flavored vs unflavored e-cigarette use reported in wave 2 of the Population Assessment of Tobacco and Health Study.

Main outcomes and measures: Binary indicators captured wave 3 smoking among 7311 youths and 4634 emerging adults who did not smoke at baseline (ie, initiation) and not smoking at wave 3 among 1503 emerging adults and 4481 prime-age adults who smoked at baseline (ie, cessation). Smoking status was based on having smoked in the past 30 days for youths and established smoking (ie, current smoking among those who smoked at least 100 cigarettes in their lifetime) for emerging and prime-age adults.

Results: The youths who did not smoke at baseline, emerging adults who smoked at baseline, and prime-age adults who smoked at baseline consisted of 51.4% to 58.0% male participants and 66.9% to 77.0% white individuals. Vaping uptake was positively associated with smoking initiation in youth (adjusted odds ratio [AOR], 6.75; 95% CI, 3.93-11.57; P < .001) and in emerging adults (AOR, 3.20; 95% CI, 1.70-6.02; P < .001). Vaping uptake was associated with cessation in adults (AOR, 1.34; 95% CI, 1.02-1.75; P = .03). Vaping nontobacco flavors was no more associated with youth smoking initiation than vaping tobacco-flavors (AOR in youth, 0.66; 95% CI, 0.16-2.76; P = .56) but was associated with increased adult smoking cessation (AOR in adults, 2.28; 95% CI, 1.04-5.01; P = .04).

Conclusions and relevance: In this study, adults who began vaping nontobacco-flavored e-cigarettes were more likely to quit smoking than those who vaped tobacco flavors. More research is needed to establish the relationship between e-cigarette flavors and smoking and to guide related policy.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Child
  • Electronic Nicotine Delivery Systems / statistics & numerical data*
  • Female
  • Flavoring Agents*
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Smoking Cessation / statistics & numerical data*
  • Tobacco Smoking / epidemiology*
  • United States
  • Vaping / epidemiology*
  • Young Adult


  • Flavoring Agents