Flavored oral nicotine products, which contain no tobacco but are not FDA-approved to help people quit smoking, are increasingly marketed and sold in the U.S., but researchers have never measured their use among U.S. teens.
In a new study, published this week in the journal Pediatrics, researchers from the Keck School of Medicine of USC surveyed more than 3,500 Southern California teens about the nicotine products they use. The new flavored oral nicotine products ranked second: 3.4% of teens had used them at least once, while 1.7% had used them in the past six months.
E-cigarettes, also known as vapes, were the most popular nicotine product, with 9.6% of teens having used them at least once and 5.5% of teens having used them in the past six months. Cigarettes, cigars, hookah, and other products were less popular.
“Surprisingly, these new flavored oral nicotine products were the second most commonly used product among our sample, second only to e-cigarettes,” said the study’s lead author, Alyssa F. Harlow, Ph.D., MPH, a postdoctoral scholar in the Department of Population and Public Health Sciences at the Keck School of Medicine of USC.
“Our findings are concerning because these products often have a high nicotine content, which we know is harmful to teens, and they’re really easy to hide and conceal. They also come in sweet flavors that may appeal to teens,” such as “cherry bomb” and “fruit medley,” Harlow said.
Prevalence and disparities
The research team collected data in 2021 as part of an ongoing behavioral health study of Southern California teens. Participants included 3,516 ninth and 10th graders from 11 high schools across Los Angeles, Riverside, San Bernardino, Orange and Imperial counties.
After e-cigarettes, non-tobacco flavored oral nicotine products (gum, lozenges, tablets, and gummies) were the most commonly used product. Combustible tobacco products ranked third, with 2% of teens reporting having ever used cigarettes, cigars, cigarillos or hookah and 1.3% having used one or more of those items in the past six months. Less than 1% of teens had used other nicotine products, such as pouches or snus, ever or in the past six months. Use of flavored oral nicotine products was more common in teens who had also used other nicotine products, such as cigarettes or e-cigarettes.
“Some of these subpopulations are young people who have historically been impacted by tobacco-related disparities,” Harlow said. “It’s important for us to continue monitoring the use of these products among young people to determine the potential influence on those disparities.”
Monitoring nicotine use
National surveys that monitor nicotine use among adolescents, including the Center for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System and the Food and Drug Administration’s Population Assessment of Tobacco and Health, are not yet tracking the new flavored oral nicotine products. Given the popularity of these products in the current sample, and the fact that they may appeal to youth, Harlow said it is vital to track their popularity with teens and young adults.
“At this time, we don’t really know what the public health implications are,” she said. “That’s why surveillance at the national level is really the first and most important step.”
While these products can pose harm to youth, they offer a potentially less harmful alternative for adults seeking to quit smoking or vaping. Harlow and her colleagues are studying young adult vapers to learn about how the appeal of the new flavored oral nicotine products compares to that of existing FDA-approved cessation products.
They are also continuing to collect data from the sample of Southern California high school students and plan to conduct longitudinal analyses of nicotine use to determine how the use of flavored oral nicotine products may relate to other behaviors, such as vaping and cigarette smoking, over time.
In addition to Harlow, the study’s other authors are Erin Vogel, Alayna P. Tackett, Junhan Cho, Dae-Hee Han, Melissa Wong, Myles G. Cockburn, Steve Y. Sussman, Jennifer B. Unger, Adam M. Leventhal and Jessica L. Barrington-Trimis from the USC Institute for Addiction Science and the Department of Population and Public Health Sciences, Keck School of Medicine of USC.
Smoking is the leading cause of preventable death worldwide (Samet, 2013), causing more than eight million deaths each year. In addition to its effects on health, tobacco use imposes enormous economic costs in terms of healthcare, the loss of productivity, fire damage, and environmental harm (World Health Organization [WHO], 2019). Use of nicotine can harm adolescents’ brains and increase risk of future addiction to other drugs (Everett et al., 2000; Kandel & Kandel, 2015; McCabe et al., 2017; Murthy, 2016).
It is known that children are vulnerable to nicotine addiction (Murthy, 2016; WHO, 2017). Because of the strong addictiveness of nicotine products, large proportions of early experimentations eventually develop into daily, addictive use. The likelihood of developing an addiction depends in partly on age. Adolescent under 15 years who have smoked have an estimated 50% chance of developing nicotine addiction. Risk of nicotine addiction increases if smoking is repeated over a prolonged period (WHO, 2017). Most addiction to tobacco develops before age 21 years (Ali et al., 2020; WHO, 2017).
One of the important problems is children’s and adolescents’ use of nicotine products; for example, most smokers begin smoking by age 18 years, and nearly all first experiences of cigarettes occur before the age of 26 years (HHS [US Department of Health and Human Services], 2014). In the Europe, children’s experimentation with cigarettes is common, and smoking often starts at a young age. The WHO’s Health Behaviour in School-Aged Children Survey (2013–2014) reported 13% of girls and 22% of boys surveyed had initiated smoking by age 13 years. A total of 12% of children reported they had started to smoke regularly by the age of 15 years (WHO, 2017).
Several international studies over the last 10 years have found that an acceptable attitude towards nicotine products can increase the use or initiation of nicotine products for their users (Cavazos-Rehg et al., 2014; Edvardsson et al., 2012; Kowitt et al., 2015; Pepper et al., 2013; Trapl et al., 2016; Tseveenjav et al., 2015; Wackowski et al., 2020). Adolescents have limited, incomplete, conflicting, or distorted knowledge about nicotine products (Choi et al., 2012). Many of them have a positive image of the properties and effects of nicotine products, which increases the chances of a young person smoking or using snus (Brennan et al., 2015; Cavazos-Rehg et al., 2014; El-Shahawy et al., 2015; Kowitt et al., 2015; Vogel et al., 2021).
Adolescents have negative perceptions of tobacco products and smokers, but they believe their peers often view tobacco products positively. They also regard the use of tobacco as a functional stress-management strategy. Health and family are strong motivators to avoid nicotine products (Brown et al., 2019). Youth are often unaware of the level of nicotine in the devices they use. Although they know the health effects of tobacco products, particularly nicotine, they have a lack of knowledge about the health effects of e-cigarettes and the amount of nicotine they use (Alexander et al., 2019).
Increased awareness of negative health effects may encourage prevention and cessation of nicotine product use among youth (Alexander et al., 2019). As many previous studies around the world have shown (Alves et al., 2020; Brown et al., 2021; Chavan & Charanrajhave, 2020; Di Giuseppe et al., 2020; Shilco et al., 2020), there is a need to strengthen the multi-professional healthcare system and, for example, various school-based smoking risk campaigns to arouse awareness, to enable early detection, and to implement strategies to prevent nicotine addiction among adolescents. According to Brown et al. (2019), peer-to-peer discussion of tobacco experiences and perceptions may help correct the incongruent viewpoints of the use of tobacco products.
Epidemiological, clinical, and preclinical data have shown that adolescent exposure to tobacco and nicotine can lead to subsequent abuse of nicotine and other substances (Kandel & Kandel, 2015). Cross-sectional studies have demonstrated an association between 30-day tobacco use and risk behaviours such as illicit substance use (Everett et al., 2000). This association is even stronger among adolescents who report use of multiple nicotine products (McCabe et al., 2017).
School-based health promotion interventions are widely studied globally and adolescents’ use of nicotine products are a known problem, which needs to be attended to. Based on this systematic literature review, school-based interventions have an effect on adolescents’ attitudes towards smoking and preventing them from starting to smoke (Giannotta et al., 2014; Isensee et al., 2014; La Torre et al., 2010; Miovsky et al., 2012) when they are targeted before the age of puberty (Isensee et al., 2014; La Torre et al., 2010). School-based interventions should be further implemented and strengthened, as the school has been shown to have significant potential to support youth’s health (Isensee et al., 2014; La Torre et al., 2010).
In addition to school-based interventions, tobacco prevention campaigns and pictorial or text-only warnings on the hazards of nicotine products have also been proven to be an effective way to reduce positive attitudes towards nicotine products and increase negative reactions towards nicotine products (Peebles et al., 2016; Zhao et al., 2016). The campaigns should be targeted to adolescents and utilise social media, which is widely used by adolescents.
There is a need for further research in relation to the influence of social media on adolescents’ use of nicotine products and in supporting non-smoking habits. In addition to quantitative data, qualitative methods should be used to find out adolescents’ attitudes towards and perceptions about nicotine products. Information is also needed on what adolescents expect from school-based interventions to make them effective.
Through this systematic review, we hope we contribute to the existing literature by addressing gaps and highlighting adolescents’ attitudes towards nicotine products and the ways of influencing them. With this review, we want to emphasise the importance of adolescents’ use of nicotine products being a global public health problem.
reference link : https://journals.sagepub.com/doi/full/10.1177/14550725221096908
More information: Alyssa F. Harlow et al, Adolescent Use of Flavored Non-Tobacco Oral Nicotine Products, Pediatrics (2022). DOI: 10.1542/peds.2022-056586