E-Cigarette Flavors, Devices, and Brand Preferences Among Youths in Canada, England, and the United States: The Value and Challenges of Comparing International Survey Data

ABSTRACT

First-generation e-cigarettes were visually more like traditional tobacco cigarettes but lacked choice in flavors, whereas newer versions have evolved, looking less like their predecessors and gaining flavor alternatives. Equally, however, choice of flavors plays an important role in potentially supporting adults who use e-cigarettes as a smoking cessation aid.4 It has therefore been a challenge for policymakers in different jurisdictions to balance actions that reduce pathways of harm for young people's health and actions that minimize disruption of smoking cessation efforts among adults, a choice often made within a limited supply of evidence. [...]comparing findings from different countries can present challenges given the international divergence in e-cigarette use, which likely reflects differences in the regulatory landscape over the past decade.7 For example, Hammond et al. highlighted that, unlike in the United States and Canada, cartridge and pod e-cigarettes remain less prevalent than refillable tank devices among youth and adult vapers in the United Kingdom. Since 2016, there has been a plateauing of e-cigarette use in the United Kingdom, in contrast to the large growth seen in the United States during this period.8 European Union legislation such as the Tobacco Products Directive likely delayed the entry of products such asJUUL into UK markets as a result of the restrictions on e-liquids with a nicotine strength of more than 20 milligrams per milliliter. [...]our later research showed that the proliferation of e-cigarette use in the United Kingdom likely contributed to hardening attitudes toward smoking amongyoung people.10 In contrast to the United States, the majority of users of nicotine-based vaping products in the United Kingdom are adults.11 After implementation of the Tobacco Products Directive, e-cigarette flavor remained an important reason for e-cigarette experimentation among young people in the United Kingdom.3 Attraction to flavors continues to be a strong reason in more recent Englandbased surveys.11 Efforts to address vaping flavor enticement among young people may thus take different forms moving forward, with North America highlighting the role of nicotine-based products and England focusing more attention on the role of non-nicotine products.