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.
Exposure to nicotine during adolescence can harm brain development, cause problems with learning, memory and attention, and lead to nicotine addiction.
"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 & 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.
The researchers also found that use of flavored oral nicotine products was greater among Hispanic teens, teen girls, and teens who identified as LGBTQ.
"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.