Study led by CU Boulder researcher finds that flavored-tobacco products reduce likelihood of later cessation, but researchers say more investigation is needed

As a senior studying psychology and neuroscience at the University of Colorado Boulder, Christine Steeger (Psych’03) took a job at a large residential treatment center for youth in nearby Westminster. During overnight shifts she found herself poring over client case files.

“While the kids were sleeping, I was reading through a lot of their history, becoming more interested in why they have these problems, and how we can prevent them,” says Steeger, who is now a research assistant professor at the Institute of Behavioral Science.

After conducting behavioral and mental health research with youth and their families for several years, she earned a PhD in developmental psychology from the University of Notre Dame in 2013 and did postdoctoral work at Yale University. She was a research scientist at the University of Washington before returning to CU Boulder in 2017.

Throughout her career, Steeger has retained her interest in substance-use prevention and prevention of other problem behaviors for youth. 

“The vaping and opioid epidemics are significant public-health issues affecting youth and adults. Given the widespread impact, society is paying more attention to these problems and how to treat and prevent them,” she says. 

Although adults were the subjects of a recent paper, “Longitudinal associations between flavored tobacco use and tobacco product cessation in a national sample of adults,” published in July 2022 in Preventive Medicine, the study also has significant implications for youth, says Steeger, who served as the study’s lead author. 

Flavored tobacco products are “designed to appeal to kids as well as adults. Big tobacco knows how to market to kids and catch their eyes,” she says.

For the study, Steeger and her co-authors, including Professor of Psychology and Neuroscience Karl G. Hill at IBS and colleagues from Yale and the University of Southern California, analyzed data from the ongoing Population Assessment of Tobacco and Health Study of thousands of subjects from 2013 through 2018 to determine whether use of flavored tobacco affected later cessation of tobacco use. 

The researchers found that past 30-day use of flavored cigarettes, cigars, hookah, e-cigarettes and smokeless tobacco was associated with lower likelihood of short-term and “longer-term” (24-month) cessation or abstinence from tobacco use.

“We were looking at how likely or unlikely people are able to quit that product a couple of years later, and how likely they were able to quit any of the five products. We found compelling evidence that flavored compared to unflavored tobacco use meant they were much less likely to quit,” Steeger says. 

She stresses that further work needs to be done, but argues that the study’s design shows the same pattern of effects across five products over a significant period of time, indicating that “characterizing flavors like menthol/mint and fruit, candy/desserts and other sweet flavors are likely contributing to prolonged use of tobacco.”

The study found that the effect for e-cigarettes was more pronounced for users aged 18-24 than those ages 25 and older. 

“That’s telling us that young adults (who use flavored e-cigarettes) may have an even harder time quitting,” Steeger says.

Meanwhile, it’s no secret that tobacco companies design and market nicotine-containing products to appeal to new users, most notably the young. Adding flavoring to various products may make it easier to hook new users.

“With e-cigarettes in particular, a lot of kids start because they are just curious about them and they come in fun flavors. And if it tastes good, the flavors can mask the harsh and bitter taste from using nicotine, allowing them to continue using the product,” Steeger says. 

Menthol flavoring, for example, may act as an analgesic to reduce irritation on mucus membranes and the respiratory system. And sweet flavorings mimicking fruit, candy, or chocolate, may trigger pleasant sensory associations with food, partially mitigating negative sensations.

Steeger stresses that researchers “certainly don’t have all the answers yet” when it comes to the consequences of using flavored tobacco products. But she notes that research lags the constant introduction of new products by tobacco companies, making it challenging to mount an effective regulatory response. She also points out that research on whether flavored e-cigarettes actually help adults quit smoking remains inconclusive.

“But this study provides additional evidence for the (U.S. Food and Drug Administration) to consider. When we are finding the same pattern of associations across both combustible and non-combustible flavored products, it’s likely that it’s contributing to sustained use,” she says. 

As the researchers conclude, “If the current study associations between flavor use and cessation behaviors reflect causal links, FDA regulations to remove flavored cigarettes and cigars from the market would reduce longer-term exposure to harmful combustible products.”

Steeger is interested in delving deeper into what may account for any association between flavored-product use and ability to quit. She recently obtained a seed grant to begin looking at disparities in both nicotine and cannabis vaping among youth across gender, sexual orientation, socio-economic status, rural or urban location, and other factors.

Understanding why and how kids start to use potentially addictive products, and which types of kids are vaping and continue to vape over time, is critically important, she says, given the forces marshaled on the other side. 

“The big tobacco companies are smart and know exactly how to market to teens,” she says. “They say they haven’t been, but just look at the ads and the range of tasty flavors that directly appeal to teens.”