Flavored tobacco#Flavored cigarettes

Cigarettes may be flavored to mask the taste or odor of the tobacco smoke, enhance the tobacco flavor, or decrease the social stigma associated with smoking. Flavors are generally added to the tobacco or rolling paper, although some cigarette brands have unconventional flavor delivery mechanisms such as inserting flavored pellets or rods into the cigarette filter. Cigarette flavors include anise, clove, cinnamon, spearmint, wintergreen, citrus, fruit, and alcohol (especially rum and cocktails).{{Cite journal| issn = 1468-3318| volume = 13| issue = 2| pages = 105–106| last1 = Simpson| first1 = David| title = USA/Brazil: the flavour of things to come| journal = Tobacco Control| date = 2004-06-01| url= | pmid = 15175519| pmc = 1747868}} Flavors may be added to the tobacco, cigarette paper, filter, or even to the foil wrapper.{{r|WHO|pp=34}} Some tobacco companies have developed unconventional flavor delivery systems, including polymer pellet technology, using a flavored filter pellet (polyethylene bead), flavor micro-encapsulation in the paper or packaging technology, flavor fibers inserted into the filter, and flavored tips.{{r|WHO|pp=34}} Flavorings are typically added at the end of the cigarette manufacturing process.{{r|WHO|pp=25}} Flavored cigarettes are heavily preferred by youth, with a 2008 study finding that adolescents and young adults ages 17–25 use flavored cigarettes at about twice the rate of adults age 25 and older, with 17- to 18-year-olds being the heaviest users of flavored cigarettes, using them three times as much as adults.{{cite journal |last1=Klein |first1=Sarah M. |last2=Giovino |first2=Gary A. |last3=Barker |first3=Dianne C. |last4=Tworek |first4=Cindy |last5=Cummings |first5=K. Michael |last6=O'Connor |first6=Richard J. |date=July 2008 |title=Use of flavored cigarettes among older adolescent and adult smokers: United States, 2004–2005 |editor-last=Munafò |editor-first=Marcus |editor-link=Marcus Munafo |journal=Nicotine & Tobacco Research |publisher=Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco |volume=10 |issue=7 |pages=1209–1214 |doi=10.1080/14622200802163159 |issn=1462-2203 |pmid=18629731 |s2cid=11815560}}

{{Main|Beedi}}

One common type of flavored cigarettes are beedis, a small, thin, hand-rolled cigarette originally from India,{{cite web |title=Smoking and Tobacco Use; Fact Sheet; Bidis and Kreteks |url=https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/bidis_kreteks/ |website=CDC's Office on Smoking and Health |publisher=Centers for Disease Control and Prevention |access-date=4 February 2019 |language=en-us |date=14 August 2018}} where they outsell regular cigarettes by a ratio of eight to one.{{cite web |title=Bidis: An Overview |url=http://global.tobaccofreekids.org/files/pdfs/en/IW_facts_products_bidis_overview.pdf |archive-url=https://web.archive.org/web/20160416132906/http://global.tobaccofreekids.org/files/pdfs/en/IW_facts_products_bidis_overview.pdf |url-status=dead |archive-date=16 April 2016 |website=Campaign for Tobacco-Free Kids |access-date=4 February 2019}} Another is kretek, a cigarette made with a blend of tobacco and cloves that is popular in Indonesia.{{cite book | last1 = Hanusz | first1 = Mark | title = Smoke; A Century of Kretek}}

No flavored cigarettes, including menthol, beedis, and kreteks, are safe. Indeed, many flavorings produce increased levels of acetaldehyde when combusted, enhancing dependence and toxicity.{{r|WHO|pp=26}} Additionally, some flavorings in cigarettes contain toxic compounds such as alkenylbenzenes.{{r|WHO|pp=37}}

{{Main|Menthol cigarette}}

The most popular cigarette flavor by far is menthol, which represents 10% of the global cigarette market and over 25% of the market in countries including the United States, Singapore, the Philippines, and Chile. Menthol is a chemical found in plants of the mint family that produces a cooling sensation in the throat. It is often used as a cigarette additive to mask the flavor and feel of the tobacco smoke or to improve the throat and mouth feel of the cigarette. Menthol increases the addictive properties of the nicotine in cigarettes,{{cite journal |last1=Biswas |first1=L. |last2=Harrison |first2=E. |last3=Gong |first3=Y. |last4=Avusula |first4=R. |last5=Lee |first5=J. |last6=Zhang |first6=M. |last7=Rousselle |first7=T. |last8=Lage |first8=J. |last9=Liu |first9=X. |date=July 2016 |title=Enhancing effect of menthol on nicotine self-administration in rats |journal=Psychopharmacology |publisher=Springer |volume=233 |issue=18 |pages=3417–3427 |doi=10.1007/s00213-016-4391-x |issn=1432-2072 |pmid=27473365 |pmc=4990499 |s2cid=16725395}}{{cite journal |last=Wickham |first=R. J. |date=September 2015 |title=How Menthol Alters Tobacco-Smoking Behavior: A Biological Perspective |journal=Yale Journal of Biology and Medicine |volume=88 |issue=3 |pages=279–287 |issn=1551-4056 |pmc=4553648 |pmid=26339211 |s2cid=8093704}} in part by increasing the density of nicotine receptors in the brain.{{cite journal |last=Kabbani |first=Nadine |date=July 2013 |title=Not so Cool? Menthol's discovered actions on the nicotinic receptor and its implications for nicotine addiction |journal=Frontiers in Pharmacology |publisher=Frontiers Media |volume=4 |pages=95 |doi=10.3389/fphar.2013.00095 |doi-access=free |issn=1663-9812 |pmc=3720998 |pmid=23898298 |s2cid=127825}}

In the United States, menthol cigarettes are used disproportionately by African Americans:{{cite journal |last1=Cohn |first1=Amy M. |last2=Alexander |first2=Adam C. |last3=Ehlke |first3=Sarah J. |date=August 2021 |title=Affirming the Abuse Liability and Addiction Potential of Menthol: Differences in Subjective Appeal to Smoking Menthol Versus Non-Menthol Cigarettes Across African American and White Young Adult Smokers |editor-last=Munafò |editor-first=Marcus |editor-link=Marcus Munafo |journal=Nicotine & Tobacco Research |publisher=Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco |volume=ntab137 |issue=1 |pages=20–27 |doi=10.1093/ntr/ntab137 |eissn=1469-994X |issn=1462-2203 |lccn=00244999 |pmc=8666118 |pmid=34405884 |s2cid=237197350}} more than 70% of African-American smokers primarily use menthols, compared to approximately 30% of White American smokers.{{cite journal |last=Gardiner |first=Phillip S. |date=February 2004 |title=The African Americanization of menthol cigarette use in the United States |url=https://www.acbhcs.org/Tobacco/docs/2017/African_Americanization.pdf |url-status=live |editor-last=Munafò |editor-first=Marcus |editor-link=Marcus Munafo |journal=Nicotine & Tobacco Research |publisher=Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco |volume=6 |issue=Suppl 1 |pages=55–65 |doi=10.1080/14622200310001649478 |eissn=1469-994X |issn=1462-2203 |lccn=00244999 |pmid=14982709 |s2cid=1486105 |archive-url=https://web.archive.org/web/20210501151043/http://www.acbhcs.org/Tobacco/docs/2017/African_Americanization.pdf |archive-date=1 May 2021 |access-date=7 January 2022}}{{cite web| url=http://archive.sph.harvard.edu/press-releases/archives/2005-releases/press08182005.html| title=Harvard Researchers Gather More Evidence Implicating Menthol in Health Disparities Between White and Black Smokers|date=August 18, 2005|publisher=Harvard School of Public Health}} In fact, menthol tobacco marketing is specifically targeted to African Americans; it is a subject of research and it has been a subject of litigation on discrimination grounds. This high use by African Americans is largely the result of deliberate marketing campaigns by tobacco companies, which exacerbated small racial differences in menthol cigarette preferences into large ones.{{Cite web| first1 = Jim |last1=Edwards |date=January 5, 2011 |title = Why Big Tobacco Targeted Blacks With Ads for Menthol Cigarettes|website=CBS News | access-date = 2018-05-24| url = https://www.cbsnews.com/news/why-big-tobacco-targeted-blacks-with-ads-for-menthol-cigarettes/}} Racial marketing strategies changed during the Fifties. The civil rights movement led to the rise of African-American publications, such as Ebony. This helped tobacco companies to target separate marketing messages by race.{{Cite conference| publisher = U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute| pages = 684| last1 = Davis| first1 = Ronald M.| last2 = Gilpin| first2 = Elizabeth A.| last3 = Loken| first3 = Barbara| last4 = Viswanath| first4 = K.| last5 = Wakefield| first5 = Melanie A.| authorlink5 = Melanie Wakefield| title = The role of the media in promoting and reducing tobacco use| series = National Cancer Institute tobacco control monograph series| date = 2008 |url=https://permanent.access.gpo.gov/lps119239/m19_complete.pdf}}{{rp|57}} Tobacco companies supported civil rights organizations, and advertised their support heavily. Industry motives were, according to their public statements, to support civil rights causes; according to an independent review of internal tobacco industry documents, they were "to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts". There had been internal resistance to tobacco sponsorship, and some organizations are now rejecting nicotine funding as a matter of policy.{{Cite journal| doi = 10.1136/tc.11.4.336 | volume = 11| issue = 4| pages = 336–345| last1 = Yerger| first1 = V. B.| last2 = Malone| first2 = R. E.| title = African American leadership groups: smoking with the enemy| journal = Tobacco Control| date = 2002-12-01| url= | pmid = 12432159| pmc = 1747674}} Tobacco company Lorillard even gave out free menthol cigarette samples to children in black neighborhoods in the U.S. in the 1950s.{{Cite news| agency = Associated Press| title = Cigarette Suit Says Maker Gave Samples To Children| work = The New York Times| access-date = 2018-05-24| date = 2004-06-27| url = https://www.nytimes.com/2004/06/27/us/cigarette-suit-says-maker-gave-samples-to-children.html}}{{cite web |title=Evans v. Lorillard: A Bittersweet Victory Against the Tobacco Industry |url=https://publichealthlawcenter.org/sites/default/files/resources/tclc-Evans-v-Lorillard-case-study-2016.pdf |website=Tobacco Control Legal Consortium |publisher=Mitchell Hamline School of Law |access-date=20 December 2018 |date=August 2016}}

In addition to high use by African Americans, menthol cigarettes are used disproportionately by adolescents, women, and lesbian, gay, bisexual, and transgender (LGBT) Americans.{{Cite journal| doi = 10.2196/jmir.5694| issn = 1439-4456| volume = 19| issue = 2| pages = e56| last1 = Rose| first1 = Shyanika W| last2 = Jo| first2 = Catherine L| last3 = Binns| first3 = Steven| last4 = Buenger| first4 = Melissa| last5 = Emery| first5 = Sherry| last6 = Ribisl| first6 = Kurt M| title = Perceptions of Menthol Cigarettes Among Twitter Users: Content and Sentiment Analysis| journal = Journal of Medical Internet Research| date = 2017-02-27| pmid = 28242592| pmc = 5348619| doi-access = free}} LGBT Americans are twice as likely as straight ones to use menthol cigarettes, according to CDC research.{{Cite journal| doi = 10.1016/j.amepre.2014.07.044| issn = 0749-3797| volume = 48| issue = 1| pages = 93–97| last1 = Fallin| first1 = Amanda| last2 = Goodin| first2 = Amie J.| last3 = King| first3 = Brian A.| title = Menthol Cigarette Smoking among Lesbian, Gay, Bisexual, and Transgender Adults| journal = American Journal of Preventive Medicine| date = January 2015| pmid = 25245795| pmc = 4454462}} Where these demographics overlap, menthol use is especially high: most female LGBT smokers use menthols, as do 80 percent of African American youth smokers and 70 percent of LGBT youth smokers.{{cite web |last1=Moodie-Mills |first1=Aisha |title=Flavored Disease and Death for Minorities |url=https://www.americanprogress.org/issues/healthcare/reports/2011/05/12/9668/flavored-disease-and-death-for-minorities/ |website=Center for American Progress |access-date=4 October 2018 |date=May 12, 2011}} Tobacco companies have targeted the LGBT community with advertising for menthol cigarettes, most notably through Project SCUM.

File:Montecristo Cigar.jpg, a brand of Cuban cigars]]

Little cigars, both cigarette-sized ones as well as mid-sized cigarillos, are typically flavored, unlike full-size, hand-wrapped premium cigars. Small cigars and cigarillos are disproportionately used by lower income and less educated people,{{Cite journal| doi = 10.1093/ntr/nts178| issn = 1462-2203| volume = 15| issue = 2| pages = 608–614| last1 = King| first1 = Brian A.| last2 = Dube| first2 = Shanta R.| last3 = Tynan| first3 = Michael A.| title = Flavored Cigar Smoking Among U.S. Adults: Findings From the 2009–2010 National Adult Tobacco Survey | journal = Nicotine & Tobacco Research | date = February 2013|pmid=22927687| doi-access = }} young people,{{Cite journal| issn = 0149-2195| volume = 63| issue = 30| pages = 650–654| last1 = Corey| first1 = C. G.| last2 = King| first2 = B. A.| last3 = Coleman| first3 = B. N.| last4 = Delnevo| first4 = C. D.| last5 = Husten| first5 = C. G.| last6 = Ambrose| first6 = B. K.| last7 = Apelberg| first7 = B. J.| title = Little filtered cigar, cigarillo, and premium cigar smoking among adults--United States, 2012-2013.| journal = MMWR. Morbidity and Mortality Weekly Report| date = August 2014| pmid = 25078654| pmc = 4584787}}{{Cite journal| doi = 10.1016/j.jadohealth.2013.07.033| issn = 1054-139X| volume = 54| issue = 1| pages = 40–46| last1 = King| first1 = Brian A.| last2 = Tynan| first2 = Michael A.| last3 = Dube| first3 = Shanta R.| last4 = Arrazola| first4 = Rene| title = Flavored-Little-Cigar and Flavored-Cigarette Use Among U.S. Middle and High School Students| journal = The Journal of Adolescent Health | date = January 2014| pmid = 24161587| pmc = 4572463}} African Americans, Hispanics, LGBT people, and men.{{Cite journal| doi = 10.1093/ntr/ntv022| pmid = 25634932| issn = 1462-2203| volume = 17| issue = 12| pages = 1473–1481| last1 = Cohn| first1 = Amy| last2 = Cobb| first2 = Caroline O.| last3 = Niaura| first3 = Raymond S.| last4 = Richardson| first4 = Amanda| title = The Other Combustible Products: Prevalence and Correlates of Little Cigar/Cigarillo Use Among Cigarette Smokers| journal = Nicotine & Tobacco Research| date = 2015-12-01| citeseerx = 10.1.1.855.9741}} Usage of flavored cigarillos has grown explosively, with sales in U.S. convenience stores up 50% between 2008 and 2015,{{cite web |last1=Bach |first1=Laura |title=Flavored Tobacco Products Attract Kids |url=https://www.tobaccofreekids.org/assets/factsheets/0383.pdf |publisher=Campaign for Tobacco-Free Kids |access-date=October 13, 2018 |date=September 13, 2018}} after tripling between 1997 and 2007. Among adult and youth cigar users, about 40 percent use flavored cigarillos. The most popular flavors for cigarillos are fruit (38.8 percent), sweet or candy (21.2 percent), and wine (17.0 percent). Flavored cigarillos are popular with lower income and younger people in part because they are inexpensive and are promoted by tobacco companies as affordable alternatives to cigarettes. Unlike cigarettes, cigarillos can be sold in small packs of one or two each for around 99¢ for two.{{Cite journal| doi = 10.1353/hpu.2013.0173| issn = 1049-2089| volume = 24| issue = 4| pages = 1657–1665| last1 = Milam| first1 = Adam J.| last2 = Bone| first2 = Lee R.| last3 = Byron| first3 = M. Justin| last4 = Hoke| first4 = Kathleen| last5 = Williams| first5 = Carla D.| last6 = Furr-Holden| first6 = C. Debra| last7 = Stillman| first7 = Frances A.| title = Cigarillo use among High-Risk Urban Young Adults| journal = Journal of Health Care for the Poor and Underserved| date = November 2013| pmid = 24185161| pmc = 3988125}} In many jurisdictions, cigarillos and other cigars are taxed at lower rates than cigarettes, making them more appealing to low-income populations, including youth, young adults, and the unemployed.

{{Further|Electronic cigarette and e-cigarette liquid marketing|Regulation of electronic cigarettes|Usage of electronic cigarettes}}

File:CDC electronic cigarettes October 2015 (cropped).png]]

E-liquid, the nicotine-containing liquid used in electronic cigarettes, is usually flavored. E-liquids come in a myriad of flavors, including mint, spice, fruit, and candy ones. A 2017 survey of internet e-cigarette retailers found 15,586 unique flavors of e-liquid and counting, up from the 7,764 found in a 2014 analysis.{{Cite journal| doi = 10.2196/jmir.8550| issn = 1439-4456| volume = 20| issue = 3| pages = e80| last1 = Hsu| first1 = Greta| last2 = Sun| first2 = Jessica Y| last3 = Zhu| first3 = Shu-Hong| title = Evolution of Electronic Cigarette Brands From 2013-2014 to 2016-2017: Analysis of Brand Websites| journal = Journal of Medical Internet Research| date = 12 March 2018| pmid = 29530840| pmc = 5869180| doi-access = free}} In surveys of regular e-cigarette users, the most popular e-liquid flavors are largely tobacco, mint and fruit,{{cite journal|last1=Hajek|first1=P|last2=Etter|first2=JF|last3=Benowitz|first3=N|last4=Eissenberg|first4=T|last5=McRobbie|first5=H|title=Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit.|url=http://tobonline.com/Media/Default/Article/Addiction-%20Hajek%2014.pdf|journal=Addiction|date=31 July 2014|pmid=25078252|doi=10.1111/add.12659|volume=109|issue=11|pages=1801–10|pmc=4487785}} although candy and dessert flavors are also common. Mango is the most popular JUUL flavor.{{cite news |last1=Teitell |first1=Beth |url=https://www.bostonglobe.com/metro/2017/11/15/where-teenagers-are-high-school-bathrooms-vaping/IJ6xYWWlOTKqsUGTTlw4UO/story.html |title='Juuling': The most widespread phenomenon you've never heard of |work=The Boston Globe |date=November 16, 2017}} Fruit flavored e-liquid is the most commonly marketed e-liquid flavor on social media.{{cite conference|last1=Liang |first1=Yunji |last2=Zheng |first2=Xiaolong |last3=Dajun Zheng |first3=Daniel |last4 = Zhou |first4 = Xingshe |editor1-first=Xiaolong |editor1-last=Zheng| editor2-first=Daniel |editor2-last=Dajun Zeng |editor3-first=Hsinchun |editor3-last=Chen|editor4-first=Scott J. |editor4-last=Leischow|title=Impact of Flavor on Electronic Cigarette Marketing in Social Media|conference=Smart Health: International Conference, ICSH 2015 |location=Phoenix, AZ, USA |date=22 January 2016 |url=https://books.google.com/books?id=cM5yCwAAQBAJ&pg=PA279|publisher=Springer|isbn=978-3-319-29175-8|page=283}} Flavored e-liquids form a major part of the appeal for using e-cigarettes,{{cite journal|last1=Hefner|first1=Kathryn|last2=Valentine|first2=Gerald|last3=Sofuoglu|first3=Mehmet|title=Electronic cigarettes and mental illness: Reviewing the evidence for help and harm among those with psychiatric and substance use disorders|journal=The American Journal on Addictions|volume=26|issue=4|pages=306–315|year=2017|issn=1055-0496|doi=10.1111/ajad.12504|pmid=28152247|s2cid=24298173}} especially for youth, for whom flavoring is cited as a major reason for using e-cigarettes.{{cite web|archive-url=https://web.archive.org/web/20141006173717/http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9207931/k.D09C/Heart_and_Stroke_Foundation_Ecigarettes_in_Canada.htm|url=http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.9207931/k.D09C/Heart_and_Stroke_Foundation_Ecigarettes_in_Canada.htm|title=Heart and Stroke Foundation: E-cigarettes in Canada|archive-date=6 October 2014|publisher=Heart and Stroke Foundation|date=September 2014}}

Some e-liquid flavorings are toxic. Cinnamaldehyde is a highly cytotoxic material in vitro used in cinnamon-flavored e-liquids.{{cite journal|last1=Ebbert|first1=Jon O.|last2=Agunwamba|first2=Amenah A.|last3=Rutten|first3=Lila J.|title=Counseling Patients on the Use of Electronic Cigarettes|journal=Mayo Clinic Proceedings|volume=90|issue=1|year=2015|pages=128–134|issn=0025-6196|doi=10.1016/j.mayocp.2014.11.004|pmid=25572196|doi-access=free}} Cinnamaldehyde have been identified as cytotoxic at the amount of about 400 times less than those allowed for use by the US Environmental Protection Agency.{{cite journal|last1=Farsalinos|first1=K. E.|last2=Polosa|first2=R.|title=Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systematic review|journal=Therapeutic Advances in Drug Safety|volume=5|issue=2|year=2014|pages=67–86|issn=2042-0986|doi=10.1177/2042098614524430|pmc=4110871|pmid=25083263}} A 2018 in vitro study found that exposing lung cells to liquid or vapor containing cinnamaldehyde causes significant and rapid damage to their cilia and mitochondria. This led the authors of the study to conclude that "inhalational exposures of cinnamaldehyde may increase the risk of respiratory infections in e-cigarette users."{{cite conference |url=http://www.abstractsonline.com/pp8/#!/4499/presentation/10252 |title=The E-Cigarette Flavoring Cinnamaldehyde Suppresses Mitochondrial Function and Transiently Impairs Cilia Beat Frequency in Human Bronchial Epithelial Cells |last1=Clapp |first1= P. |last2=Lavrich |first2=K. |date=May 23, 2018 |location=San Diego, CA |conference=American Thoracic Society 2018 International Conference }} Some e-liquids containing cinnamaldehyde stimulate TRPA1, which might induce effects on the lung. E-liquids contain possibly toxic aldehydes and reactive oxygen species (ROS).{{cite journal|last1=Rowell|first1=Temperance R|last2=Tarran|first2=Robert|title=Will Chronic E-Cigarette Use Cause Lung Disease?|journal=American Journal of Physiology. Lung Cellular and Molecular Physiology|year=2015|pages=L1398–L1409|issn=1040-0605|doi=10.1152/ajplung.00272.2015|pmid=26408554|pmc=4683316|volume=309|issue=12}} Many flavors are known aldehydes, such as anisaldehyde, cinnamaldehyde, and isovaleraldehyde. A 2012 study found butterscotch flavor was highly toxic with one liquid and two others had a low toxicity.{{cite journal|last1=Bhatnagar|first1=A.|last2=Whitsel|first2=L. P.|last3=Ribisl|first3=K. M.|last4=Bullen|first4=C.|last5=Chaloupka|first5=F.|last6=Piano|first6=M. R.|last7=Robertson|first7=R. M.|last8=McAuley|first8=T.|last9=Goff|first9=D.|last10=Benowitz|first10=N.|title=Electronic Cigarettes: A Policy Statement From the American Heart Association|journal=Circulation|date=24 August 2014|volume=130|issue=16|pages=1418–1436|doi=10.1161/CIR.0000000000000107|pmid=25156991|url=https://cloudfront.escholarship.org/dist/prd/content/qt52p2317d/qt52p2317d.pdf?t=otlwup|pmc=7643636}} A 2014 in vitro study demonstrated that e-cigarette use of a "balsamic" flavor with no nicotine can activate the release of proinflammatory cytokine in lung epithelial cells and keratinocytes.{{cite journal|last1=Rom|first1=Oren|last2=Pecorelli|first2=Alessandra|last3=Valacchi|first3=Giuseppe|last4=Reznick|first4=Abraham Z.|title=Are E-cigarettes a safe and good alternative to cigarette smoking?|journal=Annals of the New York Academy of Sciences|volume=1340|issue=1|year=2014|pages=65–74|issn=0077-8923|doi=10.1111/nyas.12609|pmid=25557889|bibcode=2015NYASA1340...65R|s2cid=26187171}} Some additives may be added to reduce the irritation on the pharynx.{{cite journal|last1=Jimenez Ruiz|first1=CA|last2=Solano Reina|first2=S|last3=de Granda Orive|first3=JI|last4=Signes-Costa Minaya|first4=J|last5=de Higes Martinez|first5=E|last6=Riesco Miranda|first6=JA|last7=Altet Gómez|first7=N|last8=Lorza Blasco|first8=JJ|last9=Barrueco Ferrero|first9=M|last10=de Lucas Ramos|first10=P|title=The electronic cigarette. Official statement of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on the efficacy, safety and regulation of electronic cigarettes.|journal=Archivos de Bronconeumologia|date=August 2014|volume=50|issue=8|pages=362–7|doi=10.1016/j.arbres.2014.02.006|pmid=24684764}} The long-term toxicity is subject to the additives and contaminants in the e-liquid.{{cite journal|last1=Bertholon|first1=J.F.|last2=Becquemin|first2=M.H.|last3=Annesi-Maesano|first3=I.|last4=Dautzenberg|first4=B.|title=Electronic Cigarettes: A Short Review|journal=Respiration|year=2013|issn=1423-0356|volume=86|issue=5|pages=433–8|doi=10.1159/000353253|pmid=24080743|doi-access=free}}

Certain e-liquid flavorings contain diacetyl and acetyl propionyl which give a buttery taste.{{cite journal|last1=Hildick-Smith|first1=Gordon J.|last2=Pesko|first2=Michael F.|last3=Shearer|first3=Lee|last4=Hughes|first4=Jenna M.|last5=Chang|first5=Jane|last6=Loughlin|first6=Gerald M.|last7=Ipp|first7=Lisa S.|title=A Practitioner's Guide to Electronic Cigarettes in the Adolescent Population|journal=Journal of Adolescent Health|volume=57|issue=6|pages=574–9|year=2015|issn=1054-139X|doi=10.1016/j.jadohealth.2015.07.020|pmid=26422289|doi-access=free}} Diacetyl and acetyl propionyl are associated with bronchiolitis obliterans ("popcorn lung"), a serious lung disease. A 2015 review recommended for specific regulation of diacetyl and acetyl propionyl in e-liquid, which are safe when ingested but have been associated with respiratory harm when inhaled.{{cite journal|last1=Farsalinos|first1=Konstantinos|last2=LeHouezec|first2=Jacques|title=Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)|journal=Risk Management and Healthcare Policy|year=2015|pages=157–67|issn=1179-1594|doi=10.2147/RMHP.S62116|pmc=4598199|pmid=26457058|volume=8 |doi-access=free }} Both diacetyl and acetyl-propionyl have been found in concentrations above those recommended by the US National Institute for Occupational Safety and Health. Diacetyl is normally found at lower levels in e-cigarettes than in traditional cigarettes. Concerns exist that the flavors and additives in e-cigarettes might lead to diseases, including the popcorn lung.{{cite journal|last1=Bhatnagar|first1=Aruni|title=Cardiovascular Perspective of the Promises and Perils of E-Cigarettes|journal=Circulation Research|volume=118|issue=12|year=2016|pages=1872–1875|issn=0009-7330|doi=10.1161/CIRCRESAHA.116.308723|pmid=27283531|pmc=5505630}} The cardiovascular effects, including a vast range of flavorings and fragrances, is unknown.{{cite journal|last1=Benowitz|first1=Neal L.|last2=Burbank|first2=Andrea D.|title=Cardiovascular toxicity of nicotine: Implications for electronic cigarette use|journal=Trends in Cardiovascular Medicine|year=2016|issn=1050-1738|doi=10.1016/j.tcm.2016.03.001|pmid=27079891|volume=26|issue=6|pmc=4958544|pages=515–23}} The irritants butyl acetate, diethyl carbonate, benzoic acid, quinoline, bis(2-ethylhexyl) phthalate, and 2,6-dimethyl phenol were present as undeclared ingredients in the e-liquid.{{cite journal|vauthors=Sanford Z, Goebel L |title=E-cigarettes: an up to date review and discussion of the controversy|journal=W V Med J|volume=110|issue=4|pages=10–5|year=2014|pmid=25322582}} Hindering safety assessments of e-liquids is the fact that the precise ingredients of e-cigarettes and e-liquids are not known.{{cite journal|last1=Schraufnagel|first1=Dean E.|last2=Blasi|first2=Francesco|last3=Drummond|first3=M. Bradley|last4=Lam|first4=David C. L.|last5=Latif|first5=Ehsan|last6=Rosen|first6=Mark J.|last7=Sansores|first7=Raul|last8=Van Zyl-Smit|first8=Richard|s2cid=43763340|title=Electronic Cigarettes. A Position Statement of the Forum of International Respiratory Societies|journal=American Journal of Respiratory and Critical Care Medicine|volume=190|issue=6|year=2014|pages=611–618|issn=1073-449X|doi=10.1164/rccm.201407-1198PP|pmid=25006874|url=https://figshare.com/articles/journal_contribution/10758143 }}

With the current popular trend of flavored e-cigarettes use among young generations, there is concern about the potential long-term health of the public.{{cite journal|last1=Drazen|first1=Jeffrey M.|last2=Morrissey|first2=Stephen|last3=Campion|first3=Edward W.|date=2019-02-14|title=The Dangerous Flavors of E-Cigarettes|journal=New England Journal of Medicine|language=en|volume=380|issue=7|pages=679–680|doi=10.1056/NEJMe1900484|pmid=30699053|issn=0028-4793|doi-access=free}}

Heated tobacco products are frequently flavored.{{cite web|url=https://www.who.int/tobacco/publications/prod_regulation/heated-tobacco-products/en/|title=Heated tobacco products (HTPs) information sheet|publisher=World Health Organization|date=May 2018}} It is possible that these products could appeal to non-smokers, especially since they are available in various flavors.{{cite web|url=http://www.rivm.nl/bibliotheek/rapporten/2016-0103.pdf|title=Alternatieve tabaksproducten: harm reduction?|trans-title=Alternative tobacco products: harm reduction?|page=36|publisher=Netherlands National Institute for Public Health and the Environment|year=2016}}

File:Vodni dymka tabak.jpg (muʽassel or shisha)]]

Muʽassel (also known as shisha), the tobacco product used in hookahs, is almost always flavored: more than 85% of mu'assel sold in the United States is flavored. Typical flavors include apple, plum, coconut, mango, mint, strawberry and cola,{{cite web |title=Shisha |url=https://www.bhf.org.uk/informationsupport/risk-factors/smoking/shisha |website=British Heart Foundation |access-date=16 January 2019 |language=en}} with mint and double apple ({{langx|ar|تفاحتين}}) being the most popular.{{cite web |title=Listing the Most Popular Shisha Flavors - |url=http://radhookahpipes.com/popular-shisha-flavors/ |website=Rad Hookah Pipes |access-date=4 February 2019 |language=en |date=11 March 2016}} Unusual flavors, including white gummy bear, blueberry muffin, spiced chai and Powerbull flavor (similar to the flavor of a Red Bull energy drink), have been introduced in recent years by modern tobacco companies.{{cite web |title=Our Range |url=http://www.alfakher.com/our-range |website=الفاخر |publisher=شركة الفاخر لتجارة التبغ |access-date=27 June 2018}} Heating these flavorings releases toxic chemicals and carcinogens such as carbon monoxide (CO), polycyclic aromatic hydrocarbons (PAHs), furans, phenols, aldehydes (such as acrolein), and acids, in addition to nitrogenous carcinogens, alcohols, and heavy metals, all of which are dangerous to human health.{{cite journal |last1=Alarabi |first1=A. B. |last2=Karim |first2=Z. A. |last3=Alshbool |first3=F. Z. |last4=Khasawneh |first4=F. T. |last5=Hernandez |first5=Keziah R. |last6=Lozano |first6=Patricia A. |last7=Montes Ramirez |first7=Jean E. |last8=Rivera |first8=José O. |date=February 2020 |title=Short-Term Exposure to Waterpipe/Hookah Smoke Triggers a Hyperactive Platelet Activation State and Increases the Risk of Thrombogenesis |journal=Arteriosclerosis, Thrombosis, and Vascular Biology |publisher=Lippincott Williams & Wilkins |volume=40 |issue=2 |pages=335–349 |doi=10.1161/ATVBAHA.119.313435 |doi-access=free |issn=1079-5642 |pmc=7000176 |pmid=31941383 |s2cid=210335103 }}{{cite journal |last1=Patel |first1=Mit P. |last2=Khangoora |first2=Vikramjit S. |last3=Marik |first3=Paul E. |date=October 2019 |title=A Review of the Pulmonary and Health Impacts of Hookah Use |journal=Annals of the American Thoracic Society |publisher=American Thoracic Society |volume=16 |issue=10 |pages=1215–1219 |doi=10.1513/AnnalsATS.201902-129CME |doi-access= |issn=2325-6621 |pmid=31091965 |s2cid=155103502 }}{{cite journal |last1=Qasim |first1=Hanan |last2=Alarabi |first2=A. B. |last3=Alzoubi |first3=K. H. |last4=Karim |first4=Z. A. |last5=Alshbool |first5=F. Z. |last6=Khasawneh |first6=F. T. |date=September 2019 |title=The effects of hookah/waterpipe smoking on general health and the cardiovascular system |url=https://environhealthprevmed.biomedcentral.com/track/pdf/10.1186/s12199-019-0811-y.pdf |url-status=live |journal=Environmental Health and Preventive Medicine |publisher=BioMed Central |volume=24 |issue=58 |page=58 |doi=10.1186/s12199-019-0811-y |doi-access=free |issn=1347-4715 |pmc=6745078 |pmid=31521105 |bibcode=2019EHPM...24...58Q |s2cid=202570973 |archive-url=https://web.archive.org/web/20210424161857/https://environhealthprevmed.biomedcentral.com/track/pdf/10.1186/s12199-019-0811-y.pdf |archive-date=24 April 2021 |access-date=8 September 2021}}{{cite journal |last1=Etemadi |first1=Arash |last2=Blount |first2=Benjamin C. |last3=Calafat |first3=Antonia M. |last4=Chang |first4=Cindy M. |last5=De Jesus |first5=Victor R. |last6=Poustchi |first6=Hossein |last7=Wang |first7=Lanqing |last8=Pourshams |first8=Akram |last9=Shakeri |first9=Ramin |last10=Shiels |first10=Meredith S. |last11=Inoue-Choi |first11=Maki |last12=Ambrose |first12=Bridget K. |last13=Christensen |first13=Carol H. |last14=Wang |first14=Baoguang |last15=Ye |first15=Xiaoyun |last16=Murphy |first16=Gwen |last17=Feng |first17=Jun |last18=Xia |first18=Baoyun |last19=Sosnoff |first19=Connie S. |last20=Boffetta |first20=Paolo |last21=Brennan |first21=Paul |last22=Bhandari |first22=Deepak |last23=Kamangar |first23=Farin |last24=Dawsey |first24=Sanford M. |last25=Abnet |first25=Christian C. |last26=Freedman |first26=Neal D. |last27=Malekzadeh |first27=Reza |date=February 2019 |title=Urinary Biomarkers of Carcinogenic Exposure among Cigarette, Waterpipe, and Smokeless Tobacco Users and Never Users of Tobacco in the Golestan Cohort Study |journal=Cancer Epidemiology, Biomarkers & Prevention |publisher=American Association for Cancer Research |volume=28 |issue=2 |pages=337–347 |doi=10.1158/1055-9965.EPI-18-0743 |eissn=1538-7755 |issn=1055-9965 |pmc=6935158 |pmid=30622099 |s2cid=58560832}}{{Cite journal| doi = 10.1038/s41598-018-35368-6| pmid = 30451904| pmc = 6242864| issn = 2045-2322| volume = 8| issue = 1| pages = 17028| last1 = Farag| first1 = Mohamed A.| last2 = Elmassry| first2 = Moamen M.| last3 = El-Ahmady| first3 = Sherweit H.| title = The characterization of flavored hookahs aroma profile and in response to heating as analyzed via headspace solid-phase microextraction (SPME) and chemometrics| journal = Scientific Reports| date = 2018-11-19| bibcode = 2018NatSR...817028F}} A comparison of 13 common hookah flavors found that melon flavors are the most dangerous, with their smoke containing four classes of hazards in high concentrations.

Many types of smokeless tobacco are flavored. Nasal snuff is typically flavored, with common flavors including coffee, chocolate, bordeaux, honey, vanilla, cherry, orange, apricot, plum, camphor, cinnamon, rose, spearmint, Bourbon, Cola, and whisky.The Old Snuff House of Fribourg & Treyer at the Sign of the Rasp & Crown, No.34 St. James's Haymarket, London, S.W., 1720, 1920. Author: George Evens and Fribourg & Treyer. Publisher: Nabu Press, London, England. Reproduced 5 August 2010, {{ISBN|978-1176904705}} Gutka, a chewing tobacco preparation commonly used in parts of India, is commonly flavored,{{cite web|url=http://www.cpaaindia.org/activities/projects.htm#gutkha|title=CPAA: Quit Smoking Campaign, Anti Tobacco & Quit Smoking Campaign|access-date=30 May 2015|archive-url=https://web.archive.org/web/20150517015526/http://www.cpaaindia.org/activities/projects.htm#gutkha|archive-date=17 May 2015|url-status=dead}} as is naswar, a type of dipping tobacco common in Central and South Asia.{{Cite journal| volume = 28| pages = 1829–1833| last1 = Sajid| first1 = Faiza| last2 = Bano| first2 = Samina| title = Effects of smokeless dipping tobacco (Naswar) consumption on antioxidant enzymes and lipid profile in its users| journal = Pakistan Journal of Pharmaceutical Sciences| date = 2015-09-20| issue = 5 Suppl| pmid = 26525023}} Moist snuff (dip), snus, and dissolvables are also often flavored. Accounting for more than half of moist snuff and more than four-fifths of snus sold, flavored smokeless tobacco has been becoming very popular and driving the growth in smokeless tobacco usage in the United States.{{Cite journal| doi = 10.1093/ntr/ntx123| issn = 1462-2203| volume = 20| issue = 6| pages = 698–706| last1 = Kuiper| first1 = Nicole M| last2 = Gammon| first2 = Doris| last3 = Loomis| first3 = Brett| last4 = Falvey| first4 = Kyle| last5 = Wang| first5 = Teresa W.| last6 = King| first6 = Brian A.| last7 = Rogers| first7 = Todd| title = Trends in Sales of Flavored and Menthol Tobacco Products in the United States during 2011–2015| journal = Nicotine & Tobacco Research| date = 3 May 2018| pmid = 28575408| pmc = 5711620}}

Flavored tobacco products—particularly flavored cigarettes (including menthol),{{Cite journal| doi = 10.2105/AJPH.2004.061200| issn = 0090-0036| volume = 96| issue = 2| pages = 244–251| last1 = Lewis| first1 = M. Jane| last2 = Wackowski| first2 = Olivia| title = Dealing With an Innovative Industry: A Look at Flavored Cigarettes Promoted by Mainstream Brands| journal = American Journal of Public Health| date = February 2006| pmid = 16380563| pmc = 1470487}} cigarillos, hookah,{{cite web |last1=Bach |first1=Laura |title=Hookah is not Harmless |url=https://www.tobaccofreekids.org/assets/factsheets/0384.pdf |website=Campaign for Tobacco-Free Kids |access-date=January 16, 2019 |date=May 10, 2016}}{{Cite journal| doi = 10.15585/mmwr.mm6722a3| pmid = 29879097| pmc = 5991815| volume = 67| issue = 22| pages = 629–633| last1 = Wang| first1 = Teresa W.| title = Tobacco Product Use Among Middle and High School Students — United States, 2011–2017| journal = MMWR. Morbidity and Mortality Weekly Report| date = June 7, 2018}} and electronic cigarettes{{cite report |date=2016 |title=E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General |url=https://e-cigarettes.surgeongeneral.gov/documents/2016_sgr_full_report_non-508.pdf |publisher=U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health |location=Rockville, MD |page=40 |access-date=1 November 2018 }}{{cite journal |last1=Kong |first1=G. |last2=Morean |first2=M.E. |last3=Cavallo |first3=D.A. |last4=Camenga |first4=D.R. |last5=Krishnan-Sarin |first5=S. |title=Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults |journal=Nicotine & Tobacco Research |year=2014 |issn=1462-2203 |doi=10.1093/ntr/ntu257 |pmid=25481917 |volume=17 |issue=7 |pages=847–54 |pmc=4674436}}—are disproportionately preferred by adolescents and young adults. Because of the high availability of these popular flavors, flavored tobacco products are widely used for at least 80% of youth tobacco users.{{Cite journal| doi = 10.1001/jama.2015.13802| pmid = 26502219| pmc = 6467270| issn = 0098-7484| volume = 314| issue = 17| pages = 1871–1873| last1 = Ambrose| first1 = Bridget K.| last2 = Day| first2 = Hannah R.| last3 = Rostron| first3 = Brian| last4 = Conway| first4 = Kevin P.| last5 = Borek| first5 = Nicolette| last6 = Hyland| first6 = Andrew| last7 = Villanti| first7 = Andrea C.| title = Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014| journal = JAMA| date = 3 November 2015}} According to the CDC, 67% of high school students and 49% of middle school students who used tobacco products in the past 30 days reported using a flavored tobacco product during that time.{{cite web |url=https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm|title=Youth and Tobacco Use|date=2019-12-10}}

Flavored tobacco products promote youth smoking initiation and help young occasional smokers to become daily smokers by reducing or masking the natural harshness and taste of tobacco smoke and increasing the social acceptability of the toxic tobacco product.{{Cite journal| doi = 10.1136/tc.11.suppl_1.i32| issn = 1468-3318| volume = 11| issue = suppl 1| pages = i32–i39| last1 = Wayne| first1 = G. Ferris| last2 = Connolly| first2 = G. N.| title = How cigarette design can affect youth initiation into smoking: Camel cigarettes 1983-93| journal = Tobacco Control| date = March 2002| url= | pmid = 11893812| pmc = 1766065}} Menthol appeals to younger or beginning smokers largely because the menthol masks the harshness and discomfort of inhaling smoke, making smoking more palatable. Trying menthols increases smoking initiation among youth and young adults, and menthols users face greater addiction and decreased success in quitting smoking.{{cite report|date=2013 |title= Preliminary Scientific Evaluation of the Possible Public Health Effects of Menthol versus Nonmenthol Cigarettes |url= https://www.fda.gov/downloads/ucm361598.pdf |archive-url= https://web.archive.org/web/20151124102929/http://www.fda.gov/downloads/UCM361598.pdf |url-status= dead |archive-date= November 24, 2015 |publisher=Food and Drug Administration |access-date=13 January 2019 }} Young people who use menthol cigarettes are 80% more likely to become life-long smokers than those who use regular cigarettes. Likewise, studies associate youth hookah use with subsequent cigarette use, increased intensity of cigarette use, and decreased success in quitting. A 2016 study found 11- to 16-year-old English children exposed to e-cigarette advertisements highlighting flavored, in contrast to flavor-free e-cigarettes, increased e-cigarette appeal and usage.{{cite journal|last1=Peterson|first1=Lisa A.|last2=Hecht|first2=Stephen S.|title=Tobacco, e-cigarettes, and child health|journal=Current Opinion in Pediatrics|volume=29|issue=2|year=2017|pages=225–230|issn=1040-8703|doi=10.1097/MOP.0000000000000456|pmid=28059903|pmc=5598780}} As such, adolescents were more likely to initiate vaping through flavored e-cigarettes than unflavored ones,{{cite journal|last1=Cormet-Boyaka|first1=Estelle|last2=Zare|first2=Samane|last3=Nemati|first3=Mehdi|last4=Zheng|first4=Yuqing|title=A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type|journal=PLOS ONE|volume=13|issue=3|year=2018|pages=e0194145|issn=1932-6203|doi=10.1371/journal.pone.0194145|pmid=29543907|pmc=5854347|bibcode=2018PLoSO..1394145Z|doi-access=free}} and a majority of youth who used an e-cigarette first tried a flavored e-cigarette.{{cite web|url=https://e-cigarettes.surgeongeneral.gov/documents/2016_SGR_Full_Report_non-508.pdf|title=E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General|publisher=Surgeon General of the United States|pages=1–298|year=2016}}

The goal of tobacco companies also drives the widespread use of flavored tobacco products. According to a 2008 study, the internal tobacco company documents found that makers of the largest menthol cigarette brands in the United States—Kool, Newport, Salem, Marlboro, and Camel—formulated the menthol levels in their cigarettes, as well as their marketing strategies, to entice young people.{{Cite journal| doi = 10.2105/AJPH.2007.125542| pmid = 18633084| pmc = 2509610| issn = 0090-0036| volume = 98| issue = 9| pages = 1685–1692| last1 = Kreslake| first1 = Jennifer M.| last2 = Wayne| first2 = Geoffrey Ferris| last3 = Alpert| first3 = Hillel R.| last4 = Koh| first4 = Howard K.| last5 = Connolly| first5 = Gregory N.| title = Tobacco Industry Control of Menthol in Cigarettes and Targeting of Adolescents and Young Adults| journal = American Journal of Public Health| date = 2008-09-01}} Likewise, multiple reviews of internal tobacco company documents have found that flavored cigarettes are deliberately introduced to appeal to young people, with flavorings often being fine-tuned to best appeal to youth.{{Cite journal| doi = 10.1377/hlthaff.24.6.1601| issn = 0278-2715| volume = 24| issue = 6| pages = 1601–1610| last1 = Carpenter| first1 = Carrie M.| last2 = Wayne| first2 = Geoffrey Ferris| last3 = Pauly| first3 = John L.| last4 = Koh| first4 = Howard K.| last5 = Connolly| first5 = Gregory N.| title = New cigarette brands with flavors that appeal to youth: tobacco marketing strategies| journal = Health Affairs| date = December 2005| pmid = 16284034| doi-access = }}{{Cite journal| doi = 10.1136/tc.2004.009191| issn = 1468-3318| volume = 13| issue = 3| pages = 211–212| last1 = Connolly| first1 = G. N.| title = Sweet and spicy flavours: new brands for minorities and youth| journal = Tobacco Control| date = 2004-09-01| url= | pmid = 15333865| pmc = 1747891}}{{Cite journal| issn = 0964-4563| volume = 11| pages = –5–17| last1 = Cummings| first1 = K. M.| last2 = Morley| first2 = C. P.| last3 = Horan| first3 = J. K.| last4 = Steger| first4 = C.| last5 = Leavell| first5 = N.-R.| title = Marketing to America's youth: evidence from corporate documents| journal = Tobacco Control| date = March 2002| issue = Suppl 1| pmid = 11893810| pmc = 1766057| doi = 10.1136/tc.11.suppl_1.i5}}

Furthermore, flavored tobacco products are often advertised to children and adolescents. Flavored cigarettes have been advertised in magazines frequently read by kids, such as Sports Illustrated, Cosmopolitan, and Rolling Stone and on television programs watched by adolescents. A majority of adolescents and young adults are exposed to cigarillo advertising in magazines and storefronts and on social media. Flavored e-cigarettes have been marketed extensively to youth in retail stores and on television and social media: 78.2 percent of American youth (20.5 million people).{{Cite web|url=https://e-cigarettes.surgeongeneral.gov/getthefacts.html|title=Get the Facts on E-cigarettes |website=Know the Risks: E-Cigarettes and Young People |publisher= U.S. Surgeon General|language=en|access-date=2018-11-08}} A 2018 analysis of the 2014, 2015, and 2016 NYTS data by the CDC found that retail stores were where most youth were exposed to e-cigarette advertisements, followed by online advertising, television advertising, and then newspaper and magazine advertising. About 24 million youth have been exposed to e-cigarette ads on cable TV, primarily due to an ad campaign for blu e-cigarettes.{{Cite journal| doi = 10.1542/peds.2014-0269| issn = 1098-4275| volume = 134| issue = 1| pages = –29–e36| last1 = Duke| first1 = Jennifer C.| last2 = Lee| first2 = Youn O.| last3 = Kim| first3 = Annice E.| last4 = Watson| first4 = Kimberly A.| last5 = Arnold| first5 = Kristin Y.| last6 = Nonnemaker| first6 = James M.| last7 = Porter| first7 = Lauren| title = Exposure to Electronic Cigarette Television Advertisements Among Youth and Young Adults| journal = Pediatrics| access-date = 2019-01-16| date = July 2014| url = http://pediatrics.aappublications.org/content/134/1/e29| pmid = 24918224| doi-access = | url-access = subscription}} On social media, marketing includes images associated with youth culture, endorsements by celebrities and social media influencers popular with youth, and themes that have been found to strongly appeal to youth (such as freedom and rebellion).{{cite journal |last1=Franck |first1=Caroline |last2=Filion |first2=Kristian B. |last3=Kimmelman |first3=Jonathan |last4=Grad |first4=Roland |last5=Eisenberg |first5=Mark J. |title=Ethical considerations of e-cigarette use for tobacco harm reduction |journal=Respiratory Research |date=2016 |volume=17 |issue=1 |pages=53 |doi=10.1186/s12931-016-0370-3 |pmid=27184265 |pmc=4869264 |issn=1465-9921|quote=However, the relative absence of restrictions to date in the US has led e-cigarette marketing to permeate most media outlets through the likes of celebrity endorsements, images associated with youth culture, and statements encouraging consumers to reclaim lost freedoms |doi-access=free }} Ads for flavored e-cigarettes have been shown to cause children to be more interested in buying and trying e-cigarettes, as compared to ads for unflavored e-cigarettes.{{cite journal |last1=Vasiljevic |first1=Milica |last2=Petrescu |first2=Dragos C. |last3=Marteau |first3=Theresa M. |title=Impact of advertisements promoting candy-like flavoured e-cigarettes on appeal of tobacco smoking among children: an experimental study |journal=Tobacco Control |date=December 2016 |volume=25 |issue=e2 |pages=e107–e112 |doi=10.1136/tobaccocontrol-2015-052593 |issn=1468-3318 |pmid=26781305|pmc=5284337 }}{{Cite journal| doi = 10.1136/tobaccocontrol-2015-052593| issn = 0964-4563| volume = 25| issue = e2| pages = –107–e112| last1 = Vasiljevic| first1 = Milica| last2 = Petrescu| first2 = Dragos C| last3 = Marteau| first3 = Theresa M| title = Impact of advertisements promoting candy-like flavoured e-cigarettes on appeal of tobacco smoking among children: an experimental study| journal = Tobacco Control| date = December 2016| pmid = 26781305| pmc = 5284337}}{{Cite journal| doi = 10.1007/s00038-015-0769-5| issn = 1661-8556| volume = 61| issue = 2| pages = 215–224| last1 = Ford| first1 = Allison| last2 = MacKintosh| first2 = Anne Marie| last3 = Bauld| first3 = Linda| last4 = Moodie| first4 = Crawford| last5 = Hastings| first5 = Gerard| title = Adolescents' responses to the promotion and flavouring of e-cigarettes| journal = International Journal of Public Health| date = 2016| pmid = 26650455| pmc = 4819499}}

{{Further|Tobacco packaging warning messages|Regulation of electronic cigarettes}}

Although a few countries have banned flavored cigarettes (except menthol), flavors in most tobacco products remain unregulated across the globe.{{cite journal|last1=Kowitt|first1=Sarah|last2=Meernik|first2=Clare|last3=Baker|first3=Hannah|last4=Osman|first4=Amira|last5=Huang|first5=Li-Ling|last6=Goldstein|first6=Adam|title=Perceptions and Experiences with Flavored Non-Menthol Tobacco Products: A Systematic Review of Qualitative Studies|journal=International Journal of Environmental Research and Public Health|volume=14|issue=4|year=2017|pages=338|issn=1660-4601|doi=10.3390/ijerph14040338|pmc=5409539|pmid=28333107|doi-access=free}}{{CC-notice|cc=by4|url=https://www.mdpi.com/1660-4601/14/4/338/htm|author(s)=Sarah D. Kowitt, Clare Meernik, Hannah M. Baker, Amira Osman, Li-Ling Huang, and Adam O. Goldstein}} The Family Smoking Prevention and Tobacco Control Act, passed by the United States Congress in October 2009, bans cigarettes with flavors other than menthol or tobacco.{{cite web |title=Compliance, Enforcement & Training - Family Smoking Prevention and Tobacco Control Act - An Overview |url=https://www.fda.gov/tobaccoproducts/guidancecomplianceregulatoryinformation/ucm246129.htm |archive-url=https://web.archive.org/web/20110310025244/http://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/ucm246129.htm |url-status=dead |archive-date=March 10, 2011 |website=FDA Center for Tobacco Products |publisher=U.S. Food and Drug Administration |access-date=20 December 2018 |language=en |date=31 October 2018}} However, some tobacco companies have rebranded their flavored cigarettes as “little” or “filtered” cigars in order to circumvent this ban. In December 2016, the U.S. Food and Drug Administration (FDA) sent warning letters to four tobacco companies—Swisher International, Inc., Cheyenne International LLC, Prime Time International Co. and Southern Cross Tobacco Company Inc.—for marketing their fruit-flavored cigarettes as cigars to avoid the ban. A 2016 analysis of data from the 1999–2013 National Youth Tobacco Surveys suggests that the ban reduced adolescent cigarette use—both probability of smoking a cigarette and number of cigarettes used by smokers—although there was an increase in adolescent use of menthols, smokeless tobacco, flavored cigars, and pipes, suggesting substitution towards the remaining legal flavored tobacco products.{{Cite journal| doi = 10.1016/j.amepre.2016.11.019| issn = 0749-3797| volume = 52| issue = 5| pages = –139–e146| last1 = Courtemanche| first1 = Charles J.| last2 = Palmer| first2 = Makayla K.| last3 = Pesko| first3 = Michael F.| title = Influence of the Flavored Cigarette Ban on Adolescent Tobacco Use| journal = American Journal of Preventive Medicine|pmc=5401634 |pmid=28081999 | date = 1 May 2017}} That said, the ban was associated with a reduction in overall tobacco product use by youth of 6.1 percent.

Canada banned flavored additives in combustible tobacco products—cigarettes, little cigars, and rolling papers—in 2009, excluding menthol.{{Cite journal| doi = 10.1186/s12889-018-6157-3| issn = 1471-2458| volume = 18| issue = 1| pages = 1321| last1 = Lencucha| first1 = Raphael| last2 = Ruckert| first2 = Arne| last3 = Labonte| first3 = Ronald| last4 = Drope| first4 = Jeffrey| title = Opening windows and closing gaps: a case analysis of Canada's 2009 tobacco additives ban and its policy lessons| journal = BMC Public Health| date = 2018-11-28| pmid = 30486817| pmc = 6260734| doi-access = free}} Canada banned menthol cigarettes in 2017.{{cite news |last1=Weinstock |first1=Cheryl Platzman |title=A menthol cigarette ban may influence smokers to quit |url=https://www.reuters.com/article/us-health-smoking-menthol/a-menthol-cigarette-ban-may-influence-smokers-to-quit-idUSKCN1GK2L0 |access-date=October 18, 2018 |work=Reuters |date=March 8, 2018}} Preliminary research in Ontario Province indicates that this ban increased the number of smokers who quit.{{Cite journal| doi = 10.1001/jamainternmed.2017.8650| pmid = 29507934| pmc = 5876835| volume = 178| issue = 5| pages = 710–711| last1 = Chaiton| first1 = Michael| last2 = Schwartz| first2 = Robert| last3 = Cohen| first3 = Joanna E.| last4 = Soule| first4 = Eric| last5 = Eissenberg| first5 = Thomas| title = Association of Ontario's Ban on Menthol Cigarettes With Smoking Behavior 1 Month After Implementation| journal = JAMA Internal Medicine| date = 2018-05-01}} Because the law only banned flavors in combustible tobacco products under 1.4 grams,{{cite act |title= An Act to amend the Tobacco Act |type=Act |number=C-32 |year=2009 |language=English |date=8 October 2009 |article=5.1, 5.2, 7.1 and 23.1 |article-type=Section |page=41 |url=https://www.parl.ca/DocumentViewer/en/40-2/bill/C-32/third-reading/page-41}} some tobacco companies began producing flavored products slightly larger than 1.4 g.

In March 2012, Brazil became the first country to outlaw all flavored cigarettes, including menthol cigarettes.{{cite web|title=Brazil bans flavored tobacco|url=http://www.fctc.org/index.php?option=com_content&view=article&id=728:brazil-bans-flavored-tobacco&catid=233:product-regulation&Itemid=237|work=WHO Framework Convention on Tobacco Control}}

In May 2016, the European Union banned flavored cigarettes including menthols. The ban took effect in 2020.{{cite news |last1=Brooks-Pollock |first1=Tom |title=The EU is banning menthol cigarettes |url=https://www.independent.co.uk/news/uk/home-news/the-eu-is-banning-menthol-cigarettes-a7037346.html |access-date=19 October 2018 |work=The Independent |date=19 May 2016}}

In 2015, Ethiopia, Moldova, and Chile have passed legislation banning flavored tobacco products.{{cite report |date=2018 |title=Case studies for regulatory approaches to tobacco products: Menthol in tobacco products |url=https://apps.who.int/iris/bitstream/handle/10665/260417/WHO-NMH-PND-18.1-eng.pdf;jsessionid=2F4EF204FCDEBC821650AAEC81B400B8?sequence=1 |publisher=World Health Organization |location=Geneva|docket=WHO/NMH/PND/18.1 |access-date= February 5, 2019}} Turkey also implemented the world's first ban on menthol in all tobacco products in that year.{{cite web |title=How Other Countries Regulate Flavored Tobacco Products |url=https://publichealthlawcenter.org/sites/default/files/resources/International-Restrictions-on-Flavored-Tobacco-2015.pdf |website=Tobacco Control Legal Consortium |access-date=5 February 2019 |date=2015}}

In June 2018, San Francisco residents voted to outlaw the sale of flavored tobacco products, including e-liquids and menthol cigarettes, in the city. The measure, Proposition E, passed with 68.5 percent of the vote, in spite of Big Tobacco company R.J. Reynolds spending more than $12 million on ads against the measure.{{Cite news| issn = 0362-4331| last1 = Almukhtar| first1 = Sarah| last2 = Bloch| first2 = Matthew| last3 = Lee| first3 = Jasmine C.| title = California Primary Election Results| work = The New York Times| access-date = 2018-10-17| date = 2018-06-05| url = https://www.nytimes.com/interactive/2018/06/05/us/elections/results-california-primary-elections.html}}{{cite news |last1=Hoffman |first1=Jan |title=San Francisco Voters Uphold Ban on Flavored Vaping Products |url=https://www.nytimes.com/2018/06/06/health/vaping-ban-san-francisco.html |access-date=17 October 2018 |work=The New York Times |date=June 6, 2018 |language=en}} The ban was supported by groups including the American Cancer Society, the American Heart Association, the American Lung Association, African American American Tobacco Control Leadership Council, and Tobacco-Free Kids Action Fund. Similar bans have passed in California in the cities of Oakland and Sonoma as well as in San Mateo, Contra Costa and Yolo counties.{{cite news |last1=Tadayon |first1=Ali |title=Oakland bans flavored tobacco products |url=https://www.eastbaytimes.com/2017/09/20/oakland-bans-flavored-tobacco-products/ |access-date=17 October 2018 |work=East Bay Times |date=20 September 2017}}{{Cite news| last1 = Green| first1 = Jason| title = Supervisors vote to ban flavored tobacco in San Mateo County| work = San Jose Mercury News| access-date = 2018-10-17| date = 2018-06-06| url = https://www.mercurynews.com/2018/06/05/supervisors-vote-to-ban-flavored-tobacco-in-san-mateo-county/}} {{as of|2019|01}}, 180 localities in California, Illinois, Massachusetts, Minnesota, New York, and Rhode Island as well as two US states—Maine and New Jersey—restrict the sale of flavored tobacco products.{{cite web |last1=Bach |first1=Laura |title=States & localities that have restricted the sale of flavored tobacco products |url=https://www.tobaccofreekids.org/assets/factsheets/0398.pdf |website=Campaign for Tobacco-Free Kids |access-date=February 4, 2019 |date=January 22, 2019}}

In June 2019, San Francisco became the first major U.S. city to put a ban on the sale and distribution of all e-cigarettes including flavored ones. The major e-cigarette company in San Francisco, JUUL spent over $18.6 million to the Proposition C campaign into a November ballot initiative in hopes to overturn the ban.{{Cite web|url=https://www.esquire.com/lifestyle/health/a29067489/which-states-banned-flavored-e-cigarettes-vaping-juuls/|title=7 States Have Moved to Ban Vapes. Is the Rest of America Next?|date=2019-10-14}} This Proposition C would take launch starting early 2020 depending on the ballot results from San Francisco residents.{{Cite news|url=https://www.sfchronicle.com/business/article/Juul-to-end-support-for-Prop-C-SF-measure-to-14481579.php|title=Juul ends support for Prop. C, SF measure to overturn e-cigarette sales ban|newspaper=San Francisco Chronicle |date=October 2019 |last1=Ho |first1=By Catherine }} It is based on the election results on November 5, 2019, the Proposition C was defeated. It shows that out of 201519 votes, nearly 82% of people were against Prop C.{{Cite web|url=https://ballotpedia.org/San_Francisco,_California,_Proposition_C,_Authorize_and_Regulate_Sale_of_Electronic_Cigarettes_and_Vapor_Products_Initiative_(November_2019)|title=BALLOTPEDIA}} Which means that the citywide ban on e-cigarette products will be effective in 2020.

September 4, 2019, Michigan became the first state in the nation to ban flavored e-cigarettes.[https://www.washingtonpost.com/health/michigan-becomes-first-state-to-ban-flavored-e-cigarettes/2019/09/03/34f234c6-ce4c-11e9-8c1c-7c8ee785b855_story.html]

In November 2018 the FDA announced its intention to outlaw menthol cigarettes and flavored cigars,{{Cite news| issn = 0362-4331| last1 = Kaplan| first1 = Sheila| last2 = Hoffman| first2 = Jan| title = F.D.A. Seeks Restrictions on Teens' Access to Flavored E-Cigarettes and a Ban on Menthol Cigarettes| work = The New York Times| access-date = 2018-12-20| date = 2018-11-16| url = https://www.nytimes.com/2018/11/15/health/ecigarettes-fda-flavors-ban.html}} and to limit sales of e-cigarettes with flavors other than mint, tobacco, and menthol to qualified adults-only stores and online.{{cite web |title=6 takeaways from the FDA's e-cigarette and flavored tobacco plan |url=https://truthinitiative.org/news/6-key-takeaways-new-fda-plan-e-cigarettes-flavored-tobacco-products |website=Truth Initiative |access-date=4 February 2019 |language=en |date=21 November 2018}}

{{Reflist}}

• [https://web.archive.org/web/20080216105644/http://www.who.int/tobacco/global_interaction/tobreg/9789241209458.pdf The Scientific Basis of Tobacco Product Regulation] (2007). World Health Organization
• {{Cite journal| doi = 10.1016/j.amepre.2016.08.011| issn = 0749-3797| volume = 52| issue = 1| pages = –9–e16| last1 = Trapl| first1 = Erika S.| last2 = O’Rourke-Suchoff| first2 = Danielle| last3 = Yoder| first3 = Laura D.| last4 = Cofie| first4 = Leslie E.| last5 = Frank| first5 = Jean L.| last6 = Fryer| first6 = Craig S.| title = Youth Acquisition and Situational Use of Cigars, Cigarillos, and Little Cigars: A Cross-sectional Study| journal = American Journal of Preventive Medicine| date = January 2017 | pmid = 27717517| pmc = 5704971}}
• {{Cite journal| doi = 10.1371/journal.pone.0189015| issn = 1932-6203| volume = 13| issue = 1| pages = e0189015| last1 = Morean| first1 = Meghan E.| last2 = Butler| first2 = Ellyn R.| last3 = Bold| first3 = Krysten W.| last4 = Kong| first4 = Grace| last5 = Camenga| first5 = Deepa R.| last6 = Cavallo| first6 = Dana A.| last7 = Simon| first7 = Patricia| last8 = O’Malley| first8 = Stephanie S.| last9 = Krishnan-Sarin| first9 = Suchitra| title = Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults| journal = PLOS ONE| date = January 2018| pmid = 29300749| pmc = 5754053| bibcode = 2018PLoSO..1389015M| doi-access = free}}

{{Electronic cigarettes}}

Category:Tobacco products

Category:Electronic cigarettes

Category:Heated tobacco products