Participants missing flavor preference data were excluded from the LCA analysis. Given the small number of missing observations, we do not expect their exclusion to impact results. The latent class model is a finite mixture model to identify and characterize clusters of similar participants. To identify distinct subgroups based on participants’ discrete responses to the 8 flavors, where each flavor question included 5 options, we started with fitting marginal latent class models for multiple polytomous outcomes . Starting with a one-class model, we fitted models with increasing numbers of classes up to 10 classes. Each model was run multiple times in the R package poLCA to have relatively good certainty in obtaining global maximum log-likelihood . Models from 2-class to 10-class were compared based on considerations statistically and for ease of interpretation . A five-class model was considered most adequate to describe the data based on statistical and interpretability considerations. Participant sociodemographic characteristics and e-cigarette and/or other tobacco use behaviors were compared between the retained latent classes using pair-wise hypothesis tests and then a multi-variable multi-nomial logistic regression model. Additionally, past 30-day e-cigarette users were asked to endorse their reasons for using e-cigarettes from a list of 21 potential reasons compiled from literature . Reasons were examined across flavor preference classes. Responses were unweighted. Results were considered statistically significant if P<0.05, cannabis growing supplies unless otherwise noted . A five-class LCA solution was chosen based on model fit and interpretability . One class of “straight line” responses was considered potentially indicative of inattentive survey taking and not included in association analyses.

The remaining four classes were subjectively labeled as mint ; no preference ; fruit/sweet ; and dislikes one or more . Consistent with preferences, past 30-day e-cigarette users who were members of the fruit/ sweet class were most likely to report using any fruit and any sweet flavored e-cigarette. However, the mint and no preference classes also reported substantial use of fruit and sweet flavors. Past 30-day e-cigarette users who were members of the mint class were most likely to report use of mint and menthol e-cigarettes. Mint use was less common in the fruit/sweet class and no preference class , but due to use of fruit-ice flavors, menthol use was common . More than one year following FDA enforcement prioritization against certain flavors and types of e-cigarettes , adolescent and young adult e-cigarette users in the present study near universally reported use of flavored products, most often sweet, fruit, or menthol. Use of cartridge/pod systems and disposable e-cigarettes was widespread. It was uncommon to report difficulty finding e-cigarettes in desirable flavors or to report more difficulty finding sweet/fruit flavors compared with prior to enforcement prioritization. Together, the results suggest ample access to and prevalent use of flavored and pod-based e-cigarettes, despite recent policy. Menthol and disposable e-cigarettes were not prioritized for enforcement, citing evidence at the time that youth preference for menthol was “much lower” than for mint and fruit . In a national online survey of adolescents and young adults conducted three months after the policy took effect, a combined category of mint, wintergreen, or menthol flavors was the most used flavor, matching or exceeding use of fruit flavors in all age groups and device types . Disposable devices, which offer convenience and conceal ability at a lower initial cost than reusable devices with interchangeable cartridges/pods, gained substantial market share in the year before the enforcement prioritization policy . Use of disposable devices was widespread in the present work, the other national online study , and 2020 NYTS findings .

These results suggest that flavors and device types not prioritized for enforcement had already or would soon rank among those most used by young people. However, not only were non-prioritized flavors and devices popular with youth, but flavors and devices that were prioritized also persisted as readily accessible and commonly used in the present data and other recent work . The emergence of fruit-ice combination flavors potentially contributes to increasing youth use of mentholated e-cigarettes. Fruit-ice e-cigarette flavors gained substantial popularity around the time of the 2020 FDA enforcement prioritization announcement and, among young adults, have been associated with more frequent vaping and dual- use of combustible tobacco . Participants in our study, when asked to endorse e-cigarette flavors they used from a list, selected menthol less often than fruit ; however, considering fruit-ice flavors as a form of both menthol and fruit greatly narrowed the popularity gap . A survey of high school students in Connecticut emphasized the cooling sensation produced by freeze, ice, or chill vape flavors over the word “menthol” and found 52% prevalence of cooling flavor use among e-cigarette users . Rather than rely on respondents to recognize menthol as a flavor, survey instruments should include ice, fruit-ice, and cooling terminology to capture menthol product use fully. “Ice” flavors not explicitly characterized as menthol in their marketing also have implications for tobacco control and regulation. In April 2021, the FDA announced a commitment to work toward a proposed product standard to eliminate menthol as a characterizing flavor in cigarettes and to ban all characterizing flavors in cigars, aimed in part at reducing youth initiation . Restricting the additives that produce the cooling sensation rather than relying on a characterizing flavor definition would be a more direct and enforceable approach to eliminate cooling flavors . In the present study, strong preference for mint or menthol comprised the largest class and was associated with more lifetime and past 30-day e-cigarette use. While greater lifetime use was also associated with fruit/sweet preference , unlike mint/menthol, fruit/sweet preference was associated with less dual-use of other tobacco.

The cross-sectional nature of the present study requires cautious interpretation, but it is possible that sweet/fruit flavors are more attractive than mint/menthol flavors to youth at lower risk for combustible tobacco use. Notably, female participants were more likely than males to prefer sweet/fruit flavors, reminiscent of tobacco industry research showing that flavored cigarettes would appeal to women and younger smokers . A previous latent class analysis of young adult e-cigarette users found that participants who used multiple devices and flavors tended to vape more . Similarly, a study of high school students reported an association between greater e-cigarette use and liking a larger number of flavors . Likewise, among middle school students in Mexico, liking fruit flavors was associated with greater lifetime e-cigarette use . Together, these results suggest that young people with more experience using e-cigarettes tend also to have stronger flavor opinions. Prospective findings have shown that youth who use sweet, fruit, or buttery e-cigarette flavors are more likely than users of mint/menthol, unflavored, or tobacco flavors to sustain their e-cigarette use over time . While prior research has focused on the most appealing e-cigarette flavors, our study revealed a novel class of individuals who strongly disliked certain flavors. Most participants in this class had weak affinity for some flavors, strongly disliked one or two flavors, cannabis indoor growing and were not unified in which flavor they disliked. Notably, participants in this class differed from all other e-cigarette users in their endorsed reasons for vaping: addiction-related reasons were much more prominent. For youth in this class, for whom nicotine dependence is a potentially stronger driver than flavors of e-cigarette use, flavor restriction policies alone may be insufficient to reduce their use. This suggests a need for multi-pronged policies, including effective youth e-cigarette cessation treatments. In August 2021, the FDA began announcing e-cigarette authorization decisions under the Premarket Tobacco Product Application pathway . The FDA denied marketing orders to many flavored products, granted authorization to a single tobacco-flavored product, Vuse Solo, but as of this writing, had yet to decide on some of the largest e-cigarette brands, including JUUL. In announcing its decision, the FDA cited relatively low youth use of the Vuse brand and tobacco flavors in the 2021 NYTS . In the present study, use of tobacco flavor was indeed relatively uncommon. However, the no preference latent class was the second largest and the group most amendable to tobacco and unflavored e-cigarettes. In its pending PMTA decisions, the FDA should consider both youth affinity for menthol e-cigarettes and the potential for authorized tobacco flavored or unflavored e-cigarettes to become viable alternatives for the many youth without strong flavor preferences. Several study limitations should be considered. While this sample was diverse in its sociodemographic characteristics, commercially administered panel survey respondents are not necessarily representative of the general population . Online survey panels may differ from the general population in their demographic and attitudinal composition. This study was cross-sectional.Only included were e-cigarette repeated ever-users; thus, perceptions of e-cigarette never-users and overall population e-cigarette use prevalence could not be estimated.

It is possible that the FDA enforcement prioritization policy deterred some youth from ever initiating e-cigarette use, and these individuals would not be eligible for this study. Included e-cigarette non-users largely did not perceive difficulty accessing flavored e-cigarettes. Recent evidence indicates that people with schizophrenia or schizoaffective disorder experience deficits in anticipatory pleasure, or pleasure related to future activities, but not in consummatory pleasure, or pleasure experienced in-the-moment . The Temporal Experience of Pleasure Scale is a self-report measure of the general propensity to experience anticipatory and consummatory pleasure . Studies in the U.S., China, Switzerland, and France have found that people with schizophrenia or schizoaffective disorder reported lower anticipatory pleasure but comparable consummatory pleasure on the TEPS compared to healthy controls . Prior studies have also found that TEPS anticipatory and consummatory pleasure scores are positively correlated with functional outcome and negatively correlated with negative symptoms . TEPS anticipatory, but not consummatory, pleasure is negatively correlated with subclinical negative symptoms and is lower in people who score higher on social anhedonia measures compared to those who do not . Studies that utilize the TEPS have thus far almost exclusively included chronically ill people with schizophrenia. However, studies using other self-report measures of anhedonia, such as the Chapman scales of physical and social anhedonia, have found that people early in the course of schizophrenia report more physical anhedonia than the controls and people experiencing their first lifetime episode of psychosis report more social anhedonia compared to the controls . To date, two studies have administered the TEPS to people early in the course of a schizophrenia spectrum disorder . Cassidy et al. found no differences in TEPS anticipatory pleasure between people with and without a psychotic disorder. However, most participants in the study had used cannabis throughout the lifetime, thus making conclusions about the contributions of psychosis versus cannabis use on TEPS scores difficult to disentangle. Schlosser et al. found that people with recent-onset schizophrenia reported less anticipatory than consummatory pleasure on the TEPS but did not differ on either scale compared to a younger, healthy control group. However, people at clinical high risk for schizophrenia reported less anticipatory pleasure than a demographically matched healthy control group. In the current study, we examined people with a recent-onset SSD to determine if and when deficits in reported anticipatory pleasure emerge in the course of the illness. We defined “recent-onset” in our study as experiencing a first episode of psychosis within one year of study participation. Based on previous studies with more chronically ill samples, we hypothesized that people with an SSD would show deficits in anticipatory pleasure but not in consummatory pleasure compared to people without an SSD. We also included measures of symptom severity, occupational functioning, and social functioning in order to examine the correlates of anticipatory pleasure.People with schizophrenia , schizophreniform disorder , or schizo affective disorder who had their first episode of psychosis within one year of study participation were invited to participate . All SSD participants were clinically stable, defined as no inpatient hospitalization within three months of study participation. People who had never experienced a psychotic episode and did not meet the criteria for a current Axis I diagnosis were included as the control group. All but eight participants with an SSD were taking at least one psychiatric medication: 72 were taking a second generation antipsychotic medication, four were taking both first and second generation antipsychotic medications, and four were taking non-antipsychotic psychiatric medication.