As hypothesized, for both e-cigarettes and moist snuff smokeless tobacco, flavored products were viewed with more curiosity and as being less dangerous, less potent and easier to use compared to non-flavored products. Associations of flavors with greater curiosity and ease of use and less perceived danger held for all non-tobacco flavors, including mint and wintergreen. Thus, evidence from this cross sectional study population suggests that mint varieties should be included alongside fruit and dessert in flavor restrictions intended to reduce youth tobacco use. Other product characteristics, such as e-cigarette device type, vapor amount and moist snuff price, also appear to shape product perceptions, which could inform tobacco control policy. In January 2020, citing concern over growing youth e-cigarette use, the FDA announced a policy to prioritize enforcement of premarket authorization requirements for some types of e-cigarettes, but exempted mint and menthol flavors. The present results suggest that youth perceive the properties of mint and wintergreen flavored tobacco similarly to fruit, dessert, and other flavors, which could undermine the effectiveness of the FDA policy. No such enforcement policy exists for conventional smokeless tobacco, but the present results demonstrate similar flavor association for moist snuff as observed for e-cigarettes. This finding is consistent with tobacco industry documents suggesting that flavored, lower priced,cannabis grow indoor lower nicotine ‘starter products’ are used to target novice users before later ‘graduation’ to established use through a series of higher nicotine products.

Use of flavored tobacco, including menthol, is more common among youth than adults and is the predominant way youth and young adults consumed tobacco across all tobacco products. A review of qualitative studies reported that flavored tobacco is viewed favorably by consumers, who associate flavors with less danger and often report that flavors contributed to their own tobacco experimentation and initiation. Given the evidence that flavors contribute to youth use for all tobacco products, current policies should consider not only restricting all non-tobacco flavors in cigarettes and e-cigarettes but in all forms of tobacco. Pod-type e-cigarettes, such as market-leading brand JUUL, have become the most popular type of e-cigarette among US youth. Independent of nicotine content and flavor, participants in the present study viewed pod devices with more curiosity and as easier to use than other device types but not necessarily as less dangerous. However, participants also associated low nicotine content e-cigarettes with less danger, more curiosity, and greater ease of use. Research suggests that youth may not recognize that pod-type e-cigarettes contain nicotine at high concentrations; a misperception potentially reinforced by the nicotine amount printed on JUUL product packaging. Prior applications of discrete choice methods in tobacco control have focused on adults and/or recruited participants through online panels. Previously reported findings include a preference for non-tobacco flavors both in e-cigarettes and water pipe tobacco, as well as identifying warning labels as a factor reducing product interest. Consistent with the present study, Shang et al.reported that adolescents least prefer tobacco-flavored e-cigarettes and cigalike closed-system devices. The present study expands such work to moist snuff products, finds e-cigarette vapor cloud size and pod type devices as independent contributors to youth perceptions, and assesses the additional outcomes of perceived danger and ease of use.

Furthermore, the present study shows no gender difference regarding e-cigarette perceptions, although beliefs associated with certain moist snuff product attributes were stronger among male participants, likely reflecting higher use and male-targeted marketing. Not all perceived qualities observed in the present study aligned with actual product properties. Participants correctly associated higher nicotine content with stronger physical effects . Other perceptions, such as flavored tobacco or small vapor cloud e-cigarettes being less dangerous, are not supported by scientific consensus. This discordance between perceived and actual effects represents a possible area for corrective public messaging or for greater regulatory vigilance for potentially misleading marketing practices. Of note, and not unexpectedly, product ever users held stronger perceptions about device type and brands than did product naïve participants. In a cross sectional setting, it cannot be distinguished to what extent experience shaped perceptions or that existing attention to product attributes contributed to use initiation. The designations curiosity, danger and ease-of-use are open to subjective interpretation. For example, danger could refer to either long-term or short term health effects. Meanwhile, ease of use could refer to concealability, access, adverse reactions, or social acceptance. While outcomes could be interpreted differently, they likely reflect multifaceted perceptions with plausible roles in decision making. When considering risks and potential benefits of tobacco products, adolescents hold views that include multiple aspects of social and physical risks. For e-cigarettes, specifically, adolescents cite multiple influences, both related to the product itself and their social context. Adolescents’ smokeless tobacco use motivations likewise comprise multiple factors, including flavors, perceived nicotine strength, and loyalty to preferred brands.

The present study shows that several of these factors each independently contribute to multi-faceted perceptions. Among these dimensions, curiosity and ease-of use are strong predictors of tobacco use behaviors.Youth who perceived flavored smokeless tobacco and flavored e-cigarettes as easier to use than unflavored options were more likely to be susceptible to smokeless tobacco use and to initiate future e-cigarette use, respectively. The present discrete choice findings demonstrate that multiple independent product related factors are associated with constructs shown to predict future tobacco use.A study limitation is that discrete choice experiments ask participants to make hypothetical choices that may not resemble the actual setting in which purchase or use decisions are made. Provided only limited information, study participants may have based some selections on word associations outside the context of e-cigarettes or moist snuff, for example, connecting the words ‘tobacco’ or ‘cigalike’ with dangers expressed in anti-smoking messages or considering ‘fine cut’ to indicate high quality rather than the coarseness of moist snuff tobacco. However, adolescents, especially those inexperienced with tobacco use, are likely to possess limited product information in real-word settings and may make the same cognitive associations when evaluating a tobacco product from words on a package, advertisement, or warning. In this study, the presentation of images prior to initiating the textonly items may have helped mimic flavor imagery on packages or advertisements; however, it cannot be ruled out that the specific images or colors chosen had some influence on respondents’ choices. A strength of discrete choice survey methods is that the contributions of multiple characteristics are considered in combination, corresponding better to real-world product choices. However, this strength relies on the unverifiable assumption that participants make rational trade-offs between product characteristics when evaluating options. To our knowledge, this study represents the first to apply discrete choice techniques to a school-based sample of youth for both smokeless tobacco and e-cigarettes, including pod-type devices. A school-based design may yield a more representative sample in terms of social-economic profile and tobacco use experiences than an online panel. However, as a limitation,vertical farming supplies data collected in rural regions of California may not generalize nationally, including to other rural geographical locations. As a non-random sample, the generalizability of this study population is also limited. Advantageously, a rural sample is likely to have greater familiarity with moist snuff products. However, the small total number of moist snuff users did not yield ideal power to examine interactions by use status. Notably, public messaging from health authorities in California emphasizing the potential harms of e-cigarettes and nicotine could have resulted in more concern about nicotine in this sample than would be observed elsewhere.Cigarettes and alcohol are two of the most commonly used recreational substances. The 2018 National Health Interview Survey reported 19.7% using any tobacco product, including 13.7% using cigarettes and 3.2% using e-cigarettes . Of those using cigarettes, the prevalence of cigarette use was higher among men than women . The National Epidemiological Survey on Alcohol Related Conditions – III found that the 12-month prevalence of Diagnostic and Statistical Manual – 5 nicotine use disorder was 20.0%, while the prevalence of lifetime DSM-5 nicotine use disorder was 27.9% . In reference to cessation efforts, results from the NHIS revealed a significant increase in the prevalence of smoking quit attempts from 52.8% in 2009 to 55.1% in 2018, as well as a significant increase in successful quit attempts from 6.3% in 2009 to 7.5% in 2018 .

The impact of these high rates of cigarette use can be seen in the health consequences. The World Health Organization recently estimated that tobacco use contributed to more than 7 million deaths per year . Cigarette smoking has been linked with a variety of diseases including cardiovascular and respiratory diseases , gastrointestinal diseases , and numerous cancers with lung cancer being among the leading causes of cancer-related mortality that contribute to these high rates of morbidity and mortality. Cigarette smokers die approximately ten years earlier than non-smokers and cigarette smoking cessation prior to the age of 40 has been estimated to reduce risk of death by approximately 90% . In addition, to direct acute and chronic health consequences, smoking exerts a large economic burden with an estimated $130 billion due to direct medical healthcare and $130 billion due to lost work productivity resulting from premature death . Alcohol use rates to remain high with recent estimates from the 2019 National Survey on Drug Use and Health that 25.8% of adults in the U.S. reported engaging in binge drinking over the past month . Binge drinking was defined as 5 or more alcoholic beverages for men, and 4 or more alcoholic beverages for women on the same occasion at least one day in the past month. For DSM-5 alcohol use disorder , NESARC-III found a 12-month prevalence of 13.9% and lifetime prevalence of 29.1% . As with cigarettes, excessive alcohol consumption has been linked with a host of health consequences. Excessive alcohol use over an extended period of time has been associated with liver disease and cirrhosis , as well as increasing the risk for cancers including mouth, liver, and breast cancer . The economic burden caused by alcohol misuse was estimated in 2010 to reach $249 billion in the United States alone, with an estimated three-quarters of the cost due to binge drinking . The high rates of use across cigarettes and alcohol contribute to an array of health consequences that consequently result in a large economic burden. While alone these two substances are consumed at high rates, they are often used concurrently. In comparison to those who have never smoked, daily, occasional, and former smokers are all at greater risks of engaging in hazardous drinking . Daily and occasional smokers were also more likely to meet diagnostic criteria for a DSM-IV alcohol abuse or dependence diagnosis . A study of smokers who called into a smoking quit line found that 23% had reported hazardous drinking . Those who reported hazardous drinking also had significantly lower smoking cessation rates at a 1-week follow up than those who reported moderate alcohol consumption . This frequent pattern of co-use of alcohol and nicotine results in multiplicative health consequences for oral cancer and individuals who co-use are more likely face mortality from tobacco-related diseases than alcohol-related diseases . Previous reports have found smokers with an alcohol diagnosis are more likely to have more severe nicotine dependence . This can also be seen across the smoking trajectory, as smokers with past or current alcohol related problems are less likely to quit smoking across their lifetime . These high rates of use, coupled with the multiplicative adverse health consequences, suggest the presence of a bidirectional relationship between cigarettes and alcohol. Due to this robust bidirectional relationship, efforts have been made to understand the underlying neurobiological mechanisms perpetuating co-use between these substances. Prior studies have established this mesolimbic dopamine pathway as a pathway that plays a key role in mediating the subjective experience of reward, as well as reward seeking, for natural rewards and substances of abuse . This mesolimbic dopamine pathway originates with a cluster of neurons in midbrain region known as the ventral tegmental area that project dopaminergic neurons into an area of the forebrain known as the nucleus accumbens . Dopamine is released in the NAcc when stimulated by natural or artificial rewards. The mesolimbic dopamine pathway serves a central role in the rewarding effects of substances of abuse. Multiple mechanisms have been proposed to explain the co-use of nicotine and alcohol.