| 摘要: | ABSTRACT
Background
The prevalence of cigarette smoking has declined globally. However, prevalence of non-cigarette tobacco products, like e-cigarettes, continues to increase. Despite a ban on use of characterizing flavors in cigarette products, their use in non-cigarette tobacco products is still unregulated in many parts of the world. Studies show that flavored tobacco products are more appealing to young people, may influence initiation across age groups and may hinder cessation attempts. We aimed to systematically review the public health impact of flavors in e-cigarettes on perceptions and use behaviors of tobacco products in order to inform for their effective regulation.
Objective
To determine the impact of non-menthol flavors in e-cigarettes on perception and use among youth, young adults and adults.
Data sources
This systematic review is an update to a previously published systematic reviewed by Huang et al (2017). We combined articles included in the original review searched and retrieved from four databases namely PubMed, EMBASE, CINAHL and PsychINFO from inception up to April 2016 with those identified in this updated review using identical databases and search string searched from January 2016 up to December 2019.
Study selection and eligibility criteria
Two reviewers independently conducted article screening to identify included articles through Covidence, a systematic review software. Any disagreements were resolved through consensus and a third reviewer addressed any further disagreements. We included peered reviewed articles of any study design except qualitative-only design, written in the English language, containing original data, describing role of non-menthol flavors in e-cigarettes on the outcomes of interest including risk/harm perceptions; attractiveness/appeal; expectancies and beliefs; intention to try; intention to quit; initiation; preference; progression to regular use; dual or poly tobacco use and cessation. We registered the protocol for this study on PROSPERO (CRD42020166841).
Study appraisal and synthesis
We used a validated quality assessment tool (QATSDD) to examine the quality of studies with a diverse range of research designs to determine the level of detail provided within identified articles and to provide an overall assessment of the general quality of included studies. We qualitatively analyzed all included studies and conducted a quantitative analysis (meta-analysis) only for eligible identified studies.
Data synthesis
Data from 72 articles that met the inclusion criteria show that tobacco users and non-users were more likely to perceive non-menthol flavored e-cigarettes as less risky/harmful. Young people, and females were also more willing to try e-cigarette and they found these flavors to be more attractive/appealing and to taste better than their older counterparts did. The variety of flavors, particularly fruit/candy/sweet flavors were among the top reasons for using e-cigarettes among youth, young adults and adults. There is also lower quit efficacy for non-menthol flavors compared to menthol/tobacco flavors among young adults and adults. The meta-analysis demonstrated that youth, young adults and adults exposed to non-menthol flavored e-cigarettes were significantly more likely (OR= 2.79; CI=1.58, 4.92; p-value=0.0004) to be willing to try e-cigarettes compared to those exposed to non-flavored/menthol/tobacco flavored e-cigarettes. However, the association exposure to non-menthol compared to tobacco/menthol or non-flavored e-cigarettes on risk perception was not significant.
Conclusion
Flavors have a positive impact on in e-cigarettes risk perception, intention to try, attractiveness and appeal, reasons for use, quit intention and preference among both users and nonusers, particularly among younger population groups. Flavors influences the favorable perception of e-cigarettes which in turn influences initiation, progression to regular use and dual/poly use among users, non-users, smokers and non-smokers, and among youth, young adults and adults.
Implications
This study adds to existing literature by providing additional evidence for the role of non-menthol flavors in e-cigarettes on experimentation, willingness to try, initiation, progression to regular use and dual/poly use, particularly among adolescent and young adults. In addition, this study provides the first evidence from meta-analysis on two outcomes, intention to try and risk perception. Regulating use of non-menthol flavors, particularly sweet, fruit, or candy flavors will help to protect the public health impact of flavored e-cigarettes by reducing the favorable view and attractiveness of the product. |
