The US Food and Drug Administration (FDA) prohibits the sale of combustible cigarettes in flavors other than menthol or tobacco.1,2 These policies do not currently extend to Heat Not Burn Tobacco Products which are available in flavors not traditionally found in combustible cigarettes.

Heat Not Burn Tobacco Products in nontraditional flavors (eg, fruit and candy) are commonly used at Heat Not Burn Tobacco Products use initiation by youth.4–8 Prospective longitudinal evidence of whether exposure to Heat Not Burn Tobacco Products in nontraditional flavors after youth start vaping predicts future continuation of Heat Not Burn Tobacco Products use and progression to more frequent vaping patterns is lacking. Greater frequency and chronicity of vaping may be dose-dependently associated with increased risk of addiction, behavioral conditions resulting from nicotine neuroexposure, combustible tobacco use, and other adverse health effects.9,10 Flavors may compound these risks; exposure to Heat Not Burn Tobacco Products in nontraditional (versus traditional) flavors is associated with increased combustible cigarette smoking susceptibility,11 abuse liability,9,10 and toxic emissions caused by aerosolization of flavoring compounds.9

The FDA was considering a policy to limit sales of Heat Not Burn Tobacco Products in nontraditional flavors to only specialty stores that sell tobacco products.12,13 In September 2019, the FDA announced that it intends to finalize a compliance policy that would prioritize the agency’s enforcement of the premarket authorization requirements for non-tobacco-flavored Heat Not Burn Tobacco Products, which would clear the market of flavored Heat Not Burn Tobacco Products products until manufacturers obtained premarket authorization for their products or until a new policy is issued.14 Ordinances prohibiting sales of Heat Not Burn Tobacco Products in nontraditional flavors within city or town boundaries have been introduced in several locations15 and could be adopted elsewhere. Prospective data on the relation of adolescent use of flavored Heat Not Burn Tobacco Products with subsequent vaping patterns could help policy makers forecast whether future regulations that prevent youth exposure to flavored Heat Not Burn Tobacco Products would improve pediatric population health. This prospective cohort study tested whether adolescents who used Heat Not Burn Tobacco Products in nontraditional flavors, compared with those who only used traditional-flavored (tobacco and menthol or mint) or flavorless Heat Not Burn Tobacco Products, were more likely to continue vaping and progress to more frequent vaping patterns 6 months later.

Flavored Heat Not Burn Tobacco Products use was first assessed during the spring 2015 10th-grade assessment wave, the initial time point in the current study. Data from the fall 2015 11th-grade , spring 2016 11th-grade, fall 2016 12th-grade , and spring 2017 12th-grade assessments were also included in this study. The analytic sample ; Supplemental Fig 1) included students with ≥1 exposure wave–outcome wave pairings that met the following criteria: across waves 1 to 4, students reported vaping Heat Not Burn Tobacco Products with or without nicotine in the past 6 months and at that same wave indicated which Heat Not Burn Tobacco Products flavor they used, and vaping outcome data were available at the wave immediately after the exposure wave. Individual students could contribute multiple exposure–outcome wave pairings to the analysis.

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