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Flavored waterpipe (WP) tobacco is the main type of tobacco used by young WP smokers, and a major factor attracting youth to smoke. However, evidence regarding the effect of limiting flavor on WP smokers' experience continues to be lacking. This study aims at evaluating the effect of flavor restriction on WP smokers' toxicant exposure, smoking topography, subjective experiences and harm perception. Thirty-two WP smokers completed two, 45-minute ad libitum smoking sessions (preferred flavor vs non-flavored tobacco) in a crossover design pilot study. Plasma nicotine concentration and exhaled carbon monoxide (eCO) were measured before and after each smoking session. Puff topography was recorded throughout the smoking session. Participants completed survey questionnaires assessing subjective smoking experiences and harm perception. Significant differences were observed in plasma nicotine concentration between the two WP tobacco conditions, with a higher increase in plasma nicotine concentration following the flavored tobacco session. There were no significant differences between the two WP tobacco conditions for eCO and smoking topography measures. Compared with the non-flavored WP tobacco, we documented enhanced subjective smoking measures of satisfaction, calmness, taste, puff liking and enjoyment following the preferred flavored WP tobacco session. Cigarette harm perception was significantly higher among participants after smoking their preferred flavor compared with non-flavored WP tobacco. Limiting tobacco flavor has a substantial effect on WP smokers' nicotine exposure, subjective experience and harm perception. Therefore, eliminating or restricting WP flavors could be an essential element of comprehensive tobacco control policies to reduce the appeal of WP tobacco products for youth. This study highlights the important role of flavor in shaping WP smokers' experiences and exposures and the potential impact that regulating flavored WP tobacco may have on curbing WP use among youth in the US. Such regulations may reduce the appeal and the interest in WP smoking initiation and continued use.

BackgroundPictorial health warning label (PHWL) is an effective risk communication measure among cigarette smokers. However, there is a lack of knowledge regarding the effect of PHWL on low- and high-frequency waterpipe (WP) smokers. This study examined the effects of PHWL on puffing behavior, subjective experiences, and toxicant exposures among low- and high-frequency WP smokers in the United States (US).MethodsSixty current (past-month) WP smokers (low-frequency; n = 30 and high-frequency; n = 30) completed two 45-min ad libitum WP smoking sessions in a cross-over design study (WP with no-PHWL vs. WP with PHWL). We compared the mean differences of puff topography, expired carbon monoxide (eCO), plasma nicotine concentration, and subjective experiences between the two smoking groups.ResultsMean age of low-frequency smokers was 21.5 years and high-frequency smokers was 21.3 years. Compared to high-frequency, low-frequency smokers had significant reduction in average total smoking time [mean difference (SD) =  −7.6 (10.2) min vs. −2.6 (6.7) min, p = 0.03] and number of puffs [mean difference (SD) =  −33.37 (70.7) vs. −0.70 (29.2), p = 0.02] following exposure to PHWL compared to no-PHWL condition. Post-session subjective experiences were lower among high-frequency smokers compared to low-frequency smokers following smoking WP with PHWL compared to the no-PHWL session (puff liking −1.2 vs. −0.5; puff satisfaction −1.0 vs. −0.3; craving reduction −0.5 vs. 1.2) (p < 0.05 for all).ConclusionOur findings indicate that placing PHWL on the WP device may be a promising strategy with differential effectiveness among WP smokers: low-frequency (reduce puffing behaviors) and high-frequency (reduce smoking experience).

SignificanceElectronic nicotine delivery system (ENDS) use has continued to increase exponentially among young people in the USA, with unique flavours being one of the most cited reasons for use. Yet, controlled studies examining the effects of restricting flavour are lacking. This study evaluates the impact of ENDS flavour manipulation on user’s puffing behaviour, subjective experience, harm perception and nicotine exposure among college-aged ENDS users.MethodsJUUL users (n=30, age 18 to 24 years) attended two 60 min ad libitum ENDS use sessions (JUUL preferred flavour vs JUUL classic tobacco flavour) in a cross-over design. Puff topography and plasma nicotine concentration were measured, and participants completed subjective experience questionnaires.ResultsIncreases were observed on measures of satisfaction, taste, enjoyment, urges to vape/smoke, pleasure, product appeal and increased concentration following using the preferred flavour pod (p values <0.05). Compared with preferred flavour, participants in the tobacco flavour were less motivated to use it in the future (70.9 vs 19.1 scores, p<0.001), even if it was the only product on the market (75.8 vs 30.7 scores, p<0.001). While nicotine levels significantly increased in both conditions from pre to post session (p values <0.001), no significant differences were observed in nicotine boost levels or on puff topography parameters when comparing both flavour conditions.ConclusionsThis pilot study provides evidence that ENDS flavours have a substantial effect in enhancing young current ENDS users’ experiences, product appeal and motivation to use the product in the future. It highlights that limiting flavours could play a potential role when designing strategic policies to reduce the appeal of ENDS use among young people.

Waterpipe (aka hookah) tobacco smokers are exposed to toxicants that can lead to oxidative DNA and RNA damage, a precursor to chronic disease formation. This study assessed toxicant exposure and biomarkers of DNA [8-oxo-7, 8-dihydro-2′-deoxyguanosine (8-oxodG)] and RNA [8-oxo-7,8-dihydroguanosine (8-oxoGuo)] oxidative damage during smoking of flavored and non-flavored waterpipe tobacco. Thirty waterpipe smokers completed two counterbalanced 2-h lab waterpipe smoking sessions (flavored vs. non-flavored waterpipe tobacco). Urinary concentrations of 8-oxodG and 8-oxoGuo and expired carbon monoxide (eCO) were measured before and after the smoking sessions. A significant increase in the urinary concentrations of 8-oxodG (from 2.12 ± 0.83 to 2.35 ± 0.91 ng/mg creatinine, p = 0.024) and 8-oxoGuo (from 2.96 ± 0.84 to 3.45 ± 0.76 ng/mg creatinine, p = 0.003) were observed after smoking the non-flavored and flavored waterpipe tobacco, respectively. Our results also showed that the mean ± SD of eCO increased significantly after smoking the flavored (from 1.3 ± 1.1 to 20.3 ± 23.6 ppm, p < 0.001) and non-flavored waterpipe tobacco (from 1.8 ± 1.2 to 24.5 ± 26.1 ppm, p < 0.001). There were no significant differences in the means of 8-oxodG ( p = 0.576), 8-oxoGuo ( p = 0.108), and eCO ( p = 0.170) between the flavored and non-flavored tobacco sessions. Smoking non-flavored and flavored waterpipe tobacco leads to oxidative stress and toxicant exposure. Our findings add to the existing evidence about the adverse effects of waterpipe tobacco smoking (WTS) and the need for strong policies to inform and protect young people from the risks of WTS.