A survey of teen smokers has added more evidence that flavored tobacco products are particularly attractive to people younger than the legal smoking age.

Cigarettes can include menthol flavoring, and other tobacco products like hookah are available in wide variety of flavors.

"Consistent with national school-based estimates, this study confirms widespread appeal of flavored products among youth tobacco users," the authors, led by Bridget K. Ambrose of the Center for Tobacco Products at the U.S. Food and Drug Administration in Silver Spring, Maryland, wrote in their research letter.

Most tobacco use begins during youth and young adulthood, and although cigarette use has been declining, other products like e-cigarettes and hookah are becoming more common, they wrote.

The researchers used data from a nationally representative study of nearly 46,000 U.S. adults and youth ages 12 to 17 who answered questions about use of cigarettes, e-cigarettes, hookahs, cigars, pipe tobacco, smokeless tobacco, dissolvable tobacco and other products.

Respondents answered whether or not the first product they ever used had been flavored to taste like menthol, mint, clove, spice, candy, fruit, chocolate, alcohol or other sweets.

Of 13,651 teens in the survey, 2,900 reported ever using a tobacco product, most commonly cigarettes or e-cigarettes, and 1,152 said they had used tobacco products over the previous month.

Almost 90 percent of teens who had used hookah, 81 percent of ever e-cigarette users, 65 percent of ever users of any cigar type, and 50 percent of ever cigarette smokers said the first product they used was flavored.

Of the teens who had used any tobacco product over the previous month, 80 percent had used a flavored one, including 60 percent of cigarette smokers.

Many youth said flavoring was a reason to use e-cigarettes, hookahs, cigars, smokeless tobacco, and snus pouches, the researchers reported in JAMA.

A 2014 study in the journal Tobacco Control found that cigar use is more common among youth age 18 to 25 than any other age group, which may be driven by the popularity of flavored cigars (see bit.ly/1l8jX4X).

"A lot of times they're bubble gum or chocolate or candy flavored, and in many cases the packages are also framed in a manner to appeal to kids," Centers for Disease Control and Prevention epidemiologist Brian King told Reuters Health when the 2014 study was published.

They are also less expensive than cigarettes because they are not subject to the same taxes, despite containing the same carcinogens, said King, who was not involved in the JAMA research letter.

"In many states these products can be purchased for mere pocket change," he said.

The FDA continues to monitor new and novel tobacco products, said Michael Felberbaum, a press officer for the FDA.

"The FDA evaluates studies as part of a larger body of evidence aimed at assisting in our mission to protect public health and furthering our understanding on particular issues," Felberbaum told Reuters Health by email. "Flavored tobacco products have become increasingly common in the United States and are especially attractive to youth."

"As such, the FDA is particularly interested in monitoring and assessing the use of flavored tobacco products among youth," he said.

SOURCE: http://bit.ly/1RxtpdR JAMA, online October 26, 2015.