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In 2021, 84.7% of youth who currently used e-cigarettes in the USA used flavoured e-cigarettes, of which fruit was the predominant flavour.18 Although it is unknown what per cent of these fruit-flavoured products contained cooling flavours, two prior studies found that nearly half of youth who currently use e-cigarettes reported using cooling flavours most often.4 5 Cooling flavours have been associated with greater frequency and intensity of using nicotine-containing e-cigarettes, increased use of disposable devices and increases in dependence.5 Additionally, emerging research suggests that cool or ice flavoured e-cigarettes may have differential health effects, including higher likelihood of generating reactive oxygen species, which can promote oxidative stress-induced damage with pulmonary cells.19 This research further documents the rapidly evolving nature of the US e-cigarette marketplace, including in response to regulation and product preferences, as well as public health outbreaks, including EVALI and COVID-19.12 20 21 In early 2020, the US FDA prohibited flavoured cartridge-based e-cigarette products

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While the FDA recognizes this chemical, diacetyl, as generally safe to eat, the case of the factory workers revealed that inhaling heated diacetyl particles day in and day out takes a harsh toll

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