Direct evidence that flavor sales bans substantially reduce youth cigarette and e-cigarette use

Most of the research on the effects of local and state bans on the sales of flavored tobacco products have assessed sales rather than actual use by youth. (They consistently showed big drops in sales of flavored tobacco products.) Summer Hawkins and colleagues at Boston College published “Flavoured tobacco product restrictions in Massachusetts associated with reductions in adolescent cigarette and e-cigarette use,” an assessment of high school student use of cigarettes and e-cigarettes following implementation of local laws restricting the sale of flavored tobacco products, as well as adding e-cigarettes to clean indoor air laws and Tobacco 21 restrictions. They found that local bans on flavored tobacco products were followed by substantial drops in cigarette and e-cigarette use.

They quantified coverage of local laws as the percentage of population covered by the laws in each county. They then used difference-in-differences to relate changes in percentage to the percentage of high school students living in places with laws to changes in e-cigarette use (yes/no) and the number of days that high school students smoked cigarettes in the past month. They also controlled for respondent characteristics, underlying time trends, and fixed differences between counties.

They found that banning the sale of flavored tobacco products was followed by a drop to 42% of the odds of high school students using e-cigarettes from before the ban (exp(-0.87)) and a 21% drop in the number of days per month high school smoked cigarettes (exp(-1.56)).

These are important conclusions because they directly contradict claims that flavor bans divert kids from e-cigarettes into cigarettes. Use of both products dropped significantly.

The actual effects of comprehensive flavor bans are likely even larger, since Summer and colleagues included laws that allowed sales of flavored products in adult-only venues or exempted menthol. Comprehensive laws that do not include such exceptions have larger effects on sales.

They did not find an effect of adding e-cigarettes to local smokefree laws, probably because the effects of these laws — which were originally passed years ago — were already baked in. It is still a good idea to protect everyone from secondhand e-cig aerosol.

Tobacco 21 laws only had an effect on 18 year-old cigarette smoking, probably because they are the primary group directly impacted.

But the important findings in this paper are the results on flavor bans.

Here is the abstract:

Background In the USA, many states do not pre-empt municipalities from enacting stricter tobacco-control policies than state or federal laws. Several municipalities in Massachusetts have passed progressive local laws aimed at reducing adolescent tobacco use. We exploited this variability to examine the associations between county-level flavoured tobacco product restrictions, tobacco 21 policies and smoke-free laws prohibiting e-cigarettes with adolescent cigarette and e-cigarette use in Massachusetts, and to assess whether policy effects varied by age.

Methods We conducted difference-in-differences models to link changes in county-level tobacco-control policies to changes in adolescents’ use of cigarettes and e-cigarettes using 2011–2017 biennial Massachusetts Youth Health Surveys.

Results Counties with greater implementation of flavoured tobacco product restrictions were associated with a decrease in the level of cigarette use among users (Coefficient −1.56; 95% CI −2.54 to −0.58). A significant interaction (p=0.03) revealed the largest reductions among 14 and 18 year olds. Increasing flavoured tobacco product restrictions were also associated with reductions in the likelihood of e-cigarette use (Coefficient −0.87; 95% CI −1.68 to −0.06). Increasing tobacco 21 restrictions were associated with decreases in cigarette use only among 18 year olds, while there was no evidence of associations between smoke-free laws with use of either tobacco product.

Conclusions Adolescents in Massachusetts decreased their use of cigarettes and e-cigarettes in response to local restrictions that limited the sale of flavoured tobacco products to adult-only retail tobacco stores. Local legislation can reduce adolescent tobacco use and municipalities should enact stricter tobacco-control policies when not pre-empted by state law.

The full citation is:

Hawkins SS, Kruzik C, O’Brien M, et al. Flavoured tobacco product restrictions in Massachusetts associated with reductions in adolescent cigarette and e-cigarette use. Tobacco Control Published Online First: 27 January 2021. doi: 10.1136/tobaccocontrol-2020-056159. It is available here.

Published by Stanton Glantz

Stanton Glantz is a retired Professor of Medicine who served on the University of California San Francisco faculty for 45 years. He conducts research on tobacco and cannabis control and cardiovascular disease/

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