The effects of flavored e-cigarette sales bans on tobacco-use behaviors among youth and adults

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PROJECT SUMMARY In 2022, more than 2 million middle and high school students reported current e-cigarette use. The availability of flavored e-liquids makes e-cigarettes particularly appealing to youth, with nearly 85% reporting use of flavored e-cigarettes. The Food and Drug Administration (FDA) has taken action to regulate flavored e- cigarettes. In 2020, the agency banned prefilled, single-use cartridges containing e-liquids in ‘non-tobacco’ flavors (e.g., fruit, candy). It later targeted flavored disposable e-cigarettes—a previously unregulated device type that quickly gained popularity among youth following the initial flavor ban. Until last April, the FDA did not have regulatory authority over synthetic nicotine (vs. tobacco-derived nicotine), which some companies used as a loophole to keep selling flavored e-cigarettes. The ‘partial’ nature of the FDA’s prior regulations enabled e- cigarette manufacturers and retailers the opportunity to circumvent flavor regulations. However, six states (MD, RI, NJ, NY, MA, UT) enacted additional flavored e-cigarette bans, which serve as natural experiments to investigate whether more restrictive flavor bans are more effective in curtailing youth e-cigarette use. Conversely, e-cigarettes may also function as potentially less harmful alternatives for adults who smoke (AWS). Recent clinical trials report greater cigarette cessation rates among participants assigned to e- cigarettes compared to nicotine replacement or counseling only, suggesting potential benefits for those interested in quitting. Since flavored e-liquids are also highly preferred by AWS, e-cigarette flavor bans aimed at reducing AYA e-cigarette use may unintentionally discourage AWS from switching to potentially less harmful products. Thus, the project will examine the public health effects of stricter flavored e-cigarette regulations, taking into account both the potential benefits and risks. Using the Population Assessment of Tobacco and Health (PATH) Survey, we will investigate mechanisms by which statewide flavored e-cigarette bans affect e- cigarette and other tobacco product use (risks) as well as smoking cessation and reduction (benefits). We will leverage the longitudinal attribute of PATH to assess individual behavioral changes between subsequent waves. Using a quasi-experimental event study difference-in-differences estimation design, we will examine (1) changes in e-cigarette and cigarette use across age groups (12-17; 18-24 and 25+) and (2) use of e-cigarettes as a tool to quit or reduce smoking among AWS. PATH also includes a rich dataset of tobacco-related biomarkers, which we will analyze to further explore the impact of flavor bans. This study will contribute highly- relevant data on the positive and negative impact of flavored e-cigarette bans. The proposal aligns with the priorities outlined in RFA-OD-21-003 by examining the use pattern of flavored tobacco products and changes in tobacco use following bans on flavored e-cigarette sales. The study team is comprised of tobacco regulatory science and health policy researchers with the complementary expertise and skillsets needed to accomplish the goals of the proposal.