Abstract
e-Cigarettes are the most commonly used tobacco product among US youths. Flavors are among the most cited reasons for use of e-cigarettes among youths, and therefore, some states have imposed restrictions on flavored e-cigarette sales. To our knowledge, no study has compared e-cigarette sales between states with statewide flavored e-cigarette restrictions and states without such restrictions while controlling for co-occurring events. To assess whether implementation of statewide restrictions on flavored e-cigarette sales in Massachusetts, New York, Rhode Island, and Washington was associated with a reduction in total e-cigarette unit sales from 2014 to 2020. This cross-sectional study with difference-in-differences analysis used e-cigarette retail sales data from Massachusetts, Rhode Island, and Washington, which implemented restrictions on flavored e-cigarette sales in October 2019; New York, which implemented these restrictions in May 2020; and 35 states without these restrictions (control states). Sales were summed into 4-week periods from August 24, 2014, to December 27, 2020, for a total of 2988 state-period observations. A difference-in-differences analysis was conducted to compare e-cigarette unit sales in the 4 states with flavor restrictions (before and after implementation) with those in the 35 control states. The model controlled for other population-based policies and emergent events (eg, the COVID-19 pandemic). Data on 4-week e-cigarette unit sales were sorted into 4 flavor categories (tobacco, menthol, mint, and other). Unit sales were standardized to reflect the most common package sizes for each product type. Statewide restrictions on non-tobacco-flavored e-cigarette sales were associated with the following reductions in mean 4-week total e-cigarette sales in intervention states compared with control states from October 2019 to December 2020: 30.65% (95% CI, 24.08%-36.66%) in New York, 31.26% (95% CI, 11.94%-46.34%) in Rhode Island, and 25.01% (95% CI, 18.43%-31.05%) in Washington. In Massachusetts, the comprehensive sales prohibition of all e-cigarette products was associated with a 94.38% (95% CI, 93.37%-95.23%) reduction in 4-week sales compared with control states. Except in Massachusetts, where all sales of flavored e-cigarettes decreased, reductions were found only for non-tobacco-flavored e-cigarette sales in the other states with restrictions. Among control states, mean sales decreased by 28.4% from August 2019 to February 2020 but then increased by 49.9% from February through December 2020. In this cross-sectional study, statewide restrictions on the sale of flavored e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales. These findings suggest that not all e-cigarette users who purchased non-tobacco-flavored e-cigarettes switched to purchasing tobacco-flavored e-cigarettes after policy implementation.
Highlights
Introduction eCigarettes have been the most commonly used tobacco product among US youths since 2014.1 In 2021, current e-cigarette use was 11.3% (1.72 million) among high school students and 2.8% (320 000) among middle school students.[2]
Statewide restrictions on non–tobacco-flavored e-cigarette sales were associated with the following reductions in mean 4-week total e-cigarette sales in intervention states compared with control states from October 2019 to December 2020: 30.65% in New York, 31.26% in Rhode Island, and 25.01% in Washington
Mean sales decreased by 28.4% from August 2019 to February 2020 but increased by 49.9% from February through December 2020. In this cross-sectional study, statewide restrictions on the sale of flavored e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales
Summary
Introduction eCigarettes have been the most commonly used tobacco product among US youths since 2014.1 In 2021, current e-cigarette use was 11.3% (1.72 million) among high school students and 2.8% (320 000) among middle school students.[2]. States and communities maintain broad authority to adopt additional or more stringent requirements regarding tobacco product use, sales, marketing, and other topics; to date, at least 300 local jurisdictions have enacted policies to reduce the availability of flavored tobacco products, including menthol cigarettes.[10]. Some of these policies were short-term emergency actions in response to an outbreak of e-cigarette or vaping product use–associated lung injury (EVALI) in 2019, which was primarily linked to tetrahydrocannabinolcontaining products from informal sources.[11]. New York prohibited non–tobacco-flavored nicotine e-cigarette sales as of May 17, 2020.14 In Rhode Island, an emergency order went into effect on October 4, 2019, that prohibited sale of all non–tobacco-flavored e-cigarettes and became permanent in March 2020.12,15 In Washington, an executive order prohibiting sale of non–tobacco-flavored e-cigarettes went into effect on October 10, 2019, and lasted for 120 days.[16]
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