Restricting the sale of flavored e-cigarettes may not be as protective for youth as initially anticipated, researchers say in a new study published in JAMA Health Forum. The research, led by Yale School of Public Health Associate Professor Abigail Friedman, found evidence that such restrictions decrease young adult vaping but increase the number who smoke traditional cigarettes relative to what would be expected without these policies. Given evidence of greater health costs from cigarette smoking than vaping e-cigarettes, these findings highlight a need for nuanced approaches to tobacco control that account for effects across different nicotine and tobacco products.
Background
E-cigarette flavor restrictions have become a popular public health measure aimed at reducing youth vaping. However, there is growing concern that these restrictions may have unintended consequences, such as encouraging smoking, a more harmful behavior. This is significant because the vast majority of smokers begin before age 30, making young adults a critical demographic for shaping tobacco-related public health outcomes. To estimate such flavor restrictions’ relationships to young adult vaping and smoking, the authors leveraged Behavioral Risk Factor Surveillance System (BRFSS) data from 2016 to 2023, matching 18- to 29-year-olds’ survey responses to the percentage of state residents covered by flavor restrictions. This approach allowed statistical analyses to isolate the effects of these policies from other tobacco regulations and environmental factors, providing a clearer picture of their impacts.
Key findings
- Reduction in vaping: State-level flavor restrictions yielded a 3.6 percentage point decline in daily vaping among 18- to 29-year-olds relative to trends in non-adopting states.
- Increase in smoking: These same policies caused a 2.2 percentage point increase in daily smoking among the same age group, relative to non-adopting states’ trends.
- Net impact: Among young adults, these policies yield about 3 additional daily smokers for every 5 fewer daily vapers.
- Maryland: Maryland’s policy — a regulation prioritizing enforcement action against sales of flavored e-cigarettes, but exempting menthol and open-system e-cigarettes — did not result in increased smoking, suggesting potential benefits from more tailored policies.
- Limitations: The analysis was limited to 31 states due to vaping data availability and was not a randomized trial. The study’s methods allow for causal interpretation under specific assumptions.
Why it matters
These findings challenge the prevailing assumption that e-cigarette flavor restrictions offer a straightforward mechanism to reduce youth vaping as a means to protect public health. Specifically, while flavored e-cigarette restrictions may achieve their goal of reducing vaping rates among young adults, consequent increases in smoking rates may offset the expected public health benefits. Public health officials and policymakers, therefore, should carefully consider the potential unintended consequences of such policies. It is crucial to adopt a comprehensive approach to tobacco control that addresses the complex interplay between e-cigarettes and traditional cigarettes. Maryland’s unique exemption of menthol and open-system devices offers a promising area for further investigation, but more research is needed to confirm why that regulation did not yield increased smoking and whether that relationship would still hold in other states.
What the researchers say
Abigail Friedman, lead author of the study: "This study’s evidence linking restrictions on flavored e-cigarette sales to increases in young adult smoking raises real concerns for population health. With substantial variation in risk profiles across modern nicotine and tobacco products, this research underscores the need to assess such policies’ cross-product effects, to ensure that they serve public health.
“Reassuringly, our findings for Maryland suggest potential benefits from more tailored policies: Exempting menthol flavors and open-system devices, Maryland’s regulation was associated with decreases in young adult vaping without increased smoking. Understanding what drove this — regulatory details versus separate contextual factors — could reveal promising approaches to reduce young adult vaping without increasing smoking, the primary driver of tobacco-related disease.”
Funding
This research was supported by grants from the National Cancer Institute, U.S. Food and Drug Administration, and the National Institute on Drug Abuse.
Published Study
The complete study, “Flavored E-Cigarette Sales Restrictions and Young Adult Tobacco Use”, can be found on the JAMA Health Forum website.