Evaluation of Statewide Restrictions on Flavored e-Cigarette Sales in the US From 2014 to 2020

Abstract

IMPORTANCE 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. OBJECTIVE 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. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study with difference-in-differencesanalysis 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. MAIN OUTCOMES AND MEASURESA 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 populationbased 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. RESULTSStatewide 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. CONCLUSIONS AND RELEVANCEIn 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 (continued)

Assessment of Patterns in e-Cigarette Use Among Adults in the US, 2017-2020

“…Implementing other policies, such as a statewide flavor ban, and increasing e-cigarette taxes may help to reverse the observed patterns. 36 Our findings have important regulatory implications. Although the prevalence of current e-cigarette use slightly decreased among young adults aged 18 to 20 years, a considerable proportion of this age group still reported using e-cigarettes.…”

Discussions of Flavored ENDS Sales Restrictions: Themes Related to Circumventing Policies on Reddit

“…JUUL's voluntary withdrawal was followed up by FDA guidance in January 2020 which removed all flavored pod-based ENDS from the marketplace [2]. At the time, JUUL was the most popular reusable e-cigarette on the market, attracting a large number of users through their flavored and high nicotine strength products [3,4]. This shift in the policy landscape resulted in bare shelves inevitably leaving users of JUUL's popular flavored pods with questions and motivation to find alternative products.…”

Trends in unit sales of cooling flavoured e-cigarettes, USA, 2017–2021

“…Similar restrictions on non-tobacco-flavoured e-cigarettes have also been implemented in New York (May 2020), Rhode Island (October 2019 and made permanent in March 2020) and Washington (October 2019 and lasted 120 days). Existing research shows that state-wide restrictions on the sale of flavoured e-cigarettes in these states were associated with a significant reduction in total e-cigarette sales 23. This reduction was mostly driven by non-tobacco-flavoured e-cigarette sales, which were partially compensated by an increase in tobacco-flavoured e-cigarette sales.…”

“…Existing research shows that state-wide restrictions on the sale of flavoured e-cigarettes in these states were associated with a significant reduction in total e-cigarette sales. 23 This reduction was mostly driven by non-tobacco-flavoured e-cigarette sales, which were partially compensated by an increase in tobacco-flavoured e-cigarette sales. However, the finding of an overall decline indicates that not all people who purchased non-tobacco-flavoured e-cigarettes switched to purchasing tobacco-flavoured e-cigarettes following policy implementation, suggesting limited e-cigarette product substitution.…”

“…However, the finding of an overall decline indicates that not all people who purchased non-tobacco-flavoured e-cigarettes switched to purchasing tobacco-flavoured e-cigarettes following policy implementation, suggesting limited e-cigarette product substitution. 23 As an increasing number of policies addressing flavoured tobacco products are implemented, it is important for national, state and local decision makers to consider the proliferation of products not covered under existing policies, as well as the health equity impact of these policies, including coverage among populations disproportionately affected by tobacco use 24 ; in the past, sales of products exempted from policies (eg, menthol e-cigarettes and flavoured disposable products) have increased rapidly following policy implementation. 12 21 Similarly, flavours that might provide the same cooling sensation as menthol on individual users, but are not currently designated as characterising flavours, might not be covered by existing policies at the national, state or local levels.…”