Flavor bans linked to drop in e-cigarette use but may slow decline in smoking

A new study by investigators from Mass General Brigham examined the effects of policies banning flavored e-cigarettes on adults and young people. Investigators found that e-cigarette use significantly declined among young adults and adults in states that had enacted flavor bans relative to states that did not. However, declines in cigarette smoking also slowed in those states with flavor bans relative to other states-a potential unintended consequence of the bans. Results are published in JAMA Network Open.

Both e-cigarettes and combustible cigarettes are essentially a source of nicotine for people who may have nicotine dependencies. We're trying to solve the problem of youth vaping, but we need to carefully consider impacts on more harmful combustible cigarette use."

Douglas Levy, PhD, Director of Policy Research at the Tobacco Research & Treatment Center at Massachusetts General Hospital

Flavored e-cigarettes are extremely popular among teens and young adults, raising public health concerns due to the addictive nicotine they contain. To reduce youth vaping, states including Massachusetts, New Jersey, New York, Rhode Island, Maryland and Utah banned the sale of flavored e-cigarettes, with many policies going into place in 2020. Levy, and other researchers at Mass General Brigham evaluated how those laws have influenced e-cigarette and cigarette use in youths and adults.

The study, led by first author David Cheng, PhD, used data from large-scale surveys administered in 50 states and D.C. from 2019 to 2023, tracking changes in the prevalence of tobacco use before (2019) and after (2020-2023) six states introduced flavor bans. Significant decreases in e-cigarette use among young adults ages 18–24 and adults over 25 were found in states with flavor bans relative to trends from other states without the bans. However, increases in cigarette smoking were also found among teenagers and young adults in those same states relative to other states.

Other key stats from the study:

• Among young adults (ages 18–24), e-cigarette use declined by 6.7 percentage points in policy states relative to other states in 2022.
• Among adults aged 25+, e-cigarette use declined by 1.2 percentage points in policy states relative to other states in 2023.
• From 2019 to 2023, youth e-cigarette use declined from 24.1% to 14.0% in policy states, compared to 24.6% to 17.2% in other states.

However, cigarette use declined less in states with flavor bans relative to other states:

• For example, in 2021:
  • Cigarette use among youths was 1.8 percentage points higher than expected in policy states.
  • Cigarette use among young adults was 3.7 percentage points higher than expected.

The associations between flavor bans and e-cigarette and cigarette use varied by state. Massachusetts saw consistent decreases in vaping associated with the bans across age groups, which could be due to the presence earlier local bans and stronger enforcement. Other states, such as Utah and Maryland, allowed certain exemptions (e.g., menthol flavors or specialty shops), which may have modified the impact of their bans.

One limitation of the study is that it was observational, meaning no experimental manipulation was involved, and unmeasured factors may have contributed to the findings. Additionally, these results reflect the initial experience of the first states to institute flavor restriction policies. The impact of restrictions may change over time for states with existing restrictions and states that newly institute restrictions.

The next step is to identify additional strategies that can curb youth nicotine use without slowing downward trends in cigarette smoking.