The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults

Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among people who smoke and smoking relapse among people who previously smoked and now use e-cigarettes: findings from a UK-based mixed methods study

BACKGROUND

Although electronic cigarettes (e-cigarettes) appear to be effective in helping people who smoke to stop smoking, concerns about use of e-cigarettes among young people have led to restrictions on non-tobacco flavoured e-liquids in some countries and some US states. These restrictions could reduce the appeal of these products to non-smoking youth but could have negative consequences for people who smoke or use e-cigarettes.

METHODS

In this mixed methods study, we recruited UK adults who smoked or used to smoke and subsequently vaped to explore their opinions of unflavoured e-liquids and their beliefs about how they would be impacted by hypothetical e-liquid flavour restrictions. Participants trialled an unflavoured e-liquid instead of their usual nicotine product for four hours and completed a survey and an online interview.

RESULTS

Using Interpretive Phenomenological Analysis and graphically presented data, we found differences in participants' opinions of unflavoured e-liquid. If only unflavoured, tobacco flavoured, and menthol flavoured e-liquids remained on the UK market, some people who smoke or vape may be unaffected, but some may relapse to smoking or continue smoking. Despite most wanting to prevent young people from initiating vaping, participants had varying opinions on whether flavour restrictions would be an effective method.

CONCLUSIONS

The findings highlight that people who smoke and vape could be impacted by flavour restrictions in a range of ways, some of which could have a potential adverse impact on harm reduction efforts in the UK (e.g., by making smoking more appealing than vaping).

E-commerce licensing loopholes: a case study of online shopping for tobacco products following a statewide sales restriction on flavoured tobacco in California

INTRODUCTION

Retailer licensing programmes can be an effective method of enforcing tobacco control laws, but most programmes do not require e-commerce retailers to obtain licenses. California's implementation of a statewide flavour restriction (Senate Bill 793 (SB-793)) in December 2022 enforced through its tobacco retailer licensing programme presented an opportunity to assess whether the exclusion of e-commerce in the definition of 'tobacco retailer' might have resulted in a shift in consumer behaviour towards e-commerce.

METHODS

To examine the association between SB-793 implementation and online shopping for tobacco, we collected weekly Google search rates related to online shopping for cigarettes and vaping products in California from January 2018 to May 2023. We compared observed rates of shopping queries after SB-793 implementation to counterfactual expected rates and prediction intervals (PI) calculated from autoregressive iterative moving average models fit to historical trends. Content analysis was performed on the search results to identify websites marketing flavoured vaping products and menthol cigarettes.

RESULTS

The week SB-793 was implemented, shopping queries were 194.4% (95% PI 100.8% to 451.5%) and 161.7% (95% PI 81.7% to 367.5%) higher than expected for cigarettes and vapes, respectively. Cigarette shopping queries remained elevated significantly for 11 weeks and vape shopping queries for 6 weeks. All search results contained links to websites that offered flavoured vaping products or menthol cigarettes to Californian consumers.

DISCUSSION

These findings raise concerns about potential loopholes in policy enforcement created by the absence of explicit regulations on e-commerce sales in retailer licensing programmes. Strengthening regulations to include e-commerce and monitoring e-commerce compliance are recommended to enhance the impact of laws enforced through retailer licensing programmes.

Youth Perspectives on Menthol Sales Restrictions in Minneapolis and Duluth, Minnesota

Although menthol cigarettes are a starter product for youth, menthol was exempted from the 2009 Tobacco Control Act, which banned all other characterizing flavors. Minneapolis and Duluth, Minnesota, implemented menthol tobacco sales restrictions in 2018 to advance health equity for youth, African American, lesbian, gay, bisexual, trans, and queer (LGBTQ), and other communities adversely affected by menthol. This evaluation assesses the policy impact on youth access to menthol tobacco, exposure to menthol advertising, and tobacco use. A core group of youth aged 14 to 17 years (n = 30) was recruited from Minneapolis and Duluth to gather data through photo voice and peer interviews 2 months before and after policy implementation. This evaluation shares the results of focus groups with these core youth where they reflected on what they observed in the community and heard from peers. The core youth identified and categorized emergent themes using the evaluation questions. Following the focus groups, the evaluation staff used these preliminary themes and coded remaining transcripts. The core youth had mixed reactions to the impact of policies on access and use because many tobacco users in their age group obtain tobacco informally through peers, family members, and online. They observed decreases in retail advertising of menthol cigarettes, although many felt e-cigarettes and online advertising were more significant issues for their age group. Findings show a need for increased education and more comprehensive policy approaches, including addressing use of flavored e-cigarettes, online tobacco sales, and informal access, making youth access to tobacco more difficult.

Impacts of Tax and Flavor Tobacco Policies on San Francisco Bay Area Tobacco Prices

California Proposition 56 increased the state tobacco tax by $2 per cigarette pack effective April 1, 2017. Between 2015-2020 San Francisco (SF) and some cities in Alameda County enacted local flavored tobacco sales restrictions. SF also increased its Cigarette Litter Abatement Fee, from $0.20/pack in 2015 to $1.00 in 2020. Compare the change in tobacco prices before (2015) and after (2019/20) the implementation of a $2 increase in tobacco excise tax and local flavored tobacco policies in SF and Alameda Counties. Descriptive study of the pre-to-post policy analysis design. We drew a proportional random sample of retailers (N=463) in SF and Alameda Counties, by city. Using multivariable, single- and multiple-level linear regressions, we compared inflation-adjusted average tobacco prices in 2015 vs. 2019/20 by county and by flavor policy, accounting for socio-demographics. Change in inflation-adjusted average tobacco prices in 2015 vs. 2019/20 by county and flavor policy, accounting for socio-demographics. Between 2015-2019/20, the increase in cigarette prices was higher than the $2 tax increase, and higher in SF than Alameda County (+$4.6 vs +$2.5). SF retailers stopped selling Newport menthol cigarettes and Blu brand menthol e-cigarettes in 2019/20. Adjusted average cigarette prices increased significantly more in SF and Alameda County cities with comprehensive or partial flavor policies versus cities without flavor policies (by $3.23 and $2.11). Local flavor policies affected menthol product availability and may have had positive spillover effects and indirectly increased pack prices.

An experimental evaluation of the effects of banning the sale of flavored tobacco products on adolescents' and young adults' future nicotine vaping intentions

BACKGROUND

Some U.S. states and municipalities have banned the sale of flavored tobacco products to help curb youth vaping. However, evidence supporting such bans is limited. This experiment tested whether removing flavored tobacco products from a retail setting diminished adolescents' (ages 11-20) future intentions to use vaping products.

METHODS

The study was implemented in the RAND StoreLab, a life-sized model convenience store. The display of flavored tobacco products in the store was manipulated with these conditions: 1) tobacco, sweet, and menthol/mint flavors displayed; 2) only tobacco and menthol/mint displayed; and 3) only tobacco flavors displayed. Participants were randomly assigned to shop in one of these conditions and completed measures of future vaping intentions post-shopping. Separate logistic regression models assessed effect of condition on future intentions to use different flavors (tobacco-, menthol/mint-, and sweet-flavored) and any flavor (composite score across flavor categories) of vaping products.

RESULTS

Study condition was not associated with intentions to use menthol/mint-, sweet-flavored, or any flavor. Compared to the condition in which all flavored products were displayed, removing menthol/mint- and sweet-flavored products significantly increased future intentions to use tobacco-flavored vaping products (OR = 3.97, 95 % CI [1.01, 15.58], p < .05). This effect was only observed among adolescents with history of vaping (OR = 11.30, 95 % CI [1.42, 89.96], p = .02).

CONCLUSIONS

Flavor bans may not affect adolescents' intentions to use menthol/mint, sweet, or "any" flavor of vaping products but may increase intentions to use tobacco-flavored products for teens who have already started vaping.

Evaluation of a Statewide Flavored Tobacco Restriction on Use, Access, and Cessation Among Black and White Tobacco Users in Massachusetts

PURPOSE

To evaluate the impact of a statewide flavored tobacco restriction among Massachusetts residents who use menthol or flavored tobacco and to assess differences in impact between Black and White users, as the tobacco industry has targeted menthol to Black users.

DESIGN

An online survey was distributed through a panel provider and household mailings.

SETTING

Eleven Massachusetts communities with higher-than-state-average Black, Indigenous or People of Color populations.

SUBJECTS

Black (n = 63) and White (n = 231) non-Hispanic residents who used menthol or other flavored tobacco products in the past year.

MEASURES

Impact of the law on use, access, and quitting behaviors.

ANALYSIS

Outcomes were assessed between Blacks and Whites using Pearson chi-square tests.

RESULTS

Over half (53% of White, 57% of Black) of respondents believed the law made it more difficult to access menthol products; two-thirds (67% of White,64% of Black) accessed menthol products in another state. Black users were significantly more likely to report purchasing menthol products off the street (P ≤ .05). One-third (28% of White, 32% of Black) believed the law made it easier to quit, and one-third (27% of White, 34% of Black) completely quit in the past year.

CONCLUSIONS

Flavored tobacco restrictions may positively and equitably impact cessation. Cross-border access and off-the-street purchasing suggest the need for greater cessation support and underscore the importance of a national policy.

Smokers' support for the ban on sale of slim cigarettes in six European countries: findings from the EUREST-PLUS ITC Europe Surveys

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries. Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST-PLUS project survey, a cross sectional study of adult smokers (n=5592) from Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm. Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0.67-0.91, daily smokers (OR=0.68; 95%CI=0.47-0.97), menthol smokers (OR=0.55; 95%CI=0.36-0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36-0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes. Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more prevalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review

Objective

To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions.

Data sources

PubMed, Scopus, Embase and Web of Science before May 3, 2022.

Study selection

Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions.

Data extraction

Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance.

Data synthesis

We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6–39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products.

Conclusion

Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14440-x.

Electronic nicotine delivery systems (ENDS) flavours and devices used by adults before and after the 2020 US FDA ENDS enforcement priority: findings from the 2018 and 2020 US ITC Smoking and Vaping Surveys

Background

In February 2020, the US Food and Drug Administration (FDA) prioritised enforcement efforts against flavoured prefilled cartridge/pod electronic nicotine delivery systems (ENDS), with the exception of tobacco and menthol. This study examined changes between prepriority enforcement (2018) and early postenforcement (February–June 2020) among adults on: ENDS flavours and devices used most often; location of last purchase of fruit/other-flavoured cartridges (covered under the enforcement priority); and smoking and vaping.

Methods

Prevalence estimates came from 1608 adult frequent (≥weekly) ENDS users (current smokers (n=1072), ex-smokers (n=536)) who participated in the 2018 and/or 2020 US ITC Smoking and Vaping Surveys. Transitions between flavours/devices and changes in smoking/vaping were assessed among baseline respondents who were followed up in 2020 (n=360). Respondents self-reported the ENDS device (disposable, cartridge/pod or tank) and the flavor that they used most often: (1) tobacco flavors (tobacco/tobacco-menthol mix) or unflavored; (2) menthol/mint; (3) fruit/other flavors.

Results

Compared to 2018, in the first 5 months of the 2020 enforcement priority, there were significant increases in the prevalence of fruit/other-flavoured cartridges (7.9% to 12.4%,p=0.026) and menthol/mint cartridges (7.1% to 13.0%, p<0.01) and decreases in tobacco-flavoured tanks (15.5% to 10.0%,p=0.002) and fruit/other-flavoured tanks (38.7% to 33.6%,p=0.038). Fewer than 10% of adults used disposables in 2018 and 2020. Among the cohort sample, the most pronounced transitions between flavours/devices occurred among those who used flavoured cartridges covered under the enforcement priority (54.6% switched to a flavour and/or device excluded from enforcement). There was an increase in purchasing fruit/other-flavoured cartridges online and a decrease in retail locations except for vape shops. Overall, there were few changes in smoking and vaping behaviours.

Conclusions

Between 2018 and the early phase of the FDA’s 2020 enforcement priority, prevalence of menthol/mint and fruit/other-flavoured cartridges increased among adults. Half of vapers using cartridge flavours covered in the enforcement switched to other flavours and/or devices that were exempt, with the exception of disposables. The extent to which more comprehensive restrictions may be problematic for adults who prefer a range of ENDS flavours remains uncertain.

Flavour loyalty may predict cessation or substitution following a cigarillo flavour ban among young adults in the USA

Significance

The purpose of this research was to measure flavour loyalty and identify how current cigarillo users may respond to a hypothetical flavour ban in the USA.

Methods

Cigarillo users aged 21–28 (n=531) were recruited between October 2020 and April 2021 to participate in an online survey. Respondents categorised their preferred, usual and current cigarillo flavours. Individuals who preferred tobacco flavours were compared with individuals who preferred any other flavours. Strength of preferences, or flavour loyalty, was defined when an individual’s preferred flavour matched what they use both usually and currently creating a spectrum of individuals with a strong tobacco preference (n=34), weak tobacco preference (n=20), weak flavour preference (n=162) and strong flavour preference (n=315). Those preferring tobacco were aggregated into any tobacco preference (n=54).

Results

Individuals who preferred any flavour scored higher on a scale of nicotine dependence. There was a dose–response relationship in those who said they would discontinue cigarillos if flavoured options were not available: 11.4% of individuals with any tobacco flavour preference, 27.8% of those with a weak flavour preference and 38.1% of those with a strong flavour preference. A similar trend was noted among those who would switch to another product: 19.2% of those with tobacco flavour preference, 34.3% of those with a weak flavour preference and 43.2% of those with a strong flavour preference.

Conclusion

Individuals who display strong flavour preferences were more likely to say they would discontinue use or seek out alternative flavoured products following a ban on flavoured cigarillos.

Impact of the FDA flavour enforcement policy on flavoured electronic cigarette use behaviour changes

INTRODUCTION

This study aims to investigate electronic cigarette (e-cigarette) use behaviour changes after the implementation of the US Food and Drug Administration (FDA) restriction on the sale of all unauthorised flavoured cartridge-based e-cigarettes other than tobacco and menthol flavour on 6 February 2020, as well as factors associated with these changes.

METHODS

Through Amazon's Mechanical Turk service, 3533 current adult flavoured e-cigarette users (who were not exclusive tobacco-flavoured or menthol-flavoured e-cigarette users) were recruited for an online survey from 8 July to 29 July 2021. Multiple logistic regression models were used to identify significant factors associated with quitting e-cigarette use, switching to other flavoured electronic nicotine delivery system (ENDS) products, switching to combustible tobacco products, switching to menthol-flavoured e-cigarettes and switching to tobacco-flavoured e-cigarettes.

RESULTS

Resulting from the FDA flavour enforcement policy, the top four e-cigarette use behaviour changes were: (1) switching to other flavoured ENDS products such as the tank system or disposable e-cigarettes (29.24%), (2) switching to menthol-flavoured pod systems (18.09%), (3) switching to combustible tobacco products (14.12%) and (4) switching to tobacco-flavoured pod systems (12.03%). There were 4.9% participants who indicated that they quit e-cigarette use. Overall, multiple factors, especially past 30-day use of certain flavours, were associated with different behaviour changes.

CONCLUSIONS

The implementation of the FDA flavour enforcement policy on cartridge-based e-cigarette was associated with significant e-cigarette behaviour changes, with multiple factors being associated with these changes. These results provide important information for future regulations of flavoured e-cigarette products.

Changes in product labelling practices and the use of flavouring chemical additives in vaping products after enactment of statewide flavour legislation

INTRODUCTION

On 18 May 2020, New York State enacted legislation banning the sale of vaping products with distinguishable flavours (other than tobacco). According to this new statute, vaping products are deemed flavoured if they include a statement, whether expressed or implied, that have distinguishable tastes or aromas other than tobacco. This study aimed to determine how manufacturers responded.

METHODS

We collected 555 vaping products from daily vapers (238 preban and 317 postban). We compared preban and postban labelling of products for expressed and implied flavour descriptions, graphics and colours. Flavouring chemicals and concentrations were identified using chromatography methods and were compared preban and postban.

RESULTS

Analysis of the labels preban and postban did not reveal a change in products with expressed flavoured descriptors (45.8% vs 44.2%) and a minimal decrease in implied descriptors (22.3% vs 14.5%). An increase in products without any descriptors was observed (28.2% vs 37.2%) notably within products from a popular pod brand. The average concentration of eight popular flavourings identified preban was 1.4±2.7 compared with 2.3±3.5 mg/mL (p<0.001) postban. No significant changes between individual flavouring concentrations in the most popular refill solutions and pods were found.

CONCLUSION

While a majority of products appeared to remain non-compliant, this study suggests that enactment of legislation on vaping products making expressed or implied flavour claims may result in some manufacturer changes to product labelling including removal of flavour descriptors. However, use of flavouring additives in vaping products appeared not to be impacted by the ban.

Associations between living in localities with e-cigarette sales restrictions and e-cigarette use change among young adults in Los Angeles County

INTRODUCTION

Local e-cigarette sales restrictions (ESRs) may impact e-cigarette use. This study examined the associations between living in localities with various ESR policies and changes in e-cigarette use among young adults in Los Angeles (LA) County, California, USA.

METHODS

Data were from a cohort of LA County young adults (18-21 years; n=2100) who completed two waves of surveys (Fall 2018-Summer 2019 and Summer-Fall 2020). Local flavoured (n=9) and comprehensive (n=2) ESRs in LA County implemented between June 2019 and May 2020 were identified, coded and merged with the baseline data. Multivariable logistic regressions were used to examine the associations between living in ESR localities and e-cigarette use at follow-up, controlling for covariates and stratified by cigarette smoking at baseline.

RESULTS

Overall, 20.9% and 14.3% of participants lived in localities with flavoured and comprehensive ESRs, respectively. Participants who were non-Hispanic, had higher socioeconomic statuses and were currently using e-cigarettes were generally more likely to live in ESR localities than their counterparts. The associations between living in ESR localities and e-cigarette use at follow-up were not found among baseline non-e-cigarette users regardless of their cigarette smoking status; a positive relationship was found among baseline e-cigarette users who also smoked cigarettes but not among non-smokers.

DISCUSSION

Participants who lived in localities with various ESR policies were different in their baseline e-cigarette use and socioeconomic backgrounds. Future research examining the potential impact of ESRs on e-cigarette use change should consider the localities' overall sociodemographic and tobacco-using characteristics and individuals' cigarette smoking histories.

Potential Impact of FDA Flavor Enforcement Policy on Vaping Behavior on Twitter

In January 2020, the FDA announced an electronic cigarette (e-cigarette) flavor enforcement policy to restrict the sale of all unauthorized cartridge-based flavored e-cigarettes except tobacco and menthol flavors, which was implemented on 6 February 2020. This study aimed to understand the potential influence of this policy on one vaping behavior change-quitting vaping-using Twitter data. Twitter posts (tweets) related to e-cigarettes were collected between June 2019 and October 2020 through a Twitter streaming API. Based on the geolocation and keywords related to quitting vaping, tweets mentioning quitting vaping from the US were filtered. The demographics (age and gender) of Twitter users who mentioned quitting vaping were further inferred using a deep learning algorithm (deepFace). The proportion of tweets and Twitter users mentioning quitting vaping were compared between before and after the announcement and implementation of the flavor policy. Compared to before the FDA flavor policy, the proportion of tweets (from 0.11% to 0.20% and 0.24%) and Twitter users (from 0.15% to 0.70% and 0.86%) mentioning quitting vaping were significantly higher after the announcement and implementation of the policy (p-value < 0.001). In addition, there was an increasing trend in the proportion of female and young adults (18-35 years old) mentioning quitting vaping on Twitter after the announcement and implementation of the policy compared to that before the policy. Our results showed that the FDA flavor enforcement policy did have a positive impact on quitting vaping on Twitter. Our study provides an initial evaluation of the potential influence of the FDA flavor enforcement policy on user vaping behavior.

The impact of two state-level approaches to restricting the sale of flavored tobacco products

Background

Flavored tobacco products are highly appealing to youth. The Federal government lacks a comprehensive flavored tobacco products policy and states have adopted different approaches restricting these products. This study analyzes the impact of Massachusetts’ comprehensive prohibition and New Jersey’s partial restriction on the sale of flavored tobacco products.

Methods

NielsenIQ Retail Scanner data were used to construct four log per capita dependent variables: e-liquid milliliters, cigarette packs, cigars, and smokeless tobacco ounces for products flavored as fruit, menthol, mint, tobacco and other. All models used difference-in-differences regressions, with Virginia and Pennsylvania serving as controls. The models controlled for state level product prices, population percentages by race/ethnicity, proportion male, median household income, unemployment rate, minimum legal sales age, tobacco 21 policies, and cumulative cases and deaths of COVID-19; the models accounted for time-specific factors by using 4-week period fixed-effects.

Results

There was a significant decrease in sales across all flavored tobacco products in Massachusetts, including fruit [-99.83%, p < 0.01], menthol [-98.33%, p < 0.01], and all other flavored [-99.28%, p < 0.01] e-cigarettes. The cigar group “all other-flavors" [-99.92%, p < 0.01] and menthol flavored cigarettes [-95.36%, p < 0.01] also significantly decreased. In New Jersey, there was a significant decrease in per capita sales of menthol-flavored e-cigarettes [-83.80%, p < 0.05] and cigar group “all other-flavors" experienced a significant increase in per capita sales [380.66%, p < 0.01].

Conclusions

This study contributes to the growing body of evidence demonstrating the impact of sales prohibitions on reducing sales of flavored tobacco products. Statewide comprehensive approaches appear more effective than partial restrictions and should be prioritized.

Implications

Results from this study support emerging research that demonstrates the promising effects of comprehensive flavoring sales prohibitions. This study can be used to inform future flavored tobacco product policy solutions developed by advocates and policy makers to curb overall tobacco initiation and use by youth and adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14172-y.

Policies restricting flavors and non-cigarette tobacco product availability: A study of vape shops in San Francisco and Alameda Counties, California, USA

We examined flavored non-cigarette tobacco availability in brick-and-mortar vape shops in San Francisco (SF) and Alameda Counties, California (USA), comparing cities organized by flavored tobacco sales restriction policy. A total of 22 brick-and-mortar vape shops were identified and audited in October-November 2019; shops were located in SF City-County and nine cities in Alameda County. Fisher Exact Tests were used to assess differences in the availability of products between vape shops in cities with versus without comprehensive or partial flavored tobacco sales restrictions enacted before November 21, 2019 (n = 15 shops in six cities with policies vs n = 7 shops in four cities without policies). In the six cities with any flavored sales restrictions, fewer vape shops sold menthol/mint flavored JUUL pods (27% vs 71%, p = 0.074), candy/fruit (53% vs 100%, p = 0.051) and menthol/mint (53% vs 100%, p = 0.051) nicotine e-cigarette liquids compared to cities without flavored tobacco sales restrictions, but results were borderline significant. Tobacco-flavored JUUL pods (47% vs 71%, p = 0.381), tobacco-flavored nicotine e-cigarette liquids (67% vs 100%, p = 0.135), and flavored e-cigarette liquids without nicotine (candy/fruit: 87% vs 71%, p = 0.565 and menthol/mint: 87% vs 57%, p = 0.274) were not included in the policies, and availability was not significantly different between cities with or without policies. Enactment of local policies was associated with lower flavored e-cigarette tobacco product availability but not tobacco-flavored or non-nicotine product availability; federal policies restricting sales of flavored tobacco products may reduce access to flavored e-cigarette products in vape shops.

Impact of existing and potential e-cigarette flavor restrictions on e-cigarette use among young adult e-cigarette users in 6 US metropolitan areas

Given the 2020 federal restrictions on flavored cartridge-based e-cigarettes and increasing state/local flavored e-cigarette sales restrictions, this mixed-methods study examined US young adult e-cigarette users' responses to flavored e-cigarette sales restrictions (e.g., changes in use, products used, access). We descriptively analyzed Fall 2020 survey data from 726 past 6-month e-cigarette users (Mage = 24.15, 51.1% female, 4.4% Black, 10.2% Asian, 12.1% Hispanic, 35.5% sexual minority), and qualitatively analyzed Spring 2021 semi-structured interview data among 40 participants (Mage = 26.30, 35.0% female, 5.0% Black, 22.5% Asian, 12.5% Hispanic, 45.0% sexual minority). Across all participants (i.e., survey and interview participants), ≥80% most commonly used non-tobacco flavors; ≥40% used tank-based devices. Survey participants most commonly reported that the federal restrictions did not impact their use: 35.8% used available flavors (i.e., tobacco, menthol), 30.4% continued to use tank-based e-cigarettes, and 10.1% switched to tank-based e-cigarettes. Only 8.4% reduced their e-cigarette use. Among interview participants, some indicated no impact on their e-cigarette use because they stocked up or obtained flavors from alternative sources (e.g., online). Some filled their own pods with e-liquids, switched to menthol/tobacco flavors, switched e-cigarette devices or brands, and/or reduced use. Regarding the anticipated impact of comprehensive flavor restrictions, some participants reported that they would: 1) quit vaping; 2) switch to cigarettes; or 3) not change their use (e.g., stock up on flavors). The potential unintended reactions to flavored e-cigarette sales restrictions (e.g., continued use of flavored cartridge-based e-cigarettes) underscore the need for ongoing surveillance of retail and consumer behavior to inform policy and compliance/enforcement efforts.

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

Objective: To examine conversations among JUUL users on Reddit related to restrictions on flavored ENDS and the shifting policy landscape. Methods: Posts and comments (n = 166,169) between May 2019 and May 2020 on the subreddit r/JUUL were scraped using pushshift.io API. Keyword filters were used to identify texts discussing flavored ENDS products (n = 33,884 texts). These were further narrowed down to texts discussing flavor policy workaround strategies (n = 7429) and N-gram analysis was performed. Finally, findings from the N-gram analysis were triangulated through qualitative review of a separate sample of texts (n = 488) from the flavor policy-related posts and comments. Results: Overall activity on the subreddit r/JUUL peaked around the time of the EVALI outbreak (September 2019) and when FDA issued guidance restricting flavored ENDS product sales (January 2020). The N-gram analysis revealed an active discussion of banned products one can “still get” or “JUUL compatible” alternatives, including specific brands, brick and mortar locations, and specific flavors. Ten dominant themes emerged from the qualitative review, with some posts containing more than one theme. Conclusion: Many users turned to Reddit for information related to the shifting regulatory landscape concerning flavored ENDS. Discussions focused on both legal alternatives to banned products as well as illegal means of acquiring JUUL pods, including residual retail supply, online, and mail vendors.

General and Device-Specific Reasons for ENDS Use: A Qualitative Study with Adult ENDS Users

BACKGROUND

A scientific consensus on the public health impact of electronic nicotine delivery systems (ENDS) remains elusive. This is partly due to the wide variation in product characteristics often lumped together under one category. Research is needed to better understand what ENDS device type characteristics motivate their use by adults.

METHODS

Nine focus groups of 32 current ENDS users who were 18+ years old, had used ENDS in the previous 30 days, and had been using ENDS for more than two months were held either in person or online between February and June 2020.

RESULTS

Participants' reasons for their choice of ENDS characteristics included both general, applying to all ENDS products, and specific, relating to particular ENDS devices. Health benefits and the lack of offensive odor were commonly identified as important reasons for using ENDS in general. Flavor and product discreteness were both general and device-specific determinants of ENDS use. Conversely, nicotine delivery, cloud size, battery properties, aesthetics, ease of use, and cost were device-specific drivers of participants' choice.

CONCLUSIONS

The reasons that adults choose to use ENDS are complex and sometimes related to both ENDS as a category and as specific ENDS product types. Regulations and public communication campaigns should reflect their ultimate objective and consider both general and specific motivations when attempting to achieve public health objectives.

Impact of Local Flavored Tobacco Sales Restrictions on Policy-Related Attitudes and Tobacco Product Access

BACKGROUND

As of September 2020, more than 300 state and local jurisdictions restrict the sales of flavored tobacco, with some including menthol.

AIMS

To evaluate the impact of local ordinances restricting the sale of flavored tobacco, we surveyed Californians regarding policy support and perceived access to flavored tobacco.

METHODS

In 2019, we conducted an online survey of 3,075 California youth and young adults recruited via social media, about half of whom lived in a policy jurisdiction. Logistic regressions assessed differences on propensity score-weighted outcomes, policy support, and perceived access.

RESULTS

Most respondents indicated agreement with almost all policy support statements. Although policy respondents were less likely than rest-of-California respondents to report perceived difficulty in buying flavored cigars, flavored vape users in policy jurisdictions were more likely than those in the rest of California to report perceived difficulty in buying flavored e-liquid. Regardless of jurisdiction, certain priority subgroups were significantly more likely to report perceived difficulty in accessing flavored cigars, flavored vaping products, flavored e-liquid, and menthol cigarettes.

DISCUSSION

With some exceptions, these findings demonstrate that among vape users in policy jurisdictions and priority subgroups, there is a higher likelihood of reporting perceived difficulty to access flavored tobacco products.

CONCLUSIONS

Findings might be an early indication of shifts in social norms about flavored tobacco products in California, which could gain traction as local sales restriction ordinances proliferate throughout the state and a statewide flavored-tobacco sales restriction goes into effect.

Multiple tobacco product use among cigarette smokers: a longitudinal examination of menthol and non-menthol smokers during young adulthood

BACKGROUND

Multiple tobacco product (MTP) use is common among young adults. Most MTP users are combustible cigarette smokers that use one or more other tobacco products. This study aims to explore menthol as a risk factor for MTP use among a cohort of young adult cigarette smokers.

METHODS

Participants were 18-29 years cigarette smokers at 24 Texas colleges in a 6-wave study. Participants (n=4700 observations) were classified as: single product users (ie, exclusive cigarette smoking); dual product users and poly product users. A multilevel, ordered logistic regression model was used to examine the association between menthol cigarette smoking and MTP use. Two longitudinal, multilevel, multinomial logistic regressions were used to examine the relationship between menthol cigarette smoking and number of tobacco products used.

RESULTS

Overall, 40.7% of the sample were single product users, 33.7% were dual product users and 25.6% were poly product users. Menthol was associated with 1.28 greater odds of MTP use. Further, menthol was associated with 1.19 greater risk of dual and 1.40 greater risk of poly product use, relative to single product use. Lastly, menthol cigarette smoking was associated with 1.18 greater risk of poly product use, relative to dual product use.

CONCLUSIONS

There was a gradient relationship between menthol cigarette smoking and number of tobacco products used among young adult cigarette smokers. Findings provide for greater regulatory and programmatic efforts to reduce the use of menthol cigarettes.

Flavored Tobacco Sales Restrictions Reduce Tobacco Product Availability and Retailer Advertising

OBJECTIVE

This study examined differences in the availability and advertising of flavored tobacco products before and after flavored tobacco sales restrictions were enacted in Alameda and San Francisco Counties in California.

MAIN OUTCOME MEASURES

Data were collected from a sample of tobacco retailers in Alameda and San Francisco Counties at two time points: 2015, before flavored tobacco policies were enacted, and in 2019-2020, after some cities had enacted policies. Retailers were separated by city into Category 1 (n = 442)-retailers in cities that enacted a flavored tobacco policy between the two data collection periods, and Category 2 (n = 89), those that had not. Means comparison tests were conducted to evaluate significant differences over time and by category.

RESULTS

There was significantly reduced availability of menthol cigarettes, flavored little cigars, smokeless tobacco, vape pens, and Blu brand menthol e-cigarettes between 2015 and 2020 in Category 1 retailers. Category 2 retailers had reduced availability only for Blu menthol e-cigarettes and demonstrated an increase in smokeless tobacco availability. Exterior store advertising for cigarettes, little cigars, cigars, and e-cigarettes also decreased significantly in Category 1 cities relative to Category 2 cities; 8.1% of Category 1 stores were advertising flavored tobacco products in 2019-2020 compared to 36.2% of Category 2 stores. There was also a 78% reduction in flavored ads between 2015-2019 in Category 1 cities compared to a 38% decrease in Category 2 cities. Tobacco advertising inside Category 2 stores increased. Finally, Category 2 cities had significantly greater availability of cigalikes, mod or tank vapes, flavored e-cigarettes, and e-liquids compared to Category 1 cities.

CONCLUSIONS

Comprehensive flavored sales restriction policies reduce flavored tobacco availability and tobacco advertising, which may help prevent youth tobacco initiation and exposure.

Electronic Cigarette Vaping Did Not Enhance the Neural Process of Working Memory for Regular Cigarette Smokers

Background

Electronic cigarettes (e-cigs) as substitute devices for regular tobacco cigarettes (r-cigs) have been increasing in recent times. We investigated neuronal substrates of vaping e-cigs and smoking r-cigs from r-cig smokers.

Methods

Twenty-two r-cig smokers made two visits following overnight smoking cessation. Functional magnetic resonance imaging (fMRI) data were acquired while participants watched smoking images. Participants were then allowed to smoke either an e-cig or r-cig until satiated and fMRI data were acquired. Their craving levels and performance on the Montreal Imaging Stress Task and a 3-back alphabet/digit recognition task were obtained and analyzed using two-way repeated-measures analysis of variance. Regions-of-interest (ROIs) were identified by comparing the abstained and satiated conditions. Neuronal activation within ROIs was regressed on the craving and behavioral data separately.

Results

Craving was more substantially reduced by smoking r-cigs than by vaping e-cigs. The response time (RT) for the 3-back task was significantly shorter following smoking r-cigs than following vaping e-cigs (interaction: F (1, 17) = 5.3, p = 0.035). Neuronal activations of the right vermis (r = 0.43, p = 0.037, CI = [-0.05, 0.74]), right caudate (r = 0.51, p = 0.015, CI = [0.05, 0.79]), and right superior frontal gyrus (r = −0.70, p = 0.001, CI = [−0.88, −0.34]) were significantly correlated with the RT for the 3-back task only for smoking r-cigs.

Conclusion

Our findings suggest that insufficient satiety from vaping e-cigs for r-cigs smokers may be insignificant effect on working memory function.

Responses to potential nicotine vaping product flavor restrictions among regular vapers using non-tobacco flavors: Findings from the 2020 ITC Smoking and Vaping Survey in Canada, England and the United States

INTRODUCTION

Some jurisdictions have implemented nicotine vaping product (NVP) flavor restrictions because of concerns about rising adolescent use. However, little is known how these restrictions may impact adult vapers. This study describes the level of support and predictive behavioral responses to a hypothetical NVP ban on non-tobacco flavors among regular adult vapers who only use flavors that would be banned.

METHODS

Data came from 851 regular vapers (all current or ex-smokers) participating in the 2020 ITC Four Country Smoking and Vaping Survey in Canada, England, and the United States (US). A random sample of respondents in each country received and completed the questions about flavor bans: (1) do you support or oppose a ban on all non-tobacco flavors; and (2) what would you do if all flavors were banned, with the exception of tobacco in the US, and tobacco and menthol in Canada and England. Those who used tobacco-flavored or unflavored NVPs were excluded from all analyses, and additionally, vapers of menthol flavor in Canada and England were excluded from Aim 2.

RESULTS

Overall, 53.6% of vapers were strongly opposed to flavor bans, 28.2% were opposed, 9.3% were in support, 3.6% were in strong support, and 5.2% did not know. Predicted behavioral responses were: 28.8% would continue vaping an available flavor, 28.3% would find a way to get their banned flavor(s), 17.1% would stop vaping and smoke instead, 12.9% said that they would stop vaping and not smoke, and 12.9% do not know what they would do. Responses to a potential flavor ban largely varied by smoking and vaping status, and by the level of support of a flavor restriction policy.

CONCLUSIONS

At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses.

Smoking cessation strategies used by former menthol cigarette smokers after a menthol ban

INTRODUCTION

Menthol cigarettes were banned in Ontario, Canada on January 1st, 2017. We used concept mapping, a mixed-method approach, to describe how menthol cigarette smokers quit smoking after the Ontario menthol ban.

METHODS

Pre-ban daily and non-daily menthol cigarette smokers who reported smoking abstinence 24 months after the ban (n = 62; 53.2% women; mean age = 43.6, SD = 12.5) generated statements describing reasons and strategies for smoking cessation/reduction after the menthol ban. Participants sorted a final list of 57 statements into groups of similar content and rated statements on how true each statement was for them and multidimensional scaling analysis identified thematic clusters.

RESULTS

Six clusters were identified: Mental and Environment Changes, Direct Ban Impacts, Health Reasons, Cues to Action, Family and Friends, and Cessation Strategies. The highest rated statements (i.e., most true) suggested many participants were motivated to quit smoking before or after the ban and 30.7% of participants believed the menthol ban helped with smoking cessation. Some of the lowest rated statements included using nicotine replacement therapy products, medication (i.e., Champix), or other tobacco products suggesting these strategies were less common. Statement ratings suggested many smokers quit without using replacement products or medication, but modifying cognitions and avoiding smoking cues were common.

CONCLUSIONS

The menthol ban aided some menthol smokers to quit, while others reported the ban did not play a role in smoking cessation. These data suggest the menthol ban had direct and indirect effects on smoking reduction behavior. Campaigns supporting similar bans that target both types of effects will likely be most effective for smoking reduction.

The Illegal Experimental Tobacco Marketplace I: Effects of Vaping Product Bans

OBJECTIVES

Banning vaping products may have unintended outcomes, such as increased demand for illegal products. This study experimentally examined the effects of a vaping ban and a flavored vaping ban on the probability of purchasing illicit vaping products, and factors affecting purchasing from a hypothetical illegal marketplace.

METHODS

A crowdsourced sample of exclusive cigarette smokers, exclusive e-cigarette users, and frequent dual users (n = 150) completed hypothetical purchasing trials in an Experimental Tobacco Marketplace under three conditions (no ban, vaping ban, and flavored vaping ban). Participants chose to purchase in a hypothetical legal experimental tobacco marketplace (LETM) or illegal experimental tobacco marketplace (IETM). Vaping products were available in each marketplace depending on the condition. Other tobacco products were always available in the LETM. A hypothetical illicit purchase task with five fine amounts assessed the effect of monetary penalties.

RESULTS

Participants from all groups were more likely to purchase from the IETM when product availability in the LETM was more restricted, with e-cigarette users being most affected. The likelihood of purchasing illegal products was systematically decreased as monetary penalties associated with the IETM increased, with e-cigarette users showing greater persistence in defending their illicit purchases.

CONCLUSIONS

Restricting vaping products from the marketplace may shift preference towards purchasing vaping products in the illegal marketplace. Nevertheless, penalties imposed on consumer's behavior might be effective in preventing illicit trade. The IETM is a methodological extension that supports the utility and flexibility of the ETM as a framework for understanding the impact of different tobacco regulatory policies.

IMPLICATIONS

This study suggests that limiting or banning vaping products as a possible strategy to reduce the adverse effects of vaping products could result in some tobacco-users seeking banned products from illegal sources. Monetary fines were shown to reduce illegal purchases. Therefore, policymakers should consider implementing strategies that may mitigate illegal purchases.

The consequential impact of JUUL on youth vaping and the landscape of tobacco products: The state of play in the COVID-19 era

JUUL is a groundbreaking electronic cigarette (e-cig) and the preeminent vaping product on the market. We present an overview of the rapid and spectacular rise of JUUL and its remarkable fall within the timespan of 2015 - 2020. We highlight JUUL's entering the market in June 2015, becoming the industry leader in mid 2017, and experiencing a litany of setbacks by late 2019 through to early 2020. We address the role played by JUUL in the ongoing epidemic of youth vaping. We also feature competing views on the public health impact of JUUL use (in particular), and e-cig vaping (in general). We further highlight the latest trends in youth vaping and sales records for JUUL and tobacco cigarettes. In view of the ongoing pandemic of COVID-19, we briefly summarize the existing evidence on the relationship between vaping and smoking and the prevalence, disease course, and clinical outcomes of COVID-19.

Appeal, subjective effects, and relative reinforcing effects of JUUL that vary in flavor and nicotine content

The U.S. Food and Drug Administration has the authority to regulate characteristics of electronic nicotine delivery systems (ENDS). Prior research indicates that regulation of certain characteristics of these products may have an effect on their appeal and use. Policies that affect appeal and use of ENDS are relevant to attempts to reduce use among young people-including young adults-but are also relevant to adults who use these products as harm reduction tools. Using a novel concurrent choice task, we evaluated the relative reinforcement of JUUL brand ENDS products that varied in flavor (n = 8) and nicotine (n = 8) among samples of young adults who use JUUL. Findings suggest that restricting JUUL flavor to tobacco-only results in decreased appeal, while reducing the nicotine content of JUUL pods to 3%-from the conventional 5%-does not have an effect on product appeal. Findings also validate a novel methodology for delivering fixed doses of ENDS vapor within the context of a task that assesses the relative reinforcement of ENDS products with varying characteristics. This methodology can be applied to assessing the relative reinforcing effects of a wide variety of tobacco products with varied characteristics. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Are California's Local Flavored Tobacco Sales Restrictions Effective in Reducing the Retail Availability of Flavored Tobacco Products? A Multicomponent Evaluation

INTRODUCTION

Flavored tobacco appeals to new users. This paper describes evaluation results of California's early ordinances restricting flavored tobacco sales.

METHODS

A multicomponent evaluation of proximal policy outcomes involved the following: (a) tracking the reach of local ordinances; (b) a retail observation survey; and (c) a statewide opinion poll of tobacco retailers. Change in the population covered by local ordinances was computed. Retail observations compared availability of flavored tobacco at retailers in jurisdictions with and without an ordinance. Mixed models compared ordinance and matched no-ordinance jurisdictions and adjusted for store type. An opinion poll assessed retailers' awareness and ease of compliance with local ordinances, comparing respondents in ordinance jurisdictions with the rest of California.

RESULTS

The proportion of Californians living in a jurisdiction with an ordinance increased from 0.6% in April 2015 to 5.82% by January 1, 2019. Flavored tobacco availability was significantly lower in ordinance jurisdictions than in matched jurisdictions: menthol cigarettes (40.6% vs. 95.0%), cigarillos/cigar wraps with explicit flavor descriptors (56.4% vs. 85.0%), and vaping products with explicit flavor descriptors (6.1% vs. 56.9%). Over half of retailers felt compliance was easy; however, retailers in ordinance jurisdictions expressed lower support for flavor sales restrictions.

CONCLUSIONS

The proportion of California's population covered by a flavor ordinance increased nine-fold between April 2015 and January 2019. Fewer retailers in ordinance jurisdictions had flavored tobacco products available compared to matched jurisdictions without an ordinance, but many still advertised flavored products they could not sell. Comprehensive ordinances and retailer outreach may facilitate sales-restriction support and compliance.

Effect of Massachusetts House Bill No. 4196 on electronic cigarette use: a mixed-methods study

BACKGROUND

Electronic cigarettes, or e-cigarettes, are devices that deliver nicotine-containing aerosol and were used by 2.8% of American adults in 2017. Many people who smoke cigarettes have used e-cigarettes for smoking cessation, and the general consensus among health providers is that while vaping is not harmless, it is less harmful than smoking. To try to reduce youth e-cigarette use, the Commonwealth of Massachusetts imposed a 75% excise tax on nicotine-containing vaping products and banned the sale of all flavored tobacco products, including combustible tobacco, effective June 1, 2020. This tax, like similar taxes in other states, aimed to reduce e-cigarette consumption. However, past research has found that e-cigarettes and cigarettes are economic substitutes, meaning that an increase in e-cigarettes prices may push more people who smoke e-cigarettes to smoke combustible cigarettes.

METHODS

To determine the impacts of several events, such as the e-cigarette and vaping-associated lung injury (EVALI) outbreak and implementation of the Massachusetts e-cigarette tax, on e-cigarette and cigarette purchasing, we conducted an interrupted time-series analysis of year-on-year consumer purchasing data to impute changes in e-cigarette and cigarette purchasing in the Greater Boston area and the entire USA after several intervention points. We then surveyed a subset of people who used e-cigarettes to evaluate the plausibility that some e-cigarette consumers would travel out-of-state to purchase e-cigarettes.

RESULTS

The purchasing data indicated that there was no significant decrease in e-cigarette purchases in the Greater Boston convenience market after tax implementation. However, we found that e-cigarette purchases decreased significantly while cigarette purchases increased after several bans on e-cigarettes and numerous policy statements related to the EVALI outbreak. The survey results suggested that people who smoke e-cigarettes did not decrease their consumption after the implementation of the tax, but instead obtained e-cigarettes outside of Massachusetts.

CONCLUSION

These results suggest that the Massachusetts flavor ban and tax did not reduce e-cigarette consumption in the Greater Boston area, and that messaging questioning the safety of e-cigarettes led to an increase in combustible cigarette use. This suggests the need for health authorities to reconsider how they communicate the relative risks of smoking and vaping.

Reducing the smoking-related health burden in the USA through diversion to electronic cigarettes: a system dynamics simulation study

BACKGROUND

Electronic cigarettes ("e-cigarettes") have altered tobacco smoking trends, and their impacts are controversial. Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA.

METHODS

A system dynamics simulation model was constructed, with separate aging chains representing people in different stages of use (both of combustible cigarettes and e-cigarettes). These structures interact with a policy module to close the gap between actual (simulated) and goal numbers of individuals who smoke, chosen to reduce the tobacco-attributable death rate (i.e., mostly combustible cigarette-attributable, but conservatively allowing e-cigarette-attributable deaths) to that due to all accidents in the general population. The policy is two-fold, removing existing e-liquid flavor bans and providing an informational campaign promoting e-cigarettes as a lower-risk alternative. Realistic practical implementation challenges are modeled in the policy sector, including time delays, political resistance, and budgetary limitations. Effects of e-cigarettes on tobacco smoking occur through three mechanisms: (1) diversion from ever initiating smoking; (2) reducing progression to established smoking; and (3) increasing smoking cessation. An important unintended effect of possible death from e-cigarettes was conservatively included.

RESULTS

The base-case model replicated the historical exponential decline in smoking and the exponential increase in e-cigarette use since 2010. Simulations suggest tobacco smoking could be reduced to the goal level approximately 40 years after implementation. Implementation obstacles (time delays, political resistance, and budgetary constraints) could delay and weaken the effect of the policy by up to 62% in the worst case, relative to the ideal-case scenario; however, these discrepancies substantially decreased over time in dampened oscillations as negative feedback loops stabilize the system after the one-time "shock" introduced by policy changes.

CONCLUSIONS

The simulation suggests that the promotion of e-cigarettes as a harm-reduction policy is a viable strategy, given current evidence that e-cigarettes offset or divert from smoking. Given the strong effects of implementation challenges on policy effectiveness in the short term, accurately modeling such obstacles can usefully inform policy design. Ongoing research is needed, given continuing changes in e-cigarette use prevalence, new policies being enacted for e-cigarettes, and emerging evidence for substitution effects between combustible cigarettes and e-cigarettes.

ENDS Flavor Preference by Menthol Cigarette Smoking Status among US Adults, 2018-2019

E-cigarette flavor preference may differ among smokers using e-cigarettes, but little information is available on preferences by menthol cigarette status. Using nationally representative data for US adults from the 2018-2019 Tobacco Use Supplement to the Current Population Survey, we analyzed e-cigarette flavor preference by menthol cigarette status and e-cigarette device type for dual-cigarette and e-cigarette users and e-cigarette users who had recently quit smoking by trying to switch to e-cigarettes ("switchers"). Approximately half (52.2%) of dual users of menthol cigarettes and e-cigarettes reported using menthol/mint-flavored e-cigarettes as did 41.4% of "switchers" who had smoked menthol cigarettes; exclusive menthol/mint flavor use was 13.1% for dual users and 21.3% for "switchers." A similar proportion (45.1%) of dual users who smoked nonmenthol cigarettes used tobacco-flavored e-cigarettes, but only 26.7% of "switchers" who had smoked nonmenthol cigarettes used tobacco-flavored e-cigarettes. Approximately 60% of dual users and "switchers" used fruit/other flavors, regardless of menthol cigarette use. By device type, 63.9% of dual users of cartridge-based e-cigarettes and menthol cigarettes used menthol/mint-flavored e-cigarettes. Approximately 75% of dual users and 85% of "switchers" who used tank or mod systems used fruit/other flavors. Menthol cigarette smokers may be particularly likely to use menthol/mint e-cigarettes, and a majority of dual users and "switchers" used fruit/other flavors. These results can inform policy measures concerning flavored electronic nicotine delivery system products.

Response to Flavored Cartridge/Pod-Based Product Ban among Adult JUUL Users: "You Get Nicotine However You Can Get It"

In order to curb increasing youth electronic cigarette (e-cig) use, the United States Food and Drug Administration (FDA) banned the sale of flavored cartridge/pod-based products in February 2020. This mixed-methods study aimed to evaluate the impact of the FDA ban on adult JUUL users. The samples of current adult JUUL users were surveyed via Amazon Mechanical Turk at three time-points n = 76 (Sample 1); n = 128 (Sample 2); n = 86 (Sample 3) before and after the FDA flavored/pod ban. The participants were asked to report the JUUL flavored pod used most often and answer questions on purchasing generic pods or refilling (Quantitative). JUUL users were then interviewed in order to explore their perceptions and behaviors related to the FDA ban of flavored cartridge/pod-based products (Qualitative; n = 16). Quantitative data analysis evaluated the differences in variables by time-point. Qualitative data were coded into themes while using the constant comparative method. We found a significant decrease in the use of mint pods (43.4%, 22.7%, 16.3%) (p < 0.01), while there was a significant increase in the use of menthol pods (6.6%, 26.6%, 37.2%) (p < 0.01). Themes that emerged from the qualitative data included switching from mint to menthol pods, refilling pods, and switching to other products that are available in the desired flavors, such as generic pods or disposable e-cigs. Future research is needed in order to evaluate the impact of these behaviors on public health.

E-Liquid Containing a Mixture of Coconut, Vanilla, and Cookie Flavors Causes Cellular Senescence and Dysregulated Repair in Pulmonary Fibroblasts: Implications on Premature Aging

Electronic cigarette (e-cig) usage has risen dramatically worldwide over the past decade. While they are touted as a safe alternative to cigarettes, recent studies indicate that high levels of nicotine and flavoring chemicals present in e-cigs may still cause adverse health effects. We hypothesized that an e-liquid containing a mixture of tobacco, coconut, vanilla, and cookie flavors would induce senescence and disrupt wound healing processes in pulmonary fibroblasts. To test this hypothesis, we exposed pulmonary fibroblasts (HFL-1) to e-liquid at varying doses and assessed cytotoxicity, inflammation, senescence, and myofibroblast differentiation. We found that e-liquid exposure caused cytotoxicity, which was accompanied by an increase in IL-8 release in the conditioned media. E-liquid exposure resulted in elevated senescence-associated beta-galactosidase (SA-β-gal) activity. Transforming growth factor-β1 (TGF-β1) induced myofibroblast differentiation was inhibited by e-liquid exposure, resulting in decreased α-smooth muscle actin and fibronectin protein levels. Together, our data suggest that an e-liquid containing a mixture of flavors induces inflammation, senescence and dysregulated wound healing responses.