Among the 3.6 million students with past-month e-cigarette use, more than 80% used flavored products . Although banning sales of e-cigarettes and/or flavored tobacco may reduce adult smokers’ options, such policies may also help combat the epidemic of youth e-cigarette use . Non-tobacco flavored e-liquids are a primary driver of young people’s experimentation with e-cigarettes. In the 2019 National Youth Tobacco Survey, middle and high school students reported flavors as one of their primary reasons for use . The majority of youth e-cigarette ever-users initiated e-cigarette use with a non-tobacco flavored product . Further, initiation of e-cigarette use with non-tobacco flavored e-liquids is associated with more rapid progression in e-cigarette use frequency . Flavors appear to increase the reinforcing potential of e-cigarettes, both in conjunction with and independent of nicotine exposure . Hence, restrictions on non-tobacco flavored e-cigarette sales have gained attention in an effort to dissuade young people’s ecigarette use and the development of nicotine-containing e-cigarette dependence. In the U.S., it is against the law for retailers to sell tobacco products, including ecigarettes, to people under 21 years of age. Nonetheless, underage consumers in the U.S. frequently purchase vaping products at both brick-and-mortar stores and online stores. In a qualitative study, underage young adults in southern California reported buying vaping products from stores by using fake IDs and by frequenting retailers they knew did not have strict age verification. Age restrictions on online sales were evaded by using websites without strict verification, by using online delivery services , and by shipping products to an overage friend’s home . Online age verification is often easy to circumvent. Of the warning letters FDA sent to online retailers selling vaping products in 2018, 29% pertained to selling vaping products to minors . States must enforce the minimum sales age in order to receive full funding from the Substance Abuse and Mental Health Services Administration . However, many jurisdictions implemented the minimum sales age prior to the federal law. Policy enforcement is likely stronger in jurisdictions that had enforcement measures in place prior to implementation of the federal law. In addition, the odds of sales violations vary by neighborhood demographics . Youth who frequently visit convenience stores and other retailers that sell tobacco are at increased risk of subsequent e-cigarette use. Stricter retail restrictions, especially restrictions on the non-tobacco flavored products that young people prefer, may therefore decrease young people’s tobacco use.
Restrictions on flavored products may also discourage young people’s e-cigarette use via their potential impact on risk perceptions. Research indicates adolescents view non-tobacco flavored e-cigarettes as less harmful than tobacco e-cigarettes ,marijuana grow system and current use of non-tobacco flavored e-cigarettes is associated with lower risk perceptions . In sum, flavors increase the appeal of e-cigarettes to young people and may alter their judgment of the risks of e-cigarette use. If flavored e-cigarette sales were further restricted, youth may perceive e-cigarettes as more harmful and may be less likely to initiate use. Prior to the widespread popularity of e-cigarettes, flavored tobacco restrictions in New York City were followed by a decrease in reported flavored tobacco product use among youth . Moreover, research conducted in Massachusetts and Minnesota found that restricting the sale of flavored tobacco products to adult-only stores successfully decreased flavored tobacco product availability . Similarly, California youth and young adults who lived in a jurisdiction that restricted flavored tobacco sales were significantly less likely than their peers in other jurisdictions to obtain vaping products from brick-and-mortar retail sources.A national study estimated that tenth graders’ odds of current daily smoking declined 2% for each 1% increase in average retailer compliance with age restrictions . Recent evidence from Massachusetts also suggests that restricting the sale of flavored tobacco products reduces youth flavored tobacco product use, including e-cigarette use. Among young adults in Southern California, those living in jurisdictions with weaker tobacco retail licensing policies were more likely to endorse flavors as a reason for e-cigarette use compared to those in jurisdictions with stronger policies . Lastly, a few studies have evaluated the effects of San Francisco’s e-cigarette sales ban on young people’s tobacco use. Following the ban, young adults obtained a greater proportion of their e-cigarettes online or through the mail, or from retailers outside the city, yet flavored ecigarette use still decreased overall. Combustible cigarette smoking significantly increased, raising concerns that many young adults may have switched to cigarettes when e-cigarettes were less available . Moreover, a difference-in-difference analysis suggested increased odds of cigarette smoking among San Francisco high school students compared to other districts . Nonetheless, most prior research suggests positive effects of flavored e-cigarette sales restrictions on youth tobacco use. While informative, these studies did not assess the impact of flavored tobacco retail policy on youth e-cigarette risk perceptions. The present study assessed e-cigarette risk perceptions, attitudes toward flavored tobacco policy, and past-month nicotine vaping in a sample of young people in 30 major U.S. cities. Ten of the 30 cities prohibit flavored e-cigarette sales. We hypothesized that young people surveyed in the 10 cities with flavored e-cigarette sale restrictions versus the 20 cities without such restrictions would perceive e-cigarettes as riskier, have stronger beliefs in the effectiveness of flavored tobacco policy, and, among ever e-cigarette users, be less likely to report past-month nicotine vaping.
We also examined demographic differences to characterize young people in the sample reporting past-month nicotine vaping and past-month retail purchasing of nicotine vaping products. Young people were recruited between August 21, 2020 and November 9, 2020 from 30 U.S. cities that are part of the Advancing Science & Practice in the Retail Environment consortium. The cities1 are located in 23 states. At the origin of the ASPiRE project, 27 cities were members of the Big Cities Health Coalition , two cities were added for representation in the southeast , and Providence was added for early adoption of novel retail policies. Using Qualtrics Research Services, recruitment efforts targeted approximately 30 participants per city, roughly balanced on age group and ever e-cigarette use . Recruitment quotas were adjusted as needed to ensure enrollment of approximately 30 participants per city. After a brief online screener, eligible participants completed an online survey of their e-cigarette perceptions and use behavior. Participants were compensated in the form of e-rewards money or points that can be exchanged for gift cards or bank transfers. E-cigarette policies in each city at the time of data collection were derived from the Campaign for Tobacco-Free Kids and supplemented with media sources to determine policy effective dates. Cities were categorized as having a sales restriction on flavored e-cigarettes or no sales restriction on flavored e-cigarettes, based on state and local policies. Dates of state and local Tobacco 21 laws were obtained from the Campaign for Tobacco-Free Kids and from the Preventing Tobacco Addiction Foundation . State e-cigarette tax was obtained from the Centers for Disease Control and Prevention State Tobacco Activities Tracking and Evaluation System . Chicago has a city-level e-cigarette tax and was therefore coded as having an ecigarette tax. A variable was created to reflect cities’ state or local laws raising the minimum legal sales age for tobacco to 21 before the federal law, because such cities likely have stronger infrastructure for enforcing the federal Tobacco 21 law. Cities were coded as 0 , 1 , or 2 . For each of the three outcome variables , null models were estimated to determine whether there was significant between-city variance in each outcome. For outcomes with significant variation between cities, generalized estimating equations tested differences in the outcome as a function of citylevel e-cigarette flavor policy, with individuals clustered by city. Bivariate analyses tested associations between those outcome measures and potential covariates at both the city level and individual level . Location in California and Texas were tested as potential city-level covariates because we sampled from multiple cities in California and Texas,cannabis vertical farming where state-level tobacco policy and enforcement may be a confounder. City-level and individual-level covariates that were significantly related to an outcome in bivariate analyses were included in the adjusted GEE model examining that outcome. Among ever-vapers, GEE models, with participants clustered by city, also examined associations of participant characteristics with past-month nicotine vaping and, among past-month nicotine vapers, purchase of vaping products at a brick-and-mortar retail location . Each characteristic was tested in relation to past-month nicotine vaping and in-store purchasing in separate GEE models. Because these analyses were exploratory, we did not adjust for multiple comparisons. Risk perceptions and policy attitudes had intraclass correlation coefficients < 0.001, indicating that participants’ city of residence did not account for a meaningful portion of the variance in risk perceptions or policy attitudes. Hence, tests of city-level e-cigarette policy on risk perceptions and policy attitudes were not run. Among ever-vapers, a null model of past month nicotine vaping estimated a between-city variance of 0.27. Therefore, analyses of past month nicotine vaping accounted for clustering by city.
Adjusting for participants’ age and race/ethnicity, which were significantly associated with past-month nicotine vaping among evervapers in bivariate analyses, e-cigarette flavor policy was not associated with the likelihood of past-month nicotine vaping among ever-vapers . Full GEE model results are presented in Supplemental Table 1.Participant characteristics are presented by past-month vaping nicotine vaping among those who had ever vaped , in Table 2. Full results from all GEE models are presented in Supplemental Table 2. On average, young people who vaped nicotine in the past month were significantly older than those who had not . Likelihood of past-month nicotine vaping also differed by race/ethnicity . Specifically, compared to non-Hispanic white participants, Black participants were less likely to have vaped nicotine. Gender , sexual identity , and family finances were not associated with past-month nicotine vaping among ever-vapers. Past-month nicotine vaping was more likely among participants who had ever vaped marijuana , but not flavor-only e-liquid or CBD . Past-month nicotine vaping was also more likely among those with lower harm perceptions . Participants who vaped nicotine were significantly more likely to see vaping ads in convenience stores, supermarkets, or gas stations , but did not reach statistical significance for ad exposure in smoke/vape/head shops or online . Having more friends with past-month nicotine vaping and cannabis vaping , living with someone who vapes , and positive vaping attitudes of important others each was associated with a greater likelihood of vaping nicotine in the past month. Likelihood of past-month vaping was not associated with perceived ease of accessing flavored vaping products or flavored e-liquid . Among participants with past-month nicotine vaping, a null model of in-store purchasing estimated a between-city variance of 0.25; therefore, GEE models accounted for clustering by city. Full results from all GEE models are presented in Supplemental Table 3. A majority of young people with past-month nicotine vaping purchased vaping products in retail stores . Young people who did versus did not purchase vaping products in-store did not significantly differ in age, race/ethnicity, gender identity, sexual identity, family finances, lifetime cannabis vaping, lifetime flavor-only e-liquid vaping, e-cigarette risk perceptions, exposure to vaping ads in any venue, friends’ past-month nicotine or cannabis vaping, living with someone who vapes, positive vaping attitudes of important others, perceived ease of accessing vaping products, self-perceived addiction to e-cigarettes, or policy attitudes . Young people who purchased in-store were more likely to use fruit-flavored and menthol-flavored vaping products than those who did not purchase in-store. Likelihood of using mint/ice/frost , candy/dessert/sweets , and tobacco flavored products did not differ between those who did versus did not purchase vaping products in-store. In addition to purchasing vaping products in stores, participants reported using friends’ vaping products , giving someone money to purchase vaping products , buying vaping products online , or receiving vaping products from family . Tobacco retail policies prohibiting flavored e-cigarette sales may benefit young people by decreasing access to kid-friendly products; however, the influence of such policy on young people’s e-cigarette risk perceptions is unknown. Contrary to hypotheses, local e-cigarette flavor policy was not associated with e-cigarette risk perceptions, policy attitudes, or past-month nicotine vaping among young people in 30 U.S. cities. Young people who reported past-month nicotine vaping had lower harm perceptions and viewed flavored tobacco policy as less effective, compared to those without past-month nicotine vaping.