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. 2025 Jul 1;8(7):e2524184.
doi: 10.1001/jamanetworkopen.2025.24184.

State E-Cigarette Flavor Restrictions and Tobacco Product Use in Youths and Adults

David Cheng  1   2 , Boram Lee  3 , Abra M Jeffers  4   5   6 , Maeve Stover  4 , Lindsay Kephart  2   4   5 , Ginny Chadwick  4   5   7 , Gina R Kruse  8 , A Eden Evins  9   10 , Nancy A Rigotti  2   4   5 , Douglas E Levy  2   4   5
Affiliations

State E-Cigarette Flavor Restrictions and Tobacco Product Use in Youths and Adults

David Cheng et al. JAMA Netw Open. .

Abstract

Importance: Seven states have policies restricting the sale of flavored e-cigarettes. Limited evidence exists regarding these policies' association with the use of tobacco products across age groups.

Objective: To evaluate associations of e-cigarette flavor restriction policies with e-cigarette and cigarette use by age group over multiple years.

Design, setting, and participants: In this cross-sectional study, annual state-level prevalences of e-cigarette and cigarette use in the US between 2015 and 2023 were separately estimated among youths (high school age) using data from the Youth Risk Behavior Survey (YRBS) and young adults (ages 18-24 years) and adults (ages ≥25 years) using the Behavioral Risk Factor Surveillance System (BRFSS). Six policy states had multiple years of postpolicy data available; other states were control states. Associations between policy and prevalence of e-cigarette and cigarette use in each postpolicy year were estimated annually using difference-in-differences analysis, setting 2019 as the prepolicy year and 2020 to 2023 as postpolicy years.

Exposure: Statewide policy restricting sales of non-tobacco flavored e-cigarettes.

Main outcomes and measures: State annual prevalence of past 30-day (YRBS) and current (BRFSS) e-cigarette and cigarette use.

Results: Prevalence data were obtained for 186 (YRBS) and 386 (BRFSS) state-years for e-cigarettes and 191 (YRBS) and 456 (BRFSS) state-years for cigarettes. In recent years, e-cigarette use prevalence decreased among youths (eg, the change in mean prevalence from 2019 to 2023 was 24.1% to 14.0% for policy states and 24.6% to 17.2% for control states) but increased in control states among young adults (eg, mean prevalence, 17.0% in 2019 to 20.4% in 2023). Cigarette use prevalence decreased in policy and control states, although policy states exhibited lower prepolicy prevalence and attenuated postpolicy decreases (eg, mean prevalence, 6.7% in 2019 to 3.8% in 2023 among young adults) relative to control states (eg, mean prevalence, 12.1% in 2019 to 6.3% in 2023 among young adults). Flavor policies were associated with reduced e-cigarette use among young adults in 2022 (average treatment effect among the treated [ATT], -6.7 percentage points; 95% CI, -1.3 to -12.1 percentage points) and adults aged 25 years or older in 2023 (ATT, -1.2 percentage points; 95% CI, -2.0 to -0.4 percentage points) and increased cigarette use among youths in 2021 (ATT, 1.8 percentage points; 95% CI, 0.7 to 2.9 percentage points) and young adults in 2021 (ATT, 3.7 percentage points; 95% CI, 2.2 to 5.2 percentage points), 2022 (ATT, 2.7 percentage points; 95% CI, 1.4 to 4.1 percentage points), and 2023 (ATT, 3.2 percentage points; 95% CI, 0.9 to 5.5 percentage points).

Conclusions and relevance: In this study, flavor restriction policies were associated with some reductions in e-cigarette use but also unintended increases in cigarette use, highlighting a need for further work evaluating potential substitution outcomes and prevention of tobacco use among youths.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Cheng reported having grants pending from AstraZeneca outside the submitted work. Dr Kruse reported having family equity ownership in Dimagi, Inc and receiving grants from AstraZeneca administered by the National Comprehensive Cancer Network outside the submitted work. Dr Rigotti reported receiving grants from Achieve Life Sciences, Inc paid to Massachusetts General Hospital and personal fees from Achieve Life Sciences, Inc ending in 2022 and UpToDate outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Smoothed Trends in Current E-Cigarette and Cigarette Use
Current e-cigarette and cigarette use prevalence was estimated based on self-reported past 30-day use in youths and use on some days or every day in young adults and adults aged 25 years or older. Respondents with missing, refused, or “don’t know” responses were excluded. Prevalence was calculated using complex survey weights to obtain state-representative estimates in each year. Smoothed trends were estimated by locally estimated scatterplot smoothing with state-level biennial (Youth Risk Behavior Survey [YRBS]) and annual (Behavioral Risk Factor Surveillance System [BRFSS]) prevalence of e-cigarette and cigarette use among policy and control states by age group.
Figure 2.
Figure 2.. Association of Flavor Restriction Policy With Current E-Cigarette and Cigarette Use
ATT indicates average treatment effect among the treated; BRFSS, Behavioral Risk Factor Surveillance System; YRBS, Youth Risk Behavior Survey.
Figure 3.
Figure 3.. Sensitivity Analyses for Association of Flavor Restriction Policy With Current E-Cigarette and Cigarette Use
Balanced analysis was restricted to states with a balanced panel for each postpolicy year. Prepolicy year 2017 analysis used 2017 instead of 2019 as the prepolicy year. E-cigarette taxation analysis was restricted to states in years with e-cigarette taxes present. No T21 (tobacco 21) analysis was restricted to states in years without tobacco 21 laws restricting sales of e-cigarettes and cigarettes for individuals aged 18 to 20 years. Require licensure analysis was restricted to states in years requiring licensure to sell e-cigarettes. E-cigarette clean indoor air analysis was restricted to states in years with prohibitions on e-cigarette use at restaurants, workplaces, and bars. ATT indicates average treatment effect among the treated; BRFSS, Behavioral Risk Factor Surveillance System; YRBS, Youth Risk Behavior Survey.
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