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E-cigarette Flavor Restrictions’ Increase Sales of Combustible Tobacco Products

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Published on October 31, 2023

Title	E-cigarette Flavor Restrictions’ Effects on Tobacco Product Sales
Authors	Abigail S Friedman PhD, Alex C. Liber PhD, Alyssa Crippen PhD, Michael F. Pesko PhD

Abstract

Over 375 US localities and 7 states have adopted permanent restrictions on sales of flavored Electronic Nicotine Delivery Systems (“ENDS”). These policies effects on combustible cigarette use (“smoking”), a more lethal habit, remain unclear. Matching new flavor policy data to retail sales data, we find a tradeoff of 15 additional cigarettes for every 1 less 0.7 mL ENDS pod sold due to ENDS flavor restrictions. Furthermore, cigarette sales increase even among brands disproportionately used by underage youth. Thus, any public health benefits of reducing ENDS use via flavor restrictions may be offset by public health costs from increased cigarette sales.

Key Findings

1. ENDS flavor bans increase cigarette sales.  First, ENDS sales fall and cigarette sales rise as a greater percentage of state residents is subject to policies restricting flavored ENDS sales. The same is true for full ENDS bans.
2. Cigarette sales grow longer ENDS flavor ban in effect.  Second, ENDS flavor policies’ relationships to ENDS and cigarette sales are larger in the long-run; that is, for policies in effect a year or longer.
3. Tobacco flavored cigarettes are dominant benefactor of flavored ENDS bans. Third, 71% of the increase in cigarette sales associated with ENDS flavor restrictions comes from tobacco-flavored cigarettes. Alongside the inclusion of controls for restrictions on menthol cigarette sales, this finding indicates that the observed substitution response to ENDS flavor policies cannot be attributed to menthol cigarettes’ availability nor fully counteracted by menthol cigarette sales prohibitions. So, availability/non-availability of menthol cigarettes is not reason.
4. Increased cigarette sales applies equally to youth. Fourth, ENDS flavor restrictions’ relationship to cigarette sales holds across cigarette product age profiles, including for brands disproportionately used by underage youth.

Key Quotes

“These findings are consistent with flavored ENDS policies encouraging substitution from ENDS towards combustible cigarettes, aligning with results from 16 of 18 other studies assessing cigarette use following adoptions of minimum legal sales age laws for ENDS, ENDS tax rate increases, and advertising restrictions (Pesko 2023). In other words, policies making ENDS more expensive, less accessible, or less appealing appear to incentivize substitution towards cigarettes.”

“Our study makes important contributions to current policy debates. States are increasingly restricting sales of flavored ENDS, while federal policymakers consider equivalent policies. The FDA has denied marketing authorizations to all non-tobacco flavored ENDS products (a regulatory step required for ENDS but not existing cigarettes), paving a path towards a de facto national ENDS flavor prohibition. Our findings linking ENDS flavor restrictions to an additional 15 cigarettes sold for every 1 less 0.7mL ENDS pod sold suggest increased cigarette sales could partly or more than fully offset any public health benefit of reducing ENDS use by restricting or prohibiting flavors. Indeed, that tradeoff equates to over a pack more cigarettes per pod for the size of current leading products (e.g., 1.8mL in a Vuse Alto).12” 

Adult-Only Retail Restrictions:
“Policymakers could also consider pairing a policy that allows more flavors in ENDS with restricting sales to adult-only stores, to reduce internalities among time-inconsistent (or uninformed) youth and expand flavor availability for adults in order to promote smoking cessation. Given evidence that ENDS use is more effective for smoking cessation than nicotine replacement therapy (Hartmann-Boyce et al. 2022) and high rates of “accidental quitting” among smokers that try ENDS without intending to quit cigarettes (Kasza et al. 2021), these approaches avoid an inequitable tradeoff inherent in banning flavors from only ENDS products, which prioritizes youth over the 11.2% of US adults that smoke (Schiller and Norris 2023).”

Funding Source

This research is supported by a rapid response project through the Center for the Assessment of Tobacco Regulations, funded by National Institutes of Health (NIH) award number 5U54CA229974-05 from the National Cancer Institute (NCI) and Food and Drug Administration (FDA), and by award number R01DA045016 from the National Institutes on Drug Abuse (NIDA).