A tale of two cities: Impact of reducing teens’ access to flavored tobacco products

A new study in the American Journal of Preventive Medicine reports that teen use of both flavored and non-flavored tobacco decreased with enforced restrictions, but increased with unrestricted access

Ann Arbor, October 24, 2019

Restricting youth access to flavored tobacco products holds the promise of reducing their overall tobacco use, according to a new study in the American Journal of Preventive Medicine, published by Elsevier.

The study found that the implementation of a flavored tobacco restriction policy (FTRP) in one Massachusetts community was associated with reduced availability of flavored tobacco in retailers and youth use of both flavored and non-flavored tobacco within six months of the policy’s implementation. Conversely, during the same period tobacco use among youth increased in a nearby community without this restriction.

“Our study suggests that with rigorous enforcement, flavor restriction policies have the potential to curb youth tobacco use in as little as six months,” explained lead investigator Melody Kingsley, MPH, Massachusetts Department of Public Health, Boston, MA, USA. “With a longer follow-up time, we expect these trends will continue. The policy may also begin to impact and reduce other tobacco-related outcomes, such as initiation on flavored tobacco, as exposure to flavored tobacco among young people continues to decline.”

Troubling nationwide increases in youth e-cigarette use led the US Surgeon General to issue an advisory about the epidemic in 2018. More recently, the emergence of lung disease linked to vaping and e-cigarettes has underscored the critical importance of developing, implementing, and evaluating population-wide strategies to curb youth use of these products. The majority of youth using tobacco use flavored products, which are available in thousands of distinct flavors with youth appeal. In response, communities in states across the country, including Massachusetts, have passed FTRPs that restrict sales of flavored tobacco. The US Food and Drug Administration has proposed increasing restrictions on the sale of flavored tobacco nationwide as well.

Ms. Kingsley noted that some municipalities have started to include menthol flavoring in FTRPs to counter the tobacco industry’s targeting of communities of color, LGBTQ communities, low-income communities, and youth overall. “Flavor restriction policies that include menthol may have an even greater impact on youth tobacco use than seen in our study,” she added.

Using data collected from tobacco retailers and high school youth in 2016-2017, the study assessed the impact on youth access to and use of tobacco products six months after the policy was implemented in Lowell, MA. The policy restricted the sale of all flavored tobacco products (excluding menthol but including e-cigarettes) to adult-only (21 years or older) establishments such as vape shops, tobacconists, and smoking bars. The investigators then evaluated availability and use of these products in Malden, MA, a similar community nearby that did not enact the policy (at the time of the study).

Availability of flavored tobacco products decreased by 70 percent in Lowell when assessed six months after policy implementation. No significant changes in flavored tobacco availability occurred in Malden over the same time period. During the same timeframe, current use (past 30 days) of both flavored and non-flavored tobacco decreased in Lowell but increased in Malden. Changes from baseline to follow-up were significantly different between communities (flavored tobacco: -5.7 percent; non-flavored tobacco: -6.2 percent). Similarly, ever use of both flavored and non-flavored tobacco decreased in Lowell but increased in Malden. The change in ever use of non-flavored tobacco was significantly different between communities, while the change in ever use of flavored tobacco approached significance (flavored tobacco: -6.1 percent; non-flavored tobacco: -8.6 percent).

Image of a graph that shows the changes in any flavored and non-flavored tobacco use between baseline and six-month follow-up.
Changes in any flavored and non-flavored tobacco use between baseline and six-month follow-up: Lowell and Malden, MA, 2016 and 2017. Note: Any tobacco use includes use of the following products: cigarettes, cigars/cigarillos, e-cigarettes, blunts/blunt wraps, and smokeless tobacco.

Timely evaluation of FTRPs is essential to ensure that they are an effective strategy for curbing youth tobacco use. To date, a few studies have found that FTRPs reduce sales and availability of flavored tobacco, but no prior evidence exists on the short-term impact of FTRPs on youth tobacco use. “Our findings speak to this urgent public health concern, adding critically important data to a growing body of research on policy options that will diminish the use of tobacco products in youth,” said co-investigator William G. Shadel, PhD, RAND Corporation, Pittsburgh, PA, USA, speaking on behalf of RAND collaborators on the project.


Notes for editors
The article is “Short-Term Impact of a Flavored Tobacco Restriction: Changes in Youth Tobacco Use in a Massachusetts Community,” by Melody Kingsley, MPH, Claude M. Setodji, PhD, Joseph D. Pane, MSP, William G. Shadel, PhD, Glory Song, MPH, Jennifer Robertson, JD, Lindsay Kephart, MPH, Patricia Henley, MEd,and W.W. Sanouri Ursprung, PhD (https://doi.org/10.1016/j.amepre.2019.07.024). It will appear in the American Journal of Preventive Medicine, volume 57, issue 6 (December 2019) published by Elsevier

This research was supported by funding from CDC cooperative agreement CDC-RFA-DP15-1509.

Full text of this article is available to credentialed journalists upon request; contact Jillian B. Morgan at +1 734 936 1590 or ajpmmedia@elsevier.com. Journalists wishing to interview the authors should contact the Massachusetts Department of Health media line at ann.scales@state.ma.us or +1 617 624 5006.

About the American Journal of Preventive Medicine
The American Journal of Preventive Medicine is the official journal of the American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials. www.ajpmonline.org

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers. www.elsevier.com

Media contact
Jillian B. Morgan, MPH, Managing Editor
+1 734 936 1590