The effects of state-level flavored electronic cigarette restrictions on adult tobacco use using multilevel modeling: Findings from the PATH Study Waves 5 & 7 (2018-2023).

Introduction: Flavors play an important role in e-cigarette use among both young people and adults, but evaluations of flavored e-cigarette policies have focused almost exclusively on youth. This longitudinal study examined how flavored e-cigarette policies affect tobacco use over time for different adult age groups using data from the Population Assessment of Tobacco and Health (PATH) Study.

Methods: Adults age 21+ at Wave 5 (2018-2019) comprised the analytic sample. Multilevel models were used to examine changes in past 30-day and established e-cigarette use, and past 30-day tobacco use other than e-cigarettes at Wave 7 (2022-2023) for residents of states that had (vs. had not) implemented flavored e-cigarette policies between Waves 5 and 7. Sociodemographic variables and state-level tobacco control policies (e.g., e-cigarette tax, clean indoor air) were controlled. Regression models tested effects overall and by age group: 21-24, 25-29, 30-39, 40+. Full-sample and replicate weights accounted for the complex sample design and nonresponse.

Results: Among those exposed to a flavored e-cigarette policy, there was a significant decrease in odds of past 30-day e-cigarette use for those age 21-24 (AOR=0.59; 95%CI: 0.36, 0.97) and in odds of established e-cigarette use for those age 25-29 (AOR=0.32; 95%CI: 0.14, 0.76) compared to those who were unexposed, adjusting for covariates. There was no change in use of tobacco products other than e-cigarettes by flavored policy exposure.

Conclusion: Flavored e-cigarette policies are effective at reducing past 30-day and established e-cigarette use among younger adults (age 21-29). The impact among older adults (30+) is less evident.

Implications: Using longitudinal data and multilevel models, this study demonstrates how flavored e-cigarette policies influence e-cigarette use (and other tobacco product use) for younger adults (21-29). We find limited evidence of policies influencing older adults (30+). This work suggests that flavored e-cigarette policies may play an important role in stopping young people from initiating e-cigarette use, and in stopping older young adults (age 25-29) from progressing to more established e-cigarette use.