In 2018, public health experts rejoiced when San Francisco voters handily passed a ballot initiative prohibiting the sale of flavored tobacco products. After all, tobacco smoking is a major danger to public health and health inequalities, and flavors appeal to young people in particular.
However, a recent Yale School of Public Health (YSPH) study suggests that the regulation may have had the opposite impact. Even after correcting for individual demographics and other tobacco-related factors, studies indicated that after the ban was implemented, high school students’ likelihood of smoking conventional cigarettes quadrupled in San Francisco’s school district compared to trends in districts without the ban.
The research, which was published on May 24 in JAMA Pediatrics, is thought to be the first to look at how comprehensive taste restrictions effect young people’s smoking behavior.
“These findings suggest a need for caution,” said Abigail Friedman, the study’s author and an assistant professor of health policy at YSPH. “While neither smoking cigarettes nor vaping nicotine are safe per se, the bulk of current evidence indicates substantially greater harms from smoking, which is responsible for nearly one in five adult deaths annually. Even if it is well-intentioned, a law that increases youth smoking could pose a threat to public health.”
Friedman utilized data from the Youth Risk Behavior Surveillance System’s 2011-2019 school district surveys on high school students under the age of 18. Smoking rates in San Francisco and the comparable school districts were similar and dropping prior to the ban’s introduction.
Friedman explained the findings by stating that electronic nicotine delivery systems have been the most popular tobacco product among American teens since at least 2014, with flavored variants being the most popular.
“Think about youth preferences: some kids who vape choose e-cigarettes over combustible tobacco products because of the flavors,” she said. “For these individuals as well as would-be vapers with similar preferences, banning flavors may remove their primary motivation for choosing vaping over smoking, pushing some of them back toward conventional cigarettes.”
The state government in Connecticut is now contemplating two flavor bills: House Bill 6450 would prohibit the sale of flavored electronic nicotine delivery devices, while Senate Bill 326 would prohibit the sale of any flavored tobacco product. Given that the US Food and Drug Administration has indicated that flavors in all combustible tobacco products would be banned within the next year, both proposals might result in a Connecticut policy comparable to San Francisco’s entire prohibition.
There are certain drawbacks to the San Francisco research. Because the restriction has only been in place for a short period, the tendency may change in the future years. San Francisco is also one of a number of cities and states that have enacted limitations on the sale of flavored tobacco, with significant disparities between the legislation. As a result, results may differ in various regions, according to Friedman.
Nonetheless, as such prohibitions spread across the country, the findings imply that policymakers should be wary about inadvertently encouraging kids to use cigarettes in the name of reducing vaping, she added.
What does she suggest as an alternative? “If Connecticut is determined to make a change before the FDA’s flavor ban for combustible products goes into effect, a good candidate might be restricting all tobacco product sales to adult-only — that is 21-plus — retailers,” she said. “This would substantively reduce children’s incidental exposure to tobacco products at convenience stores and gas stations, and adolescents’ access to them, without increasing incentives to choose more lethal combustible products over non-combustible options like e-cigarettes.”