||5R21CA268199-02 Interpret this number
||Impact Analysis of Flavor Restrictions and Tobacco 21 Policies on Youth Tobacco Use
Decreasing trends in adolescent tobacco use have been increasingly countered by use of alternative
tobacco products. In 2019, 32.7% of adolescents used electronic nicotine delivery systems (ENDS) and 6.0%
cigarettes, with over 70% using a flavored product. As evidence mounts on the increased risk of transitioning
from ENDS to cigarettes and longer-term tobacco use, innovative policies are needed. Recently, 7 states have
enacted bans on flavored tobacco products. Sixteen states and DC enacted state-wide tobacco 21 (T21)
policies prior to passage of the federal T21 law in Dec 2019. However, there have been no evaluations of
state-wide flavor restrictions or the federal T21 law on adolescent tobacco use overall nor on disparities in use.
The overarching goals of the study are to examine the impact of state flavor restrictions and state and
federal T21 policies on disparities in tobacco use among youth aged 14-24 years. The Behavior Risk Factor
Surveillance System (BRFSS), an annual phone-based survey of health-related behaviors among adults aged
18+ years from all 50 states and DC, introduced questions on ENDS in 2016. The Youth Risk Behavior Survey
(YRBS), a biennial school-based survey of health-related behaviors from 44 states, introduced questions on
ENDS in 2015. Differences in state tobacco control policies create a natural experiment, allowing us to
evaluate their effects using these representative datasets.
This project has three Specific Aims. In Aim 1, we will evaluate the impact of flavor restrictions and T21
policies on tobacco use (cigarettes, ENDS, smokeless tobacco) across age (18-20-year-olds versus 21-24-
year-olds) in the BRFSS as well as examine the differential impact of both tobacco policies on tobacco use
across socio-demographic strata. In Aim 2, we will evaluate the impact of flavor restrictions and T21 policies on
tobacco use (cigarettes, ENDS, smokeless tobacco, cigars) across age (14-17-year-olds versus 18-year-olds)
in the YRBS as well as examine the differential impact of both tobacco policies on tobacco use across socio-
demographic strata. Against this backdrop, Covid-19 was declared a national emergency in mid-March 2020
and states have issued a patchwork of policies, including closure of non-essential businesses and stay-at-
home orders. While the decrease in adolescent tobacco use from 2019 to 2020 may be attributable to the
enactment of recent tobacco control policies, they have not been formally evaluated. In Aim 3, we will examine
the further impact of Covid-19 state closures and re-openings on tobacco use overall, by age and across socio-
demographic strata, in addition to flavor restrictions and T21 policies.
We propose to conduct an impact analysis that rigorously evaluates flavor restrictions and T21 policies on
disparities in youth tobacco use. The goals of this research will be to inform policies within the FDA’s Center for
Tobacco Products regulatory authority related to youth tobacco use as well as to reduce the burden of tobacco
and tobacco-related health disparities among youth.