Impact of Local Flavored Tobacco Sales Restrictions on Policy-Related Attitudes and Tobacco Product Access

Abstract

Background

As of September 2020, more than 300 state and local jurisdictions restrict the sales of flavored tobacco, with some including menthol.

Aims

To evaluate the impact of local ordinances restricting the sale of flavored tobacco, we surveyed Californians regarding policy support and perceived access to flavored tobacco.

Methods

In 2019, we conducted an online survey of 3,075 California youth and young adults recruited via social media, about half of whom lived in a policy jurisdiction. Logistic regressions assessed differences on propensity score–weighted outcomes, policy support, and perceived access.

Results

Most respondents indicated agreement with almost all policy support statements. Although policy respondents were less likely than rest-of-California respondents to report perceived difficulty in buying flavored cigars, flavored vape users in policy jurisdictions were more likely than those in the rest of California to report perceived difficulty in buying flavored e-liquid. Regardless of jurisdiction, certain priority subgroups were significantly more likely to report perceived difficulty in accessing flavored cigars, flavored vaping products, flavored e-liquid, and menthol cigarettes.

Discussion

With some exceptions, these findings demonstrate that among vape users in policy jurisdictions and priority subgroups, there is a higher likelihood of reporting perceived difficulty to access flavored tobacco products.

Conclusions

Findings might be an early indication of shifts in social norms about flavored tobacco products in California, which could gain traction as local sales restriction ordinances proliferate throughout the state and a statewide flavored-tobacco sales restriction goes into effect.

Keywords

adolescents flavors menthol tobacco

The popularity of flavored tobacco products among youth and young adults remains a significant public health concern (Hinds et al., 2018; Huang et al., 2017; Kowitt et al., 2017; Villanti, Collins, et al., 2017; Villanti, Johnson, et al., 2017; Wang et al., 2019). In the United States, tobacco product use among middle and high school students remains high, with 23.6% of high school students and 6.7% of middle school students reporting current (past 30-day) use and 69.6% of current tobacco users utilizing at least one flavored product (Gentzke et al., 2020; Wang et al., 2019). The most commonly used tobacco product by middle and high school students in the United States is e-cigarettes (Cullen et al., 2019; Gentzke et al., 2020; Nguyen et al., 2019), and 22.4% of students who have ever tried using e-cigarettes report doing so because “they are available in flavors, such as mint, candy, fruit, or chocolate” (Wang et al., 2019). Among youth participating in the 2019 Monitoring the Future survey, past 30-day JUUL users reported most often using mango, mint, and fruit flavors (Leventhal et al., 2019; McKelvey et al., 2018; Nguyen et al., 2019). In fact, less than 2.0% of youth reported most often using tobacco-related JUUL flavors (Classic Tobacco, Virginia Tobacco; McKelvey et al., 2018). Furthermore, flavored tobacco products are often perceived as less harmful than nonflavored tobacco products, and the taste of flavorings appear to be a key element in youth experimentation, initiation, and sustained use of tobacco products (Kowitt et al., 2017).

In California, 17.5% of residents aged 18 to 29 years and 10.9% of high school students use at least one flavored tobacco product, most frequently e-cigarettes (California Health Interview Survey, 2020b). Cigarette smoking rates are higher among California adults who report being lesbian, gay, bisexual, or transgender (LGBT; 18.0%), African American (12.2%), low income (14.8%), Hispanic or Latino men (14.3%), or living in a rural area (14.8%; California Health Interview Survey, 2020a, 2020b). Historically, the tobacco industry has targeted African American (Cruz et al., 2010; Kostygina et al., 2016; Moran et al., 2019) and LGBT (Stevens et al., 2004) communities, likely contributing to their disproportionately higher tobacco use rates and the growing health inequities among priority sociodemographic subpopulation groups.

State and local sales restrictions of flavored tobacco are theorized to decrease its availability and marketing and thus decrease product appeal and susceptibility to use, which in turn may decrease tobacco product initiation and regular use. In 2009, the U.S. Family Smoking Prevention and Tobacco Control Act prohibited characterizing flavors (except for menthol) in cigarettes (Family Smoking Prevention and Tobacco Control Act, 2009) and gave states and localities the authority to further restrict products. More than 300 jurisdictions have implemented some type of flavored tobacco sales restriction (Truth Initiative, 2020), the impacts of which have been documented in some jurisdictions (Farley & Johns, 2017; Rogers et al., 2017; Rogers et al., 2019). However, policy effects are likely blunted by industry counteractions, such as the marketing of flavored noncigarette tobacco products with ambiguous names (e.g., “Jazz,” “Wild Rush”), which complicates enforcement and may allow for evasion of local sales restrictions (Rogers et al., 2019).

In this context, the California Tobacco Control Program (CTCP) initiated in 2015 a Flavored Tobacco Products Campaign, with funding provided by the Centers for Disease Control and Prevention (California Department of Public Health, n.d.). Part of the campaign provided local health departments and other tobacco control partners with the tools needed to educate policymakers about adoption and implementation of sales restrictions on menthol-flavored products and those with other characterizing flavors such as fruit or candy. By January 2019 (when data collection began), 24 California jurisdictions had implemented such ordinances (California Tobacco Control Branch, n.d.). Although the California legislature passed a statewide flavored tobacco sales restriction in August 2020 (California Legislative Information, 2020), it was not implemented at the time of data collection. Some local policies allow one or more significant exemptions: menthol tobacco could still be sold, retailers in operation prior to the policy effective date can continue selling flavored tobacco (i.e., “grandfather” provisions), sales restrictions are limited to retailers located within a certain distance from schools or other youth-populated areas, and “adult-only” stores can continue selling flavored tobacco. Initial evaluations of San Francisco’s comprehensive flavored tobacco sales restriction ordinance—which does not exempt any tobacco product or retailer type—indicate a high level of retailer compliance (Vyas et al., 2020) and decreased self-reported use of flavored noncigarette tobacco products and increased use of cigarettes among a small, convenience sample of flavored tobacco users living or working in San Francisco (Yang et al., 2020).

As part of the Flavored Tobacco Products Campaign, the CTCP implemented a multimethod evaluation to assess the adoption and implementation of local flavored sales restrictions as well as to measure their proximal effects on the retail environment and more distal impacts on California residents. In this study, we aimed to evaluate the impact of local flavored tobacco sales restrictions through an online survey of youth and young adult California residents. We evaluated differential policy support attitudes and perceived ease of purchasing flavored tobacco products reported by respondents in jurisdictions with and without flavored tobacco sales restrictions. With concern for health equity, we also assessed differences in these measures among priority sociodemographic subpopulations throughout the state.

Impact Statement

Our findings uncovered important differences in policy support and reported access to flavored tobacco products among key sociodemographic subgroups, which might be an early indication of shifts in social norms about flavored tobacco products in California.

Methods

Study Conditions

Our sampling methods were designed to yield a minimum of 3,000 completed surveys equally divided between respondents residing in jurisdictions that restrict sales of flavored tobacco products (Policy) and those living in the rest of California (ROC) without a sales restriction policy. We defined inclusion and exclusion criteria for the Policy study condition as follows: Policy jurisdictions included nine California counties and municipalities with restrictions on sales of flavored noncigarette tobacco products and/or menthol cigarettes that had effective dates on or before January 1, 2019 (San Francisco, El Cerrito, Los Gatos, Manhattan Beach, Oakland, San Leandro, Palo Alto, Saratoga, and Beverly Hills). Excluded were two jurisdictions with sales restrictions that applied only to retailers located near schools or youth-populated areas. In California, county policies only apply to retailers located in unincorporated areas. Due to concern that youth and young adult survey respondents who live in these unincorporated areas (covered by the policy) may on occasion inaccurately report living in a more well-known incorporated jurisdiction, we excluded all county policies except the County of San Francisco. The ROC condition consisted of all California jurisdictions that were not included in the Policy condition or otherwise excluded (see Figure 1).

Figure 1.

Map of study conditions.

Measures

Our Qualtrics online survey consisted of 82 questions focusing on attitudes toward flavored tobacco sales policies, perceived accessibility of flavored tobacco products, tobacco usage, and demographics. Respondents were assigned to a Policy or ROC condition based on a screener question that asked for their county and city/town of residence. Respondents could choose from a drop-down list of 58 California counties followed by another drop-down list of cities and towns for the selected county. An option for “unincorporated area of county” was also included. All screener questions included a “prefer not to answer” option.

A 4-point Likert-type scale was used to assess level of agreement (strongly disagree, disagree, agree, strongly agree) with statements supportive of flavored tobacco restriction policies; four key outcomes included the following: “The sale of flavored tobacco should not be allowed”; “Eliminating the sale of flavored tobacco will help prevent youth from using tobacco”; “The sale of menthol cigarettes should not be allowed”; and “Eliminating the sale of menthol cigarettes will help smokers quit.” A Likert-type scale (very hard, somewhat hard, somewhat easy, very easy) was also used to assess perceived access to menthol cigarettes, flavored cigars, flavored vaping products, and flavored e-liquid; four key outcomes included the following: “How hard or easy would it be to buy a flavored vaping product (e.g., JUUL, Suorin, Blu) from a store in the town where you live?” as well as equivalent questions for “flavored e-liquid”; “flavored cigars (e.g., Swisher, Black & Mild, Backwoods)”; and “menthol cigarettes.” These survey items intentionally used 4-point scales, omitting an uninterpretable neutral response option and retaining consistency with ongoing CTCP surveys. Respondents could skip any survey questions they did not wish to answer. In addition, the survey assessed past 12-month and past 30-day use of different types of flavored and unflavored tobacco products. We also assessed demographics, including lesbian, gay, bisexual, transgender, questioning (LGBTQ) status, which was determined by self-reported sexual identity as gay, lesbian, bisexual, or a recoded write-in response, and/or self-reported gender identity as trans male/trans man, trans female/trans woman, genderqueer/gender nonconforming, or “different identity.”

Recruitment Methods

Paid advertisements on Facebook and Instagram were used to recruit youth and young adults aged 15 to 29 years to participate in the online survey. Advertisements invited people to take the survey and noted a $15 incentive for completing the survey if eligible; our team utilized robust fraud prevention and detection measures. Participants who clicked on the advertisement were asked to provide informed consent prior to being directed to a set of screener questions. Eligibility was defined as living in a Policy jurisdiction or in ROC (and not in a jurisdiction with a flavored tobacco sales policy that was excluded from the study), being 15 to 29 years of age, and having the ability to read English. Survey quotas were set to attain a sample of respondents proportional to jurisdiction population while also maximizing participation from respondents from priority subpopulations, as specified by the CTCP. This involved ongoing monitoring of survey respondent characteristics during data collection and regular adjustments to our tailored social media advertising campaign designed to recruit preferential respondents who were under 21 years of age (the minimum legal age of sale [MLA] of tobacco products in California as of June 2016), Black, and current users of flavored tobacco products.

Of the 3,862 people who screened in as eligible, 3,212 of them (83.2%) completed the survey. Collected responses were cleaned to remove 137 responses that were identified as ineligible, incomplete, from respondents who sped through the survey (duration more than two standard deviations below the mean), and/or from respondents who were not attentively reading the questions (incorrect responses to designed attention-check items placed throughout the survey). The final sample size was 3,075 complete and eligible responses (1,539 from Policy and 1,536 from ROC). The study was reviewed and approved by the RTI International Institutional Review Board.

Analysis

Propensity score weights were created based on age-group, race/ethnicity, gender, and parents’ education and applied to the survey data when estimating outcomes of interest to help balance demographic differences between Policy and ROC respondents and reduce bias (Brookhart et al., 2006; see Supplemental Table). We categorized respondents into three age-groups: youth (aged 15–17 years), non-MLA young adults (aged 18–20 years), and MLA young adults (aged 21–29 years). Eight key outcomes took the form of dichotomous variables: four items measuring general agreement with flavored tobacco policies (1 = strongly agree and agree, 0 = strongly disagree and disagree) and four items measuring general perceived difficulty of access to different flavored tobacco products (1 = very hard and somewhat hard; 0 = very easy and somewhat easy). While our outcomes of interest were measured on 4-point scales, they conceptually reflected two alternative states: agreement versus disagreement and perceived difficulty versus ease. The distribution of responses tended to be skewed with few respondents in the extremes, suggesting that a collapse of categories to match the two alternative states would be appropriate. Dichotomizing these outcomes allowed us to examine differential policy support attitudes and perceived ease of purchasing flavored tobacco products reported by respondents in jurisdictions with and without flavored tobacco sales restrictions.

All analyses were conducted using Stata version 15 (StataCorp, 2017). Unweighted descriptive statistics were calculated for sample characteristics. We weighted percentages and standard errors of the outcomes of interest among Policy and ROC respondents. Weighted logistic regressions were conducted for each dichotomized outcome with study condition (Policy vs. ROC) as the primary independent variable and controlling for respondent-reported age-group, LGBTQ identity, current level of school, race/ethnicity, past 30-day flavored tobacco use, past 12-month cigarette use, and household finances. Based on their jurisdiction of residence, we applied to each respondent two community-level covariates: median household income, obtained from the California Tobacco and Health Assessment Tool (n.d.), and percentage of rural population, obtained from the American Community Survey (U.S. Census Bureau, n.d.), using Census 2010 definitions and Economic Research Service rural–urban continuum codes (U.S. Department of Agriculture, Economic Research Service, 2013). Analyses for outcomes of perceived difficulty of access were also stratified by current use of each relevant tobacco product.

Results

Sample Characteristics

The unweighted sample characteristics (Table 1) reflect our efforts to maximize respondents who were under 21 years old, Black, and current users of flavored tobacco products. Respondents from Policy and ROC generally had similar demographic characteristics, and the groups were further balanced after applying propensity score weights (see Supplemental Table).

Table 1.

Descriptive Sample Characteristics (Unweighted Data).

Respondent-level characteristic	Policy		ROC		Total
Respondent-level characteristic	n	%	n	%	n	%
Age
15–17 Years (youth)	225	14.6	292	19.0	517	16.8
18–20 Years (non-MLA young adults)	540	35.1	498	32.4	1,038	33.8
21–29 Years (MLA adults)	774	50.3	746	48.6	1,520	49.4
Race/ethnicity
White, non-Hispanic	425	27.6	422	27.5	847	27.5
Black, Hispanic, and non-Hispanic	117	7.6	121	7.9	238	7.7
Asian/Pacific Islander, non-Hispanic	584	37.9	300	19.5	884	28.7
Other/multirace, non-Hispanic	105	6.8	71	4.6	176	5.7
Hispanic, non-Black	268	17.4	595	38.7	863	28.1
Gender identity
Male	492	32.0	511	33.3	1,003	32.6
Female	977	63.5	947	61.7	1,924	62.6
Other	57	3.7	68	4.4	125	4.1
LGBTQ
Yes	354	23.0	371	24.2	725	23.6
No	1,132	73.6	1,127	73.4	2,259	73.5
Current level of school
Not currently in school	438	28.5	374	24.3	812	26.4
Grade/high/technical school	293	19.0	346	22.5	639	20.8
College	588	38.2	650	42.3	1,238	40.3
Graduate/professional school	218	14.2	165	10.7	383	12.5
Household finances
Live comfortably	725	47.1	571	37.2	1,296	42.1
Meet needs with some left over	490	31.8	489	31.8	979	31.8
Meet basic expenses	296	19.2	426	27.7	722	23.5
Don’t meet basic expenses	28	1.8	50	3.3	78	2.5
Past 12-month cigarette use
Yes	354	23.0	323	21.0	677	22.0
No	1,185	77.0	1,213	79.0	2,398	78.0
Past 30-day flavored tobacco use
Yes	546	35.5	544	35.4	1,090	35.4
No	993	64.5	992	64.6	1,985	64.6
Total	1,539	50	1,536	50	3,075	100
Community-level characteristics	Policy		ROC		Total
Community-level characteristics	M	SD	M	SD	M	SD
Median household income ($)	78,035	20,907	61,099	19,717	69,626	22,015
Average percentage of rural population	0.04	0.15	0.49	3.81	0.26	2.67

Note. Propensity score weights were not applied to these calculations. MLA = minimum legal age of sale; LGBTQ = lesbian, gay, bisexual, transgender, questioning; ROC = rest of California.

Policy Support

The weighted proportion of respondents in both Policy and ROC jurisdictions who indicated overall agreement with each key policy support statement listed was more than half, with one exception. Slightly less than half of the Policy respondents agreed that “the sale of flavored tobacco should not be allowed.” However, there were no significant differences between Policy and ROC respondents on any of the policy support outcomes after controlling for covariates (Table 2).

Table 2.

Weighted Percentages and Adjusted Odds Ratios for Policy Support and Perceived Access Outcomes by Study Condition.

Outcome	Policy weighted % and SE	ROC weighted % and SE	Policy, AOR [95% CI]
Agreement with Policy statements
The sale of flavored tobacco should not be allowed.	48.50 (1.39)	51.12 (1.37)	1.05 [0.87, 1.26]
Eliminating the sale of flavored tobacco will help prevent youth from using tobacco.	68.22 (1.30)	68.86 (1.26)	0.93 [0.76, 1.14]
The sale of menthol cigarettes should not be allowed.	50.34 (1.39)	54.27 (1.36)	0.98 [0.81, 1.18]
Eliminating the sale of menthol cigarettes will help smokers quit.	52.98 (1.38)	55.11 (1.36)	0.95 [0.79, 1.14]
Perceived difficulty in accessing flavored tobacco products
Flavored vaping products	17.53 (1.10)	14.75 (0.97)	1.19 [0.94, 1.50]
Flavored e-liquid	20.09 (1.15)	16.97 (1.02)	1.24 [0.99, 1.55]
Flavored cigars	20.35 (1.15)	23.51 (1.18)	0.73 [0.58, 0.91]
Menthol cigarettes	20.53 (1.17)	18.26 (1.07)	1.06 [0.85, 1.32]
Perceived difficulty in accessing flavored tobacco products stratified by product use
Flavored vaping products (among flavored vape users)	20.23 (2.15)	11.91 (1.63)	1.67 [0.997, 2.78]
Flavored e-liquid (among flavored vape users)	23.05 (2.20)	11.72 (1.59)	2.08 [1.28, 3.39]
Flavored cigars (among flavored cigar users)	15.12 (5.00)	8.51 (3.16)	5.10 [0.75, 34.86]
Menthol cigarettes (among menthol cigarette users)	23.56 (4.96)	8.41 (2.87)	2.63 [0.81, 8.52]

Note. Propensity score weights were applied to these calculations. Significant findings are bolded. ROC = rest of California; Policy, AOR = covariate-adjusted odds ratio of Policy condition relative to ROC condition.

Adjusted odds ratios from weighted logistic regressions indicate significant differences in policy support among priority respondent subgroups across study conditions (Table 3). Youth (aged 15–17 years) were more likely than MLA young adults (aged 21–29 years) to agree that the sale of flavored tobacco should not be allowed and that eliminating the sale of flavored tobacco will help prevent youth from using tobacco. Non-MLA young adults (aged 18–20 years) were more likely than MLA young adults (aged 21–29 years) to agree that eliminating the sale of flavored tobacco will help prevent youth from using tobacco, that the sale of menthol cigarettes should not be allowed, and that eliminating the sale of menthol cigarettes will help smokers quit. Asian and Hispanic respondents were more likely than non-Hispanic White respondents to agree that the sale of menthol cigarettes should not be allowed. LGBTQ respondents were less likely to agree that the sale of menthol cigarettes should not be allowed. Flavored tobacco users were significantly less likely to agree with every policy support statement than those who did not use flavored tobacco (Table 3). Respondents living in communities with a higher proportion of rural population were less likely to agree that eliminating the sale of flavored tobacco would help prevent youth from using tobacco. Similarly, respondents living in communities with a lower median household income were less likely to agree that the sale of menthol cigarettes should not be allowed.

Table 3.

Adjusted Odds Ratios for Policy Support and Perceived Access Outcomes by Priority Subgroups.

Outcome	AOR [95% CI] for agreement with Policy statements				AOR [95% CI] for perceived difficulty accessing flavored tobacco
Outcome	“The sale of flavored tobacco should not be allowed.”	“Eliminating the sale of flavored tobacco will help prevent youth from using tobacco.”	“The sale of menthol cigarettes should not be allowed.”	“Eliminating the sale of menthol cigarettes will help smokers quit”	Flavored vaping products	Flavored e-liquid	Flavored cigars	Menthol cigarettes
Respondent-level characteristics
Age
15–17 (youth)	1.81 [1.08, 3.05]	1.48 [1.13, 1.94]	1.55 [0.89, 2.68]	1.50 [0.91, 2.48]	2.60 [1.38, 4.87]	1.81 [1.02, 3.20]	2.92 [1.63, 5.23]	4.40 [2.45, 7.90]
18–20 (non-MLA young adults)	1.19 [0.91, 1.54]	1.80 [1.03, 3.15]	1.51 [1.15, 1.98]	1.45 [1.13, 1.86]	1.92 [1.35, 2.73]	2.14 [1.54, 2.96]	1.94 [1.41, 2.67]	2.26 [1.59, 3.23]
21–29 (MLA young adults)	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Race/ethnicity
Black, Hispanic/non-Hispanic	0.93 [0.65, 1.31]	0.84 [0.59, 1.18]	1.31 [0.93, 1.85]	1.01 [0.73, 1.39]	1.95 [1.27, 2.99]	1.47 [0.96, 2.25]	0.71 [0.44, 1.15]	1.01 [0.65, 1.56]
Asian/Pacific Islander, non-Hispanic	1.05 [0.83, 1.32]	0.99 [0.77, 1.27]	1.32 [1.04, 1.67]	1.10 [0.88, 1.38]	1.31 [0.96, 1.79]	1.30 [0.97, 1.74]	1.92 [1.46, 2.54]	1.34 [1.00, 1.78]
Other/multiracial, non-Hispanic	0.90 [0.61, 1.31]	1.32 [0.88, 1.99]	1.49 [0.99, 2.22]	1.08 [0.73, 1.61]	0.90 [0.54, 1.50]	0.91 [0.56, 1.47]	0.97 [0.61, 1.54]	0.96 [0.59, 1.55]
Hispanic, non-Black	1.19 [0.94, 1.50]	0.95 [0.74, 1.22]	1.49 [1.17, 1.90	1.14 [0.91, 1.43]	1.49 [1.09, 2.04]	1.55 [1.16, 2.07]	1.37 [1.03, 1.83]	1.23 [0.92, 1.66]
White, non-Hispanic	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
LGBTQ
Yes	0.82 [0.67, 1.01]	0.83 [0.67, 1.02]	0.78 [0.63, 0.96]	0.92 [0.75, 1.12]	0.90 [0.69, 1.18]	0.93 [0.72, 1.20]	1.41 [1.11, 1.79]	1.31 [1.03, 1.66]
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Past 30-day flavored tobacco use
Yes	0.36 [0.29, 0.44]	0.52 [0.43, 0.65]	0.38 [0.31, 0.46]	0.55 [0.45, 0.67]	0.90 [0.68, 1.19]	0.86 [0.66, 1.12]	0.69 [0.53, 0.89]	1.11 [0.86, 1.44]
No	Ref	Ref	Ref	Ref	Ref	Ref	Ref	Ref
Community-level characteristics
Median household income	0.97 [0.93, 1.01]	1.00 [0.96, 1.05]	0.95 [0.91, 0.99]	1.00 [0.96, 1.04]	1.04 [0.99, 1.10]	1.02 [0.98, 1.08]	1.08 [1.03, 1.13]	1.04 [0.99, 1.09]
Average percentage of rural population	0.98 [0.96, 1.00]	0.83 [0.73, 0.94]	0.97 [0.95, 1.00]	0.96 [0.91, 1.01]	1.03 [1.00, 1.06]	1.05 [1.03, 1.08]	1.02 [0.99, 1.05]	1.02 [0.99, 1.05]

Note. Propensity score weights were applied to these calculations. Significant findings are bolded. Ref = reference category; MLA = minimum legal age of sale; LGBTQ = lesbian, gay, bisexual, transgender, questioning; AOR = adjusted odds ratio.

Perceived Access

Weighted findings in Table 2 reveal that about one in five respondents in both Policy and ROC jurisdictions perceived that flavored tobacco products would be somewhat or very hard to buy from a local store. After controlling for covariates, the predicted odds of reporting that it would be difficult to buy flavored cigars locally were 0.73 (95% confidence interval [CI: 0.58, 0.91]) times lower among respondents in Policy jurisdictions than among respondents in ROC (Table 2). Among past-30-day users of flavored vaping products, the predicted odds of reporting that it would be difficult to buy flavored e-liquid locally were 2.08 (95% CI [1.28, 3.39]) times higher among respondents in Policy jurisdictions than among respondents in ROC (Table 2).

We estimated significant covariate-adjusted differences in perceived access to flavored tobacco products among priority subgroups across study conditions (Table 3). Youth and non-MLA young adults were more likely than MLA young adults to report that it would be difficult to access all four types of flavored tobacco products (Table 3). LGBTQ respondents were more likely to perceive difficulty in buying flavored cigars and menthol cigarettes than non-LGBTQ respondents. Black and Hispanic respondents were more likely to perceive difficulty in buying flavored vaping products than White non-Hispanics. Hispanic respondents were also more likely to perceive difficulty in buying flavored e-liquid and cigars than White non-Hispanics. Asian respondents were more likely to perceive difficulty in buying flavored cigars and menthol cigarettes than White non-Hispanics. Flavored tobacco users were less likely to perceive difficulty in buying flavored cigars than respondents who did not use flavored tobacco. Respondents living in communities with a higher median household income were more likely to perceive difficulty in buying flavored cigars, while those living in communities with a higher proportion of rural population were more likely to perceive difficulty in buying flavored e-liquid and flavored vaping products.

Discussion

Evaluations of local policies to restrict the sales of flavored tobacco have to date measured policy compliance by (1) observing tobacco retailers and/or products through sales data or store observations (Borland et al., 2019; Brock et al., 2019; Czaplicki et al., 2019; Kingsley et al., 2020; Rogers et al., 2019; Vyas et al., 2020) and (2) examining changes in self-reported use of tobacco products among consumers (Courtemanche et al., 2017; Farley & Johns, 2017; Kingsley et al., 2019; Pearlman et al., 2019; Yang et al., 2020). The current results provide insight into the associations between exposure to local flavored tobacco sales restrictions and support for policies that restrict flavored tobacco products among local youth and young adult residents and their perceived ease of access to flavored tobacco products, both of which are antecedent indicators associated with tobacco use behaviors (Chaiton et al., 2020; Guillory et al., 2019; Schmitt et al., 2014; Wackowski et al., 2014; Yang et al., 2020). The analyses of our main hypothesis revealed minimal effects of residing in an area covered by a local flavored tobacco sales policy on policy support and perceived access. However, secondary analyses showed that among flavored vape users the odds of reporting that it would be difficult to buy flavored e-liquid locally were 108% higher for those residing in Policy areas versus those in ROC. Contrary to expectation, policy support was not greater among youth and young adults in jurisdictions where restrictions were implemented than in the ROC. Perhaps any potential differences were offset by a statewide mass media campaign to educate the public about the tobacco industry’s use of flavors to make their products more palatable and appealing to youth (Tobacco Free California, 2019).

Our results uncovered another counterhypothetical finding: After controlling for all other covariates, the odds of respondents reporting that it would be difficult to buy flavored cigars locally were 27% lower among respondents in policy jurisdictions than among respondents in ROC. Among subgroups, flavored tobacco users were also less likely to report perceived difficulty in buying flavored cigars than those who do not use flavored tobacco, even among respondents in policy jurisdictions. It is possible that flavored tobacco users and respondents in policy jurisdictions selectively attend to media coverage about flavored sales restrictions and thus are more aware of flavored tobacco products in their communities. Similarly, flavored tobacco users are likely more aware of sources for obtaining these products, or of the availability of flavored cigars labeled with concept names (e.g., Jazz), which can remain in the marketplace after implementation of flavored sales restrictions (Rogers et al., 2019).

Ancillary analyses revealed some important differences among key sociodemographic subgroups in degree of policy support and perceived access to tobacco products. For example, policy support varied by age such that youth (15–17 years) and non-MLA young adults (18–20 years) were generally more supportive of flavored tobacco restrictions than MLA young adults (21–29 years). In addition, youth and non-MLA young adults generally endorsed the potential public health impacts of flavored tobacco restrictions (e.g., “help prevent youth from using tobacco”) more than MLA young adults. Prior research on California residents’ support for flavored tobacco product restrictions has been limited to adults, and in 2018, 51% of California voters believed that sales of flavored tobacco products should probably or definitely be prohibited (American Lung Association in California Center for Tobacco Policy & Organizing, n.d.).

Regarding perceived access, youth and non-MLA young adults across study conditions were more likely than MLA young adults to report perceived difficulty in accessing all four types of flavored tobacco products (vaping products, e-liquid, cigars, and menthol cigarettes) from a store in the respondent’s town of residence. While these results align with a sales restriction’s theoretical intention of reducing youth access, it is important to keep in mind that the majority of U.S. youth obtain tobacco products through social sources (Tanski et al., 2019). That being said, youth who attempt to purchase tobacco in a retail setting are often successful (Tanski et al., 2019). A recent analysis of young adult (aged 18–19 years) purchase attempts in California revealed that overall around one fifth of stores sold tobacco to underage decoys yet almost half of tobacco and vape shops sold vaping products to underage decoys (Roeseler et al., 2019). Therefore, limiting retail access to tobacco by youth and non-MLA young adults remains an important public health goal.

Significant differences by race were mostly limited to Asian and Hispanic (non-Black) respondents, although Black respondents were more likely than non-Hispanic White respondents to perceive difficulty in buying flavored vaping products. Respondents living in communities with a higher proportion of rural population were less likely to agree that eliminating the sale of flavored tobacco would help prevent youth from using tobacco and more likely to perceive difficulty in buying flavored e-liquid. Similarly, results from a 2018 survey of California residents residing in rural areas found that the majority of respondents believed that stores in their area should be allowed to continue selling flavored products, with many also agreeing with the reasoning that “the choice to buy flavored tobacco products should be left up to adults, not decided by the government” (American Lung Association in California Center for Tobacco Policy & Organizing, n.d.).

This study’s strengths include a novel social recruitment strategy that was able to reach youth and young adults in geographically small areas having flavored tobacco sales restrictions. In addition, our recruitment strategy was successful in maximizing participation from Black respondents and current users of flavored tobacco products. Although the use of a nonequivalent posttest-only control-group study design with a convenience sample of respondents assessed cross-sectionally after policy implementation potentially creates internal validity limitations, other than the policies under study we saw no evidence of differential historical events occurring across study areas. Our main outcomes were measured on a 4-point Likert-type scales, and the lack of a neutral response option could have resulted in more respondents skipping questions. Additionally, survey questions measuring perceived difficulty of access to flavored tobacco products could have been interpreted by respondents to reflect barriers other than the local policy, such as age, lack of transportation, or a lack of nearby tobacco retailers. In addition, any inaccuracies in self-reported jurisdiction could have biased results, although this would have been toward the null.

The patchwork of local policies (see Figure 1) likely limits the detected effect, as political boundaries may not reflect how people interact with their environment. For example, many Californians live, work, and shop in different jurisdictions, some with and some without flavored tobacco restrictions. Additional possible reasons for the limited effects observed include heterogeneity across jurisdictions on characteristics and strength of policy provisions, duration of policy implementation, and differential enforcement procedures and actions. Additional analyses exploring these variations could reveal associations with other individual-level attitudinal and behavioral indicators, such as tobacco use susceptibility. Finally, it is possible that insufficient time had passed since some of these policies have been fully implemented; for example, although the implementation date of the San Francisco policy was January 1, 2019, fully active enforcement had not yet occurred at the time of data collection (Vyas et al., 2020). These limitations should be taken into account when attempting to draw conclusions about the associations between policy exposure and key outcomes. Nevertheless, there is some indication that local policy implementation is associated with early shifts in social norms about access to and use of flavored tobacco products in California. These shifts in social norms could gain traction as state and local sales restrictions continue to proliferate throughout the state and nation.

Supplemental Material

sj-docx-1-heb-10.1177_10901981211027520 – Supplemental material for Impact of Local Flavored Tobacco Sales Restrictions on Policy-Related Attitudes and Tobacco Product Access

Supplemental material, sj-docx-1-heb-10.1177_10901981211027520 for Impact of Local Flavored Tobacco Sales Restrictions on Policy-Related Attitudes and Tobacco Product Access by Ashley L. Feld, Todd Rogers, Jennifer Gaber, Jessica Pikowski, Matthew C. Farrelly, Lisa Henriksen, Trent O. Johnson, Bonnie Halpern-Felsher, Elizabeth Andersen-Rodgers and Xueying Zhang in Health Education & Behavior

Footnotes

Acknowledgements

The authors thank Joel Hampton, Andrew Freeman, Josh Goetz, Alicia Wentz, and Sallie Fiore of RTI International, as well as Jamie Guillory of Prime Affect Research and Nina C. Schleicher of Stanford Prevention Research Center for their assistance.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was provided by the Centers for Disease Control and Prevention Grant No. 5 NU58DP005969-04-00 and the California Department of Public Health under contract from Stanford Prevention Research Center to RTI International (Contract No. 17-10041). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the California Department of Public Health. The contents are the responsibility of the authors alone.

ORCID iDs

Ashley L. Feld

Lisa Henriksen

Trent O. Johnson

Supplemental Material

Supplemental material for this article is available online at .

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