Study Suggests Flavor Bans Boosted Teen Smoking

In 2018, San Francisco voters overwhelmingly approved a ballot measure banning the sale of flavored vaping products. Public health advocates celebrated the law that supporters say was justified because flavors attract youth to vaping. A new study suggests that law may have backfired and driven more kids to try combustible cigarettes.

According to a new study from the Yale School of Public Health (YSPH), researchers say that after the ban’s implementation, high school students’ odds of smoking conventional cigarettes doubled in San Francisco’s school district relative to trends in districts without the ban, even when adjusting for individual demographics and other tobacco policies, according to press release.

The study, published in JAMA Pediatrics on May 24, is believed to be the first to assess how complete flavor bans affect youth smoking habits. “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 used data on high school students under 18 years of age from the Youth Risk Behavior Surveillance System’s 2011-2019 school district surveys. Prior to the ban’s implementation, past-30-day smoking rates in San Francisco and the comparison school districts were similar and declining. Yet once the flavor ban was fully implemented in 2019, San Francisco’s smoking rates diverged from trends observed elsewhere, increasing as the comparison districts’ rates continued to fall.

To explain these results, Friedman noted that electronic nicotine-delivery systems (ENDS) have been the most popular tobacco product among U.S. youth since at least 2014, with flavored options largely preferred. “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 San Francisco study does have limitations. Because there has been only a short time since the ban was implemented, the trend may differ in coming years. San Francisco is also just one of several localities and states that have implemented restrictions on flavored tobacco sales, with extensive differences between these laws. Thus, effects may differ in other places, Friedman wrote.

Still, as similar restrictions continue to appear across the country, the findings suggest that policymakers should be careful not to indirectly push minors toward cigarettes in their quest to reduce vaping, she said.