English HELP WITH ENGL ASSIGNMENTS DUE IN 24 HOURS - 48 HOURS
Tob Regul Sci.™ 2021;7(2):135-143 135
In the summer of 2019, a nationwide outbreak of cases of severe pulmonary illness and deaths, subsequently named e-cigarette and vaping
product use-associated lung injury (EVALI) by the US Centers for Disease Control and Prevention, increased safety concerns about electronic ciga- rette (e-cigarette) use.1,2 The cases prompted calls for public health action to counter this newly-rec- ognized health threat. The state of Massachusetts took the most stringent action when the governor imposed a temporary emergency order on Septem- ber 25, 2019. It banned the sale of all e-cigarettes
in stores and online statewide.3 States bordering Massachusetts did not restrict the sale of e-ciga- rettes during this time, and residents could travel to neighboring states to obtain e-cigarettes legally. This total e-cigarette sales ban ended on December 11, 2019, when a new state law that banned the sale of flavored e-cigarettes but permitted the sale of tobacco-flavored e-cigarettes took effect.4
Regulations that reduce access to e-cigarettes have the potential for mixed consequences. Where- as they might reduce e-cigarette use by adoles- cents, they might also reduce adult smokers’ access
Sara Kalkhoran, Assistant Professor, Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Mas- sachusetts General Hospital, Boston, MA, United States; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. Kelly M. Kalagher, Clinical Research Coordinator, Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States. Jordan M. Neil, Research Fel- low, Mongan Institute, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. Nancy A. Rigotti, Professor, Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States. Correspondence Dr Kalkhoran; skalkhoran@mgh.harvard.edu
Cigarette and E-cigarette Use Among Smokers After a Statewide E-cigarette Sales Ban
Sara Kalkhoran, MD, MAS Kelly M. Kalagher, BS Jordan M. Neil, PhD Nancy A. Rigotti, MD
Objectives: Following the US outbreak of lung injury associated with e-cigarettes in 2019, Mas- sachusetts banned all e-cigarette sales for 3 months. We assessed e-cigarette and cigarette use among adult cigarette smokers following this ban. Methods: We carried out an explor- atory mixed-methods study of cigarette smokers aged 40-80 years. Using telephone surveys, we asked smokers about cigarette and e-cigarette use and e-cigarette purchases during the e-cigarette sales ban. Results: We surveyed 284 adult cigarette smokers; 8% currently used e- cigarettes. Among the 24 dual users of cigarettes and nicotine e-cigarettes during the e-ciga- rette sales ban, 54% quit or reduced e-cigarette use. Most dual users (71%) did not change their cigarette consumption; however, most dual users who increased cigarette smoking had quit or reduced vaping because of the ban (83%). During the ban, most participants reported purchas- ing e-cigarettes in-state or online. Others purchased e-cigarettes out-of-state or obtained them from family/friends. Conclusions: The total e-cigarette sales ban in Massachusetts prompted by EVALI reduced some adult cigarette smokers’ access to and use of e-cigarettes. However, the ban was circumvented by individuals purchasing e-cigarettes illegally and by purchasing products legally out-of-state. These findings illustrate the challenges faced by policymakers trying to stop access to addictive products.
Key words: dual use; electronic cigarette; policy; tobacco use; vaping Tob Regul Sci.™ 2021;7(2):135-143 DOI: doi.org/10.18001/TRS.7.2.5
Cigarette and E-cigarette Use Among Smokers After a Statewide E-cigarette Sales Ban
136
to these products, which have the potential to be harm reduction or smoking cessation aids.5 Substi- tuting e-cigarettes for continued cigarette smoking is likely to reduce smokers’ risks of tobacco-related morbidity and mortality by a substantial margin, even though long-term health risks remain un- known.6 In prior studies, state laws that prohib- ited use of e-cigarettes indoors or restricted sales of tobacco products and e-cigarettes to individuals under the age of 21 were negatively associated with e-cigarette use among adults.7 To our knowledge, no studies have assessed the effects of a total e-ciga- rette sales ban on e-cigarette use among adults.
This exploratory study assessed the attitudes and behaviors of a convenience sample of Massachusetts adult cigarette smokers following the co-occurrence of the EVALI outbreak and Massachusetts’ total ban on e-cigarette sales. We targeted middle-aged and older adult smokers to capture those who may have been using e-cigarettes to reduce harm from combustible cigarettes and might be negatively im- pacted by restricted access to these products.
METHODS Design
We conducted a cross-sectional survey of current cigarette smokers or dual users of e-cigarettes and cigarettes who received primary care at 15 prac- tices in one healthcare system in Massachusetts. Surveys were administered between November 7, 2019 and February 27, 2020. Respondents who used e-cigarettes during the time of the Massachu- setts total sales ban were invited to participate in a qualitative interview about e-cigarette use patterns and attitudes in the context of the ban. Qualitative interviews were conducted by telephone between March 6, 2020 and June 9, 2020.
Setting and Participants Using the electronic health record (EHR), we
identified current cigarette smokers aged 40-80 years who spoke English and received primary care at 15 Massachusetts General Hospital-affiliated practices. We contacted primary care providers (PCPs) of individuals identified as potentially eli- gible from the EHR for permission to contact their patients and asked them to identify patients that they did not want us to contact about the study
(reasons given for exclusion included non-English speaking, patient no longer smoking, patient passed away, transferred care to another PCP, cognitive or behavioral concerns). Patients not excluded by their PCPs were mailed study information and could opt out of further contact. Individuals who did not opt out received up to 3 telephone calls from study staff who described the study, confirmed eligibility, ob- tained verbal informed consent, and administered the survey. Participants received a $25 gift card for participation.
Quantitative Survey Measures Age, sex, and primary health insurance were ob-
tained from the EHR. Other measures were ob- tained by telephone survey.
Cigarette smoking variables. Participants self- reported past 30-day cigarette smoking, number of cigarettes smoked per day, time to first morning cigarette (a measure of nicotine dependence),8 and past-year cigarette quit attempts. The present study focuses on current smokers, which we defined as reporting smoking cigarettes on at least one of the past 30 days.
E-cigarette use variables. Participants reported ever and past 30-day (defined as current) e-ciga- rette use. Former e-cigarette use was defined as ever use, but no reported past 30-day use.
Behaviors related to the e-cigarette ban. To as- sess the impact of the ban, we identified partici- pants living in Massachusetts who reported that they were using e-cigarettes around the start of the ban. For respondents who completed the survey during the ban (November 7-December 11), this included all current e-cigarette users plus former e-cigarette users who reported a change in vaping behavior because of the ban (ie, answered “yes” to “Did you change how you used e-cigarettes/ vape as a result of the recent ban on sales of vap- ing products/e-cigarettes in Massachusetts?”). For participants completing the survey after the total sales ban ended (December 12, 2019-February 27, 2020), we included all participants who reported having used e-cigarettes in the month before the ban started, and current and former e-cigarette users who reported changing how they used e- cigarettes because of the ban and had not quit e- cigarettes before the ban started. Participants who were surveyed during the total sales ban and were
Kalkhoran et al
Tob Regul Sci.™ 2021;7(2):135-143 137 DOI: doi.org/10.18001/TRS.7.2.5
current e-cigarette users were asked where they cur- rently obtained or purchased e-cigarettes. Partici- pants surveyed after December 11 were asked how they had obtained e-cigarettes during the total sales ban. We also asked all participants their opinion about several different policies that aim to restrict the sale of nicotine-containing e-cigarettes/vaping devices to adults.
Qualitative Interviews In-depth qualitative interviews were conducted
with 8 respondents who reported e-cigarette use during the ban, lived in Massachusetts, agreed to complete an additional interview, and could be reached to administer it. Participants meeting cri- teria for the qualitative interviews were called at random and invited to participate in the qualita- tive interview until the sample size of 8 participants was reached. Each interview was conducted by a trained research assistant, using a semi-structured interview guide to ask participants how they ob- tained e-cigarettes during the total sales ban, how the ban affected their e-cigarette use, and their opinion of alternative restrictions on e-cigarette sales. Interviews lasted approximately 15-30 min- utes, were audio-recorded with patient consent, and transcribed.
Data Analysis We described sociodemographic and tobacco
use characteristics of current, former, and never e- cigarette users, comparing groups using t-tests for continuous variables and c2 tests for categorical variables. We then described participant e-cigarette use and purchasing behaviors in response to the ban. Finally, we described opinions about sales of nicotine e-cigarettes by e-cigarette use status. All analyses were done using Stata version 13 (Stata- Corp LLC, College Station, TX).
For the qualitative analysis, interview transcripts were coded independently by 2 authors (SK, KK) using Dedoose Version 8.0.35 (SocioCultural Re- search Consultants, LLC, Los Angeles, CA). An initial coding framework was created using a de- ductive coding process, in which 3 primary do- mains were identified a priori to supplement results from the quantitative surveys. These domains were: (1) e-cigarette and cigarette use during the sales ban, (2) source of e-cigarettes during the ban, and
(3) opinion about e-cigarette sales restrictions. The constant comparative method9 was then used to establish a codebook. The 2 coders met after com- pleting a line-by-line review of every 2 transcripts (25% of the sample), refined codes, and added new codes to the codebook where appropriate. After each meeting, the codebook and coded transcripts were reviewed with a third author as part of a con- sensus building approach (JN). Analytic decisions were discussed collaboratively and discrepancies were resolved by reviewing the raw data. Final cod- ing decisions were agreed upon before the next 2 transcripts were coded. If new codes emerged that did not fit the coding scheme, the codebook was updated and previously coded transcripts were closely re-reviewed to ensure they reflected the most updated coding scheme. After the final tran- script was coded, no new themes were identified, and thus, thematic saturation had occurred within the study’s 3 a priori domains.
RESULTS We attempted to contact 1203 individuals whose
PCP approved their participation. We reached 665 (55%) by phone, and among those reached, 568 (85%) were eligible for the survey. Among eligible respondents, 304 (54%) consented and 301 (53%) completed the survey. This report focuses on the 284 participants who resided in Massachusetts and confirmed the EHR report of current cigarette smoking. One-third (N = 98) completed the sur- vey during the total e-cigarette ban, and two-thirds (N = 203) completed it in the 2 months after the ban ended.
At the time of the survey, 22 (8%) of the 284 par- ticipants were current e-cigarette users, 144 (51%) were former e-cigarette users, and 118 (41%) were never e-cigarette users. Table 1 reports the demo- graphic and cigarette use characteristics by e-cig- arette use category. Current e-cigarette users were younger than both never (p < .001) and former (p = .006) e-cigarette users; there were no other statis- tically significant differences among groups.
E-cigarette and Cigarette Use during the Sales Ban
A total of 24 Massachusetts residents reported us- ing both cigarettes and nicotine e-cigarettes around the start of the total ban on e-cigarettes sales. Of
Cigarette and E-cigarette Use Among Smokers After a Statewide E-cigarette Sales Ban
138
these, 13 (54%) reported either quitting or cut- ting down on e-cigarette use because of the ban, including 5 (21%) who reported having quit using e-cigarettes because of the ban (Table 2). In con- trast, only one respondent (4%) reported reduc- ing cigarette smoking during the ban, but 6 (25%) reported increasing how many cigarettes they smoked during the ban. Five of these 6 participants who reported increased cigarette smoking also re- ported having quit or reduced vaping because of the ban (data not shown). Therefore, 5 (38%) of the 13 participants who reduced e-cigarette use as a
result of the ban may have increased the number of cigarettes smoked in compensation.
In the qualitative interviews, participants report- ed using cigarettes as a substitute when e-cigarettes were unavailable. One participant explained that when he was in Massachusetts and had “run out of electronic cigarettes [he] had to buy regular ciga- rettes” (Participant 2035, Age 47, Male). Another participant was more direct in how the ban affected his relapse to cigarette smoking by saying: “I went back to smoking cigarettes when I thought I was do- ing so well getting away from the cigarettes [by using
Table 1 Participant Characteristics by E-cigarette Use Status at Time of Survey
All participants
(N = 284)
Current e-cigarette users
(N = 22)
Former e-cigarette users
(N = 144)
Never e-cigarette users
(N = 118)
Age, mean (SD) 58.3 (9.5) 51.6 (8.2) 57.1 (8.7) 61.2 (9.8) Female sex 153 (54%) 9 (41%) 80 (56%) 64 (54%) Race White Black Other Multiple race
236 (85%) 20 (7%) 15 (5%) 8 (3%)
21 (95%) 1 (5%)
0 0
124 (87%) 9 (6%) 6 (4%) 4 (3%)
91 (80%) 10 (9%) 9 (8%) 4 (4%)
Hispanic ethnicity 25 (9%) 2 (9%) 12 (8%) 11 (9%) Level of education Less than High School (HS) HS/GED Some college 4 year college degree or higher
31 (11%) 98 (35%) 68 (24%) 87 (31%)
2 (9%) 6 (27%) 6 (27%) 8 (36%)
8 (6%) 52 (36%) 38 (26%) 46 (32%)
21 (18%) 40 (34%) 24 (20%) 33 (28%)
Insurance Commercial Medicare Medicaid Uninsured
118 (42%) 98 (35%) 61 (21%) 7 (2%)
9 (41%) 6 (27%) 6 (27%) 1 (5%)
61 (42%) 43 (30%) 37 (26%) 3 (2%)
48 (41%) 49 (42%) 18 (15%) 3 (3%)
Cigarettes per day 13.1 (8.3) 10.8 (7.8) 14.1 (9.4) 12.4 (6.7) First cigarette within 30 mins of waking 173 (61%) 12 (55%) 88 (61%) 73 (62%) Past year quit attempt 134 (47%) 13 (59%) 67 (47%) 54 (46%) Product currently used in e-cigarette Nicotine only Marijuana only
-- --
16 (73%) 6 (27%)
-- --
-- --
Days of e-cigarette use in the past 30 days 1-5 6-10 11-25 26-30
13 (59%) 2 (9%) 2 (9%) 5 (23%)
Note. Current e-cigarette users were younger than both never (p < .001) and former (p = .006) e-cigarette users. All other p values were not significant.
Kalkhoran et al
Tob Regul Sci.™ 2021;7(2):135-143 139 DOI: doi.org/10.18001/TRS.7.2.5
e-cigarettes]. Boom. And there I was back to them again” (Participant 1154, 55, Male). This partici- pant also expressed frustration about how the ban represented what he perceived to be mixed-mes- saging about e-cigarettes – “I mean, why don’t they get their [expletive] straightened out – you know what I’m saying – before they put products out. I mean, look at how many people switched to the vaping, and then, all of [a] sudden, they cut everybody off on it. First, they say it’s okay to be out there, then they tell you it’s not to be using it. They should have gotten this straightened out before they ever put the product out, okay? (Participant 1154, 55, Male).”
Source of E-cigarettes during the Ban Table 2 shows how participants obtained e-ciga-
rettes during the sales ban. Of the 24 participants who reported e-cigarette use around the time of the ban, 6 participants reported that they did not purchase e-cigarettes during the ban, and purchas- ing behaviors for 3 participants were unknown. Of the 15 participants reporting a location of e-ciga- rette purchase during the ban, 12 (80%) reported purchasing the product, and 3 (20%) reported obtaining them from non-commercial sources. Over one-half (7/12) of those who purchased the products reported purchasing them from stores in Massachusetts or online, actions that appeared to violate the ban. The remainder purchased e-ciga- rettes out-of-state.
Participants described several strategies that they used to maintain a supply of e-cigarettes during the sales ban. One strategy was to have a large supply of e-cigarettes in hand ahead of the ban. One par- ticipant stated: “I was able to get enough of what I needed before the ban…I didn’t need anything during the ban” (Participant 2148, 40, Female). A second strategy was to obtain products from out-of-state during the ban. One participant obtained products because “I travel a lot throughout the United States, so every time I’m out of state I buy enough supply” (Participant #2035, 47, Male). Others drove to nearby states, saying: “We went to New Hampshire a couple of times and we kind of stocked up” (Par- ticipant 1142, 58, Male). A third strategy was to obtain e-cigarettes from sources that are not legal, either purchasing e-cigarettes in Massachusetts – “I was able to get a bottle from the place I usually bought from. They had it in the back” (Participant 2198,
54, Male), or possibly, from another illicit source – “If a person smokes or if they drink or whatever, you know where to…I can always find it is what I’m saying” (Participant 1142, 58, Male).
Opinion about E-cigarette Sales Restrictions Figure 1 illustrates opinions about restrictions
on the sale of nicotine e-cigarettes. The opinions of current and never e-cigarette users differed (p = .003). One-half of respondents preferred no ban on e-cigarette sales, including a majority of cur- rent e-cigarette users (ie, dual users of cigarettes and e-cigarettes) and a majority of former e-ciga- rette users. When interviewed, some participants expressed frustration at not having freedom of choice regarding use of e-cigarettes. Participants said about e-cigarette users: “They should have the right to do what they want, and not for the state to tell people – ‘You can’t do this,’ and ‘You can’t do that’” (Participant 2025, 49, Female). Other participants
Table 2 E-cigarette Use and Source during Complete
Ban on E-cigarette Sales among Massachusetts Residents
N %
Change in e-cigarette use (N = 24) No change Reduced Quit
11 8 5
46% 33% 21%
Change in cigarette smoking (N = 24) No change Increased Reduced
17 6 1
71% 25% 4%
Source of e-cigarettes obtained during ban (N = 15)a
Purchase a commercial product In Massachusetts Vape shop Other type of store Outside Massachusetts Vape shop Other type of store Online Obtain from friends/family
12 6 2 4 6 2 3 1 3
80%
20%
Note. a Six participants reported that they did not purchase e-cigarettes during the ban, and data on purchasing behavior was unavailable for 3 participants
Cigarette and E-cigarette Use Among Smokers After a Statewide E-cigarette Sales Ban
140
mentioned the ban was implemented after they had invested resources into e-cigarettes: “It’s like just when I bought the expensive device that I got and load it up, they put the ban on it, and I was like ‘what the hell’” (Participant 1154, 55, Male).
Some dual users of e-cigarettes and cigarettes ex- pressed support for a ban on e-cigarette sales out of concern for young people even if that policy might not be in their own interest. An example includes: “I feel like way more teenagers have been getting a hold of tobacco products because of [e-cigarettes] than necessary. And more regulations on it and how it’s be- ing sold will prevent the kids from getting it, hope- fully” (Participant 2148, 40, Female).
DISCUSSION This exploratory study used a mixed-methods
approach to explore adult smokers’ responses to a statewide ban on all e-cigarette sales that was put in place when EVALI cases raised concerns about e-cigarettes’ safety. Massachusetts’ emergency order aimed to reduce e-cigarette users’ access to and use
of these products temporarily until more informa- tion about the health risks of vaping products be- came available. To our knowledge, this report is the first to describe attitudes and behaviors following a total ban on e-cigarette sales. The results suggest that the emergency order had some success in re- ducing state residents’ access to and use of e-ciga- rettes. However, the ban on e-cigarette purchases was circumvented by a number of respondents who reported purchasing the products illegally in the state or online and by those who purchased products legally outside the state. Although the abrupt nature of the sales ban is understandable given the sudden onset of EVALI cases, some re- spondents were frustrated by what they perceived as mixed messages about e-cigarettes that they had previously been told were a less harmful alterna- tive. These findings illustrate the challenges faced by policymakers trying to stop access to addic- tive products and respond to unanticipated public health challenges.
Among cigarette smokers who also used e-ciga-
0%
20%
40%
60%
80%
100%
Ban sale of all nicotine e-cigarettes
Ban sale of flavored nicotine e-cigarettes
No ban
Current e-cig users Former e-cig users Never e-cig users Overall
Figure 1 Support for Ban on Sales of Nicotine E-cigarettes in Massachusetts by E-cigarette Use Status
Kalkhoran et al
Tob Regul Sci.™ 2021;7(2):135-143 141 DOI: doi.org/10.18001/TRS.7.2.5
rettes at the time of the ban (ie, dual users), more than half reported reducing their e-cigarette use after the ban. However, many participants who reported reducing e-cigarette use appeared to have compensated by increasing their cigarette con- sumption, a substitution that presumably replaced a lower-risk nicotine product with a higher-risk nic- otine product. Because our sample size was small, we caution that this finding is exploratory and should be evaluated in larger and more represen- tative studies to determine whether compensatory increases in adult cigarette smoking accompany e-cigarette sales restrictions. Ideally, longitudinal studies are needed to assess the effects of e-cigarette sales restrictions on future cigarette use, particular- ly among dual users of cigarettes and e-cigarettes. One strategy that might reduce the potential for a compensatory increase in cigarette smoking is to pair sales restrictions with a concomitant increase in the availability and affordability of smoking ces- sation treatment. Massachusetts’ emergency order attempted to do this by authorizing pharmacists to dispense over-the-counter nicotine replacement therapy to adults without a physician’s prescription and by eliminating copayments for smoking cessa- tion pharmacotherapy among Medicaid recipients. The impact of this strategy cannot be assessed in this study which did not ask respondents about it.
Some e-cigarette users who continued using e- cigarettes during the ban reported obtaining the products in Massachusetts. This is consistent with prior studies that found incomplete compliance with flavor bans in various US cities.10,11 Other e-cigarette users in our study obtained the prod- ucts from out-of-state, online, or a family or friend source, suggesting that at least some e-cigarette users who wanted to continue using the products were able to find ways to continue use despite the ban. The relatively small size of Massachusetts and its proximity to states without similar regulations likely contributed to e-cigarette users’ ability to purchase the product out of state. Our survey did not ask respondents who purchased e-cigarettes out of state during the ban whether this was a new pur- chase pattern or a continuation of a previous pat- tern due to pre-existing price differences between states.
Most cigarette smokers who were current or former e-cigarette users during the state’s total e-
cigarette sales ban did not support that policy, and even 40% of cigarette smokers who had never used e-cigarettes did not support the ban. However, half of all respondents did support some form of ban on sales of nicotine e-cigarettes. One reason for this support was suggested in the qualitative inter- views in which current e-cigarette users cited con- cerns about the product’s use by young people. The timing of our data collection was during and after a complete sales ban, and how the support for e- cigarette regulations may have been affected by the ban already being in place is not known.
This study is subject to several limitations. First, data were collected among middle-aged and older adult current cigarette smokers, and findings are not generalizable to younger smokers or to non- smokers of any age. The education level of par- ticipants in our study is twice as high as national samples of US adult cigarette smokers or dual users of e-cigarettes and cigarettes,12 and this may also limit generalizability. Second, we surveyed smokers who had a primary care provider; their responses might differ from smokers without a regular source of medical care who may differ in access to conven- tional smoking cessation treatment medications and may have different sources of information about e-cigarettes. Third, our data were collected in a single US state under unique circumstances (ie, a complete ban on e-cigarette sales) and may not reflect the attitudes and behaviors of smokers in other parts of the country and in response to less stringent policies, such as those on flavored e-ciga- rettes or age restrictions on e-cigarette sales. Fourth, whereas some of the surveys were collected during the complete sales ban, others were collected right after the ban and during a flavor ban and may be subject to recall bias. In subgroup analyses by time of survey administration, we did not see statistically significant differences in changes in e-cigarette use (p = .33) or changes in cigarette smoking (p = .64) by whether the survey was taken during or after the ban; however, subgroup sample sizes were small and not powered to detect significant differences. Fifth, the findings reflect survey respondents’ reac- tions to 2 contemporaneous events – the EVALI outbreak and the resulting e-cigarette sales ban. It is not possible to distinguish the independent ef- fect of each event. Sixth, this study focused on cur- rent cigarette smokers and dual users of cigarettes and e-cigarettes because this population could be
Cigarette and E-cigarette Use Among Smokers After a Statewide E-cigarette Sales Ban
142
identified through documentation in electronic health records; it does not capture individuals who quit cigarettes after the ban on e-cigarettes or indi- viduals who used e-cigarettes only, for whom there was no routine documentation of use status in our health record. Finally, because only a small number of respondents used e-cigarettes during and after the complete sales ban, our study findings require confirmation in larger and more representative samples.
IMPLICATIONS FOR TOBACCO REGULATION
To our knowledge, this exploratory study pro- vides the first information about the impact of in- troducing a total statewide ban on e-cigarette sales on smokers’ attitudes and behaviors. It suggests that the effects are complex, with both more and less desirable outcomes. Many adult cigarette smokers stopped or reduced e-cigarette use after the ban, an appropriate response to reduce their risk of EVALI at a time when its cause was under investigation. However, some of the e-cigarette users who reduced e-cigarette use in response to the ban appeared to compensate by increasing conventional cigarette smoking, substituting a riskier nicotine product for e-cigarettes. Whether this compensation persisted when the total e-cigarette sales ban changed to a fla- vored e-cigarette sales ban that allowed a return to e-cigarette use cannot be determined in this study. Important considerations for policymakers include the need for close monitoring of all tobacco prod- uct sales during the implementation of a ban on one type of nicotine or tobacco product, to moni- tor for retailor noncompliance and for potential compensatory increases in other tobacco use as a result of decreased product availability. Improving access to smoking cessation resources during a ban on e-cigarette sales may help to reduce compensa- tory increases in cigarette smoking that may occur among individuals using e-cigarettes as a harm re- duction tool from cigarettes.
Furthermore, 46% of e-cigarette users continued using these products despite a government action whose intent was to reduce the risk of EVALI. Al- though some of these e-cigarette users obtained the products legally by out-of-state purchase, others obtained the products illegally by in-state or online purchases, demonstrating that incomplete compli-
ance with the total e-cigarette sales ban occurred. This highlights the importance of having systems in place to monitor enforcement of bans on e-ciga- rette sales at stores that sell these products, and also of ensuring that online retailers place the same re- strictions on sales as local retailers. A federal statute could help to reduce some forms of ban non-com- pliance, such as those due to variable regulations across neighboring states, but would still carry the possibility of illegal sales within states. Another implication is that states and communities should expect that the impact of local and state bans will be less than expected due to cross-border sales, and projected effects of policies need to account for this factor, which will be stronger in smaller sized ju- risdictions (ie, towns and smaller states). Finally, these findings might have relevance for flavor bans if adult dual users are not interested in using to- bacco flavored e-cigarettes and would prefer com- bustible cigarettes instead.
Human Subjects Approval Statement The Mass General Brigham Institutional Review
Board approved the study.
Conflict of Interest Disclosure Statement Drs. Kalkhoran and Rigotti receive royalties from
UpToDate Inc. Dr. Rigotti has been an unpaid consultant to Pfizer Inc and a paid consultant to Achieve Life Sciences. No other authors have con- flicts of interest to disclose.
Acknowledgements The authors thank Corey Bryton for his assistance
with quantitative survey administration. This study was supported by the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health (K23HL136854 to Dr. Kalkhoran). The data presented in this manuscript were presented as part of an oral presentation at the 2020 American Public Health Association national meeting.
References 1. Krishnasamy VP, Hallowell BD, Ko JY, et al. Update:
characteristics of a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury – United States, August 2019-January 2020. MMWR Morb Mortal Wkly Rep. 2020;69(3):90-94.
2. Werner AK, Koumans EH, Chatham-Stephens K, et al.
Kalkhoran et al
Tob Regul Sci.™ 2021;7(2):135-143 143 DOI: doi.org/10.18001/TRS.7.2.5
Hospitalizations and deaths associated with EVALI. N Engl J Med. 2020;382(17):1589-1598.
3. Mass.gov. Governor Charlie Baker Declares Public Health Emergency, Announces Temporary Four-Month Ban on Sale of All Vape Products. https://www.mass.gov/news/ governor-charlie-baker-declares-public-health-emergen- cy-announces-temporary-four-month-ban-on. Published September 24, 2019. Accessed September 11, 2020.
4. Mass.gov. 2019 Tobacco Control Law. https://www.mass. gov/guides/2019-tobacco-control-law. Accessed Septem- ber 11, 2020.
5. Sindelar JL. Regulating vaping – policies, possibilities, and perils. N Engl J Med. 2020;382(20):e54.
6. National Academies of Sciences, Engineering, and Medi- cine. Public Health Consequences of E-cigarettes. Washing- ton, DC: The National Academies Press; 2018.
7. Du Y, Liu B, Xu G, et al. Association of electron- ic cigarette regulations with electronic cigarette use among adults in the United States. JAMA Netw Open.
2020;3(1):e1920255. 8. Baker TB, Piper ME, McCarthy DE, et al. Time to first
cigarette in the morning as an index of ability to quit smoking: implications for nicotine dependence. Nicotine Tob Res. 2007;9(Suppl 4):S555-S570.
9. Glaser BG. The constant comparative method of qualita- tive analysis. Social Problems. 1965;12(4):436-445.
10. Yang Y, Lindblom EN, Salloum RG, Ward KD. The im- pact of a comprehensive tobacco product flavor ban in San Francisco among young adults. Addict Behav Rep. 2020;11:100273.
11. Rogers T, Brown EM, McCrae TM, et al. Compliance with a sales policy on flavored non-cigarette tobacco products. Tob Regul Sci. 2017;3(2 Suppl 1):S84-S93.
12. Kalkhoran S, Chang Y, Rigotti NA. Electronic cigarette use and cigarette abstinence over two years among U.S. smokers in the population assessment of tobacco and health study. Nicotine Tob Res. 2020;22(5):728-733.
Copyright of Tobacco Regulatory Science is the property of Tobacco Regulatory Science Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.