Do E-Cigarette Flavor Bans Reduce Vaping?

This study asked whether state bans on flavored e-cigarettes reduce vaping or lead to more cigarette smoking among young people and adults. Researchers analyzed survey data from 2015–2023 using the Youth Risk Behavior Survey and the Behavioral Risk Factor Surveillance System across six states with flavor bans and several control states. They found that flavor bans reduced e-cigarette use among young adults by about 6.7 percentage points in 2022 and among adults by 1.2 points in 2023. However, cigarette use rose among youths and young adults, increasing up to 3.7 percentage points in some years, suggesting possible substitution effects.

The Policy Scientist’s Perspective

This article addresses a policy issue of high public relevance: whether restrictions on flavored e-cigarettes reduce nicotine dependence or instead shift users back to traditional cigarettes. The topic matters because it lies at the intersection of youth health, regulatory design, and unintended behavioral responses—issues central to both tobacco control and broader public health strategy. Its use of state-level panel data and difference-in-differences estimation represents a credible causal inference technique. The YRBS and BRFSS datasets are large, validated, and nationally representative, supporting solid internal reliability and external generalizability to other U.S. jurisdictions with comparable enforcement capacity. The findings—showing declines in vaping but some substitution toward cigarettes—extend prior work on substitution effects, a theme present in earlier state and local studies. This makes the article an important recent addition to the literature, especially as more states consider similar restrictions and need empirical evidence about their broader behavioral consequences.

Full Citation and Link to Article

Cheng, D., Lee, B., Jeffers, A. M., Stover, M., Kephart, L., Chadwick, G., Kruse, G. R., Evins, A. E., Rigotti, N. A., & Levy, D. E. (2025). State E-cigarette flavor restrictions and tobacco product use in youths and adults. JAMA Network Open, 8(7), e2524184. https://doi.org/10.1001/jamanetworkopen.2025.24184

Extended Summary

Central Research Question

This study examines whether statewide restrictions on flavored e-cigarettes are associated with changes in the use of both e-cigarettes and combustible cigarettes among different age groups in the United States. Specifically, the authors ask whether flavor bans—implemented to deter youth vaping—actually reduce e-cigarette use or unintentionally encourage substitution toward conventional cigarettes. The question is policy-relevant because flavor restrictions are among the most widely debated tobacco control measures, balancing youth prevention goals against potential public health harms from increased cigarette smoking. The study further explores whether these associations vary across age groups and states, and whether the effects persist or evolve over multiple post-policy years.

Previous Literature

Prior research has documented the rapid increase in e-cigarette use among adolescents and young adults since the mid-2010s, with flavored products accounting for a substantial majority of use. Studies have established that flavored e-cigarettes appeal disproportionately to youths and nonsmokers, with surveys showing that over 85% of middle and high school e-cigarette users consume flavored varieties. Earlier research also suggests that e-cigarette use among adolescents is associated with symptoms of nicotine dependence and an elevated risk of future cigarette use, though causality remains debated.

The literature on the effects of flavor restrictions is still emerging. Local evaluations in Massachusetts and Minnesota found that flavor bans were associated with reductions in sales and use of both e-cigarettes and cigarettes. Early multi-state studies also observed short-term declines in e-cigarette sales following the introduction of flavor bans, though substitution toward tobacco-flavored e-cigarettes and traditional cigarettes was sometimes detected. More recent studies have attempted to quantify behavioral substitution more directly, showing that when access to flavored products declines, some users shift to non-flavored or menthol e-cigarettes, while others revert to combustible cigarettes.

Before this study, statewide analyses were limited by short follow-up periods and incomplete pre-policy baselines. Some recent preprints examined similar questions using the Youth Risk Behavior Survey (YRBS) and Behavioral Risk Factor Surveillance System (BRFSS) data, but these lacked 2019—the key pre-policy year just before the first flavor bans took effect. As a result, existing evidence could not fully assess changes relative to baseline trends. The current article improves on this prior work by extending the time horizon through 2023, incorporating six states with multiple years of post-policy data, and using a standardized pre-policy baseline to enhance comparability.

Data

The authors use two nationally recognized public health surveillance systems to measure tobacco product use across states: the Youth Risk Behavior Survey (YRBS) and the Behavioral Risk Factor Surveillance System (BRFSS). The YRBS provides biennial, school-based cross-sectional data on high school students in grades 9 through 12, while the BRFSS provides annual, telephone-based data on adults aged 18 and older. Together, these data sources cover the years 2015 through 2023, allowing the authors to evaluate trends both before and after state flavor restrictions were implemented.

The study categorizes respondents into three age groups: youths (high school-aged, from YRBS), young adults (ages 18–24), and adults aged 25 and older (both from BRFSS). Current e-cigarette use was defined as any use in the past 30 days for YRBS respondents and as use on “some days” or “every day” for BRFSS respondents. Cigarette use followed the same definition. The key exposure variable was whether a state had implemented a permanent, statewide policy restricting sales of non-tobacco-flavored e-cigarettes. Six states met this criterion with sufficient post-policy data: Massachusetts, New Jersey, New York, Maryland, Rhode Island, and Utah. States without such restrictions served as controls.

To control for policy heterogeneity, the authors also documented other relevant state tobacco policies, including minimum legal sales age of 21 (T21), e-cigarette excise taxes, retail licensure requirements, and clean indoor air laws that ban vaping in restaurants, workplaces, or bars. These contextual variables were used in sensitivity analyses to ensure robustness. In total, the data encompassed 186 state-years of YRBS data and 386 state-years of BRFSS data on e-cigarette use, along with 191 and 456 corresponding state-years of cigarette use data. These large, representative datasets enhance both the internal validity and generalizability of the findings to U.S. states with similar enforcement capacity.

Methods

The authors applied a difference-in-differences (DiD) research design using state-level panel data from 2019 (pre-policy) through 2023 (post-policy). This quasi-experimental method estimates policy effects by comparing changes in outcome variables over time between “treatment” states that adopted flavor restrictions and “control” states that did not. The central parameter of interest—the average treatment effect among the treated (ATT)—represents the difference in changes between the two groups, assuming parallel pre-policy trends.

The authors evaluated separate models for each post-policy year and age group, allowing for unbalanced panels since not all states contributed data in every year. Robust standard errors were clustered at the state level with small-sample corrections. Event-study plots and pre-policy trend graphs were used to check the plausibility of the parallel trends assumption.

Secondary analyses excluded states with partial exemptions (Maryland and Utah, which permitted mint and menthol flavors) and examined heterogeneity in effects by state. Additional models estimated policy associations with cigarette use among respondents who currently, formerly, or never used e-cigarettes, providing insight into substitution dynamics. Sensitivity analyses tested robustness to alternative baselines (2017 vs. 2019), restricted balanced panels, and the presence or absence of other tobacco control laws.

This design cannot establish causality in the same way as a randomized controlled trial, but it represents one of the strongest causal inference strategies available in observational policy evaluation. The use of multiple years of pre- and post-policy data, as well as adjustments for other state-level controls, strengthens the internal validity of the results.

Findings/Size Effects

Overall, flavor restriction policies were associated with reductions in e-cigarette use among young adults and adults, but with increases in cigarette use among youths and young adults. Specifically, the difference-in-differences estimates indicated that among young adults (ages 18–24), e-cigarette use fell by 6.7 percentage points in 2022 (95% CI, −12.1 to −1.3), while among adults aged 25 and older, it fell by 1.2 percentage points in 2023 (95% CI, −2.0 to −0.4). These reductions suggest that flavor bans were successful in lowering vaping prevalence among some age groups, albeit modestly.

However, the policies were also associated with statistically significant increases in cigarette use among youths and young adults. Among youths, cigarette prevalence increased by 1.8 percentage points in 2021 (95% CI, 0.7 to 2.9), though not in 2023. Among young adults, increases were observed across multiple years: 3.7 percentage points in 2021, 2.7 in 2022, and 3.2 in 2023. Among adults 25 and older, no significant changes in cigarette use were detected.

The authors interpret these findings as evidence of potential substitution effects—some e-cigarette users, when deprived of flavored products, may switch to combustible cigarettes rather than quitting nicotine altogether. Analyses by smoking history support this interpretation: increased cigarette use was concentrated among individuals who currently or formerly used e-cigarettes, rather than among those who had never vaped.

State-specific analyses revealed substantial heterogeneity. Massachusetts and Maryland exhibited the most consistent reductions in e-cigarette use across all post-policy years and age groups, with Massachusetts showing declines as large as 12.8 percentage points among young adults in 2023. In contrast, Rhode Island showed mixed outcomes, with reductions in some populations but increases among young adults in certain years. Across all states, increases in cigarette use were most evident among younger populations, suggesting that substitution effects may be strongest where nicotine dependence is newer or more behaviorally elastic.

Sensitivity analyses produced consistent results across specifications. When states with menthol exemptions were excluded, findings remained similar. Subanalyses controlling for other tobacco policies—such as e-cigarette taxation or T21 laws—did not materially change the direction or significance of the key results.

Conclusion

This study provides some of the most comprehensive evidence to date on the behavioral impacts of statewide e-cigarette flavor restrictions. The findings indicate that such policies can reduce e-cigarette use among young adults and older adults, but they may also produce unintended increases in cigarette use among youths and younger adults. These results underscore the importance of considering substitution effects when designing tobacco control policies.

The study’s strength lies in its use of large, representative data sources, consistent definitions of use, and a robust quasi-experimental design that extends the analysis through multiple post-policy years. The difference-in-differences approach offers credible causal inference within observational limits, and the authors’ sensitivity checks bolster confidence in the results. However, the study cannot fully disentangle policy effects from contemporaneous influences, such as the COVID-19 pandemic or local enforcement variation.

The evidence suggests that while flavor restrictions can reduce youth vaping, they may not eliminate nicotine use altogether and can, under certain conditions, shift consumption toward more harmful products. From a policy standpoint, the article advances the field by documenting these cross-product substitution effects on a multi-state, multi-year basis using nationally comparable data. It therefore represents a meaningful, empirically grounded contribution to the ongoing debate over the net public health impact of flavored e-cigarette bans.