When San Francisco voters overwhelmingly approved a 2018 ballot measure banning the sale of flavored tobacco products–including menthol cigarettes and flavored vape liquids–public health advocates celebrated. After all, tobacco use poses a significant threat to public health and health equity, and flavors are particularly attractive to youths.
But according to a new study from the Yale School of Public Health, that law may have had the opposite effect. Analyses found that, after the ban’s implementation, the odds of San Francisco high school students smoking conventional cigarettes doubled relative to trends in school districts without the ban, even when adjusting for individual demographics and other tobacco policies.
The study 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, Ph.D., the study’s author and an associate professor in the Department of Health Policy and Management. “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 1 in 5 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 2011-19 school district surveys. Prior to the ban’s implementation, smoking rates for the preceding 30 days 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 have been the most popular tobacco product among U.S. youths since at least 2014, with flavored options largely preferred.
As similar restrictions 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.
What does Friedman suggest as an alternative? A good candidate might be restricting all tobacco product sales to adults 21 and older.
The study is published in the journal JAMA Pediatrics.