Cross-state Border Nicotine Vaping Products Purchase - Early Evidence from State Emergency Sales Restrictions in 2019.

INTRODUCTION: While retail sales and retailer inspection studies generally indicate high compliance with state sales restrictions on Nicotine Vaping Products (NVPs) within the restricted area, studies using survey data generally indicate that most users could readily continue gaining access to restricted NVPs. Our study bridges a gap in the current literature and investigates the potential role of cross-state border purchases to evade state emergency NVP sales restrictions in 2019. METHODS: The study sample was restricted to NVP sales from the states neighboring Massachusetts (MA), Rhode Island (RI), and Washington (WA), three states that implemented all NVP or flavored NVP sales restrictions in 2019. Among these neighboring states, the 2019 weekly county-level NVP sales by flavors (tobacco, mint/menthol, and other flavors) were compiled using Nielsen Scanner data. A quasi-experimental, comparison group pre-post study design was used to study the impacts of NVP sales restrictions on cross-state border NVP purchases. RESULTS: Weekly NVP sales for border counties significantly increased in response to the MA, RI, and WA bans for tobacco flavored (56%, 45%, 14%, respectively), menthol/mint flavored (51%, 2%, 41%, respectively), and other flavored (79%, 3%, 4%, respectively) products, compared to sales for non-border counties (all p-values <0.01). CONCLUSIONS: Our study identified significant cross-state border NVP purchases in all studied states to circumvent NVP emergency sales restrictions in response to the EVALI outbreak. Policymakers should factor in these purchasing behaviors to evade sales restrictions when evaluating any future potential policies at the state or local levels. IMPLICATIONS: While retail sales data and retailer inspections indicate high compliance with Nicotine Vaping Product (NVP) flavor sales restrictions from major retail outlets, survey data obtain mixed findings on the effects of sales restrictions on vaping behaviors. Our study identified a significant increase in cross-state border NVP purchases to circumvent NVP sales restrictions in 2019, consistent across all three settings of Massachusetts, Rhode Island, and Washington. Policymakers should factor in these cross-state border NVP purchases in response to sales restrictions when evaluating any future potential NVP sales restrictions.

Noticing education campaigns or public health messages about vaping among youth in the United States, Canada and England from 2018 to 2022.

Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16-19 year-olds in United States, Canada and England (2018-2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.

How Complete Are Tobacco Sales Data? Assessing The Comprehensiveness Of US Tobacco Product Retail Sales Data Through Comparisons To Excise Tax Collections.

INTRODUCTION: Sales data analyses are increasingly used to guide tobacco regulatory science. However, such data do not cover specialist retailers like vape shops or tobacconists. Understanding the extent of the cigarette and electronic nicotine delivery system (ENDS) markets covered by sales data is critical to establishing such analyses' generalizability and potential biases. METHODS: Using retail sales data from Information Resources Incorporated (IRI) and Nielsen, we conduct tax gap analyses comparing states' cigarette and ENDS tax revenue to tax collection estimates based on retail sales data. For the 23 US states in both retail sales datasets, cigarette tax gap analyses were conducted for each year from 2018-2020. Four (Louisiana, North Carolina, Ohio, and Washington) of those 23 states levied per unit ENDS taxes and provided monthly tax revenue data covering January 2018 - October 2021, where we conducted monthly tax gap analyses for both cigarettes and ENDS. RESULTS: Across states covered by both sales datasets, annual mean cigarette sales in IRI and Nielsen account for 92.3% (95% CI 88.3-96.2%) and 84.0% (95% CI 79.3-88.7%) of state cigarette tax revenue, respectively. Monthly average coverage rates for ENDS sales were lower, ranging from 42.3% to 86.1% for IRI and 43.6% to 88.5% for Nielsen, but remained stable over time. CONCLUSIONS: IRI and Nielsen sales data capture almost the entire US cigarette market and a substantial but lower portion of the US ENDS market. With proper care to address shortcomings, sales data analyses can capture changes in the US market for these tobacco products. IMPLICATIONS: Policy evaluations and analyses using e-cigarette and cigarette sales data are often criticized because these data do not cover online sales or sales by specialty retailers like tobacconists.Cigarette sales data consistently cover nearly 90% of taxed sales, while e-cigarette sales data cover around 50% of taxed volumes.Retail sales data capture nearly all cigarette sales and a substantial portion of ENDS sales with relatively stable rates of coverage over time, supporting their continued use in tobacco surveillance and policy evaluation work.

The smoking and vaping model, A user-friendly model for examining the country-specific impact of nicotine VAPING product use: application to Germany.

BACKGROUND: Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs. METHODS: SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM's adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data. RESULTS: Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period. CONCLUSIONS: SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.

Brand Differences in Underage Tobacco Use as Evidence for Targeted Sanctions-Reviving the Lookback.

This survey study uses data from the 2020-2021 National Survey on Drug Use and Health to estimate brand differences in underage cigarette and cigar use in the US.

Potential Implications for Tobacco Industry Transformation of the Acquisition of Swedish Match by Philip Morris International.

Philip Morris International's recent purchase of Swedish Match may prove to be a vital tobacco industry development. We focus on PMIs potential progress in moving from primarily selling cigarettes toward primarily selling noncombustible nicotine delivery products (NCNDPs). We also consider the potential contribution of the acquisition to industry transformation whereby other cigarette firms may potentially move toward primarily selling NCNDPs. We examine the potential impact on noncombustible nicotine delivery product use, including nicotine pouches (a major Swedish Match product), e-cigarettes, heated tobacco products, and, most importantly, on sales of the industry's staple, combustible cigarettes. We focus on the United States as a special case, where PMI is limited from entering the cigarette market. Implications: Philip Morris International's purchase of Swedish Match and policies regarding nicotine pouches (NPs) have been overlooked in the tobacco control literature. The acquisition indicates the importance of the NP market to the largest nonstate-owned tobacco company. The acquisition has the potential through pricing and marketing tactics to either encourage or discourage the use of NPs, e-cigarettes, heated tobacco products, and most importantly cigarettes. Due to its inability to sell cigarettes in the United States, PMI will have incentives to use its alternative nicotine delivery products, including its newly acquired NPs, to reduce the sale of cigarettes by other companies. However, the potential effects in other countries, where PMI does sell cigarettes, are less clear. Monitoring and analyzing tobacco company acquisitions is essential to studying future transitions in using different kinds of tobacco products, especially from cigarettes to lower-risk alternative nicotine delivery products.

The longitudinal association between coupon receipt and established cigarette smoking initiation among young adults in USA.

INTRODUCTION: Tobacco companies frequently distribute coupons for their products. This marketing tactic may be particularly effective among young adults, who tend to be especially price-sensitive. Young adulthood is also a stage during which many individuals initiate established cigarette smoking and are especially vulnerable to the effects of tobacco marketing. METHODS: We used five waves of data from the US Population Assessment on Tobacco and Health Study (2013-2019) to assess the longitudinal relationship between cigarette coupon receipt and initiation of established cigarette smoking among young adults (18-24 years) who did not report current smoking and had smoked <100 cigarettes in their lifetime at baseline. Initiation of established cigarette smoking was defined as reporting current cigarette use and having smoked ≥100 cigarettes at follow-up. To test this relationship, we fit four discrete time survival models to an unbalanced person-period data set. The first model included our time-varying coupon receipt variable, which was lagged one wave. Subsequent models added sociodemographic, cigarette smoking exposure and other tobacco use variables. RESULTS: Adopting the model adjusting for sociodemographic variables, respondents who received a coupon were found to be more likely to initiate established cigarette smoking at follow-up (adjusted HR (aHR): 2.31, 95% CI 1.41 to 3.80). This relationship remained significant when controlling for all covariates in the fully adjusted model (aHR: 1.96, 95% CI 1.18 to 3.26). CONCLUSIONS: These findings show that receiving tobacco coupons may increase the likelihood that young adults will initiate established cigarette smoking, underscoring the need to address the effects of this tobacco marketing tactic.

MRTP claim authorisation and General Snus sales in the USA: evidence from a difference-in-differences model.

BACKGROUND: The 2009 Tobacco Control Act granted the US Food and Drug Administration (FDA) regulatory authority over tobacco products, including the ability to authorise modified-risk tobacco product (MRTP) claims. In October 2019, the FDA authorised the first-ever MRTP claim for General Snus, which allowed the product to be marketed as reduced risk (relative to cigarettes). MRTP authorisation may increase otherwise low rates of snus use in the USA (<0.5% for children and adults). METHODS: Using 2017-2021 Nielsen sales data from 19 US states, we conducted a difference-in-differences analysis to determine whether logged unit sales of General Snus were affected by the MRTP authorisation, compared with (1) sales of other snus brands and (2) sales of non-snus smokeless products; we also examined (3) if sales of non-General Snus brands were affected by General Snus's MRTP authorisation, compared with sales of non-snus smokeless tobacco products. RESULTS: Although sales declined in absolute terms, sales of General Snus relative to other snus brands were unchanged after MRTP authorisation (-9.0%, 95% CI -19.6% to 1.60%, p=0.098). However, compared with non-snus smokeless brand sales, sales of General Snus (+14.7%, 95% CI 5.23% to 24.2%, p=0.002) rose after MRTP authorisation. Compared with non-snus smokeless products, sales of non-General Snus brands also rose after MRTP authorisation (+23.7%, 95% CI 9.5% to 38.0%, p=0.001). CONCLUSIONS: Although only General Snus received MRTP authorisation, this designation appears to have slowed declines for the entire snus category. This suggests consumers may make determinations regarding product risk to a product class rather than individual products.

Machine learning application for predicting smoking cessation among US adults: An analysis of waves 1-3 of the PATH study.

Identifying determinants of smoking cessation is critical for developing optimal cessation treatments and interventions. Machine learning (ML) is becoming more prevalent for smoking cessation success prediction in treatment programs. However, only individuals with an intention to quit smoking cigarettes participate in such programs, which limits the generalizability of the results. This study applies data from the Population Assessment of Tobacco and Health (PATH), a United States longitudinal nationally representative survey, to select primary determinants of smoking cessation and to train ML classification models for predicting smoking cessation among the general population. An analytical sample of 9,281 adult current established smokers from the PATH survey wave 1 was used to develop classification models to predict smoking cessation by wave 2. Random forest and gradient boosting machines were applied for variable selection, and the SHapley Additive explanation method was used to show the effect direction of the top-ranked variables. The final model predicted wave 2 smoking cessation for current established smokers in wave 1 with an accuracy of 72% in the test dataset. The validation results showed that a similar model could predict wave 3 smoking cessation of wave 2 smokers with an accuracy of 70%. Our analysis indicated that more past 30 days e-cigarette use at the time of quitting, fewer past 30 days cigarette use before quitting, ages older than 18 at smoking initiation, fewer years of smoking, poly tobacco past 30-days use before quitting, and higher BMI resulted in higher chances of cigarette cessation for adult smokers in the US.

An examination of quitting smoking as a reason for vaping by the type of nicotine vaping device used most often among adults who smoke and vape: Findings from the Canada, England and the United States 2020 ITC Smoking and Vaping Survey.

Several nicotine vaping product (NVP) device types are available to consumers, and many people who smoke report vaping to help them quit. This study included data from the Wave 3 (2020) ITC Smoking and Vaping Survey in the US, Canada, and England and included 2324 adults who were smoking cigarettes and vaping at least weekly. Device types currently used most often (disposables, cartridges/pods, or tank systems) were assessed using weighted descriptive statistics. Multivariable regression analyses were used to compare differences between respondents who reported vaping to quit smoking ('yes' vs. 'no/don't know') by device type, overall and by country. Overall, 71.3% of respondents reported vaping to help them quit smoking, with no country differences (p = 0.12). Those using tanks (78.7%, p < 0.001) and cartridges/pods (69.5%, p = 0.02) were more likely to report this reason for vaping than those using disposables (59.3%); respondents using tanks were also more likely than those using cartridges/pods (p = 0.001) to report this reason. By country, respondents in England using cartridges/pods or tanks (vs. disposables) were more likely to report vaping to quit smoking (with no difference between cartridges/pods and tanks). In Canada, respondents using tanks were more likely to report vaping to quit smoking than those using cartridges/pods or disposables (no difference between disposables and cartridges/pods). No significant differences by device type were found in the US. In conclusion, most adult respondents who smoked and vaped reported using either cartridges/pods or tanks, which were associated with greater odds of vaping for the purpose of quitting smoking versus disposables, with some country variations.

HOW COMPLETE ARE TOBACCO SALES DATA? ASSESSING THE COMPREHENSIVENESS OF TOBACCO PRODUCT RETAIL SALES DATA THROUGH COMPARISONS TO EXCISE TAX COLLECTIONS.

Introduction: Sales data analyses are increasingly used to guide tobacco regulatory science. However, such data do not cover specialist retailers like vape shops or tobacconists. Understanding the extent of the cigarette and electronic nicotine delivery system (ENDS) markets covered by sales data is critical to establishing such analyses' generalizability and potential biases. Methods: Sales data from Information Resources Incorporated (IRI) and Nielsen Retail Scanner data are used to conduct a tax gap analysis, comparing state tax collections based on cigarette and ENDS sales data to states' annual 2018-2020 cigarette tax collections and monthly ENDS and cigarette tax revenue data for January 2018 to October 2021. Cigarette analyses consider the 23 US states covered by both IRI and Nielsen. ENDS analyses consider the subset of those states with per unit ENDS taxes: Louisiana, North Carolina, Ohio, and Washington. Results: Across states covered by both sales datasets, IRI's mean cigarette sales coverage was 92.3% (95% CI 88.3-96.2%), while Nielsen's was 84.0% (95% CI 79.3-88.7%). Coverage rates for average ENDS sales were lower, ranging from 42.3% to 86.1% for IRI and 43.6% to 88.5% for Nielsen, but remained stable over time. Conclusions: IRI and Nielsen sales data capture almost the entire US cigarette market and, while coverage rates are lower, a substantial portion of the US market for ENDS as well. Coverage rates are relatively stable over time. Thus, with proper care to address shortcomings, sales data analyses can capture changes in the US market for these tobacco products.

The role of flavored electronic nicotine delivery systems in smoking cessation: A systematic review.

Background: Electronic nicotine delivery systems (ENDS) come in numerous flavors and may aid smoking cessation. This systematic review examines evidence on the role of ENDS flavors in smoking cessation. Methods: We searched EMBASE OVID, PsychInfo, and Medline databases for studies that: 1) examined cigarette cessation outcomes for persons using ENDS (intent, attempts, and success) and 2) reported results separated by respondent's ENDS flavor used. We extracted crude and adjusted odds ratios for associations between cessation outcomes and types of ENDS flavors used (nontobacco vs. tobacco/unflavored; nontobacco and nonmenthol vs. tobacco/unflavored and menthol). We did not consider cessation outcomes among people not using ENDS. We evaluated the evidence using the GRADE approach, focusing on consistency and reliability of findings across studies. Results: 29 studies met inclusion criteria, producing 36 odds ratios (ORs) comparing cessation outcomes across ENDS flavor groups. Three ORs examined quit intent, five examined quit attempts, and 28 examined quit success. Using GRADE, we reached Low levels of certainty that there was not an association between ENDS flavor use and intention to quit smoking or making a quit attempt. There were Very Low levels of certainty that nontobacco flavored versus tobacco/unflavored ENDS use was not associated with smoking cessation success, with similar findings for nonmenthol and nontobacco compared to tobacco and menthol flavored ENDS. Conclusion: The evidence about the role of different flavored ENDS use and smoking cessation outcomes is inconclusive, reflecting highly heterogeneous study definitions and methodological limitations. More high-quality evidence, ideally from randomized controlled trials, is required.

The EVALI outbreak and tobacco sales in the USA, 2014-2020.

BACKGROUND: The E-cigarette, or Vaping Product-Use Associated Lung Injury (EVALI) Outbreak of 2019 hospitalised thousands and killed dozens of people in the USA and raised perceptions of the dangers posed to health by electronic cigarettes (e-cigarettes). These illnesses along with continued increases in youth vaping rates lead to the passage of many state and federal laws intended to curtail the sale of flavoured e-cigarettes. Little is known about the impact of these events on US e-cigarette and cigarette retail sales. METHODS: Using Nielsen Scantrack sales data from January 2014 to January 2020 for 23 US states, we evaluate the effect of the EVALI outbreak. First-differenced state-panel regressions tracking unit sales of total-level and category-level e-cigarettes and cigarette sales controlling for price, Tobacco 21 policy coverage, product distribution, seasonality, EVALI-attributable deaths, and state-level e-cigarette policies affecting the availability of e-cigarettes (non-tobacco flavoured and total) were employed. RESULTS: Dollar sales of e-cigarettes declined 29% from their pre-EVALI peak by January 2020. Total sales of e-cigarettes declined in response to EVALI deaths and the total e-cigarette sales ban put in place in Massachusetts adopted in its wake. Cigarette sales were largely unchanged by either the direct or indirect policy effects of the EVALI outbreak, except for in Massachusetts, where cigarette sales-particularly those smoked by young people-rose temporarily after a total ban on e-cigarette sales. CONCLUSION: Sales of e-cigarettes declined in response to the EVALI outbreak and from the most restrictive regulatory policies that were adopted in response, while sales of cigarettes were affected less.

Public health impact of a US ban on menthol in cigarettes and cigars: a simulation study.

INTRODUCTION: The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs). METHODS: After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060. RESULTS: As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications. CONCLUSIONS AND RELEVANCE: Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.

Follow the money: a closer look at US tobacco industry marketing expenditures.

INTRODUCTION: While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases. METHODS: We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes. RESULTS: US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels. CONCLUSIONS: Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

The Australia Smoking and Vaping Model: The Potential Impact of Increasing Access to Nicotine Vaping Products.

BACKGROUND: We model the potential impact of relaxing current nicotine vaping product (NVP) restrictions on public health in Australia. AIMS AND METHODS: A Restricted NVP Scenario was first developed to project current smoking and vaping rates, where a U.S. smoking model was calibrated to recent Australian trends. To model less restrictive NVP policies, a Permissive NVP Scenario applied rates of switching from smoking to vaping, initiation into NVP and cigarette use, and cessation from smoking and vaping based on U.S. trends. The model measures vaping risk relative to the excess mortality rate of smoking. The public health impacts are measured as the difference between smoking- and vaping-attributable deaths (SVADs) and life years lost (LYLs) in the Restricted and Permissive NVP Scenarios. Sensitivity analysis is conducted regarding the NVP excess risk and other factors. RESULTS: Assuming an NVP excess risk of 5% that of smoking, 104.2 thousand SVADs (7.7% reduction) and 2.05 million LYLs (17.3% reduction) are averted during 2017-2080 in the Permissive NVP Scenario compared to the Restricted NVP Scenario. Assuming 40% NVP excess risk, 70 thousand SVADs and 1.2 million LYLs are averted. The impact is sensitive to the rate at which smokers switch to NVPs and quit smoking, and relatively insensitive to the smoking initiation and NVP initiation and cessation rates. CONCLUSIONS: The model suggests the potential for public health gains to be achieved by relaxing NVP access regulations. However, the model would benefit from better information regarding the impact of NVPs on smoking under a relaxation of current restrictions. IMPLICATIONS: Australia has implemented a strong array of cigarette-oriented policies, but has restricted access to NVPs. The Smoking and Vaping Model offers a framework for modeling hypothetical policy scenarios. The Australian model shows the potential for public health gains by maintaining cigarette-oriented policies while relaxing the current restrictive NVP policy. Modeling results under a permissive NVP policy are particularly sensitive to the estimated rates of smoking cessation and switching to vaping, which are not well established and will likely depend on past and future cigarette-oriented policies and the specific NVP policies implemented in Australia.

The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review.

OBJECTIVE: To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions. DATA SOURCES: PubMed, Scopus, Embase and Web of Science before May 3, 2022. STUDY SELECTION: Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions. DATA EXTRACTION: Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance. DATA SYNTHESIS: We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6-39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products. CONCLUSION: Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.