Local and State Policy Action Taken in the United States to Address the Emergence of E-Cigarettes and Vaping: A Scoping Review of Literature.

INTRODUCTION: In response to rising rates of youth vaping and e-cigarette use, states and localities in the United States have adopted various tobacco control policies and have extended their utility to these emerging products. However, the extent to which these policies have been evaluated for their impact on youth use is unknown. METHOD: Two databases (PubMed, Google Scholar) were searched for English language peer-reviewed articles pertaining to electronic cigarette policy evaluation between 2009 and 2020. Primary articles of interest were journal articles that evaluated an e-cigarette policy. Secondary articles of interest were journal articles that identified any e-cigarette policy action without a formal evaluation component, those that evaluated tobacco policy, or those that described e-cigarette behaviors and trends. Tertiary articles included gray literature that provided context for e-cigarette trends and additional policy identification. RESULTS: The final sample consisted of 12 relevant articles with an e-cigarette policy evaluation component and 62 relevant articles without such component, and 19 gray literature sources. Findings were synthesized based on policy type: product classification, age restrictions, smoke-free policies, flavor bans, sales restrictions, taxation, packaging, and advertising. CONCLUSION: Policies that address access and use of e-cigarettes are common on the federal, state, and local level, are mostly reactionary, and mimic tobacco control efforts. Few policies have been formally evaluated for their effectiveness in reducing or preventing youth vaping. Strengthening the evidence base should be a priority for researchers going forward, given the potential of these policies to intervene on social and environmental conditions that affect youth initiation and uptake.

Longer-Term Impact of the Flavored Tobacco Restriction in Two Massachusetts Communities: A Mixed-Methods Study.

INTRODUCTION: In response to high rates of youth tobacco use, many states and localities are considering regulations on flavored tobacco products. The purpose of this study was to assess whether flavored tobacco restrictions (FTRs) in Massachusetts curb youth tobacco use over time and whether a dose-response effect of length of policy implementation on tobacco-related outcomes exists. AIMS AND METHODS: Using a quasiexperimental design, two municipalities with a FTR (adopting municipalities) were matched to a comparison municipality without a FTR. Surveys were administered before (December 2015) and after (January and February 2018) policy implementation to high school students in these municipalities (more than 2000 surveys completed at both timepoints). At follow-up, adopting municipalities had a policy in place for 1 and 2 years, respectively. In 2019, focus groups were conducted with high school students in each municipality. RESULTS: Increases seen in current tobacco use from baseline to follow-up were significantly smaller in adopting municipalities compared to the comparison (-9.4% [-14.2%, -4.6%] and -6.3% [-10.8%, -1.8%], respectively). However, policy impact was greater in one adopting municipality despite shorter length of implementation. Focus groups indicated reasons for differential impact, including proximity to localities without FTRs. CONCLUSIONS: Restrictions implemented in adopting municipalities had positive impacts on youth tobacco awareness and use 1-2 years postimplementation. Policy impact varies depending on remaining points of access to flavored tobacco, as such policy effectiveness may increase as more localities restrict these products. IMPLICATIONS: In response to high rates of youth flavored tobacco use (including flavored vape products), federal, state, and localities have passed FTRs that reduce availability of flavored tobacco in youth-accessible stores. Previous research has found that FTRs may curb youth tobacco use in the short-term; however, the long-term effectiveness remains unknown.This is the first study to show FTRs can curb youth tobacco use and reduce youth awareness of tobacco prices and brands even 2 years after policy passage. Municipality-specific factors, including proximity to localities without FTRs, may attenuate policy impact, highlighting the importance of widespread policy adoption.

Evaluating tobacco retailer experience and compliance with a flavoured tobacco product restriction in Boston, Massachusetts: impact on product availability, advertisement and consumer demand.

BACKGROUND: Flavoured tobacco products are widely available in youth-accessible retailers and are associated with increased youth initiation and use. The city of Boston, Massachusetts restricted the sale of flavoured tobacco products, including cigars, smokeless tobacco and e-cigarettes, to adult-only retailers. This paper describes the impact of the restriction on product availability, advertisement and consumer demand. METHODS: Between January and December 2016, data were collected in 488 retailers in Boston at baseline and 469 retailers at 8-month follow-up, measuring the type, brand and flavour of tobacco products being sold. Process measures detailing the educational enforcement process, and retailer experience were also captured. McNemar tests and t-tests were used to assess the impact of the restriction on product availability. RESULTS: After policy implementation, only 14.4% of youth-accessible retailers sold flavoured products compared with 100% of retailers at baseline (p<0.001). Flavoured tobacco product advertisements decreased from being present at 58.9% of retailers to 28.0% at follow-up (p<0.001). Postimplementation, retailers sold fewer total flavoured products, with remaining products often considered as concept flavours (eg, jazz, blue). At follow-up, 64.0% of retailers reported that customers only asked for flavoured products a few times a week or did not ask at all. Retailers reported that educational visits and the flavoured product guidance list aided with compliance. CONCLUSION: Tobacco retailers across Boston were largely in compliance with the regulation. Availability of flavoured tobacco products in youth-accessible retailers declined city-wide after policy implementation. Strong educational and enforcement infrastructure may greatly enhance retailer compliance.

Single Cigar Price and Availability in Communities With and Without a Cigar Packaging and Pricing Regulation.

Single cigars are available for sale throughout the tobacco retail environment, are often sold for prices as low as 49 cents, and are available in flavors that appeal to youth. Since 2012, 151 municipalities in Massachusetts have enacted a minimum cigar packaging and pricing regulation that increases the price of a single cigar to a minimum of $2.50 and the price of multi-packs of 2 cigars to a minimum of $5.00. We used pricing data collected from retailers across the state to measure the effect of the regulation on price and availability of single cigars over the long term. From 2014 through 2018, the statewide average price of single cigars increased from $1.35 to $1.64, concurrent with a decrease in statewide availability. Prices of single cigars were higher in communities with the regulation but also rose over time in communities without the regulation. The increased price and decreased availability of single cigars may reduce youth exposure and access to these products.

Additive impact of multiple point-of-sale tobacco control policies on youth tobacco-related outcomes.

Objectives: The tobacco industry utilizes tactics to increase youth awareness, exposure, access and use of tobacco. To address these tactics, municipalities in Massachusetts have passed point-of-sale policies including: 1) restricting flavored tobacco (FTR), 2) restricting cigar package sizes and prices (CPPR), 3) banning tobacco in pharmacies (PB), and 4) raising the minimum legal sales age of tobacco to 21 (MLSA 21). This study evaluated whether more policies, and a combination of policies addressing all three industry tactics, are associated with more favorable youth tobacco-related outcomes. Study design: This study was a cross-sectional survey. Methods: Municipalities were selected based on number of policies and similarity of municipality and tobacco retailer characteristics. The final sample included: Somerville with all four policies, Worcester with two policies (MLSA 21 and PB), and New Bedford with one policy (PB). Surveys were administered to youth in a public high school in each municipality. Multivariable models were used to compare tobacco-related outcomes between municipalities with varying numbers of policies. Results: After adjusting for individual-level demographics, we observed a protective effect of having more policies on flavored tobacco initiation and tobacco exposure and awareness. A protective effect of number of policies on tobacco use was not found, but associations were primarily in the expected direction. Current tobacco users in Somerville had higher odds of menthol use compared to New Bedford. Conclusions: Implementing multiple policies addressing varied industry tactics may be effective for youth tobacco prevention. Including menthol in FTRs may help improve youth tobacco-related outcomes.

Examining the external validity of the CRUZA study, a randomized trial to promote implementation of evidence-based cancer control programs by faith-based organizations.

The CRUZA trial tested the efficacy of an organizational-level intervention to increase capacity among Catholic parishes to implement evidence-based interventions (EBIs) for cancer control. This paper examines the external generalizability of the CRUZA study findings by comparing characteristics of parishes that agreed to participate in the intervention trial versus those that declined participation. Sixty-five Roman Catholic parishes that offered Spanish-language mass in Massachusetts were invited to complete a four-part survey assessing organization-level characteristics that, based on the Consolidated Framework for Implementation Research (CFIR), may be associated with EBI implementation. Forty-nine parishes (75%) completed the survey and were invited to participate in the CRUZA trial, which randomized parishes to either a "capacity enhancement intervention" or a "standard dissemination" group. Of these 49 parishes, 31 (63%) agreed to participate in the trial, whereas 18 parishes (37%) declined participation. Parishes that participated in the CRUZA intervention trial were similar to those that did not participate with respect to "inner organizational setting" characteristics of the CFIR, including innovation and values fit, implementation climate, and organizational culture. Change commitment, a submeasure of organizational readiness that reflects the shared resolve of organizational members to implement an innovation, was significantly higher among the participating parishes (mean = 3.93, SD = 1.08) as compared to nonparticipating parishes (mean = 3.27, SD = 1.08) (Z = -2.16, p = .03). Parishes that agreed to participate in the CRUZA intervention trial were similar to those that declined participation with regard to organizational characteristics that may predict implementation of EBIs. Pragmatic tools to assess external generalizability in community-based implementation trials and to promote readiness among faith-based organizations to implement EBIs are needed to enhance the reach and impact of public health research. Clinical Trial information: The CRUZA trial identifier number with clinicaltrials.gov is NCT01740219.

Organizational characteristics conducive to the implementation of health programs among Latino churches.

BACKGROUND: Faith-based organizations (FBOs) can be effective partners in the implementation of health interventions to reach underserved audiences. However, little is known about the capacity they have or need to engage in these efforts. We examined inner-setting organizational characteristics hypothesized to be important for program implementation by the Consolidated Framework for Implementation Research (CFIR). METHODS: This cross-sectional study involved 34 churches with predominantly Latino congregations in Massachusetts. FBO leaders completed a survey assessing inner-setting CFIR organizational characteristics, including organizational readiness, implementation climate, organizational culture, and innovation "fit" with organizational mission. RESULTS: There was limited variability in CFIR organizational characteristics, with scores on a scale from 1 to 5 skewed toward higher values, ranging from 3.27 (SD 0.94) for implementation climate to 4.58 (SD 0.54). Twenty-one percent of the FBOs had offered health programs in the prior year. CONCLUSIONS: FBOs had high scores on most of the organizational factors hypothesized to be important for the implementation of health programs, although relatively few FBOs offered them. While this suggests that FBOs have favorable characteristics for health programming, prospective studies are needed to understand relative salience of inner-setting organizational characteristics versus factors external to the organization (e.g., policies, incentives), as well as the potential direction of relationships between internal organizational characteristics and health program offerings. TRIAL REGISTRATION: Clinical trials identifier number NCT01740219 (clinicaltrials.gov).

The association between neighborhood racial composition and menthol cigarette pricing in Boston, MA.

OBJECTIVES: To examine the relationship between neighborhood demographics and pack prices of four brands of mentholated and non-mentholated cigarettes in Boston, Massachusetts. METHODS: Using tobacco pricing survey data collected July 2015 to June 2016, we examined cigarette prices in tobacco retailers (n = 689) located in block groups (n = 325) of Boston. Multilevel models examined both the association of menthol and non-menthol cigarette prices, and the percentage of retailers selling cigarettes below established minimum price in relation to neighborhood demographics. RESULTS: Each 10 percentage point increase in the proportion of black residents per block group was associated with a price decrease of 3 cents for menthol cigarettes (p < 0.01). Each 10 percentage point increase in the proportion of black residents per block group was associated with a 19 percentage point increase in proportion of retailers selling menthol cigarettes ≥25 cents below minimum price (p < 0.01). CONCLUSION: Mentholated cigarettes were priced significantly lower in neighborhoods of color in Boston. Strengthened pricing laws, with consideration given to menthol products in the retail environment, may be needed to address environmental contributors to smoking disparities.

Short-Term Impact of a Flavored Tobacco Restriction: Changes in Youth Tobacco Use in a Massachusetts Community.

INTRODUCTION: To counter the high prevalence of flavored tobacco use among youth, many U.S. localities have passed policies that restrict youth access to these products. This study aims to evaluate the short-term impact of a flavored tobacco restriction policy on youth access to, and use of, flavored tobacco products in a Massachusetts community. METHODS: A community with the policy (Lowell) was matched to a community without the policy (Malden) with similar demographics, retailer characteristics, and point-of-sale tobacco policies. Product inventories were assessed in tobacco retailers in the 2 communities, and surveys were administered to high school-aged youth in those communities. Inventories and surveys were conducted around the time the policy took effect in October 2016 (baseline) and approximately 6 months later (follow-up); all data were analyzed in 2017. Chi-squared tests and difference-in-difference models were used to estimate the impact of the policy on flavored tobacco availability and youth perceptions and behaviors related to flavored tobacco use. RESULTS: Flavored tobacco availability decreased significantly in Lowell from baseline to follow-up periods by 70 percentage points (p<0.001), whereas no significant changes in flavored tobacco availability were seen in Malden. In addition, current use of both flavored and non-flavored tobacco decreased in Lowell, but increased in Malden from baseline to follow-up; these changes were significantly different between communities (flavored tobacco: -5.7%, p=0.03; non-flavored tobacco: -6.2%, p=0.01). CONCLUSIONS: Policies that restrict the sale of flavored tobacco have the potential to curb youth tobacco use in as few as 6 months.