Flavored Tobacco Product Use Among California Adolescents Before and Immediately After a Statewide Flavor Ban

Abstract

Introduction

In December 2022, a California law banned the retail sale of most flavored tobacco products (including e-cigarettes). This investigation evaluates adolescents’ use of flavored tobacco before and after enactment.

Aims and Methods

The Teens Nicotine and Tobacco Project included online surveys of California adolescents (age 12–17) in 2022 (N = 5127) and 2023 (N = 5015) that assessed past 30-day use of various tobacco products, flavored product use, and perceived access to flavored e-cigarettes. Eight focus groups conducted in 2023 and 2024 (total N = 35) queried flavored tobacco experiences and perceptions.

Results

Among participants who used specific products, the prevalence of flavored product use declined for cigarettes (2022: 72.0%; 2023: 57.2%), cigars (2022: 87.2%; 2023: 67.4%), and smokeless tobacco (2022: 93.1%; 2023: 83.1%) but not for e-cigarettes (2022: 91.0%; 2023: 90.7%) or hookah (2022: 88.1%; 2023: 85.6%; the flavor law exempted some hookah sales). In 2023, 10.2% of all participants used any flavored tobacco product (2022: 10.0%), primarily flavored e-cigarettes (2022: 8.6%; 2023: 8.8%). In 2023, 22.0% of all participants were aware of the statewide flavor ban, including 44.1% of participants who reported tobacco use. Few focus group participants were aware of the statewide law or perceived difficulties accessing flavored e-cigarettes.

Conclusions

Shortly following a statewide flavor ban, adolescent use of flavored cigarettes, cigars, and smokeless tobacco declined, but flavored e-cigarette use was unchanged. More time for implementation and enforcement may be needed to see full policy impact.

Implications

These findings suggest that a statewide flavored tobacco policy in California was followed shortly by declines in adolescent use of some flavored tobacco products. Additional time for implementation and enforcement, along with potential further actions, such as greater restrictions on online sales, could be necessary to curb youth access to flavored e-cigarettes.

Introduction

Menthol in cigarettes and other sweet, fruit, mint, or cooling flavors in electronic cigarettes (known as e-cigarettes or vapes) and other tobacco products contribute to the interest and use of these products among adolescents and young adults.^1,2 Menthol and other tobacco flavors can reduce harshness and improve taste,³ and flavored tobacco products are perceived as less harmful and with increased curiosity.^4,5 Among US middle and high school students who use any form of tobacco, 87% report using a flavored product.⁶

Aiming to reduce youth tobacco use, numerous cities, states, and other jurisdictions have enacted various policies to restrict sales of flavored tobacco, reaching nearly 400 US jurisdictions by mid-2023.⁷ Evaluations of these policies largely suggest that flavored tobacco bans reduce access to and use of flavored tobacco products among youth and young adults.^8–11 However, effectiveness differs according to policy strength,¹² and has sometimes been limited by cross-border and illicit commerce,¹³ consumers substituting other tobacco products for flavored ones,^10,14 and tobacco industry efforts to evade restrictions or exploit policy loopholes.^15,16 While pending federal regulations would prohibit menthol in cigarettes and flavors in cigars (if enacted and enforced),¹⁶ further evaluation of state and local flavor restrictions would inform future policy decisions to regulate flavored tobacco.

In California, Senate Bill (SB)-793 was signed into law in August 2020. The law prohibited sales of flavored tobacco products throughout the state, including flavored e-cigarettes and menthol cigarettes, but exempted premium cigars (wholesale price ≥$12), loose-leaf tobacco, and hookah (in licensed stores that prohibit access to those under age 21).¹⁷ The law did not immediately take effect because tobacco companies initiated a referendum to overturn it. This action led to Proposition 31, which asked California voters to decide to uphold or overturn SB-793 during the November 2022 statewide election. Voters approved Proposition 31, upholding SB-793.¹⁸ The law became effective on December 21, 2022, making California the second US state to prohibit sales of most flavored tobacco products.

The primary goal of this investigation is to compare the prevalence of flavored tobacco use among California adolescents before and after the enactment of SB-793. Also, this study examines perceived access to flavored e-cigarettes and awareness of the California flavored tobacco law. The study relies on online survey data and focus group findings from the Teens, Nicotine, and Tobacco (TNT) Project, an ongoing statewide youth tobacco surveillance project.

Methods

The TNT Project launched in 2021 to provide the California Tobacco Prevention Program with rapid tobacco use surveillance data, as described elsewhere.^19,20 The TNT Project has two components: an annual online survey and qualitative focus groups, both featuring California adolescents aged 12–17. This analysis includes data from the 2022 and 2023 TNT Online Surveys and from three sets of focus groups completed in 2023 and early 2024. The University of California San Francisco Institutional Review Board approved all study procedures.

Survey Design

The TNT Online Survey is a non-probability sample drawn from multiple commercial market research panels. Respondents are panel members (or the children of panelists) who have agreed to complete surveys online for incentives, such as redeemable reward points. Eligible were California residents aged 12–17. Signed informed consent was not collected to maintain anonymity, but potential participants viewed study information before affirming their comprehension and willingness to continue. Surveys were completed in English or Spanish. The 2022 TNT Online Survey (N = 5127) included two cycles completed in June–July 2022 and November–December 2022. The two cycles of the 2023 TNT Online Survey (N = 5015) were completed in May–June 2023 and November–December 2023. Cycles were independent (participants were not followed between them) and pooled into annual survey datasets.

Measures

Closed-ended survey instruments were used to record age, gender identity, and race/ethnicity. Tobacco use, including e-cigarette use, was assessed separately for each type of product using items that included visual examples and brief descriptions. Past 30-day use was defined as using a product ≥ 1 day in the past 30 days. Participants who reported past 30-day use were asked whether the product(s) they used in the past 30 days were flavored.²⁰ For cigarettes, participants were asked: “In the past 30 days, were any of the cigarettes you smoked flavored to taste like menthol or mint? Common mint/menthol brands include Newport, Salem, and Kool” (options: yes, no, I don’t know). “Yes” responses were coded as flavored use. For e-cigarettes, cigars, hookah, and smokeless tobacco, participants who reported past 30-day use were asked to select all that apply from a list, “In the past 30 days: What flavor(s), if any, were the [name of tobacco product] you used?” Selecting any response other than “unflavored,” “tobacco flavored,” or “I don’t know” was coded as flavored use. Items were identical in 2022 and 2023 (Table S1).

In both years, participants who used e-cigarettes were asked, “Right now, how easy or difficult is it to get vapes in flavors that you like?” (4 response options from “very difficult” to “very easy”). Participants who did not use e-cigarettes were asked, “If you had access to vapes and wanted to get one now, how easy or difficult would it be to get vapes in flavors that you like?” (same response option as above, plus “I don’t know”).²¹ Two new items added to the 2023 survey asked participants whether it was legal in California to buy “flavored nicotine vapes” and “flavored cigarettes, little cigars and cigarillos, dip, and other tobacco.” The next item revealed that, as of 2023, flavored tobacco sold in California is not allowed to be flavored and asked, “Before this survey, were you aware of this law?” To affirm appropriate wording and comprehension, items underwent cognitive interview testing with a sample of California adolescents (English: n = 9; Spanish: n = 4) prior to survey implementation. Notably, cognitive interview testing suggested better comprehension when items referred to buying flavored tobacco; however, SB-793 specifically prohibits selling flavored tobacco.

Quantitative Analysis

To enhance generalizability to the geographic, gender, and race/ethnicity distribution of California adolescents aged 12–17, all survey estimates were weighted using weights developed from American Community Survey Public Use Microdata Sample files. Raking with trimming was used to adjust the initial weights to the full cross-classification of all geodemographic factors. To improve data quality, excluded were responses that failed a ReCAPTCHA challenge, responded to a “hidden” item (not visible to people but potentially visible to computer bots), recorded from an Internet Protocol (IP) address outside the United States, exhibited suspicious scaling patterns (eg, reporting the maximum use frequency for all tobacco products), or had inappropriate responses in open-text fields. Additional weights were developed that accounted for factors that were not disqualifying but potentially indicative of lower quality, such as completion from midnight to 4:00 am, imperfect ReCAPTCHA scores, or failed attention checks. Among all recorded responses (excluded and retained), we fitted a logistic regression model to estimate the predicted probability of being excluded, based on response attributes. Retained responses were weighted by the inverse of that probability.²⁰ Weighted proportions and 95% CIs were produced using the svy: command suite in Stata 16. Weighted chi-square tests were performed to compare the 2022 and 2023 survey estimates. Several sensitivity and exploratory analyses are included in Supplementary Tables. Also, calculations are added that exclude hookah and premium cigars (“big” cigars in surveys), two products exempted from the statewide law.

Focus Group Design

Two experienced moderators led 90-minute videoconference focus groups with California residents aged 12–17 in May–June 2023 (two groups; nine total participants; one group in Spanish), November–December 2023 (three groups; 15 participants), and January–February 2024 (three groups; 11 participants). Participants were recruited via invitations to adolescents in existing studies led by the authors, partnership with a community-based nonprofit organization, in-person flyer distribution, and the ResearchMatch participant registry.²² Purposeful recruitment was implemented to balance geography, economic background, gender, and tobacco use experience. Overall, focus group participants were 40% female; 37% White, 34% Hispanic/Latinx, 17% American Indian/Alaska Native; 26% had ever used e-cigarettes; and the mean age was 14.8 years. Parents provided signed informed consent. Participants provided signed assent and received a $50 electronic gift code.

Qualitative Analysis

Focus groups covered various topics, including flavored tobacco products and awareness of flavored tobacco policies in California. Discussions followed structured guides with prompts. Audio recordings were transcribed verbatim. Two researchers analyzed de-identified focus group transcripts using Dedoose software. Relevant excerpts were thematically analyzed, summarized, and discussed among study investigators, to allow for iterative feedback and interpretation. Unifying themes were identified and sample supporting quotes were selected for presentation in the manuscript.

Results

Overall, the distribution of participant characteristics was similar in the 2022 and 2023 TNT Online Surveys (Table 1). In one notable difference, there was a higher percentage of female participants in 2022. The prevalence of past 30-day tobacco use (any product) was slightly higher in the 2023 survey (2022: 11.4%; 2023: 12.2%), although cigarette use and smokeless tobacco use were lower (Table 1).

Table 1.

Participant characteristics, Teens Nicotine and Tobacco Project online surveys 2022–2023

	2022 N = 5127 Percent1	2023 N = 5015 Percent1	p-value
Age, years
12–13	34.7	35.0	<.001
14–15	26.9	31.8
16–17	38.4	33.1
Gender
Male	38.0	49.4	<.001
Female	58.2	48.6
Other	3.9	2.0
Race/ethnicity
Hispanic/Latino	51.8	53.7	.73
Non-Hispanic Asian	14.2	14.0
Non-Hispanic Black	4.2	4.1
Non-Hispanic White	22.2	20.7
Non-Hispanic Other2	7.5	7.5
California Region3
Central Coast	6.4	6.7	.20
Los Angeles	21.2	19.6
Northern and Sierra	3.0	2.5
Other Southern	32.3	31.7
Sacramento Area	6.8	5.7
San Francisco Bay Area	17.1	19.1
San Joaquin Valley	13.2	14.8
Past 30-day use4 of
Any tobacco5	11.4	12.2	.34
E-cigarettes	9.5	9.7	.78
Cigarettes	3.7	2.8	.01
Cigars6	2.9	3.4	.31
Hookah	1.8	1.6	.44
Smokeless tobacco7	2.4	1.2	<.001

¹Percentages weighted for statewide representation and data quality. Percentages may not add to 100% due to rounding.

²Includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, More than one selected race, and “other”.

³Calculated from county of residence; follows categories used in the California Health Interview Survey.

⁴Past 30-day use percentages not mutually exclusive; indicates use of the product ≥1 day in the past 30 days.

⁵Includes e-cigarettes, cigarettes, cigars, hookah, smokeless tobacco, heated tobacco, nicotine pouches, and/or nicotine tablets, lozenges, or gummies.

⁶Includes big cigars and/or little cigars or cigarillos.

⁷Includes moist snuff, chewing tobacco, and/or snus.

Among all participants, the prevalence of using any flavored tobacco product was similar in the 2022 and 2023 surveys (Table 2). In 2022, 10.0% of participants used a flavored tobacco product in the past 30 days, compared to 10.2% in 2023. Most flavored tobacco use was in the form of e-cigarettes: 8.6% of all participants reported using a flavored e-cigarette in 2022, as did 8.8% of participants in 2023 (Table 2).

Table 2.

Prevalence of flavored product use in 2022 and 2023

	2022		2023		p-value
	N 1	Flavored use Percent (95% CI)	N 1	Flavored use Percent (95% CI)
Among all participants
Any tobacco2	5067	10.0 (9.0, 11.0)	4986	10.2 (9.0, 11.5)	.80
E-cigarettes	5115	8.6 (7.7, 9.6)	5013	8.8 (7.7, 10.0)	.82
Cigarettes	5120	2.7 (2.3, 3.1)	5014	1.6 (1.3, 2.0)	<.001
Cigars3	5084	2.5 (2.1, 3.1)	4992	2.3 (1.8, 2.9)	.47
Hookah	5094	1.6 (1.3, 2.0)	4999	1.4 (1.0, 1.8)	.39
Smokeless tobacco4	5120	2.3 (1.9, 2.7)	5014	1.0 (0.8, 1.3)	<.001
Among participants who used the following products in the past 30 days
Any tobacco2	1370	90.2 (87.3, 92.4)	1328	86.4 (80.5, 90.7)	.17
E-cigarettes	1206	91.0 (87.5, 93.6)	1083	90.7 (86.0, 93.9)	.90
Cigarettes	767	72.0 (66.1, 77.2)	722	57.2 (48.3, 65.6)	.004
Cigars3	477	87.2 (81.3, 91.5)	451	67.4 (53.6, 78.7)	.001
Hookah	436	88.1 (81.2, 92.7)	367	85.6 (73.9, 92.6)	.64
Smokeless tobacco4	617	93.1 (89.0, 95.8)	427	83.1 (71.4, 90.6)	.02

¹Sample size (N) is unweighted; percentages weighted for statewide representation and data quality.

²Includes e-cigarettes, cigarettes, cigars, hookah, and/or smokeless tobacco.

³Includes big cigars and/or little cigars or cigarillos.

⁴Includes moist snuff, chewing tobacco, and/or snus.

Among participants who smoked cigarettes, menthol cigarette use was substantially lower in 2023 (2022: 72.0%; 2023: 57.2%, Table 2). Likewise, among participants who smoked cigars, flavored cigar use was lower (2022: 87.2%; 2023: 67.4%), and among participants who use smokeless tobacco, flavored smokeless tobacco use declined (2022: 93.1%; 2023: 83.1%). When participants who used only big cigars were excluded from calculations, flavored cigar use prevalence was higher than when big cigars were included but remained lower in 2023 than the year before (2022: 88.3%; 2023: 70.4%; p = .005, not shown in tables). Despite the lower levels of flavored cigarette, cigar, and smokeless tobacco use, when combined with the persistently high levels of flavored e-cigarette use, there was only a small difference in flavored tobacco use among all participants who used tobacco in any form (2022: 90.2%; 2023: 86.4%; Table 2). Excluding hookah and exclusive use of big cigars had little impact on this calculation (2022: 89.9%; 2023: 86.2%; p = .19, not shown in tables).

In both 2022 and 2023, most participants did not perceive that it would be difficult to acquire e-cigarettes in flavors that they liked (Table 3). In 2023, 69.2% of participants who reported past 30-day e-cigarette use responded that it would be either somewhat or very easy to acquire flavored vapes, nearly exactly matching this estimate from 2022 (69.3%). Although “I don’t know” was the most common response among participants who did not use e-cigarettes, in both years, combined responses of “somewhat easy” or “very easy” were approximately three to four times as common as combined responses of “somewhat difficult” or “very difficult” (Table 3).

Table 3.

Perceived ease or difficulty of finding e-cigarettes in appealing flavors in 2022 and 2023

	2022 Percent1 (95% CI)	2023 Percent1 (95% CI)	p-value
Participants with past 30-day e-cigarette use: “…how easy or difficult is it to get vapes in flavors that you like?”
Very difficult	10.0 (7.2, 13.9)	11.5 (8.3, 15.8)	.91
Somewhat difficult	20.7 (17.0, 25.0)	19.3 (15.0, 24.4)
Somewhat easy	34.2 (29.5, 39.3)	35.1 (29.2, 41.5)
Very easy	35.0 (30.3, 40.1)	34.1 (28.4, 40.3)
Participants without past 30-day e-cigarette use: “If you had access… and wanted… how easy or difficult would it be to get vapes in flavors that you like?”
Very difficult	4.6 (3.8, 5.6)	6.0 (4.9, 7.3)	.25
Somewhat difficult	5.2 (4.3, 6.3)	5.4 (4.3, 6.7)
Somewhat easy	19.1 (17.5, 20.8)	17.1 (15.2, 19.2)
Very easy	19.8 (18.2, 21.6)	18.9 (16.8, 21.3)
I don’t know2	51.2 (49.1, 53.3)	52.6 (49.9, 55.3)

¹Percentages weighted for statewide representation and data quality. Percentages may not add to 100% due to rounding.

²This response option presented only to participants who reported no past 30-day e-cigarette use.

There was limited awareness of statewide flavor policies among 2023 survey participants (Table 4). Among the total sample, slightly more than half reported that they did not know whether it was legal to sell flavored vapes (53.5%) or other flavored tobacco (51.5%) in California (Table 4). Participants who used tobacco in the past 30 days were more likely to respond that it was not legal to sell flavored tobacco products than participants who did not use tobacco. However, many participants incorrectly indicated that such products were legal (Table 4). Only about one-fifth of the total sample indicated that they were aware that flavored tobacco could not be sold statewide, including 44.1% of participants who used tobacco and 18.9% of participants who did not (Table 4).

Table 4.

Awareness of California flavored tobacco policy in 2023

Question2	Response selected Percent1 (95% CI)
	Total sample N = 4883	Participants with past 30-day tobacco use3 N = 1341	Participants without past 30-day tobacco use3 N = 3542
Is it legal to buy flavored nicotine vapes in California?4,5
Yes	27.0 (24.7, 29.4)	35.3 (29.7, 41.4)	25.8 (23.4, 28.4)
No	19.5 (17.7, 21.5)	33.1 (28.0, 38.7)	17.6 (15.7, 19.7)
I don’t know	53.5 (51.0, 56.0)	31.5 (26.4, 37.1)	56.5 (53.8, 59.3)
Is it legal to buy flavored cigarettes, little cigars and cigarillos, dip, and other tobacco in California?4,5
Yes	30.8 (28.4, 33.3)	38.3 (32.5, 44.5)	29.8 (27.2, 32.5)
No	17.7 (15.9, 19.6)	28.6 (23.8, 33.9)	16.2 (14.3, 18.2)
I don’t know	51.5 (49.0, 54.0)	33.1 (27.9, 38.7)	54.1 (51.3, 56.8)
As of 2023, all cigarettes, cigars, dip, and nicotine vapes sold in California are not allowed to have any added flavors, like fruit, candy, mint, or menthol. Before this survey, were you aware of this law?
Yes	22.0 (20.0, 23.9)	44.1 (38.2, 50.1)	18.9 (17.0, 20.9)
No	78.0 (76.1, 79.9)	55.9 (49.9, 61.8)	81.1 (79.1, 83.0)

¹Percentages weighted for statewide representation and data quality. Percentages may not add to 100% due to rounding.

²These questions were only included in the 2023 survey.

³Use defined as using e-cigarettes, cigarettes, cigars, hookah, smokeless tobacco, heated tobacco, nicotine pouches, and/or nicotine tablets, lozenges, or gummies ≥ 1 day in the past 30 days.

⁴These questions were presented prior to revealing (in the subsequent question) that selling flavored tobacco is not allowed in California.

⁵Although SB-793 prohibits selling flavored tobacco (retailer liability), items referred to buying flavored products for better comprehension among participants.

Supplementary analyses produced findings consistent with the main results when analysis was separated by seasonal survey cycle (Table S2), stratified by age (Table S3), stratified by geographic region (Table S4), or excluded responses from non-California IP addresses (Table S5). Among all participants who used e-cigarettes, the specific flavors used were similarly distributed in 2022 and 2023: fruit was the most commonly used flavor each year, by far (Table S6).

In focus group conversations, a few participants were aware that a statewide law disallowed flavored tobacco sales (Table S7). One participant expressed an uncertain recollection of a flavor ban that “didn’t do nothing ‘cause you can still get things [favored vapes].” Indeed, participants often doubted that a flavor law was in place based on how frequently they observed their peers using flavored e-cigarettes. One adolescent summarized that “Everything’s still kinda the same.” Additional participants unfamiliar with the statewide law were skeptical that such a measure could deter teenagers from accessing flavored e-cigarettes, noting that adolescents can obtain flavored e-cigarettes via online sources or through social connections able to go out of state (Table S7). One focus group did mention hearing complaints about difficulty accessing flavored e-cigarettes but surmised that peers were still able to get them with effort (Table S7). Reflecting on flavored tobacco, generally, focus group participants consistently relayed that flavored e-cigarettes are well-liked and widely used among their peers, in contrast to “plain” or “gross” unflavored vapes or “nasty” cigarettes (Table S7).

Discussion

Following the enactment of a statewide ban on flavored tobacco sales in California, this investigation found evidence that the use of menthol cigarettes, flavored cigars, and flavored smokeless tobacco declined among adolescents in the first year of the law. However, the majority of participants who used these products still used flavored varieties. This study also found that the overall use of flavored tobacco products among California adolescents did not change dramatically. E-cigarettes account for most tobacco product use in this age group: the overall prevalence of e-cigarette use was approximately the same in 2023 as in 2022, and among participants who reported e-cigarette use, about 90% used flavored e-cigarettes each year. Most participants did not perceive that it would be difficult for them to acquire flavored e-cigarettes, and most were unaware that the sale of most flavored tobacco was not allowed in the state. Similarly, the California Youth Tobacco Survey reported no statistically significant decline in flavored product use among past 30-day e-cigarette users between 2022 (92%) and 2023 (89%),²³ at levels that aligned with 2023 national estimates for middle and high school students (89% flavored use).⁶ The present findings suggest that the California flavored tobacco ban has decreased the use of some forms of flavored tobacco among adolescents, such as cigarettes and cigars, but that potential challenges exist related to implementation, enforcement, and/or evasion of the law, particularly for e-cigarettes.

The relatively modest impacts observed in this study may indicate that more time is required for policy effects to be fully realized. Previous analysis of smoke-free bar and workplace laws suggests it may take several years to observe the total policy impact.²⁴ Indeed, short-term policy impacts may differ from those observed over time. Following action by the Food and Drug Administration to prohibit all non-menthol cigarette flavors in 2009, there was evidence of an immediate increase in youth and young adult cigarette smoking prior to a sustained decline.¹⁴ Speculatively, tobacco retailers may have a short-term excess inventory of flavored products, consumers may stock up on preferred products, or tobacco companies may increase marketing in advance of a flavor ban. Individuals may need time to quit using tobacco successfully. Implementation of SB-793 in California requires educating stakeholders (including tobacco retailers), raising public awareness (which could be limited among youth too young to vote), and dedicating enforcement resources (which the bill itself did not provide). There was no official state-level enforcement agency for California’s flavored tobacco sales law until January 2024. Lags in implementation, potentially variable by local jurisdiction, may extend the time needed to evaluate SB-793 fully.

Prior to SB-793, multiple California municipalities had enacted their own local restrictions on flavored tobacco sales. These local policies might have already reduced youth tobacco use and might partly explain a more muted effect of the statewide measure. Alternatively, experience and resources already in place to enforce existing local measures might have helped SB-793 implementation. Evaluations of local flavor restrictions associate them with reduced availability of flavored tobacco in retail locations¹¹ and less perceived access to flavored e-cigarettes,²⁵ with more comprehensive restrictions associated with greater reductions in retail availability¹² and adult use²⁶ of flavored tobacco. One study found that local flavored tobacco policies in the San Francisco Bay Area were not associated with less self-reported e-cigarette use among youth.²⁷ Another online survey of young adults in San Francisco found modest reductions in the use of flavored tobacco and a common perception that flavored products were still widely available.²⁸ In contrast, a study of retail sales data, which excluded vape shops, found a sharp reduction in flavored tobacco sales in San Francisco.²⁹

The focus of SB-793 implementation on California brick-and-mortar retail locations leaves open the possibility of evading flavored tobacco restrictions via online sales, as was discussed in focus groups in this study. In the weeks immediately following SB-793 enactment, online searches surged for cigarettes and vaping products,³⁰ and researchers posing as youth in California were able to purchase flavored e-cigarettes online.³¹ The potential for online sales to undermine state and local tobacco control measures underscores the need for policies to end internet sales of tobacco products.¹⁶ While focus group conversations suggested that sales across state lines could increase, this is unlikely a major concern in California, where most population centers are distant from state boundaries.

Eliminating menthol in cigarettes is a potentially powerful public health instrument. Data suggest about one-fourth of menthol cigarette smokers quit smoking entirely within 2 years of a menthol ban.³² This investigation observed a decline in menthol cigarette use among adolescents who smoked, but menthol use remained above 50%. Following statewide bans on menthol cigarette sales in California and Massachusetts, several cigarette manufacturers began marketing their cigarette brands as “non-menthol” cigarettes. These cigarettes included descriptors like “crisp” and “refreshing” on their packaging, implying a cooling effect, while some contained synthetic cooling agents that produce a menthol-like sensation.^15,33,34 Likewise, e-cigarette, cigar, and other tobacco product manufacturers use names, like “Blue Breeze,” to evoke sensations without naming a specific taste.^35,36 In fact, new “concept flavor” cigars appeared shortly after local flavor restrictions in Rhode Island³⁷ and following SB-793 enactment in California,³⁸ reflecting a wider increasing trend in concept flavor products.³⁹ These products likely engender confusion among retailers, law enforcement, and consumers about what constitutes a flavored tobacco product and plausibly represent a tobacco industry tactic to evade flavor restrictions.

There could be impacts of the statewide flavored tobacco law on adolescent tobacco use that the present analysis did not fully capture. This study examined the prevalence of using any flavored tobacco within the past 30 days. For example, in this analysis, participants were considered to have used flavored tobacco if they reported that any of the tobacco that they used in the past 30 days was flavored. It is conceivable that under a flavor ban, adolescents might have used flavored tobacco on fewer occasions within a 30-day period, which this survey would not detect. Likewise, the survey did not measure “ever” use of flavored tobacco, which might differ from patterns for the past 30-day use. Also, to allow direct comparisons, survey item wording was not changed from 2022 to 2023. However, the existing items did not map perfectly to the SB-793 exemption for premium cigars and did not contain response options specific to newly introduced “non-menthol” cigarette brands that appeared in California following the SB-793 enactment.

Additionally, adolescents might respond to a flavored tobacco ban by using unflavored varieties, switching tobacco products, or stopping use entirely. A concern has been raised that bans on flavored e-cigarettes could lead some young people to smoke cigarettes in their place.⁴⁰ This study did not follow individuals over time and thus, could not directly assess within-person changes in behavior, such as product switching. However, it was notable that the overall prevalence of cigarette and smokeless tobacco use declined from the year before. The use of cigars and hookah, a product exempted under SB-793 in age-restricted establishments, did not increase statistically significantly.

Study limitations must be considered. Results should be interpreted cautiously. Supplementary analyses that considered potential differences by season, age, and geographic region were based on relatively small samples and may lack precision. Online survey and focus group data may not be representative statewide. Respondents who choose to engage in online survey research may be systematically different from the general population; however, prior work has shown that online survey populations can be reasonably generalizable, especially when post-stratification weights are applied.⁴¹ Among other limitations, this repeated cross-sectional analysis was largely descriptive in nature. Causal inference should consider any possible confounding factors or unmeasured temporal trends between the 2022 and 2023 samples. While qualitative findings enriched and helped confirm the survey results, focus group and survey data came from separate, contemporaneous samples. Future analyses should examine the potential impacts of SB-793 within jurisdictions with stronger or weaker local flavored tobacco policies.

To conclude, comparing annual online survey results before and after the enactment of a statewide ban on most forms of flavored tobacco, there were declines in the use of flavored cigarettes, cigars, and smokeless tobacco among California adolescents. However, no changes were observed in the use of flavored e-cigarettes or the overall prevalence of tobacco use. While this evaluation may come too early to capture the full impact of the new policy, it suggests some promising trends and reveals potential challenges, including but not limited to policy enforcement, evasion via online sales, and the tobacco industry response to the law. Flavored tobacco sales restrictions are a key tool in the tobacco prevention and control armamentarium but more time for implementation and enforcement may be needed to see the full impact of SB-793 in California. Complementary and comprehensive tobacco prevention and control policies at the local, state, and federal levels are called for to curb further youth access to flavored e-cigarettes and other tobacco products.

Supplementary material

Supplementary material is available at Nicotine and Tobacco Research online.

Author contributions

Benjamin Chaffee (Conceptualization [lead], Formal analysis [lead], Funding acquisition [lead], Investigation [lead], Methodology [lead], Project administration [equal], Supervision [lead], Writing—original draft [lead], Writing—review & editing [equal]), Candice Donaldson (Conceptualization [equal], Investigation [equal], Methodology [supporting], Project administration [supporting], Writing—review & editing [equal]), Elizabeth Couch (Conceptualization [supporting], Investigation [supporting], Project administration [lead], Writing—review & editing [equal]), Claudia Guerra (Formal analysis [equal], Investigation [supporting], Methodology [supporting], Writing—review & editing [equal]), Omara Farooq (Conceptualization [equal], Project administration [lead], Writing—review & editing [equal]), Nancy Cheng (Formal analysis [supporting], Investigation [equal], Methodology [equal], Writing—review & editing [equal]), Niloufar Ameli (Formal analysis [supporting], Investigation [equal], Methodology [supporting], Writing—review & editing [equal]), Monica Wilkinson (Project administration [supporting], Writing—review & editing [equal]), Stuart Gansky (Funding acquisition [supporting], Investigation [supporting], Supervision [equal], Writing—review & editing [equal]), Xueying Zhang (Conceptualization [equal], Project administration [equal], Supervision [equal], Writing—review & editing [equal]), and Kristin Hoeft (Formal analysis [supporting], Funding acquisition [supporting], Investigation [equal], Supervision [supporting], Writing—review & editing [equal])

Declaration of Interests

Study authors are employees or contractors of the California Department of Public Health (CDPH). Beginning in 2024, the CDPH Office of Youth Tobacco Enforcement is the state agency tasked with enforcement of California Senate Bill (SB) 793. Study authors are not employed by the CDPH Office of Youth Tobacco Enforcement and have no role in SB-793 enforcement. All authors report that there are no other conflicts of interest to declare. The findings and conclusions in this article are those of the author(s) and do not necessarily represent the views or opinions of the National Institutes of Health, CDPH, or the California Health and Human Services Agency.

Funding

This work was supported by the California Department of Public Health (contract numbers CDPH-20-10026 and CDPH-23-10363) and the National Institutes of Health (grant numbers U54 HL147127 and UL1 TR001872).

Data Availability

Additional information about the Teens, Nicotine, and Tobacco Study, including questionnaires and codebooks can be found at the University of California eScholarship repository. https://escholarship.org/uc/item/06g1d0rx.