Abstract
Objectives. To assess explicit- (products clearly labeled flavored) and emergent concept- (products implying flavoring but not clearly labeled) flavored tobacco product availability following New York City’s flavor restriction.
Methods. We examined explicit- and concept-flavored tobacco product availability, with 2017 New York City Retailer Advertising of Tobacco Survey data (n = 1557 retailers). We assessed associations between block group–level demographic characteristics and product availability by using logistic regression.
Results. Most retailers sold explicit-flavored (70.9%) or concept-flavored (69.3%) products. The proportion of non-Hispanic Black neighborhood residents predicted explicit- and concept-flavored product availability, as did having a high school within a retailer’s block group for concept-flavored products.
Conclusions. Explicit- and concept-flavored other tobacco products persisted throughout New York City, despite 2009 legislation restricting sales.
Public Health Implications. Making local sales restrictions or federal production bans inclusive of all explicit and concept flavors would reduce retailer and industry evasion opportunities and protect the health of youths and others.
Flavored tobacco products are associated with youth smoking initiation and continued tobacco use.1 Recent evidence has also demonstrated that flavored tobacco products are popular with young adults, women, and Black smokers.2,3 Flavored cigars are particularly popular with youths and young adults, and the most commonly smoked type are cigarillos, which are generally shorter and narrower than larger cigars, usually do not include a filter, and feature a plastic or wooden tip.2,4,5
Federal, state, and local jurisdictions have taken legislative action to reduce youth access to these products. As part of the Family Smoking Prevention and Tobacco Control Act, in September 2009, Congress prohibited the production of flavored cigarettes, excluding menthol.6 In October 2009, New York City followed suit by prohibiting the sale of nonmenthol flavored tobacco products other than cigarettes, excluding electronic cigarettes.6,7 Subsequently, jurisdictions across the country have passed various laws restricting sales of flavored tobacco products, including Providence, Rhode Island; Minneapolis, Minnesota; Chicago, Illinois; Boston, Massachusetts, and other Massachusetts towns; Oakland, Santa Clara, and San Francisco, California; and the state of Maine.8
Evaluations of restrictions on flavored cigarettes and other tobacco products (OTPs) have demonstrated effectiveness across several metrics, including low numbers of recorded violations from inspection data, declines in the sales of flavored products from retail sales data, and declines in self-reported use of flavored or any tobacco products from youth surveys.9–13 Yet the retail tobacco landscape remains rife with flavored products, despite laws prohibiting them.12,14–17 While some products are explicitly labeled as flavored, such as “vanilla,” “strawberry,” and “piña colada,” an increasing variety of products are ambiguously named to imply product flavoring, including “ba-boom,” “purple,” and “tropical sunset.”12,14–17 These “concept flavors” have established a foothold in the retail market.12,14–17 Chemical testing has shown that these concept-flavored products contain concentrations of chemical flavoring similar to those measured in explicit-flavored products.16
New York City’s law restricting the sale of flavored OTPs has been enforced since November 2010. The city’s enforcement protocol is focused on manufacturer statements, which are typically a label, name, or image on a product.18 For example, a cigar with a label that says “chocolate” is presumed to be flavored. Alternatively, if a cigar bears a picture of a blueberry, it is presumed to be flavored regardless of the text on the product. Early New York City evaluation findings drawn from retail store sales data through 2012 and January 2014 demonstrated significant declines in sales of flavored OTPs after implementation of the flavor law.9,13 Bodegas or corner stores, despite comprising more than half of New York City tobacco retailers, were excluded from these evaluations because of lack of retail sales data.9,13 The current analysis used data from the 2017 New York City Retailer Advertising of Tobacco Survey (RATS) to examine availability of both explicit- and concept-flavored OTPs, particularly large cigars and cigarillos, and neighborhood-level demographic predictors of flavored product availability. In this study, we used more recent data and expanded previous analyses to include concept-flavored OTPs.
METHODS
RATS is a point-of-sale advertising study to assess the tobacco retail environment and retailer compliance with tobacco-control policies in a cross-sectional sample of licensed tobacco retailers citywide. As described in detail by Watson et al., a statewide version of this study was developed by RTI International and has been conducted annually from 2004 to 2015, with the exception of 2013.19 Retailer types were defined as convenience (including those at gas stations), pharmacy, large grocery, small grocery, mass merchandizer, tobacco shop, or other. Small grocery stores included delicatessens and bodegas (corner stores) that often have a deli counter or hot food bar, while convenience stores sold a more limited line of food products (e.g., no raw meat), and included popular chains, such as 7-Eleven.
Sample
The 2015 New York State RATS included an oversample of New York City stores and stratified sampling by retailer type and geographic regions defined as the 5 boroughs that comprise New York City (Bronx, Brooklyn, Manhattan, Queens, and Staten Island; each borough corresponds to a county) and a single stratum for the rest of the state. In 2015, completed assessments were conducted for 79% of sampled retailers, resulting in data from 1745 retailers in New York City and 489 retailers from the rest of the state. The 2017 New York City RATS resurveyed New York City retailers with completed assessments in the 2015 RATS, with the goal of assessing at least 300 retailers from each of the 5 boroughs. To achieve this, a minimum of 330 retailers were selected per borough from the 2015 sample; no retailers from outside of New York City were sampled in 2017. When the minimum number of retailers was not achieved from the matched 2015 sample, additional licensed tobacco retailers were randomly selected by borough (206 additional retailers total).
RATS data were collected with an audit instrument designed to assess availability of specific tobacco products and flavors, presence of interior and exterior point-of-sale advertising or price promotions for specific products, and compliance with tobacco-control policies, including cigarette price floors and the presence of signage stating the minimum legal cigarette purchase age. All survey items regarding concept- and explicit- flavored products were collected for the first time in 2017. Professional data collectors were staffed from a professional data collection agency, and all underwent intensive, multiday training conducted by RTI, which included both classroom learning modules covering definitions and images of products and field training to gain practice identifying products in real-world settings and to standardize categorizations across data collectors.
Explicit-flavored tobacco products were defined as those that used pictures or description to invoke a smell or taste (e.g., products such as Swisher Sweets Grape and Zig Zag Peach). Concept-flavored products were defined as having ambiguous descriptors that did not invoke any particular smell or taste (e.g., jazz, blue, fusion, blue ocean mist), but have been established in the literature as conveying and containing flavors.12,14–17 Availability (yes or no) of each flavor category was recorded separately for specific tobacco products, including little cigars, large cigars or cigarillos (LaCCs), smokeless tobacco, shisha, e-cigarettes, and e-liquid.
Between June and August 2017, trained data collectors visited 1683 sampled retailers in New York City. A single data collector visited each retailer, and store owners and managers were not informed in advance of surveyors’ visits. Assessments were completed for 1562 (92.8%) retailers, including 1375 that had been included in the 2015 cycle. Of the 121 retailers without completed assessments, nearly half (46%) were closed at the time that the data collector visited and approximately 30% did not sell tobacco. During 11 visits (9%), the store owner or manager asked the data collector to leave before any data were collected, and in another 11 instances (9%), the data collector noted that the store did not exist.
Retailer addresses were geocoded and linked to demographic characteristics from the 2012–2016 American Community Survey 5-year Summary File. For each retailer, we assessed the following demographic variables at the Census block group level: proportion of youths (aged < 18 years), proportion of Hispanic residents (any race), proportion of non-Hispanic Black residents, and proportion of non-Hispanic Asian residents. We assessed proportion of residents below poverty thresholds, based on family income relative to family size and composition, at the census tract level, the smallest geographic unit for which information was available. Using New York City Department of City Planning’s Facilities Explorer tool, we obtained and geocoded addresses of all city schools to determine the number of high schools in each retailer’s block group; when multiple schools were colocated at a single address, they were considered 1 school. The minimum age to purchase tobacco in New York City was raised to 21 years in 2014; thus, we did not consider elementary or middle schools, as we hypothesized that these students were unlikely to be able to purchase tobacco autonomously.20 We excluded 2 retailers because their addresses were recorded too ambiguously to be geocoded. We excluded 3 additional retailers because they were located in block groups listed as having zero population in the American Community Survey.
Statistical Analysis
We examined bivariable associations between availability of explicit- and concept-flavored products separately, with block group–level demographic characteristics, using the χ2 test to assess statistical significance at the α level of .05. The distributions of some neighborhood demographics were nonnormal (e.g., for proportion of Black residents: mean = 21.9%; median = 7.8%); therefore, neighborhood demographics are presented as quartiles. We dichotomized presence of a high school within a retailer’s block group (any vs none). We estimated adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) for flavored product availability from logistic regression models by using the PREDMARG statement in SUDAAN’s RLOGIST procedure. Models included presence of high school within a retailer’s block group and all neighborhood demographic characteristics (in quartiles). In addition to models for any flavored product availability, we fit models for availability of explicit- and concept-flavored LaCCs as the outcomes.
We conducted analyses in SAS version 9.4 (SAS Institute, Cary, NC) and SAS-callable SUDAAN version 11.0.1 (Research Triangle Institute, Raleigh, NC). We used sampling weights calculated as the inverse probability of selection within borough, with adjustment for eligibility, nonresponse, and borough population, in all analyses.
RESULTS
We included a total of 1557 tobacco retailers in main analyses, the majority of which were small grocery stores or bodegas (n = 1044; 67.1%) or convenience or gas station stores (n = 270; 17.3%). There was little clustering of stores within block groups; approximately 80% of the 1209 block groups in our analysis contained a single retailer (mean = 1.29).
The proportions of retailers selling at least 1 explicit- or concept-flavored tobacco product were 70.9% and 69.3%, respectively (Table 1). Explicit- and concept-flavored LaCCs were available in a majority of retailers (58.4% and 62.5%, respectively). Conversely, explicit- and concept-flavored little cigars (3.5% and 2.8%, respectively) and shisha (5.1% and 2.4%, respectively) were only available in a small proportion of retailers. While not considered a tobacco product in New York City, explicit-flavored e-cigarettes were available in 35.7% of stores and concept-flavored e-cigarettes were available in 20.0% of stores.
TABLE 1—
Proportion of New York City Tobacco Retailers Carrying Explicit-Flavored and Concept-Flavored Tobacco Products Other Than Cigarettes: New York City Retailer Advertising of Tobacco Survey, 2017
| Explicit Flavor Available, % | Concept Flavor Available, % | |
| Any OTP | 70.9 | 69.3 |
| Large cigars or cigarillos | 58.4 | 62.5 |
| Little cigars | 3.5 | 2.8 |
| Smokeless tobacco | 5.6 | 9.7 |
| Shisha | 5.1 | 2.4 |
| E-cigarettes or e-liquid | 35.7 | 20.0 |
Note. OTP = tobacco products other than cigarettes. Sample size n = 1557. All prevalence estimates account for survey weights.
In bivariable analyses, explicit-flavored product availability was associated with the proportion of Black residents in a retailer’s neighborhood (e.g., top quartile = 80.1% vs bottom quartile = 63.5%; P < .001; Table 2). We observed significant associations between availability of concept-flavored tobacco products and proportion of residents aged younger than 18 years (e.g., top quartile = 73.8% vs bottom quartile = 62.7%; P = .01), proportion of Black residents (e.g., top quartile = 81.3% vs bottom quartile = 56.0%; P < .001), proportion of Asian residents (e.g., top quartile = 62.5% vs bottom quartile = 76.3%; P < .001), and presence of a high school in retailer’s block group (no: 67.9% vs yes: 81.0%; P = .002).
TABLE 2—
Availability of Explicit-Flavored and Concept-Flavored Products by Quartile of Retailer Block Group Demographics and Presence of High School: New York City Retailer Advertising of Tobacco Survey, 2017
| Any Explicit-Flavored Product |
Any Concept-Flavored Product |
|||
| % | Pa | % | Pa | |
| % youth | .35 | .013 | ||
| ≤ 12.9 | 68.5 | 62.7 | ||
| > 12.9–20.4 | 74.8 | 67.6 | ||
| > 20.4–26.3 | 69.7 | 72.9 | ||
| > 26.3 | 70.7 | 73.8 | ||
| % povertyb | .20 | .13 | ||
| ≤ 10.7 | 69.4 | 64.7 | ||
| > 10.7–18.1 | 67.1 | 68.2 | ||
| > 18.1–28.7 | 74.3 | 70.7 | ||
| > 28.7 | 72.8 | 73.5 | ||
| % non-Hispanic Black | < .001 | < .001 | ||
| ≤ 0.7 | 63.5 | 56.0 | ||
| > 0.7–5.8 | 69.2 | 64.9 | ||
| > 5.8–27.4 | 70.8 | 74.8 | ||
| > 27.4 | 80.1 | 81.3 | ||
| % Hispanic | .21 | .47 | ||
| ≤ 9.3 | 66.1 | 68.3 | ||
| > 9.3–22.6 | 72.7 | 70.5 | ||
| > 22.6–53.1 | 73.0 | 66.3 | ||
| > 53.1 | 71.9 | 72.0 | ||
| % non-Hispanic Asian | .14 | < .001 | ||
| ≤ 1.6 | 72.4 | 76.3 | ||
| > 1.6–6.9 | 74.5 | 74.8 | ||
| > 6.9–18.3 | 70.7 | 63.5 | ||
| > 18.3 | 66.2 | 62.5 | ||
| % Asian | .17 | < .001 | ||
| ≤ 1.8 | 72.6 | 77.4 | ||
| > 1.8–7.1 | 74.1 | 73.5 | ||
| > 7.1–18.3 | 70.8 | 63.8 | ||
| > 18.3 | 66.3 | 62.4 | ||
| Any high school | .09 | .002 | ||
| No | 70.2 | 67.9 | ||
| Yes | 77.2 | 81.0 | ||
Note. n = 1557 sampled retailers.
P values from Rao-Scott χ2 test; all prevalence estimates and tests account for survey weights.
Poverty was assessed at census tract level.
In multivariable models, the proportion of Black residents in a retailer’s block group was positively associated with availability of any explicit-flavored product (PR comparing top vs bottom quartile = 1.28; 95% CI = 1.14, 1.44; Table 3). Though not statistically significant, there was some evidence that availability of explicit-flavored products was higher in locations with more Hispanic residents (PR comparing top vs bottom quartile = 1.12; 95% CI = 0.97, 1.29) and in retailers with at least 1 high school in their block group relative to those without (PR = 1.08; 95% CI = 0.98, 1.20). The proportion of Black residents was also a significant predictor of concept-flavored product availability (PR comparing top vs bottom quartile = 1.37; 95% CI = 1.19, 1.57). Retailers sharing a block group with at least 1 high school were also more likely to sell concept-flavored products than were retailers with no high schools in their block group (PR = 1.16; 95% CI = 1.05, 1.28). Results were largely unchanged when restricted to convenience stores (including those at gas stations) and small grocery stores or bodegas (n = 1334), though the association between concept-flavored product availability and high school proximity was attenuated (PR = 1.05; 95% CI = 0.95, 1.18; data not shown).
TABLE 3—
Adjusted Prevalence Ratios and 95% Confidence Intervals for Flavored Product Availability by Quartile of Retailer Block Group Demographics and Presence of High School: New York City Retailer Advertising of Tobacco Survey, 2017
| Explicit-Flavored Product Availability, PR (95% CI) |
Concept-Flavored Product Availability, PR (95% CI) |
|||
| Any Product (n = 1557) | LaCC (n = 1554) | Any Product (n = 1557) | LaCC (n = 1554) | |
| % youth | ||||
| ≤ 12.9 (Ref) | 1 | 1 | 1 | 1 |
| > 12.9–20.4 | 1.05 (0.95, 1.16) | 1.09 (0.95, 1.25) | 1.07 (0.95, 1.20) | 1.11 (0.97, 1.28) |
| > 20.4–26.3 | 0.95 (0.85, 1.06) | 0.98 (0.84, 1.14) | 1.12 (1.00, 1.27) | 1.19 (1.04, 1.37) |
| > 26.3 | 0.93 (0.82, 1.05) | 1.03 (0.88, 1.21) | 1.10 (0.97, 1.25) | 1.16 (1.00, 1.36) |
| % povertya | ||||
| ≤ 10.7 (Ref) | 1 | 1 | 1 | 1 |
| > 10.7–18.1 | 0.93 (0.83, 1.04) | 0.91 (0.79, 1.04) | 1.04 (0.93, 1.16) | 1.05 (0.93, 1.20) |
| > 18.1–28.7 | 1.03 (0.93, 1.15) | 1.01 (0.88, 1.16) | 1.05 (0.94, 1.18) | 1.11 (0.97, 1.27) |
| > 28.7 | 0.99 (0.87, 1.14) | 0.88 (0.73, 1.05) | 0.98 (0.85, 1.13) | 0.98 (0.83, 1.16) |
| % non-Hispanic Black | ||||
| ≤ 0.7 (Ref) | 1 | 1 | 1 | 1 |
| > 0.7–5.8 | 1.08 (0.96, 1.22) | 1.06 (0.90, 1.24) | 1.15 (1.01, 1.31) | 1.12 (0.96, 1.29) |
| > 5.8–27.4 | 1.10 (0.97, 1.25) | 1.18 (1.01, 1.39) | 1.30 (1.15, 1.48) | 1.35 (1.16, 1.56) |
| > 27.4 | 1.28 (1.14, 1.44) | 1.50 (1.29, 1.74) | 1.37 (1.19, 1.57) | 1.46 (1.26, 1.70) |
| % Hispanic | ||||
| ≤ 9.3 (Ref) | 1 | 1 | 1 | 1 |
| > 9.3–22.6 | 1.11 (0.99, 1.24) | 1.12 (0.96, 1.30) | 1.02 (0.92, 1.12) | 1.05 (0.93, 1.18) |
| > 22.6–53.1 | 1.11 (0.98, 1.25) | 1.12 (0.96, 1.31) | 0.92 (0.82, 1.04) | 0.97 (0.84, 1.11) |
| > 53.1 | 1.12 (0.97, 1.29) | 1.22 (1.02, 1.46) | 0.94 (0.82, 1.09) | 1.02 (0.87, 1.20) |
| % non-Hispanic Asian | ||||
| ≤ 1.6 (Ref) | 1 | 1 | 1 | 1 |
| > 1.6–6.9 | 1.07 (0.96, 1.19) | 1.05 (0.92, 1.20) | 1.01 (0.91, 1.12) | 0.99 (0.87, 1.11) |
| > 6.9–18.3 | 1.06 (0.94, 1.20) | 0.96 (0.83, 1.12) | 0.92 (0.81, 1.03) | 0.93 (0.81, 1.07) |
| > 18.3 | 1.02 (0.90, 1.17) | 0.94 (0.79, 1.11) | 0.91 (0.79, 1.04) | 0.89 (0.76, 1.04) |
| Any high school | ||||
| No (Ref) | 1 | 1 | 1 | 1 |
| Yes | 1.08 (0.98, 1.20) | 1.17 (1.02, 1.33) | 1.16 (1.05, 1.28) | 1.13 (1.00, 1.28) |
Note. CI = confidence interval; LaCC = large cigars or cigarillos; PR = prevalence ratio. Mutually adjusted for all other variables in table, accounting for survey weights.
Poverty was assessed at census tract level.
In multivariable analyses of LaCC availability specifically, the proportions of Black and Hispanic residents were positively associated with explicit-flavored LaCC availability (PR comparing top vs bottom quartile for proportion of Black residents = 1.50; 95% CI = 1.29, 1.74; for proportion of Hispanic residents PR = 1.22; 95% CI = 1.02, 1.46). Proportion of Black residents was also associated with concept-flavored LaCCs (PR comparing top vs bottom quartile = 1.46; 95% CI = 1.26, 1.70); there was also evidence that proportion of residents aged younger than 18 years was associated with availability of these products (PR comparing top vs bottom quartile = 1.16; 95% CI = 0.995, 1.35). Presence of a nearby high school was also associated with flavored LaCC availability (explicit-flavored LaCCs PR = 1.17; 95% CI = 1.02, 1.33; concept-flavored LaCCs PR = 1.13; 95% CI = 1.005, 1.280).
DISCUSSION
Availability of explicit-flavored tobacco products persisted at tobacco retailers throughout New York City, despite local legislation restricting their sale. These compliance issues were in line with findings from other jurisdictions. An evaluation of Chicago’s restriction on menthol cigarette sales within 500 feet of schools demonstrated 57% compliance with the law.21
There may be multiple reasons why the initial New York City evaluations showed reductions of flavored OTP sales while the current study showed widespread retail store availability of explicit- and concept-flavored tobacco.9,13 Only 4% of tobacco retailer inspections conducted by the New York City Department of Consumer Affairs at all New York City stores between 2010 and 2014 received a violation for selling explicit-flavored products, suggesting limited availability of these products in New York City at that time.9 However, the literature has demonstrated an increase in the availability of concept-flavored products over time and a concomitant rise in the availability of explicit-flavored products, including in New York City.9,12–17 The more ambiguous concept-flavored products limit the ability of New York City inspectors to issue violations for these products. More education is needed to remind retailers which products are prohibited under the New York City flavored OTP sales law and of retailers’ responsibility to adhere to this law. Alternatively, our findings may suggest willful noncompliance by retailers, or a combination of these 2 factors.
Concept flavors were not prevalent when New York City initially implemented the law prohibiting the sale of flavored OTPs, but rather have emerged over time as a likely result of industry response to local sales restrictions on explicit-flavored OTPs and recognition of the marketability of concept-flavored products.14,15,17 The availability of concept-flavored products presents a loophole for wholesalers who operate in New York City and surrounding areas.22 Approximately 120 wholesale dealers are licensed by New York City (New York City Administrative Code §11–1303) to supply tobacco products to more than 8000 New York City tobacco retail outlets, and each wholesaler must also have a New York State tobacco wholesale license (NY Tax Law §480).22 Dozens of these wholesalers are located outside of New York City and presumably supply tobacco products to retailers in other jurisdictions that do not have restrictions on flavored tobacco product sales. This incentivizes wholesalers to stock concept- and explicit-flavored tobacco products and creates availability of these products for New York City retailers. Once wholesalers possess concept-flavored tobacco products, they have a motive to sell them to New York City retailers. Although it is illegal for retailers to sell concept-flavored tobacco products, both retailers and inspectors may be challenged by ambiguity inherent in concept-flavored product names, which can further undermine compliance with the law.
LaCCs were more likely to be available as explicit- or concept-flavored products compared with other noncigarette tobacco products, including shisha, smokeless tobacco, and little cigars. LaCCs are often cheaper than cigarettes, encourage initiation and regular smoking, are marketed to youths and in neighborhoods with more Black residents, and are also often used to roll marijuana blunts.1,2,23–25 Trends in smoking habits among New York City high-school students have shifted over time, with declines in current cigarette use concurrent with increases in cigar use.26
Our findings that explicit- and concept-flavored products—particularly LaCCs—were more widely available in neighborhoods with higher proportions of Black and Hispanic residents and with high schools, were not surprising. These findings parallel information from studies of tobacco industry documents that identify flavored tobacco products as a mechanism for targeting youths, as well as a national study showing that most tobacco retailers sold flavored cigars, and the odds of selling flavored cigars were more than twice as high in neighborhoods with more Black residents.27,28 Most New Yorkers live in racially segregated neighborhoods, which enables targeted marketing to specific racial/ethnic groups, including vulnerable populations.29,30 Targeted marketing of health-harming substances, like tobacco, has been established in the literature as one pathway by which racism harms health.27,29–32 Persistent and multipronged efforts are needed to eliminate the disparities accumulating from these historical patterns.27,29–32 New York City has been working toward this goal through multipronged efforts that include policy change and education. Multiple laws have been enacted to reduce the availability of cheap tobacco in all communities, including laws that raise prices of tobacco products and prohibit tobacco product discounts.32 New York City has also conducted educational campaigns and interventions to reach populations adversely impacted by targeted marketing and availability, with a focus on communities of color.32,33 These include hard-hitting media campaigns such as “Marie” and “Beth” that highlight the lasting health consequences of smoking and efforts to develop culturally appropriate cessation support strategies.32–34
Limitations
This study does have limitations. We were unable to assess changes over time because availability of explicit- and concept-flavored tobacco products was first assessed in 2017. Data from New York City tobacco retailers may not be generalizable to other regions or nationally. The majority of tobacco retailers in New York City are bodegas, which may differ from the distribution of tobacco retailers in other jurisdictions. Data collected were observational, based on presence of items at the retailer the day they were surveyed; data do not represent volume of sales or length of time products remain on shelves. In addition, we did not collect formal reliability statistics for items on the 2017 RATS audit instrument, so we were unable to quantify the consistency in observations made by our data collectors. However, our professional data collectors underwent rigorous training, which included examples of several common flavored products. Lastly, while analyses were conducted at the block group level, because of high retailer density and ease of travel, purchasing may occur across block groups.
Public Health Implications
Given tobacco industry efforts to circumvent flavor regulations through concept flavors,14–17 broader adoption by more jurisdictions of prohibitions on sales of flavored tobacco products would be valuable. Although local sales policies can achieve some success, retailers receive flavored OTPs from wholesalers, who typically do business in a range of jurisdictions, potentially including localities that do not have restrictions on sales of flavored tobacco. If the legal market for flavored tobacco products becomes smaller, the supply is also likely to diminish.
In addition, efforts to educate retailers about concept-flavored products could be initiated or expanded to improve compliance with policies. Moreover, local legislation may address concept flavors more effectively if the burden of proof is shifted to manufacturers who would be required to certify—with a protocol for enforcement oversight—that specific tobacco products are not flavored as a condition for selling them in a given jurisdiction. This would shift the enforcement burden from local agencies to manufacturers, who are more aware of their products’ characteristics.
A federal manufacturing ban—which appears to be a US Food and Drug Administration (FDA) priority—would be sweeping and most impactful.35 The FDA could expand the ban on manufacture of flavored cigarettes to include flavored OTPs, and it could broaden the ban on flavors by eliminating the exception for menthol. Only the FDA can enact a law this strong; local jurisdictions do not have the authority to regulate ingredients in tobacco products. While the federal flavored cigarette ban led to declines in cigarette use, it appears to have encouraged substitution with menthol cigarettes, cigars, and pipes.11 An expanded law has the potential to substantially decrease youth and future adult smoking prevalence as the majority of youths and young adults initiate with flavored tobacco products.1
CONFLICTS OF INTEREST
The authors have no conflict of interest to declare.
HUMAN PARTICIPANT PROTECTION
Institutional review board approval was not needed as this study did not meet the definition of human participant research.
REFERENCES
- 1.Villanti AC, Johnson AL, Ambrose BK et al. Flavored tobacco product use in youth and adults: findings from the first wave of the PATH study (2013–2014) Am J Prev Med. 2017;53(2):139–151. doi: 10.1016/j.amepre.2017.01.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Delnevo CD, Giovenco DP, Ambrose BK, Corey CG, Conway KP. Preference for flavoured cigar brands among youth, young adults and adults in the USA. Tob Control. 2015;24(4):389–394. doi: 10.1136/tobaccocontrol-2013-051408. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Feirman SP, Lock D, Cohen JE, Holtgrave DR, Li T. Flavored tobacco products in the United States: a systematic review assessing use and attitudes. Nicotine Tob Res. 2016;18(5):739–749. doi: 10.1093/ntr/ntv176. [DOI] [PubMed] [Google Scholar]
- 4.Corey CG, King BA, Coleman BN et al. Little filtered cigar, cigarillo, and premium cigar smoking among adults—United States, 2012–2013. MMWR Morb Mortal Wkly Rep. 2014;63(30):650–654. [PMC free article] [PubMed] [Google Scholar]
- 5.Centers for Disease Control and Prevention. Smoking and tobacco use. Cigars. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/cigars. Accessed April 27, 2018.
- 6.GPO Family Smoking Prevention and Tobacco Control Act, Pub L 111-31. Available at: http://www.gpo.gov/fdsys/pkg/PLAW-111publ31/pdf/PLAW-111publ31.pdf. Accessed November 8, 2015.
- 7.A local law to amend the New York City charter and the administrative code of the city of New York, in relation to the regulation of tobacco products. October 28, 2009. Int 0433-2006. New York City Administrative Code, Title 17. Health. Chapter 7. Regulation of tobacco products. Available at: https://www1.nyc.gov/assets/dca/downloads/pdf/about/retail_cigarette_dealer_law_rules.pdf. Accessed November 20, 2016.
- 8.Public Health Law Center. Regulating flavored tobacco products. September 2017. Available at: http://www.publichealthlawcenter.org/sites/default/files/resources/Regulating-Flavored-Tobacco-Products-2017.pdf. Accessed April 26, 2018.
- 9.Farley SM, Johns M. New York City flavoured tobacco product sales ban evaluation. Tob Control. 2017;26(1):78–84. doi: 10.1136/tobaccocontrol-2015-052418. [DOI] [PubMed] [Google Scholar]
- 10.Welsh Boles E, Guardino GA, Abdullahi N, Larson HE, Pearlman DN. Emerging tobacco use among Rhode Island high school students: understanding youth tobacco use at the city/town level. Rhode Island Department of Health. 2017. Available at: https://health.ri.gov/publications/briefs/20170418EmergingTobaccoUseAmongRIHighSchoolStudentsUnderstandingYouthTobaccoUse%20AtTheCityTownLevel.pdf. Accessed February 7, 2020.
- 11.Courtemanche CJ, Palmer MK, Pesko MF. Influence of the flavored cigarette ban on adolescent tobacco use. Am J Prev Med. 2017;52(5):e139–e146. doi: 10.1016/j.amepre.2016.11.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Brock B, Carlson SC, Leizinger A, D’Silva J, Matter CM, Schillo BA. A tale of two cities: exploring the retail impact of flavoured tobacco restrictions in the twin cities of Minneapolis and Saint Paul, Minnesota. Tob Control. 2018 doi: 10.1136/tobaccocontrol-2017-054154. Epub ahead of print. [DOI] [PubMed] [Google Scholar]
- 13.Rogers T, Brown EM, Mccrae TM et al. Compliance with a sales policy on flavored non-cigarette tobacco products. Tob Regul Sci. 2017;3(2 suppl 1):S84–S93. doi: 10.18001/TRS.3.2(Suppl1).9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Delnevo CD, Giovenco DP, Miller Lo EJ. Changes in the mass-merchandise cigar market since the Tobacco Control Act. Tob Regul Sci. 2017;3(2 suppl 1):S8–S16. doi: 10.18001/trs.3.2(suppl1).2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Viola AS, Giovenco DP, Miller Lo EJ, Delnevo CD. A cigar by any other name would taste as sweet. Tob Control. 2016;25(5):605–606. doi: 10.1136/tobaccocontrol-2015-052518. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Farley SM, Schroth KRJ, Grimshaw V et al. Flavour chemicals in a sample of non-cigarette tobacco products without explicit flavor names sold in New York City in 2015. Tob Control. 2018;27:170–176. doi: 10.1136/tobaccocontrol-2016-053552. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Gammon DG, Rogers T, Coats EM et al. National and state patterns of concept-flavoured cigar sales, USA, 2012–2016. Tob Control. 2019;28(4):394–500. doi: 10.1136/tobaccocontrol-2018-054348. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.New York City Department of Health and Mental Hygiene. Notice of adoption of a new chapter 28 (“Restriction on the sale of certain flavored tobacco products”) in title 24 of the rules of the City of New York. Available at: https://www1.nyc.gov/assets/doh/downloads/pdf/smoke/flavored-law-implementing-rules.pdf. Accessed May 1, 2019.
- 19.Watson KA, Gammon DG, Loomis BR, Juster HR, Anker E. Trends in cigarette advertising, price-reducing promotions, and policy compliance in New York State licensed tobacco retailers, 2004 to 2015. Am J Health Promot. 32(8):1670–1687. [DOI] [PubMed]
- 20.Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: National Academies Press; 2015. [PubMed] [Google Scholar]
- 21.Czaplicki L, Cohen JE, Jones MR, Smith KC, Rutkow L, Owczarzak J. Compliance with the City of Chicago’s partial ban on menthol cigarette sales. Tob Control. 2018 doi: 10.1136/tobaccocontrol-2018-054319. Epub ahead of print. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.New York City Department of Finance. Licensed tobacco wholesale/distributor dealers. Effective February 1, 2019. Available at: https://www1.nyc.gov/assets/finance/downloads/pdf/otp_license.pdf. Accessed May 8, 2019.
- 23.Delnevo CD, Foulds J, Hrywna M. Trading tobacco: are youths choosing cigars over cigarettes? Am J Public Health. 2005;95(12):2123. doi: 10.2105/AJPH.2005.072728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Cantrell J, Kreslake JM, Ganz O et al. Marketing little cigars and cigarillos: advertising, price, and associations with neighborhood demographics. Am J Public Health. 2013;103(10):1902–1909. doi: 10.2105/AJPH.2013.301362. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Sifaneck SJ, Johnson BD, Dunlap E. Cigars-for-blunts: choice of tobacco products by blunt smokers. J Ethn Subst Abuse. 2005;4(3-4):23–42. doi: 10.1300/J233v04n03_02. [DOI] [PubMed] [Google Scholar]
- 26.Elfassy T, Yi SS, Kansagra SM. Trends in cigarette, cigar, and smokeless tobacco use among New York City public high school youth smokers, 2001–2013. Prev Med Rep. 2015;2:488–491. doi: 10.1016/j.pmedr.2015.06.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Dachille K Tobacco Control Legal Consortium. Pick your poison: responses to the marketing and sale of flavored tobacco products. 2009. Available at: http://digitalcommons.law.umaryland.edu/cgi/viewcontent.cgi?article=1857&context=fac_pubs. Accessed May 10, 2018.
- 28.Ribisl KM, D’Angelo H, Feld AL et al. Disparities in tobacco marketing and product availability at the point of sale: results of a national study. Prev Med. 2017;105:381–388. doi: 10.1016/j.ypmed.2017.04.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Bailey ZD, Krieger N, Agénor M, Graves J, Linas N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453–1463. doi: 10.1016/S0140-6736(17)30569-X. [DOI] [PubMed] [Google Scholar]
- 30.Grier SA, Kumanyika S. Targeted marketing and public health. Annu Rev Public Health. 2010;31(1):349–369. doi: 10.1146/annurev.publhealth.012809.103607. [DOI] [PubMed] [Google Scholar]
- 31.Krieger N. Discrimination and health inequities. Int J Health Serv. 2014;44(4):643–710. doi: 10.2190/HS.44.4.b. [DOI] [PubMed] [Google Scholar]
- 32.Kilgore EA, Mandel-Ricci J, Johns M et al. Making it harder to smoke and easier to quit: the effect of 10 years of tobacco control in New York City. Am J Public Health. 2014;104(6):e5–e8. doi: 10.2105/AJPH.2014.301940. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Quinn EC, Sacks R, Farley SM, Thihalolipavan S. Development of culturally appropriate support strategies to increase uptake of nicotine replacement therapy among Russian- and Chinese-speaking smokers in New York City. J Community Health. 2017;42(3):431–436. doi: 10.1007/s10900-016-0272-9. [DOI] [PubMed] [Google Scholar]
- 34.New York City Department of Health and Mental Hygiene. Beth “sick for life.” April 8, 2015. Available at: https://www.youtube.com/watch?v=LhMM4jUIC80. Accessed February 5, 2020.
- 35.US Food and Drug Administration. Statement from FDA Commissioner Scott Gottlieb, MD, on proposed new steps to protect youth by preventing access to flavored tobacco products and banning menthol in cigarettes. November 15, 2018. Available at: https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-proposed-new-steps-protect-youth-preventing-access. Accessed May 9, 2019.