Abstract
This cohort study examines whether cigarette sales changed after Massachusetts banned menthol-flavored tobacco products.
In April 2021, the US Food and Drug Administration announced its intention to ban menthol flavors from cigarettes and cigars.1 Before this announcement, Massachusetts was the only state to implement a statewide comprehensive flavor ban on tobacco products in June 2020.2 Evidence of the effectiveness of comprehensive flavor bans on cigarette sales and smoking remains inconclusive in the US; studies have found decreases in menthol and overall tobacco product sales3 and no changes in the intensity of smoking4 after San Francisco’s flavor ban. In addition, no study, to our knowledge, has quantified a potential switch to nonflavored tobacco after banning flavored tobacco products. We examined changes in menthol and nonflavored cigarette sales in Massachusetts compared with sales in states without a flavor ban.
Methods
In this cohort study, we used Nielsen Retail Scanner Data of sales volume (reported in 4-week cycles) of menthol and nonflavored cigarette brands sold by US-based retailers. Our outcomes were state-level sales per 1000 people of packs of menthol, nonflavored, and all (menthol and nonflavored) cigarettes from January 2017 to July 2021 based on state-level annual population data obtained from the US Census Bureau. For the population data not available in 2021, we used the average population growth rate to calculate the population for each state in 2021. We used a controlled before and after design with difference-in-differences (eMethods in the Supplement) to examine temporal changes in cigarette sales in Massachusetts before (January 2017 to May 2020) and after (June 2020 to July 2021) the comprehensive flavor ban. The temporal changes were then compared with changes in the 27 states in Nielsen Retail Scanner Data that did not implement state or local flavor bans, and the analyses were controlled for product prices, state-level time-varying factors, seasonality, and state time-invariant factors. State-level time-varying sociodemographic factors were obtained from the US Census Bureau Basic Monthly Current Population Survey. The study did not directly involve human participants and did not require institutional review board approval or informed consent in accordance with the Common Rule. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
All statistical tests were 2-sided, and P < .05 was considered to be statistically significant. Analyses were conducted using Stata, version 15.1 (StataCorp).
Results
We analyzed 1652 four-week sales of cigarette data consisting of 59 observations from Massachusetts (44 from before and 15 from after the menthol flavor ban) and 1593 observations from the comparison states (1188 from before and 405 from after the menthol flavor ban). Mean (SD) cigarette prices per pack were higher in Massachusetts than in comparison states ($9.94 [$0.25] vs $6.65 [$1.34]) (Table 1). Individuals in Massachusetts compared with those in the comparison states were less likely to be married (49.28% vs 52.24%) and more likely to be aged 25 to 64 years (54.20% vs 51.49%), Asian (7.20% vs 3.83%) or White (82.57% vs 79.24%) persons, have a college degree (44.23% vs 30.18%), and have a household income of $150 000 or more (22.46% vs 10.95%). There were nondivergent trends in state-level sales of menthol and nonflavored cigarette packs per 1000 people in Massachusetts and comparison states during the period before Massachusetts’s comprehensive flavor ban. After the comprehensive flavor ban, the unadjusted 4-week sales of packs of cigarettes per 1000 people decreased in Massachusetts for menthol (404.93 to 32.24), nonflavored (916.37 to 856.79), and all (1321.32 to 887.69) cigarettes (Table 2). In comparison states, the unadjusted 4-week sales of packs of cigarettes per 1000 people decreased for menthol (738.33 to 717.73), nonflavored (1524.85 to 1361.00), and all (2263.36 to 2180.56) cigarettes after the Massachusetts comprehensive flavor ban. After the flavor ban, the adjusted 4-week sales of cigarettes in Massachusetts vs the comparison states decreased by 372.27 (95% CI, −428.90 to −315.64; P < .001) packs per 1000 people for menthol cigarettes but increased by 120.25 (95% CI, 72.61-167.88; P < .001) packs per 1000 people for nonflavored cigarettes. Overall, the adjusted 4-week sales of all cigarettes decreased by 282.65 (95% CI, −356.07 to −209.23; P < .001) packs per 1000 people in Massachusetts vs the comparison states.
Table 1. Cigarette Sales and Sociodemographic Characteristics for Massachusetts and Comparison Statesa.
| Massachusetts | Comparison statesb | Mean difference (SE) | P value | |
|---|---|---|---|---|
| Price per pack in Feb 2021, $ | ||||
| Menthol cigarettes, mean (SD) | 10.16 (0.28) | 6.79 (1.31) | 3.36 (0.17) | <.001 |
| Nonflavored cigarettes, mean (SD) | 9.87 (0.28) | 6.58 (1.36) | 3.29 (0.18) | <.001 |
| All (menthol and nonmenthol) cigarettes, mean (SD) | 9.94 (0.25) | 6.65 (1.34) | 3.31 (0.18) | <.001 |
| Sociodemographic characteristics | ||||
| Sex, % (SD) | ||||
| Male | 48.26 (0.99) | 48.40 (1.05) | −0.15 (0.14) | .29 |
| Female | 51.74 (0.99) | 51.60 (1.05) | 0.15 (0.14) | .29 |
| Marital status, % (SD) | ||||
| Married | 49.28 (1.04) | 52.24 (2.26) | −2.96 (0.30) | <.001 |
| Unmarried | 50.72 (1.04) | 47.76 (2.30) | 2.96 (0.30) | <.001 |
| Age, % (SD) | ||||
| <25 y | 28.06 (1.12) | 29.70 (2.08) | −1.64 (0.27) | <.001 |
| 25-44 y | 26.68 (1.08) | 24.61 (1.66) | 2.07 (0.22) | <.001 |
| 45-64 y | 27.52 (1.29) | 26.85 (1.62) | 0.68 (0.21) | .002 |
| ≥65 y | 17.74 (1.65) | 18.84 (2.27) | −1.10 (0.30) | <.001 |
| Race and ethnicity, % (SD) | ||||
| Asian | 7.20 (0.78) | 3.83 (2.73) | 3.37 (0.36) | <.001 |
| Black | 7.23 (0.97) | 13.51 (8.97) | −6.29 (1.17) | <.001 |
| White | 82.57 (1.65) | 79.24 (8.41) | 3.33 (1.10) | .002 |
| Otherc | 3.00 (0.81) | 3.41 (2.56) | −0.41 (0.33) | 0.22 |
| Educational level, % (SD) | ||||
| No high school diploma | 10.60 (0.92) | 13.87 (2.46) | −3.27 (0.32) | <.001 |
| High school diploma | 24.09 (1.50) | 29.15 (3.76) | −5.06 (0.49) | <.001 |
| Some college | 21.08 (0.91) | 26.80 (3.07) | −5.72 (0.40) | <.001 |
| College or higher degree | 44.23 (2.18) | 30.18 (5.56) | 14.05 (0.73) | <.001 |
| Household income, % (SD) | ||||
| <$10 000 | 19.03 (1.77) | 19.49 (3.43) | −0.46 (0.46) | .31 |
| $10 000-$29 999 | 10.12 (1.79) | 14.31 (3.72) | −4.19 (0.49) | <.001 |
| $30 000-$59 999 | 15.69 (1.68) | 22.71 (3.14) | −7.02 (0.41) | <.001 |
| $60 000-$149 999 | 32.71 (1.39) | 32.54 (3.76) | 0.17 (0.49) | 0.73 |
| $150 000+ | 22.46 (2.33) | 10.95 (4.61) | 11.51 (0.61) | <.001 |
| Unemployment rate, % (SD) | 4.97 (3.14) | 4.92 (2.39) | 0.05 (0.32) | .87 |
| Mean COVID-19 infection cases per 1000 people (SD) | 13.84 (29.31) | 14.13 (30.75) | −0.29 (4.07) | .94 |
| Observations, No. | 59 | 1593 | NA | NA |
Abbreviation: NA, not applicable.
The Nielsen Retail Scanner Data used in the study contains universal product code-level sales of cigarette products reported in dollar and unit volumes at 4-week cycles collected at the point-of-sale from convenience stores, including gas stations, and other channels, such as food or grocery, drug, and mass-market stores.
The eMethods in Supplement contains the full list of states included in the comparison states.
Other included the following races and ethnicities as included in the US Census Bureau Basic Monthly Current Population Survey: American Indian, Alaska Native only, Hawaiian/Pacific Islander only, and multiple races.
Table 2. Four-Week Sales of Packs of Menthol, Nonflavored, and All Cigarettes per 1000 People Before and After Massachusetts’ Menthol Flavor Ban.
| Type of cigarette | Per 1000 people (95% CI) | Difference-in-differences estimate (95% CI) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Massachusetts | Comparison statesa | ||||||||
| Before flavor ban (January 2017-May 2020) | After flavor ban (June 2020-July 2021) | Difference | Before flavor ban (January 2017-May 2020) | After flavor ban (June 2020-July 2021) | Difference | Unadjusted | Adjustedb | P value | |
| Menthol cigarettes | 404.93 (391.00 to 418.85) | 32.24 (8.16 to 56.32) | −372.68 (−399.77 to −345.60) | 738.33 (709.71 to 766.95) | 717.73 (668.84 to 766.61) | −20.60 (−77.28 to 36.08) | −352.08 (−648.84 to −55.32) | −372.27 (−428.90 to −315.64) | <.001 |
| Nonflavored cigarettes | 916.37 (872.72 to 960.01) | 856.79 (807.24 to 906.33) | −59.58 (−138.82 to 19.66) | 1524.85 (1469.01 to 1580.68) | 1361.00 (1268.00 to 1454.00) | −163.85 (−273.74 to −53.95) | 104.27 (−470.83 to 679.36) | 120.25 (72.61 to 167.88) | <.001 |
| All cigarettes | 1321.32 (1265.04 to 1377.60) | 887.69 (818.16 to 957.22) | −433.63 (−536.85 to −330.40) | 2263.36 (2181.19 to 2345.53) | 2180.56 (1942.59 to 2218.54) | −182.80 (−344.84 to −20.76) | −250.83 (−1098.24 to 596.58) | −282.65 (−356.07 to −209.23) | <.001 |
| Observations, No. | 44 | 15 | NA | 1188 | 405 | NA | 1652 | 1652 | NA |
Abbreviation: NA, not applicable.
See the eMethods in Supplement for the list of states included in the comparison states.
The adjusted cigarette sales were obtained using linear regression models and an indicator for a menthol flavor ban in Massachusetts in June 2020. Models included mean cigarette price, state fixed effects controlling for time-invariant smoking characteristics, state-level time-varying factors (unemployment rate, age, sex, marital status, household income, education, race and ethnicity, and COVID-19 infection cases), and survey date fixed effects to account for time-invariant characteristics that are common in the fiscal year and seasonality in smoking. Standard errors were clustered within states.
Discussion
The comprehensive flavor ban in Massachusetts was associated with a statistically significant decrease in state-level menthol and all cigarette sales. Limitations of the study include that cross-border or online cigarette sales in Massachusetts were not accounted for, that states with partial bans were not included, and that Massachusetts enacted other tobacco-related legislation that may have affected the results.5 Also, the findings should be interpreted cautiously as sales data may not fully capture cigarette consumption.
Nonflavored cigarette sales in Massachusetts vs the comparison states increased after the ban, suggesting the potential substitution of nonflavored cigarettes for menthol cigarettes. The US Food and Drug Administration plans to implement a nationwide menthol ban that can regulate the manufacturing, marketing, and sale of menthol cigarettes; therefore, policies and interventions are needed to address possible menthol cigarette users’ switching to nonflavored cigarettes that can undermine the effectiveness of the menthol flavor ban. Future studies are needed to examine changes in noncombustible and other combustible tobacco product sales and in cigarette consumption.
eMethods. Difference-in-Differences Specification.
eReferences
References
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Associated Data
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Supplementary Materials
eMethods. Difference-in-Differences Specification.
eReferences