Wei Bao, MD, PhD

State regulation and taxation of electronic cigarettes may be affecting their rate of use.

A new cross-sectional study of data from the Behavioral Risk Factor Surveillance System (BRFSS) survey showed adults in states which prohibited e-cigarette use in public and work indoor areas, required retailers to purchase a license to sell the product, or prohibited the sales of e-cigarettes to persons under 21 years old, were less likely to use e-cigarettes than adults in states without such laws.

The new findings come nearly 1 month after the US Food and Drug Administration (FDA) announced a federal ban on multiple vaping product features, including flavored cartridges, and required products do not be targeted nor accessible to minors. The ban will begin early next week.

Investigators from the University of Iowa College of Public Health, led by Wei Bao, MD, PhD, of the Department of Epidemiology, noted the initial regulation of e-cigarette manufacturing, distribution, and marketing as a tobacco product came from the FDA in May 2016. Even prior to that, state, local, and territorial governments were establishing their own regulation of the product.

Many states—not all—carry a variation of standard e-cigarette regulations today:

Prohibiting use in indoor areas of private workplaces, restaurants, and bars

Requiring retailers to purchase licenses to sell ecigarettes

Prohibiting selfservice displays of e-cigarettes

Prohibiting sales of tobacco products including ecigarettes to persons younger than 21

Taxation of ecigarettes

Their assessment of nationwide data across all 50 states and participating US territories examined the association between such regulations and current e-cigarette use among US adults.

Bao and colleagues used data of participating adults from the 2016 and 2017 entries to the BRFSS survey. Their population included 894,997 participants, with 51.3% being women and 62.6% being non-Hispanic white. The remaining population was 16.3% non-Hispanic black, 11.4% Hispanic, and 9.8% non-Hispanic other races.

Of the entire observed adult population, just 28,907 (4.4%) were using e-cigarettes at the time. A majority of e-cigarette users were between 18-34 years old (52.5%), male (60.1%), non-Hispanic white (70.6%), and with a high school graduation-college attendance education (72.8%).

Approximately one-third (32.6%) of e-cigarette users were everyday smokers.

Across the observed 53 states and territories, the most commonly set laws for e-cigarette regulation by 2017 were the prohibition of self-service displays (n = 26) the requirement of retailers purchasing a license to sell the product (n = 15), and the prohibition of e-cigarette use in indoor public and workplace areas (n = 10).

Investigators adjusted for demographic, socioeconomic, and lifestyle factors to establish odds ratios (ORs) for e-cigarette use per state regulations.

They found adults were less likely to use e-cigarettes in states which prohibited use in indoor areas of private workplaces, restaurants, and bars (OR, 0.90; 95% CI, 0.83-0.98); required retailers to purchase a license to sell e-cigarettes (0.90; 95% CI, 0.85-0.95); prohibited sales of tobacco products to persons younger than 21 (0.86; 95% CI, 0.74-0.99); and applied taxes to e-cigarettes (0.89; 95% CI, 0.83-0.96).

Just state laws prohibiting self-service displays of e-cigarettes was associated with increased odds of adult e-cigarette use (1.04; 95% CI, 0.99-1.09).

Investigators noted, via a US Centers for Disease Control and Prevention (CDC) report, that state legislation regarding e-cigarettes peaked between 2013-2015—a trend which coincides with data showing adult e-cigarette use decreased substantially between 2014-2016. They suggested this may indicate a positive overall correlation between e-cigarette regulation and decreased use.

“It is interesting and reassuring that e-cigarette—related regulations similar to the aforementioned laws may also help reduce e-cigarette use,” they wrote.

Due to the fluctuating roles of e-cigarette and vaping products in the US—from a popular habit among younger adults, to a cessation tool among former combustible cigarette smokers—the findings have strong public health implications.

Bao and colleagues called for greater research into the actual efficacy and safety of e-cigarettes, as well as continued monitoring of state-level patterns in adult e-cigarette use, stratified by regulations.

“Although the reasons for this association remain unclear and warrant further investigation, it indicates that state-level regulations may be a hopeful approach to curb the increase in e-cigarette use among young adults,” they concluded.

The study, “Association of Electronic Cigarette Regulations With Electronic Cigarette Use Among Adults in the United States,” was published online in JAMA Network Open.