(Alison Cross)

The state’s failure to pass a ban on flavored tobacco products may have put it in a better strategic position to prevent and combat teen tobacco use.

Legislators could not agree on the ban in June, but a new—albeit small—study by Abigail Friedman, assistant professor of health policy at the Yale School of Public Health, found that after San Francisco banned flavored tobacco products in 2018, including flavored e-cigarettes, cigarette smoking increased among the city’s high school students.

In comparatively similar school districts across the country with no flavor ban, cigarette smoking continued to decline, according to Friedman’s study, published in May in JAMA Pediatrics.

“This raises concerns that reducing access to flavored electronic nicotine delivery systems may motivate youths who would otherwise vape to substitute smoking,” Friedman wrote.

The results of the Yale study may be a case of correlation rather than causation. Data show that between 2017 and 2019, other high-risk youth behaviors such as alcohol, cannabis and cocaine use that trended downward for four or more years also increased. Friedman cautioned that the study has limited generalizability outside of San Francisco and said that future investigations should evaluate whether these upward and downward trends continue.

Dr. Kourosh Parham, an ear, nose, and throat physician at UConn Health, said the data from San Francisco highlights the fact that nicotine addiction is complex and not easily solved by one form of legislation.

“Any effort to restrict the use of e-cigarettes needs to be coordinated with a parallel effort to address the traditional combustible tobacco products,” Parham said. “In isolation, one campaign without addressing the other is not going to succeed. Close coordination is required to educate and utilize resources that are available to get away from the use of these products.”

While many view vaping as healthier than smoking, Parham added that because of the toxicity and dangers of both products, choosing vaping over smoking is like “choosing one devil over the other.”

Co-founder of Parents Against Vaping e-cigarettes, Dorian Fuhrman, said the study, which only collected data for the year before and after the flavor ban’s implementation, is too brief to determine a cause and effect between legislation and patterns of tobacco use. She said banning flavored e-cigarettes is key to preventing youth initiation with nicotine addiction.

“By taking flavored e-cigarettes off the market, you’re closing the on-ramp for tobacco use among kids, so you aren’t getting new smokers,” Fuhrman said.

After the tobacco-flavor ban went into effect, current high school smokers in San Francisco increased from 4.7% of students in 2017 to 6.5% in 2019, according to the 2019 Youth Risk Behavior Survey. The percentage of students who had ever tried smoking also increased from 16.7% to 18.6%.

The percentage of students who vaped also continued to increase despite the ban. The rate of students who had ever used an electronic vapor product increased from 25% in 2017 to 31.1% in 2019. Current vapers jumped from 7.1% of San Francisco students in 2017 to 16% in 2019.

According to data from the Connecticut Youth Tobacco Survey and Connecticut Youth Risk Behavior Survey, the state has seen high school-aged tobacco users increase since 2013. In 2013, 19% of high school students had used some form of tobacco product. By 2019, that number had grown to 28%. Over the same period, cigarette smoking among high schoolers declined from 9% to 4%, and e-cigarette use more than quadrupled from 5% of high schoolers in 2013 to 27% in 2019.

In the past, anti-tobacco advocates have criticized Connecticut for the lack of state-funded tobacco prevention and cessation programs. In fiscal year 2021, the state made more than $300 million from smokers and vapers through tobacco taxes and an additional $133 million from tobacco settlements, but none of this money went to tobacco-related programs. Earlier this year, the American Lung Association’s report card gave the state Fs for its tobacco prevention and cessation funding and for not stemming the use of flavored tobacco products.