A Qualitative Comparative Analysis of State Flavored E-Cigarette Policy Implementation and E-Cigarette Use.

Abstract

Flavors are a key driver of youth and young adult e-cigarette use. U.S. states have enacted policies restricting flavored e-cigarette sales, but their effectiveness may vary because of differences in policy design and enforcement. Qualitative comparative analysis (QCA) was used to identify necessary and sufficient policy implementation conditions associated with changes in e-cigarette use across age groups. Values for conditions were derived through triangulation of multiple data sources, including interviews and surveys with key informants from states with flavored e-cigarette policies, statutory and regulatory text, and policy surveillance databases. Binary conditions were coded into sets representing policy provisions, implementation characteristics, and enforcement features. State-specific e-cigarette use data from 2019-2023 were obtained from the Youth Risk Behavior Survey and Behavioral Risk Factor Surveillance System. Among young adults (18-24 years) in five states with flavor policies, reductions in e-cigarette use were linked to five enforcement conditions: state authority to suspend licenses or confiscate products, local authority to levy fines, compliance checks, local enforcement, and health department enforcement. The same configuration of enforcement conditions associated with reductions among young adults was linked to the absence of reductions among adults ≥25 years. No conditions were sufficient among high school youth. Conditions associated with decreased young adult e-cigarette use may reduce initiation among young adults while supporting cessation and transitions to less harmful products among adults who use nicotine products. Robust authority, monitoring, and enforcement infrastructure may enhance policy impact and should be considered in future policy design and implementation.