Tobacco product flavour policies in the USA.

Objectives: Characterise US residents' exposure to restrictions on sales of flavoured electronic nicotine delivery system (ENDS), cigars and menthol cigarettes across states and time, and assess correlations between these policies.

Methods: From 2022 to 2024, we compiled flavour policy locations from advocacy groups and online searches, located corresponding legal texts and reviewed these to identify policy details, including effective dates. Using census data, we calculated the proportion of state residents covered by each policy quarterly from 2009 to 2024 and estimated correlations between them and cigarette taxes.

Results: By January 2024, menthol cigarettes, flavoured cigars and flavoured ENDS sales restrictions covered 17.6%, 18.1% and 28.1% of US residents. About 1 in 10 US residents is subject to flavoured ENDS restrictions without concurrent restrictions on flavoured cigar and menthol cigarette sales. Strong correlations between flavour policy coverage and cigarette tax rates indicate a need to adjust for exposure to a range of tobacco control policies in analyses evaluating any one of these regulations' effects.

Conclusions: While state and local adoption of restrictions on flavoured tobacco product sales has proliferated, flavour policy coverage for combustible tobacco products lags well behind that for ENDS. If this leads some people who vape flavoured ENDS to substitute towards flavoured cigars and/or menthol cigarettes, this policy combination could harm population health.

Policy implications: Rapid implementation of proposed US Food and Drug Administration rules barring flavoured cigar and menthol cigarette sales is needed to ensure that regulation of more lethal, combustible tobacco products is not more lenient than restrictions on less harmful nicotine products.