National longitudinal risk of tobacco use among youth and young adults in US local jurisdictions with and without flavor and comprehensive smoke-free policies, 2014-2019

Flavored tobacco products are associated with youth and young adult tobacco use and disparities by racial and ethnic minorities and those of lower socioeconomic status. We used Truth Longitudinal Cohort of 19 341participants aged 15-21 years (9 waves, 2014-2019) examining policy exposure impacts on tobacco use. Participants' current any and menthol cigarette and/or flavored cigar use were linked to living in a jurisdiction with a flavored sales restriction and/or comprehensive smoke-free policy based on home address at wave. We estimated risk ratios using Poisson regression for any tobacco product and menthol cigarettes and/or flavored cigar use with interactions of policy and wave by race and ethnicity and financial situation. Policy exposure to flavored sales restrictions rose from 1% of participants at wave 1 to 13% at wave 9. Respondents in areas with flavor plus comprehensive smoke-free policy reduced tobacco use risk by 13% (adjusted relative risk [RR] = 0.87, 95% confidence interval [CI] = 0.77 to 0.99) and no flavor plus comprehensive smoke-free by 8% (adjusted RR = 0.92, 95% CI = 0.87 to 0.98) vs those in no flavor plus noncomprehensive smoke-free policies areas. There were no statistically significant relationships between policy and menthol cigarette and/or flavored cigar use, but most policies in this period exempted menthol and/or mint-flavored tobacco product from the policy thus allowing for sales of menthol cigarettes and menthol and/or mint-flavored cigars. No interactions of policy by race and ethnicity or socioeconomic status were statistically significant. Flavor and comprehensive smoke-free policy exposure compared with exposure to neither policy were prospectively associated with reduced any tobacco use. The impact of flavor policy exposure on any tobacco use was consistent across diverse racial and ethnic groups and socioeconomic position. As flavor policies have strengthened and spread, they have potential for reducing risk of tobacco use among youth and young adults from all populations, including those experiencing tobacco-related health disparities.