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To organize our review, we developed a conceptual model (CM) for flavored/menthol tobacco sales restrictions, illustrating the presumed causal pathways linking policy implementation and intended immediate, short-term, intermediate, and long-term public health outcomes ( Figure 1). We examine the strength of current evidence on the effectiveness of flavored and menthol tobacco sales restrictions to achieve intended policy outcomes. This review is designed to inform advocates, regulators, public health practitioners, and policymakers about the degree to which policy implementation has achieved intended outcomes and, in some cases, prompted actions by the tobacco industry and consumers that could undermine policy effectiveness. The purpose of our review is to provide a comprehensive analysis of published papers reporting results of evaluation studies of actual, implemented flavored product sales laws, including menthol tobacco product sales restrictions, in the United States. While a recent scoping review summarized the effects of implemented and hypothetical policies restricting the sale of menthol tobacco products, 14 there has yet to be a comprehensive review evaluating intended and unintended outcomes of implemented US flavor and menthol restrictions, including those with exclusions of certain tobacco products or exemptions of certain retailer types or locations. 11Ĭoincident with the proliferation of these restrictions is the growing evidence demonstrating the impact these policies have on retailer compliance, product availability, marketing, sales, and population health outcomes. 13 Additionally, to address the dramatic growth in reported use of e-cigarettes among US youth, 4 more than 40 US jurisdictions have banned the sale of all e-cigarettes, regardless of their flavor characteristics. 11 Moreover, in response to the e-cigarette, or vaping, product-use associated lung injury (EVALI) outbreak which began in August 2019, 12 several US states implemented temporary e-cigarette sales restrictions in 2019. As of March 31, 2021, 336 jurisdictions in the United States (states and local counties and municipalities) had passed restrictions on the sale of flavored tobacco products some of which restrict sale of menthol tobacco products. In the absence of comprehensive US federal actions to remove flavored (including menthol) non-cigarette tobacco products, such as cigars and e-cigarettes, and menthol cigarettes from the marketplace, many jurisdictions have adopted policies to restrict the sales of flavored and menthol tobacco products. 5, 6 Disparities in use of menthol cigarette and other favored and menthol tobacco, exacerbated by tobacco industry marketing practices, are especially problematic for certain US subpopulations, notably Black/African American smokers, as well as for LQBTQ and other vulnerable populations, who disproportionately suffer from tobacco-related disease and death.
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4 In the past decade, US sales of menthol cigarettes have increased, as have sales of flavored and menthol cigarillos and little cigars, flavored chewing tobacco, and flavored e-cigarettes. The majority of middle and high school students use flavored e-cigarettes, 1–3 with fruit (73.1% 75.6% prevalence, respectively) mint (55.8% 46.5%) menthol (37.0% 23.5%) and candy, desserts, or other sweets (36.4% 47.2%) reported as the most common flavors. 1 Electronic nicotine delivery systems (i.e., e-cigarettes or “vapes”) are the tobacco products most commonly used by US youth. Flavored tobacco products, including menthol-flavored tobacco products, are widely available for sale in US retail settings and are especially attractive to youth.