Three State-Level Tobacco Control Policies to Address Vaping Among Young People and Changes in Vaping Product Access and Use,Vermont,2019-2021

Abstract

In response to the sharp increase in vaping among children, adolescents, and young adults, the Vermont legislature passed 3 policies in 2019 to reduce access to and availability of tobacco products. The objective of this case study was to describe the content, context, actors, processes, and evaluation of the policies: increasing the purchase age to 21 years, establishing a wholesale tax on electronic cigarettes (e-cigarettes), and banning the mail delivery of all tobacco products. We used state-level surveillance data from the Youth Risk Behavior Survey, the Young Adult Survey, and the Behavioral Risk Factor Surveillance System to assess changes in access to and use of vaping products among children, adolescents, and young adults before and after policy implementation. We found decreases in perceived access to vaping products among middle and high school students. In 2019, 29% of middle school students and 73% of high school students reported that it was easy to access vaping products, which decreased in 2021 to 18% and 58%, respectively. Past-30-day use of vaping products decreased among both middle school and high school students from 2019 to 2021. In 2019, 8% of middle school students and 26% of high school students reported past-30-day use of vaping products, which decreased in 2021 to 5% and 16%, respectively. Vaping behavior among young adults increased in Vermont. In 2017, 6% of young adults reported current e-cigarette use, rising to 22% in 2022. Tobacco control strategies should continue to focus on evidence-based policies that curtail initiation, limit use, and expand treatment for nicotine and tobacco use among children, adolescents, and young adults.

Keywords

tobacco control policy youth vaping

The use of nicotine electronic cigarettes (e-cigarettes) or other electronic vapor products (vaping) among children, adolescents, and young adults comes with substantial risks to physical and behavioral health, including negative effects on pulmonary, oral, cardiovascular, and mental health.^1-3 The trajectory of those who vape nicotine toward the use of combustible cigarettes is also a concern.⁴ Despite its negative health effects, nicotine vaping sharply increased among middle and high school students in the United States, from 1.5% in 2011 to 20.8% in 2018,⁵ fueled by tobacco industry tactics to increase consumption of tobacco and nicotine products during the lifespan.⁶

State-level policy approaches, in concert with a comprehensive tobacco control program, can lower the likelihood of initiation of vaping and use of e-cigarettes.⁷ Age restriction policies can decrease the perceived ease of access to vaping products among young people and reduce tobacco and nicotine use, especially among young adults aged 18 to 21 years.^8-10 Taxation of products is another strategy to reduce use: evidence shows that 90% of e-cigarette taxes are passed onto consumer prices.¹¹ Recent studies demonstrate that higher e-cigarette tax rates are associated with decreased rates of vaping among young adults, although some evidence suggests that such taxes have the unintended consequence of increasing the prevalence of using combustible cigarettes.^12,13 Policies that regulate tobacco retail sales, such as bans on online sales of e-cigarettes, have not been widely studied.¹⁴ Up to 37% of underage users report purchasing vaping products online,¹⁵ indicating a potential avenue for limiting access to vaping products among young people.

In response to the increase in vaping among children, adolescents, and young adults, the Vermont legislature passed 3 state-level policies in 2019^16-18 to reduce access to and availability of e-cigarette products among this population. Because tobacco control policies can diffuse vertically to different levels of government, such as the federal level, or horizontally from state to state,¹⁹ studying the process and effects of state-level policies is important. States vary by legislative professionalization, the political party in control, and the politics of voters in the state²⁰; understanding the policy process from various states, including smaller states such as Vermont, is valuable. The objective of this case study was to describe the content, context, actors, and processes involved in these tobacco control policies and evaluate changes in access to e-cigarettes and vaping behavior among children, adolescents, and young adults.

Methods

This study used the health policy triangle as a framework to describe the intervention and focused on the context in which the policies are being implemented, the content, the actors involved in the policy development and implementation, and the processes of policy initiation, development, and implementation.²¹

Context

Vermont is a rural state in the Northeast, with 64.9% of its population residing in rural areas.²² Rurality is notable because young people residing in rural areas are more likely than young people residing in urban areas to use cigarettes and smokeless tobacco.²³ Vermont was well positioned to implement tobacco control policies because of its history of tobacco policy at the state level and partnerships between state agencies, including a 2008 ban on internet sales and mailing of cigarettes, ahead of the national-level 2010 Prevent All Cigarette Trafficking Act.²⁴ Additional pricing policies were passed in the 2014 and 2015 legislative sessions,^25,26 which raised the tax level of combustible cigarettes and positioned Vermont in the top 10 highest in cigarette taxes among states.

Content

The 3 policies passed in 2019 were (1) an e-cigarette online sales ban (Act 22),¹⁶ (2) limiting tobacco sales to people aged ≥21 years (Tobacco 21; Act 27),¹⁷ and (3) an increased tax on e-cigarettes (Act 28).¹⁸ Act 22, which banned online sales of e-cigarettes (effective July 1, 2019), aimed to reduce access to and availability of e-cigarettes. The policy states that no tobacco products may be “ordered or purchased by mail or through a computer network, telephonic network, or other electronic network . . . to be shipped to anyone other than a licensed wholesale dealer or retail dealer.”¹⁶

Act 27 (effective September 1, 2019) declares that “a person under 21 years of age shall not possess, purchase, or attempt to purchase tobacco products, tobacco substitutes, or tobacco paraphernalia” with the exception of tobacco possession “in connection with Indigenous cultural tobacco practices.”¹⁷ The act also identified the Department of Liquor and Lottery (DLL) as the enforcement agency to restrict tobacco access and delay initiation of tobacco among young people.

Act 28, the e-cigarette tax (effective July 1, 2019), aimed to deter customers from purchasing e-cigarettes and prevent initiation of e-cigarette use among young people by expanding the definition of “other tobacco products” to include “tobacco substitutes . . . liquids, whether nicotine based or not; and devices sold separately for use with tobacco substitute,” meaning that these products, including e-cigarettes or vapes, are now subject “to the 92% wholesale tax imposed on other tobacco products.”¹⁸

Actors

The actors involved in the 2019 tobacco control policies passed in Vermont included individuals, groups, and organizations involved in the development, implementation, and evaluation of the policies (Table 1). The Vermont General Assembly was the primary developer of the policies, although many representatives from the education, medical, public health, and nonprofit sectors were involved in education throughout the development phase of the process.

Table 1.

Actors involved in tobacco control policies, Vermont, 2019

Policy	Actor	Role in the policy process
Policy	Actor	Development	Education	Implementation	Evaluation
Tobacco 21¹⁷	General Assembly	x
	Department of Health		x		x
	Department of Liquor and Lottery			x	x
	Nonprofit organizations		x
	Medical representatives		x
	K-12 education leadership and staff		x
	Higher education institutions				x
	Tobacco retailers		x	x
E-cigarette wholesale tax¹⁸	General Assembly	x
	Department of Health		x		x
	Department of Taxes			x	x
	Nonprofit organizations		x
	Medical representatives		x
	K-12 education leadership and staff		x
	Higher education institutions				x
	Tobacco retailers		x	x
E-cigarette online sales ban¹⁶	General Assembly	x
	Department of Health		x		x
	Office of the Vermont Attorney General		x	x	x
	Department of Liquor and Lottery		x	x	x
	Nonprofit organizations		x
	Medical representatives		x
	K-12 education leadership and staff		x
	Higher education institutions				x
	Tobacco industry		x

Abbreviations: e-cigarette, electronic cigarette; K-12, kindergarten through grade 12.

Process

The process to develop and implement the 2019 tobacco control policies in Vermont was based on precedents set by other states and political buy-in in the General Assembly. Ten states had previously raised the legal purchasing age of tobacco to 21 years.²⁷ For the e-cigarette tax, prior to 2019, 8 states had passed special tax laws on e-cigarettes that were structured in various ways, from taxes per fluid milliliter to taxes on wholesale pricing.²⁸ Education and advocacy efforts among state agencies, nonprofit organizations, medical representatives, and education representatives were also critical to the process.^29,30

The process of policy implementation also included education and enforcement. Enforcement is vital to the success of Tobacco 21 policy,³¹ which in Vermont consisted of retailer compliance checks of brick-and-mortar tobacco retailers contracted through the US Food and Drug Administration (FDA) and age requirements checked by the DLL. Annual retailer compliance was consistently high both before and after Tobacco 21 went into effect: it was 90% or higher from state fiscal years 2018 through 2021, which includes the period before and after implementation of Tobacco 21.³²

For the ban on online e-cigarette sales, a partnership among the Vermont Tobacco Control Program, the Vermont DLL, and the Office of Vermont Attorney General (AGO) was responsible for enforcement. The Vermont DLL maintains a comprehensive list of online tobacco retailers and tests them for compliance with the ban on delivery sales. In 2020 and 2021, DLL tested 273 unique retailers, and some retailers were tested multiple times for compliance.³³ In 2021, 63% of tested online retailers complied with policy, compared with only 38% in 2020. DLL referred the retailers found to be noncompliant with Vermont’s ban on delivery sales to the AGO. From December 2020 through April 2022, the partnership among the Vermont Tobacco Control Program, DLL, and AGO resulted in 23 settlements with noncompliant online retailers, bringing in $833 750 in penalties to the state.³⁴

Implementation of the e-cigarette tax was overseen by the Department of Taxes, which ensured that wholesale retailers in the state complied with the 92% wholesale price tax. In the first 12 months after the law went into effect (July 2019–June 2020), the Department of Taxes collected $4.15 million in e-cigarette taxes, and in the subsequent 12 months (July 2020–June 2021), the department collected $7.33 million in taxes from e-cigarette wholesale product sales (Vermont Department of Taxes, written communication, February 22, 2022).

Ethics

This case study used surveillance data from the State of Vermont. Data from the Vermont Behavioral Risk Factor Surveillance System (BRFSS) and the Vermont Youth Risk Behavior Survey (YRBS), funded by the Centers for Disease Control and Prevention (CDC), have no individually identifiable information and do not meet the requirements of human subjects research as determined by the US Department of Health and Human Services. The CDC Institutional Review Board determined that surveillance conducted by a state, local, territorial, or tribal entity is public health practice and not research.

Evaluation Methods

We used an observational, serial cross-sectional design to assess changes in access to and use of vaping products among children, adolescents, and young adults before and after implementation of policies. We used data from the Vermont YRBS, the Vermont Young Adult Survey, and the Vermont BRFSS (Table 2).

Table 2.

Data sources and measures used for evaluation of tobacco control policies, Vermont, 2019

Data source	Survey years used	Age of respondents	Measures	Survey question(s)
Vermont Youth Risk Behavior Survey³⁵	2019, 2021	Middle school students in grades 6-8 and high school students in grades 9-12	Vaping prevalencePerceived access to vaping products	“Have you used electronic vapor products during the last 30 days?”“If you wanted to get electronic vapor products, how hard or easy would it be for you to get some?”
Vermont Young Adult Survey³⁶	2020, 2022	Adults aged 18-25 years	Perceived access to vaping products	“How easy is it for underage persons to buy e-cigarettes or other electronic vapor products?”
Vermont Behavioral Risk Factor Surveillance System³⁷	2016, 2017, 2020, 2021, 2022	Adults aged 18-24 years	Vaping prevalence	“Do you now use e-cigarettes and other electronic vaping products every day, some days, or not at all?”

Abbreviation: e-cigarette, electronic cigarette.

We used data from the Vermont YRBS to assess changes in perceived access and vaping behavior from 2019 to 2021. The Vermont YRBS is a school-based survey administered to middle school students in grades 6-8 (children and adolescents aged 11-13 y) and high school students in grades 9-12 (adolescents and young adults aged 14-18 y).³⁵ E-cigarette items on the YRBS have been found to be reliable (κ = 0.81).³⁸ Due to COVID-19–related societal disruptions, the 2021 YRBS was conducted in the fall, rather than in the spring as in previous years, so the average age of the survey participants was younger than in previous years. Therefore, 2021 YRBS results are not directly comparable with results from other years. The Vermont Department of Health weighted the survey based on sex, grade, and race and ethnicity to obtain a representative sample for Vermont. We calculated weighted prevalence estimates and 95% CIs for each variable.

We used data from the Vermont Young Adult Survey³⁶ in 2020 (n = 2340) and 2022 (n = 1538) to measure changes in perceived access to vaping products among underaged people and assess changes in access due to Tobacco 21. The Young Adult Survey is an online survey among adults aged 18 to 25 years. The survey contractor weighted the survey data to the 2019 young adult population of Vermont based on age group, sex, and county of residence. We used data from 2020 and 2022 because 2020 was the first year the survey asked about perceived ease of access to vaping products. We calculated weighted prevalence estimates and 95% CIs for each measure for both the total sample of those aged 18 to 25 years and a subsample of those aged 18 to 20 years. We created this subsample because this population would have been directly affected by Tobacco 21.

We used data from the 2016, 2017, 2020, 2021, and 2022 Vermont BRFSS surveys to assess vaping behavior among adults aged 18 to 24 years. The BRFSS is an annual telephone survey administered to adults (aged ≥18 y).³⁷ The self-reported items on tobacco use in the BRFSS have been found to be reliable overall.³⁹ The Vermont Department of Health weighted the results from the survey to represent the adult population of Vermont. We assessed the prevalence of vaping behavior in this population by using a calculated variable for current e-cigarette use. The item on e-cigarette use was not included in the Vermont BRFSS survey in 2018 or 2019. We calculated weighted prevalence estimates and 95% CIs for each variable.

Outcomes

Vermont YRBS

The percentage of Vermont YRBS respondents who reported that it was “sort of easy” or “very easy” to access vaping products decreased from 29% (95% CI, 29%-30%) in 2019 to 18% (95% CI, 17%-18%) in 2021 among middle school students and from 73% (95% CI, 72%-73%) in 2019 to 58% (95% CI, 57%-59%) in 2021 among high school students. The prevalence of past-30-day use of vaping products also decreased in this population from 2019 to 2021: from 8% (95% CI, 7%-8%) in 2019 to 5% (95% CI, 4%-5%) in 2021 among middle school students and from 26% (95% CI, 26%-27%) in 2019 to 16% (95% CI, 16%-17%) in 2021 among high school students.

Vermont Young Adult Survey

We found no changes from 2020 to 2022 in perceived access to vaping products among underaged people in either the total sample for the Vermont Young Adult Survey (aged 18-25 y) or the subsample (aged 18-20 y). In 2020, 57% (95% CI, 54%-59%) of all respondents reported it was “somewhat easy” or “very easy” for underaged people to buy e-cigarettes compared with 53% (95% CI, 50%-56%) in 2022. In 2020, 62% (95% CI, 58%-66%) of respondents aged 18 to 20 years reported it was “somewhat easy” or “very easy” for underaged people to buy e-cigarettes, compared with 55% (95% CI, 50%-60%) in 2022.

Vermont BRFSS

The prevalence of current e-cigarette use among Vermont BRFSS respondents aged 18 to 24 years increased from 6% (95% CI, 3%-9%) in 2017 to 22% (95% CI, 16%-27%) in 2022 (Figure).

Figure.

Prevalence of electronic cigarette (e-cigarette) use among adults aged 18-24 years in Vermont, 2016-2022. Data are from the 2016, 2017, 2020, 2021, and 2022 Vermont Behavioral Risk Factor Surveillance System (BRFSS) surveys.³⁸ The item on e-cigarette use was not included in the Vermont BRFSS survey in 2018 or 2019. Error bars indicate 95% CIs.

Lessons Learned

This case study described 3 tobacco control policies passed in Vermont in 2019 and changes in access to and use of vaping products among children, adolescents, and young adults. Among middle and high school students, we found a decrease in perceived access to vaping products and past-30-day vaping behavior from 2019 to 2021. Among young adults, we found no changes in perceived access to vaping products among underaged people and an increase in the prevalence of current e-cigarette use from 2017 to 2022.

The decreases in perceived access and vaping behavior among middle school and high school students in Vermont indicate positive findings among these age groups after passage of policies on age restrictions, online sales, and wholesale taxes. Previous evaluations of Tobacco 21 policies showed increases in checking identification among retailers and increases in perceived risk of vaping products among young people.^40,41 The decrease in past-30-day vaping behavior follows national trends of declines from peak prevalence in 2019. However, nationwide, among current vapers, the frequency of vaping increased, and among young people who vape, the percentage who vape daily increased.⁴² Another contextual factor to consider is that the prevalence of cannabis vaping has been increasing among children, adolescents, and young adults, and as nicotine products have been restricted, these populations may have switched to other product types.⁴³

The finding from this evaluation that vaping behavior among young adults in Vermont increased during the study period follows national trends of increases in exclusive vaping among young adults.⁴⁴ Young adults may be less price sensitive than children and adolescents, and many underage young adults use social sources to obtain products,⁴⁵ indicating that other tobacco control policies and treatment may be needed to address vaping in this age group. In addition, young adults are exposed to vaping marketing through more channels than adolescents are,⁴⁶ and exposure to marketing is associated with increases in subsequent past-30-day use of vaping products among young adults.⁴⁷

Several lessons learned and recommendations may benefit other jurisdictions seeking to implement such policies. Establishing and maintaining strong partnerships across state agencies was pivotal to policy implementation. Such partnerships allowed for an exchange of data on compliance and enforcement and bolstered education among retailers. In addition, communication channels were available at state agencies for people who were witnessing firsthand the rise in vaping among young people, such as school nurses, school principals, and public health workers, so they could communicate their concerns to state officials. The Vermont Department of Health and the University of Vermont established a partnership to conduct research on timely and evolving topics, including vaping among young people. The partnership will continue through further assessment and publication on awareness and behavior changes among substances from policies in Vermont.

Gaps in and limitations to Vermont’s tobacco control policies may be affecting access to vaping products among young people. First, the content of the e-cigarette tax bill (Act 28)¹⁸ allowed wholesale entities to also be licensed as tobacco retailers, which permitted them to lessen the tax by selling the products to themselves at a lower rate, thereby offsetting the cost to consumers. Second, despite the AGO’s efforts in regulatory actions against online vaping retailers, the presence of social media and international retailers poses challenges for enforcement. Online vape shops often rely on self-certification of age, allowing minors to easily access products.⁴⁸ Vaping products are widely available through social media platforms where young people are highly active (eg, TikTok⁴⁹).

Other contextual factors may have contributed to the changes we observed in product access and vaping behavior among young people, including the emergence of EVALI (e-cigarette, or vaping, product use–associated lung injury) in late 2019 and the COVID-19 pandemic in 2020. The emergence of EVALI could have influenced the decrease in vaping behavior among young people due to increased perceptions of harm of vaping products in this population.⁵⁰ The COVID-19 pandemic may also have influenced changes in product access and vaping behavior, although evidence is mixed on the effect of the COVID-19 pandemic on vaping among young adults.⁵¹ The FDA banned flavored cartridge–based vaping products in early 2020, although data from the Population Assessment of Tobacco and Health indicated that most children and adolescents aged 12 to 17 years who already vaped or started vaping at the time of the ban used flavor or device combinations that were excluded from the FDA’s enforcement.⁵²

This case study had several limitations. First, it focused on identifying changes in product access and vaping behavior outcomes, regardless of whether the changes necessarily resulted from the 3 tobacco control policies, and, therefore, we used a nonexperimental or descriptive design. Such designs cannot clearly link changes to policies because they are unable to rule out alternative explanations for the changes. Second, this study did not disentangle the effects of the policies on perceived access to vaping products and vaping behavior. Future research should assess the specific pathways of the policies to understand which policy or policies may be driving behavior changes. Third, the 2021 YRBS was conducted in the fall, rather than in the spring as in previous years, so the average age of survey participants was younger than in previous years and some risk behavior prevalence estimates may be lower than in other years due to the younger age of participants. Finally, the Young Adult Survey did not ask questions about perceived access until 2020, so the data presented do not represent a true baseline but, rather, indicate trends in perceived access after the policies were passed, warranting the need for further research.

Policy passage and enforcement are established evidence-based tobacco control strategies. The passage of Tobacco 21, an e-cigarette tax, and a ban on online e-cigarette sales in Vermont aimed to reduce access to and use of vaping products among children, adolescents, and young adults. Multicomponent tobacco control policies that focus on various aspects of tobacco control, including age restrictions, sales restrictions, and taxation, can contribute to decreases in access to and use of vaping products among young people. Future tobacco control strategies should continue to focus on policies, whether passed singly or in a prevention package, that can have the most impact on reducing rates of initiation and use and increase cessation activity. More research and evaluation are needed on state-level successes and challenges in passing these policies.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the Vermont Department of Health.

ORCID iD

Melissa Chapman Haynes, PhD

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