Comment from Michael Pesko

As a researcher specializing in the economics of health behaviors and tobacco control, I am writing to share recent peer-reviewed evidence regarding the unintended consequences of flavored electronic nicotine delivery system (ENDS) sales restrictions. These findings, published in the American Journal of Health Economics (2025) and JAMA Health Forum (2024), provide critical data on how such policies influence tobacco product substitution across the United States. 1. Substitution from ENDS to Combustible Cigarettes Our analysis of retail sales data across 44 states (2018–2023) found that for every 0.7 mL ENDS pod (equivalent to one JUUL pod) not sold due to flavor restrictions, twelve additional combustible cigarettes were purchased. This substitution effect was not limited to adults; the increase in cigarette sales included brands disproportionately used by underage youth. These results suggest that while flavor restrictions effectively reduce ENDS sales, they inadvertently increase the consumption of the most lethal form of nicotine delivery: combustible cigarettes. 2. Impacts on Young Adult Behavior Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we evaluated the impact of statewide ENDS flavor restrictions on young adults (ages 18–29). We found that while these policies were associated with a 3.6 percentage point reduction in daily vaping, they were simultaneously associated with a 2.2 percentage point increase in daily cigarette smoking. These data indicate that for a significant portion of the young adult population, ENDS and cigarettes are economic substitutes. 3. Lessons from the "Maryland Model" Our research highlights a potential regulatory middle ground. In Maryland, where a non-menthol flavor restriction applied only to disposables and cartridges—while exempting menthol and "open-system" devices—we observed a reduction in both vaping and smoking among young adults. This suggests that policies targeting the specific device types most popular with youth, rather than blanket flavor bans, may better balance the goals of reducing youth uptake while avoiding a shift back to combustible tobacco for adults and young adults. Conclusion I urge the FDA to consider these substitution effects in its regulatory impact analyses. Policies that significantly reduce the appeal or availability of ENDS without a concurrent and more aggressive strategy for combustible cigarettes risk net-negative public health outcomes. I have attached the following studies to this comment for the agency’s review: Friedman AS, et al. "E-cigarette Flavor Restrictions' Effects on Tobacco Product Sales." American Journal of Health Economics (2025). Friedman AS, et al. "Flavored E-Cigarette Sales Restrictions and Young Adult Tobacco Use." JAMA Health Forum (2024). Thank you for the opportunity to provide this evidence. Sincerely, Michael Pesko J Rhodes Foster Professor of Economics University of Missouri