Association Between the Washington Ban on Flavored Vape Products and Tobacco Use Among

University Students
Background
Negative health outcomes related to e-cigarette (vape) usage amongst young adults have risen in
recent years due to the high rate of usage in comparison to other populations. Vaping habits that form during
this time may continue into adulthood or turn into cigarette smoking addictions.1 As these e-cigarettes are
relatively new and characteristics of this product such as nicotine dosage and flavorings vary between brands,
the potential long-term health effects of e-cigarette usage remains relatively inconclusive.1 However, recent
reports of hospitalizations suggest a connection between vaping and lung damage due to e-cigarette, vaping,
or product use-associated lung injury (EVALI).2 Vitamin E acetate, a common ingredient of e-cigarettes, is
strongly linked with cases of EVALI.2
With the rising prevalence of e-cigarettes and health concerns surrounding the product, the Washington
state government issued a temporary, emergency ban in October 2019, on flavored vape products to reduce
the prevalence of use, especially amongst young adults.3 To date, no studies have been published,
documenting the potential impact of this ban on vaping habits amongst the young adult population in
Washington (WA).
With this lack of literature in mind, we seek to understand the nicotine habits of university students
during the WA ban by documenting the smoking and e-cigarette use of matriculated students at the University
of Washington, before and during the ban. Understanding the impact of the ban in deterring use of e-cigarettes
and possibly switching to other sources of nicotine can better inform policy on the efficacy of banning flavored
vape products, ultimately protecting the health of the public and preventing unnecessary harm.
Specific Aims and Hypotheses
Our descriptive aim is to assess the current prevalence of use of three different tobacco products:
tobacco flavored vapes, flavored vapes, and traditional cigarettes. We hypothesize that current nicotine trends
amongst UW students will be centered around tobacco flavored vape products or traditional cigarettes due to
the ban on flavored vape products.
Our analytic aim is to compare the odds of being a high user of three different tobacco products before
and during the ban. These three products are flavored vapes, tobacco flavored vapes, and cigarettes. We
hypothesize that the odds of high use of flavored vape products will be lower during the ban compared to
before the ban, and that the odds of high use of alternative tobacco products such as cigarettes or tobacco
flavored vape products will be higher during the ban than before.
Methods
A. Study Population.
Our target population is university students who vape, and our source population is University of
Washington students who had ever vaped before the ban in October 2019. We are applying this inclusion
criteria because we are interested in how people who vaped changed their vaping habits during the ban. We
will use non-probability sampling for efficiency of targeting e-cigarette users, cost-effectiveness and time
limitations. Our recruitment plan is to use flyers with a link to a google survey posted throughout campus with
approval from the buildings. We will also post on different social media platforms such as Facebook and
Instagram. If we do not receive enough responses, we will actively stand in red square or other parts of
campus and try to get more people to respond. Our ideal sample size was between 150-200 responses. It is
unclear how many people were sampled for our study because we do not know if they interacted with our
recruitment materials.
B. Data Collection Procedures.
Data was collected using a survey posted on social media platforms like Facebook, twitter, text
messages. The questionnaire was self-administered through a google form with a mixture of multiple-choice
questions and ratings. The survey link was posted on a number of recruitment materials, allowing for
participants to complete the survey at their own convenience. Participants had the choice to take the survey at
any pace they wanted and wherever they wanted which contributed to them feeling comfortable while
answering any sensitive questions.
C. Data Analysis Plan.
Our exposure of interest is the Washington State ban on flavored vape products. The unexposed group
is everybody in the five months before the ban was instated, and the exposed group is everybody during the
120-day ban starting October 2019. Our outcomes of interest are frequency of flavored vaping, tobacco-
flavored vaping and cigarette usage. To measure our outcomes, we will categorize people into low and high
use groups based on the frequency they report. Our survey will ask participants to recall their vaping/smoking
status before the ban which we will compare their current smoking/vaping status.
On our scale, low use is defined as never vaping/smoking to vaping/smoking once a week. High use is
vaping/smoking any more than once a week. Instead of analyzing for confounding, we will consider residency
status as an effect modifier. Because our study population is UW students, many of the students are coming
from out of state and/or another country. Although all UW students are exposed to the ban because they
attend school in Washington state, some students may go home to their permanent residence on their school
breaks where flavored vape products may be legal. As a result, this may reduce the association between the
ban and these students’ tobacco use. We are not taking confounding into account because we do not have the
tools to do so using a matched case control analysis. However, a potential confounder could include stress, as
the ban coincides with the beginning of the school year and stress may impact tobacco use.
For our descriptive aim, we will report three separate proportions. We will report the proportion of
participants who used flavored vapes, tobacco flavored vapes and traditional cigarettes during the ban. For our
analytic aims we will report three separate pair-matched odds ratios; the odds ratio of being a high user of
flavored vapes, tobacco-flavored vapes and cigarettes, comparing before and during the ban. We will analyze
our effect modifier only for flavored vape use. We will have two strata, one with the presence of our effect
modifier and one without. We will then compare the odds ratios in both strata for flavored vape use.
Results
Population Characteristics
46 University of Washington students participated in our study. The average age was 21 years old.
69.6% identified as cis-female and 30.4% identified as cis-male. The majority (88.9%) were permanent
residents of Washington while 11.1% were out of state residents (Table 1).
Aim 1 Findings
For Aim 1, we calculated the prevalence of nicotine product use during the ban on flavored vape products in
WA among UW students. For comparison, we have also calculated the prevalence before the ban. Flavored
vaping products were most prevalent among UW students before and during the ban. Before the ban, the
prevalence of using flavored vaping products was 96% while during the ban it was 63%, (Table 2 and Figure
1). The prevalence of tobacco flavored vaping products was 28% before the ban and 35% during the ban
(Table 2 and Figure 1). For traditional cigarettes, the prevalence before the ban was 30% and 28% during the
ban (Table 2 and Figure 1). Very few people answered “other” and “prefer not to answer”.
Aim 2 Findings
We will not report an odds ratio of high use for flavored cigarettes because there is a zero value in our
data. No participants changed from being low users of flavored vapes before the ban to high users during the
ban. 11 participants changed from being a high user before the ban to a low user during the ban. 35
participants did not change category (Table 3). This suggests that the participants were more likely to be a low
user of flavored vapes during the ban than before, adding evidence that the ban was effective in reducing
flavored vape use among adolescents. For flavored vape use we also addressed residency status as an effect
modifier. Among Washington residents (n=40), 9 participants switched from high to low use during the ban. No
participants switched from low use before the ban to high use during the ban. For non-Washington residents
(n=6), 2 participants switched from high to low use and no participants switched from low to high use. This
indicates that in both groups, the ban may have been effective in reducing flavored vape use, however, the
population in the non-Washington group was too small to make inferences.
The odds ratio of being a high user of tobacco flavored vapes during the ban compared to before was
1.667 [0.3983, 6.973]. Participants were 66.7% more likely to use tobacco flavored vapes in high amounts
during the ban than before the ban (see Table 4 for exact numbers). Because no participants changed their
traditional cigarette smoking status, we will not report an odds ratio. 1 participant was a high user of cigarettes
before and after the ban and the 45 participants started and remained low users of cigarettes (Table 5). There
was no association between the ban and whether people switched to being high cigarette users.

Discussion
 Our findings for Aim 1 do not support our hypothesis that tobacco flavored vaping or cigarettes would
be more prevalent than flavored vaping due to the ban. Flavored vapes are still the most common form of
tobacco usage among our participants, showing the entrenchment of flavored vaping in youth culture. A much
higher proportion of students (67%) used flavored vapes during the ban compared to cigarettes (28%) or
tobacco flavored vapes (35%).
Our findings for Aim 2 support our hypothesis that students would be less likely to use flavored vaping
products at high amounts during the ban compared to before. No students switched from low to high usage
and 11 switched from high to low usage. This suggests that the ban may have been effective in reducing
flavored vaping, although causation cannot be established. Residency status appeared to have a negligible
effect on the odds of high flavored vaping use. These results are not statistically significant as the number of
non-Washington residents is so small. Students in our study were more likely to use tobacco flavored vape
products during the ban than before which also supports our hypothesis that students would switch to other
forms of tobacco products. Students may have switched from using flavored vape products to tobacco flavored
vape products which were not included in the ban. Contrary to our hypothesis, there was no change in high
and low use for traditional cigarettes, indicating that students did not switch over to traditional cigarettes during
the ban.
The benefit of conducting a cross-sectional study is its cost efficiency, ease of implementation, and
speed. The strengths of our survey include maintaining anonymity, confidentiality and participants were able to
complete it at their own convenience. While conducting a cross-sectional study allowed us to study issues that
would not be ethical to conduct clinical trials on, it prevented the establishment of temporality and causation
due to the chicken and egg conundrum. Because of this, we are unable to say whether the flavor ban caused a
change in vaping and smoking status of the three products we studied. Another limitation of our study is that it
may be prone to social desirability bias because our survey includes personal questions involving potentially
illegal behaviors. Our study is also vulnerable to recall bias as our survey inquired participants to remember
their tobacco use habits before and during the ban. Results may have been skewed due to the difficulty of
remembering smoking and vaping habits prior October to 2019. Furthermore, the external validity of our study
is limited as our population consisted of University of Washington students. This population has a higher
density of higher education, thus decreasing generalizability of the impact of vaping amongst the general
population of adolescents and young adults. Our sample size was also lower than expected, making odds
ratios calculations difficult and lowering generalizability of our findings. Having a larger sample size would have
increased external validity and reduced potential confounders. If we were to do this study again, we would
spend more time recruiting participants to increase our sample size.
Vaping has become an incredibly prevalent public health issue within our society. The harms
associated with smoking cigarettes have been known to the public for a very long time but because e-
cigarettes are a relatively new trend within the past ten years whose effects are not fully understood by
scientists and other health professionals. Because it has become such a huge epidemic amongst many
different populations, politicians and scientists have increased the amount of research being conducted
regarding the long- and short-term effects that these products could have on people’s bodies. In recent news,
there was a string of deaths related to black market vape cartridges, and the United States government
scrambled to implement a policy to help reduce the risk of death. University students are one of the
populations most vulnerable to vaping due to the social aspects of smoking and the relief from stress that
nicotine provides. The purpose of the temporary Washington state ban was to understand if the risk of death or
lung related injuries from vaping could be reduced by getting rid of the fruit and mint flavors that people use the
most frequently. This study is important to understand the effectiveness of different policy implementations and
the vaping patterns of college students. This study has many implications regarding the safety of young adults
and teenagers who use this product the most and the trends surrounding substance use and regulation within
the US government. Conducting studies to measure the efficacy of policy helps us to reduce harm and to make
sure that funds are being properly allocated to handle this issue in the best possible way with the best results.
Because Washington is one of the only states in the country to ban flavored vape products this study provides
unique insight into a policy in action.
It is difficult to draw a conclusion based on our findings given the limitations of our study. Our study
could have been improved by opening the data to other states that enacted the ban or even to students at
other universities within Washington state. Despite the limitations, our data does show us that our participants
were less likely to use flavored vapes during the ban. Moving forward, simply implementing a ban on the
flavored products is not a sustainable solution to reduce the harm that is associated with vaping. To reduce
harm, the best next step would be to try to reduce the illegal activity that allows dangerous and unregulated
products on the black market. The government has already taken strides to remedy this issue by raising the
age required to purchase nicotine products to 21 across the US in the hopes to reduce the number of
teenagers who will have access to these addictive products. More research is required to measure the impact
of these new policies and to fully understand the harm that can come from vaping.

Citations
 1. E-Cigarette Use among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016.
2. Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Centers for
Disease Control and Prevention. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-
disease.html#latest-outbreak-information. Published February 25, 2020. Accessed March 15, 2020.
3. Singh, S., Windle, S., Filion, K., Thombs, B., O'Loughlin, J., Grad, R., & Eisenberg, M. (n.d.). E-
cigarettes and youth: Patterns of use, potential harms, and recommendations. Preventive Medicine., 106009.

Appendix
Literature Review Matrix

* Reference Population Study Key Key Confounder( Key Outstanding

(author, year, studied design exposure(s) outcome(s) s) evaluated findings questions
journal, group studied* studied* noted
member who
contributed
article)

-Hiller, Spindle,
55 college Concept E-cigarette The use of -age Many -the study may
Dick, Eissenberg,
students Mapping use cigarettes students not be
Breland, Soule -race
instead of E- reported generalizable to
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cigarettes stress other
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and populations that
Adolescent Health participatory
anxiety asaren’t students
-Meg Wright approach
the
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-Article Title: reasons
study sample
Reasons for for the
and most of
Transition from transition
them were
Electronic
women
Cigarette Use to
Cigarette
Smoking Among
Young Adult
College Students

Randomized “four e- “covert and Youth

Alisa A Padon, non
trial cigarette ads overt who saw
PhD, Kirsten smoking
with high/low measurements an e-
Lochbuehler, youth age
youth appeal” of e-cigarette cigarette
PhD, Erin K 13–17
and tobacco ad had an
Maloney, PhD,
cigarette increased
Joseph N
attitudes and probabilit
Cappella, PhD
susceptibility to y of
Nicotine & use” choosing
Tobacco an e-
Research, cigarette
Volume 20, Issue item in a
8, August 2018
 product
05 July 2017
choice
Abigail Sauer task
compared
to the
control
and had a
more
positive
opinion of
e-
cigarettes
. Youth
who saw
ads with
low
appeal
still had
an
increased
susceptibi
lity to e-
cigarette
usage
and
tobacco
in
comparis
on to the
control
group.

Brose, L.S., Smokers, Longitudinal Baseline Relapse to gender, Research on

Overall
Bowen, J., recent ex- web-based Vaping status smoking income, vaping and
39.6%
McNeill, A. et al. smokers survey nicotine relapse to
relapsed
Associations and vapers replacement smoking needs
between vaping therapy Those to include info
and relapse to who on cessation
smoking: vaped time, more
preliminary infrequentdetails on
findings from a ly higher frequency and
longitudinal rate of prior
survey in the UK. relapse characteristics
Harm Reduct J (65.0%) like dependency
16, 76 (2019) than
doi:10.1186/s129 never
54-019-0344-0 vaped:
drey Immel
 35.9%

Those who used e-

cigs daily were just as
likely to relapse as
never users

Martinez JA et al., College -cannabis use -how college -cannabis

-cohort -student
2015, Journal of students and college grades are use is
identity
Drug Education, -survey grades affected by associate
formation and
MaKayla Poirier samples cannabis use d with
drug use
lower
Article title: How -demographic grade
Robustly Does and point
Cannabis Use psychosocial average
Associate to indicators of
College Grades? identity (sex,
Findings From race, age,
Two Cohorts work, Greek,
sorts, drug
use history)

Al-Zyoud, et al. Smokers Cohort study Smoking Changes in None noted Smoking Are there
“Salivary and non- salivary creates potential
Microbiome and smokers in microbiota negative confounders
Cigarette Jordan changes such as drinking
Smoking: A First in human alcohol, age,
of Its Kind saliva etc., foods eaten
Investigation in microbiot in certain
Jordan.” MDPI, a, and demographics?
Multidisciplinary which is a
Digital Publishing mediator
Institute, 30 Dec. towards
2019, oral
www.mdpi.com/16 cancers.
60-
4601/17/1/256/ht
m.
Sean Whitson
 Non-collegeCase control Hookah None Can their lack of
Ly, C., Nicksic, N. hookah study warning labels Acceptance of The study college
E., Loukas, A., Users, in hooker warning participan education be a
Prokhorov, A. V., Austin, labels, ts lacked confounder
& Perry, C. L. Texas assessment on enough affecting their
(2018). where hookah education understanding
Receptivity of warning labels on the of health risks
Young Adult are placed, and health associated with
Hookah Users to the efficiency of effects hookah
Health Warning these labels to chemical consumption?
Labels. Tobacco influence exposure,
Regulatory hookah users’ cancer
Science, 4(1), behavior risks of
536–547. doi: hookah.
10.18001/trs.4.1.1

Yasmin Ibrahim

Conceptual Diagram (DAG):

Effect Modifier: Residency Status

Exposure: Washington flavor vape ban ------> Outcome: Vaping Status

Recruitment materials:
Social media script: Hello all vapers! My team and I are doing a research project for my class, Research
Methods in Public Health. If you’re a UW student who vaped before the Washington Ban on flavored vaping
products (or still vapes), we would love it if you completed our survey! Our study is looking at how the ban
affected vaping habits among students. The survey is completely anonymous and none of your information will
be identifiable.
Feel free to contact SPH480@uw.edu for any questions or concerns.

Link to our Google survey:

https://docs.google.com/forms/d/e/1FAIpQLSc3V7i2H5jP6CVLhvi9iJUpGq1nqdm4o21roLJBEcn664fNqw/viewf
orm?usp=sf_link

Flyer
Table 1.

Characteristic Statistic (SD) or % (n/N)

(n=46)

Age 21 (SD=1.18)

Gender

Female 69.6% (32)

Male 30.4% (14)

Non-binary 0% (n/N)

Prefer not to say 0% (n/N)

 Residency status

Washington resident 88.9% (41)

Out of state resident 11.1% (5)

International resident 0% (n/N)

Table 2.
Substance Use % (n/N) Substance Use %(n/N)
Before Ban (n=46) During Ban
(n=46)

Flavored Vaping 44 96% 29 63%

Products

Tobacco Flavored 13 28% 16 35%

Vaping Products

Traditional 14 30% 13 28%

Cigarettes

None/Other 2 4% 3 6%

Prefer Not to 0 0% 1 2%
Answer
Figure 1.
Table 3. Exact numbers for high and low flavored vape use before and during ban.

Flavored Vapes

Before Ban

Outcome (+)High Outcome(-) Low Total

Use Use

During Ban Outcome (+) High Use 16 0 16

Outcome (-) Low Use 11 19 30

Total 27 19 46

Table 4. Exact numbers for high and low tobacco-flavored vape use before and during ban.
 Tobacco Flavored Vapes

Before Ban

Outcome (+) High Outcome (-) Low Total

Use Use

During Ban Outcome (+) High Use 3 5 8

Outcome (-) Low Use 3 35 38

Total 6 40 46

Table 5. Exact numbers for high and low cigarette use before and during ban.

Cigarettes

Before Ban

Outcome (+) High Outcome (-) Low Total

Use Use

During Ban Outcome (+) High Use 1 0 1

Outcome (-) Low Use 0 45 45

Total 1 45 46