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Coupons and state tobacco policy context as predictors of tobacco use
among those reporting e-cigarette use in the U.S.: Findings from the
Population Assessment of Tobacco and Health (PATH) Study waves
5–6 (2018–2021)
J.H. Kingsbury
a,b,*
, H.L. Kimmel
a
, M.J. Parks
a,b
, M.R. Creamer
a
, C. Blanco
a
, W.M. Compton
a
a
National Institute on Drug Abuse, 6001 Executive Blvd, N. Bethesda, MD 20852, USA
b
Kelly Government Solutions, 8380 Colesville Rd #500, Silver Spring, MD 20910, USA
ARTICLE INFO
Keywords:
e-cigarettes
Public policy
Cessation
Tobacco use
Coupons
Marketing
ABSTRACT
Background: Receipt of cigarette and e-cigarette coupons predicts initiation and progression of use and hinders
cessation. Less is known about how coupons operate in different tobacco regulatory environments. The current
study utilized longitudinal data from the Population Assessment of Tobacco and Health (PATH) Study to address
this research gap.
Methods: Adults who reported past 30-day (P30D) e-cigarette use at Wave 5 (2018–2019) were included (N =
3632). The primary outcome was Wave 6 (2021) P30D any tobacco use. Wave 5 predictors were receipt of e-
cigarette coupons, state e-cigarette tax, state tobacco policy context, avored e-cigarette use, income, and ed-
ucation. Covariates were age, sex, race, state coupon policy, and Wave 5 use of tobacco other than e-cigarettes.
Weighted logistic regression models examined effects overall and in samples stratied by state e-cigarette tax and
tobacco policy context.
Results: Controlling for covariates, Wave 5 coupon receipt (AOR =1.57; 95 % CI: 1.07, 2.31) and preference for
avored e-cigarettes (AOR =1.70; 1.37, 2.10) were positively associated with Wave 6 tobacco use. Stronger state
tobacco policy context was negatively associated with tobacco use (AOR =0.69; 0.55, 0.88). Coupon receipt
predicted tobacco use in states with an e-cigarette tax (AOR =2.39; 1.22, 4.68) and with stronger tobacco policy
contexts (AOR =1.80; 1.07, 3.02), but not in states without an e-cigarette tax (AOR =1.29; 0.83, 1.99) or with
weaker tobacco policy contexts (AOR =1.33; 0.78, 2.24).
Conclusions: Policies that restrict price-discounting could help discourage e-cigarette use, reinforce e-cigarette
taxes and other tobacco control policies, and promote cessation of all tobacco among those reporting e-cigarette
use.
1. Introduction
Cigarette use is declining in the U.S. and many adults who used to
smoke cigarettes have switched to e-cigarettes (Brouwer et al., 2024;
Sanford et al., 2024). While there is support among many public health
ofcials for the notion that those who smoke would benet from
completely transitioning to e-cigarettes (Centers for Disease Control and
Prevention, 2024b), quitting all tobacco product use is optimal for
health. Despite the large body of research examining factors that predict
cigarette cessation and transitioning to e-cigarettes, little is known about
predictors of e-cigarette cessation among adults who use e-cigarettes, as
much of the work in this area has targeted youth and young adults
(Palmer et al., 2022). Researchers have cited an urgent need for addi-
tional work in this area to better understand the conditions in which
adults who use e-cigarettes stop using these products (Palmer et al.,
2022).
Tobacco use initiation, progression, and cessation are inuenced by a
combination of both micro- and macro-level factors (Han and Son,
2022). While individual-level factors such as risk perceptions consis-
tently predict tobacco use (Kim et al., 2022; Hyland et al., 2004),
* Corresponding author at: National Institute on Drug Abuse, 6001 Executive Blvd, N. Bethesda, MD 20852, USA.
E-mail addresses: John.kingsbury@nih.gov (J.H. Kingsbury), heather.kimmel@nih.gov (H.L. Kimmel), michael.parks@nih.gov (M.J. Parks), melisa.creamer@nih.
gov (M.R. Creamer), carlos.blanco2@nih.gov (C. Blanco), wcompton@nida.nih.gov (W.M. Compton).
Contents lists available at ScienceDirect
Preventive Medicine Reports
journal homepage: www.elsevier.com/locate/pmedr
https://doi.org/10.1016/j.pmedr.2024.102943
Received 8 October 2024; Received in revised form 5 December 2024; Accepted 5 December 2024
Preventive Medicine Reports 49 (2025) 102943
Available online 9 December 2024
2211-3355/© 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (
http://creativecommons.org/licenses/by-
nc-nd/4.0/ ).
altering the environment is among the most effective ways to change
tobacco use behavior (Caraballo et al., 2019). Where people live and
what they are exposed to can have a dramatic inuence on tobacco use.
State-level clean indoor air policies have become increasingly common
and have led to reductions in use and exposure to secondhand smoke
(Siegel et al., 2005; Mojtabai et al., 2019). Use of avored tobacco, both
menthol and other avors, has become widespread (Odani et al., 2020)
and preference for avors is a commonly cited reason for e-cigarette use
among adults trying to quit smoking cigarettes (Russell et al., 2018; Mok
et al., 2022). However, avored e-cigarettes are also associated with
onset of tobacco use and continued vaping among youth (Goldenson
et al., 2019; Leventhal et al., 2019); local- and state-level restrictions on
the sale of avored tobacco have correspondingly increased (Truth
Initiative, 2024a). Perhaps the most successful tobacco control measure
is increasing the price of tobacco via taxation (Chaloupka et al., 2011;
Chaloupka et al., 2012). Recently, e-cigarette taxes have been proposed
in several states in an attempt to curb e-cigarette use (Centers for Disease
Control and Prevention, 2024a). In sum, by increasing the price of to-
bacco and restricting where people can smoke and where tobacco
products are sold, public policies promote decreased tobacco initiation
and increased cessation at the population level.
Conversely, exposure to tobacco marketing, including price dis-
counting strategies such as direct mail coupons, is associated with so-
cioeconomic and tobacco use status. Previous research using the
Population Assessment of Tobacco and Health (PATH) Study found that
receipt of coupons for cigarettes and e-cigarettes is more common
among those reporting lower socioeconomic status and those with cur-
rent use. To our knowledge, only one study has examined the effects of e-
cigarette coupon receipt on e-cigarette use. This study found that e-
cigarette coupon receipt prospectively predicted e-cigarette initiation,
decreased cessation of e-cigarettes, and increased relapse (Duan et al.,
2023). These results are similar to studies on cigarette coupon receipt,
which have reported that coupon receipt prospectively predicts initia-
tion of smoking, progression to established smoking among those
reporting experimental use, and smoking relapse among those who
report former use (Choi et al., 2018; Hamilton-Moseley et al., 2023).
Collectively, these studies suggest that receipt of coupons for tobacco
products are associated with subsequent use of these products.
However, while there is strong evidence that (1) coupon receipt in-
creases tobacco use and (2) regulatory actions have the potential to
reduce tobacco use, no studies have examined the association between
coupon receipt and future tobacco use within different tobacco control
contexts. Furthermore, research on how different regulatory environ-
ments promote (or inhibit) cessation has not focused on cessation of all
tobacco products, including e-cigarettes. The current study utilized
longitudinal data from the PATH Study to address these research gaps.
2. Methods
2.1. Sample
This study utilized data from the PATH Study, a nationally repre-
sentative, longitudinal cohort study of tobacco use among U.S. adults
and youth (Piesse et al., 2021). The PATH Study used a stratied
address-based, area-probability sampling design and oversampled those
who use tobacco, those aged 18 to 24 years, and African American
individuals.
The current study utilized data from Waves 5 and 6 of the PATH
Study. Data collection dates were December 2018 to November 2019 for
Wave 5 and March 2021 to November 2021 for Wave 6. Adults (18+)
who reported past 30-day e-cigarette use at Wave 5 and had complete
data for all study variables were included in the current study (N =
3632). PATH Study data collection is conducted by Westat and these
procedures were approved by Westat's Institutional Review Board in
July 2021 (Project Number 8954). Adult participants completed written
informed consent. Additional details on the PATH Study design and
methods are published elsewhere (Hyland et al., 2017). Details on
interview procedures, questionnaires, sampling and weighting and in-
formation on accessing the data are available at https://doi.org/
10.3886/Series606.
2.2. Measures
The primary outcome was any tobacco use at Wave 6. Tobacco use
behaviors were assessed with the question, “In the past 30 days, have
you used _____, even one or two times?” for the following products: cig-
arettes, e-cigarettes, traditional cigars, little cigars or cigarillos, ltered
cigars, premium cigars, pipe, hookah, snus, and smokeless tobacco.
Participants who responded “yes” to any of these questions were coded
as a “yes” for any tobacco use. Established e-cigarette use was assessed by
asking whether participants had ever used e-cigarettes fairly regularly.
Current established e-cigarette use was determined by identifying those
who newly reported using e-cigarettes “fairly regularly” (i.e., responded
“no” to fairly regular use in all previous waves) and reported current
past 30-day use.
The primary predictor was receipt of e-cigarette coupons in Wave 5.
Participants who reported receiving a coupon in the past 12 months for
“e-cigarettes or other electronic nicotine products (including e-liquid)”
were coded as a “yes.” Preference for avored e-cigarettes was assessed
with the item, “E-liquid comes in avors I like” (yes/no). State policy
data were obtained from websites of public health, nonprot organiza-
tions that focus on commercial tobacco prevention and control (i.e.,
Truth Initiative (Truth Initiative, 2024a), Campaign for Tobacco-Free
Kids (Campaign for Tobacco-Free Kids, 2024a; Campaign for Tobacco-
Free Kids, 2024b), American Nonsmokers' Rights Foundation
(American Nonsmokers' Rights Foundation, 2024)). Participants living
in a state that had implemented an e-cigarette tax prior to Wave 6 data
collection were coded as a “yes” for state e-cigarette tax (Campaign for
Tobacco-Free Kids, 2024b). Participants whose home states had imple-
mented comprehensive clean indoor air laws (American Nonsmokers'
Rights Foundation, 2024), avored tobacco sales restrictions (Truth
Initiative, 2024a), and/or menthol tobacco sales restrictions (Campaign
for Tobacco-Free Kids, 2024a) prior to Wave 6 data collection were
coded as “stronger” policy contexts for the state tobacco policy context
variable and those whose home states had not implemented any of these
policies prior to Wave 6 were coded as “weaker” policy contexts. Annual
household income (<$50,000; $50,000–$99,999; $100,000+) and ed-
ucation (less than high school diploma; high school diploma or General
Educational Development diploma (GED); some college or Associate
degree; Bachelor's degree or more) were also included as predictor
variables. Covariates were age, sex, race (White; Black; Other race,
including multi-racial), use of any tobacco other than e-cigarettes in the
past 30-days at Wave 5 (yes/no), and state coupon policy (yes/no). State
tobacco coupon policy was included as a covariate because three states
(New York, New Jersey, and Rhode Island) had implemented policies
prohibiting the redemption of tobacco coupons prior to Wave 6 (Truth
Initiative, 2024b).
2.3. Statistical analysis
Weighted logistic regression models were used to examine the effects
of coupon receipt (plus other predictors) on any tobacco use. Effects
were rst estimated in the overall sample, and then stratied models
were run to examine associations by state e-cigarette tax status and state
tobacco policy context. Of note, state tobacco coupon policy was not
included as a covariate in models stratied by state tobacco policy
context because there were no respondents who lived in states with a
weaker tobacco policy context and a tobacco coupon policy.
Follow-up analyses examined the effect of e-cigarette coupon receipt
on progression from past 30-day use at Wave 5 to current established e-
cigarette use at Wave 6. For these analyses, the sample was limited to
those reporting that they had never used e-cigarettes fairly regularly but
J.H. Kingsbury et al.
Preventive Medicine Reports 49 (2025) 102943
2
had used in the past 30 days at Wave 5. The original logistic regression
model was employed with current established e-cigarette use at Wave 6
as the outcome.
Due to the COVID-19 pandemic, Wave 6 data were collected via two
modes: in-person and telephone. In-person was prioritized over tele-
phone data collection where permitted by local jurisdictions and
participant comfort. Sensitivity analyses were conducted to determine if
study results were different when accounting for mode. The mode effect
variable did not alter study results and was left out of nal models.
Analyses were conducted in 2023 using the default mode for SPSS
Complex Samples v25. The current study analyzed the adult restricted
use les (National Addiction and HIV Data Archive Program, 2024) and
state identier restricted use les, and used the Wave 6 all-waves lon-
gitudinal weights for the W4 cohort.
3. Results
Table 1 presents weighted characteristics of people who used e-cig-
arettes in the past 30 days at Wave 5 overall and by e-cigarette coupon
receipt status. Those who used e-cigarettes at Wave 5 were 55.5 % male,
77.7 % White, and had a mean age of 35.6 at Wave 6. In Wave 5, 9.7 %
received an e-cigarette coupon. A majority preferred avored e-ciga-
rettes at Wave 5 (72.4 %) and lived in states with stronger tobacco policy
contexts (53.8 %) and no e-cigarette tax (62.4 %). At Wave 5, 67.2 %
used tobacco other than e-cigarettes. At Wave 6, 73.6 % used any
tobacco.
As shown in Table 2, those who received an e-cigarette coupon (AOR
=1.57; 95 % CI: 1.07, 2.31) and preference for avored e-cigarettes at
Wave 5 (AOR =1.70; 95 % CI: 1.37, 2.10) had higher odds of tobacco
use at Wave 6, while living in stronger tobacco policy contexts at Wave 5
was negatively associated with Wave 6 tobacco use (AOR =0.69; 95 %
CI: 0.55, 0.88). Wave 6 tobacco use was more common among those
with lower levels of education compared to a Bachelor's degree or higher
(<high school diploma: AOR =1.87; 95 % CI: 1.21, 2.89; high school
diploma or GED: AOR =1.56; 95 % CI: 1.15, 2.10).
Table 3 shows models stratied by those living in states with and
without an e-cigarette tax. Estimates were similar between states with
and without e-cigarette taxes, with two notable exceptions: the odds of
any tobacco use at Wave 6 were higher for those who received an e-
cigarette coupon at Wave 5, but only among those living in states with
an e-cigarette tax (AOR =2.39; 95 % CI: 1.22, 4.68; no e-cigarette tax:
AOR =1.29; 95 % CI: 0.83, 1.99). There was no effect of state tobacco
Table 1
Weighted characteristics by e-cigarette coupon receipt for PATH Study adults, Waves 5 (2018–2019) and 6 (2021), United States.
Overall Coupon receipt No coupon receipt
Characteristics N Weighted % (95 % CI) n Weighted % (95 % CI) n Weighted % (95 % CI)
Wave 6 Age 3632 *35.6 (35.0, 36.3) 343 *37.4 (35.7, 39.1) 3289 *35.4 (34.7, 36.2)
Wave 6 Sex
Male 1874 55.5 (53.5, 57.4) 165 51.0 (44.5, 57.5) 1709 56.0 (53.9, 58.0)
Female 1758 44.5 (42.6, 46.5) 178 49.0 (42.5, 55.5) 1580 44.0 (42.0, 46.1)
Wave 6 Race
White 2719 77.7 (75.1, 80.1) 276 83.0 (78.5, 86.6) 2443 77.1 (74.4, 79.7)
Black 450 12.1 (10.2, 14.2) 34 9.0 (6.1, 12.9) 416 12.4 (10.5, 14.7)
Some other race 463 10.2 (8.9, 11.7) 33 8.1 (5.5, 11.7) 430 10.5 (9.1, 11.9)
Wave 5 Annual household income
<$50,000 2182 58.6 (55.9, 61.3) 205 59.1 (52.8, 65.0) 1977 58.6 (55.7, 61.4)
$50,000–99,999 820 24.3 (22.5, 26.2) 73 21.7 (17.5, 26.6) 747 24.6 (22.7, 26.6)
$100,000+630 17.1 (15.1, 19.2) 65 19.2 (14.2, 25.5) 565 16.8 (14.9, 19.0)
Wave 5 Education
<High school education 356 9.3 (7.9, 10.9) 31 8.1 (5.2, 12.5) 325 9.4 (8.0, 11.0)
High school diploma or GED 1204 33.3 (31.4, 35.3) 92 26.8 (21.7, 32.7) 1112 34.0 (31.9, 36.2)
Some college or associate 1543 41.3 (39.4, 43.2) 168 47.7 (41.6, 53.8) 1375 40.6 (38.6, 42.6)
Bachelor's degree +529 16.1 (14.4, 17.9) 52 17.4 (12.9, 23.0) 477 16.0 (14.2, 17.9)
State tobacco coupon policy
Yes 215 6.9 (4.8, 9.8) 18 4.9 (3.0, 8.0) 197 7.1 (4.9, 10.2)
No 3417 93.1 (90.2, 95.2) 325 95.1 (92.0, 97.0) 3092 92.9 (89.8, 95.1)
Wave 5 Preference for avored e-cigarettes
Yes 2647 72.4 (70.2, 74.5) 280 80.3 (74.7, 85.0) 2367 71.6 (69.2, 73.8)
No 985 27.6 (25.5, 29.8) 63 19.7 (15.0, 25.3) 922 28.4 (26.2, 30.8)
Wave 5 State tobacco policy context
Stronger 2016 53.8 (49.2, 58.3) 192 51.7 (43.7, 59.5) 1824 54.0 (49.5, 58.5)
Weaker 1616 46.2 (41.7, 50.8) 151 48.3 (40.5, 56.3) 1465 46.0 (41.5, 50.5)
Wave 5 State e-cigarette tax
Yes 1346 37.6 (31.9, 43.7) 120 34.7 (27.2, 42.9) 1226 37.9 (32.1, 44.1)
No 2286 62.4 (56.3, 68.1) 223 65.3 (57.1, 72.8) 2063 62.1 (55.9, 67.9)
Wave 5 Tob. use other than e-cigarettes
Yes 2332 67.2 (65.0, 69.3) 220 67.9 (62.5, 72.8) 2112 67.1 (64.8, 69.3)
No 1300 32.8 (30.7, 35.0) 123 32.1 (27.2, 37.5) 1177 32.9 (30.7, 35.2)
Wave 6 Any tobacco use
Yes 2581 73.6 (71.4, 75.6) 277 81.2 (75.7, 85.6) 2304 72.7 (70.3, 75.0)
No 1051 26.4 (24.4, 28.6) 66 18.8 (14.4, 24.3) 985 27.3 (25.0, 29.7)
Wave 5 E-cigarette coupon receipt
Yes 343 9.7 (8.7, 10.8) – – – –
No 3289 90.3 (89.2, 91.3) – – – –
NOTE: *Indicates mean. GED =General Educational Development diploma. Tob. =Tobacco. Ns are unweighted. Wave 5 Preference for avored e-cigarettes was
assessed with the item, “E-liquid comes in avors I like.” Participants whose home states had implemented at least one of comprehensive clean indoor air laws, avored
tobacco sales restrictions, or menthol tobacco sales restrictions prior to Wave 6 were coded as “stronger” policy contexts for the Wave 5 state tobacco policy context
variable and those whose home states had not implemented any of these policies prior to Wave 6 were coded as “weaker” policy contexts. Participants living in a state
that had implemented an e-cigarette tax prior to Wave 6 were coded as a “yes” for state e-cigarette tax. Wave 6 any tobacco use represents past 30-day use of one or
more of cigarettes, e-cigarettes, traditional cigars, little cigars or cigarillos, ltered cigars, premium cigars, pipe, hookah, snus, and smokeless tobacco. Wave 5 e-
cigarette coupon receipt was assessed by asking whether respondents had received a coupon in the past 12 months for “e-cigarettes or other electronic nicotine
products (including e-liquid).”
J.H. Kingsbury et al.
Preventive Medicine Reports 49 (2025) 102943
3
policy context on tobacco use in states with an e-cigarette tax (AOR =
0.85; 95 % CI: 0.63, 1.14), whereas in states without an e-cigarette tax, a
stronger tobacco policy context at Wave 5 was negatively associated
with Wave 6 tobacco use (AOR =0.63; 95 % CI: 0.47, 0.84).
Table 4 shows results of models stratied by state tobacco policy
context. Among those living in states with stronger tobacco policy
contexts, both coupon receipt (AOR =1.80; 95 % CI: 1.07, 3.02) and e-
cigarette tax (AOR =1.36; 95 % CI: 1.02, 1.80) positively predicted
tobacco use. Conversely, among those living in states with weaker to-
bacco policy contexts, neither coupon receipt (AOR =1.33; 95 % CI:
0.78, 2.24) nor e-cigarette tax (AOR =0.99; 95 % CI: 0.69, 1.44) pre-
dicted tobacco use.
Analyses examining the effects of study predictors on established e-
cigarette use at Wave 6 among those with past 30-day use, but not
established use, at Wave 5 are shown in Supplemental Table 1. Wave 6
established e-cigarette use was more common among those who
received an e-cigarette coupon (AOR =1.98; 95 % CI: 1.14, 3.44) and
preference for avored e-cigarettes (AOR =1.73; 95 % CI: 1.21, 2.48).
4. Discussion
This nationally representative study of adults who use e-cigarettes
nds that receipt of e-cigarette coupons predicted subsequent tobacco
use even when controlling for use of other tobacco products, as well as
progression of e-cigarette use. Notably, the signicant results for any
tobacco use were only present among those living in states with e-cig-
arettes taxes or strong state tobacco policy contexts. These ndings
suggest that direct mail coupons may undermine e-cigarette taxes and
other tobacco regulations (Sheikh et al., 2023), which is similar to re-
sults of other studies examining coupon receipt and redemption
following cigarette tax increases (Choi et al., 2012; Hyland et al., 2005).
Typically, receipt of these coupons is unsolicited. Previous research on
the PATH Study found that less than 10 % of those who currently use
tobacco, and only 5 % of those not currently using signed up for email
alerts or other tobacco promotions (Choi et al., 2018). Moreover, to-
bacco direct mail coupons are frequently targeted to those in lower in-
come communities (Choi et al., 2018) so, if left unregulated, this
marketing strategy has the potential to perpetuate tobacco-related
health disparities.
The results showing that coupon receipt predicts progression to
regular e-cigarette use (among those who had not used regularly in the
past) is consistent with previous research on coupon receipt for both
cigarettes (Choi et al., 2018) and e-cigarettes (Duan et al., 2023). This
nding highlights how coupons can encourage more intense usage
among those who had not used as intensely in the past.
For those living in states with a stronger tobacco policy context, state
e-cigarette tax predicted an increased likelihood of any tobacco use.
Previous studies have reported similar results, demonstrating that e-
cigarette taxes can increase cigarette use and decrease e-cigarette use
(Pesko et al., 2020), and that cigarettes and e-cigarettes are economic
substitutes for each other (Stoklosa et al., 2016). The current study
builds on this research by highlighting how this pattern of substituting
may be more common for those in states with stronger tobacco regula-
tion. Taken together, ndings from the current study and the extant
literature suggest that tax increases may be more benecial if they apply
to all tobacco and nicotine products, thereby avoiding the unintended
consequence of incentivizing tobacco products unaffected by a single-
product tax.
A stronger state tobacco policy context was negatively associated
with tobacco use, suggesting that tobacco control policies are working as
intended. Interestingly, the effect of tobacco policy context was more
evident in states without an e-cigarette tax, suggesting that state tobacco
control policies, such as those that prohibit tobacco use indoors or
restrict the sale of avored tobacco, have more impact in locales with
Table 2
Weighted associations for PATH Study adults between Wave 5 (2018–2019) e-
cigarette coupon receipt, preference for avored e-cigarettes, and state tobacco
policies and Wave 6 (2021) any tobacco use, United States.
AOR Weighted 95 %
CI
Receipt of e-cigarette
coupon
Yes 1.57* 1.07, 2.31
No 1.00 –
Preference for avored e-
cigarettes
Yes 1.70*** 1.37, 2.10
No 1.00 –
State tobacco policy
context
Stronger 0.69** 0.55, 0.88
Weaker 1.00 –
State e-cigarette tax
Yes 1.14 0.89, 1.46
No 1.00 –
Annual household
income
<$50,000 1.05 0.81, 1.37
$50,000-99,999 1.04 0.77, 1.40
$100,000+1.00 –
Education
<High school education 1.87** 1.21, 2.89
High school diploma or
GED 1.56** 1.15, 2.10
Some college or
associate degree 1.21 0.90, 1.62
Bachelor's degree+1.00 –
Notes. N =3632. *p <.05, **p <.01, ***p <.001. GED =General Educational
Development diploma. Age, sex, race, state tobacco coupon policy, and Wave 5
Tobacco use other than e-cigarettes were included as covariates. AOR: Adjusted
odds ratio. CI: Condence interval.
Table 3
Weighted associations for PATH Study adults between Wave 5 (2018–2019) e-cigarette coupon receipt, preference for avored e-cigarettes, and state tobacco policy
context and Wave 6 (2021) any tobacco use, stratied by state e-cigarette tax, United States.
State e-cigarette tax,
n =1346
No State e-cigarette tax,
n =2286
AOR Weighted 95 % CI AOR Weighted 95 % CI
Receipt of e-cigarette coupon Yes 2.39** 1.22, 4.68 1.29 0.83, 1.99
No 1.00 –1.00 –
Preference for avored e-cigarettes
Yes 1.54** 1.12, 2.12 1.83*** 1.42, 2.34
No 1.00 –1.00 –
State tobacco policy context
Stronger 0.85 0.63, 1.14 0.63** 0.47, 0.84
Weaker 1.00 –1.00 –
Annual household income
<$50,000 1.04 0.74, 1.46 1.07 0.76, 1.52
$50,000–99,999 1.09 0.72, 1.66 1.00 0.71, 1.41
$100,000+1.00 –1.00 –
Education
<High school education 2.81** 1.52, 5.21 1.45 0.84, 2.50
High school diploma or GED 2.21** 1.38, 3.56 1.25 0.87, 1.78
Some college or associate degree 1.38 0.87, 2.20 1.09 0.80, 1.50
Bachelor's degree+1.00 –1.00 –
Notes. *p <.05, **p <.01, ***p <.001. GED =General Educational Development diploma. Age, sex, race, state tobacco coupon policy, and Wave 5 Tobacco use other
than e-cigarettes were included as covariates. AOR: Adjusted odds ratio. CI: Condence interval.
J.H. Kingsbury et al.
Preventive Medicine Reports 49 (2025) 102943
4
weaker pricing or taxation policies.
Preference for avored e-cigarettes was among the strongest pre-
dictors of future tobacco use. While avors may help some adults who
smoke to transition to e-cigarettes (Chen, 2018), use of avored prod-
ucts predicts continued tobacco product use (Chen, 2018) and thus may
deter those who use from quitting all tobacco. Targeted interventions
aimed at supporting those who use avored e-cigarettes are needed to
help these individuals successfully quit tobacco completely.
4.1. Limitations
The current study has several limitations. First, tobacco use and
coupon receipt data were based on self-report, and the number and type
of coupon received (e.g., buy-one-get-one, $2.00 off) were not assessed.
In addition, while this study measured the inuence of various state-
level tobacco policies, it did not account for all state tobacco policies
or local policies. However, state-level policies are often correlated with a
range of state and local policies that inuence tobacco use (Fox et al.,
2017), indicating omitted variable biases were likely minimal.
4.2. Conclusion
The current study highlights the harmful effects of tobacco industry
marketing via coupons on future tobacco use for those reporting past e-
cigarette use, and that e-cigarette coupons may be used to undermine
the effects of e-cigarette taxes and other tobacco control policies. This
study also provides valuable information on how contextual variables,
and in particular, state-level tobacco policies, can support cessation of
all tobacco, including e-cigarettes, among those with past e-cigarette
use. Findings suggest that policies prohibiting e-cigarette coupons could
help protect those who use e-cigarettes from subsequent tobacco use.
Given the powerful role that contextual factors have on tobacco use,
public health practitioners should focus efforts on promoting policy and
retail environments that are most conducive to reducing and quitting
tobacco use.
Disclosures
Wilson Compton reports long-term stock holdings in General Electric
Company, 3M Company, and Pzer Incorporated, unrelated to this
article. The other authors have no conicts of interest.
Disclaimer
The ndings and conclusions in this report are those of the authors
and do not necessarily represent the ofcial position of the U.S.
Department of Health and Human Services or any of its afliated in-
stitutions or agencies.
Funding
This manuscript is supported with Federal funds from the Center for
Tobacco Products (CTP), Food and Drug Administration (FDA),
Department of Health and Human Services, through an interagency
agreement between the FDA Center for Tobacco Products and the Na-
tional Institute on Drug Abuse (NIDA), National Institutes of Health
(NIH) and a collaboration between NIDA and the National Cancer
Institute, the National Institute on Minority Health and Health Dispar-
ities, the National Heart, Lung, and Blood Institute, the National Insti-
tute on Alcohol Abuse and Alcoholism, the National Institute of
Environmental Health Sciences, the Ofce of Behavioral and Social
Sciences Research, the Ofce of Disease Prevention, the National Insti-
tute of Diabetes and Digestive and Kidney Diseases, and the National
Library of Medicine. The PATH Study is supported with Federal funds
from NIH NIDA and FDA CTP, under contract to Westat (contract no.
HHSN27120160001C). Drs. Kimmel, Creamer, Blanco, and Compton
were substantially involved in providing scientic expertise and
providing scientic management for contract no. HHSN27120160001C.
CRediT authorship contribution statement
J.H. Kingsbury: Writing – review & editing, Writing – original draft,
Methodology, Investigation, Formal analysis, Conceptualization. H.L.
Kimmel: Writing – review & editing, Supervision, Project administra-
tion, Funding acquisition, Conceptualization. M.J. Parks: Writing –
review & editing, Methodology, Investigation. M.R. Creamer: Writing –
review & editing, Investigation, Funding acquisition. C. Blanco: Writing
– review & editing, Project administration, Funding acquisition. W.M.
Compton: Writing – review & editing, Project administration, Investi-
gation, Funding acquisition.
Declaration of competing interest
The authors declare the following nancial interests/personal re-
lationships which may be considered as potential competing interests:
Wilson Compton reports long-term stock holdings in General Electric
Company, 3M Company, and Pzer Incorporated, unrelated to this
article. The other authors have no conicts of interest.
Data availability
Data are stored on a private enclave, and access to the data used in
the project are available through an application process. See NAHDAP
website: https://www.icpsr.umich.edu/web/NAHDAP/studies/36231
Table 4
Weighted associations for PATH Study adults between Wave 5 (2018–2019) e-
cigarette coupon receipt, preference for avored e-cigarettes, and state e-ciga-
rette tax and Wave 6 (2021) any tobacco use, stratied by state tobacco policy
context, United States.
Stronger policy
context, n =2016
Weaker policy
context, n =1616
AOR Weighted
95 % CI
AOR Weighted
95 % CI
Receipt of e-
cigarette
coupon
Yes 1.80* 1.07, 3.02 1.33 0.78, 2.24
No 1.00 –1.00 –
Preference for
avored e-
cigarettes
Yes 1.76*** 1.34, 2.31 1.58** 1.14, 2.20
No 1.00 –1.00 –
State e-
cigarette
tax
Yes 1.36* 1.02, 1.80 0.99 0.69, 1.44
No 1.00 –1.00 –
Annual
household
income
<$50,000 1.07 0.76, 1.50 1.08 0.69, 1.69
$50,000-
99,999 0.97 0.66, 1.42 1.17 0.74, 1.87
$100,000+1.00 –1.00 –
Education
<High
school
education
2.13** 1.21, 3.76 1.37 0.72, 2.61
High school
diploma or
GED 1.81** 1.21, 2.73 1.14 0.72, 1.80
Some college
or associate
degree 1.45 0.99, 2.14 0.85 0.55, 1.33
Bachelor's
degree+1.00 –1.00 –
Notes. *p <.05, **p <.01, ***p <.001. GED =General Educational Develop-
ment diploma. Age, sex, race, and Wave 5 Tobacco use other than e-cigarettes
were included as covariates. AOR: Adjusted odds ratio. CI: Condence interval.
“Stronger policy context” refers to states that had implemented comprehensive
clean indoor air laws, avored tobacco sales restrictions, and/or menthol to-
bacco sales restrictions prior to Wave 6 data collection (2021), and “Weaker
policy context” refers to states that had not implemented any of these policies
prior to Wave 6.
J.H. Kingsbury et al.
Preventive Medicine Reports 49 (2025) 102943
5
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