ObjectiveThis study aimed to evaluate the effectiveness of flavoured tobacco product restriction policies in reducing availability of flavoured products in Massachusetts communities.MethodsData were obtained from surveys of tobacco retailers conducted from July 2015 to March 2017. On a community level, flavoured product availability was defined as the per cent of retailers during a given 3-month quarter that sold flavoured cigars/cigarillos, electronic cigarettes and/or e-liquids. Communities that implemented the policy during the study period were grouped into wave 1 (n=18; 1481 retail surveys) and wave 2 (n=20; 483 retail surveys) by date of policy implementation; communities without a flavoured product restriction served as the control group (n=234; 4932 retail surveys). A difference-in-difference analysis was used to compare the change in flavoured product availability in wave 1 and wave 2 communities 3 months pre-policy and post-policy implementation to the change over the same time periods in the control group.ResultsFrom pre-policy to post-policy implementation period, communities in both waves experienced significant reductions in flavoured product availability (ranging from 27.2% to 50.9%), even after adjusting for community-level characteristics. In both waves 1 and 2, reductions in flavoured product availability were significantly greater compared with comparison communities during the same time frame, adjusting for community-level characteristics.ConclusionsCompliance with flavoured product restriction policies is high among tobacco retailers throughout Massachusetts, regardless of community demographic and retail characteristics. Reduced availability of flavoured tobacco in the retail environment has the potential to reduce youth exposure, access and use of these products.

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BackgroundFlavoured tobacco products are widely available in youth-accessible retailers and are associated with increased youth initiation and use. The city of Boston, Massachusetts restricted the sale of flavoured tobacco products, including cigars, smokeless tobacco and e-cigarettes, to adult-only retailers. This paper describes the impact of the restriction on product availability, advertisement and consumer demand.MethodsBetween January and December 2016, data were collected in 488 retailers in Boston at baseline and 469 retailers at 8-month follow-up, measuring the type, brand and flavour of tobacco products being sold. Process measures detailing the educational enforcement process, and retailer experience were also captured. McNemar tests and t-tests were used to assess the impact of the restriction on product availability.ResultsAfter policy implementation, only 14.4% of youth-accessible retailers sold flavoured products compared with 100% of retailers at baseline (p<0.001). Flavoured tobacco product advertisements decreased from being present at 58.9% of retailers to 28.0% at follow-up (p<0.001). Postimplementation, retailers sold fewer total flavoured products, with remaining products often considered as concept flavours (eg, jazz, blue). At follow-up, 64.0% of retailers reported that customers only asked for flavoured products a few times a week or did not ask at all. Retailers reported that educational visits and the flavoured product guidance list aided with compliance.ConclusionTobacco retailers across Boston were largely in compliance with the regulation. Availability of flavoured tobacco products in youth-accessible retailers declined city-wide after policy implementation. Strong educational and enforcement infrastructure may greatly enhance retailer compliance.

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Collaboration between emergency medical services (EMS) and hospitals receiving stroke patients is critical to ensure prompt, effective treatment, and is a key component of the stroke systems of care (SSoC). The goal of our study was to evaluate the association between presentation by EMS and EMS prenotification with odds of receiving Tissue-type Plasminogen Activator (IV-tPA) in a state implementing SSoC while rigorously accounting for missing data. We utilized data from the Massachusetts Paul Coverdell Stroke Registry for this study, and analyzed adult patients presenting with ischemic stroke to Massachusetts Coverdell hospitals between 2016 and 2018. Patients with contraindications to IV-tPA were excluded. We used generalized estimating equations to assess associations between presentation by EMS, EMS prenotification, and receipt of IV-tPA. We also performed a sensitivity analysis using multiple imputation to assess the sensitivity of our findings to missing data. We identified 9,230 eligible patients with ischemic stroke during the study period. In multivariate complete case regressions, presentation by EMS and EMS prenotification were associated with statistically significant increased odds of receiving IV-tPA (odds ratio [OR] 1.52, 95% confidence interval [CI] 1. OR 1.75, respectively). Analysis of imputed data indicated level or stronger associations. Our analysis indicates that presentation by EMS and EMS prenotification are associated with increased odds of receiving IV-tPA in a state implementing the SSoC. Our results lend importance to the critical role of EMS in the SSoC. Future interventions should work to increase rates of prenotification by EMS and assess inequities in receipt of IV-tPA.