UC Irvine

INTRODUCTION: State and local jurisdictions in the United States (U.S.) are increasingly adopting flavored tobacco sales restrictions (FTSRs) to mitigate tobacco initiation and use. Policy implementation is highly understudied yet can impact policy effectiveness. This review examines existing literature on state and local FTSR policy design and implementation in the U.S. METHODS: We systematically searched for PubMed articles published by 12/31/2024 which were: original research articles in English focused on a U.S. state or local FTSR that reported at least one policy implementation outcome measure. We excluded articles that were systematic reviews or reported on federal or non-FTSR policy. Guided by policy and implementation science frameworks, we developed a data extraction template to report: policy design elements, study characteristics, and implementation measures (i.e., inputs, activities, outcomes). RESULTS: Of 1,595 articles identified, 30 were retained for review. Most evaluated local FTSRs, and eight evaluated a statewide policy. Pre-post test and cross-sectional study designs were the most common. Frequently reported implementation outcomes were acceptability, appropriateness, feasibility, and fidelity/compliance. Studies with pre-post test designs and comparison groups showed significantly increased fidelity/compliance (i.e., reduced availability of restricted products) in FTSR jurisdictions. A majority (56.7%) detailed an implementation input for infrastructure (e.g., resources) or activity (e.g., outreach). Few described enforcement-related mechanisms. CONCLUSIONS: Key gaps exist in policy implementation articles on state and local FTSRs in the U.S., including infrequent reporting of enforcement agencies and penalties which may impact implementation. Additional mixed methods research is needed to compare FTSR implementation across jurisdictions with varying policy designs.