State tobacco control policy variation in the United States: Insights from the health policy triangle and multiple...

Tobacco control policies vary substantially across U.S. states, producing uneven regulatory environments and public health protections. These differences may shape population exposure to tobacco products, including youth access to electronic nicotine delivery systems. This study compares tobacco control policies across five U.S. states to examine how policy structure, governance context, and political dynamics influence regulatory environments.

A comparative case study design was used to examine tobacco control policy environments in California, New York, Massachusetts, Alabama, and Florida. These states were purposively selected to represent variation in tobacco regulatory approaches and political contexts. Guided by the Health Policy Triangle and Kingdon's Multiple Streams Framework, we analyzed smoke-free laws, flavored tobacco regulations, taxation structures, retail licensing systems, and e-cigarette policies using legal statutes, policy reports, and publicly available prevalence indicators from 2022.

California and Massachusetts demonstrated the most comprehensive regulatory frameworks, including strong smoke-free protections, flavored tobacco restrictions, higher excise taxes, and structured retailer licensing systems. Alabama exhibited comparatively limited regulatory infrastructure, with lower cigarette taxes and fewer statewide restrictions on flavored tobacco products. Florida maintained moderate state-level protections but limited local policy innovation through statewide preemption laws. Youth e-cigarette prevalence ranged from 5.6% in California to 17.5% in Alabama, reflecting differences in tobacco control environments across states.

Variation in tobacco control environments reflects differences in regulatory design, implementation capacity, and political context. Integrating the Health Policy Triangle and Multiple Streams Framework highlights how institutional structures and policy processes shape tobacco control regulation across decentralized governance systems.