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Calif Tobacco Control Program has saved the state half a trillion dollars in medical costs

by Stanton A. Glantz, PhD

Steve Anderson and Jim Lightwood just published Health Care Cost Savings Attributable to the California Tobacco Control Program, 1989 to 2018 through the University of California eScholarship initiative.  Using sophisticated econometric analysis they convincing show that in its first 30 years, the program reduced actual medical costs by a total of $500 billion (in 2019 dollars).

In 2019, California medical costs were about $37 billion below what one would have expected had the voters not passed Prop 99 in 1988.  At a time that California, like all states, is struggling with the financial challenges created by the coronavirus epidemic, the California Tobacco Program (CTCP) is not only saving lives but also making a substantial contribution to helping California meet its current financial challenges.

This amount only includes medical care costs (doctors, hospitals, drugs, and related costs), not indirect costs such as lost productivity or the value of lives lost.   The savings in those areas are generally even more than the direct medical costs.

Moreover, using an alternative measure of medical costs, the Center for Medicare and Medicaid Services, the estimated savings are even higher: $737 billion.

These savings accumulate rapidly and grow over time.  In addition, Arnold and Lightwood showed that the medical savings that follow from each dollar spent on the California Tobacco Control Program (adjusted for population growth and inflation) has remained remarkably stable over time.  The policy bottom line:  The more money invested in the Tobacco Control Program, the more the savings in medical costs.

They also estimated that the Program has prevented 15.7 billion packs of cigarettes from being smoked worth $51.4 billion in pre-tax sales to the cigarette companies through 2018.  No wonder the companies hate the program so much.

Their bottom line:  “The estimated effect on smoking behavior of an additional dollar spent (adjusted for inflation) on education is the same now has been constant since 2008. The lower estimated total effect of the CTCP program on smoking behavior per year has declined since 2008, but that is due to reductions in real expenditure devoted to the program. If funding were increased, the total effect of the CTCP program should return to its previous levels.”

The full citation is Lightwood, J., & Anderson, S. (2020). Health Care Cost Savings Attributable to the  California Tobacco Control Program, 1989 to 2018. UCSF: Center for Tobacco Control Research and Education. Retrieved from .

Colorado Governor Signs Strong Tobacco 21 Legislation

Colorado Governor Signs Strong Tobacco 21 Legislation

HB20-2001 Provides Strong Enforcement and a Tobacco Retail License Program

The Colorado legislature passed a Tobacco 21 bill that Governor Polis signed on July 14, 2020. Colorado is the 30th state to pass a Tobacco 21 law. The bill raises the minimum legal sales age for all nicotine and tobacco products to 21 and enhances enforcement provisions that hold profiteering retailers, rather than kids, accountable for unlawful sales.

The bill requires the Colorado Department of Public Health and Environment to conduct two compliance checks per retailer each year– an effort proven to ensure retailer compliance and lower violation rates. The bill also establishes a comprehensive tobacco retail licensing (TRL) program for the state that both funds enforcement and protects honest retailers from the unfair advantage of underage sales.

Most states that have raised their tobacco sales age have failed to include enforcement provisions that ensure the effectiveness of the policy; Colorado wisely recognized that an unenforced law is no law at all.

Preventing Tobacco Addiction Foundation President Rob Crane, MD, stated: “Colorado has made a statement that they won’t tolerate sales of these addictive and deadly products to kids. We applaud their bold vision, effective use of a tobacco retail license, and comprehensive approach to preventing addiction and protecting kids.”

We thank Governor Polis and the Colorado Legislature for this critical public health law that will help stem the massive teen vaping epidemic and better protect Colorado’s kids!

Lawmakers Say Puff Bar Used Pandemic to Market to Teens


June 2, 2020

House lawmakers asked the Food and Drug Administration this week to ban Puff Bar, the fast-growing e-cigarette that has quickly replaced Juul as the vape of choice among young people.

The disposable devices come in more than 20 flavors, among them piña colada, pink lemonade, watermelon and a mysterious blend called O.M.G. Although the Trump administration banned fruit, mint and dessert flavors in refillable cartridge-based e-cigarettes like Juul earlier this year, it carved out an exemption for brands that are used once and thrown away.

Puff Bar, which launched last year, has been the key beneficiary of the loophole. It has built on its early success by adding a line of flavor pods called Puff Krush that are compatible with the Juul device, upsetting that company, whose own business has sunk since it restricted sales in the United States to tobacco and menthol varieties last fall. Based on data used only for tracked channels, which include convenience stores and some other retailers but not online sales or vape shops, Puff Bar sales have consistently been over $3 million a week since April, with volumes now over 300,000 sticks per week.

“Puff Bar is quickly becoming the new Juul,” Rep. Raja Krishnamoorthi, Democrat of Illinois, wrote in a letter to the F.D.A. on Monday. Mr. Krishnamoorthi, the chairman of the House Subcommittee on Economic and Consumer Policy, accused the e-cigarette company of exploiting the coronavirus to sell its products to schoolchildren.

To make his case, the lawmaker included a copy of a Puff Bar advertisement featuring a photograph of a bedroom, with the words: “We know that the inside-vibes have been … quite a challenge. Stay sane with Puff Bar this solo-break. We know you’ll love it. It’s the perfect escape from the back-to-back zoom calls, parental texts and WFH stress.”

Mr. Krishnamoorthi said that “this advertisement is designed to convince children home from school to vape in their rooms without their parents noticing.”

A second advertisement included in the complaint features an attractive young woman wearing a tight T-shirt and spewing big clouds of vapor. The same picture was used in a separate advertisement that suggested vaping a Puff Bar as a way to relax over spring break.

Todd Eric Gallinger, a lawyer who represented a company called Cool Clouds Distribution in a trademark application for the Puff logo, did not return a call seeking comment. The Puff Bar website does not list the names of any of the company’s executives. Indeed, since it began, the provenance of the Los Angeles-based business has been a secret. Its website states: “Who makes Puff Bar? Everyone wants to know the mastermind team behind the latest craze in the world of electronic cigarettes. Where did the Puff Bar team come from and where do they plan to go from here?”

Wherever it is, the company isn’t telling. The only details revealed indicate that the product is made in China and the flavors are developed in Malaysia.

But the company has not been under the radar. Tobacco-control advocates, including educators, organizations like Parents Against Vaping E-cigarettes and others, have been concerned about Puff Bar since it turned up in schools late last fall. Robin Koval, the chief executive and president of Truth Initiative, which seeks an end to tobacco use, said she supports a Puff Bar ban.

“It is an outrage that during a pandemic that attacks the lungs, Puff Bar is freely targeting our nation’s youth, putting their lives at even greater risk,” Ms. Koval said. “These egregious ads from Puff Bar are the latest example.”

In a recent online survey of 364 current vapers, ages 15 through 24, the Truth Initiative found that 57 percent were worried that vaping put them at risk of serious illness from the coronavirus, and slightly more than half wanted to quit.

The F.D.A. declined to discuss Puff Bar. Still, in an email, Mitchell Zeller, the director of the agency’s Center for Tobacco Products, wrote that the agency intended to take action against any electronic nicotine product “if it is targeted to youths, if its marketing is likely to promote use by minors, or if the manufacturer fails to take adequate measures to prevent minors’ access.”

When the F.D.A. started regulating e-cigarettes, it permitted the continued sale of products that were on the market as of Aug. 8, 2016, pending agency review. Since Puff Bar was introduced after that date, the agency does generally have the authority to remove it, despite the fact that the product is disposable and even if the agency cannot prove the company is targeting youths. The exception would be if Puff Bar had already been on the market before the 2016 deadline, under a different name, or sold by another company.

In recent weeks, the agency has blocked the importing of two e-cigarette products from China: EonSmoke, which sold disposable e-cigarettes in a number of flavors before shutting down, and RELX, available in flavors including Drunk in Mexico, Naked in Iceland and Mango.

Sheila Kaplan is a prize-winning investigative reporter who covers the Food and Drug Administration, the tobacco industry and the intersection of money, medicine and politics. @bySheilaKaplan

PTAF’s statement on the FDA’s approval of Philip Morris to Market IQOS Heated Cigarette as Modified Risk Tobacco Product

In approving Philip Morris product, IQOS, the FDA has once again demonstrated that it is not the appropriate agency to regulate nicotine and tobacco products. FDA’s Center for Tobacco Products (CTP) has ignored its own scientific guidelines and the advice of public health experts around the country. In addition, Philip Morris has marketed IQOS in other countries in ways that clearly appeal to kids. The inexcusable mistakes that triggered the teen vaping epidemic and the appalling fumble of flavor regulation reverberate in this decision. FDA is constructed to work with manufacturers to bring healthful nutrition, therapeutics, and devices to the public. It is entirely unprepared to deal with an industry rooted in deception and deadly addiction. One of the first and most important public health actions of a new administration and congress should be to remove the CTP from the FDA and expeditiously replace its leadership.

Are smokers protected from COVID-19?

Over the years, public health campaigns have highlighted the dangers to health associated with smoking cigarettes and actively sought to discourage the practice.

Current data from the Office of National Statistics (ONS) from 2018 suggests that around 7.2 million adults smoke cigarettes which is a 5% decrease since 2011.1 While there several health benefits that accrue from smoking cessation, recent press reports seem to suggest that smokers are somehow protected from COVID-19.

Indeed, early reports from China on the clinical characteristics of patients admitted to hospital with COVID-19 found that the proportion of smokers was less than expected based on the estimated prevalence of smoking in the country which is 27.7%.2 For instance, in one study, the proportion of smokers was found to be considerably less than the average at 1.4%3 and while higher at 7% in another study,4 this was still lower than the average. Since these early reports from China, several other studies from different countries have also demonstrated that a lower than expected number of smokers have been hospitalized with COVID-19. In a study of those hospitalized with COVID-19 in New York, the prevalence of smokers was 5.1%5 which is less than half of the most recent estimate of the overall US smoking prevalence of 13.7%.6 Similarly, a retrospective analysis of 441 patients admitted to a hospital in northern Italy, found that less than 5% of patients were smokers, compared to an estimated age-adjusted prevalence of 14.9%.7 In a study of 340 patients in a French university hospital, it was found that 6.1% of patients were smokers compared to a population rate of 25.4%.8 Finally, in a yet to be peer-reviewed meta- analysis of available studies, Spanish researchers calculated that smokers were statistically less likely (odds ratio = 0.18, 95% CI 0.14 – 0.23) to be hospitalized for COVID-19.9

But are these observations simply a fluke or is there a plausible explanation that could account for the reduced incidence of COVID-19 among smokers?

One hypothesis proposes that it is nicotine which provides a degree of protection against the virus. This is based on an observation in 1990, that acute nicotine inhalation can increase both systolic and diastolic blood pressure and that this effect is mediated via an increase in angiotensin converting enzyme activity.10 In addition, other work has shown how the nicotine- induced rise in the level of ACE is also associated with a downregulation of the level of ACE- 211 which is now considered to be a functional receptor for COVID-19 entry into cells.12 Other work has shown that nicotine is able to activate nicotinic acetylcholine receptors on immune cells and that this effect leads to an inhibition of the release of pro-inflammatory cytokines and protects against acute inflammation in lung tissue.13 While this appears to represent a rationale for how nicotine may be protective against COVID-19, other and more recent work published as a research letter to the European Respiratory Journal,14 found that in both smokers and those with COPD, there was an increased airway expression of ACE-2. The authors concluded that this offered a possible explanation as to why those with COPD are at an increased risk of infection but the data effectively countered the potentially protective role of nicotine. In an effort to

untangle the association between smoking and COVID-19, an as yet non-peer reviewed analysis of 67 observational studies conducted in several different studies concluded that there is substantial uncertainty about the associations between smoking and COVID-19 outcomes.15 Moreover, an evidence review by Healthcare Improvement Scotland, also concluded that there is no significant association between smoking and severe disease.16 In contrast, the most recent meta-analysis of 19 peer-reviewed papers that included 11,590 patients concluded that smoking is a risk factor for the progression of COVID-19, with smokers having a higher odds of COVID- 19 progression.17

In summary and based on the available evidence, it seems unlikely that smoking offers some degree of protection from the effects of COVID-19. The ONS report1 shows that smoking rates are the lowest at 7.9% in those 65 years and over and it is possible that the lower incidence of infection among smokers, simply reflects the fact that fewer older people smoke rather than an intrinsic and protective effect among smokers. Until more definitive evidence emerges, it would seem prudent that current healthcare advice to stop smoking is continued rather than patients relying on a potentially spurious belief that somehow smoking will prevent them from becoming infected with COVID-19.


  1. Office for National Statistics. Adult smoking habits in the UK: 2018. adultsmokinghabitsingreatbritain/2018 (accessed May 2020).
  2. Parascandola M, Xiao L. Tobacco and the lung cancer epidemic in China. Trans Lung Cancer Res 2019;8(S1):S21-S30.
  3. Zhang JJ et al. Clinical characteristics of 140 patients infected with SARS-CoV-2 in Wuhan, China. Allergy 2020; Feb 19.
  4. Huang C et al. Clinical features of patients infected with novel 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
  5. Goyal P et al. Clinical characteristics of Covid-19 in New York City. N Engl J Med 2020; Apr 17.
  6. Centers for Disease Control and Prevention. Smoking & Tobacco (accessed May 2020).
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  8. Miyara M, Tubach F, Pourcher V et al. Low rate of daily active tobacco smoking in patients withsymptomatic COVID-19. Qeios 2020.
  9. Gonzalez-Rubio J et al. What is happening with smokers and COVID-19? A systematic review and meta-analysis. Preprints 2020; doi: 10.20944/preprints202004.0540.v1.
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  11. Oakes JM et al. Nicotine and the renin-angiostensin system. Am J Physiolo Regul Integ Comp Physiol2018;315(5):R895-R906.
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  13. Mabley J, Gordon S, Pacher P. Nicotine exerts and an anti-inflammatory effect in a murine model of acutelung injury. Inflammation 2011;34(4):231-7.
  14. Leung JM et al. ACE-2 expression in the small airway epithelia of smokers and COPD patients:implications for COVID-19. Eur Respir J 2020;55:20000688.
  15. Simons D et al. The association of smoking status with SARS-CoV-2 infections, hospitalisation andmortality from COVID-19: a living rapid evidence review. Qeiosi.
  16. Healthcare improvement Scotland. Assessment of COVID-19 in primary care. (accessed May 2020).
  17. Patanavanich R, Glantz SA. Smoking is associated with COVID-19 progression: a meta-analysis. NicotineTob Res 2020;May 13.