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Local Tobacco 21 Policies are Associated With Lower Odds of Tobacco Use Among Adolescents

Abstract

Introduction

Tobacco 21 (T21) policies have shown promise in reducing cigarette use among adolescents. This study examined whether local T21 policies affected adolescent use of a variety of tobacco products and whether results differed by grade level.

Methods

We used repeated cross-sectional data from eighth, ninth, and eleventh-grade respondents to the 2016 (n = 107 981) and 2019 (n = 102 196) Minnesota Student Surveys. Generalized estimating equations modeled eight adolescent tobacco use outcomes in 2019 (past 30-day use of any tobacco, cigarettes, cigars, e-cigarettes, hookah, chewing tobacco, flavored tobacco, and multiple products) by T21 exposure, defined as respondents’ attendance at a school within a jurisdiction with T21 policy implementation between the two surveys. Models controlled for demographic characteristics and product-specific baseline tobacco use at the school level in 2016 and were stratified by grade.

Results

After adjusting for baseline tobacco use and other demographics, T21-exposed eighth and ninth-grade students had significantly lower odds of tobacco use than unexposed peers in five of eight models, i.e. any tobacco (aOR = 0.80, 95% CI: 0.74, 0.87), cigarettes (aOR = 0.81, 95% CI: 0.67, 0.99), e-cigarettes (aOR = 0.78, 95% CI: 0.71, 0.85), flavored tobacco (aOR = 0.79, CI: 0.70, 0.89), and dual/poly tobacco (aOR = 0.77, 95% CI: 0.65, 0.92). T21-exposed eleventh-grade students did not differ significantly in their odds of any tobacco use outcomes relative to their unexposed peers.

Conclusions

T21 exposure is associated with lower odds of multiple forms of tobacco use, particularly among younger adolescent populations, supporting the implementation of T21 policies to reduce tobacco use in this population.

Menthol Reinforces Sustained Cigarette Smoking Among Youth

Cigarette smoking frequency, quantity, dependence, and quit intentions during adolescence: Comparison of menthol and non-menthol smokers (National Youth Tobacco Survey 2017-2020)

Affiliations 

Abstract

Background: Use of menthol cigarettes is linked to sustained cigarette smoking adults. However, the relationship between menthol and smoking profile has not been thoroughly explored in adolescent cigarette smokers. This study examines the relationship between use of menthol cigarette and smoking frequency (i.e., days per month), quantity (i.e., cigarettes per day), quit intentions, and nicotine dependence (i.e., craving tobacco; use within 30 min of waking).

Methods: We pooled four years (2017-2020) of cross-sectional data from the National Youth Tobacco Survey. Participants were 2699 adolescent, past 30-day cigarette smokers. Multinomial logistic regression models examined the relationship between menthol and cigarette smoking frequency and quantity. Logistic regressions examined the relationship between menthol and intentions to quit smoking and nicotine dependence. Models controlled for socio-demographics and other tobacco use.

Results: Menthol cigarette smokers had greater risk of smoking 20-30 days per month relative to 1-5 days per month (RRR: 1.90; 95% CI: 1.41 – 2.54) and greater risk of smoking 11+ cigarettes per day relative to 1 or less cigarettes per day (RRR: 1.35; 95% CI: 1.01 – 1.80), adjusting for covariates. Menthol cigarette smokers had lower odds of intentions to quit smoking (Adj OR: 0.70; 95% CI: 0.58 – 0.84) but great odds of craving tobacco (OR: 1.47; 95% CI: 1.20 – 1.81) and using tobacco within 30 minutes of waking (OR: 1.63; 95% CI: 1.29 – 2.05), adjusting for covariates CONCLUSION: Findings suggest the relationship between menthol and cigarette smoking profile (i.e., frequency, quantity, quit intentions) is different for youth than that of adults. This study adds adolescent-specific evidence to existing research that suggests menthol reinforces sustained cigarette smoking among youth.

Why States Should Strengthen — Not Limit — Public Health Authority

May 18, 2021

Oxiris Barbot and Sarah de Guia

Some legislatures are moving to restrict what health departments can do. This ill-advised political interference can cost lives now and aggravate inequities in the post-pandemic era.

The COVID-19 pandemic has been a once-in-a-century stress test for the United States. Despite strong evidence that properly resourced public health agencies are crucial in protecting Americans from both man-made catastrophes and natural disasters such as COVID-19, many state legislatures are considering or have already approved policy changes that will strip authority from state and local health departments.

With more than 585,000 Americans dead from the coronavirus and many more still at risk of death or long-lasting medical complications, state lawmakers must not block public health agencies’ ability to use their full power to save lives. Instead, lawmakers should take steps to strengthen public health authority at the state and local levels.

When one of us, Oxiris Barbot, served as commissioner of health for New York City, she saw firsthand how political interference in the exercise of public health authority can cost lives and impair emergency response efforts. Given personal attacks and threats against public health officials, the relentless pressures of managing the COVID-19 crisis and, over the past decade, drastic funding cuts to public health preparedness and emergency response programs, public health leaders need our support now more than ever. Severely limiting the ability of local and state health officials to do their jobs, as many state legislatures have been doing, will only prolong the pandemic and needlessly risk the health and lives of millions of Americans.

As the pandemic enters yet another phase — including the possibility of a fourth wave of infections in some states — and the need to ensure rapid vaccination of those in the hardest-hit communities intensifies, state and local policymakers can best serve their constituents by emphasizing the importance of employing evidence-based interventions recommended by experts. In many places, however, the opposite is happening. A majority of state legislatures have either passed or are considering bills that would drastically limit state and local public health powers. These legislative proposals range from stripping regulatory authority from local boards of health to prohibiting localities from enacting mask mandates and limiting the duration of emergency declarations from the executive branch.

Take, for example, Kansas’ Senate Bill 40, which was signed into law in March. Among the bill’s dizzying array of legal changes is authorization for the Legislature to revoke certain orders issued by the secretary of health and environment. Another restrictive statute is Montana’s House Bill 121, also recently signed into law, which requires approval from local elected officials for local boards of health to enact certain new regulations and also allows local politicians to modify or reject health orders issued during a state of emergency.

While most of the proposed or approved legislative changes in these and other states will hinder public health officials’ ability to respond to the ongoing pandemic, that is only one way in which the policy changes will negatively affect public health. Limiting public health authority will also disrupt public health officials’ ability to respond to future emergencies and improve long-term health outcomes for vulnerable populations. It is virtually certain that these ill-considered policy changes will aggravate existing health and wealth inequities in the post-pandemic era.

In the aftermath of the national tragedy of COVID-19, policymakers will have a responsibility to evaluate our public health system and determine which parts need reform. But the rushed, reactionary, anti-regulatory approach that many state legislatures are taking will create more problems than it will solve, exposing Americans to unnecessary risks and perpetuating existing injustices.

Instead of rolling back authority, legislatures should be actively protecting public health authority at the state and local levels so that experts can continue to promote solutions that will bolster economic growth, reduce inequities and address chronic health conditions. Strengthening public health infrastructure and leadership is the best route to a better post-pandemic future in which every American has a fair chance to live a healthy, prosperous life.

Dr. Oxiris Barbot, a former commissioner of health for New York City, is an adjunct assistant professor at Columbia University’s Mailman School of Public Health, a senior fellow for public health and social justice at the JPB Foundation, and a ChangeLab Solutions board member. Sarah de Guia is the CEO at ChangeLab Solutions. An attorney, she previously served as executive director of the California Pan-Ethnic Health Network.

FDA Commits to Evidence-Based Actions Aimed at Saving Lives and Preventing Future Generations of Smokers

Today, the U.S. Food and Drug Administration announced it is committing to advancing two tobacco product standards to significantly reduce disease and death from using combusted tobacco products, the leading cause of preventable death in the U.S. The FDA is working toward issuing proposed product standards within the next year to ban menthol as a characterizing flavor in cigarettes and ban all characterizing flavors (including menthol) in cigars; the authority to adopt product standards is one of the most powerful tobacco regulatory tools Congress gave the agency. This decision is based on clear science and evidence establishing the addictiveness and harm of these products and builds on important, previous actions that banned other flavored cigarettes in 2009.

“Banning menthol—the last allowable flavor—in cigarettes and banning all flavors in cigars will help save lives, particularly among those disproportionately affected by these deadly products. With these actions, the FDA will help significantly reduce youth initiation, increase the chances of smoking cessation among current smokers, and address health disparities experienced by communities of color, low-income populations, and LGBTQ+ individuals, all of whom are far more likely to use these tobacco products,” said Acting FDA Commissioner Janet Woodcock, M.D. “Together, these actions represent powerful, science-based approaches that will have an extraordinary public health impact. Armed with strong scientific evidence, and with full support from the Administration, we believe these actions will launch us on a trajectory toward ending tobacco-related disease and death in the U.S.” 

The agency is taking urgent action to reduce tobacco addiction and curb deaths. There is strong evidence that a menthol ban will help people quit. Studies show that menthol increases the appeal of tobacco and facilitates progression to regular smoking, particularly among youth and young adults. Menthol masks unpleasant flavors and harshness of tobacco products, making them easier to start using. Tobacco products with menthol can also be more addictive and harder to quit by enhancing the effects of nicotine. One studyExternal Link Disclaimer suggests that banning menthol cigarettes in the U.S. would lead an additional 923,000 smokers to quit, including 230,000 African Americans in the first 13 to 17 months after a ban goes into effect. An earlier studyExternal Link Disclaimer projected that about 633,000 deaths would be averted, including about 237,000 deaths averted for African Americans.

“For far too long, certain populations, including African Americans, have been targeted, and disproportionately impacted by tobacco use. Despite the tremendous progress we’ve made in getting people to stop smoking over the past 55 years, that progress hasn’t been experienced by everyone equally,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products. “These flavor standards would reduce cigarette and cigar initiation and use, reduce health disparities, and promote health equity by addressing a significant and disparate source of harm. Taken together, these policies will help save lives and improve the public health of our country as we confront the leading cause of preventable disease and death.”

If implemented, the FDA’s enforcement of any ban on menthol cigarettes and all flavored cigars will only address manufacturers, distributors, wholesalers, importers and retailers. The FDA cannot and will not enforce against individual consumer possession or use of menthol cigarettes or any tobacco product. The FDA will work to make sure that any unlawful tobacco products do not make their way onto the market.

These actions are an important opportunity to achieve significant, meaningful public health gains and advance health equity. The FDA is working expeditiously on the two issues, and the next step will be for the agency to publish proposed rules in the Federal Register allowing an opportunity for public comment.

The agency also recognizes the importance of ensuring broad and equitable access to all the tools and resources that can help currently addicted smokers seeking to quit, including those who smoke menthol cigarettes and would be impacted by these public health measures. The FDA will work with partners in other federal agencies to make sure the support is there for those who are trying to quit. Smokers interested in quitting today should visit smokefree.gov or call 1-800-QUIT-NOW to learn about cessation services available in their state.

The FDA also remains focused on its regulatory oversight of e-cigarettes and other electronic nicotine delivery systems (ENDS). The Center for Tobacco Products recently provided an update on its ongoing work of conducting the premarket review of ENDS and other tobacco product applications, and has issued warning letters to ENDS product manufacturers and retailers who continue to sell products that are illegally on the market. The FDA has also made a significant investment in a multimedia e-cigarette public education campaign. The campaign targets nearly 10.7 million youth aged 12-17 who have ever used e-cigarettes or are open to trying them, and highlights information about the potential risks of e-cigarette use.

Background on Today’s Actions

Menthol Product Standard

Today, the FDA granted a citizen petition requesting that the agency pursue rulemaking to prohibit menthol in cigarettes, affirming its commitment to proposing such a product standard.

The 2009 Tobacco Control Act (TCA) did not include menthol in its ban on characterizing flavors in cigarettes, leaving menthol cigarettes as the only flavored combusted cigarettes still marketed in the U.S. The law instructed the FDA to further consider the issue of menthol in cigarettes.

Since then, the FDA sought input from an independent advisory committee as required by the TCAExternal Link Disclaimer, and further demonstrated its interest by issuing an Advance Notice of Proposed Rulemaking, undertaking an independent evaluation and supporting broader research efforts—all to better understand the differences between menthol and non-menthol cigarettes and the impact of menthol on population health.

In the U.S., it is estimated that there are nearly 18.6 million current smokers of menthol cigarettes. But use of menthol cigarettes among smokers is not uniform: out of all Black smokers, nearly 85% smoke menthol cigarettes, compared to 30% of White smokers who smoke menthols. In addition, among youth, from 2011 to 2018, declines in menthol cigarette use were observed among non-Hispanic White youth but not among non-Hispanic Black or Hispanic youth.

Cigar Flavor Product Standard

After the 2009 statutory ban on flavors in cigarettes other than menthol, use of flavored cigars increased dramatically, suggesting that the public health goals of the flavored cigarette ban may have been undermined by continued availability of these flavored cigars.

Flavored mass-produced cigars and cigarillos are combusted tobacco products that can closely resemble cigarettes, pose many of the same public health problems, and are disproportionately popular among youth and other populations. In 2020, non-Hispanic Black high school students reported past 30-day cigar smoking at levels twice as high as their White counterparts.

Nearly 74% of youth aged 12-17 who use cigars say they smoke cigars because they come in flavors they enjoy. Among youth who have ever tried a cigar, 68% of cigarillo users and 56% of filtered cigar users report that their first cigar was a flavored product. Moreover, in 2020, more young people tried a cigar every day than tried a cigarette.

Empowering State and Local Regulation of Tobacco and Nicotine Products to Protect Youths

Rob Crane, MD1,2Micah L. Berman, JD3Jack Waxman4,5

Driven by a wave of student and parent activism and a focus on health equity, at least 300 local jurisdictions and 5 states have passed laws restricting the sale of flavored nicotine products targeted to middle school and high school students. Focused on redressing race/ethnicity–based health disparities, 2 of those states, California and Massachusetts, have enacted prohibitions on the sale of menthol-flavored cigarettes. Federal law, however, prevents state or local regulation of actual ingredients in tobacco products, rendering these restrictions less than fully effective.

Flavors play an important role in youth initiation of use of nicotine and tobacco products of all kinds. Cities and states that have restricted flavored products have done so chiefly to counter what the US Surgeon General in 2019 termed an “epidemic” of adolescent e-cigarette use. One in 5 high school students have reported using e-cigarettes within the last month, and 2 in 5 of those reported having used them 20 or more days per month. A growing body of evidence suggests that early exposure to nicotine puts these individuals at substantially higher risk of initiating cigarette use.1

In response to mounting public concern, the Trump administration promised to ban all flavored e-cigarette products, but quickly backtracked in the face of industry pressure. The US Food and Drug Administration (FDA) guidance restricted flavors in cartridge-based e-cigarettes but not disposable ones, and it covered mint-flavored e-cigarettes but not menthol-flavored ones. Not surprisingly, use of disposable e-cigarettes and menthol-flavored products subsequently surged.2

Meanwhile, some state and local governments have been striving to address this burgeoning epidemic. States considering strong regulatory stands, such as California and Massachusetts, have found their tools limited. When the 2009 Family Smoking Prevention and Tobacco Control Act became law, it empowered the FDA to regulate tobacco and nicotine products for the first time, but it also preempted state and local governments from various regulatory actions, including blocking any control over tobacco product standards, manufacturing processes, and labeling. The usual argument for preemption is that companies have difficulty complying with different regulations in different localities. However, an industry that promotes nicotine addiction should not be granted such considerations. Doing what works to reduce youth nicotine use is a far more important imperative.

Federal preemption has stifled local regulation in important ways. The law makes it difficult for state and local governments to regulate flavors effectively. Almost all cigarettes and other nicotine products, including so-called tobacco-flavored e-cigarettes, have chocolate, licorice, various sugary sweeteners, or other flavors carefully designed to mask the bitter, peppery taste of nicotine, even if the particular flavor is not individually distinguishable. The addictive nicotine content thus can be increased while the noxious taste and throat hit is minimized. On its website, the leading domestic manufacturer, Philip Morris USA, lists more than 100 flavors and flavor enhancers added to cigarette tobacco, despite the ostensible federal prohibition of flavored cigarette products.

All existing local and state laws dance around the issue of actual ingredient regulation—which is preempted by the Tobacco Control Act—by prohibiting the sale of products with what are known as characterizing flavors. This crude workaround attempts to prevent the sale of a product with a specific distinguishable flavor, such as chocolate, mango, or cherry, but a nuanced combination of flavors is allowed. A regulator must smell or taste the product to try to determine subjectively if the flavor is characterizing. This absurd scenario simply leads companies to relabel their mixed flavor products with more ambiguous names, such as buzzjazz, or sweet.3

While flavors are an obvious allure, the use of high-dose nicotine salts by major e-cigarette manufacturers is perhaps even more dangerous. This deft chemical alteration of nicotine makes it more palatable to young users. Because nicotine salts have a lower pH, they are absorbed more slowly from the respiratory tract, allowing youthful users to gradually adapt to nicotine’s effects. Paradoxically, this slower absorption may make older adults who smoke less likely to switch to popular e-cigarettes that use nicotine salts. That may be one reason the onramp to nicotine addiction for adolescents is much more heavily populated than the offramp for adults who smoke.4 Combustible cigarettes transport high doses of nicotine to the brain within seconds, while nicotine salt e-cigarettes deliver a very large dose after minutes.

The Tobacco Control Act also granted a specific and deeply problematic exemption for menthol flavoring in traditional cigarettes. After decades of predatory marketing targeted specifically to racial/ethnic minority communities, Black individuals who smoke use menthol cigarettes at nearly 3 times the rate of White people who smoke. The addition of menthol creates a more powerful addiction and makes it more difficult to quit, thereby substantially increasing the risk of smoking-associated illnesses.5 The power of menthol in prolonging addiction is underscored by the gradual attrition in use of nonmenthol cigarettes, while menthol brands have maintained steady sales.6

Although the FDA has had the authority to prohibit nicotine salts or flavor-related ingredients, including menthol, since 2009, it has persistently failed to act. In response, cities, counties, and states have taken brave and innovative steps to better protect their adolescents, demonstrating that innovations in public health often begin at the local level. Witness the 500-plus localities and 19 states that have independently enacted Tobacco 21 laws long opposed by the industry, eventually forcing Congress to make the age 21 years the new nationwide standard for sales of nicotine and tobacco products.

More than 3.5 million US middle and high school students and a similar number of college-aged young adults are on a path to nicotine addiction because of slickly marketed, highly flavored, nicotine-salt e-cigarettes. Given the propensity for youthful e-cigarette users to move to traditional cigarettes and the deleterious outcomes of nicotine addiction on the adolescent brain, this generational wave of addiction is a public health crisis.7

In the new Biden administration, perhaps the FDA will consider a more muscular response. But even if pointed in the right direction, the wheels of FDA regulation move slowly. For instance, the FDA announced that it would extend its tobacco-associated regulatory authority to e-cigarettes in 2011, but this largely jurisdictional rule took more than 5 years to finalize, while youth e-cigarette use skyrocketed. Similarly, the FDA has repeatedly studied and reported on the deleterious outcomes of menthol, but over 11 years, it has taken no action. Rather than wait for the FDA, US Congress must eliminate federal preemption on regulation of nicotine product ingredients to allow local and state governments all the tools they need to develop their own effective policy responses more rapidly.

 

Article Information

Corresponding Author: Rob Crane, MD, Department of Family Medicine, The Ohio State University College of Medicine, 5600 Dublin Rd, Dublin, OH 43017 (crane.17@osu.edu).

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Crane R et al. JAMA Health Forum.

Conflict of Interest Disclosures: None reported.

 

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