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.

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

Dale S Mantey ¹, Onyema Greg Chido-Amajuoyi ², Onyinye Omega-Njemnobi ³, LaTrice Montgomery ⁴

Affiliations expand

• PMID: 34087763
• DOI: 10.1016/j.addbeh.2021.106986

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.

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.