Understanding the New Tobacco Epidemic for California ... · Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public

Understanding the New Tobacco Epidemic for California:Flavored Tobacco ProductsElisa Tong, Associate Professor of Internal Medicine, UC DavisKimberlee Homer Vagadori, Project Director, California Youth Advocacy Network

A New Tobacco Epidemic

Flavorshookkids.org by California Tobacco Control Program

OBJECTIVES

• Policy history• California’s data• Health concerns

• What are these products?• Schools and colleges• Local action to date

1950-60s: Industry Public Relations Surgeon General Report, FTC radio/TV ad restrictions

cdc.gov

Presenter

Presentation Notes

A Frank Statement to Cigarette Smokers was a historic first advertisement in a campaign run by major American tobacco companies on January 4, 1954, to create doubt by disputing recent scientific studies linking smoking cigarettes to lung cancer and other dangerous health effects. Recent reports on experiments with mice have given wide publicity to the theory that cigarette smoking is in some way linked with lung cancer in human beings. Although conducted by doctors of professional standing, these experiments are not regarded as conclusive in the field of cancer research. However, we do not believe that any serious medical research, even though its results are inconclusive, should be disregarded or lightly dismissed. At the same time, we feel it is in the public interest to call attention to the fact that eminent doctors and research scientists have publicly questioned the claimed significance of these experiments. Distinguished authorities point out: 1. That medical research of recent years indicates many possible causes of lung cancer. 2. That there is no agreement among the authorities regarding what the cause is. 3. That there is no proof that cigarette smoking is one of the causes. 4. That statistics purporting to link cigarette smoking with the disease could apply with equal force to any one of many other aspects of modern life. Indeed, the validity of the statistics themselves is questioned by numerous scientists. We accept an interest in people’s health as a basic responsibility, paramount to every other consideration in our business. We believe the products we make are not injurious to health. We always have and always will cooperate closely with those whose task it is to safeguard the public health. For more than 300 years tobacco has given solace, relaxation and enjoyment to mankind. At one time or another during those years critics have held it responsible for practically every disease of the human body. One by one these charges have been abandoned for lack of evidence. Regardless of the record of the past, the fact that cigarette smoking today should even be suspected as a cause of serious disease is a matter of deep concern to us. Many people have asked us what we are doing to meet the public’s concern aroused by recent reports. Here is the answer: 1. We are pledging aid and assistance to the research effort into all phases of tobacco use and health. This joint financial aid will of course be in addition to what is already being contributed by individual companies. 1 The original of this statement was published in various periodicals, including The Tobacco Leaf for January, 1954, which is available at http://www.pmdocs.com/PDF/2015002376.PDF, marked Bates No. 2015002376.

1970s-80s: “Tar” Wars, Smoke-free Laws

tobaccofreeflorida.com/timeline/

2006: US DOJ Verdict – Industry Violated Civil Racketeer Influenced and Corrupt Organizations (RICO) laws

The Industry “continues to engage in and execute…50 year scheme to defraud public” on health effects and marketing to children

“Corrective” statements aired in 2017-8, but only 40% of US adults aware JAMA Netw Open 2019

• Adverse health effects of smoking• Addictiveness of smoking and nicotine• Lack of health benefits from smoking “low tar”, “light”,

“ultra light”, “mild”, and “natural” cigarettes (deceptively marketed as less harmful)

• Manipulation of cigarette design and composition to ensure optimum nicotine delivery

• Adverse health effects of exposure to secondhand smoke

www.tobaccofreekids.org/what-we-do/industry-watch/doj; Chido-Amajuoyi JAMA Netw Open 2019

Presenter

Presentation Notes

Exposure to Court-Ordered Tobacco Industry Antismoking Advertisements Among US Adults Onyema Greg Chido-Amajuoyi, MBBS, MPH1; Robert K. Yu, MCS2; Israel Agaku, DMD, MPH, PhD3; et alSanjay Shete, PhD1,2,4 Author Affiliations Article Information JAMA Netw Open. 2019;2(7):e196935. doi:10.1001/jamanetworkopen.2019.6935 Question What was the reach of federal court–ordered antismoking advertisements among the US adult population? Findings In a cross-sectional survey of US adults, estimated exposure to federal court–ordered antismoking advertisements was 40.6%. Exposure rates were lowest among those aged 18 to 34 years (37.4%), those with a high school education or less (34.5%), those earning less than $35 000 per year (37.5%), and Hispanic current smoker respondents (42.2%). Meaning Penetration of the tobacco industry–funded antismoking advertisements was suboptimal within the US population and in populations at greatest risk of tobacco use.

http://www.tobaccofreekids.org/what-we-do/industry-watch/doj

2009: Food & Drug Administration• FDA has authority to regulate the

manufacture, distribution, and marketing of tobacco products

• Approval to market, make cessation or reduced harm claims

• Funds Tobacco Centers of RegulatoryScience (TCORS)

• FDA banned flavors in cigarettes except menthol

• FDA has a moratorium on regulating e-cigarettes until 2022

OBJECTIVES



California: Smoking Declining (10%) but still 2.8M

Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public Health; May 2019.

CA Young Adults (23.6%): 58% use flavors



CA Youth (12.7%): ~85% vape and use flavors


CA Youth Subgroups: Higher rate includes 12th graders

California Youth Increased E-Cigarette Use by 45% in 1 Year

14.8

11.8

9.2

13.3*

02468

10121416

2014/2015 2015/2016 2016/2017 2017/2018

Perc

ent

School year

+ 45%

Figure: Percent of 11th and 12th grade California students who currently use e-cigarettes (past month)

California Healthy Kids Survey, 2014-2018 (n=571,668)

* 24 counties were above 13.3% , with 8 counties reporting 23%-34%

Look Up Your School District Dashboard:https://calschls.org/reports-data/data-dashboards/secondary-dashboard/

https://calschls.org/reports-data/data-dashboards/secondary-dashboard/

OBJECTIVES



What’s in an Electronic Smoking Device?

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdfhttps://no-smoke.org/electronic-smoking-devices-secondhand-aerosol/

Growing scientific evidence of harms:• Cellular toxicity• Particulates

worsen lung function

• Impaired arterial dilation

• Immune function

Presenter

Presentation Notes

Moreen Acetaldehyde Benzene Cadmium Formaldehyde Isoprene Lead & Nickel Nicotine N- Nitrosonornicotine Toluene Propylene gycol (primary component in the aerosol emitted) Take away: Smoke is smoke Not approved as smoking cessation device

https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf

https://no-smoke.org/electronic-smoking-devices-secondhand-aerosol/

Flavors: Easy to Hit

Eating flavors is not the same as inhaling flavors.

Heated chemicals also react differently than burned chemicals.

Initiate – numbs the throat

Inhale – deeper inhalation

Harder to quit – acts on nicotine receptors (Ton 2015; Levy 2011)

Marketing – 70% California African Americans who smoke use menthol

Pricing - 75 cents cheaper in Sacramento’s Oak Park African American neighborhood

Nicotine: Easy to Addict

• Brain develops until 25 years• Machine data not real life

• Industry manipulated nicotine in “freebased” cigarettes (low pH)

• Users can compensate• New nicotine salts: high

bioavailability• Nicotine not harmless

• Cardiovascular system

US: Not Recommend E-cigs for Cessation

UK (8/15): Support US (10/15): No recommendation“Inadequate evidence on the benefit of [Electronic Nicotine Devices] to achieve tobacco cessation in adults or improve perinatal outcomes in infants…balance of benefits and harms cannot be determined”

“In a nutshell, best estimates show e-cigarettes are 95% less harmful to your health than normal cigarettes, and when supported by a smoking cessation service, help most smokers to quit tobacco altogether.”

“E-cigarettes for Smoking Cessation”?

• Refillable e-cigs vs. preferred nicotine medications (3 months with counseling)• 18% e-cigs vs. 10% nicotine meds: sustained abstinence rates by carbon monoxide

• Among 1-year abstinent group for smoking, e-cig group did not stop tobacco• 80% e-cig group still using e-cigs vs. 9% nicotine group still using• Switching: concern for long-term health problems with cellular toxicity (Borrelli editorial, NEJM 2019)

7 FDA-approved Tobacco Cessation Aids:Double Chances of Quitting and with Counseling

Nicotine Replacement Therapy (OTC)• Patch• Lozenge• Gum (chew and park)• Combination: long and short-acting

Higher potency nicotine (prescription)• Nasal Spray• Inhaler

Pills (prescription)• Buproprion• Varenicline

Presenter

Presentation Notes

Shannon FDA Approved And it addresses the physiological part of quitting (nicotine stimulates release of chemicals in the brain- curves withdrawal symptoms) (Psychological dependence- Ambivalence, Routine, Utility (manage stress, reward, concentration)) ~95% relapse rate when quitting cold-turkey within the first week Medications can make the difference from white-knuckling through the addiction Encourages quit attempts Recommend prescribing over-the-counter medications as some plans cover the cost of these medications

OBJECTIVES



A Growing List of Tobacco Products

Presenter

Presentation Notes

Moreen Can you identify what each product is? Top left: cigarettes, cigars swisher sweets (cigarillos), hookah, chewing tobacco Bottom left: Snus(pouched chewing tobacco), Electronic cigarettes, JUUL (electronic nicotine pods) – One pod of Juul equals to one pack of cigarettes All of these products are Tobacco Products. Electronic nicotine delivery systems (ENDS)- are not safe and harm reduction does not equate to risk reduction.

Pod Systems: Nicotine Salts Increase Bioavailability*May be refilled

Flavorshookkids.org, California Department of Public Health

#

1. Friends or family members use them

2. Flavors

3. Beliefs e-cigarettes are less harmful

Reasons Youth Vape

25

Source: Centers for Disease Control. (2016). Reasons for Electronic Cigarette Use Among Middle and High School Students – National Youth Tobacco Survey, United States, 2016.

New Tobacco Products: Easy to Hide

Evolving products lead to changes in use and exposure

Youth and Young Adult UseE-cigarette use associated with later use of cigarettes and marijuana (gateway)Products being used by young people who may have not considered using tobaccoHigher rates of e-cigarette use than any other tobacco products• Cigarette smoking going down, use of new

products going up or staying same

27

Concerns

Nicotine ExposureHigh levels of nicotine in productsDifferent patterns of use/consumptionAddictionPrevent Quit AttemptsPeople interested in quitting tobacco are switching

OBJECTIVES



California Tobacco Use Prevention Education (K-12)California Department of Education

CA Smoke and Tobacco-Free College Policies

• University of California systemwide (2014)• 2008 health campuses

• California State University systemwide (2017)

• Community Colleges

OBJECTIVES



Policies and LawsPriorities

32

TOBACCO RETAIL LICENSING

33

Generally, there are two ways youth gain access to tobacco: 1. Social Sources (Ex: From family or

friends)2. Retail Sources (Ex: Convenience or

Grocery stores)

Since it is nearly impossible to monitor the social side, action must be taken to control illegal sales in the retail environment.

34

The Problem

35

Tobacco Sales in CA since 2016 “Tobacco 21”


The Facts

In California…• 34,426 retailers sell tobacco• 82% of retailers sell candy, mint, or liquor flavored non-

cigarette tobacco products (an increase from 79.4% in 2013)• 81% of retailers within 1,000 feet of schools sell flavored

tobacco products (increase from 77% in 2013)

37

• Approximately 68% current and former smokers start by the age of 18, and 99% start by the age of 26

• Each year, 10,900 youth in California become daily smokers

• 2/3 will become long term users

• Tobacco kills ½ of its long term users

38

The Effects


CA Local Policies: Restricting Sales of Flavored Tobacco

35 Local Ordinances Restricting Flavored Tobacco Sales (as of May 2019)

American Lung Association: https://center4tobaccopolicy.org/tobacco-policy/tobacco-retail-environment/

https://center4tobaccopolicy.org/tobacco-policy/tobacco-retail-environment/

Public Health & Health Partners, Schools, Colleges:Educating the Local Community and Empowering Youth

SUMMARY

• Policy history shows industry strategies to promote use• New tobacco epidemic is in California• Health concerns include high potency nicotine, flavors and

initiation, immediate health effects for heart and lung• New tobacco products easy to hide and rapidly changing• California schools and colleges facing challenges of epidemic• Growing local ordinances in major areas

Documents

Understanding the New Tobacco Epidemic for California ... · Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public