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M o l l y C o t a n t , M P H
E l a i n e L y o n , M A
L a u r a d e l a R a m b e l j e , M A
S u s a n P u l a s k i , M A , C P C - M
O c t o b e r 8 , 2 0 1 5
Emerging Issues in Tobacco Control
What is Tobacco 21?
Raising the minimum age of legal access to tobacco products to 21 years of age
“Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we
sell about 25 billion cigarettes and enjoy a 70% market share.” Philip Morris report, January 21, 1986
Tobacco Use – A Critical Public Health Issue
Cigarette smoking is the leading cause of preventable disease and death in the U.S.
Each year, more than 16,200 Michiganders die from tobacco use
10,300 Michigan children become new regular, daily smokers annually, 1/3 of whom will die prematurely due to this addiction. E-cigarette use is rising rapidly among youth.
The young adult brain and addiction
Parts of the brain most responsible for decision making, impulse control, sensation seeking and susceptibility to peer pressure continue to develop and change through young adulthood
More susceptible to addiction since the brain is not fully mature: adolescent brains are uniquely vulnerable to the effects of nicotine
Source: Institute of Medicine
The young adult brain and addiction
Because of nicotine addiction, approximately 3 out of 4 teen smokers continue smoking into adulthood, even if they intended to quit after a few years.
95% of adults began smoking before age 21
4 out of 5 become regular, daily smokers before age 21
Studies show earlier onset of tobacco use make it harder to quit later should a person choose to do so.
What influences youth and young adults to initiate tobacco use?
91% of youth obtain cigarettes from social sources – family, friends or other individuals
Tobacco marketing: targets youth and young adults who are VERY influenced by it $276 million spent to market tobacco in Michigan in 2011
More than 80% of underage smokers choose brands from among the top three most heavily advertised
Surgeon General: The more young people are exposed to cigarette advertising and promotional activities, the more likely they are to smoke; nearly 9 out of 10 smokers initiate smoking by age 18
Who has adopted Tobacco 21 policy?
Needham, MA was the first in 2005 New York City: November 2013 Hawaii County, HI: November 2013 Suffolk County: March 2014 Evanston, IL: November 2014 Englewood, NJ: August 2014 Columbia, MO: December 2014 Hawaii: June 2015 Bexley and Upper Arlington, Ohio: July 2015 Healdsburg and Santa Clara, CA Grandview Heights, Ohio: September 2015 As of September 14, 2015, at least 90 localities in 8 states have raised the minimum legal sale age for tobacco products to 21. (TFK)
Benefits of a Tobacco 21 policy
Institute of Medicine Report: “Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products” 3/12/15
Likely benefits from raising the age of legal
access to tobacco products are numerous
and expansive, particularly when a Tobacco 21
policy is part of broader comprehensive tobacco
prevention and control programming.
Institute of Medicine Report Benefits of a Tobacco 21 Policy
Initiation of tobacco use by adolescents and young adults will be prevented or delayed
Smoking prevalence will be substantially reduced over time Health of adolescents and young adults will immediately improve due to a reduction in the number of those with smoking-caused diminished health status
“If a man has never smoked by age 18, the odds are three-to-one he never will. By age 24, the odds are twenty-to-one.”
RJ Reynolds researcher, 1982
Institute of Medicine Report Benefits of a Tobacco 21 Policy
Smoking prevalence will be substantially reduced over time, leading to…
Maternal, fetal and infant health outcomes will improve due to a reduction in the likelihood of maternal and paternal smoking
Smoking related mortality will be substantially reduced over time
Tobacco 21 Saves Lives
Institute of Medicine report, using established simulation models, projects:
249,000 fewer premature deaths
45,000 fewer deaths from lung cancer
4.2 million fewer years of life lost
for those born between 2000 and 2019
Tobacco 21 will likely reduce healthcare costs
The reduction in smoking prevalence resulting from Tobacco 21 will likely lead to reduced future tobacco related costs:
$4.59 billion/year spent in Michigan on smoking-caused health costs. Of this, $1.36 billion/year spent on state and federal smoking-related Medicaid expenditures.
42% of Michigan adult Medicaid enrollees ages 19-64 currently use tobacco
$4.78 billion/year spent in Michigan on smoking-caused productivity losses
Institute of Medicine statement
“…in the absence of transformative changes in the tobacco market, social norms and attitudes, or the epidemiology of tobacco use, the committee is reasonably confident that raising the MLA (minimum age of legal access to tobacco products) will reduce tobacco initiation, particularly among adolescents 15 to 17 years of age, will improve health across the lifespan, and will save lives.”
National Academy of Sciences, “Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products,” March 2015, p. S-9.
Tobacco 21 Myths and Facts
Myth: Retailers will go out of business or lose business to other towns
FACTS: When Needham, MA increased the purchase age to 21, not a
single convenience store went out of business. Restaurant and bar owners had the same fear when Michigan’s Smokefree Air Law was enacted, but this did not happen.
When customers need to travel a significant distance to obtain tobacco products, they are likely to decrease their use. This is especially true for youth, who often have limited transportation options.
Tobacco 21 Myths and Facts
Myth: If you can go to war and bear arms at 18, you should be able to smoke.
FACTS:
Soldiers who smoke are less combat ready and take longer to heal
A comprehensive study on 9.3 million military beneficiaries has revealed lung cancer mortality rates are double among Veterans
Veterans who protected our freedom but contracted emphysema from addiction to military discounted cigarettes have lost their freedom
The U.S. Military has recognized the danger of tobacco use. In 2011, 24.5% of service members reported cigarette use (vs. 20.6% among civilians), and 12.8% reported smokeless tobacco use (vs. 2.3% among civilians).
“The minimum age of military service does not equal readiness to enlist in a lifetime of nicotine addiction.”
“Running the Numbers” The Ohio State University College of Public Health, March 3, 2015
Tobacco 21 Myths and Facts
Myth: At age 18, individuals are able to do everything that older adults can do.
FACT: There are many things that an individual cannot do until 21 years of age or older: Buy alcohol Casino gambling Get a ‘license to carry’ gun permit Rent a car - must be age 25 Rent a room in some hotels Become President of the United States – must be 35 years of age
“For the majority of smokers, tobacco use is not an ‘adult choice;’ it is the result of an addiction that began when they were in high school or younger.”
“Running the Numbers” The Ohio State University College of Public Health, March 3, 2015
Tobacco 21 has Public Support
For more information about Tobacco 21
Contact the MDHHS Tobacco Section:
Molly Cotant [email protected]
Elaine Lyon [email protected]
Contact Angela Clock, Executive Director of Tobacco Free Michigan, for a Resolution of Support: [email protected]
Tobacco 21 Resources
“Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products,” Institute of Medicine of the National Academy of Sciences, March 2015
Campaign for Tobacco Free Kids “Increasing the Minimum Legal Sale Age for
Tobacco Products to 21” www.tobaccofreekids.org Department of Health and Human Services, Centers for Disease Control “Raising
the Minimum Age for Legal Purchase of Tobacco Products: Summary of the Scientific Evidence,” May 2015
“Preventing Tobacco Use Among Youth and Young Adults. A Report of the Surgeon
General.” Department of Health and Human Services, Public Health Service Office of the Surgeon General, 2012
“Tobacco 21 – An Idea Whose Time Has Come” Jonathan P. Winickoff, Mark Gottlieb, Michelle Mello New England Journal of Medicine, 7/22/14
“Raising the Minimum Legal Sale Age of Tobacco and Related Products” Tobacco
Control Legal Consortium www.publichealthlawcenter.org
Tobacco 21 Resources
“Limiting Youth Access to Tobacco: Comparing the Long-term Health Impacts of Increasing Cigarette Excise Taxes and Raising the Legal Smoking Age to 21 in the United States” Sajjad Ahmad and John Billimek Health Policy 80(2007) 378-391
“Why NY May Raise Age to Buy Tobacco to 21” http://www.wsj.com/video/why-
new-york-may-raise-age-to-buy-tobacco-to-21/E2434768-6FC0-441A-AC64-7800DB27254A.html?KEYWORDS=tobacco#!E2434768-6FC0-441A-AC64-7800DB27254A
“More Cities to Raise Tobacco to Age 21” http://www.wsj.com/articles/more-cities-
raise-tobacco-age-to-21-1414526579 “Running the Numbers,” The Ohio State University College of Public Health, March
3, 2015 “Thirteen Years of Tobacco Efforts in Needham”
http://www.needhamma.gov/DocumentCenter/Home/View/1868 Preventing Tobacco Addiction Foundation http://tobacco21.org/
New Generation Tobacco Products: Big Tobacco’s Candy Land
New Generation Tobacco Products include: E-cigarettes, snus, sticks, strips, orbs, hookah, dokha,
other forms of dissolvables, etc.
But don’t forget established forms of Other Tobacco Products, including: Spit/Chew/Snuff, Cigars, Pipes
Dual use of cigarettes and other forms of tobacco products is expected to rise as individuals seek to avoid smoke-free laws and policies.
IMPORTANT:
Nicotine Replacement Therapy ≠ New Generation Tobacco Products.
Many new generation products resemble candy, are brightly packaged, and are aggressively marketed toward youth. May 2014 study revealed tobacco
products are flavored using the same flavorings found in Kool Aid and Jolly Ranchers!
Many products come in small packages easily opened by children; even small amounts of nicotine can be lethal to children.
Nicotine impairs fetal brain and lung development, and alters development of the cerebral cortex and hippocampus (centers for decision-making) in adolescents.
Youth perceive e-cigarettes and other new generation products to be less harmful than cigarettes While e-cigarettes may be ‘less harmful’
than cigarettes, clean air is the standard for comparison
OTP can be just as, more, or differently harmful
Nicotine is addictive
Possible ‘gateway phenomenon’ among young e-cigarette users- Association, NOT yet Causality Progressing to hookah and blunts More likely to progress to combustible
tobacco in one year More likely to use both conventional
cigarettes (dual use) and alcohol
Local Michigan Youth Coalitions Fight Back! https://www.youtube.com/watch?v=ybKk1I08mTo
Little Cigars and Cigarillos
& Spit/Snuff/Dip/Chewing
Tobacco Fruit and candy flavors Sold individually in colorful
wrappers. Easy to hid.
Cheap – costing less than an ice cream cone or candy.
Bright colors make them
easy to confuse with other products.
Spit Tobacco: History of
association with baseball.
Extremely difficult to quit.
Snus
Tobacco in a small pouch, similar to a small tea bag
Strips
Nicospan is nicotine-based
Camel Strips and others are ground tobacco pressed into a strip
Snus and Strips marketed as alternative to smoking in smoke-free environment
Special Concerns
Youth attracted to many flavors.
Easy to hide or confuse with other products.
All forms of smokeless tobacco use associated with oral, esophageal and pancreatic cancer.
Sticks, Orbs, Discs
Sticks and Orbs are made
of ground tobacco pressed
into stick or oval form;
dissolvable
Discs contain nicotine and
do not dissolve (Verve)
“Spitless” nature of
products increases concern
for oral, esophageal and
stomach cancers
Hookah
A 1-hour-long hookah session
involves inhaling 100–200 times
the volume of smoke inhaled from
a single cigarette
Charcoal used to heat the shisha
increases exposure to carbon
monoxide and secondhand smoke
Special Concerns
Risk of transmitting tuberculosis,
herpes or hepatitis, among others
Hookah smokers at risk for oral,
stomach, lung, esophageal
cancers; reduced lung function,
and decreased fertility
o Allows user to inhale aerosol
containing nicotine and/or
other substances.
o Disposable or rechargeable
and/or refillable.
o Contain a cartridge filled with
liquid nicotine, flavorings and
glycerin or propylene glycol.
o When coil heats, it converts the
contents of the cartridge into aerosol.
E-cigarettes are NOT an approved U.S. Food and Drug Administration (FDA) quit tobacco device and should NOT be marketed as such. 9/22/15: U.S. Preventive Services Task Force: “the evidence on
the use of ENDS for tobacco cessation is insufficient…”
E-cigarettes are NOT a safe alternative to other forms of tobacco.
…despite this, we are seeing a lot of false claims…
Accelerating demand: 2010-2013 ever use among adult current and former smokers increased four-
fold 2011-2013 youth never-smokers who had used an e-cigarette tripled; Middle
and High School use of e-cigarettes tripled between 2013 and 2014.
Poison: The American Association of Poison Control Centers report rising incidents of exposure to e-cigarette devices or nicotine refill fluid:
From 271 in 2011 to 3,783 in 2014. 2,209 through August 2015. MI: 32 incidents of poisoning in 2013, and 108 in 2014.
Nicotine exposure, whether through inhalation, ingestion, or skin contact, can be hazardous to the health and safety of children, young people, pregnant women, nursing mothers, people with heart conditions and the elderly.
Dual Use
Flavorings
Primary, Secondhand, Thirdhand Aerosol Exposure: Some studies have indicated adverse health impacts for both the user and bystander. NIOSH, ASHRAE, American Industrial
Hygiene Association and American College of Physicians recommend current smoking bans extend to E-Cigarettes
Propylene Glycol Secondhand and Thirdhand Nicotine Glycerin/glycerol
Reported Impacts to FDA: Pneumonia Congestive heart failure Disorientation Seizure Hypotension, and others
Lack of quality control 2009 FDA tests cartridge ingredients from two leading brands of e-cigarettes, finding:
levels of cancer-causing and toxic chemicals, including diethylene glycol, an ingredient in antifreeze.
In some cases cartridges labeled as containing no nicotine
had nicotine.
Lack of regulation FDA is not regulating the manufacture of e-cigarette components or contents at this time.
Lack of regulation Consumer Product Safety
Commission is not regulating the manufacture of e-cigarettes or components.
As Big Tobacco enters market, expect quality to improve.
E-cigarette Risks Explosions Fires Poisoning – NY Toddler Enables discreet use of
other drugs (heroin, marijuana, crack cocaine)
Hazardous Waste & Litter
Social norm reversal. Marketed to maintain
addiction. Playing out of Big
Tobacco’s playbook: Back on TV. In the workplace. In schools. False health claims.
Currently legal for minors to purchase e-cigarettes, e-hookah, their components, and refills.
E-cigarettes and their components are not currently subject to
the Tobacco Tax. E-cigarettes are not covered by the Smoke-Free Air Law. Various e-cigarette bills have been introduced in the Michigan
legislature to curb youth access.
Governor Snyder and Michigan’s former Chief Medical Executive, Dr. Matthew Davis, have called for e-cigarettes to be treated as tobacco products.
Local Action! E-Cig Bans in… Parks, Other Outdoor Locations: Ann Arbor,
Washtenaw County, Hastings
Indoor Air: Washtenaw County
Government Buildings and Vehicles for Employees: Genesee County, Oakland County, Branch-Hillsdale-St. Joseph Community Health Agency, Michigan LARA, Michigan DHHS, Michigan DEQ
Sales to Minors: Birmingham, Rochester Hills, Rochester, Sterling Heights, (Ingham County in draft)
Educate the public! Reminder that e-cigarettes are not FDA-approved cessation medication, and are not even
regulated for safety Evidence-based medication: 7 FDA-approved medications or nicotine-replacement
therapy
Change Policy!
Implement the 5 As: Ask about e-cigarettes and other forms of tobacco use Advise, Assess, Assist, Arrange
Michigan Tobacco Quitline 1-800-QUIT-NOW (1-800-784-8669) Fax referral available https://michigan.quitlogix.org/providers_partners/default.aspx
Tell the FDA about faulty tobacco products! www.safetyreporting.hhs.gov
Susan Pulaski, MA, CPC-M
Health Department of NW Michigan
Laura de la Rambelje, MA
MDHHS
Angela Clock at Tobacco-Free Michigan for the latest on legislative activity: [email protected]
