emerging issues in tobacco control

S p e a k e r s :

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 cotantm@michigan.gov

Elaine Lyon lyone@michigan.gov

Contact Angela Clock, Executive Director of Tobacco Free Michigan, for a Resolution of Support: tobaccofreemi@gmail.com

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

s.pulaski@nwhealth.org

Laura de la Rambelje, MA

MDHHS

delaRambeljeL@michigan.gov

Angela Clock at Tobacco-Free Michigan for the latest on legislative activity: tobaccofreemi@gmail.com