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Flavored Tobacco Products Understanding the New Tobacco Epidemic for California: Flavored Tobacco Products Elisa Tong, Associate Professor of Internal Medicine, UC Davis Kimberlee 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 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 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 Regulatory Science (TCORS) • FDA banned flavors in cigarettes except menthol • FDA has a moratorium on regulating e-cigarettes until 2022 OBJECTIVES • Policy history • California’s data • Health concerns • What are these products? • Schools and colleges • Local action to date 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 Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public Health; May 2019. CA Youth (12.7%): ~85% vape and use flavors Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public Health; May 2019. CA Youth Subgroups: Higher rate includes 12th graders Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public Health; May 2019. California Youth Increased E-Cigarette Use by 45% in 1 Year Figure: Percent of 11th and 12th grade California students who currently use e-cigarettes (past month) * 24 16 14.8 + 45% counties 14 13.3* were above 11.8 13.3% , 12 with 8 10 9.2 counties 8 reporting 23%-34% Percent 6 4 2 0 2014/2015 2015/2016 2016/2017 2017/2018 School year California Healthy Kids Survey, 2014-2018 (n=571,668) Look Up Your School District Dashboard: https://calschls.org/reports-data/data-dashboards/secondary-dashboard/ OBJECTIVES • Policy history • California’s data • Health concerns • What are these products? • Schools and colleges • Local action to date What’s in an Electronic Smoking Device? Growing scientific evidence of harms: • Cellular toxicity • Particulates worsen lung function • Impaired arterial dilation • Immune function 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 Initiate – numbs the throat Inhale – deeper inhalation Harder to quit – acts on nicotine Eating flavors is not the receptors (Ton 2015; Levy 2011) same as inhaling flavors. Marketing – 70% California African Americans who smoke Heated chemicals also use menthol react differently than burned chemicals. 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 “In a nutshell, best estimates show e- “Inadequate evidence on the cigarettes are 95% less harmful to your benefit of [Electronic Nicotine health than normal cigarettes, and when Devices] to achieve tobacco supported by a smoking cessation service, cessation in adults or improve help most smokers to quit tobacco perinatal outcomes in altogether.” infants…balance of benefits and harms cannot be determined” “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 OBJECTIVES • Policy history • California’s data • Health concerns • What are these products? • Schools and colleges • Local action to date A Growing List of Tobacco Products Pod Systems: Nicotine Salts Increase Bioavailability *May be refilled Flavorshookkids.org, California Department of Public Health # Reasons Youth Vape 1. Friends or family members use them 2. Flavors 3. Beliefs e-cigarettes are less harmful Source: Centers for Disease Control. (2016). Reasons for Electronic Cigarette Use Among Middle and High School Students – National Youth Tobacco Survey, United States, 2016. 25 New Tobacco Products: Easy to Hide Concerns Youth and Young Adult Use E-cigarette use associated with later use of cigarettes and marijuana (gateway) Products being used by young people who may have not considered using tobacco Higher rates of e-cigarette use than any other Evolving products lead to tobacco products changes in use and exposure • Cigarette smoking going down, use of new products going up or staying same Nicotine Exposure High levels of nicotine in products Different patterns of use/consumption Addiction Prevent Quit Attempts People interested in quitting tobacco are switching 27 OBJECTIVES • Policy history • California’s data • Health concerns • What are these products? • Schools and colleges • Local action to date 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 • Policy history • California’s data • Health concerns • What are these products? • Schools and colleges • Local action to date Policies and Laws Priorities 32 TOBACCO RETAIL LICENSING 33 The Problem 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 35 Tobacco Sales in CA since 2016 “Tobacco 21” Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public Health; May 2019. 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 The Effects • 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 CA Local Policies: Restricting Sales of Flavored Tobacco Vuong TD, Zhang X, Roeseler A. California Tobacco Facts & Figures 2019. Sacramento, CA: California Department of Public Health; May 2019. 35 Local Ordinances Restricting Flavored Tobacco Sales (as of May 2019) American Lung Association: 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.
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