Category Archives: Tobacco control
Tobacco featured prominently as a public health issue at the American Public Health Association (APHA) meeting this week, including a regulatory update from Mitch Zeller, JD, who became director of the U.S. Food and Drug Administration’s (FDA) Center for Tobacco Products earlier this year. Zeller previously worked on tobacco issues in government as associate commissioner and director of FDA’s first Office of Tobacco Programs, and also as a U.S. delegate to the World Health Organization (WHO) Working Group for the Framework Convention on Tobacco Control.
NewPublicHealth spoke with Zeller ahead of the APHA meeting.
Mitch Zeller: I think most broadly my goals are to help give the center and the agency the greatest chance of fulfilling the public health mission behind the law passed in 2009 giving the Food and Drug Administration authority over tobacco. This really is an important piece of legislation. It’s really stunning that in 2013—with everything that we know about the harms associated with tobacco use—that it remains the leading cause of preventable death and disease both in this country and globally.
There are some very powerful tools that Congress has given FDA to use wisely and supported by evidence. That’s where I think, the greatest opportunity lies: to use the tools relying on regulatory science to try to protect consumers and reduce the death and disease toll from tobacco.
There are two areas where I think these tools can make a profound positive impact on public health. The first is something called product standards, which is basically the power to ban, restrict or limit the allowable levels of ingredients in tobacco or tobacco smoke. We are exploring potential product standards in three areas: toxicity, addiction and appeal. And we are funding research in all three areas and working very hard behind the scenes to find out what our options are for potential product standards in those three areas.
“Are they harm reduction or are they smoking cessation? It’s a tough situation because, on the one hand, you have what it does and on the other you have the claims are that are allowable under the law. It’s a strange situation where they are being regulated as tobacco products. But they are not tobacco products. There’s no tobacco in them.”
Many hard facts about e-cigarettes are still unclear. What is clear is that marketers are pushing hard to make the switch from smoking to “vaping” an ongoing trend. In the above quote from a TechCrunch article, Michael Siegel, MD, Professor at Boston University’s Public School of Health, mulled over some very real concerns about where we’re heading in terms of e-cigarette regulation.
The current debate between the manufactures and public health experts surrounds the health impacts of the nicotine product. The e-cigarette “boom” began around 2007, starting first with smaller companies. After making a dent in cigarette sales—unlike cessation therapies such as the patch and gums—tobacco companies took notice and are starting to jump onboard.
Today e-cigarettes are especially rising in popularity among what some may consider the “hip” crowd. From a recent article in The New York Times:
Do we need an endgame strategy to finally end the devastating hold tobacco has on its users? Scholars, scientists and policy experts grapple with endgame proposals in a special supplement to the journal Tobacco Control. Some of the articles are based on a workshop held last year at the University of Michigan, with financial support from the Robert Wood Johnson Foundation and the American Legacy Foundation. The workshop was hosted by Kenneth Warner, PhD, a former dean at the University of Michigan School of Public Health and now a professor at the School.
Although smoking has declined significantly in most developed nations in the last half-century, due to policy changes and increased education about the health hazards, says Warner, too many people continue to die from the most preventable cause of premature death and illness. It's estimated that worldwide six million people a year die from illnesses caused by cigarettes, including more than 400,000 in the U.S. alone."There is a newfound interest in discussing the idea of an endgame strategy. The fact that we can talk about it openly reflects a sea change,” says Warner.
>>Read the articles in the tobacco endgame supplement.
Some of the strategies in the supplement include:
- Requiring manufacturers to reduce nicotine content sufficiently to make cigarettes nonaddictive.
- A "sinking lid" strategy that would call for quotas on sales and imports of tobacco, which would reduce supply and drive up price to deter tobacco purchases.
- A "tobacco-free generation" proposal calling for laws that would prevent the sale of tobacco to those born after a given year, usually cited as 2000, to keep young people from starting to smoke; or ban the sale of cigarettes altogether.
"What we are doing today is not enough," says Warner. "Even if we do very well with tobacco control, as we have for several decades now, we'll have a huge number of smokers for years to come, and smoking will continue to cause millions of deaths.”
NewPublicHealth recently spoke with Dr. Warner about some of the strategies proposed for ending tobacco use.
NewPublicHealth: Why is there a need for novel, even radical, endgame strategy?
Ken Warner: While a lot of people have quit smoking, if you look at the rate at which people are quitting in the United States, in the last few years it may actually have declined. In Canada, there is some concern that their very low rates of smoking may actually have gone up. In Singapore, which had the lowest smoking prevalence among developed nations, the smoking rate went up from 12.6 percent to 14.3 percent between 2004 and 2010. So what we're observing is that in some of the countries that have had pretty good success with tobacco control, smoking is now being reduced somewhat more slowly, or possibly even increasing. And if we stay at the current rate of smoking, or even if the smoking rate continues to decline slowly, smoking will remain the leading cause of preventable premature death for many years to come.
NPH: What are some of the reasons that we’re seeing a plateau in the reduction of tobacco use?
While twelve states currently have laws regulating sales of electronic cigarettes (known as e-cigarettes) to minors, a new post on the Network for Public Health Law blog calls on more states to restrict sales to minors while the Food and Drug Administration continues their review of the device.
E-cigarettes contain nicotine, but no tobacco and often come in kid-alluring flavors such as chocolate and vanilla. According to the Network post, one small FDA study found carcinogens and toxins in e-cigarettes. Health experts are concerned that the electronic devices may also be a gateway tool for young adults to actual, cancer-causing, tobacco-filled cigarettes.
E-cigarette use has skyrocketed among adults, according to a recent study by researchers funded by the Centers for Disease Control and Prevention. In 2011, about 21 percent of adults who smoke traditional cigarettes had used electronic cigarettes, up from about 10 percent in 2010. Awareness of e-cigarettes rose from about four in 10 adults in 2010 to six in 10 adults in 2011.
Thomas Farley, MD, MPH, Health Commissioner of the New York City Department of Health and Mental Hygiene, is the keynote speaker at the opening session of the Public Health Law Research annual meeting that started yesterday afternoon in New Orleans. In advance of the meeting, NewPublicHealth spoke with Dr. Farley about the role of legal research in moving the public health agenda forward, how New York City is doing in the weeks following Hurricane Sandy, and the flu epidemic hitting the city that prompted New York State Governor Cuomo to declare a public health emergency earlier this week.
NewPublicHealth: What will you focus on during your address at the Public Health Law Research Program annual meeting?
Dr. Farley: I will be going through a number of policies that we have put in place here in New York City to promote health. Most of those will be around food, but some will be around tobacco. So that includes things such as our raising of tobacco taxes, our smoke-free air rule and around our prohibition on the use of trans fats in restaurants, our calorie labeling initiative and our portion rule [limits on beverage sizes at some food outlets]. And I will share some thoughts about the role researchers can play in policy development for an agency like ours.
NPH: How important has legal research been for some of the recent public health initiatives that have been introduced in New York City?
Cynthia Hallett, executive director of Americans for Nonsmokers’ Rights, will speak today about tobacco policies at a Public Health Law Conference session on innovative community policy. The other presenters include Aaron Wernham of the Health Impact Project and Marion Standish, director of community health at the California Endowment. NewPublicHealth caught up with Ms. Hallett before the session.
NewPublicHealth: What is the focus of the panel discussion you’re a part of?
Cynthia Hallett: We will be sharing some of our collective experiences on successful health policy efforts and some of the resources that would be available for others as they’re thinking about what kind of health policies they want to try to pursue at the community level.
NPH: What will you be presenting about tobacco?
Last month at the Association of State and Territorial Health Officials Annual Meeting (ASTHO), attendees focused during one session on the progress made in reducing tobacco death and disease—and the significant room for improvement, as tobacco remains the leading cause of preventable death in the United States.
We caught up with Lawrence Deyton, MSPH, MD, director of the Food and Drug Administration’s (FDA) Center for Tobacco Products at the ASTHO meeting to get his take on the value of tobacco control as a prevention strategy, as well as the role of state and local public health officials.
NewPublicHealth: What did you go to ASTHO to learn, and what did you share?
Dr. Deyton: State health officers are on the front lines of tobacco control. They see the impact in their communities. I went to the ASTHO meeting to both hear from them, and to explain where we are in tobacco regulation at the FDA and to invite the public health community to get more involved in the regulatory process by commenting.
The depth and breadth of my respect for the work state health officers do—and the budgets they have to do it with—is great. We’ll want to see comments from all stakeholders, including folks from ASTHO, on our proposed regulations, because public health officials all have a very important view we’ll want to hear about. They may have the data that could be important to support their recommendations.
NPH: What is the FDA Center for Tobacco Products doing to help prevent tobacco-related death in the U.S., and what do you want public health leaders to know about this work?
Public health experts hope high school juniors and seniors will add another question to their list as they begin to visit colleges this year: is the campus smoke free?
According to the Tobacco-Free College Campus Initiative—launched last month at the University of Michigan by the Department of Health and Human Services along with private, public and education partners—about 17 percent of colleges and universities in the United States already have tobacco-free (no form of tobacco allowed) or smoke-free (no cigarettes allowed) policies, and more schools are moving toward such policies.
Cynthia Hallett, executive director of Americans for Nonsmokers’ Rights in Berkeley, Calif., says the trend toward eliminating smoking on college campuses began in the early 2000s. Before then, says Hallett, skepticism over student and faculty interest may have kept the schools from initiating policies against smoking. “With so many campuses now [outlawing smoking] and the growing number of resources available, such as model policies and guidelines for implementation and enforcement, it is becoming much easier for colleges and universities to initiate smoke- and tobacco-free policies,” Hallett says.
Hallett says effective arguments to push colleges toward tobacco-free campuses include:
- Tobacco use initiation peaks from 18 to 25 years of age. College attendance could be a turning point in choosing not to use tobacco.
- According to a recent report from the U.S. Surgeon General, about 25 percent of full-time college students aged 18 to 22 years old were current smokers in 2010.
- The number of smokers who initiated smoking after age 18 increased from 600,000 in 2002 to 1 million in 2010.
- Progression from occasional to daily smoking almost always occurs by age 26, and curbing tobacco influence on campuses could prevent a new cohort of lifetime smokers.
Recent campus initiatives to help students stop or never start smoking include:
- The University of Kentucky has an aggressive tobacco-free policy, which was implemented in 2009. Current efforts focus on educating new students about the policy each year and using innovative approaches to smoking cessation including mobile apps. The university also has faculty and students who are part of the Tobacco-Free Take Action volunteer group, who approach smokers and request they put out their cigarette, and also offer resources to help the smoker quit.
- Harrisburg University of Science and Technology in Pennsylvania, only seven years old, has always been smoke free and its age gives it an edge over many other universities in that respect, according to a university spokesman.
- City Colleges of Chicago, which has 120,000 students, implemented a 100-percent tobacco-free policy across its seven campuses last month. The policy includes offering students a smoking cessation program called “Courage to Quit.” The college system conducted a survey that found that 85 percent of students, faculty and staff respondents believe a tobacco-free policy would improve health for staff and students. The policy is the first component in City Colleges’ overall Healthy Campus initiative, which will also include healthy and affordable food choices, green initiatives and healthy activities.
- In January 2012, University of California President Mark Yudof announced that all 10 University of California campuses would become smoke-free as of January 2014. University Student Health Services offers an individual tobacco cessation program that helps students identify triggers, reasons for quitting, and barriers to quitting as well as a variety of quitting techniques.
>>Bonus Link: Americans for Nonsmokers’ Rights maintains a list of colleges and universities with smoke-free policies.
New York’s high cigarette tax—the highest in the country, at $4.35 per pack—has helped the state cut smoking levels dramatically for both adults and high school students, according to a new study in PLoS One.
The state’s rate of adult smoking dropped by 28 percent from 2003 to 2010, while the national rate for the same period dropped only 11 percent. The rate for New York high school students dropped 38 percent from 2003 to 2011, compared to a national drop of 17 percent. There are approximately 664,000 adult smokers in New York.
While a clear contributor, a high cigarette tax is just one of the tactics that’s helped improve the state’s health, according to the Campaign for Tobacco-Free Kids (CTFK). New York also has a comprehensive smoke-free air law, as well as prevention and cessation programs. Overall, these public health strategies have helped prevent more than 300,000 kids from smoking and saved approximately $11.6 billion in health care costs.
Despite the clear public health successes, CTFK says more still needs to be done to help low-income New Yorkers quit smoking. While the study determined their smoking rate is also well below the national rate, 24.3 percent of New Yorkers earning less than $30,000 annually are smokers.
>> Read more on the study from the Campaign for Tobacco-Free Kids.
>> Read more on how tobacco taxes can help cut health care costs.
The U.S. Food and Drug Administration has announced that it will require tobacco companies to report on a range of toxic chemical ingredients, as well as back up any claims for "safer" tobacco products.
Both actions will have a public comment period, ending June 4, 2012, before the rules become final.
Under the proposed regulations, tobacco companies will be required to report quantities of 20 different ingredients associated with cancer, lung disease and other health problems on consumer-friendly packaging by the end of the year, and the agency plans to make the information available to the public in a consumer-friendly format by April 2013.
Tobacco manufacturers will also have to substantiate claims if they want to market a tobacco product as "less risky" to health.
>>Read a statement from the Campaign for Tobacco-Free Kids on the new rules.
>>Read more about modified risk tobacco products.
>>Read more about potentially harmful chemicals in tobacco products.