Category Archives: Tobacco
The public comment period for rules regulating the sale and use of e-cigarettes proposed in April by the U.S. Food and Drug Administration (FDA) ends on August 8, after which the agency is expected to release final rules governing the products. Experts say the timing is critical because sales of the products—which weren’t even on the market a decade ago—are heating up, with revenues approaching $1 billion a year, according to Forbes Magazine.
Last week, Health Affairs and the Robert Wood Johnson Foundation (RWJF) released a health policy brief about e-cigarettes that sets out key issues concerning the products and provides important background, particularly for people poised to comment on the FDA’s proposed rules.
Among the issues the policy brief addresses are e-cigarette safety; whether the devices ought to be regulated as a medical (smoking cessation) device or as a cigarette; and whether e-cigarettes pose a risk as a “gateway” drug to tobacco products. It notes that the FDA is currently funding close to 40 studies on e-cigarettes.
The issue is especially critical because sales to kids and teens are increasing, and there is still insufficient information on whether the vapor emitted by the devices pose a cancer risk. A 2013 study of 40,000 middle and high school students around the country by researchers at UC San Francisco found that e-cigarette use in that group doubled between 2011 and 2012, from 3.1 percent to 6.5 percent.
Read the policy brief from Health Affairs and RWJF.
>>Bonus Link: Read a NewPublicHealth post on initiatives by major cities to regulate the sale and use of e-cigarettes.
Data on thirdhand smoke—tobacco smoke left on surfaces, walls and floors—was first published in 2009. The data has raised significant concerns that the smoke can linger for months or longer, as well as combine with indoor air compounds to possibly form new carcinogens. In the last few months researchers from the California Thirdhand Smoke Consortium, funded by the University of California’s Tobacco-Related Disease Research Program (TDRP), have been presenting and publishing data that indicates that thirdhand smoke is linked to serious health risks in animals and humans—though more research is needed to better measure thirdhand smoke constituents and their health impact.
Consortium researchers published the first animal study on thirdhand smoke in January in the journal PLOS One, finding that mice exposed to thirdhand smoke developed a range of medical conditions, including liver damage and hyperactivity. Research published last year, as well as presented at the annual meeting of the American Chemical Society a few weeks ago, finds that thirdhand smoke likely causes damage to human DNA.
And last month several of the Consortium scholars presented their findings at a tobacco conference n California.
“The potential health risks of what we call thirdhand smoke are only now being studied. This is a new frontier,” said Georg Matt, a Consortium member and psychology professor of at San Diego State University who focuses on policies to protect nonsmokers. “We don’t yet know the degree of risk, but we are already finding that indoor smoking leaves a nearly indelible imprint. We need to find out what risk this pollution poses.”
Big Cities Health Coalition, Other Groups Push FDA to Expand Its Proposed Regulations on E-Cigarettes
A growing number of public health groups are urging the U.S. Food and Drug Administration (FDA) to go well beyond the new rules the agency proposed last month to expand its authority over tobacco, including e-cigarettes. Late last week the Big Cities Health Coalition, made up of twenty of the largest cities in the United States—including Boston, New York City, Chicago and Los Angeles—held a briefing in Washington, D.C. to address what they see as significant gaps in the recently released FDA tobacco regulations. The Coalition is a project of the National Association of County and City Health Officials (NACCHO). “What began as a sliver of the tobacco market is now predicted to eclipse traditional tobacco sales by mid-century,” said the Coalition in a letter to the agency last week.
The letter and Washington, D.C., briefing highlighted concerns about regulating e-cigarettes that the current FDA rules do not address:
- E-cigarettes are being marketed in ways that appeal to youth and could undermine existing tobacco regulations
- E-cigarette manufacturers are making unsubstantiated claims regarding health and safety
- E-cigarettes do not carry health warning labels
Marketing to children was a key concern during the Coalition’s briefing. “The FDA should aggressively limit access to minors and not allow marketing to them or flavorings,” said Barbara Ferrer, MPH, PhD, executive director of the Boston Public Health Commission. All of the commissioners at the briefing voiced a need to regulate flavorings, which can include flavors such as—bubble gum and watermelon—and which the commissioners say are a direct enticement for young people.
“Bubble gum is not a flavor that’s aimed at you or me,” said Mary Bassett, MD, MPH, Commissioner of the New York City Department of Health and Mental Hygiene.
Many of the Coalition member cities have already proposed or enacted laws regarding e-cigarettes that are stricter than the ones proposed by last month by the FDA. A sampling of city regulations regarding e-cigarettes includes:
- Boston — E-cigarettes are not permitted in the workplace; sales are not permitted to anyone under 18; and neither cigarette smoking nor e-cigarette “vaping” are permitted in the city’s public parks.
- New York City — Bans the sale of e-cigarettes to anyone under 21, and as of August 2014 “vaping” will not be permitted anywhere cigarette smoking is not allowed.
- Chicago — Requires retailers to obtain tobacco licenses in order to sell e-cigarettes, prohibits sales of e-cigarettes within 500 feet of schools, requires e-cigarettes to be sold behind store counters and prohibits use of e-cigarettes wherever smoking is prohibited.
- Los Angeles — E-cigarettes cannot be used in public buildings, in parks, at beaches and at other locations where cigarette and tobacco smoking is prohibited. Sales are not allowed to people under 18.
“City health commissioners and mayors are playing and will continue to play critical roles in regulating tobacco products, including e-cigarettes,” said Vince Willmore, vice president for communications at the Campaign for Tobacco-Free Kids in Washington, D.C. “Overall, the main things public health advocates can do is to comment on the FDA rule and urge that it be finalized as quickly as possible; push for action in their own states and communities to regulate e-cigarettes as tobacco products; and continue to focus attention on the problems posed by e-cigarettes.”
The FDA has proposed a 75-day comment period rather than the usual 90-day period, pointed out Robin Koval, president and CEO of Legacy. Last week the organization released a new report on e-cigarettes that looked at the rise of e-cigarette use among youth, as well as the entry of the major tobacco companies into the e-cigarette market.
Koval said she would like to see the FDA commit to a specific time frame for sending its proposed rules to Congress once the comment period is over because “there isn’t’ any time to lose in getting the regulations out...these markets are building growth aggressively.”
>>Bonus Link: Read about a new study in The New York Times, which found that e-cigarettes can become hot enough to release some carcinogens found in conventional cigarettes.
Today is the 19th annual Kick Butts Day. Organized by the Campaign for Tobacco-Free Kids and sponsored by the United Health Foundation, Kick Butts Day is a day of activism to empower young adults to help decrease tobacco use in the United States. According to Tobacco-Free Kids, tobacco use is the number one cause of preventable death in the United States, killing 480,000 people and costing the nation at least $289 billion in health care bills and other economic losses each year.
This year, Kick Butts Day comes just weeks after the 50thanniversary of the first Surgeon General’s Report on Smoking and Health. A new Surgeon General’s report found that smoking is even more hazardous than previously thought—without urgent action to prevent kids from starting to smoke, 5.6 million U.S. children alive today will die prematurely from smoking-caused deaths.
Nationwide, tobacco companies spend $8.8 billion a year—one million dollars each hour—to market cigarettes and smokeless tobacco products, according to Tobacco-Free Kids. In particular, tobacco companies target youth with magazine ads; store ads and discounts; and fruit- and candy-flavored small cigars that look just like cigarettes.
The United States has cut high school smoking rates by more than half since 1997, but 18.1 percent of high school students still smoke and more than 3,000 kids try their first cigarette each day.
In observance of Kick Butts Day, more than 1,000 events will be held in schools and communities across the country, including:
- A walking tobacco audit in Bellingham, Washington, which lets young people chart how many tobacco retailers and ads they see on their way to school.
- A numbers campaign in Howe, South Dakota to visually display how many people die of tobacco-related causes.
- “They put WHAT in a cigarette?” event in Limestone, Maine to display products such as batteries and hair spray that also contain some of the 7,000 chemicals found in cigarettes.
Actions that encourage young people and adults to stop or never start smoking can happen all year, not just on Kick Butts Day. for Tobacco-Free Kids has a range of activities schools and communities can prepare and present, most at little cost.
>>Bonus Link: A tobacco timeline from the Robert Wood Johnson Foundation highlights important milestones in the fight against tobacco since the release of the first Surgeon General’s report on Smoking and Health fifty years ago.
U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius led off an event at the White House today to mark the 50th anniversary of the inaugural Surgeon General’s Report on Smoking and Health and to release a new progress report on smoking and health by telling the crowd of tobacco advocacy experts that “we’re still a country very much addicted to tobacco.” The new report finds that while the number of U.S. smokers is down from half of the adult population five decades ago to about 18 percent today, if the current smoking trends continue, 5.6 million children alive today will die of tobacco-related diseases in the years ahead.
The report also shows that although many diseases other than lung cancer have been linked to tobacco in the last fifty years, even more illnesses are now known to be linked to tobacco, including:
- Strokes from secondhand smoke
- Rheumatoid arthritis
- Ectopic pregnancies
- Erectile dysfunction
- Colorectal and liver cancer
“Fifty years later, tobacco remains a public health catastrophe and the tobacco fight still rages on every corner of our country,” said HHS Assistant Secretary for Health Howard Koh, MD, MPH at today’s event.
Tom Frieden, MD, MPH, director of the U.S. Centers for Disease Control and Prevention, added that most current smokers want to quit. What is keeping smoking rates high, said Frieden, includes advertising and promotional activities by tobacco companies, especially to children and adolescents, as well as disparities in smoking among certain ethnic groups, low-income populations and many people who are mentally ill.
Effective evidence-based measures cited in the report that can reduce smoking include media campaigns, increased tobacco taxes and new smoking cessation benefits made available to people with health insurance coverage under the Affordable Care Act.
Additionally, actions to reduce smoking that are expected in the coming year include the likely confirmation of a new Surgeon General, a U.S. Food and Drug Administration media campaign aimed at showcasing the dangers of smoking to young people and a new Tips from Former Smokers campaign that will include a video public service announcement (PSA) filmed at the bedside of Terrie Hill, whose previous PSA has been viewed 2 million times and who died of smoking-related illness last year at the age of 53.
>>Bonus Fact: The 1964 Surgeon General Report was released by then-Surgeon General Luther Terry. Among the members of his family attending the White House event today was Dr. Terry’s granddaughter, a graduate of the Harvard School of Public Health.
To mark the 50th anniversary of the 1964 first Surgeon General’s Report on Smoking and Health, JAMA, the Journal of the American Medical Association, released a theme issue this week on fifty years of tobacco control. The study getting the most attention is one by researchers at several medical centers and schools of public health, who estimate that tobacco control efforts in the United States since 1964 have added decades to the lives of eight million American.
Other tobacco topics in the issue include:
- Adults with mental illness have a harder time quitting tobacco than do other smokers
- Smoking rates among most health care providers have dropped sharply in recent years, with the exception being licensed practical nurses
The issue also has several opinion pieces on tobacco-related issues, including one co-written by JAMA Editor Helene Cole, MD, and Michael Fiore, MD, MPH, director of the University of Wisconsin Center for Tobacco Research and Intervention, who call for key tobacco policy changes such as:
- Increasing tobacco taxes
- Stronger application of U.S. Food and Drug Administration (FDA) regulation of tobacco products, including cigars and e-cigarettes
- Massive public health campaigns
In fact, the FDA has announced it will spend $300 million in 2014 on ads urging teens to be tobacco free, and the U.S. Centers for Disease Control and Prevention plans to continue its “Tips from Former Smokers” campaign.
>>Bonus Link: Read a NewPublicHealth post on the press conference yesterday by the major tobacco control advocacy groups to mark the 50th anniversary of the 1964 Surgeon General Report on Smoking and Health.
Fifty Years after First Surgeon General’s Report on Smoking and Health, Tobacco Advocacy Groups Pledge to 'End the Tobacco Epidemic for Good'
National tobacco control advocacy groups including the Campaign for Tobacco Free Kids, Americans for Non Smokers Rights, the American Cancer Society Cancer Action Network, and the American Lung and Heart Associations observed the 50th anniversary of the Surgeon General’s Report on Smoking and Health by calling for “bold actions” to “end the tobacco epidemic for good.”
The historic 1964 Surgeons General’s report, the first of many since then that have documented specific health dangers from tobacco, was the first major report to link smoking to lung cancer. It was also a critical first step toward reducing smoking rates from close to 50 percent in 1964 to about 18 percent today, according to the advocacy groups. Significantly, a study published yesterday in JAMA, shows that from 1964 to 2012, at least 8 million premature, smoking-related deaths were prevented, and each of those eight million people gained, on average, 20 years of life. Even more significant, the study authors estimate that reductions in smoking contributed 30 percent of the increase in U.S. life expectancy in from 1964 to 2012.
However, the groups quickly turned their attention to the 440,000 Americans who still die of tobacco-related illnesses each year and resolved collectively to achieve new tobacco control landmarks including:
- Reduce smoking rates to fewer than 10 percent within ten years
- Protect all Americans from secondhand smoke within five years
- Ultimately eliminate the death and disease caused by tobacco smoke
At a question and answer period following the press conference additional proposed strategies were discussed by the groups’ top representatives, including:
- Expanded regulation by the Food and Drug Administration (FDA) of all tobacco products—regulations on some products, such as menthol and electronic cigarettes, are still pending.
- Guidance from the U.S. Department of Health and Human Services on a common smoking cessation benefit Americans can access through the health insurance they receive under the Affordable Care Act.
- Greater inroads on reducing smoking rates among people with mental illness. According to research from the U.S. Centers for Disease Control and Prevention, Americans with mental illnesses have a 70 percent greater likelihood of smoking than the general population.
- Greater efforts to reduce marketing and other tactics by tobacco companies in third world countries where smoking rates remain high.
“We can end the tobacco epidemic by fully and effectively implementing proven strategies,” said Tobacco-Free Kids president Matthew Myers, “including higher tobacco taxes, comprehensive smoke-free workplace laws, hard-hitting mass media campaigns, well-funded tobacco prevention and cessation programs, and effective Food and Drug Administration regulation of the manufacturing, marketing and sale of tobacco products. By doing what we know works, we can accelerate declines in tobacco use and ultimately eliminate the death and disease it causes.”
- Read a NewPublicHealth interview with Mitch Zeller, director of the FDA’s Center for Tobacco Products, on the Center’s goals for ending tobacco use in the United States.
- Read a NewPublicHealth interview on “tobacco end game strategies” with Professor Kenneth Warner, of the University of Michigan School of Public Health and a co-author of the new JAMA study on the lives saved through tobacco-control efforts.
Fifteen Years after Tobacco Settlement, States Falling Short in Funding Tobacco Prevention: Q&A with Danny McGoldrick
On November 23, 1998, 46 states settled their lawsuits against the nation’s major tobacco companies to recover tobacco-related health care costs, joining four states—Mississippi, Texas, Florida and Minnesota—that had reached earlier, individual settlements.
These settlements require the tobacco companies to make annual payments to the states in perpetuity, with total payments estimated at $246 billion over the first 25 years.
Yesterday a coalition of health advocacy groups released the latest edition of A Broken Promise to Our Kids, an annual report on state use of tobacco funds for tobacco prevention and cessation efforts. As in years past, the report finds that most states fall short in the amount of money they allocate to prevent kids from smoking and to help current smokers quit.
The groups that jointly issued the report include the Campaign for Tobacco-Free Kids, the American Heart Association, American Cancer Society Cancer Action Network, the American Lung Association, the Robert Wood Johnson Foundation and Americans for Nonsmokers’ Rights.
Key findings of the 2013 report include:
- Over the past 15 years, states have spent just 2.3 percent of their total tobacco-generated revenue on tobacco prevention and cessation programs.
- The states this year will collect $25 billion from the tobacco settlement and tobacco taxes, but will spend just 1.9 percent of it—$481.2 million—on tobacco prevention programs. This means the states are spending less than two cents of every dollar in tobacco revenue to fight tobacco use.
- States are falling short of the U.S. Centers for Disease Control and Prevention’s (CDC) recommended funding levels for tobacco prevention programs. Altogether, the states have budgeted just 13 percent of the $3.7 billion the CDC recommends.
- Only two states—Alaska and North Dakota—currently fund tobacco prevention programs at the CDC-recommended level.
To discuss the ramifications of the latest edition of the Broken Promises report, NewPublicHealth recently spoke with Danny McGoldrick, vice president of research at the Campaign for Tobacco-Free Kids.
NewPublicHealth: Can you give us some background on the Tobacco Master Settlement Agreement?
Danny McGoldrick: This is the 15th anniversary of the Tobacco Master Settlement Agreement, when 46 states and the District of Columbia settled their lawsuits against the tobacco companies mostly to recover the costs that they’d incurred treating smoking-caused disease in their states. Four other states had settled individually with the tobacco companies prior to the Master Settlement Agreement, and so this provided for some restrictions on tobacco company marketing; they promised never to market to kids again, which is ironic, but it also resulted in the tobacco companies sending about $250 billion over just the first 25 years of the settlement for the states to spend as they saw fit. They left that to the province of the state legislators and governors to decide how those funds should be spent.
As smartphone technology becomes ever more ubiquitous and the dangers of tobacco become ever more apparent, it's not surprising that there are 414 quit-smoking apps available between iPhones and Androids, with Androids alone seeing about 700,000 downloads of these apps each month.
There's no question that these apps are in demand in the United States, where an estimated 11 million smokers own a smartphone and more than half of smokers in 2010 tried to quit.
The question is: Are they effective?
According to a new study in the American Journal of Preventive Medicine, the answer is too often "no," with many of the most popular apps failing to employ and advocate known and successful anti-tobacco strategies.
"Quit-smoking apps are an increasingly available tool for smokers," said lead author Lorien Abroms, ScD, an associate professor of Prevention and Community Health at the George Washington University School of Public Health and Health Services (SPHHS), according to Health Canal. "Yet our study suggests these apps have a long way to go to comply with practices that we know can help people stub out that last cigarette."
The study looked at the 50 top anti-smoking apps for both iPhones and Androids, analyzing their tactics on a number of fronts, including how well they aligned with guidelines from the U.S. Public Health Service on treating tobacco use. The review found serious issues with the apps' advice, especially concerning clinical practices. It found that:
- Most lacked basic advice on how to quit smoking and did not help people establish a "quit plan"
- None recommend calling a quit-line, which can more than double the chances of successfully quitting tobacco
- Fewer than one in 20 of the apps recommended medications, even though studies show how nicotine replacement therapy can help curb cravings
Taken together these, last two findings are especially troubling, as their pairing has been found to more than triple the chances of a person successfully breaking their nicotine addiction. One of the biggest takeaways from the study, according to Abroms, is that while quit-smoking apps can be important components of a larger plan to quit smoking, there might also be a simpler way to use those fancy smartphones.
"They should simply pick up their smartphone and call a quit-line now to get proven help on how to beat a tobacco addiction."
And the lack of adequate advice and guidance isn't limited to quit-smoking apps. A study by the IMS Institute for Healthcare Informatics found that while apps remain popular, they also remain limited.
"It clearly demonstrated that, to date, most efforts in app development have been in the overall wellness category with diet and exercise apps accounting for the majority available. An assessment finds that healthcare apps available today have both limited and simple functionality--the majority do little more than provide information.
Read the full story at Health Canal.
>>Bonus content: Read the previous NewPublicHealth post, "Public Health: There's An App For That"
>>Bonus link: Mobile Health and FDA Guidance
>>Bonus links: Here's a quick look at a few of the newest apps designed to improve public health in a variety of ways:
- My Health Apps offers a vast array of apps, sorted by categories such as "Mental Health," "Me and My Doctor" and "Staying Healthy"
- Hula, which helps people find STD testing, get the results on their phone and even share verified results
- My Fitness Pal, which combines guidance and community to help people lose weight
- Planned Parenthood offers a series of teen-focused apps on important issues such as birth control, condoms and even substance abuse
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.