December 2016 Newsletter

New research reveals extensive benefits of graphic warnings on cigarette packs
Mobilizing around menthol and other flavored products
Tobacco industry spends $100 million to oppose cigarette taxes on ballot initiatives—and loses big in CA
New tobacco control policy recommendations take on emerging issues
New York State, City argue UPS owes $873 million for delivering illegal cigarettes
Tobacco Retail Licensing gaining momentum
Cigarette smoking causes nearly a third of U.S. cancer deaths
Retailers in UK less reliant on tobacco profits than industry claims
Clearing the air in public housing
Cuomo signals desire to see vape shops obtain state registration
New Policy Center resources available
The Surgeon General takes on youth use of e-cigarettes
Regional Meetings Recap

New research reveals extensive benefits of graphic warnings on cigarette packs

Graphic health warnings could reduce smoking prevalence by 10 percent in 50 years.

A study published in the November 2016 Tobacco Control estimates widespread public health benefits from requiring graphic health warnings on cigarette packaging. Using a computer model, authors found that graphic health warnings would prevent more than 650,000 smoking-related deaths over 50 years in the United States. In the short term, the warnings would reduce smoking prevalence by 5 percent, with this reduction improving to an impressive 10 percent in the long term relative to the current baseline.

Currently, nearly half a million Americans die each year from smoking-related causes; graphic health warnings are just one component of a comprehensive tobacco control strategy intended to prevent and delay smoking initiation, reduce prevalence, and increase cessation among currently addicted smokers.

Study authors further calculated that graphic health warnings would prevent more than 45,000 cases of low-birth-weight, more than 70,000 preterm births, and 1,000 cases of sudden infant death syndrome in the U.S.

Evidence of success from other countries that have implemented graphic health warnings augments data from research models, yet these warnings have not been implemented in the U.S. The Family Smoking Prevention and Tobacco Control Act includes a requirement that 50 percent of all packaging and 20 percent of all advertising display graphic health warnings. The U.S. Food and Drug Administration (FDA) proposed graphic warnings in 2011, but tobacco companies successfully challenged the sufficiency of the government’s evidence establishing the effectiveness of the proposed warnings in reducing and deterring tobacco consumption. Rather than further appeal the ruling, the agency decided it would reconsider and reissue proposed warnings. Meanwhile, the U.S. has fallen to last place in a global ranking of warning label size on cigarette packs.

It has been three years since the FDA announced it would develop new warnings. Recently, a coalition of public health advocates filed a complaint urging a Massachusetts federal district court to order the FDA to fulfill its responsibility under the Tobacco Control Act to require graphic health warnings for tobacco products.

Mobilizing around menthol and other flavored products

As black health experts call on the Obama administration to fight the use of flavors in cigarettes, Health Canada moves forward with a proposal to ban menthol in tobacco products.

Evidence of menthol’s harmful effects in tobacco products—and evidence of menthol marketing targeting minorities—has been mounting for years. The U.S. Food and Drug Administration published a report in 2013 identifying these harmful health effects and disparate negative impacts on certain populations—yet FDA has failed to take any action to reduce the use of menthol in tobacco products. About 45,000 African-Americans die each year from smoking-related diseases, and black men have the highest lung cancer mortality rate of any demographic group. Furthermore, use of menthol cigarettes, especially by youth, continues to rise in the United States.

In a September 2016 letter to President Obama, a group of African-American activists and health experts framed tobacco-related health disparities as an issue of social justice. “What we’re trying to do is involve the president of the United States in this discussion,” says Phillip Gardiner, Chairman of the African American Tobacco Control Leadership Council. “We die disproportionately of cancer-related diseases. Part of what has taken place here is the use of menthol cigarettes.”

Meanwhile, the Canadian government is moving forward with a ban on mentholated tobacco products, building on existing restrictions on the use of flavors in most combustible tobacco products. The proposed amendments to Canada’s Tobacco Act would prohibit the use of menthol in cigarettes, blunt wraps, and most cigars. The proposed rule was published on November 5, 2016 and public comments will be accepted for 75 days from that date.

In the U.S., advocates are looking to local governments to restrict the sale of menthol and other flavored products. New York City was the first jurisdiction to restrict the sale of flavored tobacco products (excluding menthol products) in 2010. Since then, several other jurisdictions have implemented similar regulations. In October 2016, Santa Clara County in California added menthol products to its restriction on the sale of flavored tobacco products (limited to adult-only facilities). Yolo County, also in California, and Chicago, Illinois have restricted the sale of flavored products, including menthol products, near schools.

Tobacco industry spends $100 million to oppose cigarette taxes on ballot initiatives—and loses big in California

Industry opposition efforts indicative of public health effectiveness of tax policy.

California voters approved an increase to the state’s cigarette tax for the first time in 20 years, passing a ballot initiative to increase the tax by $2 per pack (to $2.87) beginning April 1, 2017. California is the second largest cigarette-consuming state by volume, accounting for 8 percent of total sales in the U.S.

Despite defeating similar ballot initiatives in 2006 and 2012, the tobacco industry’s marketing expenditures of more than $71 million weren’t enough to counteract health advocacy groups (who raised more than $30 million) this time around.

Voters in three other states (Colorado, North Dakota, and Missouri) defeated similar ballot questions. The tobacco industry spent an additional $30 million on defeating these initiatives.

The new tax in California will raise up to $1.4 billion per year for the state’s healthcare and cessation programs, benefitting low-income residents who smoke at higher rates. Furthermore, experts at the University of California San Francisco estimate that the tax will benefit taxpayers and businesses with $1 billion per year in health savings.

With the passage of the new ballot measure, California joins six other states that tax e-cigarettes in addition to conventional tobacco products.

New tobacco control policy recommendations take on emerging issues

Health equity primary motivation to implement evidence-based policy

The Tobacco Control Network (TCN) of the Association of State and Territorial Health Organizations (ASTHO) recently updated its tobacco control policy recommendations (last published in 2012).

Best practices for reducing tobacco use include:

  • Cigarette excise taxes (at least $2);
  • Tobacco product price promotion restrictions;
  • Full funding of sustainable, comprehensive tobacco control programs;
  • Smoke-free multi-unit housing policies and tobacco-free school and campus policies;
  • Retail license requirements for the sale of tobacco products and electronic smoking devices;
  • Local retailer density and zoning restrictions; and
  • Cessation treatment support within healthcare systems

Other promising practices include:

  • Excise taxes for electronic smoking devices and e-cigarette liquids;
  • Tobacco-free outdoor policies;
  • Prohibitions on the sale of menthol- and other-flavored tobacco products;
  • A minimum legal sales age for purchasing tobacco products to 21 years;
  • Inclusion of tobacco-related availability restrictions to electronic smoking devices; and
  • Inclusion of e-cigarettes and related aerosol devices in the definition of tobacco products

The full report focuses on tobacco-related health disparities and interventions that can effectively promote health equity. According to TCN, tobacco control programs have used past recommendations to direct their programs, complete readiness assessments, develop five-year workplans, and educate state leadership about evidence-based tobacco control strategies.

New York State, City argue UPS owes $873 million for delivering illegal cigarettes

The company failed to comply with state laws aimed at preventing trafficking.

In a suit brought against UPS, lawyers for New York State and New York City argued in November that the company ignored telltale signs of illegal cigarette trafficking. U.S. District Judge Katherine Forrest will decide the case by December 25, 2016.

UPS could face a fine of $873 million for failing to comply with state laws that curtail illegal shipments of tobacco products. Mail order shipments of tobacco products risk undermining age verification processes and other tobacco controls that keep prices high—a key strategy for promoting cessation among addicted smokers and preventing initiation by new users. In addition to state tax laws, the federal Prevent All Cigarette Trafficking Act (Pact Act) of 2010 aimed to close loopholes allowing internet sales by restricting cigarette dealers from using private mail carriers.

For more than a decade, cigarette dealers located on sovereign Native American land reservations (that are not required to collect tobacco taxes if their products are sold on site) have been illegally using private mail carriers to ship untaxed cigarettes to other parts of the state, defying enforcement efforts by New York state and local governments. UPS staff not only ignored the fact that recipient addresses were obviously tobacco retailers, but also allowed dealers to receive price discounts for bulk shipping and allowed drivers to accept gifts from dealers.

The potential penalty is partially comprised of about $30 million in lost tax revenue due to the estimated 700,000 cartons that were illegally shipped from 2010 to 2014.

Tobacco Retail Licensing gaining momentum

Philadelphia is the latest jurisdiction to adopt innovative tobacco retail requirements.

Last week, Philadelphia became the latest city to adopt through tobacco retail licensing a package of evidence-based tobacco control policies designed to reduce the impact of marketing on its neighborhoods. The Board of Health finalized regulations to reduce the density of tobacco retail sales and marketing within the city, including:

  • Raising the annual permit fee from $50 to $300;
  • Capping the number of retail permits to 1 per 1,000 people within each city planning zone (based on commuter census figures);
  • Prohibiting issuance of new permits to retailers within 500 feet of a school;
  • Increasing penalties for selling to minors

The tobacco industry has taken over the retail environment to recruit new consumers and keep current users from quitting. The Surgeon General has concluded that tobacco marketing causes youth tobacco use. Evidence shows that marketing within the retail environment entices new youth consumers and undermines cessation attempts by the majority of tobacco users who want to quit. Tobacco outlet density increases residents’ exposure to this marketing, so the number of outlets and their locations are key to the industry’s market.

Evidence informs us that there is a higher density of tobacco sales outlets in lower-income neighborhoods, correlating with higher tobacco use rates among consumers of lower socioeconomic status. Tobacco retail licensing systems that incorporate strategies to reduce the density of sales and marketing outlets should not only reduce overall tobacco use in the long run, but also help jurisdictions achieve better health equity. Indeed, San Francisco recently assessed its first year after implementation of a revamped licensing system, which now caps the number of outlets permitted to sell tobacco products at 45 for each of the city’s 11 supervisorial districts. Already the city has achieved a reduction in the number of outlets selling tobacco (10.2 percent); in particular, two lower-socioeconomic status districts (which had the highest baseline outlet densities) have realized a greater density reduction than surrounding districts.

In New York, local jurisdictions are taking heed of the plethora of studies connecting tobacco marketing and use rates and considering and implementing policy strategies to reduce the industry’s impact on their communities. The City of Newburgh has implemented the most robust tobacco retail licensing system in New York, through which it caps the number of licenses, limits eligibility to those outlets more than 1000 feet from schools, and issues only one new license for every two non-renewed or revoked in the previous year (thereby gradually reducing the density of tobacco sales and marketing throughout the city). Ulster, Cayuga and Dutchess counties have also implemented tobacco retail licensing systems, and New York City requires licenses to sell cigarettes and e-cigarettes.

Cigarette smoking causes nearly a third of U.S. cancer deaths

Rates vary by region, but smoking remains the number one cause of preventable death and disease in America.

According to new research published in October, smoking is the direct culprit behind nearly a third of cancer deaths in the United States. Despite being the number one cause of preventable deaths, there are still more than 40 million smokers today.

The cancer rates varied by sex and geography, with cigarette smoking causing up to 40 percent of cancer deaths among men in Southern states. Lenient tobacco policy is one factor driving this trend, according to the authors; lax tobacco use controls and cheaper prices are two reasons for higher smoking rates in the American South.

“Comprehensive tobacco-control programs can have a huge impact in reducing smoking and cancer rates,” says Patricia Folan, Director of the Center for Tobacco Control at Northwell Health in Great Neck, New York. Those that are especially effective “include hard-hitting anti-smoking media campaigns, smoke-free laws, increased taxes on cigarettes and other tobacco products, state Quitlines, and funding for cessation medications and reimbursement for counseling.”

Southern states also have large populations of lower-socioeconomic status residents, which is another driving factor behind smoking prevalence and smoking-related disease. Cigarette smoking is higher among adults living below the poverty level and among those with less education. Comprehensive tobacco control programs target health disparities by working to reduce tobacco use among these groups.

The study authors caution that these new numbers may underestimate tobacco’s devastating effects because they only considered the top 12 types of cancers and did not include tobacco products other than cigarettes in their analysis.

Retailers in UK less reliant on tobacco profits than industry claims

Study finds arguments against tobacco sales regulations overblown.

Action on Smoking and Health, a health advocacy group in the United Kingdom, recently found that tobacco industry’s dire prediction of lost profits to small businesses resulting from tobacco product sales regulations is totally unfounded. Its recent study found that corner stores average a profit of only £242 (or $302) per week on tobacco products compared to £2,611 (or $3,263) from non-tobacco products.

The study also found that tobacco products are not driving customers to their stores to purchase other items: 79 percent of small retailer transactions do not include the purchase of tobacco products. Moreover, a recent telephone survey of local newsagents found that some retailers feel they have to sell tobacco to remain competitive, but may resent it because the products tie up cash in stock, but earn retailers very little in return.

ASH chief executive Deborah Arnott said, “Tobacco is a high-cost, low-profit product and money spent on tobacco is money not available for other more profitable purchases. Our report invites retailers to see the long-term decline in smoking as an opportunity, not a threat.”

While the study was conducted in the UK, its findings translate to US retailers. Recently, the tobacco industry and its allies have turned up the heat on small businesses, imploring them to resist new tobacco regulations for fear of being forced to close up shop. Now it appears the industry is crying wolf, exaggerating the importance of tobacco sales to retail profits and foot traffic (all in the name of benefiting tobacco manufacturers’ bottom line). At least one retailer surveyed by ASH welcomed the report and hopes that retailers will consider whether tobacco companies and local representatives really have the retailers’ interests in mind.

Clearing the air in public housing

HUD issues final rule prohibiting smoking in and around public housing.

On Wednesday, November 30, 2016, the U.S. Department of Housing and Urban Development (HUD) issued its final rule concerning smoking in public housing units and buildings. The rule prohibits smoking tobacco products in indoor areas of public housing complexes and administrative offices. It also creates a buffer zone of 25 feet from each building in which smoking is prohibited outdoors.

There is no safe level of exposure to secondhand smoke. Smoke infiltrates between individual living units through walls, ductwork, windows, and vents, among other routes, and cannot be completely eliminated even through ventilation upgrades. A recent CDC study found that smoke incursions in multi-unit buildings disparately affects those with lower income, women, younger adults, non-Hispanic blacks and Hispanics. The rule will not only create more equity in environmental smoke exposure at home, but will also benefit the 760,000 children that currently live in public housing.

“Every child deserves to grow up in a safe, healthy home free from harmful second-hand cigarette smoke,” said Housing and Urban Development Secretary Julián Castro said in a statement. “HUD’s smoke-free rule is a reflection of our commitment to using housing as a platform to create healthy communities. By working collaboratively with public housing agencies, HUD’s rule will create healthier homes for all of our families and prevent devastating and costly smoking-related fires.”

The rules leave the issue of enforcement to local housing agencies. While HUD recommends graduated enforcement approach (beginning with warnings), it is taking a hands-off approach. “The last thing that we want are evictions,” Castro told The New York Times. “We don’t see this as a policy that is meant to end in a whole lot of evictions. We’re confident that public housing authority staff can work with residents so that that can be avoided.”

The new rule will have the biggest impact in New York State, home to the largest public housing agency in the country (New York City). The New York Times recently reported that the City’s housing agency “has lagged behind some of its smaller counterparts in adopting smoke-free policies.”

The rule does not prohibit the use of e-cigarettes and similar devices but does apply to all lit tobacco products, such as cigarettes, cigars, pipes and hookah. Local housing agencies retain authority to implement stricter requirements (such as including e-cigarette use in the prohibition) and have 18 months to begin enforcing the new federal requirements.

Cuomo signals desire to see vape shops obtain state registration

Governor directs executive agencies to work together in veto message

New York Governor Andrew Cuomo recently considered—and rejected—legislation that would have set up a state registration system for vendors of e-cigarettes and similar aerosol devices. While the veto of such a bill might at first blush signal a desire not to regulate aerosol device sales, it actually alleviated concerns by public health advocates that e-cigarettes would be treated differently than conventional tobacco products.

Sales of e-cigarettes and e-liquids are subject to several state and federal tobacco control regulations. However, while retailers of conventional tobacco products are required to register with the New York Department of Taxation and Finance (DTF), in part to assist with regulatory enforcement, the definition of “tobacco products” in the registration requirement does not include e-cigarettes. As a result, enforcement of relevant tobacco controls on e-cigarette sales could be hindered.

Senate Bill number 6003 (approved by both the Assembly and Senate earlier this year) would have required retailers that sell e-cigarettes (to the exclusion of conventional tobacco products) register with the New York Department of Health (DOH). While most public health advocates agree that these retailers should obtain a state registration, creating a separate system within a different agency would burden the Department of Health and confuse the context in which e-cigarettes are regulated (i.e., as tobacco products).

Recognizing these flaws, Governor Cuomo vetoed the bill at the end of November, but used his veto message to direct DTF and DOH to work together with legislative sponsors of the bill and other interested stakeholders to develop legislation that would change the definition of “tobacco products” in the New York tax code to include e-cigarettes. Such legislation would place e-cigarettes in the proper regulatory context and streamline retailer registration across the state.

New Policy Center resources available

The Policy Center recently published:

In our latest technical report, we describe evolving e-cigarette technology and the rationale for regulating these tobacco products. The report, “Local Regulation of E-cigarettes,” includes a model use regulation to illustrate how easily e-cigarettes may be incorporated into proposed and existing regulations.

There has also been an uptick in industry opposition to common-sense tobacco controls at the local level in recent months. For example, the National Association of Tobacco Outlets (NATO)– which is an industry supported group—is working to oppose local point of sale regulations. Our new compilation of fact sheets focuses on misleading industry claims about effective public health policy interventions, and aims to equip public health advocates to refute misinformation.

Finally, we have updated two other fact sheets. Our “Point of Sale Problem in Numbers” fact sheet identifies key statistics about retail tobacco marketing and its effect on youth. Second, our “Retail Stores as Recruitment Centers for Youth Smokers” fact sheet describes the influence on youth of industry marketing in the retail environment.

The Surgeon General takes on youth use of e-cigarettes

New report and interactive website seek to educate parents, youth, and young adults on dangers of nicotine addiction

Although conventional cigarette smoking has significantly declined over the past several decades, one in six U.S. high school students reported using e-cigarettes during the previous month in 2015. Thus e-cigarettes are now the most commonly used tobacco product among youth. This represents a major public health concern given the association of e-cigarette use with other tobacco products, including combustible tobacco products. In response, the Surgeon General published an interactive educational website along with a report detailing the risks these products pose to public health.

The report represents the first comprehensive federal review of the impact of e-cigarettes on youth and young adults in this country. Nicotine is a highly addictive drug, and youth and young adults are uniquely susceptible to long-term consequences of nicotine exposure on the developing adolescent brain. E-cigarettes are widely marketed through media and methods that previously were used by manufacturers of conventional tobacco products to recruit youth users. Moreover, e-cigarette liquids (or e-liquids) are available in thousands of flavors, including sweet candy and fruit flavors appealing to youth. Moreover, the flavor compounds used in e-liquids can themselves be harmful, regardless of nicotine content.

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said U.S. Surgeon General Dr. Vivek H. Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The U.S. Food and Drug Administration (FDA) recently “deemed” e-cigarettes (among other tobacco products) to be products over which the agency has authority to regulate. But while the FDA has extended some sales restrictions to the products—such as restricting sales to those over 18 and prohibiting claims (without approval) that the products are less harmful than conventional tobacco products—the agency’s authority is limited. State and local governments can fill gaps left by federal product regulations. The Surgeon General’s report serves as a call to states and authorized local governments to adopt tobacco controls that regulate e-cigarettes.

While the national Monitoring the Future survey did find a recent drop in e-cigarette use (from 16 percent of high school students in 2015 to 13 percent in 2016), it remains to be seen whether the newest data is indicative of a larger trend. “Whether adolescent vaping has peaked or only paused is something we will be able to determine in the coming years,” says Richard Miech, a senior investigator of the research project.

The Policy Center recently published a technical report, “Local Regulation of E-cigarettes,” which includes evidence-based policy strategies that may be implemented by state and local governments to regulate the sales of devices in ways that will reduce and prevent youth and young adult use.

Regional Meetings Recap

Policy Center staff convened grantees of the Advancing Tobacco-Free Communities and Reality Check programs at three regional meetings.

Thank you to those of you who attended our regional meetings—we appreciate the travel and time you each devoted and value your comments provided at the meetings.

We enjoyed meeting in person with the grantees and dissecting local tobacco policies that influence the retail environment in New York communities. Hearing firsthand about your successes, challenges, and opportunities for future work in your communities provided essential insights to our work, and our work will certainly be informed by these discussions.

We look forward to continued dialogue, and as always—please do not hesitate to contact us with comments, questions, or concerns! Contact us at tobacco@tobaccopolicycenter.org.