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Home My WebLink About2020-02-25 Item 7 - Written Communications - Vallarte Flavored Tobacco Products LIFELONG � ADDICTION 4 OFTEN STARTS OUT • 0vj� WEFT , 1, 80% of kids who ever tried tobacco started with a flavored product.. s ABSTRACT a Sacramento has a higher tobacco use rate than the rest of the state. Tobacco costs J Sacramento $870 million dollars in health { # care costs. The Surgeon General has called vaping a youth epidemic. Sac City Unified School District saw a 50% increase in 11th !V� grade vaping in 2017-2018. Flavorings are the #1 reason kids start, and diacetyl in j most flavorings can be harmful to lungs as a btu cause for bronchiolitis obliterans. Menthol is the only flavor still in cigarettes, but its -2018Cakf 0"- „ ,, chemicals make it easier to start and inhale but harder to quit. Targeted marketing has led to >70% African American smokers -� using menthol, and African Americans have one of the highest tobacco use rates in Sacramento and tobacco-related health disparities. Vaping is not approved for tobacco cessation, and has harmful chemicals that impact heart and lung health that is not just water vapor. Switching is not quitting with the risk of continued nicotine addiction, particularly with high _. 520;6 Ca0f—la Deas of Pkk Heal!h potency nicotine. LICQAVIS COMPREHENSIVE HEALTH CANCER CENTER ti Topics and Expefts UCD Comprehensive Cancer Center Smoke and Tobacco-Free Initiative Primo Lara, Director of UC Davis Comprehensive Cancer Center, Professor of Medicine Tobacco and Cancer- Sacramento and Beyond Moon Chen, Professor of Medicine and Associate Director, Population Sciences & Community Outreach and Engagement, UC Davis Comprehensive Cancer Center Landscape of Flavored Tobacco Products Kim Homer-Vagadori, Project Director, California Youth Advocacy Network Health and Cessation Concerns Elisa Tong, Associate Professor, Department of Internal Medicine, UC Davis Health African American Disparities including Menthol and Marketing Kimberly Bankston-Lee, Senior Program Manager, The Saving Our Legacy Project: African Americans for Smoke-Free Safe Places Impact on Sacramento Schools Joelle Orrock, Tobacco Use Prevention Education Coordinator, Sacramento County Office of Education Age Restriction Policies Melanie Dove, Postdoctoral Fellow, Center for Healthcare Policy Research, UC Davis Policies in Other Communities and Counties Diana Cassady, Professor, Department of Public Health Sciences, UC Davis Sacramento County Tobacco Education Program and Tobacco Control Coalition Danica Peterson, Health Educator, Sacramento County Tobacco Education Program UC Davis • UC Davis Comprehensive Cancer Center (UCD CCC) mission: Comprehensive cancer research, clinical care, and outreach and education. Cancer Center Mission • UCD CCC Community Outreach and Engagement program hosts our Smoke and Tobacco-Free Initiative. This initiative PRIMO LARA combines our patient, population, and policy education efforts. Professor of UC has a systemwide Smoke and Tobacco-Free policy across Hematology/Oncology and its 14 campuses since 2014, and UC Davis Health was among Director, UC Davis the first health campuses to implement a policy in 2008. • Nationwide, Cancer Centers are taking action on tobacco. The Smoke and Tobacco-Free Initiative stems from being part of the National Cancer Institute's Cancer Center Cessation Initiative, which is integrating tobacco treatment into cancer care across 42 cancer centers. Tobacco and Cancer: • Tobacco products cause cancer and worsen treatment. Sacramento and Tobacco causes 14 different cancers besides other chronic heart and lung disease and immune problems. Tobacco use Beyond worsens cancer treatment outcomes including wound healing after surgery or radiation, medication effectiveness, immune MOON CHEN function, and development of secondary cancers. Professor of Hematology/Oncology and . Sacramento County has higher tobacco product use rates Associate Director, Population than the rest of California. In 2016-7, cigarette and vaping Sciences & Community use was 15.9% in Sacramento County and 13.7% in California. Outreach and Engagement, Among those using tobacco products, vaping rates were UC Davis Comprehensive 25.7% in Sacramento County and 19.2% in California. The Cancer Center total amount of current tobacco users in Sacramento County is estimated at 179,000 people, and in California is estimated at 4,022,000. (2016-2017 California Health Interview Survey) • Flavored tobacco product use has led to a national "epidemic" of youth use. The U.S. Centers for Disease Control and Prevention has reported that electronic cigarette use among high schoolers jumped by 80% in one year(1.5% in 2011, 11.7% in 2017, 20.8% in 2018), likely due to the flashdrive product Juul. Almost 80% of youth aged 12-17 years who have ever used tobacco started with a flavored tobacco product. Among adults who ever used tobacco, using a flavored tobacco product as their first product had a 32% higher prevalence of current tobacco product use. The concern is the creation of a new generation of tobacco users who may never have started, and also opening the gateway to using cigarettes. • High rates of using flavored tobacco products in California and stagnating teen tobacco use rates. Among California adults who use other tobacco products besides cigarettes in 2016, 70% reported using flavors in the past 6 months. Among the subset of young adults aged 18-24, 80% reported using flavors. Among California teens, tobacco use rates have stagnated at 14% in 2016 despite less cigarette smoking (4% in 2016 and 14% in 2010). Landscape of Flavored Rapidly growing variety of flavored tobacco products beyond Tobacco Products cigarettes. Flavored tobacco products include liquids put into vaping devices, little cigars and cigarillos, and menthol cigarettes. E-cigarettes may also be called e-hookahs, hookah KIM HOMER-VAGADORI, pens, vapes, vape pens, or mods. Some can only be used Project Director, California once, while others can be refilled or have tanks. Flavors had Youth Advocacy Network been removed from cigarettes except for menthol by the Food and Drug Administration (FDA) in 2009. Users may not identify as smokers, and asking about smoking only may not capture tobacco product use. • Extremely high levels of nicotine. New flashdrive products use tobacco salts, which are bioabsorbed easier with much less vapor. 1 flashdrive pod = 1 pack of cigarettes for nicotine content. Some products are now even more concentrated. Youth and adults alike may be unaware of the high levels of nicotine and symptoms of addiction. • Flavors, packaging, and marketing appeal to youth. The e- liquid is typically flavored, with over 15,500 unique flavors, which have doubled since 2014. Flavors that appeal to youth include fruit, candy, mint. Packaging that appeal to youth include bright colors, cartoons, toys. Kids are using products in the school classroom and bathroom, and rating them on YouTube videos. • Menthol is a starter flavor for California students. Among California high school students who smoke cigarettes, 44% use menthol cigarettes. • Tobacco industry is changing rapidly. Every tobacco company has a vaping product, and fall 2018 Altria (Philip Morris' parent company) bought a 35% stake in the most popular flashdrive product brand (75% of the market). Now there are dozens of knock-off versions of the product. Altria is also seeking to introduce a "heat-not-burn" cigarette product called iQOS that is popular overseas. Health and Cessation Immediate and long-term health concerns for tobacco use and Concerns exposure. Immediate health effects occur within minutes for heart and lung function with fine particles and chemicals leading to inflammation. Long-term health effects occur over ELISA TONG, years for cancer risks, destruction of lung tissue, or Associate Professor, atherosclerosis of the cardiovascular system. Department of Internal Medicine, UC Davis Nicotine is not harmless. Increasing nicotine poisonings of young children attracted to flavored tobacco products and packaging, and harmful if e-liquid gets on skin or eyes. Nicotine negatively affects the young developing brain which matures by 25 years, and is associated with prefrontal cortex ability for judgment, attention, and behavior contributing to mental health issues. High levels of nicotine (60 mg) could potentially kill an adult, as it affects the cardiovascular system and is used in insecticides. In contrast, nicotine medication doses range from 1 mg to 21 mg (patch for 24 hour absorption). • Growing evidence of toxic effects from aerosol ingredients. Aerosol from electronic smoking devices: Polyethylene glycol is not water vapor and can irritate lungs; at least 10 toxic chemicals known to cause cancer or reproductive harm (e.g. formaldehyde, nickel, lead, benzene, cadmium, toluene, isoprene, acetaldehyde, N-Nitrosonornicotine). Flavorings: diacetyl is in 75% of flavored e-liquids and is associated with irreversible lung damage called bronchiolitis obliterans. Menthol: more likely to initiate, more likely to inhale deeper, less likely to quit; menthol acts on the nicotinic receptor which may affect addiciton. Heated chemicals react differently than burned chemicals, and chemicals have different effects when inhaled than eaten. Growing body of scientific evidence comes from FDA-funded Tobacco Centers of Regulatory Science (e.g. UCSF), which informs the FDA, and California's Tobacco- Related Disease Research Program. • Vaping is not recommended for cessation. There are 7 FDA- approved medications for cessation that are not inhaled into the lungs and deliver less nicotine (nicotine patch, lozenge, gum, inhaler, nasal spray; bupropion and varenicline). The United States Preventive Services Task Force concluded there is "Insufficient" evidence to recommend electronic nicotine delivery devices for cessation. The FDA has not approved any vaping devices for cessation purposes. The risk of switching tobacco products, even for harm reduction purposes, is maintaining nicotine addiction and "dual use" of products. • Sacramento has a high health economic burden of$860 million for tobacco use and exposure. Sacramento county's health economic costs from smoking are estimated at$860 million (see attachment). Immediate health effects like asthma and heart attacks create a significant health care burden and higher health care costs within 1 year. There are also significant indirect societal costs from loss of productivity. African American Menthol makes it easier to inhale tobacco toxins and harder to Disparities including quit. The anesthetic qualities of menthol numb the throat, masking the harsh taste and burn of tobacco that allows for Menthol and Marketing deeper inhalation of toxins and greater amounts of nicotine. The presence of menthol makes cigarettes harder to quit KIMBERLY BANKSTON-LEE, compared to other cigarettes, despite more quit attempts, as it The Saving Our Legacy may affect nicotine receptors (Ton et al., 2015; Levy et al., Project: African Americans for 2011). "The `cool refreshing taste of menthol' ultimately, allows Smoke-Free Safe Places the poisons in cigarettes and cigarillos to `go down easier'."(Dr. Phil Gardiner, African American Tobacco Control Leadership Council; see op ed with Dr. David Cooke, Head of General Thoracic Surgery, UC Davis and Task Force Chair of the Comprehensive Lung Cancer Screening Program) • Sacramento African Americans have high tobacco use disparities due to menthol. In California, 70% African American adults who smoke consume menthols, compared to 18% of white adults who smoke. In Sacramento County, African Americans have one of the highest smoking rates (19% or 20,000 people) (California Health Interview Survey 2015-2017). • Targeted marketing and pricing affects Sacramento neighborhoods. Research has shown how the tobacco companies have heavily marketed menthol products to African Americans since the 1960s, and is not just a "flavor preference." Menthol cigarettes are 75 cents cheaper in Sacramento's lower socioeconomic neighborhoods that have more African Americans (Oak Park compared to East Sacramento). Direct-mail coupons, in-store price promotions and advertisings, retailer incentives are other key marketing strategies. • Packaging sizes. While cigarettes can only be sold as a pack (20 in a pack), other tobacco products like little cigars are often sold in small packages for less than a dollar. This makes it easier for low socioeconomic populations including youth and young adults to purchase. Age Restriction State age restriction and enforcement for under 21 years old. Policies Since 2016, California has been the second state to implement a "Tobacco 21" law which prohibits sales of tobacco products to under 21 years of age (except active duty military). In MELANIE DOVE, Postdoctoral California, 64% of current cigarette smokers started by the age Fellow, Center for Healthcare of 18, and 96.3% started by the age of 26, so delaying Policy Research, UC Davis initiation is thought to be an effective tobacco control strategy. Enforcement is conducted through "sting" operations with penalties under the Stop Access to Kids Enforcement (STAKE) Act. However, online sales do not verify age beyond "agreeing" to adult status, and can include resale sites like eBay or Craigslist or local online exchange boards. • California illegal sales are rising including in tobacco-only stores. In the California Youth Adult Tobacco Purchase Survey 2017-2018, retail violation rates are increasing for illegal sales to young adults 18-19 years: 13% to 22% for electronic smoking devices and 14% to 18% for tobacco. Among vape shops and tobacco store retailers, over 30% are still selling tobacco to 18- 19 year olds. • Purchasing restrictions for California youth is not enough with widespread access. Among 208 California high school students under 18 years old and currently using electronic cigarettes, 50.8% borrowed them, 9.3% bought them in a store, 8.9% reported someone else bought them, 6.9% reported an adult gave them an electronic cigarette, 3.9% got them online, and 20% reported some other way. (2017 California Youth Risk Behavior Surveillance System). Since vaping products are refillable and rechargeable, traditional youth purchasing restrictions as for cigarettes that have a one- time use have major limitations. Impact on Sacramento Sacramento County Office of Education coordinates Tobacco Schools Use Prevention Education activities from California Department of Education funding with 5 school districts: Sacramento, Elk Grove, San Juan, Folsom, Twin Rivers. JOELLE ORROCK, Tobacco Through a competitive grant process, schools are funded to Use Prevention Education provide programs for grades 6-12 with evidence-based Coordinator, Sacramento tobacco-specific prevention and cessation programs for County Office of Education adolescents within the school setting. • Students are using products at school and seeing it in digital/social media. Local parents and educators are calling several times a week about students using these products. Parents and teachers may not be aware of these products which do not look like traditional cigarettes, as they can be put into hoodie strings or on top of water bottles. Bathrooms are a common place for use. With less aerosol and flavored odors, students are using tobacco products in the classroom and blowing it out under the desk or inside their shirts. Social influencers, including teens, promote products through YouTube product reviews, Instagram, and tweets which make it difficult to track. • Sacramento high school student vaping has risen by 50% despite cigarette use dropping. Among 11' grade high school students in the Sacramento City Unified School District, electronic cigarette use increased by 50% (8% in 2016-2017 to 12% in 2017-2018), while cigarette use decreased (10% in 2016-2017 to 6% in 2017-2018). Almost half of the 11th grade students reported cigarettes were "very or fairly easy to obtain." (California Healthy Kids Survey). • Restricting sales are important as 75% of stores near Sacramento schools sell flavored tobacco products. In the 2016 Healthy Stores for a Healthy Community survey, 74% of surveyed stores near schools in Sacramento County were found to sell flavored non-cigarette tobacco products. (healthystoreshealthycommunity.com/counties/sacramento) The density of tobacco retailers, particularly in neighborhoods surrounding schools, has been associated with increased youth smoking rates.(Henriksen) Youth are more likely to experiment with tobacco products when retailers are located near schools. (McCarthy) Policies In Other Cigarettes do not have flavors except menthol. In 2009 the Communities And federal Food and Drug Administration banned the sale of flavored cigarettes because of their appeal to children. After Counties 2009, researchers found that there was a reduction in youth smoking, but also a shift among youth smokers to menthol DIANA CASSADY, Professor, cigarettes. After the ban on flavored cigarettes, the tobacco Department of Public Health industry flooded the market with flavored cigarillos and e- Sciences, UC Davis cigarettes. • Other countries do not allow flavored tobacco products. In response to these new flavored products and their appeal to youth, Brazil was the first country to prohibit flavored tobacco products in 2012. The European Union followed, covering 28 member countries. Turkey, with very high smoking rates, banned the sale of menthol flavored cigarettes in 2015 and will ban mint flavored products in 2020. Twenty-nine countries ban the sale of any type of e-cigarette. • Other states have flavored tobacco product regulations. In the United States 182 cities and counties have some form of restriction on the sale of flavored tobacco products, including Chicago, New York City, Boston, and Minneapolis. Many smaller cities in Massachusetts and Minnesota also have adopted regulations on flavored tobacco products. • Other California cities and counties have flavored tobacco product regulations including Yolo County. Twenty-five of those local policies have been passed in California as of November 2018 (see attachment). The City of Hayward was the first to regulate the sale of flavored tobacco products in 2014, with more policies passed each year: 11 California cities passed policies in 2018. Closest to Sacramento, the Yolo County Board of Supervisors passed their tobacco product regulation policy in October 2016 to prohibit the sale of flavored electronic cigarettes, menthol, little cigars, smokeless, components and accessories (e.g. blunt wrappers), and without exemptions. Sacramento County • The Sacramento County Tobacco Education Program (TEP) is Tobacco Education housed under the Sacramento County Department of Health Services, Public Health Division. The TEP is funded by the Program and Tobacco California Tobacco Control Program (CTCP), under the Control Coalition California Department of Public Health (CDPH) through a combination of Proposition 99 and 56 tobacco taxes. DANICA PETERSON, Health Focus to support education. The TEP focuses on providing Educator, Sacramento County tobacco-related information and education to individuals, Tobacco Education Program organizations, and the community. Methods include presentations, creation of fact sheets and infographics, presentations, and resource sharing and technical assistance. • Focus to support policy and social norm change. Another primary focus is on policy and social norm change. Methods include the pursuit of legislative policies; the pursuit of voluntary policies; providing staffing, training, and support for the local Tobacco Control Coalition (TCC); youth and adult engagement in tobacco control. Importantly, due to its funding source from tobacco taxes, the TEP is not allowed to lobby or openly support any specific legislation. However, they are able to provide information and education on the issues and support to the Tobacco Control Coalition (TCC), whose non Proposition 99/56 funded members are allowed to lobby. • The Tobacco Control Coalition (TCC) currently meets 6 times per year, every other month, to discuss tobacco-related issues in the community. The vision of the Coalition is to "transform Sacramento County into a tobacco-free society in the 21St century." Currently, the Coalition also consists of 4 subcommittees/taskforces: The Equity and Diversity Subcommittee, The Youth and Young Adult (YYA) Subcommittee, the Cessation Taskforce, and the Policy Taskforce. Health Burden and Economic Costs of Smoking in Sacramento TOTAL COSTS: 2009 = $790,670,000 2019 = $860 million DIRECT HEALTH CARE COSTS: 2009 = $416,692,000 2019 = $491 million Sacramento I"ut .,.,.", k Aw T'wMetr S.+to 1.se.n1. as.[ est sa�.l. ♦rtanAitrti •,e, Rrwtnr !iwokw VO4kr t laweba. 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Pr.�lar11,p1 219'7 1-rawAk ta1 1 i)14IQ )".An334 Tial 511.717 I Se. Tod 5"Wo $21 ►8061 6913V 104"2 172..766 363.[2[1 63111 Prrrs6trr 1� 2T1 719AA: 177.11 172,p93 279447 40,JQS 111Y18rr 3aftda 9M," 134„ 1kalA REFERENCES Ambrose, B.K., et al., Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014. JAMA, 2015: p. 1-3. Croyle RT, Morgan GD, Fiore MC. Addressing a Core Gap in Cancer Care—The NCI Moonshot Program to Help Oncology Patients Stop Smoking. New England Journal of Medicine 2019; 380:512-515. Cullen KA, Ambrose BK, Gentzke AS, et al. Use of electronic cigarettes and any tobacco product among middle and high school students–United States, 2011-2018. MMWR 2019; 67: 1276-1277. California Department of Public Health, California Tobacco Control Program. California Tobacco Facts and Figures 2018. Sacramento, CA: California Department of Public Health; 2018. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/ResearchandEvaluation/FactsandFigures/ CATobaccoFacts Fig ures2018_Printers.pdf California Department of Public Health, California Tobacco Control Program, State Health Officer's Report on E-Cigarettes:A Community Health Threat, Sacramento, CA 2015 http://3e113223sc6v7z23p 1 x7dax1-wpengine.netdna-ssl.com/wp-content/uploads/2016/07/State-Health-e-cig-report_digital.pdf California Department of Public Health,California Tobacco Control Program.The Truth About Flavored Tobacco. Sacramento, CA. January 2018. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document°/a20Library/Policy/FlavoredTobaccoAndMenthol/FinalF IavoredTobaccolnfographic.pdf California Department of Public Health, California Tobacco Control Program.Tobacco 21 Infographic for Retailers.Sacramento, CA. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/Tobacco2l Law/Tobacco-21- Infographic.pdf California Department of Public Health, California Tobacco Control Program. Young Adult Tobacco Purchase Survey, 2018. Sacramento, CA: California Department of Public Health; October 2018. www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Library/ResearchandEvaluation/FactsandFigures/2 018YATPSChartsADA.pdf Cooke DT and Gardiner P. To save African American lives,flavored tobacco ban must include menthol cigarettes. Opinion Editorial. March 12, 2019. Sacramento Bee. www.sacbee.com/opinion/op-ed/article227429344.htmi Henriksen L, Feighery EC, Schleicher NC, et al. 2008. "Is Adolescent Smoking Related to Density and Proximity of Tobacco Outlets and Retail Cigarette Advertising Near Schools?" Preventive Medicine 47: 210-214 Levy D, Blackman K, Tauras J, CHaloupka FJ,Villanti AC, Niaura RS, Vallone DM, Abrams D. Quit Attempts and Quit Rates Among Menthol and Nonmenthol Smokers in the United States. Am J Public Health. 2011 July; 101(7):1241-1247. Max W, Sung H-Y, Shi Y, &Stark B. The Cost of Smoking in California, 2009. San Francisco, CA: Institute for Health &Aging, University of California, San Francisco, 2014. www.trdrp.org/files/cost-smoking-ca-final-report.pdf McCarthy,W.J., Mistry, R., Lu,Y., Patel, M.,Zheng, H., Dietsch, B., Density of tobacco retailers near schools: effects on tobacco use among students.American Journal of Public Health, 2009. 99(11): p. 2006 2013.) Ternus-Bellamy,A. County Supervisors OK Ban on Flavored Tobacco Sales. Yolo County News. Davis Enterprise. October 2016. www.davisenterprise.com/local-news/county-government/county-supervisors-ok-ban-on-flavored-tobacco-sales/ Tobacco Free California. California Department of Public Health, California Tobacco Control Program. www.tobaccofreeca.com. Ton HT, Smart AE, Aguilar BL, Olson TT, Kellar KJ,Ahern GP. Menthol Enhances the Desensitization of Human a3(34 Nicotinic Acetylcholine Receptors. Mol Pharmacol. 2015 Aug; 88(2):256-64. U.S. Food &Drug Administration. Flavors in Tobacco Products: What are the Potential Risks and Benefits to Public Health? October 31, 2018. www.fda.gov/TobaccoProducts/Labeling/Products Ing redientsComponents/ucm611737.htm i : .. �._ Key Data Points on Flavored Tobacco Products Flavored Tobacco Products Overall • 81% of youth who have ever used a tobacco product initiated tobacco use with a flavored product.' (PATH Wave 1, 2013-2014) • 80% of current youth tobacco users used a flavored tobacco product in the past month.2 (PATH Wave 1, 2013-2014) E-Cigarettes • Among high school students, e-cigarette use more than doubled from 2017 to 2019, increasing from 11.7% to 27.5%.3 (2019 NYTS) • 5 million youth were current e-cigarette users in 2019 -an increase of nearly 3 million students since 2017.4 (2019 NYTS) • In 2018, 27.7% of high school e-cigarette users were frequent users, using e-cigarettes on at least 20 of the preceding 30 days.5 (2018 NYTS) • 1 in 9 of all high school seniors (11.7°/x) report that they vaped nicotine nearly daily, a strong indication of addiction.6 (2019 Monitoring the Future Survey) • As of 2017, researchers had identified more than 15,500 unique e-cigarette flavors available online.' • 97% of current youth (ages 12-17) e-cigarette users had used a flavored e-cigarette in the past month.8 (PATH Wave 4, 2016-2017) • Current use of menthol or mint flavored e-cigarettes among high school e-cigarette users increased from 51.2% in 2018 to 63.9% in 2019. Mint and menthol flavors are about as popular as fruit flavors among high school e-cigarette users.9 (2019 NYTS) • 70.3% of current youth (ages 12-17) e-cigarette users say they use e-cigarettes "because they come in flavors I like."10 (PATH Wave 4, 2016-2017) • The spike in youth e-cigarette use is undermining recent progress in reducing youth tobacco use. The increase in e-cigarette use drove a 38% increase in use of any tobacco product among high school students, from 19.6% in 2017 to 27.1% in 2018.11 (2018 NYTS) • E-cigarette use is "strongly associated" with the use of other tobacco products among youth. One study found that from 2013 to 2016, youth e-cigarette use was associated with more than four times the odds of trying cigarettes and nearly three times the odds of current cigarette use.12 Cigars • Sales of flavored cigars have increased by nearly 50% from 2008 to 2015, with more than 250 unique cigar flavors available.13 • 71.7% of current youth cigar smokers had used a flavored product in the last month.14 (PATH Wave 1, 2013-2014) • 73.8% of youth cigar smokers smoked cigars "because they come in flavors I like."15(PATH Wave 1, 2013- 2014) Menthol Cigarettes • Data from the Federal Trade Commission (FTC)show that in 2017 (the most recent year for which data are available), menthol cigarettes comprised 36% of the market, the highest proportion on record since FTC began collecting this data in 1963.16 • Over half(54%)of youth smokers ages 12-17 use menthol cigarettes compared to one-third (32%)of older adult smokers." Prevalence of menthol use is even higher among African Americans: 85% of all African- American smokers smoke menthol cigarettes and seven out of ten African-American youth smokers smoke menthol cigarettes.18 (2014 NSDUH) • TPSAC estimated that by 2020, 4,700 excess deaths in the African-American community will be attributable to menthol cigarettes, and over 460,000 African Americans will have started smoking because of menthol cigarettes.19 Flavored Tobacco Restrictions • Over 200 localities have restricted the sale of flavored tobacco products, although laws differ in their application to specific products and store types • Over 50 localities have restricted the sale of all flavored tobacco products, including menthol cigarettes • Over two dozen localities have completely prohibited the sale of all flavored tobacco products, with no product or retailer exemptions September 23, 2019 1 Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association, published online October 26,2015. 2 Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association, published online October 26,2015. 3 FDA,"Trump Administration Combating Epidemic of Youth E-Cigarette Use with Plan to Clear Market of Unauthorized,Non-Tobacco-Flavored E-Cigarette Products,"September 11,2019,https://www.fda.gov/news-events/press-announcements/trump-administration-combating-epidemic-youth-e-cigarette-use- plan-clear-market-unauthorized-non?utm source=CTPEblast&utm medium=email&utm term=stratout&utm conte nt=press release&utm campaign=ctp- yqg g.Current use defined as any use in the past month. 4 Bloomberg,Vaping Furor Intensifies as Trump Vows Tougher U.S.Scrutiny,September 11,2019 https://www.bloomberg.com/news/articles/2019-09-11/trump-to- hold-meeting-on-vaping-after-reports-of-u-s-i I Iness. 5 CDC,"Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students-United States,2011-2018,"Morbidity and Mortality Weekly Report(MMWR),67(45): 1276-1277.https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s cid=mm6745a5 w.Current use defined as any use in the past month 6 Miech,Richard,et al.,"Trends in Adolescent Vaping,2017-2019, The New England Journal of Medicine September 18,2019. 7 Zhu,S-H,et al.,"Evolution of Electronic Cigarette Brands from 2013-2014 to 2016-2017:Analysis of Brand Websites,"Journal of Medical Internet Research,20(3),published online March 12,2018. 8 FDA,"Modifications to Compliance Policy for Certain Deemed Products:Guidance for Industry,Draft Guidance,"March 13,2019, httos://www.fda.gov/media/I 21384/down load. 9 FDA,"Trump Administration Combating Epidemic of Youth E-Cigarette Use with Plan to Clear Market of Unauthorized,Non-Tobacco-Flavored E-Cigarette Products,"September 11,2019,https://www.fda.gov/news-events/press-announcements/trump-administration-combating-epidemic-youth-e-cigarette-use- plan-clear-market-unauthorized-non?utm source=CTPEblast&utm medium=email&utm term=stratout&utm content=pressrelease&utm campaign=ctp- ymp ag.Current use defined as any use in the past month.See also,CDC,"Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students-United States,2011-2018,"MMWR,67(45): 1276-1277.https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s cid=mm6745a5 w. 10 FDA,"Modifications to Compliance Policy for Certain Deemed Products:Guidance for Industry,Draft Guidance,"March 13,2019, https://www.fda.gov/media/l 21384/down load. 11 CDC,"Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students-United States,2011-2018,"MMWR,67(45): 1276-1277.https://www.cdc.gov/mmwr/volumes/67/wr/mm6745a5.htm?s cid=mm6745a5 w. 12 HHS,E-Cigarette Use Among Youth and Young Adults.A Report of the Surgeon General.Atlanta,GA:U.S.Department of Health and Human Services, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health,2016; Berry,KM,et al.,"Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths,"JAMA Network Open,2(2), published online February 1,2019. 13 Delnevo,CD,et al.,"Changes in the mass-merchandise cigar market since the Tobacco Control Act," Tobacco Regulatory Science,3(2 Suppl 1):S8-S16, 2017. 14 Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association, published online October 26,2015. 15 Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association, published online October 26,2015. 16 U.S.Federal Trade Commission(FTC),Cigarette Report for2017,2019,https://www.ftc.Qov/system/files/documents/reports/federal-trade-commission- cigarette-report-2017-federal-trade-commission-smokeless-tobacco-report/ftc cigarette report 2017 pdf[data for top 5 manufacturers only]. 17 Villanti,A,et al.,"Changes in the prevalence and correlates of menthol cigarette use in the USA,2004-2014," Tobacco Control,published online October 20,2016. 18 Villanti,A,et al.,"Changes in the prevalence and correlates of menthol cigarette use in the USA,2004-2014,"Tobacco Control,published online October 20,2016 19 TPSAC,FDA,"Menthol Cigarettes and Public Health:Review of the Scientific Evidence and Recommendations,2011, http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisoryCommittee/UCM269697 pdf. Surgeon General's Advisory on E-cigarette Use Among Youth 1, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e-cigarette use. The recent surge in e-cigarette use among youth, which has been fueled by new types of e-cigarettes that have recently entered the market, is a cause for great concern. We must take action now to protect the health of our nation's young people. KNOW THE RISKS.TAKE ACTION. PROTECT OUR KIDS. The E-cigarette Epidemic Among Youth Considerable progress has been made in reducing cigarette smoking among our nation's youth.' However, the tobacco product landscape continues to evolve to include a variety of tobacco products, including smoked, smokeless, and electronic products, such as e-cigarettes.2 E-cigarettes are designed to deliver nicotine, flavorings, and other additives to the user via an inhaled aerosol.2 E-cigarettes entered the U.S. marketplace around 2007, and since 2014, they have been the most commonly used tobacco product among U.S. youth.2 E-cigarette use among U.S. middle and high school students increased 900% during 2011-2015, before declining for the first time during 2015-2017.3 However, current e-cigarette use increased 78% among high school students during the past year, from 11.7% in 2017 to 20.8% in 2018.4 In 2018, more than 3.6 million U.S. youth, including 1 in 5 high school students and 1 in 20 middle school students, currently use e-cigarettes.4 E-cigarette aerosol is not harmless.2 Most e-cigarettes contain nicotine—the addictive drug in regular cigarettes, cigars, and other tobacco products.2 Nicotine exposure during adolescence can harm the developing brain — which continues to develop until about age 25.2 Nicotine exposure during adolescence can impact learning, memory, and attention.'2 Using nicotine in adolescence can also increase risk for future addiction to other drugs.'2 In addition to nicotine, the aerosol that users inhale and exhale from e-cigarettes can potentially expose both themselves and bystanders to other harmful substances, including heavy metals, volatile organic compounds, and ultrafine particles that can be inhaled deeply into the lung S.2 Many e-cigarettes also come in kid-friendly flavors. In addition to making e-cigarettes more appealing to young people,5 some of the chemicals used to make certain flavors may also have health risks.2 E-cigarettes can also be used to deliver other drugs, including marijuana.2 In 2016, one-third of U.S. middle and high school students who ever used e-cigarettes had used marijuana in e-cigarettes.6 For adults, e-cigarettes may have the potential to reduce risk for current smokers if they completely transition from cigarettes to e-cigarettes; however, a majority of adults who use e-cigarettes also smoke cigarettes!For youth, the use of multiple tobacco products puts youth at even greater risk for addiction and tobacco-related harms.1,2 Moreover, a 2018 National Academy of Sciences, Engineering, and Medicine report concluded that there was moderate evidence that e-cigarette use increases the frequency and intensity of cigarette smoking in the future.7 But any e-cigarette use among young people is unsafe, even if they do not progress to future cigarette smoking.2 E-cigarettes Come in Many Shapes and Sizes E-cigarettes are a rapidly changing product class, and are known by many different names, including °e-cigs," "e- hookahs," "mods," and "vape pens.,2 Recently, a new type of e-cigarette has become increasingly popular among our nation's youth due to its minimal exhaled aerosol, reduced odor, and small size, making it easy to conceal.8 Many of these new e-cigarettes look like a USB flash drive, among other shapes. One of the most commonly sold 1 USB flash drive shaped e-cigarettes is JUUL, which experienced a 600% surge in sales during 2016-2017, giving it the greatest market share of any e-cigarette in the U.S. by the end of 2017.9 Other companies are now also starting to sell e-cigarettes that look like USB flash drives. All JUUL e-cigarettes have a high level of nicotine. A typical JUUL cartridge, or"pod," contains about as much nicotine as a pack of 20 regular cigarettes.10 These products also use nicotine salts, which allow particularly high levels of nicotine to be inhaled more easily and with less irritation than the free-base nicotine that has traditionally been used in tobacco products, including e-cigarettes. This is of particular concern for young people, because it could make it easier for them to initiate the use of nicotine through these products and also could make it easier to progress to regular e-cigarette use and nicotine dependence. However, despite these risks, approximately two- thirds of JUUL users aged 15-24 do not know that JUUL always contains nicotine." You Can Take Action We must take aggressive steps to protect our children from these highly potent products that risk exposing a new generation of young people to nicotine.2,'The bad news is that e-cigarette use has become an epidemic among our nation's young people. However, the good news is that we know what works to effectively protect our kids from all forms of tobacco product use, including e-cigarettes.'2,t2 We must now apply these strategies to e- cigarettes, including USB flash drive shaped products such as JUUL. To achieve success, we must work together, aligning and coordinating efforts across both old and new partners at the national, state, and local levels. Everyone can play an important role in protecting our nation's young people from the risks of e-cigarettes. Information for Parents • You have an important role to play in addressing this public health epidemic. • Learn about the different shapes and types of e-cigarettes and the risks of all forms of e-cigarette use for young people at https://e-cigarettes.surgeongeneral.gov/. • Set a good example by being tobacco-free. If you use tobacco products. it's never too late to quit. Talk to a healthcare professional about quitting all forms of tobacco product use. For free help, visit smokefree.gov or call 1-800-QUIT-NOW. • Adopt tobacco-free rules, including e-cigarettes, in your home and vehicle. • Talk to your child or teen about why e-cigarettes are harmful for them. It's never too late. • Get the Surgeon General's tip sheet for parents, Talk With Your Teen About E-cigarettes, at https://e- cigarettes.surgeongeneral.gov/. Start the conversation early with children about why e-cigarettes, including JUUL, are harmful for them. • Let your child know that you want them to stay away from all tobacco products, including e-cigarettes, because they are not safe for them. Seek help and get involved. Set up an appointment with your child's health care provider so that they can hear from a medical professional about the health risks of tobacco products, including e-cigarettes. Speak with your child's teacher and school administrator about enforcement of tobacco-free school policies and tobacco prevention curriculum. Encourage your child to learn the facts and get tips for quitting tobacco products at Teen.smokefree.gov. Information for Teachers • You have an important role to play in addressing this public health epidemic. • Learn about the different shapes and types of e-cigarettes and the risks of all forms of e-cigarette use, including JUUL, for young people at https://e-cigarettes.surgeongeneral.gov/. • Develop, implement, and enforce tobacco-free school policies and prevention programs that are free from tobacco industry influence, and that address all types of tobacco products, including e-cigarettes. 2 • Engage your students in discussions about the dangers of e-cigarette use. To help you, the Food and Drug Administration (FDA), and Scholastic, developed free resources for teachers. These materials can be found at www.scholastic.com/youthvapingrisks. Information for Health Professionals • You have an important role to play in addressing this public health epidemic. • Learn about the different shapes and types of e-cigarettes and the risks of all forms of e-cigarette use, including JUUL, for young people at https://e-cigarettes.surgeongeneral.gov/. • Ask about e-cigarettes, including small, discreet devices such as JUUL, when screening patients for the use of any tobacco products. • Educate patients about the risks of all forms of tobacco product use, including e-cigarettes, for young people. • Encourage patients to quit. For free help, patients can visit smokefree.gov or call 1-800-QUIT-NOW. Information for States, Communities, Tribes, and Territories • You have an important role to play in addressing this public health epidemic. • Implement evidence-based population-level strategies to reduce e-cigarette use among young people, such as including e-cigarettes in smoke-free indoor air policies, restricting young peoples' access to e- cigarettes in retail settings, licensing retailers, implementing price policies, and developing educational initiatives targeting young people. • Implement strategies to curb e-cigarette advertising and marketing that are appealing to young people. • Implement strategies to reduce access to flavored tobacco products by young people. KNOW THE RISKS. TAKE ACTION. PROTECT OUR KIDS. References 1. Office of the Surgeon General.The Health Consequences of Smoking-50 Years of Progress:A Report of the Surgeon General.Atlanta,GA:US Department of Health and Human Services,Centers for Disease Control and Prevention(US), National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health;2014. https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-repo rt.pdf. 2. Office of the Surgeon General.E-cigarette Use among Youth and Young Adults:A Report of the Surgeon General. Washington,DC:U.S.Department of Health and Human Services,Centers for Disease Control and Prevention;2016. https://www.cdc.gov/tobacco/`data statistics/sgr/e-cigarettes/pdfs/2016 sgr entire report 508.pdf. 3. Wang TW,Gentzke A,Sharapova S,et al.Tobacco Use Among Middle and High School Students-United States,2011- 2017.MMWR Morbidity and Mortality Weekly Report. 2018;67(22):629-633. 4. Cullen KA,Ambrose BK,Gentzke AS,Apelberg BJ,Jamal A,King BA.Notes from the Field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students—United States,2011-2018.MMWR Morbidity&Mortality Weekly Report 2018;67(45):1276-1277. 5. Ambrose BK,Day HR, Rostron B,et al.Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014. Jamo. 2015;314(17):1871-1873. 6. Trivers KF,Phillips E,Gentzke AS,Tynan MA,Neff U. Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth.JAMA pediatrics. 2018;172(11):1097-1099. 7. National Academies of Sciences,Engineering,and Medicine.2018. Public Health Consequences of E-Cigarettes. Washington,DC:The National Academies Press.https://doi.org/10.17226/24952. 8. Ramamurthi D,Chau C,Jackler RK.JUUL and other stealth vaporisers:hiding the habit from parents and teachers. Tob Control. 2018.Epub ahead of print.doi: 10.1136/tobaccocontrol-2018-054455. 9. King BA,Gammon DG, Marynak KL, Rogers T.Electronic Cigarette Sales in the United States,2013-2017.Jama. 2018;320(13):1379-1380. 3 10. Willett JG,Bennett M,Hair EC,et al.Recognition,use and perceptions of JUUL among youth and young adults. Tob Control. 2018.Epub ahead of print.doi:10.1136/tobaccocontrol-2018-054273. 11. Truth Initiative.JUUL e-cigarettes gain popularity among youth,but awareness of nicotine presence remains low. htti)s://truthinitiative.org/news/i uuI-e-cigarettes-gain-popularity-among-youth. 12. US Department of Health and Human Services.Preventing tobacco use among youth and young adults. Atlanta,GA:US Department of Health and Human Services,CDC;2012. https://www.cdc.gov/tobacco/data statistics/sgr/2012/index.htm. 4 M AMERICAN American Cancer Action LUNG Heart 0.0111 Wt1M k ASSOCIATION Association't IN CALIFORNIA P'go December 14, 2018 Within the past month, two big announcements were made regarding tobacco control at the federal and state levels: • On November 15, the U.S. Food and Drug Administration (FDA) announced that it intends to prohibit the sale of menthol cigarettes and flavored cigars as well as implement certain restrictions on e-cigarette sales.' The FDA also intends to release a "best practices" guide for online tobacco retailers and may strengthen federal policies around youth access to flavored tobacco. • On December 3, six members of the California legislature introduced bills banning the sale of flavored tobacco products, including menthol, and requiring age verification for tobacco products sold online." While these announcements are good news, California cities and counties should continue taking steps to protect youth and vulnerable populations from flavored tobacco. Our organizations have long advocated to prohibit the sale of all flavored tobacco products, including menthol cigarettes and flavored cigars, because flavors have been shown to encourage youth use."' The FDA's own scientific advisory committee found that menthol increases youth initiation and makes it harder for people who smoke to quit.' Menthol products have also been linked to higher degree of addiction among youth and priority populations.v The tobacco industry has for decades targeted the marketing and sale of menthol cigarettes disproportionately to the African American community.' E-cigarettes and other flavored tobacco products also contain harmful ingredients which can cause irreversible damage." The 2018 National Youth Tobacco Survey showed that 20% of high school students currently use e-cigarettes, which is 78% higher than the 2017 report. "' Of those, two thirds used flavored products and over half used menthol or mint flavored products. We have already seen how long it takes for federal decisions surrounding tobacco to take effect, such as the corrective action statements which were decided in 2006 and implemented in 2017.'x The FDA has only announced its intention to take action —the proposal and other details of the plan have not yet been released. In addition, the process to finalize FDA regulations is a lengthy one that could take a decade or more. California cities and counties should adopt the strongest policies possible to ensure their communities are protected. We cannot wait. Likewise, state legislation is a long process, and without the pressure of local adoption, could take years, if passed at all. The introduced legislation may also take amendments over time that weaken its protective measures. It is essential to continue to build momentum by adopting these policies at the local level. The best way to prevent tobacco addiction is to prevent youth and young adults from ever starting to use it in the first place. This is done through comprehensive policies that limit access to tobacco products.x Since 80% of young people who have ever tried a tobacco product started with a flavored product, prohibiting the sale of flavored tobacco products, including menthol, will remove youth's temptation to start.x' Local tobacco retail licensing with suspension and expulsion clauses have also shown to reduce the number of illegal sales.x" It is critically important that local decision-makers go above and beyond the proposed FDA regulations, and not wait for the state or federal government to act. For more information, please contact Lindsey Freitas, American Lung Association in California (lindsey.freitas@lung.org), Tim Gibbs, American Cancer Society Cancer Action Network (tim.gibbs@cancer.org), or Jamie Morgan, American Heart Association (jam ie.morgan@heart.org). Sincerely, American Lung Association in California American Cancer Society Cancer Action Network American Heart Association 'U.S. Food&Drug Administration. (2018, November 15).Statement from FDA Commission Scott Gottlieb, M.D.,on proposed new steps to protect youth by preventing access to flavored tobacco products and banning menthol in cigarettes. Retrieved from https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm625884.htm "Hill,J. (2018, December 3).State Lawmakers Introduce Bill to Ban Sales of Flavored E-Cigarettes and All Other Flavored Tobacco Products to Combat Use by Youths,Also Introduce Bill to Set Stricter Rules for Age Verification on Sales of Tobacco Products Online and by Mail. Senator Jerry Hill. Retrieved from https://sdl3.senate.ca.gov/news/2018-12-03-state-lawmakers-introduce-bill- ba n-sa I es-flavo red-e-cigarettes-and-a I I-other "'Gammon, D.G., MS, King, B.A., PhD, MPH,Marynak, K.L., MPP,&Rogers,T. (2018,October 10). Electronic Cigarette Sales in the United States,2013-2017.JAMA Network. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/2705175 "U.S. Food&Drug Administration.(n.d.)Preliminary Scientific Evaluation of the Possible Public Health Effects of Menthol versus Nonmenthol Cigarettes. Retrieved from https://www.fda.gov/downloads/ucm361598.pdf Henningfield,J.E. (2013). Does Menthol Enhance the Addictiveness of Cigarettes?An Agenda for Research. Nicotine and Tobacco Research. "Centers for Disease Control and Prevention. (2018,August 21).African Americans and Tobacco Use. Retrieved from https://www.cdc.gov/tobacco/disparities/african-americans/index.htm "Destaillats, H.,Gundel, L.A., Litter, M.I., Logue,J.M., Montesinos,V.N., Russell,M.L.,&Sleiman, M. (2016,July 27). Emissions from Electronic Cigarettes: Key Parameters Affecting the Release of Harmful Chemicals. Environmental Science&Technology. Retrieved from https://pubs.acs.org/doi/pdf/10.1021/acs.est.6b01741 Ambrose,B.K., PhD,Appleberg,B.J., PhD,Cullen, K.A., PhD,Gentzke,A.S., PhD,Jamal,A., MBBS,&King,B.A., PhD. (2018, November 16)Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students—United States, 2011-2018. Retrieved from https://www.cdc.gov/mmwr/ vol umes/67/wr/mm6745a5.htm?s cid=mm6745a5 w#F1 down ''Campaign for Tobacco-Free Kids.(2018, May 2)U.S. Racketeering Verdict:Big Tobacco Guilty as Charged. Retrieved from https://www.tobaccofreekids.org/what-we-do/industry-watch/doj Centers for Disease Control and Prevention. (2014). Best Practices for Comprehensive Tobacco Control Programs—2014. Retrieved from https://www,cdc.gov/tobacco/stateandcommunity/best_practices/index.htm "Ambrose,B.K., PhD, MPH, Borek, N., PhD,Conway, K.P., PhD, Day, H.R., PhD, Hyland,A., PhD, Rostron,B., PhD,&Villanti, A.C., PhD,MPH. (2015, November 3). Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014. JAMANetwork. Retrieved from https://j a ma network.com/journals/jama/fuIlarticle/2464690 `"Center for Tobacco Policy&Organizing. (2018 September).Tobacco Retailer Licensing is Effective. Retrieved from https://center4tobaccopol icy.org/wp-content/upload s/2018/09/Tobacco-Retailer-LIce nsing-is-Effective-September-2018.pdf AMERICAN Matrix of Local Ordinances Restricting LUNG THE CENTER ASSOCIATION., for Tobacco Policy&Organizing N'A,110 MA the Sale of Flavored Tobacco Products WNW_ sa} ! MAY 2019 The tobacco industry has a long history of using flavored S.Components&Accessories- Restricts the sale of flavored tobacco to target youth and communities of color.The accessory products such as blunt wraps and a-juice additives. majority of youth who start experimenting with tobacco These products cannot be smoked alone and serve as a begin with flavored tobacco.'These products come in a delivery system for smoked products. variety of candy-like flavors including bubble gum,grape, 6. Products Marketed as Flavored -Tobacco companies menthol and cotton candy and include e-cigarettes, hookah sometimes try to circumvent flavor restrictions by marketing tobacco,cigars,smokeless tobacco,and even flavored products as flavored without directly labelling them as accessories such as blunt wraps. such.This policy option allows communities to broaden the Since 2009,the United States Food and Drug Administration definition of flavored tobacco to include these products. (FDA) has banned flavored cigarettes nationwide. However, this ban included an exemption for menthol flavored What exemptions are allowed? cigarettes and doesn't extend to non-cigarette tobacco products.There are currently no state laws in California 1.Adult-Only Stores Exempted -Adult-only retailers are restricting the sale of flavored tobacco products. It is up to limited to customers who are 21 and over.This limits sales of flavored tobacco to stores that youth do not have access to. local communities to take action to protect their youth from the lure of enticing flavored tobacco. 2.Grandfathered Retailers Exempted -Allows retailers that The first community to restrict the sale of flavored tobacco in were in operation prior to a specifed date to continue selling California was Santa Clara County in 2010.Since then,thirty- flavored tobacco products. five communities have passed similar policies. 3.Limited to Youth-Populated Areas- Retailers are required What products may be included? to be a certain distance away from schools, parks,or other youth-oriented locations. Since many flavored tobacco 1.E-Cigarettes - Restricts the sale of flavored electronic products target youth, including buffer zones is a way to limit cigarettes. their access to flavored products. 2.Menthol - Restricts the sale of tobacco products labelled Resources as menthol, including cigarettes,smokeless tobacco, little cigars,etc. The Center has additional resources on tobacco retailer licensing ordinances, plug-in policies,and ordinances 3.Little Cigars - Restricts the sale of flavored little cigars, restricting menthol tobacco available at: http:// which are small, usually filtered cigars wrapped in brown center4tobaccopolicy.org/tobacco-policy/tobacco-retai1- paper containing tobacco leaf. Little cigars became a popular environment/. Changel-ab Solutions has model ordinance alternative following the FDA's ban on flavored cigarettes. language available for ordinances restricting flavored 4.Smokeless Tobacco - Restricts the sale of flavored tobacco at: http://changelabsolutions.org. smokeless tobacco such as chewing tobacco, dip, snus and snuff. . The Center for Tobacco Policy&Organizing I American Lung Association in California 15311 Street,Suite 201,Sacramento,CA 958141 Phone:(916)554.58641 Fax:(916)442.8585 �• •• D2019.California Department of Public Health.Funded under contract#14-10213. THE AMERICAN LUNG ASSOCIATION IN CALIFORNIA THE CENTER FOR TOBACCO POLICY&ORGANIZING p• of Products Included Exemptions .. Adult-Only �. .. , . . •Cigars & •.. Retailers Exempted Exempted? San Carlos April 2019 X X X X X X Larkspur X X X X X X April 2019 Sacramento April 2019 X X X X X X Albany X X X X X X April 2019 Corte Madera March 2019 X X X X X X Hermosa Beach X X X X X X X Jan 2019 San Pablo Dec 2018 X X X X X X Alameda Nov 2018 X X X X X X Santa Cruz Nov 2018 X X X X X X Marin County X X X X X X Nov 2018 Saratoga X X X X X Oct 2018 Half Moon Bay X X X X X Oct 2018 X Portola Valley X X X X X X Sep 2018 Beverly Hills August 2018 X X X X X X Richmond July 2018 X X X X X X Sausalito July 2018 X X X X X San Mateo County X X X X X X June 2018 San Francisco June 2018 X X X X X X Mono County July 2018 X Windsor March 2018 X X" X X X . The Center for Tobacco Policy&Organizing I American Lung Association in California 15311 Street,Suite 201,Sacramento,CA 95814 1 Phone:(916)554.5864 1 Fax:(916)442.8585 •• •• cp2019.California Department of Public Health.Funded under contract#14-10213. _j E-cigarettes,which heat a nicotine solution into a vapor,are often promoted as a less harmful alternative to traditional cigarettes but the FDA has not approved any vaping product to help smokers quit.The makers of all vaping products face a May deadline to submit applications for government health and safety review. Mike Chang,owner of Master Piece Smoke Shop in New York City,says most of his customers who buy disposables switched from Juul after the company pulled its mint,mango and dessert flavors last fall.The company took that voluntary step under pressure from multiple federal investigations and lawsuits from state and local authorities. The San Francisco company's retail sales have fallen 35%since their peak last July,driven by the loss of flavors,according to Wall Street research firm Piper Sandler.Juul does not sell disposable e-cigarettes. In a government survey last year,more than 1 in 4 high school students reported using e- cigarettes in the prior month.The next federal study begins this spring. AP videojournalist Marshall Ritzel contributed to this report. Copyright AP-Associated Press This article tagged under f y � FOA• VAPING MORE FROM THE WEB •BON VOYAGED Can You Actually Ace This Basic Knowledge onlineSpon501ed Quiz? •THEPHOTOSTICKMOSILE Tiny Gadget for Your Spoosore° Photos,The Idea Is... Sales of disposable e-cigarettes and all other tobacco and vaping products are prohibited to teenagers under the government's new age limit,which went from 18 to 21 late last year. High school student Philip Fuhrman says most of his New York classmates who vape have ditched Juul for disposables like Stig,a tiny e-cigarette sold in flavors like mighty mint and mango bomb. They're easier to hide because"they're smaller and when you're done you can just throw it away," said the 16-year-old Fuhrman,who says he no longer vapes.Hes now an anti-vaping activist and his mother is one of the founders of a parents'group opposed to youth vaping. At$20 for a three-pack,Stig may not seem cheap.But Fuhrman and other teens say it's a smaller investment than the$40 or$50 needed to buy a Juul device and a four-pack of pods.Furhman says teens will instead buy a pack of Stigs"for the weekend and then just be done with it" The makers of Stig,Puff Bar and Fogg disposables did not respond to requests for comment. Analysts report that disposables are still just 5%of the nearly$15 billion global vaping market, according to the firm ECigintelligence. O:46 New York City Bans Flavored Vaping Products 1:52 Family Says Vaping Killed Their 28-Year-Old Son An Orlando family is grieving the loss of their 28-year-old son,who died last week.They said he died as a result of vaping Kyle Boyd's mother,Kimberly,said he was fine last Monday after he came. Read more Researchers who study e-cigarette trash around high schools say they have noticed a shift in what teens are vaping.Jeremiah Mock,of the University of California,San Francisco,has been finding discarded Puff Bars in local school parking lots over the last three months. Vape shop owners also say the market is changing. Since the FDA announcement,distributors and manufacturers have ramped up their disposable offerings,according to Vapewerks owner Jeremy Gardner in Cumberland,Maryland. "How do disposables get a free pass when they're essentially the same thing as a Juul or anything else that comes with a prefilled pod?"he asked. Gardner doesn't stock his most requested brand,Puff Bar,but sells a rival disposable.Most of his business comes from larger,tank-based vapes,which are more popular with adults and allow users to customize flavors and nicotine concentrations.Those products are exempt from government flavor restrictions. 20%Precip 650 WHAT DO YOU THINK? , How do you feel about the idea of you and your spouse/partner sleeping separate beds?a All for it Okay with it Against it Does not apply New York City becomes the fust major U S city to ban flavored vaping products "They are very accessible and seem to be the new buzzy product;"said Dr.Karen Wilson,a tobacco researcher and pediatrician at Mount Sinai's medical school in New York. The FDA confirmed that the flavor restriction won't apply to"self-contained,disposable products;' but only to rechargeable ones that use pods or cartridges prefilled with a nicotine solution. The agency's rationale.Reusable vaping devices are far and away the most popular with underage users,preferred by more than 60%of high schoolers who vape,according to survey data collected How To Easily Clean Earwax last year. C-Grips.com Open ? The FDA's top tobacco regulator said it can still go after any vaping product that appeals to teenagers. "If we see a product that is targeted to kids,we will take action:Mitch Zeller,who heads the agency's tobacco center,said in a statement. Thursday was the deadline for makers of reusable e-cigarettes to stop selling fruity and candy flavors.Juul was already in compliance.It dropped its best selling mint and most other flavors before the ban was announced in early January and only sells tobacco and menthol. At a congressional hearing Wednesday,the head of Fontem U.S.,which makes blu vapes,was pressed to drop its vivid vanilla and cherry crush disposable e-cigarettes. Fontem chief Antoine Blonde countered that its customers are adults,not children.Less than 3% of high school students who vape reported blu as their preferred brand,according to 2019 government data. "We're not aware of any issue caused by our disposable flavors;"Blonde said. More Vaping Coverage THEW— MING •JAN 2 Trump Plan to Curb Teen Vaping Exempts Some Flavors VAPING •REC2U.2019 K. 'Vast Majority'of Vaping Illnesses Blamed on Vitamin E 4% SHARE TRENDING Weekend Events 2nd Coronavirus Case Insulin Pump Recall Friends'-The .Ott LOCAL WEATHER INVESTIGATIONS SPORTSWRAP THESCENE ENTERTAINMENT 640 TRENDING weekend Events 2nd Ccronavirus Case insulin Pump Recall 'Friends'-Themed Branch FDA Crackdown on Vaping Flavors Has Blind Spot: Disposables The flavor restrictions that went into effect Thursday only apply to reusable e-cigarettes like Juul,the brand that helped trigger the teen vaping craze By Matthew Perrone•Published on February 7,2020 at 11:29 pm f y p/MM=tq�Rgllri 'nN p'0�cw... M`. �•-•-- nlaerrw.►Rcetlm is urwdr.Nrcc t How To Easily Clean Earwax GCrips%m Open wARNIN(: WaaNrm:: Trending Stories TAh product ccm a . n,:ra.ns vurwxru 4 [(''',,,,� CORONAVIRUS NrcwrK ~ ! �) CDC Confirms Second Coronavirus Case in San Diego County INNATIONAL CITY This _.._ wows various brards and Flavors of disposable vape devices at a. Family Identifies Driver Killed in Read more Crash Off I-5 Near National City FLU SEASON The U.S.government on Thursday began enforcing restrictions on flavored electronic cigarettes Distinguishing Between aimed at curbing underage vaping.But some teenagers may be one step ahead of the rules. Coronavirus and Flu CORONAVIRUS Parents,researchers and students warn that some young people have already moved on to a 'Miscommunication,Not newer kind of vape that isn't covered by the flavor ban. Fill labeling likely Caused Coronavirus Mix-Up at UC San... These disposable e-cigarettes are sold under brands like Puff Bar,Stig and Fogg in flavors such as pink lemonade,blueberry ice and tropical mango. SPONSORED Watch this new video to learn The Food and Drug Administration's crackdown narrowly targets reusable vaping devices like Juul, more the blockbuster brand that helped trigger the teen vaping craze in the U.S.Under the new policy, only menthol and tobacco flavors are allowed for those devices. Weather Forecast Critics of the=DA policy fear teens will simply switch to the cheaper disposables,which are widely --)NIGHT ' available at convenience stores and gas stations. vL 4O 50° Scattered Clouds ro++.uaaow THE IRICAN LUNG ASSOCIATION IN CALIFORNIA THE CENTER FOR TOBACCO POLICY&ORGANIZING Page 3 of 3 Products City/C • .. Adult-Only D- .. • Exempted.Cigars &Accessories . '.. Cloverdale X X X Dec 2017 X Fairfax Dec 2017 X X** X X X San Leandro Oct 2017 X X X X X Palo Alto Oct 2017 X X X X X X X Oakland Sep 2017 X X X X X X X Contra Costa County X X X X X X X July 2017 1000 ft Los Gatos May 2017 X X X X X X X Novato Jan 2017 X X" X X X Santa Clara County X X X X X X X Oct 2016 Yolo County Oct 2016 X X X X X Manhattan Beach Dec 2015 X X X X X X EI Cerrito Oct 2015 X X' X X X X Berkeley X X XX X X X Sep 2015 600 ft Sonoma X X** X X X June 2015 Hayward X July 2014 X X* X X X X X 500 ft 'Ambrose,B.K.,et al.,Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014.JAMA,2015:p.1-3. `Does not include menthol cigarettes **Exempts packages of at least 5 or more —Doesn't apply to pipe tobacco • • : • ••• • • The Center for Tobacco Policy&Organizing I American Lung Association in California 1531 1 Street,Suite 201,Sacramento,CA 95814 1 Phone:(916)554.5864 1 Fax:(916)442.8585 02019.California Department of Public Health.Funded under contract#14-10213.