Ohio Health Policy News

Cigarette tax revenue in Ohio has been significantly higher than expected through September, a troubling sign that Ohioans are smoking and using other tobacco products more during the pandemic (Source: “‘Troubling trend’: Ohioans appear to be smoking more amid pandemic stress,” Dayton Daily News, Oct. 20).

Cigarette excise tax revenue was $16.1 million (21.8%) above what the state had anticipated for September and $23.5 million (13.6%) above estimate for the first quarter of the state fiscal year.

The Ohio Office of Budget and Management said in its monthly budget report that the "substantial overage is likely related to heightened consumption during the continuing pandemic.”

“It’s a very troubling trend because Ohio already has very high rates of tobacco use and it’s a major cause of our poor health outcomes in Ohio,” said Amy Bush Stevens, vice president of Health Policy Institute of Ohio.

Smoking is the No. 1 cause of preventable deaths. About 20.5% of adults smoked cigarettes in Ohio in 2018, according to the Centers for Disease Control and Prevention, placing the state as the 11th highest smoking rate in the country.

The coronavirus pandemic is a higher risk time for smokers. Smoking impairs lung function, making it harder for the body to fight off coronaviruses and other respiratory diseases. The CDC states being a current or former cigarette smoker increases risk of severe illness from COVID-19.

The number of high school students regularly using e-cigarettes dropped significantly over the past year, after several years of soaring use, according to a new government survey of teenagers (Source: “E-Cigarette Use Falls Sharply Among Teenagers, C.D.C. Finds,” New York Times, Sept. 9).

The encouraging public health news was tempered by evidence that many high school users were taking advantage of a regulatory loophole to get access to flavored products.

But the CDC data suggested that even greater progress may have been stymied by the growing popularity of a new product — disposable e-cigarettes, which, under a loophole in federal regulations, are still allowed to be sold in youth-friendly flavors.

The shifting trends were captured by the 2020 National Youth Tobacco Survey, an annual look at teen use of tobacco-related products, administered by the Centers for Disease Control and Prevention.

Because the coronavirus attacks the lungs, experts are warning that those who smoke or vape are at greater risk for COVID-19 complications (Source: “Smokers and Vapers May Be at Greater Risk for Covid-19,” New York Times, April 9, 2020).

”Quitting during this pandemic could not only save your life, but by preventing the need for your treatment in a hospital, you might also save someone else’s life,” said Dr. Jonathan Winickoff, director of pediatric research at the Tobacco Research and Treatment Center at Massachusetts General Hospital.

Studies already amply show that cigarette smoking weakens the immune system and compromises lung function. Research into the health effects of vaping is limited because the devices are relatively new, but studies suggest that e-cigarettes may cause inflammation in the airways and lungs.

Warnings about smoking use and COVID are an especially important consideration in Ohio. The state ranks in the bottom quartile for adult smoking and children living in a household with a smoker, according to HPIO’s 2019 Health Value Dashboard. Analysis of the rankings found that tobacco use and secondhand smoke exposure contribute to many of Ohio’s greatest health challenges, including infant mortality, cardiovascular disease, cancer and asthma.

The U.S. government on Thursday began enforcing restrictions on flavored electronic cigarettes aimed at curbing underage vaping, but experts warn that some young people have already moved on to a newer kind of vape that isn’t covered by the flavor ban (Source: “FDA crackdown on vaping flavors has blind spot: disposables,” Associated Press, Feb. 6, 2020).

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.

The Food and Drug Administration’s crackdown narrowly targets reusable vaping devices like Juul, the 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. Critics of the FDA policy fear teens will simply switch to the cheaper disposables, which are widely available at convenience stores and gas stations.

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 Food and Drug Administration on Thursday announced restrictions on the sale and manufacturing of all flavors of e-cigarette pods except tobacco and menthol (Source: “FDA to enact scaled-back e-cigarette flavor ban,” Modern Healthcare, Jan. 2, 2020).

FDA Commissioner Dr. Stephen Hahn said the policy was intended to limit youth e-cigarette use but maximize the potential benefit to adults trying to quit smoking combustible cigarettes. The flavor restrictions do not apply to tank vaping systems found at vape shops that HHS officials said are more often used by adults.

The Trump administration in September indicated it wanted to ban all e-cigarette flavors besides tobacco. Campaign for Tobacco-Free Kids President Matthew Myers said the exceptions were concessions to the vaping industry and vape shops that had furiously lobbied to water down the flavor ban.

"By leaving menthol flavored e-cigarettes widely available and completely exempting liquid flavored products, this policy will not stop the youth e-cigarette epidemic," the group said in a statement.

HHS officials justified leaving menthol-flavored e-cigarette pods on the market by pointing to the 2019 Monitoring the Future survey, which showed less than 1% of frequent youth e-cigarette users surveyed in the 10th grade most often used the classic tobacco flavor, compared to 4.8% who preferred menthol. Mint was the most popular flavor at 52.1%.

The U.S. House and Senate have now passed a provision that would ban the sale of tobacco and e-cigarettes to anyone under 21 (Source: “Congress Approves Raising Age to 21 for E-Cigarette and Tobacco Sales,” New York Times, Dec. 19, 2019).

The rule comes at a time when Congress and the Trump administration are facing public pressure to reduce the soaring rates of teenage vaping. President Trump has spoken in favor of increasing the age limit, and is expected to sign the measure into law as part of the overall spending package.

Nineteen states, including Ohio, and more than 500 cities and towns have already raised the age to 21. Setting it as a national age limit is viewed as an effort to appease those who are calling for a full ban on e-cigarettes or a flavor ban to prevent addicting a new generation to nicotine.

While many lawmakers and public health experts welcomed a higher age limit for sales of cigarette items, others argue that tougher enforcement of sales laws, as well as higher taxes on products, are also needed to deter teenage use.

Doctors and public health experts have long been concerned about the effects of nicotine on the teenage brain. The National Academy of Medicine has estimated that 90% of adult smokers first start the habit before turning 19, when developing brains are most vulnerable to nicotine addiction. In a 2015 study, the academy reported that banning legal access to those under 21 would spur a 12% reduction in tobacco use by the time current teenagers became adults; with the biggest impact among 15-to-17-year olds.

As new restrictions at the local, state and federal level are poised to wipe out thousands of fruit-, candy- and dessert-flavored vapes that have attracted teens, experts who study tobacco policy fear the scattershot approach of the clampdown could have damaging, unintended consequences, including driving adults who vape back to cigarette smoking, which remains the nation’s leading preventable cause of death (Source: “Clampdown on vaping could send users back toward cigarettes,” Associated Press via ABC News, Oct. 5, 2019).

“This could take us from potentially the single biggest improvement in public health in the United States toward a public health disaster in which cigarettes continue to be the dominant nicotine product,” said Jonathan Foulds, an addiction researcher and tobacco specialist at Penn State University.

The policy debate underscores the challenge of finding the right regulatory scheme for e-cigarettes, products for which there is little high-quality research.

More than 30 countries prohibit vaping products. In contrast, the United Kingdom has fully embraced them as a public health tool, urging doctors to promote them to help smokers quit. The U.S. FDA has been struggling to find the right approach since it gained authority over e-cigarettes in 2016.

Further complicating the picture is the fact that no e-cigarette brand has yet been shown to help smokers quit in rigorous studies. But large-scale surveys suggest smokers who use e-cigarettes daily are up to six times more likely to quit than those who don’t use them.

About 25% of high school seniors surveyed this year said they vaped nicotine in the previous month, up from about 21% the year before (Source: “Teen vaping of nicotine jumped again this year, survey finds,” Associated Press, Sept. 18, 2019).

The University of Michigan study was published online Wednesday by the New England Journal of Medicine. Researchers surveyed more than 42,000 students across the country in grades 8, 10 and 12.

The study also found cigarette smoking declined in high school seniors, from about 8% to 6%. The researchers have not reported how many students said they vaped marijuana.

A government survey released last week showed similar trends.

The Trump administration and the Ohio Department of Health both shared new plans to reduce youth vaping, amid an urgent public health investigation into 450 cases of lung illness across the U.S. associated with e-cigarettes (Source: “Ohio to spend $4.1M on initiatives aimed to fight youth vaping,” Dayton Daily News, Sept. 11, 2019).

Dr. Amy Acton, director of the Ohio Department of Health, announced $4.1 million in new initiatives to prevent youth vaping. President Trump said Wednesday that his administration is working on a plan to ban all non-tobacco-flavors from vaping products.

State and local public health officials in Ohio have confirmed that 10 reports of severe pulmonary illness are likely due to vaping and are investigating an additional 14 reports of illness. In 33 states, the CDC says that it’s aware of more than 450 possible cases of severe pulmonary illness after vaping and six deaths.

The DeWine administration has already worked on several initiatives to curb teen vaping. This includes raising the purchase age to 21 starting Oct. 17 and placing an excise tax on e-cigarettes, which in the past were not subject to an excise tax. Raising the price of tobacco through an excise tax is an evidence-based way to reduce consumption.

Gov. Gretchen Whitmer of Michigan said Wednesday that her state would be the first to outlaw the sale of flavored e-cigarettes, part of a national crackdown on vaping amid a recent spike in illnesses tied to the products (Source: “Amid Vaping Crackdown, Michigan to Ban Sale of Flavored E-Cigarettes,” New York Times, Sept. 4, 2019).

Whitmer said the decision came in response to increased e-cigarette use among teenagers and marketing that she said targeted youths.

The move in Michigan is part of a wave of growing pressure from politicians around the country for more regulation of e-cigarettes and their use by teenagers. Several state attorneys general have called for the federal government to ban flavored e-cigarettes, and bills to stop sales of flavored vaping products have been introduced in California and Massachusetts.

In recent weeks, public health agencies have reported a number of serious illnesses believed to be tied to vaping, including a death in Illinois, raising questions about the products’ safety at any age. This week, Oregon health officials said they were investigating the death of another person, who had used a vaping device containing cannabis. The health department in Milwaukee and the Illinois attorney general have issued statements urging people not to use e-cigarettes. This year, San Francisco became the first American city to ban the sale of the products.