Up in Smoke: Tobacco Legislation Policy Dynamics Are Changing

December 23, 2021 by Alec Stone MA, MPA, Former ONS Director of Government Affairs and Advocacy

President Obama signing the Family Smoking Prevention and Tobacco Control Act of 2009

Before clinical trials proved otherwise, physicians hailed (https://tobacco.stanford.edu/) cigarettes’ therapeutic benefits in black-and-white television commercials and old-time newspaper ads, such as easing tension and enhancing cognition. But as a popular cigarette slogan (https://historydaily.org/youve-come-a-long-way-baby-virginia-slims-and-the-womens-lib-movement) from the 1970s suggests, we’ve “come a long way, baby!” In the 1950s, researchers began publishing study findings implicating (https://cebp.aacrjournals.org/content/23/1/32) smoking as a cause of lung cancer. Today, the evidence (https://www.drugabuse.gov/publications/research-reports/tobacco-nicotine-e-cigarettes/nicotine-addictive) is conclusive: nicotine is addictive and damaging to a person’s health.

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. Everyone can play an important role in protecting (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html) our nation’s young people from the risks of e-cigarettes.

Former U.S. Surgeon General Jerome Adams, MD, MPH

As Public Health Behaviors Change, Oversight Does Too

After the first U.S. surgeon general report on smoking published in 1964, health legislation focused (https://www.cdc.gov/tobacco/data_statistics/by_topic/policy/legislation/index.htm) on requiring warning labels, restricting advertising, and limiting undesired secondhand exposure, but federal oversight was relatively limited. Then in the early 2000s, researchers conducting time-series analyses began to report (https://journals.sagepub.com/doi/10.1177/0044118X07308070) an increase in youth smoking. Congress responded with bipartisan support for a wave of legislation to curtail new and underage smokers, and the Family Smoking Prevention and Tobacco Control Act (https://www.congress.gov/bill/111th-congress/house-bill/1256) of 2009 finally gave the U.S. Food and Drug Administration (FDA) oversight jurisdiction for tobacco marketing, distribution, and use. Tobacco sales correspondingly fell, particularly among youth.

So Big Tobacco introduced new products: e-cigarettes, flavored tobacco, and vaping devices. The industry manipulated the statutory language, suggesting that the products could be used as stepdown therapies for smoking cessation strategies. However, the products are particularly appealing to underage users, and they are still harmful to health. Many users don’t understand that a single e-cigarette cartridge is the equivalent of 20 traditional cigarettes. According to the Centers for Disease Control and Prevention (CDC), “Approximately two-thirds of JUUL users aged 15–24 do not know that JUUL always contains nicotine (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html).” In 2018, the U.S. surgeon general declared (https://www.cdc.gov/tobacco/basic_information/e-cigarettes/surgeon-general-advisory/index.html) that youth smoking had become a national epidemic.

Following the Letter and Intent of the Law

Part of the Family Smoking Prevention Act enhanced federal regulatory oversight of the tobacco industry. FDA’s Center for Tobacco Products worked with the smoking cessation community to develop an aggressive approach to educate decision­ makers about the new devices. “FDA continues to take action against those who sell or target e-cigarettes and e-liquids to kids, as seen just this year by the denial of more than one million premarket applications for flavored electronic nicotine delivery system products,” Center for Tobacco Products Director Mitch Zeller said (https://www.fda.gov/news-events/press-announcements/youth-e-cigarette-use-remains-serious-public-health-concern-amid-covid-19-pandemic) in September 2021. “It is critical that these products come off the market and out of the hands of our nation’s youth.”

A leader in the smoking advocacy community is the Campaign for Tobacco Free Kids, of which ONS is a coalition member. In a September 2021 letter to Acting FDA Commissioner Janet Woodcock, MD, the campaign and six other national health and medical organizations wrote (https://www.tobaccofreekids.org/assets/content/what_we_do/federal_issues/fda/regulatory/2021_09_24_Letter-FDA-Deny-PMTAs-Flavored-E-Cigs.pdf), “We urge FDA to expedite decisions on premarket tobacco product applications submitted for all non–tobacco-flavored e-cigarette products, and promptly deny those applications, including those for menthol-flavored products, based on the accumulated scientific evidence of the adverse impact of those products on public health.”

America Needs to Take Action

The plea came within days of a joint FDA-CDC report on youth smoking, which demonstrated a devastating increase from 2019–2021. “Among youth who currently used e-cigarettes, 43.6% of high school students and 17.2% of middle school students reported using e-cigarettes on 20 or more of the past 30 days. Also among current (https://www.fda.gov/news-events/press-announcements/youth-e-cigarette-use-remains-serious-public-health-concern-amid-covid-19-pandemic) users, more than 1 in 4 (27.6%) high school students and about 1 in 12 (8.3%) middle school students who used e-cigarettes used them daily.” And the numbers represent today’s usage, during the COVID-19 coronavirus pandemic. Researchers have linked (https://www.who.int/news-room/commentaries/detail/smoking-and-covid-19) smoking to increased severity of the disease and its symptoms.

“The FDA-CDC report shows that even during the COVID-19 pandemic, e-cigarette use among youth remains a serious public health concern,” Karen Hacker, MD, MPH, director of CDC’s National Center for Chronic Disease Prevention and Health Promotion, said (https://www.fda.gov/news-events/press-announcements/youth-e-cigarette-use-remains-serious-public-health-concern-amid-covid-19-pandemic). “It’s critical we continue working together to protect young people from the risks associated with tobacco product use, including e-cigarettes. Our public health efforts include CDC’s National and State Tobacco Control Program, and resources for educators, parents and providers to warn youth about tobacco products and help them quit.”

ONS Perspective

The tobacco industry has leveraged technology, social media influencers, and advertisers to entice a new generation of smokers. Nurses, who were already leaders in advocacy against tobacco use, are finding the tide overwhelming. With limited hospital capacity for anything—like lung cancer—other than patients with COVID-19 occupying staff resources, greater health concerns have overshadowed legislative work to restrict tobacco’s marketing, sale, and distribution to underage users. Perhaps this was exactly what Big Tobacco needed to regain its influence.

Now, more than ever, oncology nurses must educate about the perils of tobacco use. Read ONS’s position statement on use of e-cigarettes and vaping (https://www.ons.org/make-difference/ons-center-advocacy-and-health-policy/position-statements/e-cigarettes-and-vaping), and join us in advocacy for the smoking cessation movement.

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