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Correspondence - #30
Orozco, Norma From:Lynda Barbour <lynda.barbour@cancer.org> Sent:Tuesday, November 16, 2021 2:49 PM To:eComment Subject:Comments for 11/16/21 Thank you for discussion this very important topic to end the sale of Flavored tobacco in Santa Ana. Our families are counting on your action to end the sale of ALL Flavored tobacco products In our work at the American Cancer Society Cancer Action Network, we often meet grieving families who have lost loved ones to tobacco-related diseases like lung cancer, bladder cancer, and cancers in oral cavities. These diseases might have been prevented if it were not for the victim being addicted to tobacco at a young age. For many, the lure of flavored products, like menthol, got them to try smoking or dipping, and then that lure became a trap; menthol anesthetized the throat, and sweet flavors masked the harsh taste. They were soon addicted and many tried multiple times to quit this habit. Unfortunately, it was too late for them. But it is not too late to help youth to never become addicted. The City can remove the lure of all flavored tobacco products, including vapes and any nicotine based product, by removing them from the shelves of your city. This reduces access, and limits exposure of product promotion; this reduces the chance that young people will EVER start. You can save lives with your action. Thank you! Lynda Barbour Lynda Barbour, MPH Senior Government Relations Director, So.California & Grant Program 619.682.7416 | m: 619.742.4861 | f: 619.296.0928 American Cancer Society Cancer Action Network, Inc. fightcancer.org | 1.800.227.2345 This message (including any attachments) is intended exclusively for the individual to whom it is addressed and may contain proprietary, protected, or confidential information. If you are not the named addressee, you are not authorized to read, print, copy, or disseminate this message or any part of it. If you have received this message in error, please notify the sender immediately. 1 Dear Honorable Mayor and City Council, My name is Atticus O'Daniel and I am the Health Navigator at the LGBTQ Center OC. Tonight I want to share with you some information on how flavored tobacco is harming youth, especially LGBTQ+ youth. According to the Truth Initiative, 19% of U.S. LGB high school students smoke cigarettes, which is nearly double the rate of heterosexual students, while 31 % of transgender youth smoke cigarettes. Additionally, More than twice as many LGB students in grades nine through 12 have smoked a cigarette before the age of 13, compared to their heterosexual peers. LGB students also smoke more frequently. LGBTQ youth are faced with more hardship, adversity, and discrimintation than their heterosexual peers. This stress, and the desire to create community and safety for one another, drive many to start using tobacco products as a way to cope. Flavored tobacco products, especially e-cigarettes and menthol flavored products, are incredibly popular with youth all over the U.S. According to the CDC, 86.4% of U.S. middle and high school students who currently use tobacco have used a flavored product, 86.4% of current e-cigarette users have used a flavored e-cigarette, and 86.6% of current cigar users have used a flavored cigar. According to the Truth Initiative, flavored products are designed to be more appealing to young people, which makes it easier to initiate and sustain tobacco use because it masks the taste of tobacco. The top reasons why young people begin using e-cigarettes are because they're curious, a peer or family member uses one, and the amount and appealing flavors. There are currently over 15,000 flavors for e-cigarettes on the market and 81 % of them are designed to be sweet. According to the CDC, they contain 70 of the same cancerous causing chemicals that are in traditional tobacco smoke, such as formaldehyde and acetone. They also contain ultrafine particles that penetrate deep into the lungs, damaging them in the process. E-cigarettes contain so much nicotine that their toxicity levels are similar to or even higher than that of cyanide. Nicotine on the young brain severely impacts mood, decision making skills, memory, and anxiety. According to the Orange County Health Care Agency, recent data shows that out of the 160 stores in Santa Ana that were surveyed, 53% sell individually wrapped cigarillos & 48% sell vaping products. Additionally, more than 32% of stores have tobacco ads placed at "kid-level"(under three feet) or are placed near kid -friendly items, such as candy or toys. In the city of Santa Ana, there are 32 within 500 feet of a school and there are 93 within 1,000 feet of a school. I want to thank you for everything you have done for your community members so far. We know you value young people's health, wellness, provide opportunities for them to succeed, and so much more. I hope you consider a solution that will protect your young community members from the harms of flavored tobacco products, which will in turn, provide them a significant chance of living happy, healthy lives. November 15, 2021 Re: Flavored Tobacco Products and OUR KIDS Dear Honorable Mayor and Council Members As two cofounders of Parents Against Vaping E-cigarettes (PAVe), a national organization founded in 2018 by three moms as a grassroots response to the youth vaping epidemic, we write today to express our strong support for ending the sale all flavored tobacco products in Santa Ana, with no exemptions. PAVe's passionate parent volunteers have been advocating for flavor -ban legislation not only in Santa Ana but across California, participating in successful legislative campaigns in San Francisco (Proposition Q in Sacramento and the County of Los Angeles (a ban on all flavored tobacco products); and at the state level where we helped pass SB 793, which is now on hold due to Big Tobacco's despicable referendum. We are grateful to serve as important partners for California's county, city, and state anti -tobacco coalitions. According to the 2020 National Youth Tobacco Survey (NYTS), 3.6 million young people are regularly vaping, and the research has proven that flavors are hooking our kids. The latest figures show that 8 out of 10 teens who vape choose flavors. With 40% of high-school users using an e-cigarette on 20 or more days out of the month, we must take action immediately to protect these teens from becoming an entire generation of nicotine addicts. This issue is made even more urgent in light of COVID; a recent Stanford -led study reports that teens who vape are 5-to-7 times more likely to contract the virus. And that's why it is essential that the Santa Ana end the sale of all flavored tobacco with no exemptions, to protect all kids from the predatory behavior of Big Tobacco, an industry that has historically used flavors to target young people. Meanwhile, SB 793 was challenged by a tobacco -industry -funded ballot initiative and is delayed in its implementation by one or two years, if it gets implemented at all. We need cities like Santa Ana to take strong action to prevent California's kids not only from dangerous flavored products but from becoming Big Tobacco's next generation of lifetime customers. That's why we urge you to immediately end the sale of all flavored tobacco products with no exemptions by matching the strong protections already passed in many other Southern California municipalities. SB 793, if it survives the referendum, provides a floor, but not a ceiling, for a local ordinance. You can, and should, go further. The 2020 federal guidance, which banned flavors for POD based systems (like JUUL) but left menthol POD based systems on the market and allowed flavored liquids for refillable systems to stay, created an enormous loophole for flavored disposable e-cigarettes. Use of disposable products, the teen favorite, has increased by 1000% among teens who vape. And, among teens who vape, almost 40% use menthol flavor, a figure made more disturbing by the fact that it does not include teens who use mentholated "iced" flavors. For these reasons we are proud to advocate for a strong TRL that includes a comprehensive flavor ordinance in Santa Ana. Please provide the kids of Santa Ana the same protections enjoyed by the kids many other surrounding municipalities. Should you have any questions about our position, please do not hesitate to contact PAVe Co - Founders Dorian Fuhrman and Meredith Berkman at (646) 838-7718. Sincerely, Dorian Fuhrman and Meredith Berkman Co Founders PAVe www.parentsagainstvaping.org Orozco, Norma From: Rodriguez, Yaneth <ylr@med.usc.edu> Sent: Monday, November 15, 2021 1:23 PM To: eComment, Sarmiento, Vicente; Mendoza, Nelida; Bacerra, Phil; Penaloza, David; Lopez, Jorge (SAPD); Penaloza, David; Phan, Thai; Hernandez, Johnathan Cc: Lourdes Baez Conde; Jessica L. Barrington-Trimis; 'ylr@usc.edu' Subject: Info & Education for 11/16/21 Agenda #30 Discussion Ordinance to Ban the Sale of Flavored Tobacco Products Attachments: Flavor and E-cigarette _Info Sheet_ 05.22.19 (updated w logo) FINAL PDF.pdf; Tobacco Retail Licensing and Youth Product Use.pdf Dear Mayor and City Council Members of the City of Santa Ana, I am writing in regards to agenda item #30 "Discuss and Consider Directing City Manager to Direct Staff to Introduce an Ordinance to Ban the Sale of Flavored Tobacco Products." As you consider the health of the community, in particular during this unprecedented time with COVID-19, you are also thinking of the health of future generations. Attached is an information sheet which contains research findings from the University of Southern California's Tobacco Center of Regulatory Science (USC TCORS). I hope this information is useful in your consideration of prohibiting the sale of Flavored tobacco Products. A main research point I would like to highlight is that a strong comprehensive ordinance to regulate e-cigarettes, flavored, and menthol tobacco products has tremendous potential to substantially reduce youth -use of tobacco products including e-cigarettes. A Southern California research study showed that strong a tobacco retail license and enforcement preventing sales to minors was associated with lower rates of youth and adult initiation of combustible and e-cigarette use. A comprehensive ban on the sale of flavored tobacco products would include traditional combustible menthol cigarettes and cigars, as well as chewing tobacco and flavored hookah. Current research suggests that it is important to consider the overall impact of e-cigarette and tobacco use on all segments of the population; however, the weight of the evidence points to a far more detrimental effect on youth. We hope that this research can educate and inform your decisions. Please let me know if you have any questions our team may be able to answer. Thank you, Yaneth Yaneth L. Rodriguez, MPH Center for Health Equity in the Americas Department of Population and Public Health Sciences Keck School of Medicine of USC University of Southern California 2001 N. Soto St. Office 302N; MC 9239 Los Angeles, CA 90032 ylr@usc.edu Keck School of Medicine of USC Flavor and Menthol Tobacco Products and E-cigarettes Since e-cigarettes have come to the Southern California market, the University of Southern California's expert faculty and research staff at the Keck School of Medicine have focused on exploring the potential impacts of e- cigarettes and flavored tobacco products on the general population as well as vulnerable populations, such as adolescents and young adults. E-cigarettes are drawing in new youth smokers who would have otherwise been unlikely to smoke combustible cigarettes. • Two studies examining trends in tobacco use over time have shown that youth with no history of cigarette use and who are otherwise unlikely to have smoked combustible cigarettes are initiating e- cigarettes (1, 2). • Cartoon images and non-traditional flavors and unique flavor names are appealing to youth and increase youth interest in e-cigarettes; most youth report initiation and continued use with flavored e-cigarettes (3-7) * • A study from Southern California youth reported that the most common reason for use of e-cigarettes are the availability of e-cigarettes in a wide variety of flavors (i.e. fruit, dessert, mint, etc.) (7, 8). • E- cigarette companies actively market and re -post flavor -related information on social media at a much higher rate than non -flavor related posts (9). • The availability of flavored e-cigarettes has been tied not only to initiation but also to continued use among youth, and a majority of youth reported that they would no longer use e-cigarettes if flavors were not available (6, 11).t • JUUL and other low profile products that resemble computerflash drivers thwart efforts to enforce smoking policy by providing easy concealment from authorities (3). • A content analysis of customer reviews of 103 vape shops revealed that the most important attribute of a shop was related to their flavor selection (10). • 17.3% of California high school students reported being a current user of an electronic vapor product, versus 13.2% national (12). t There are clear health -related consequences of e-cigarette use among youth. • Youth who use e-cigarettes are 3 times as likely as those who have never used e-cigarettes to begin smoking combustible cigarettes (13-19)*. • Youth who use e-cigarettes and subsequently begin smoking cigarettes follow a similar trajectory into more frequent cigarette smoking as their peers who began smoking cigarettes without using e- cigarettes first (1, 2). • A study among Southern California Hispanic young adults reported that using e-cigarettes increased the likelihood of transitioning from a non -user to user of cigarettes or marijuana and was not associated with smoking cessation (38). • Level of nicotine in e-cigarettes has been associated with higher frequency of subsequent cigarette smoking (36). • Exposure to nicotine in e-cigarettes is addictive (14-19)*. • E-cigarettes can have adverse respiratory effects (20)*. • E-liquids contain many harmful chemicals (i.e. acetals, formaldehyde, cinnamaldehyde, diacetyl, benzaldehyde, etc.) that are used to create the wide variety of flavors (21, 22). t tResearch conducted outside of USC *Both USC and Outside Research Updated 5/22/2019 Keck School of Medicine of USC Flavor and Menthol Tobacco Products and E-cigarettes There is inconsistent evidence regarding the use of e-cigarette as a cessation tool among youth, young adult, and adult smokers. • Studies have shown that many cigarette smokers, after using e-cigarettes, are likely to remain cigarette smokers rather than transitioning to e-cigarettes or quitting smoking, and this effect may be particularly salient in Hispanic young adults (19, 23-25)*. • More recently, a single clinical trial has shown that regular e-cigarette use alongside counseling services increased cessation relative to other cessation products among participants in England; similar findings have not been observed in the US to date (37). t Menthol products makes smoking cessation more difficult and are disproportionately marketed to vulnerable populations such as ethnic minorities. • Among adult smokers in California, 18% of white cigarette smokers smoke menthol cigarettes where as 70% of African American cigarette smokers use menthol. Additionally, almost 50% of LGB smokers use menthol cigarettes compared to 28%of straight smokers (31). t • Among Hispanic/Latino current adult smokers in the US, 46% smoke menthol cigarettes (27). t • Among Hispanic/Latino young adult current smokers (aged 18-25) in the US from 2008 to 2010, 47.3% smoked menthol cigarettes (28). t • Between 2008-2010 and 2012-2014, the largest increase in menthol cigarette use among race/ethnic groups was in found in Hispanic smokers (rising 9.8 percentage points) (29). t • The use of flavored products, such as menthol cigarettes, makes cessation more difficult (26). t • Studies have displayed negative associations among menthol cigarette use and successful cessation in Hispanic communities (30). t • Approximately 90% of all cigarettes have menthol in them regardless of if they are advertised as menthol cigarettes or not (34). t Implementing enforceable regulations can prevent youth initiation of e-cigarettes and other tobacco products. • In Southern California, strong enforcement preventing sales to minors was associated with lower rates of youth and adult initiation of combustible and e-cigarette use (35). Communities that had tobacco retail licenses with sufficient fees to conduct enforcement efforts (e.g., sting operations) had lower rates of youth cigarette and e-cigarette use. • A retail license ordinance to regulate e-cigarettes, flavored, and menthol tobacco products in Los Angeles County has tremendous potential to substantially reduce youth -use of tobacco products including e-cigarettes (35). • The availability of e-cigarettes in flavors, and current location of retailers in close proximity to areas where youth congregate increases use of these products among young people (35); policies to reduce availability of these products across the community will likely have a substantial impact on youth use of tobacco products. Current research suggests that it is important to considerthe overall impact of e-cigarettes on all segments of the population; however, the weight of the evidence points to a far more detrimental effect on youth. We hope that this research can educate and inform future decision -makers. For additional information, contact Yaneth Rodriguez at vlr@usc.edu tResearch conducted outside of USC *Both USC and Outside Research Updated 5/22/2019 Keck School of Medicine of USC Flavor and Menthol Tobacco Products and E-cigarettes References 1. Barrington-Trimis JL, Urman R, Leventhal AM, Gauderman WJ, Cruz TB, Gilreath TD, et al. E-cigarettes, cigarettes, and the prevalence of adolescent tobacco use. Pediatrics. 2016;138(2). https://www.ncbi.nlm.nlh.gov/pmc/articles/PMC4960723/pdf/PEDS 20153983.pdf 2. Leventhal AM, Strong DR, Sussman S, Kirkpatrick MG, Unger JB, Barrington -TrimisJL, et al. Psychiatric comorbidity in adolescent electronic and conventional cigarette use. Journal of psychiatric research. 2016;73:71-& 3. Barrington-Trimis JL, Leventhal AM. Adolescents' use of "Pod Mod" e-cigarettes-urgent concerns. New England Journal of Medicine. 2018;379(12):1099-102. 4. Jackler RK, Ramamunhi D. Unicorns cartoons: marketing sweet and creamy a -juice to youth. Tobacco control. 2017;26(4):471-5. 5. Kong G, Morean ME, Cavallo DA, Camenga DR, Krishnan -Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine & tobacco research. 2014; 17(7):847-54. 6. Bald KW, Kong G, Cavallo DA, Camenga DR, Krishnan -Sarin S. Reasons for trying e-cigarettes and risk of continued use. Pediatrics. 2016;138(3). 7. Goldenson NI, Kirkpatrick MG, Barrington-Trimis JL, Pang RD, McBeth JF, Pentz MA, et al. Effects of sweet flavorings and nicotine on the appeal and sensory properties of e-cigarettes among young adult vapers: Application of a navel methodology. Drug and alcohol dependence. 2016; 168:176-80. 8. Hong H, McConnell R, Liu F, Unman R, Barrington-Trimis JL. The impact of local regulation on reasons for electronic cigarette use among Southern California young adults. Addictive behaviors. 2019;91:253-8. 9. Chu K-H, Unger JB, Cruz TB, Soto DW. Electronic cigarettes on twitter -spreading the appeal of flavors. Tobacco regulatory science. 2015;1(1):36-41. 10. Sussman S, Garcia R, Cruz TB, Baemonde-Garbanati L, Pentz MA, Unger JB. Consumers' perceptions of vape shops in Southern California: an analysis of online Yelp reviews. Tobacco induced diseases. 2014; 12(1):22. 11. Harrell M, Weaver S, Loukas A, Creamer M, Marti C, Jackson C, et al. Flavored e-cigarette use: Characterizing youth, young adult, and adult users. Preventive medicine reports. 2017; 5:33-40. 12. https://nccccdc.gov/vouthonline/App/Results.aspx?TT=G&OUT=O&SID=HS&QID=QQ&LID=CA&YID=2017&LID2=XX&YID2=2017&COL=T&ROW1=N&ROW2=N&HT=QQ &LCF=LL&FS=Sl&FR=Rl&FG=Gl&FSL=Sl&FRL=Rl&FGL=Gl&PV=&TST=True&C1=CA2017&C2=XX2017&QP=G&DP=1&VA=CI&CS=N&SYID=&EYID=&SC=DEFAULT&SO= ASC&PF=1 13. Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta -analysis. JAMA pediatrics. 2017;171(8):788-97. 14. Barrington-Trimis JL, Unman R, Berhane K, Unger JB, Cruz TB, Pentz MA, et al. E-cigarettes and future cigarette use. Pediatrics. 2016;138(1). 15. Leventhal AM, Stone MD, Andrabi N, Barrington-Trimis 1, Strong DR, Sussman S, et al. Association of e-cigarette vaping and progression to heavier patterns of cigarette smoking. Jama. 2016;316(18):1918-20. 16. Unger JB, Soto DW, Leventhal A. E-cigarette use and subsequent cigarette and marijuana use among Hispanic young adults. Drug and alcohol dependence. 2016;163:261-4. 17. Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, Sussman S, Riggs NR, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. Jama. 2015;314(7):700-7. 18. Miech R, Patrick ME, O'malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. Tobacco control. 2017;26(e2):e106-e11. 19. Barrington-Trimis JL, Kong G, Leventhal AM, Liu F, Mayer M, Cruz TB, et al. E-cigarette Use and Subsequent Smoking Frequency Among Adolescents. Pediatrics. 2018;142(6). 20. McConnell R, Barrington-Trimis JL, Wang K, Unman R, Hong H, Unger 1, et al. Electronic cigarette use and respiratory symptoms in adolescents. American journal of respiratory and critical care medicine. 2017;195(8):1043-9. 21. Hanna C Erythropel, Sairam V Jahba, Tamara M DeWinter, Melissa Mendizabal, Paul T Anastas, Sven E Jordt, Julie B Zimmerman. Formation of flavorant-propylene Glycol Adducts With Novel Toxicological Properties in Chemically Unstable E-Cigarette Liquids. Nicotine & Tobacco Research, 2018; DOI: 10.1093/ntr/ntvl92 22. Tierney PA, Karpinski CD, Brown JE, et al. Flavour chemicals in electronic cigarette fluids. Tobacco Control. 2016;25: e10-e15. 23. McRobbie H, Bullen C, Hartmann -Boyce 1, Hajek P. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of systematic reviews. 2014(12). 24. Hajek P, Phillips -Waller A, Przulj D, Fascia F, Myers Smith K, Bisal N, et al. A randomized trial of e-cigarettes versus nicotine -replacement therapy. New England Journal of Medicine. 2019;380(7):629-37. 25. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real -world and clinical settings: a systematic review and meta -analysis. The Lancet Respiratory Medicine. 2016;4(2):116-28. 26. https://www.changelabsolutions.ore/publications/california-comprehensive-tobacco-retailer-licensing 27. https://www.fda.gov/tobaccoproduas/labeling/productsingredientscompments/ucm20l9416.htm 28. https://truthinitiative.org/news/tobacco-social-justice-issue-racial-and-ethnic-minorities 29. Villanti AC, Mowery PD, Delnevo CD, et al Changes in the prevalence and correlates of menthol cigarette use in the USA, 2004-2014 Tobacco Control 2016;25:ii14-ii20. 30. Keeler, C., Max, W., Yerger, V., Yao, T., Ong, M. K., & Sung, H. Y. (2016). The Association of Menthol Cigarette Use With Quit Attempts, Successful Cessation, and Intention to Quit Across Racial/Ethnic Groups in the United States. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco, 19(12),1450-1464. doi:10.1093/ntr/ntw215 31. Behavioral Risk Factor Surveillance System 2013-2015. Sacramento, CA: California Department of Public Health. 32. Yerger V.B. and R. E. Malone, African American leadership groups: smoking with the enemy. Tobacco Control, 2002. 11(4): p. 336-345. 33. Myron Levin, Lorillard, other tobacco companies use politics to protect menthol brands, in Fairwarning. November 18, 2015, News and Record: Greensboro, North Carolina. 34. Wickham, R., Focus: Addiction: How Menthol Alters Tobacco -Smoking Behavior: A Biological Perspective. The Yale Journal of Biology and Medicine, 2015. 88(3): p. 279. 35. Astor RL, Urman R, Barrington-Trimis JL, Berhane K, Steinberg J, Cousineau M, et al. Tobacco Retail Licensing and Youth Product Use. Pediatrics. 2019;143(2):e20173536. 36. Goldenson, N. I., Leventhal, A. M., Stone, M. D., McConnell, R. S., & Barrington-Trimis, J. L. (2017). Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA pediatrics, 171(12), 1192-1199. 37. Rigotti, N. A., Chang, Y., Tindle, H. A., Kalkhoran, S. M., Levy, D. E., Regan, S.,... & Singer, D. E. (2018). Association of E-Cigarette Use With Smoking Cessation Among Smokers Who Plan to Quit After a Hospitalization. Annals of internal medicine, 168(9), 613-620. 38. Unger, J. B., Soto, D. W., & Leventhal, A. (2016). E-cigarette use and subsequent cigarette and marijuana use among Hispanic young adults. Drug and alcohol dependence, 163, 261-264. tResearch conducted outside of USC *Both USC and Outside Research Updated 5/22/2019 Tobacco Retail Licensing and Youth Product Use Roee L. Astor, MPH o Robert Urman, PhD,a Jessica L. Barrington -Trim is, PhD? Kites Berhane, PhD? Jane Steinberg, PhD,- Michael Cousineau, PhD, -Adam M. Leventhal, PhD, -Jennifer B. Unger, PhD, - Tess Cruz, PhD,- Mary Ann Portz, PhDo Jonathan M. Samet, MD, MS,b Rob McConnell, MOO BACKGROUND: Restricting youth access to tobacco is a central feature of US tobacco regulatory policy, but impact of local tobacco retail licensing (TRL) regulation on cigarette smoking rates remains uncertain. Effects of TRL on other tobacco product use and use as adolescents reach the age to legally purchase tobacco products has not been investigated. METHODS: Prevalences of ever and past 30-day cigarette, electronic cigarette (e-cigarette), cigar, and hookah use were assessed in a survey of a cohort of 1553 11th- and 12th-grade adolescents (mean age: 17.3 years); rates of initiation were evaluated 1.5 years later. An American Lung Association (2014) youth access grade was assigned to each of 14 political jurisdictions in which participants lived on the basis of the strength of the local TRL ordinance. RESULTS: At baseline, participants living in 4 jurisdictions with "A" grades (ie, with most restrictive ordinances) had lower odds of ever cigarette use (odds ratio [OR] 0.61; 95% confidence interval [Cl] 0.41-0.90) and of past 30-day use (OR 0.51; 95% Cl 0.29-0.59) than participants in 10 D- to F-grade jurisdictions. At follow-up at legal age of purchase, lower odds of cigarette use initiation (OR 0.67; 95% Cl 0.45-0.99) occurred in jurisdictions with stronger TRL policy. Lower odds of e-cigarette initiation at follow-up (OR 0.74; 95% Cl 0.55-0.99) and of initiation with past 30-day use (OR 0.45; 95% Cl 0.23-0.90) were also associated with better regulation. CONCLUSIONS: Strong local TRL ordinance may lower rates of cigarette and e-cigarette use among youth and young adults. 0 V WHAT'S KNOWN ON THIS SUBJECT: Restricting youth access to tobacco has long been a central feature of "Department of Preventive Medicine, Keck School of Medicine, UnivenutyofSouthern California Los Angeles, US tobacco regulatory policy, butthe Impact of local California; and °Colorado School of Public Health, University ofColomdo Anschutz Medical Center, Aurora, Colorado tobacco retail licensing regulation on electronic cigarette use rates remains uncertain. Or McConnell conceptualized and designed the study and reviewed and revised the manuscript; Mr Astor collected data on tobacco retail licensing in study communities, conducted a literature WHAT THIS STUDY ADDS: Strong local tobacco retail review, and drafted the manuscript; Or Urman conducted all data analyses; Drs Barrington-Trimis, licensing ordinances may lower rates of cigarette Berhane, Steinberg, Cousineau, Leventhal, Unger, Cruz, Pentz, and Samet provided advice on the and electronic Cigarette use among youth and analysis and interpretation of results and reviewed and provided guidance on the development of young adults. Success of regulations restricting the manuscript; and all authors approved the final manuscript as submitted youth access to Cigarettes and alternative tobacco 001: https://doi.org/10.1542/peds.2017-3536 products may depend on ensuring a robust Accepted for publication Oct 31, 2018 enforcement scheme. Address correspondence to Rob McConnell, MD, Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N Soto St, 230-1), Los Angeles, CA 90089. E-mail: rmcconne@usc.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 0 2019 by the American Academy of Pediatrics To cite: Astor RL, Urman R, Barrington-Trimis JL, at al. Tobacco Retail Licensing and Youth Product Use. Pediatrics. 2019;143(2):e20173536 Downloaded from www.aappublications.org/news by guest PEDIATRICS Volume 143, number 2, February 2019:e20173536 Most US states have had laws to restrict the sale of cigarettes to minors for decades.' Because there was widespread violation of these laws by tobacco vendors,' Congress passed the Synar Amendment to the Public Health Service Act in 1993,3 which required that states enact laws banning cigarette sales to minors and that they enforce such laws with compliance checks using undercover "decoys" posing as underage customers 4,s Enforcement of these youth access regulations is a central feature of US tobacco control programs. However, although compliance checks of vendors have been shown to reduce sales to minors, their effectiveness in reducing youth smoking rates is less certain, for example, because they may obtain cigarettes legally purchased by older friends.6.7 Key regulatory features that are reported to reduce both compliance violations and youth cigarette use include a mandatory tobacco retailer licensing fee to provide sustainable funding of undercover decoys to make at least 1 annual visit to each vendor and fines or penalties for violations.7,8 Low rates of vendor compliance checks, which occur annually at only a small fraction of tobacco vendors under existing state and federal enforcement programs,9.10 and inadequate penalties may explain why associations with youth smoking rates have not consistently been observed.? Within states, compliance enforcement may vary markedly on the basis of local ordinances that provide funding to do so. Given the expense involved in enforcement and the lack of expert consensus on its benefits, additional studies are warranted to assess the effectiveness in reducing youth cigarette use. The impact of youth access restriction on the initiation of alternative tobacco products, such as electronic cigarettes (e-cigarettes), hookah, and cigars, has not been studied, although prevalence of ever using these products is high." An additional gap in understanding the effectiveness of youth tobacco access restriction is during the transition to the legal age of purchase. Most adult smokers historically have initiated cigarette use by age 18,11 which is the legal age of purchase in most states. There have been few prospective studies examining the effect of tobacco licensing and youth access restriction on cigarette and alternative tobacco product use during this transition to adult life. Among participants in the Southern California Children's Health Study, we evaluated whether youth living in jurisdictions with a strong tobacco retail licensing (TRL) ordinance had reduced prevalence of cigarette and other tobacco use, compared with participants in jurisdictions with a poor TRL ordinance. In addition, using prospectively collected data, we assessed the association of local ordinances with the initiation of tobacco product use during a cohort follow-up as youth reached 18 years of age, the age at which the sale of tobacco products was legal in California at the time of the study. METHODS Study Population Between January and June of 2014, a total of 209711th- and 12th-grade participants in the Southern California Children's Health Study (mean age: 17.3; SD: 0.6) completed self-administered questionnaires collecting detailed information about cigarette and alternative tobacco product use. Follow-up online questionnaire data were collected on 1SS3 participants (74%of the 2097 at baseline) as they reached 18 years of age, between January 201S and June 2016 (mean age: 18.8; SD: 0.6). Additional characteristics of the study sample have been described previously.13,14 Ethics Statement The study was approved by the University of Southern California Institutional Review Board. Parental written informed consent and child assent were obtained for all Children's Health Study participants <18 years of age. Participants age 18 or older provided written informed consent. Tobacco and Alternative Tobacco Product Use At each survey, participants were asked whether they had ever tried e-cigarettes, cigarettes, cigars, or hookah and the number of days each product was used in the past 30 days." Participants who had "never tried" a product (not "even 1 or 2 puffs") were classified as never users. Those reporting an age at first use of each tobacco product were classified as ever (lifetime prevalent) users of that product at baseline. Rates of initiation were calculated on the basis of a new report of use of a tobacco product at follow-up among participants not reporting use of that product at baseline. Both prevalent users and initiators of each tobacco product were further characterized on the basis of past 30-day use. Evaluation of Local Tobacco Regulatory Licensing to Reduce Youth Access There were 14 political jurisdictions with corresponding tobacco product ordinances across the 12 participating Children's Health Study communities. Four study jurisdictions were assigned an A grade on the basis of the 2014 American Lung Association (ALA) "Reducing Sales of Tobacco Products" to youth scale, which is used to evaluate the strength of the local TRL ordinance across California." An A grade required adequate annual retail license fees, which were paid by all tobacco retailers (including gas stations, convenience stores, larger grocery stores, and pharmacies), Downloaded from wwwnappublications.org/news by guest on May 7, 2019 ASTOR at al to cover the administration of an enforcement program and regular compliance checks in each store. An A grade also required (1) an annual renewal of this local license; (2) a provision that any violation of local, state, or federal law is a violation of the license; and (3) a graduated penalty system for violators, including financial deterrents such as fines or other penalties, including license revocation or suspension." The remaining study jurisdictions were assigned an F grade (8) or a D grade (1). An F grade indicated either (1) no local ordinance mandating a license fee or (2) a fee insufficient to fund administrative and compliance checks as well as none of the 3 other provisions for an A grade. The jurisdiction with the D grade had a licensing fee that was insufficient to cover administration and compliance checks, but ithad at least 1 of the other 3 provisions listed above that were needed for an A grade. The D and F communities were collapsed for data analysis, because the insufficient annual fee is a central feature of regulation to reduce youth access.7,11 No study jurisdiction in this sample had B or C grades corresponding to TRL policies of intermediate quality." ALA assigned grades to other categories of tobacco policy (smoke - free housing policy, smoke -free outdoor policy, and overall tobacco policy)." These policies, which are not specific to youth tobacco product access, were not associated with tobacco product use in this study, and results are not presented. Covariates Self-administered questionnaires completed by parents of participants were used to assess sociodemographic characteristics, including sex, ethnicity (Hispanic, non -Hispanic white, other), age at baseline, and parental education (completed high school or less, some college, or completed college or more). Statistical Analysis Unconditional logistic regression models were used to evaluate the associations of living in a jurisdiction with an ALA grade A versus D or F TRL ordinance with baseline ever and past 30-day use of cigarettes, e-cigarettes, hookah, cigars, or use of any of these tobacco products in separate models. Models were also fit to evaluate associations of ALA grade with the initiation of each product, with or without past 30-day use. In models used to evaluate the initiation of use of each tobacco product between baseline and follow-up, the sample was restricted to baseline never users of that product Odds ratios (ORs) and 95% confidence intervals (CIs) were used to estimate the association of each tobacco product use with an ALA grade. All models were adjusted for sex, ethnicity, highest parental education, and baseline age, factors that have been associated both with e-cigarette use and cigarette use in previous studies.13.14 Each tobacco product — specific model was also adjusted for a baseline history of use of any other tobacco product, because there was clustering of the tobacco product outcomes.13 A missing indicator category for covariates and any other tobacco product use was included where appropriate. Additionally, all models included a random effect for community to account for similarities among subjects within jurisdictions. In a sensitivity analysis, models were further adjusted for time between baseline and follow-up questionnaire completion. Statistical analyses were based on 2-sided hypotheses tested at a O.OS level of significance, using SAS 9.4 (SAS Institute, Inc, Cary, NC). RESULTS Of the 2097 participants, 31.1% (652) lived in a jurisdiction with an ALA 2014 TRL A grade, and 68.9% (1445) students lived in jurisdictions with D or F grades. Sex and ethnic distributions were similar in A and D or F jurisdictions, but students in A jurisdictions were more likely to come from less -educated households (Table 1). Unadjusted prevalence and initiation rates for each tobacco product were lower in jurisdictions with A than with D or F grades, with the exception of new initiation of hookah with past 30-day use. Initiation rates were substantial among never tobacco product users at baseline, in particular for e-cigarette use. Both prevalence and initiation rates of past 30-day tobacco product use generally did not exceed 10% for any product For baseline prevalence of ever and past 30-day use of cigarette and e-cigarette ever use, and to a lesser degree for prevalence of cigar use, jurisdictions with A grades had generally lower use rates than D or F jurisdictions (Supplemental Fig 3). However, within both grade groups, there was considerable variability in prevalence rates across jurisdictions for all tobacco products. Rates in individual jurisdictions had wide Cls (results not shown) because of small sample size. Rates of tobacco product initiation at follow-up were also generally quite variable across the jurisdictions within both A and D or F grades (Supplemental Fig 4). At baseline, participants living in the 4 jurisdictions with A grades had lower odds of ever using a cigarette (OR 0.61; 95% Cl 0.41-0.90) and of past 30-day use (OR 0.51; 95% Cl 0.29-0.89) than participants in 10 D- to F-grade jurisdictions, after adjusting for sociodemographic covariates and other tobacco product use at baseline (Fig 1). Living in A -grade jurisdictions was associated with lower odds of initiation of cigarette use between baseline and the follow-up questionnaire (OR 0.67; 95% Cl 0.45-0.99 [Fig 2]). The risks of Downloaded from www.aappublications.org/news by guest on May 7, 2019 PEDIATRICS Volume 143, number 2, February 2019 TABLE 1 Prevalence of Sociodemographic Characteristics, Lifetime, and Current (Last 30-Day) Use of Each Tobacco Product at Baseline and Rates of Product Initiation at follow-up Among Youth Residing in a Jurisdiction With ALA Reduced Tobacco Sales, Grade A or D or F Sex Male Female Ethnicity Hispanic white Non -Hispanic white Other Parent education Less than or equal to high school Some college College or more Prevalent ever tobacco product use at baseline Cigarette E-cigarette Hookah Cigars Any tobacco product Prevalent past 30-d tobacco product use at baseline Cigarette E-cigarette Hookah Cigars Any tobacco product Initiation of tobacco product use (between baseline and follow- up)b Cigarette E-cigarette Hookah Cigars Any tobacco product Initiation with past 30-d tobacco product use at fallow -up° Grade A Grade D or F N (%a) N (%a) 324 (49.7) 735 (50.9) 328 (50.3) 710 (49.1) 349 (53.5) 736 (50.9) 230 (35.3) 504 (34.9) 73 01.2) 205 04.2) 245 (41.3) 460 (34.3) 219 (36.9) 502 (37.4) 129 (21.8) 379 (28.3) 89 (13.7) 302 (21.0) 123 (19.0) 379 (26.4) 158 (24.3) 411 (28.6) 69 (10.6) 204 (14.2) 214 (32.9) 564 (39.2) 24 (3.7) 95 (6.6) 56016) 145(10.1) 62 (9.5) 162 (11.3) 21 (3.2) 55 (3.8) 107 (16.5) 267 (18.6) 52 (13.1) 156 (18.0) 92 (24.7) 235 (29.7) 55 (15.9) 146 (18.9) 49 (12.0) 158 (17.1) 85 (27.7) 198 (30) Cigarette 17 (4.3) 52 (6.0) E-cigarette 17 (4.7) 69 (8.9) Hookah 16 (4.7) 32 (4.2) Cigars 12 (2.9) 36 (3.9) Any tobacco product 24 (7.9) 78 (12.1) The denominator (852 in grade A. 1445 in grade D or F) varies because of missing values in covanates b Restricted to nonusers of each product (or of any tobacco product) at baseline. initiation of e-cigarettes (OR 0.74; 95% Cl 0.55-0.99) and of initiation with past 30-day use (OR 0.45; 95%CI 0.23-0.90) were also lower in A -grade than D- or F-grade jurisdictions. In sensitivity analyses adjusting for time since turning 18 at follow-up, there was no change in the protective effect estimate of living in awell-regulated (A -grade) jurisdiction (results not shown). Participants still living in their jurisdiction of origin at follow-up evaluation would have had consistent exposure to the same regulatory environment In this sample, there were stronger protective A -grade compared with D- or F-grade associations with cigarette and e-cigarette initiation at follow-up (and of initiation of e-cigarettes with past 30-day use) than in the entire sample (results not shown). The protective association of A -grade residence with initiation of cigar use was similar in magnitude to the association with cigarette and e-cigarette use but was not statistically significant DISCUSSION Central features of the ALA TRL grade include a licensing fee sufficient to fund compliance checks and enforcement of regulations prohibiting tobacco sales to minors and penalties for violating the law, features of TRL that have been reported to be necessary to reduce sales to and use by youth.? Compared with living in a jurisdiction with poor TRL policy, youth in a jurisdiction satisfying these criteria were less likely to smoke in high school. In a prospective follow-up of the cohort, the odds of initiation of e-cigarette use, with or without past 30-day use, and of initiation of cigarette use were also lower in well -regulated jurisdictions. Stronger associations among participants still living in their jurisdiction of origin at follow-up evaluation, with consistent exposure to the same regulatory environment throughout, also suggest that the benefits of good TRL policy extended both beyond cigarette use to e-cigarette use and into early adult life at age 18 when the sale of tobacco products was legal at the time of the study. The protective associations were large, with risk lower by one- third to a half in the strong compared with weak TRL jurisdictions (depending on the outcome). There has been uncertainty regarding the effects of youth access restrictions on cigarette use 6,7,16 Some authors of prospective studies in which age -specific prevalence of tobacco use was assessed before and after regulatory intervention to restrict youth access found reductions in cigarette use,17-10 but others found no benefit"," Authors of 1 review of studies that reported changes in smoking associated with youth access restrictions found no relationship of vendor compliance or of changes in vendor compliance, with smoking prevalence in a meta -analysis of available studies,6 perhaps because the restriction of commercial access resulted in a shift to social sources of cigarettes such as older friends or siblings. Authors of other observational studies have Downloaded from www.aappublications.org/news by guest on May 7, 2019 ASTOR et al 3.0 25 _ 2.0 U m 1.5 W a O 1.0 0.5 oe 11 • Lifetime use ♦ Past 30-day use Cigarettes E-cigarettes hookah Cigars Anytobacco FIGURE 1 Associations of prevalent lifetime and current (last 30-day) use of each tobacco product at baseline with residence in ALA Reduced Tobacco Sales grade A jurisdictions, compared with residence in grade D or F jurisdictions. Models were adjusted for sex, ethnicity, parental education, age at baseline, and for any other tobacco product use at baseline (except for any tobacco product use prevalence, which was compared with never users of any tobacco product) and included a random effect for jurisdiction. z ae 0 '<o N O 'o • Initiation ♦ Initiation with past 30 day use Cigarettes E-cigarettes Hookah Cigars Arytobacco FIGURE 2 Associations of initiation of use of each tobacco product between baseline and follow-up and of initiation and current (last 30-day) use, with residence in ALA Reduced Tobacco Sales grade A jurisdictions, compared with residence in grade D or F jurisdictions. Each model was restricted to nonusers of product at baseline. Models were adjusted for sex, ethnicity, parental education, age at baseline, and for any other tobacco product use at baseline (except for any tobacco product use initiation, which was compared with never users of any tobacco product at either baseline or follow-up) and included a random effect forjurisdiction. found reduced smoking rates in communities with youth access restrictions, but it was not clear that reduced access mediated the reduction in smoking rates.19,23 For example, sustained reductions in adolescent daily smoking rates were observed in Minnesota communities that were randomly assigned to intervention supporting community organizers to develop and promote good TLR ordinances, compared with nonintervention communities.20 However, it was not clear whether the observed reductions in smoking rates were due to youth access restrictions and improved vendor compliance or to other regulatory features resulting from the intervention, such as bans on vending machines and requirements for posted signs reporting age of sale policies, or for storing cigarettes behind the sales counter.17 Our results are broadly consistent with findings of a comprehensive review in which authors concluded that lower smoking rates occur if local TRL requires yearly compliance checks with effective enforcement 7 Our study is 1 of the few that assessed associations of TRL with both prevalence and initiation rates in a prospective assessment of the same participants during an adolescent period of known high incidence of initiation. The prospective cohort design of the study also provided the opportunity to examine the impact of TRL on legal tobacco product use by young adults. The reduced risk of initiation of cigarette and e-cigarette use at follow-up in jurisdictions with better TRL regulation (with effect estimates that were unaffected by adjusting for time since turning 18 at follow-up) suggests that regulation may have lowered initiation rates even after participants reached the age for legal purchase. Although most adult smokers historically first use cigarettes before age 18,12 in our cohort, rates of initiation of tobacco Downloaded from www.aappublications.org/news by guest on May 7, 2019 PEDIATRICS Volume 143, number 2, February 2019 product use were substantial, even in well -regulated jurisdictions. For example, in jurisdictions with an A grade, rates of initiation of cigarette and e-cigarette use during the follow-up period were 13.1% and 24.7%, respectively (from Table 1); these high rates of experimentation indicate a need for interventions to reduce initiation in this susceptible age window. An alternative explanation for the protective effects of better TRL policy is that the associations reflected broadly unfavorable community attitudes toward cigarette use, including other tobacco regulations that affected the use of cigarettes and e-cigarettes to minors. If this were the explanation, we might expect to have seen associations with the other ALA tobacco grades relating to, for example, smoke -free housing, smoke -free outdoor air, or the overall tobacco grade in a jurisdiction. However, protective effects only of the TRL grade were observed. Lower odds of cigar use initiation associated with better TRL regulation, although not statistically significant, were similar in magnitude to reductions in odds of the initiation of cigarettes and e-cigarettes. However, living in a jurisdiction with stronger regulation was not protective for baseline prevalence or subsequent initiation of hookah use. Sales of hookah paraphernalia often occur in specialty shops and hookah bars where cigarettes may not have been sold24 and therefore may not consistently have been subjected to the same rigorous compliance checks as traditional cigarette vendors. E-cigarettes are commonly sold at locations that also sell cigarettes that would have been subject to TRL regulation, and a state law passed in 2010 made it illegal to sell e-cigarettes to minors.21 However, e-cigarettes are also sold in specialty "vape" shops,26 and at the time of the study, e-cigarettes were not specifically categorized as a tobacco producL27 Therefore, vape shops were not required by state law to obtain a tobacco vendor license if they were not selling other tobacco products. If strong TRL regulation was responsible for the lower rates of e-cigarette use in A -grade jurisdictions, it is possible that similar TRL requirements for vape shops would have resulted in larger protective effects. The US Food and Drug Administration (FDA) has contracts with regulators in most states to restrict youth tobacco access and also conducts its own inspections and hires third parties to conduct compliance checks?$ However, the frequency of compliance checks is generally low, because of resource limitations, and penalties for violation of the law vary widely between states. California, for example, which has been a leader in tobacco control, annually inspected, on average, only 7% of tobacco retailers in 20169,10If a high rate of compliance checks, accompanied by enforcement, is necessary to reduce youth smoking as our results suggest, then strong local TRL ordinances may be an important option to reduce teen tobacco product use through access restriction.10,29,30 The study has some limitations. The ALA criteria for an A grade covered a relatively broad spectrum of TRL policy relevant to youth access, including larger fees, compliance access, and penalties if vendors violated the law. Identifying the possible effects of specific features of the TRL policy was not possible. A minimum proportion of vendors actually undergoing compliance checks was not specified, and it was not possible to assess the effect of the proportion of vendors visited. In addition, the "deeming rule" that defined e-cigarettes and hookah as tobacco products means that TRL will be required of all vendors of these products.31 The recent increase in the legal age of tobacco product purchase to 21 years in California, passed after data collection for this study was completed, means that the associations of TRL policy with use during the transition to legal age of purchase may no longer be applicable to California. However, the results may broadly be generalizable to local jurisdictions in states with a legal purchase age of 18 years, with the exception of a few states that have prohibited local jurisdictions from enacting more stringent local regulation.32 The increase of poorly regulated e-cigarette Internet vendors, a relatively new way for minors to obtain tobacco products illegally at the time of data collection, may limit the future impact of TRL as a regulatory tool.33 Future follow-up of this cohort is warranted to determine the persistence of associations with strong youth TRL and to examine longitudinally potential mediating factors, such as social characteristics of neighborhoods and communities and individuals' changing tobacco social environment over time. There were also other potential confounders or mediators of TRL effects, such as differences in school -level tobacco prevention programs or number of tobacco outlets by jurisdiction, that were not available to study. CONCLUSIONS The results suggest that a strong local TRL ordinance that provides adequate resources to fund regular compliance checks and enforcement may result in large reductions in the use of cigarettes and may also result in reduced e-cigarette use. The benefits of these policies may extend into early adult life. The study also suggests that the success of future FDA regulation to reduce youth cigarette and alternative tobacco product access and use, under rules Downloaded from wwwnappublications.org/news by guest on May 7, 2019 ASTOR at al deeming these products to be subject to FDA regulation,31 may depend on the availability of resources for universal annual compliance checks and enforcement targeted to both traditional and alternative tobacco product vendors. Continued monitoring is needed to assess the impact on the effectiveness of TRL policy within the rapidly evolving tobacco product patterns of use, new national regulation, and poorly regulated Internet sales. ACKNOWLEDGMENT April Roeseler provided useful comments on the development of the article. ABBREVIATIONS ALA: American Lung Association Cl: confidence interval e-cigarette: electronic cigarette FDA: US Food and Drug Administration OR: odds ratio TRL: tobacco retail licensing FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported by grant P50CA180905 from the National Cancer Institute at the National Institutes of Health (NIH) and the US Food and Drug Administration Center for Tobacco Products and by grant IR21HD084812-01 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development at the NIH. No fund ers had any role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the N I H or the US Food and Drug Administration. Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. REFERENCES 1. Centers for Disease Control (CDC). State laws restricting minors' access to tobacco. MMWR Morb Mortal Wkly Rep. 1990;39 (21):349-353 2. Preventing tobacco use among young people. A report of the surgeon general. Executive summary. MMWR Recomm Rep. 1994AMRR-01-10 3. United States Department of Health and Human Services. Substance abuse prevention and treatment block grants: sale or distribution oftobacco productsto individuals under 18 years of age. Fed Regist. 1993;58(164):45156-45174 4. United States Department of Health and Human Services Office of the Inspector General. State oversight of tobacco sales to minors. 1995. 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Barrington -Trims JL, Berhane K, Unger JB, et al. Psychosocial factors associated with adolescent electronic cigarette and cigarette use. Pediatrics. 2015;136 (2):308-317 14. Barrington-Trimis A, Orman R, Berhane K, of al. E-cigarettes and future cigarette use. Pediatrics. 2138 0 ):e20160379 15. American Lung Association in California. State of tobacco control 2014—California local grades. 2015. Available at: http://tobaccocontrol. usc.edu/files/SOTC_2014_CA—REPORT_ and_GRADES-3-7.pdf. Accessed August 11.2017 16. Etter J. Laws prohibiting the sale of tobacco to minors: impact and adverse consequences. Am J Prev Med. 2006;31(1):47 51 17. Forster A, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The effects of community policies to reduce youth access to tobacco. Am J Public Health. 1998;88(8):1193-1198 Downloaded from www.aappublications.org/news by guest on May 7, 2019 PEDIATRICS Volume 143, number 2, February 2019 18. Jason LA,Ji PY,Anes MD, Birkhead SH. 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Rigotti NA, Di Franza JR, Chang Y, 27 Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco -sales laws on adolescents' access to tobacco and smoking behavior. N Engl JMed. 1997;337(15):1044-1051 22. Bagott M, Jordan C, Wright C, Jarvis S. How easy is it for young people to obtain cigarettes, and do test sales by trading standards have any effect? A survey of two schools in Gateshead. Child Care Health Dev. 1998;24(3):207-216 23. Siegel M, Biener L, Rigotti NA. The effect of local tobacco sales laws on adolescent smoking initiation. Prev Mod. 1999;29 (5 ):334-342 24. Cawkwell PB, Lee L, Weitzman M, Sherman SE. Tracking hookah bars in Legislative Counsel's Digest. Amendment to the stop tobacco access to kids enforcement (STAKE) act, Assembly Bill 1301. 2011-2012 regular session. (Ca 2012). 2012. Available at: www.leginfo.ca.gov/pub/11-12/bill/ asm/ab-1301-1350/ab-1301_bill- 20120618—amended_sen_v92.html. Accessed February 25, 2017 28. US Food and Drug Administration. FDA tobacco retail inspection contracts. 2016. Available at: wwwfda.gov/ TobaccoProducts/GuidanceCompl ianc eRegulatoryl nformation/Beta i I/ ucm228914.htm. Accessed January 10, 2016 29. U.S. Food and Drug Administration; Tobacco Control Legal Consortium. State and local tobacco regulation in a post -deeming world. 2016. Available at: http://publichealthlawconterorg/ sites/default/files/resources/tcic-fda- deemingreg-state-and-local-regulation- 2016.pdf. Accessed February 13, 2017 30. McLaughlin I. License to kill?: tobacco retailer licensing as an effective enforcement tool. 2010. Available at: http://publichealthlawcenter.org/ sites/default/files/resources/tcic-syn- retailer-2010.pdf. Accessed February 25,2017 31. Food and Drug Administration, HHS. Deeming tobacco products to be subject to the federal food, drug, and cosmetic act, as amended by the family smoking prevention and tobacco control act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products. Final rule. Fed Regist. 2016;81(90):28973-29106 32. Lempert LK, Grano R, Glantz SA. The importance of product definitions in US e-cigarette laws and regulations. Tob Control. 2016;25 (e 1): e4"51 33. Mackey TK, Miner A, Cuomo RE. Exploring the ecigarette ecommerce marketplace: identifying Internet e-cigarette marketing characteristics and regulatory gaps. Drug Alcohol Depend. 2015;156:97-103 Downloaded from www.aappublications.org/news by guest on May 7, 2019 ASTOR at al Tobacco Retail Licensing and Youth Product Use Roee L. Astor, Robert Urman, Jessica L. Barrington-Trimis, Kiros Berhane, Jane Steinberg, Michael Cousineau, Adam M. Leventhal, Jennifer B. Unger, Tess Cruz, Mary Ann Pentz, Jonathan M. Samet and Rob McConnell Pediatrics 2019;143; DOI: 10. 1 542/peds.2017-3536 originally published online January 7, 2019; Updated Information & including high resolution figures, can be found at Services http://pediatrics.aappublications.org/content/143/2/e2Ol73536 References This article cites 23 articles, 6 of which you can access for free at: http://pediatrics. aappublications. org/content/ 143/2/e2O l73536#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Substance Use http://www.aappublications.org/cgi/collection/substance abuse sub Smoking http://www.aappublications.org/cgi/collection/smoking sub Public Health http://www.aappublications.org/cgi/collection/pubfic health —sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/PerTnissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhttnl f American Academy of Pediatrics DEDICATED TO THE HEALTH OF ALL CHILDREN- Downloaded from wwwnappublications.org/news by guest on May 7, 2019 PEDIATRICS Tobacco Retail Licensing and Youth Product Use Roee L. Astor, Robert Urman, Jessica L. Barrington-Trimis, Kiros Berhane, Jane Steinberg, Michael Cousineau, Adam M. Leventhal, Jennifer B. Unger, Tess Cruz, Mary Ann Pentz, Jonathan M. Samet and Rob McConnell Pediatrics 2019;143; DOI: 10.1542/peds.2017-3536 originally published online January 7, 2019; The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/143/2/e2Ol73536 Data Supplement at: http://pediatrics. aappublications. org/content/suppV2O l9/01/03/peds.2017-3536.DCSupplemental Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. f American Academy of Pediatrics DEDICATED TO THE HEALTH OF ALL CHILDREN- _i a Downloaded from wwwnappublications.org/news by guest on May 7, 2019 November 15, 2021 The Honorable Vicente Sarmiento, Mayor Santa Ana City Council 20 Civic Center Plaza Santa Ana. CA 92701 Re: Flavored Tobacco Products Dear Mayor Sarmiento and Members of the Santa Ana City Council: The Campaign for Tobacco -Free Kids & the Tobacco -Free Kids Action Fund are pleased to submit this letter in support of your efforts in the City of Santa Ana to reduce tobacco use, particularly among youth. The Campaign for Tobacco -Free Kids is the nation's largest non-profit, non -governmental advocacy organization solely devoted to reducing tobacco use and its deadly toll by advocating for public policies that prevent kids from using tobacco, and help smokers quit. We commend Santa Ana for being a national leader in its commitment to reducing the death and disease from tobacco use. It is encouraging to see cities and counties in California continue to take thoughtful, evidenced -based steps to reduce the number of kids who start using tobacco and help tobacco users quit. While California has made great strides in reducing tobacco use, tobacco use remains the number one preventable cause of premature death and disease in Santa Ana and the nation, killing 480,000 Americans annually. As you discuss policy options, we stand with dozens of other national health organizations to urge you to end the sale of all flavored tobacco products including candy flavored e- cigarettes, sweet flavored cigarillos, and menthol cigarettes. Prohibiting the sale of all flavored tobacco products in all tobacco retailers is a critical step that will help protect children living in Santa Ana from the unrelenting efforts by the tobacco industry to hook them to a deadly addiction. Flavored tobacco products are designed to alter the taste and reduce the harshness of tobacco products so they are more appealing and easy for beginners, who are almost always kids. These products are pervasive and are marketed and sold in a variety of kid -friendly flavors. With their colorful packaging and sweet flavors, flavored tobacco products are often hard to distinguish from the candy displays near which they are frequently placed in retail outlets. In California, nine out of ten high school tobacco users report using flavored products.' Menthol Cigarettes Increase Smoking Among Youth No other flavored product contributes more to the death and disease caused by tobacco use than menthol cigarettes. We applaud your decision not to exempt menthol cigarettes from your ordinance. Menthol delivers a pleasant minty taste and imparts a cooling and soothing sensation. These characteristics successfully mask the harshness of tobacco, making it easier for beginner smokers and kids to tolerate smoking. The FDA's Tobacco Product Scientific Advisory Committee (TPSAC) has reported that: • Menthol cigarettes increase the number of children who experiment with cigarettes and the number of children who become regular smokers, increasing overall youth smoking. • Young people who initiate using menthol cigarettes are more likely to become addicted and become long-term daily smokers. • The availability of menthol cigarettes reduces smoking cessation in some populations, especially among Black Americans, and increases the overall prevalence of smoking among Black Americans. • Menthol cigarettes are marketed disproportionately to younger smokers and are disproportionately marketed per capita to Black Americans. After a thorough review of the evidence, TPSAC concluded that "Removal of menthol cigarettes from the marketplace would benefit public health in the United States."' A decade later —in April 2021—the FDA announced its intention to pursue rulemaking to prohibit menthol cigarettes and flavored cigars. However, until any FDA action is finalized, states and cities should continue their growing efforts to end the sale of menthol cigarettes and other flavored tobacco products. It will take time for the FDA to finalize and implement the necessary regulations to prohibit menthol cigarettes and flavored cigars, and tobacco industry lawsuits could cause more delays. States and cities have an obligation to protect the health of their citizens and must act now to stop tobacco companies from targeting kids, Black Americans and other groups with menthol cigarettes and other flavored products. We can't afford more delay in taking action to protect kids and save lives. Flavored Tobacco Products Are Pervasive A 2009 federal law, the Family Smoking Prevention and Tobacco Control Act, prohibited the sale of cigarettes with characterizing flavors other than menthol or tobacco, including candy and fruit flavors. While overall cigarette sales have been declining since the 2009 law, the proportion of smokers using menthol cigarettes (the only remaining flavored cigarette) has been increasing.' Menthol cigarettes comprised 37 percent of the market in 2019.1 The Tobacco Control Act's prohibition on characterizing flavors did not apply to other tobacco products, and as a result, tobacco companies have significantly stepped up the introduction and marketing of flavored non -cigarette tobacco products. In fact, the overall market for flavored tobacco products is actually growing. In recent years, there has been an explosion of sweet -flavored tobacco products, especially e-cigarettes and cigars. These products are available in a wide assortment of flavors — like mango, blue razz, pink punch and mint for e-cigarettes and chocolate, watermelon, and cherry dynamite for cigars. Tobacco companies are making and marketing deadly and addictive products that look and taste like a new line of flavors from a Ben and Jerry's ice cream store. Flavors are not just a critical part of the product design, but are a key marketing ploy for the industry. The 2016 Surgeon General Report on JUUI MN e-cigarettes concluded, "E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches logo that have been used in the past for marketing conventional tobacco products to youth and young adults."' The 2019 National Youth ymdu °°m.m. Tobacco Survey found that 69.3% of middle and high school "`W" °°" .lm 11, students —over 18.2 million youth —had been exposed to e-cigarette advertisements from at least one source.6 Sales of cigars (i.e., large cigars, cigarillos, and small cigars) have more than doubled between 2000 and 2019, and much of the growth is attributable to smaller types of cigars, many of which are flavored and inexpensive.' The number of unique cigar flavor names more than doubled from 2008 to 2015, from 108 to 250.' The top five most popular cigar brands among 12- to 17-year olds who have used cigars — Black & Mild, Swisher Sweets, White Owl, Backwoods, and Dutch Masters —all come in flavor varieties.' These products are often sold singly or can be priced as low as 3 or 4 for 99 cents, making them even more appealing to price -sensitive youth. Note that cigar smoke is composed of the same toxic and carcinogenic constituents found in cigarette smoke.10 Although tobacco companies claim to be responding to adult tobacco users' demand for variety, it's clear that flavored tobacco products play a key role in enticing new users, particularly kids, to a lifetime of addiction. This growing market of flavored tobacco products is undermining progress in reducing youth tobacco use. Flavored Tobacco Products Are Popular Among Youth These sweet products have fueled the popularity of e-cigarettes and cigars among youth. A government study found that eight out of ten of kids who have ever used tobacco products started with a flavored product. 11 Across all tobacco products, the data is clear: flavored tobacco products are overwhelmingly used by youth as a starter product, and preference for flavors declines with age. The 2020 National Youth Tobacco Survey shows that among high school students, e-cigarette use declined to 19.6% in 2020, after increasing by an alarming 135 percent from 2017 to 2019 (from 11.7% to 27.5%).12 While the significant decline in youth users since 2019 is a sign of progress, youth e- cigarette use remains a public health crisis. 3.6 million kids still use e-cigarettes —the same number as when the U.S. Surgeon General called youth e-cigarette use an "epidemic."13 In California, 8.2%of high school students report using e-cigarettes. The California Student Tobacco Survey found that an increasing proportion of these youth are using flavored products (96.2% in 2019- 2020, up from 86.4% in 2017-2018). Among California high school e-cigarette users, the most commonly used flavor types are fruit (63.9%), mint or menthol (14.7%) and candy or sweet (13%). 14 Almost all e-cigarettes contain nicotine, a highly addictive drug. Young people are especially vulnerable to nicotine addiction.15 The Surgeon General has concluded that, "The use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe."16The manufacturer ofJUUL, a popular e-cigarette among youth, claims that each JUUL pod contains as much nicotine as a pack of twenty cigarettes. Since the introduction of Juul, many youth are now using products that effectively deliver massive doses of nicotine and it is clear that large numbers of teen e-cigarette users are struggling with nicotine addiction. Youth e-cigarette users are also at risk of smoking cigarettes. A 2018 report from the National Academies of Science, Engineering & Medicine found that "There is substantial evidence that e- cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults."17 More recent research confirms this finding.18 Therefore, it is critical for any policy restricting sales of flavored tobacco products to include e-cigarettes. In January 2020, the FDA restricted some flavors in cartridge -based e-cigarettes, but exempted all menthol -flavored e-cigarettes and left flavored e-liquids and disposable e-cigarettes widely available in every imaginable flavor. New data show that the market share of these products has grown substantially and that youth quickly migrated to the flavored products that were exempt from the FDA's policy. Among high school e-cigarette users, use of disposable e-cigarettes increased by 1,000% from 2019 to 2020, and in 2020, 37% of high school users of flavored e-cigarettes reported using menthol products.19 E-cigarette market share data from California confirm these trends: • From February 2020 to June 2021, disposable e-cigarette sales in California increased by 51.9%. Disposable products are sleek, easily concealed, pre -charged, cheap (some for less than $5) and can even have higher nicotine concentrations than JUUL. They are widely sold in kid -friendly flavors like fruit and candy. • From February 2020 to June 2021, menthol -flavored e-cigarette sales in California increased by 43.1% (from 226.4 thousand to 324.0 thousand units) and menthol -flavored cartridge sales increased by 44%. While the FDA recently announced that it had denied marketing applications for certain flavored e- cigarettes, many of the flavored products most popular among kids, like Juul, are still on the market. Every day these products remain on the market, our kids remain in jeopardy. Because of the delays and gaps in the FDA's actions, it is critical that states and cities step up their efforts to eliminate ALL flavored e-cigarettes, as well as other flavored tobacco products. The evidence is also clear that as long as any flavored e-cigarettes — including menthol -flavored products —are on the market, kids will shift to them and we will not end this public health crisis. Santa Ana must close the gaps left by the FDA and protect our kids from these dangerous and addictive products. As the only flavored cigarette left on the market, it's also no surprise that menthol cigarettes are popular among youth. Menthol cools and numbs the throat, reducing the harshness of cigarette smoke, thereby making menthol cigarettes more appealing to youth who are initiating smoking. About half of youth smokers use menthol cigarettes. 20 As noted previously, young people who initiate using menthol cigarettes are more likely to become addicted and become long-term daily smokers.21 Tobacco companies have a long history of targeting and marketing flavored tobacco products to Black Americas and youth. Tobacco industry marketing, often targeted at minority communities, has been instrumental in increasing the use of menthol products and in the disproportionate use of menthol products by minority groups and youth. TPSAC concluded that menthol cigarettes are marketed disproportionately to younger smokers and Black Americans.22 Dating back to the 1950s, the tobacco industry has targeted these communities with marketing for menthol cigarettes through sponsorship of community and music events, targeted magazine advertising, youthful imagery, and marketing in the retail environment. This targeting continues today: in 2018, California tobacco retailers in neighborhoods with the highest proportions of Black residents were more likely to advertise menthol cigarettes and charged an estimated 25 cents less for Newport cigarettes, compared with stores in neighborhoods with the lowest proportion of Black residents.23 Nationwide, as a result of this targeting, 85% of Black smokers smoke menthol cigarettes, compared to 29%of White smokers. 24 Menthol cigarettes are a major reason why Black Americans suffer disproportionately from tobacco use. The tobacco industry's "investment" in the African American community has had a destructive impact. In 2013, the FDA released a report finding that menthol cigarettes lead to increased smoking initiation among youth and young adults, greater addiction, and decreased success in quitting smoking.26 Tobacco use is the number one cause of preventable death among Black Americans, claiming 45,000 Black lives every year. 26 Tobacco use is a major contributor to three of the leading causes of death among Black Americans - heart disease, cancer and stroke.27 The higher rates of some tobacco -caused diseases among Black Americans result, in part, from their greater use of menthol cigarettes, which are associated with reduced cessation.28 A study released just this month found that among the Black community, 157,000 smoking -related premature deaths and 1.5 million excess life - years between the years 1980 and 2018 can be attributed to menthol cigarettes.29 The scientific evidence leaves no doubt that menthol cigarettes and other flavored tobacco products increase the number of people, particularly kids, who try the product, become addicted and die a premature death as a result. Prohibiting the sale of menthol cigarettes and other flavored tobacco products is an important step toward protecting our children from the tobacco industry's aggressive efforts to hook children to a deadly, addictive product. This issue is about protecting our kids and vulnerable populations. By prohibiting the sale of all flavored tobacco products, Santa Ana would join over seventy cities and counties in California that are already enacted comprehensive laws to end the sale of all flavored tobacco products. Thank you for considering a strong and comprehensive policy without exemptions. It will save lives. Sincerely, Lindsey Freitas, MPA Regional Advocacy Director Campaign for Tobacco -Free Kids Ifreitas@tobaccofreekids.org Appendix Al: Examples of Flavored Tobacco Products 2 °sr 99a t'A'ARNING+ CO moAlna can aaw` mof me na e ap• not�naalo. WARNING. Th18 Pro uct contains nicotine. Nicotine is an addictivecaemlcal. A2: Examples of Menthol Marketing Source: TrinketsandTrash.org, CounterTobacco.Org 'Zhu S-H, Braden K, Zhu ang Y-L, Gamst A, Cole AG, Wolfson T, Li S. (2021). Results of the Statewide 2019-20 California Student Tobacco Survey. San Diego, California: Center for Research and Intervention in Tobacco Control (CRITC), University of California San Diego. 2 Tobacco Products Scientific Advisory Committee (TPSAC), Menthol Cigarettes and Public Hearth: Review of the Scientific Evidence and Recommendations, July 21, 2011 http://www.fda.gov/downloads/Advisory Committees/Comm itteesMectingMaterials/robaccoProductsScientificAdvisoryCommittee/UCM269697.pdf. 3 Villanti, A., et al., "Changes in the prevalence and correlates of menthol cigarette use in the USA, 2004-2014," Tobacco Control, 25(Suppl 2):ii14-ii20, 2016. 4 U.S. Federal Trade Commission (FTC), Cigarette Report for 2019, 2021, hftps://www.ftc.gov/system/files/documents/reports/federal-trade-commission- cigarette-report-2019-smokeless-tobacco-report-2019/cigarette report for 2019.pdf [data for top 5 manufacturers only]. 5 HHS, E-Cigarette Use Among Youth and Young Adults. AReport ofthe 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. 6 Wang, TW, et al., "Tobacco Product Use and Associated Factors Among Middle and High School Students -United States, 2019," MMWR, 68(12): December 6, 2019, https://www.cdc.gov/mmwr/volumes/68/ss/pdfs/ss6812al-H.pdf. 7 U.S. Alcohol and Tobacco Tax and Trade Bureau (TTB), Tobacco Statistics. 8 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. 9 SAMHSA's public online data analysis system (PDAS). National Survey on Drug Use and Health, 2015, https://pdas.samhsa.gov/#/survey/NSDUH-2015- 10 National Cancer Institute (NCI), Cigars: Health Effects and Trends. Smoking and Tobacco Control Monograph No. 9, 1998, http://cancercontrol.cancer.gov/Brpftcrb/monographs/9/m9 complete.pdf. Chang, CM, et al., "Systematic review of cigar smoking and all cause and smoking related mortality," BMC Public Health, 2015. 11 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. 12 Wang, NV, et al., "E-cigarette Use Among Middle and High School Students - United States, 2020," MMWR, Volume 69, September 9, 2020, https:/Awvvw.cdc.gov/mmwr/volumes/69/vw/pdfs/mm6937ol-H.pd . 13 Office of the Surgeon General, "Surgeon General's Advisory on E-Cigarete Use Among Youth,' December 18, 2018, httpsWc- cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-am onq-youth-2018.pdf. 14 Zhu S-H, Braden K, Zhuang Y-L, Gamst A, Cole AG, Wolfson T, Li S. (2021). Results of the Statewide 2019-20 California Student Tobacco Survey. San Diego, California: Center for Research and Intervention in Tobacco Control (CRITC), University of California San Diego. 15 HHS, E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon Genera). 16 HHS, E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon Genera). 17 National Academies of Sciences, Engineering, and Medicine (NASEM), Public Health Consequences ofE-Cigarettes, 2018, http://nati o nal aca dem i es.o rg/hm d/Rep orts/2018/pub li c-health-consequences-of-a-ciga rette s. as px. 18 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, Pierce, JP, et al., "Use of E-Cigarettes and Other Tobacco Products and Progression to Daily Cigarette Smoking,' Pediatrics, 147(2), published online January 11, 2021. 19 Wang, NV, et al., "E-cigarette Use Among Middle and High School Students - United States, 2020," MMWR, Volume 69, September 9, 2020, https:/Awvvw.cdc.gov/mmwr/volumes/69/vw/pdfs/mm6937ol-H.pd . 20 Wang, NV, et al., "Tobacco Product Use and Associated Factors Among Middle and High School Students -United States, 2019," MMWR 68(12), December 6, 2019, https:/Avwvw.cdc.gov/mmwr/volumes/68/ss/pdfs/ss6812al-H.pdf. 21 TPSAC, Menthol Cigarettes and Pubic Health: Review of the Scientific Evidence and Recommendations, July 21, 2011. 22 TPSAC, Menthol Cigarettes and Pubic Health: Review of the Scientific Evidence and Recommendations, July 21, 2011. 23 Henriksen, L, et al., "Menthol cigarettes in black neighbourhoods: still cheaper after all these years," Tobacco Control, published online August 12, 2021. 24 Delnevo, CD, et al., "Banning Menthol Cigarettes: A Social Justice Issue Long Overdue," Nicotine & Tobacco Research, 22(10): 1673-1675, 2020. u FDA, Preliminary Scientific Evaluation of the Possible Puhlic Health Effects ofMenthol versus Nonmenthol Cigarettes, 2013. 26American Cancer Society, "Cancer Facts & Figures for African Americans, 2016-2018," 2016, http://www.cancer.org/acs/groups/content/(oleditorial/documents/document/acspc-047403.pdf:. American Heart Association, "African Americans and public/(olwcm/(olsop/(olsmd/documents/downloadable/ucm 319568.pdf. HHS, "Tobacco Use Among US Racial/Ethnic Minority Groups -African Americans, American Indians and Alaskan Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General," 1998, http://www.cdc.govAobacco/data statistics/sgr/1998/complete report/pdfs/complete report.pdf 27 HHS, "Tobacco Use Among US Racial/Ethnic Minority Groups -African Americans, American Indians and Alaskan Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General," 1998, CDC, National Vital Statistics Report, Vol. 68, No. 9. Table 10, 2019 https:/hvvvw.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68 09-508.pdf. 28 HHS, "Tobacco Use Among US Racial/Ethnic Minority Groups -African Americans, American Indians and Alaskan Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General," 1998, HHS, Reducing the Health Consequences of Smoking: 25 Years of Progress: A Reportof the Surgeon Genera), 2014. See also Alexander, LA, et al., "Why we must continue to investigate menthol's role in the African American smoking paradox,' Nicotine & Tobacco Research, 18(S1): S91-S101, 2016. 29 Mendez, D and Lee, TT, "Consequences of a match made in hell: the harm caused by menthol smoking to the African American population over 1980- 2018," Tobacco Control, published online September 16, 2021. TosA�co�FfuE im Kids AcTov fuND AN:= im amr„r„ 9 `� � 1 American AMF,RICA t Lung Association. ON TnAcx California �b -0 Partners-, Wellness l �� ram..':.NCADD Same Agenry New Name-bparded Sett 0 FIRST5 ORANGE COUNTY November 15, 2021 toAmerican Heart Association. AMERICANS FOR NONSMONERS'R .I eC(INTER" BOY SCOUTS OF AMERICA ORANGE COUNTY COUNCIL The Honorable Vicente Sarmiento, Mayor Santa Ana City Council 20 Civic Center Plaza Santa Ana, CA 92701 Dear Mayor Sarmiento and Members of the Santa Ana City Council: A ff LLC rar.�/n....i.rn... rs..r. C. I ... �.a nut u... A C O A L I T I O N V�y�c �Ya53S ye�g ,�y''J ?""Cwnbuiuttt 4'a+nib.... \7 Phoenix House CALIFORNIA On behalf of our organizations, we are writing to express our strong support of a comprehensive policy to end the sale of menthol and all other flavored tobacco products in Santa Ana, without exemption. Ending the sale of these products will help protect youth and communities of color from these addictive and deadly products. We are in the midst of a youth tobacco -use epidemic, in which tobacco companies are luring kids into a lifetime of nicotine addiction through the sale and targeted marketing of candy - flavored tobacco products. Tobacco companies knowingly hide dangerous and addictive nicotine —a chemical we know harms brain development— behind candy flavors gummy bear, blue raz, fruity pebbles, and minty menthol in order to hook kids on tobacco. These products often mimic popular candies, drinks, or snacks in both packaging and flavor, making them particularly appealing to youth. Today, more than 2 million middle and high school students use e-cigarettes nationally, and 70 percent of youth e-cigarette users say they use them "because they come in flavors I like." Youth are not the only targets of Big Tobacco's deceptive marketing campaigns. For decades, the tobacco industry has targeted the African American community, hooking generations of African Americans on minty menthol cigarettes and profiting off addiction, disease, and death. Today, 85 percent of African Americans who smoke use minty menthols, smoking them at higher rates than other demographics while quitting smoking at lower rates. African Americans die at higher rates than other groups from tobacco -related diseases such as cancer, heart disease, and stroke. Lung cancer kills more African Americans than any other type of cancer. In Santa Ana, we know that flavors, including menthol, are hooking youth on tobacco. Legislation was recently enacted to prevent online sales to those under 21, but that is just one piece of the puzzle as online sales represent only a fraction of the ways flavored tobacco products reach youth. The vast majority of underage e-cigarette users in California obtain the products from social sources, such as their friends. Ending the sale of these products is the best way to protect youth and people of color from the predatory practices of Big Tobacco. The dangers of smoking are well documented. Smoking causes cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis. In addition, there is growing evidence that vaping can also harm lung health. More than 100 local jurisdictions have taken action to end the sale of flavored tobacco and protect future generations from getting hooked on this dangerous habit. These include the cities of Buena Park, Stanton, Delano, Adelanto and San Francisco as well as Los Angeles County, to name a few. While SB 793 was recently enacted to end the sale of most flavored tobacco products, tobacco companies spent more than $20 million to place the law on hold until the next statewide general election. Santa Ana kids can't wait an entire year to be protected - local action is needed to protect the community right now and address the urgent issue of youth tobacco use. Every day we delay protecting youth and communities of color is a day that Big Tobacco has the opportunity to use fruit and candy -flavored tobacco to addict more life-long customers. A strong Tobacco Retail Licensing (TRL) program will provide enforcement for a flavored tobacco sales restriction policy and is a proven way to prevent and limit youth tobacco use. We recommend the city strengthen the existing TRL program by requiring annual compliance checks on all tobacco retailers and restricting the density of tobacco retail locations. In California, youth and young adults living in places with strong retail licensing policies are less likely to use cigarettes and e-cigarettes than their counterparts who live in places with poor retail licensure policies. For these reasons, we are proud to support a comprehensive policy that ends the sale of all flavored tobacco products without exemption. Sincerely, African American Tobacco Control Leadership Council America On Track American Cancer Society Cancer Action Network American Heart Association American Lung Association Americans for Nonsmokers's Rights Boy Scouts of America —Orange County Council First Five Orange County LGBTQ Center Orange County Orange County Tobacco and Vape Free Coalition Partners 4 Wellness Parents Against Vaping e-cigarettes - PAVe Phoenix House California The Cambodian Family Tobacco Free Kids Action Fund