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Home My WebLink AboutCORRESPONDENCE - #39 il • 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. pop • 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 2019.4 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 JUUU e-cigarettes concluded, "E-cigarettes are marketed by promoting = flavors and using a wide variety of media channels and approaches � �■ that have been used in the past for marketing conventional tobacco wwww 3100 MMG I products to youth and young adults."'The 2019 National Youth w°P IM This protluct contains `rreen9cerm. Tobacco Survey found that 69.3°/ of middle and high school O aaiuecnemi°ai. »8 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 ZfIGARS to smaller types of cigars, many of which are flavored and inexpensive.' ,Ahl. o,o The number of unique cigar flavor names more than doubled from 2008 to . 2015, from 108 to 250.1 The top five most popular cigar brands among 12- SAVE-2 CHERRY DYNAMIT to 17-year olds who have used cigars—Black & Mild, Swisher Sweets, White Owl, Backwoods, and Dutch Masters—all come in flavor varieties.9 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 of JUUL, 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.25 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.21 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 CIGARS 2 CIGARS SAVE-21 `°�99a m SWISS ROLL CHERRY PASSION DYNAMITE FRUIT WARNING:Cigar JUUU MI nx> la I i i I• I PEACH oao� � 131.111E J � RASPBERRY lUE"AS PaEaF WARNING This WnNNI prod twtree WARNING: This 1 tobacco-free This product contains corneim 1 .nicohne.Nicotine nicotine.Nicotine is an �" INh•This pradixt is an adT.i. "N1N0 NI[oana b'- �Th�b weGu�:. na rti ne.N mu woEnc. add chemical. addictive chemical. oemrtn ttmrcc e-., rN nkot� A2: Examples of Menthol Marketing Source:TrinketsandTrash.org, CounterTobacco.Org I, 8 r mr i. ffi - ,� M SPECIAL pFiiCE! Newport 1 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. 2 Tobacco Products Scientific Advisory Committee(TPSAC),Menthol Cigarettes and Public Health:Review of the Scientific Evidence and Recommendations, July 21,2011 http://www.fda.qov/downloads/AdvisoryComm ittees/Comm itteesMeeti ng Materials/TobaccoProductsScientificAdvisoryCom mittee/U CM269697.pdf. 3 Uillanti,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, https://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.A Report of the Surgeon General.Atlanta,GA: U.S.Department of Health and Human Services, Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health,2016. 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:gpdas.samhsa.gov/`#/survey/NSDUH-2015- DS0001/crosstab/?row=CGR30BR2&column=CATAG2&weight=ANALWT C&results received=true. 10 National Cancer Institute(NCI),Cigars:Health Effects and Trends.Smoking and Tobacco Control Monograph No. 9, 1998, http://cancercontrol.cancer.gov/Brp/tcrb/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,TW,et al.,"E-cigarette Use Among Middle and High School Students-United States,2020,"MMWR,Volume 69,September 9,2020, hftps://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937el-H.pdf. 13 Office of the Surgeon General,"Surgeon General's Advisory on E-Cigarette Use Among Youth,"December 18,2018, https://e- cigarettes.surgeongeneral.qov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-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 General. 16 HHS,E-Cigarette Use Among Youth and Young Adults.A Report of the Surgeon General. 17 National Academies of Sciences,Engineering,and Medicine(NASEM),Public Health Consequences ofE-Cigarettes,2018, http://nationalacademies.org/hmd/Reports/2018/public-health-consequences-of-e-cigarettes.aspx. 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,TW,et al.,"E-cigarette Use Among Middle and High School Students-United States,2020,"MMWR,Volume 69,September 9,2020, hftps://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937el-H.pdf. 20 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. 21 TPSAC,Menthol Cigarettes and Public Health:Review of the Scientific Evidence and Recommendations,July 21,2011. 22 TPSAC,Menthol Cigarettes and Public 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. 25 FDA,Preliminary Scientific Evaluation of the Possible Public Health Effects ofMenthol versus Nonmenthol Cigarettes, 2013. 26American Cancer Society,"Cancer Facts&Figures for African Americans,2016-2018,"2016, http://www.cancer.orq/acs/groups/content/(a)editorial/documents/documenVacspc-047403.pdf:.American Heart Association,"African Americans and Cardiovascular Diseases:Statistical Fact Sheet,2012 Update,'http://www.heart.org/idc/groups/heart- public/(a).wcm/(a).sop/(a).smd/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..qov/tobacco/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://www.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 Report of the Surgeon General,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. ACancerAction lMetwork- American] Heart TCLC'Th lbr 1/ I.rnlr,.T cr ob, , Association.'aw /�. American AMERICANS FOR o0o P+AD 1,110 AMERICA Lung Association. SONONSMOKERS'RIGHiS m� • a ON TRACK California m Creating Br;gljte Futures C O A L I T I O N for Comvuur;ries d Yonrl slime l.'l'J p e.o a qq ryo � 4�-7 FiiSa 56$ PAVE �' Partners4WeIIness � L6BTQC(ENTER " vL � -- v r«me.ly NCADD O C SanK Agency•New Name fpanded SewAs �� " •••••• I'V ��`eC'a�n6odsan�FctmiL). November 5, 2021 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: 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 LGBTQ Center Orange County Orange County Tobacco and Vape Free Coalition Partners 4 Wellness Parents Against Vaping e-cigarettes - PAVe The Cambodian Family Tobacco Free Kids Action Fund Orozco, Norma From: Nathaniel Greensides <mynci90@gmail.com> Sent: Tuesday, December 21, 2021 4:29 PM To: eComment; Hernandez, Johnathan Subject: City Council Meeting Agenda Item 39 I would like to voice my support of this item. Flavored tobacco products not only are detrimental to the health of everyone - especially any young people in our community - but also, these flavored tobacco products are worse for the environment than traditional "analog" tobacco and nicotine products with the plastic and metals required in the manufacturing process of the devices themselves as well as the chemicals involved in the creation of the liquid and pods (not to mention that the pods wind up in landfills never to break down completely if at all). Separately, I believe that there also is a need to ensure that smoking cessation products are made available to those who have developed the habit to ensure that any withdrawal effects are mitigated on top of educational campaigns against flavored nicotine and tobacco products. Sincerely, Nathaniel Greensides Ward 5 Resident i Orozco, Norma From: Rodriguez, Yaneth <ylr@med.usc.edu> Sent: Tuesday, December 21, 2021 3:39 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 Agenda item #39 Ordinance Prohibiting 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, Examining Hookah as an Introduction to Nicotine Products among College Students.pdf, Measurement and predictive value of susceptibility to cigarettes ecigarettes cigars and hookah among Texas adolescents.pdf Importance: High Dear Mayor and City Council Members of the City of Santa Ana, I am writing in regards to agenda item#39 "Ordinance Prohibiting the Sale of Flavored Tobacco Products." Attached is an information sheet which contains research findings from the University of Southern California's Tobacco Center of Regulatory Science (USC TCORS). I also attached the journal articles where some of the information below can be found. 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. I have also attached to this email additional information for your consideration regarding hookah. For each of the data points below, I have included a copy of the PDF article with important data points highlighted. Hookah considerations: • Hispanic/Latinx adolescents are more susceptible to hookah and 44% more likely reported current hookah use. • One out of four college nicotine users started with hookah. 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 Rodriguez 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 i 2001 N. Soto St. Office 302N; MC 9239 Los Angeles, CA 90032 ylr@usc.edu 2 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 computer flash 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 'Research 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 consider the 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 'Research 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.nih.gov/pmc/articles/PMC4960723/pdf/PEDS 20153983.pdf 2. Leventhal AM,Strong DR,Sussman S,Kirkpatrick MG,Unger JB,Barrington-Trimis JL,et al.Psychiatric comorbidity in adolescent electronic and conventional cigarette use.Journal of psychiatric research.2016;73:71-8. 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,Ramamurthi 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. Bold 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 novel methodology.Drug and alcohol dependence.2016;168:176-80. 8. Hong H,McConnell R,Liu F,Urman 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,Baezconde-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://nccd.cdc.gov/vouthonIine/App/Results.aspx?TT=G&OUT=O&SID=HS&QlD=QQ&LID=CA&YID=2017&LlD2=XX&YID2=2017&COL=T&ROW1=N&ROW2=N&HT=QQ &LCT=LL&FS=Sl&FR=Rl&FG=Gl&FSL=S1&FRL=R1&FG L=Gl&PV=&TST=True&C1=CA2017&C2=XX2017&QP=G&DP=1&VA=CI&CS=N&SYI D=&EYI D=&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,Urman 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 J,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-yearfollow-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,Urman R,Hong H,Unger J,et al.Electronic cigarette use and respiratory symptoms in adolescents.American journal of respiratory and critical care medicine.2017;195(8):1043-9. 21. Hanno C Erythropel,Sairam V Jabba,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/ntv192 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 J,Hajek P.Electronic cigarettes for smoking cessation and reduction.Cochrane Database of systematic reviews.2014(12). 24. Hajek P,Phillips-Waller A,Przulj D,Pesola 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.org/publications/caIifornia-comprehensive-tobacco-retailer-licensing 27. https://www.fda.gov/tobaccoproducts/labeling/productsingredientscomPonents/ucm2019416.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):e 20173536. 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. 'Research conducted outside of USC *Both USC and Outside Research Updated 5/22/2019 Tobacco Retail Licensing and Youth Product Use Roee L.Astor,MPH,a Robert Urman,PhD,a Jessica L.Barrington-Trimis,PhD,a Kiros Berhane,PhD,a Jane Steinberg,PhD,a Michael Cousineau,PhD,a Adam M.Leventhal,PhD,a Jennifer B.Unger,PhD,a Tess Cruz,PhD,a Mary Ann Pentz,PhD,a Jonathan M.Samet,MD,MS,e Rob McConnell,MDa 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 [CI] 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.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. l U 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,University of Southern California,Los Angeles, UStobaCCOregLllatorypollCy,buttheimpactoflocal California;and°Colorado School of Public Health,University of Colorado 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-D,Los Angeles,CA 90089.E-mail: rmcconne@usc.edu PEDIATRICS(ISSN Numbers:Print,0031-4005;Online,1098-4275). Copyright©2019 by the American Academy of Pediatrics To cite:Astor RL, Urman R, Barrington-Trimis JL, et 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 using these products is high."An Ethics Statement restrict the sale of cigarettes to additional gap in understanding the The stud approved b the minors for decades.'Because there effectiveness of youth tobacco access y was pp y University of Southern California was widespread violation of these restriction is during the transition laws by tobacco vendors,z Congress to the legal age of purchase.Most Institutional Review Board.Parental written informed consent and passed the Synar Amendment to the adult smokers historically have Public Health Service Act in 1993,3 initiated cigarette use by age 18,12 child assent were obtained for all which required that states enact laws which is the legal age of purchase <18 y Children's Health Study participants 18 y of age.Participants age 18 banning cigarette sales to minors in most states.There have been few and that they enforce such laws with prospective studies examining the or older provided written informed consent. compliance checks using undercover effect of tobacco licensing and youth "decoys"posing as underage access restriction on cigarette and Tobacco and Alternative Tobacco customers.4-5 alternative tobacco product use Product Use Enforcement of these youth access during this transition to adult life. At each survey,participants were regulations is a central feature of US Among participants in the Southern asked whether they had ever tried tobacco control programs.However, California Children's Health Study, e-cigarettes,cigarettes,cigars,or although compliance checks of we evaluated whether youth living hookah and the number of days vendors have been shown to reduce in jurisdictions with a strong tobacco each product was used in the past sales to minors,their effectiveness retail licensing(TRL)ordinance had 30 days.12 Participants who had in reducing youth smoking rates is reduced prevalence of cigarette and "never tried"a product(not"even 1 less certain,for example,because other tobacco use,compared with or 2 puffs")were classified as never they may obtain cigarettes legally participants in jurisdictions with users.Those reporting an age at first purchased by older friends.6,7 Key a poor TRL ordinance.In addition, use of each tobacco product were regulatory features that are reported using prospectively collected data, classified as ever(lifetime prevalent) to reduce both compliance violations we assessed the association of local users of that product at baseline. and youth cigarette use include a ordinances with the initiation of Rates of initiation were calculated on mandatory tobacco retailer licensing tobacco product use during a cohort the basis of a new report of use of a fee to provide sustainable funding of follow-up as youth reached 18 years tobacco product at follow-up among undercover decoys to make at least 1 of age,the age at which the sale participants not reporting use of that annual visit to each vendor and fines of tobacco products was legal in product at baseline.Both prevalent or penalties for violations.7,8 California at the time of the study. users and initiators of each tobacco Low rates of vendor compliance product were further characterized checks,which occur annually at only on the basis of past 30-day use. a small fraction of tobacco vendors under existingstate and federal METHODS Evaluation of Local Tobacco enforcement programs,9,10 and Regulatory Licensing to Reduce inadequate penalties may explain Study Population Youth Access why associations with youth smoking rates have not consistently been Between January and June of 2014, There were 14 political jurisdictions observed. Within states,compliance a total of 2097 11th-and 12th-grade with corresponding tobacco enforcement may vary markedly compliance participants in the Southern product ordinances across the 12 the basis of local ordinances that California Children's Health Study participating Children's Health provide funding to do so.riven the (mean age: 17.3;SD:0.6)completed Study communities.Four study expense involved in enforcement self-administered questionnaires jurisdictions were assigned an and the lack of expert consensus on collecting detailed information about A grade on the basis of the 2014 its benefits,additional studies are cigarette and alternative tobacco American Lung Association(ALA) warranted to assess the effectiveness product use.Follow-up online "Reducing Sales of Tobacco Products" in reducing youth cigarette use. questionnaire data were collected to youth scale,which is used to on 1553 participants(74%of the evaluate the strength of the local TRL The impact of youth access 2097 at baseline)as they reached ordinance across California.ls An restriction on the initiation of 18 years of age,between January A grade required adequate annual alternative tobacco products,such as 2015 and June 2016(mean age: 18.8; retail license fees,which were paid electronic cigarettes(e-cigarettes), SD:0.6).Additional characteristics by all tobacco retailers(including gas hookah,and cigars,has not been of the study sample have been stations,convenience stores,larger studied,although prevalence of ever described previously.13,14 grocery stores,and pharmacies), Downloaded from www.aappublications.org/news by guest on May 7,2019 2 ASTOR et al to cover the administration of an college,or completed college or ALA 2014 TRL A grade,and 68.9% enforcement program and regular more). (1445)students lived in jurisdictions compliance checks in each store.An with D or F grades.Sex and ethnic A grade also required(1)an annual Statistical Analysis distributions were similar in A and renewal of this local license; (2)a D or F jurisdictions,but students in provision that any violation of local, Unconditional logistic regression models were used to evaluate the A jurisdictions were more likely to state,or federal law is a violation come from less-educated households of the license;and(3)a graduated associations of living in a jurisdiction with (Table 1).Unadjusted prevalence penalty system for violators, r ALA grade A versus D or F and initiation rates for each tobacco including financial deterrents such TRL ordinance with baseline ever product were lower in jurisdictions as fines or other penalties,including and past 30 day use of cigarettes, with A than with D or F grades, license revocation or suspension.15 e-cigarettes,hookah,cigars,or use with the exception of new initiation of any of these tobacco products in of hookah with past 30-day use. The remaining study jurisdictions separate models.Models were also fit Initiation rates were substantial were assigned an F grade(8)or a to evaluate associations of ALA grade among never tobacco product D grade(1).An F grade indicated with the initiation of each product, with or without past 30-day use.In users at baseline,in particular for either(1)no local ordinance p y e-cigarette use.Both prevalence and mandating a license fee or(2)a fee models used to evaluate the initiation initiation rates of past 30-day tobacco insufficient to fund administrative of use of each tobacco product product use generally did not exceed and compliance checks as well as between baseline and follow-up,the 10%for any product. none of the 3 other provisions for an sample was restricted to baseline A grade.The jurisdiction with the D never users of that product.Odds For baseline prevalence of ever and grade had a licensing fee that was ratios(ORs)and 95%confidence past 30-day use of cigarette and insufficient to cover administration intervals(CIs)were used to estimate e-cigarette ever use,and to a lesser and compliance checks,but it had the association of each tobacco degree for prevalence of cigar use, at least 1 of the other 3 provisions product use with an ALA grade. jurisdictions with A grades had listed above that were needed for an All models were adjusted for sex, generally lower use rates than D or A grade.The D and F communities ethnicity,highest parental education, F jurisdictions(Supplemental Fig 3). were collapsed for data analysis, and baseline age,factors that have However,within both grade groups, because the insufficient annual fee been associated both with e-cigarette there was considerable variability in is a central feature of regulation to use and cigarette use in previous prevalence rates across jurisdictions reduce youth access.7,15 No study studies.13,14 Each tobacco product— for all tobacco products.Rates in jurisdiction in this sample had B or C specific model was also adjusted for individual jurisdictions had wide Cls grades corresponding to TRL policies a baseline history of use of any other (results not shown)because of small of intermediate quality.15 tobacco product,because there was sample size.Rates of tobacco product clustering of the tobacco product initiation at follow-up were also ALA assigned grades to other outcomes.13 A missing indicator generally quite variable across the categories of tobacco policy(smoke- category for covariates and any other jurisdictions within both A and D or F free housing policy,smoke-free tobacco product use was included grades(Supplemental Fig 4). outdoor policy,and overall tobacco where appropriate.Additionally,all At baseline,participants living in the policy).15 These policies,which are models included a random effect for 4 jurisdictions with A grades had not specific to youth tobacco product community to account for similarities lower odds of ever using a cigarette access,were not associated with among subjects within jurisdictions. (OR 0.61;95%CI 0.41-0.90)and tobacco product use in this study,and In a sensitivity analysis,models were of past 30-day use(OR 0.51;95% results are not presented. further adjusted for time between CI 0.29-0.89)than participants in baseline and follow-up questionnaire 10 D-to F-grade jurisdictions,after Covariates completion.Statistical analyses were adjusting for so cio demographic Self-administered questionnaires based on 2-sided hypotheses tested covariates and other tobacco product completed by parents of at a 0.05 level of significance,using use at baseline(Fig 1). SAS 9.4(SAS Institute,Inc,Cary,NC). participants were used to assess Living in A-grade jurisdictions socio demographic characteristics, was associated with lower odds including sex,ethnicity(Hispanic, RESULTS of initiation of cigarette use non-Hispanic white,other),age at between baseline and the follow-up baseline,and parental education Of the 2097 participants,31.1% questionnaire(OR 0.67;95%CI (completed high school or less,some (652)lived in a jurisdiction with an 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 3 TABLE 1 Prevalence of Sociodemographic Characteristics,Lifetime,and Current(Last 30-Day)Use of sufficient to fund compliance checks Each Tobacco Product at Baseline and Rates of Product Initiation at Follow-up Among Youth and enforcement of regulations Residing in a Jurisdiction With ALA Reduced Tobacco Sales,Grade A or D or F prohibiting tobacco sales to minors Grade A Grade D or F and penalties for violating the law, N(%a) N(%a) features of TRL that have been Sex reported to be necessary to reduce Male 324(49.7) 735(50.9) sales to and use by youth.?Compared Female 328(50.3) 710(49.1) with living in a jurisdiction with poor Ethnicity TRL policy,youth in a jurisdiction Hispanic white 349(53.5) 736(50.9) satisfying these criteria were less Non-Hispanic white 230(35.3) 504(34.9) likely to smoke in high school.In a Other 73(11.2) 205(14.2) Parent education prospective follow-up of the cohort, Less than or equal to high school 245(41.3) 460(34.3) the odds of initiation of e-cigarette Some college 219(36.9) 502(37.4) use,with or without past 30-day College or more 129(21.8) 379(28.3) use,and of initiation of cigarette use Prevalent ever tobacco product use at baseline were also lower in well regulated Cigarette 89(13.7) 302(21.0) E-cigarette 123(19.0) 379(26.4) jurisdictions.Stronger associations Hookah 158(24.3) 411 (28.6) among participants still living in their Cigars 69(10.6) 204(14.2) jurisdiction of origin at follow-up Any tobacco product 214(32.9) 564(39.2) evaluation,with consistent exposure Prevalent past 30-d tobacco product use at baseline to the same regulatory environment Cigarette 24(3.7) 95(6.6) E-cigarette 56(8.6) 145(10.1) throughout,also suggest that the Hookah 62(9.5) 162(11.3) benefits of good TRL policy extended Cigars 21 (3.2) 55(3.8) both beyond cigarette use to Any tobacco product 107(16.5) 267(18.6) e-cigarette use and into early adult Initiation oftobacco product use(between baseline and follow life at age 18 when the sale of Up)e Cigarette 52(13.1) 156(18.0) products was legal at the time of the E-cigarette 92(24.7) 235(29.7) study.The protective associations Hookah 55(15.9) 146(18.9) were large,with risk lower by one- Cigars 49(12.0) 158(17.1) third to a half in the strong compared Any tobacco product 85(27.7) 198(30) Initiation with past 30-d tobacco product use at follow-upe with weak TRL jurisdictions Cigarette 17(4.3) 52(6.0) (depending on the outcome). E-cigarette 17(4.7) 69(8.9) Hookah 16(4.7) 32(4.2) There has been uncertainty Cigars 12(2.9) 36(3.9) Any tobacco product 24(7.9) 78(12.1) regarding the effects of youth access restrictions on cigarette use.6,7,16 a The denominator(652 in grade A;1445 in grade D or F)varies because of missing values in covariates. h Restricted to nonusers of each product(or of any tobacco product)at baseline. Some authors Of prospective Studley in which age-specific prevalence of initiation of e-cigarettes(OR 0.74; compared with D-or F-grade tobacco use was assessed before 95%CI 0.55-0.99)and of initiation associations with cigarette and and after regulatory intervention with past 30-day use(OR 0.45;95%CI e-cigarette initiation at follow-up(and to restrict youth access found 0.23-0.90)were also lower in A-grade ofinitiation of e-cigarettes with past reductions in cigarette use,17-20 but than D-or F-grade jurisdictions.In 30-day use)than in the entire sample others found no benefit.21,22 Authors results not shown sensitivity analyses adjusting for time ( )•The protective of 1 review of studies that reported association of A rade residence with changes in smoking associated with since turning 18 at follow-up,there g youth access restrictions found no was no change in the protective effect initiation of cigar use was similar in magnitude to the association with relationship of vendor compliance estimate of living in awell-regulated or of changes in vendor compliance, A- jurisdiction results not cigarette and e-cigarette use but was ( grade) ( not statistically significant. with smoking prevalence in a shown).Participants still living in meta-analysis of available studieS,6 their jurisdiction of origin at follow-up perhaps because the restriction of evaluation would have had consistent DISCUSSION commercial access resulted in a shift exposure to the same regulatory to social sources of cigarettes such environment.In this sample,there Central features of the ALA TRL as older friends or siblings.Authors were stronger protective A-grade grade include a licensing fee of other observational studies have Downloaded from www.aappublications.org/news by guest on May 7,2019 4 ASTOR et al 3.0 found reduced smoking rates in communities with youth access • Lifetime use♦ Past 30-day use restrictions,but it was not clear 15 that reduced access mediated the reduction in smoking rates.19,23 For example,sustained reductions in 2.0 adolescent daily smoking rates were U a° observed in Minnesota communities that were randomly assigned to s intervention supporting community organizers to develop and promote 10 a.° good TLR ordinances,compared with nonintervention communities.20 However,it was not clear whether 0.5 the observed reductions in smoking rates were due to youth access restrictions and improved o° vendor compliance or to other Cigarettes E-cigarettes Hookah Cigars Anytobacco regulatory features resulting from FIGURE 1 the intervention,such as bans on Associations of prevalent lifetime and current(last 30-day)use of each tobacco product at baseline vending machines and requirements with residence in ALA Reduced Tobacco Sales grade A jurisdictions, compared with residence for posted signs reporting age of in grade D or F jurisdictions. Models were adjusted for sex, ethnicity, parental education, age at sale policies,or for storing cigarettes baseline, and for any other tobacco product use at baseline (except for any tobacco product use behind the sales counter.17 prevalence,which was compared with never users of any tobacco product) and included a random effect for jurisdiction. Our results are broadly consistent with findings of a comprehensive 3.0 review in which authors concluded • Initiation that lower smoking rates occur if 2.5 ♦ Initiationwith past30 day use local TRL requires yearly compliance checks with effective enforcement.? Our study is 1 of the few that o assessed associations of TRL with v both prevalence and initiation rates in a prospective assessment e of the same participants during an adolescent period of known o high incidence of initiation.The 1° prospective cohort design of the study also provided the opportunity to examine the impact of TRL on a 5 legal tobacco product use by young adults.The reduced risk of initiation 0.0- of cigarette and e-cigarette use at follow-up in jurisdictions with Cigarettes E-cigarettes Hookah Cigars Anytobacco better TRL regulation(with effect FIGURE 2 estimates that were unaffected by Associations of initiation of use of each tobacco product between baseline and follow-up and of adjusting for time since turning 18 at initiation and current (last 30-day) use, with residence in ALA Reduced Tobacco Sales grade A follow-up)suggests that regulation jurisdictions, compared with residence in grade D or F jurisdictions. Each model was restricted may have lowered initiation rates 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 even after participants reached the use initiation,which was compared with never users of any tobacco product at either baseline or age for legal purchase.Although most follow-up)and included a random effect for jurisdiction. 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 5 product use were substantial,even the time of the study,e-cigarettes will be required of all vendors of in well-regulated jurisdictions.For were not specifically categorized as these products.31 The recent increase example,in jurisdictions with an A a tobacco product.27 Therefore,vape in the legal age of tobacco product grade,rates of initiation of cigarette shops were not required by state law purchase to 21 years in California, and e-cigarette use during the to obtain a tobacco vendor license if passed after data collection for this follow-up period were 13.1%and they were not selling other tobacco study was completed,means that 24.7%,respectively(from Table 1); products.If strong TRL regulation the associations of TRL policy with these high rates of experimentation was responsible for the lower use during the transition to legal indicate a need for interventions to rates of e-cigarette use in A-grade age of purchase may no longer be reduce initiation in this susceptible jurisdictions,it is possible that applicable to California.However,the age window. similar TRL requirements for vape results may broadly be generalizable shops would have resulted in larger to local jurisdictions in states with a An alternative explanation for the protective effects of protective effects. legal purchase age of 18 years,with better TRL policy is that the The US Food and Drug the exception of a few states that have prohibited local jurisdictions associations reflected broadly Administration(FDA)has contracts from enacting more stringent local unfavorable community attitudes with regulators in most states to from enacting The increase n poorly toward cigarette use,including restrict youth tobacco access and reguregulated . cigarette Internet other tobacco regulations that also conducts its own inspections vendors a relatively new way for affected the use of cigarettes and and hires third parties to conduct e-cigarettes to minors.If this were compliance checks. 8 minors ,o obtain tobacco products However,the illegally the time of data collection, the explanation,we might expect frequency of compliance checks is TRL may impact of limit the future impa to have seen associations with generally low,because of resource li li a regulatory tmpa Future the other ALA tobacco grades limitations,and penalties for follow-up of this cohort warranted .3 relating to,for example,smoke-free violation of the law vary widely to determine the persistence warranted housing,smoke-free outdoor air, between states.California,for associations with strong youth of or the overall tobacco grade in a example,which has been a leader TRL and to examine longitudinally jurisdiction.However,protective in tobacco control,annually potential mediating factors, effects only of the TRL grade were inspected,on average,only 7%of such as social characteristics of observed. tobacco retailers in 2016.9,10 If a neighborhoods and communities and high rate of compliance checks, Lower odds of cigar use initiation accompanied by enforcement,is individuals' changing tobacco social associated with better TRL environment over time.There were as our results suggest,then strong regulation,although not statistically necessary reduce youth smoking also other potential confounders or significant,were similar in magnitude local TRL ordinances may be an mediators of TRL effects,such as to reductions in odds of the initiation important option to reduce teen differences in school-level tobacco of cigarettes and e-cigarettes. prevention programs or number of tobacco product use through access However,living in a jurisdiction restriction.10,29,30 tobacco outlets by jurisdiction,that with stronger regulation was not were not available to study. protective for baseline prevalence The study has some limitations.The or subsequent initiation of hookah ALA criteria for an A grade covered use.Sales of hookah paraphernalia a relatively broad spectrum of TRL CONCLUSIONS often occur in specialty shops and policy relevant to youth access, hookah bars where cigarettes may including larger fees,compliance The results suggest that a strong not have been sold24 and therefore access,and penalties if vendors local TRL ordinance that provides may not consistently have been violated the law.Identifying the adequate resources to fund regular subjected to the same rigorous possible effects of specific features compliance checks and enforcement compliance checks as traditional of the TRL policy was not possible. may result in large reductions in cigarette vendors.E-cigarettes are A minimum proportion of vendors the use of cigarettes and may also commonly sold at locations that actually undergoing compliance result in reduced e-cigarette use.The also sell cigarettes that would have checks was not specified,and it was benefits of these policies may extend been subject to TRL regulation,and not possible to assess the effect of into early adult life.The study also a state law passed in 2010 made it the proportion of vendors visited. suggests that the success of future illegal to sell e-cigarettes to minors.25 In addition,the"deeming rule"that FDA regulation to reduce youth However,e-cigarettes are also sold defined e-cigarettes and hookah as cigarette and alternative tobacco in specialty"vape"shops,26 and at tobacco products means that TRL product access and use,under rules Downloaded from www.aappublications.org/news by guest on May 7,2019 6 ASTOR et al deeming these products to be subject policy within the rapidly evolving to FDA regulation,31 may depend tobacco product patterns of use, ABBREVIATIONS on the availability of resources new national regulation,and poorly ALA: American Lung Association for universal annual compliance regulated Internet sales. Cl: confidence interval checks and enforcement targeted e-cigarette: electronic cigarette to both traditional and alternative ACKNOWLEDGMENT FDA: US Food and Drug tobacco product vendors.Continued April Roeseler provided useful Administration OR: odds ratio monitoring is needed to assess the comments on the development of the TRL: tobacco retail licensing impact on the effectiveness of TRL article. 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 1 R21 HD084812-01 from the Eunice Kennedy Shriver National Institute for Child Health and Human Development at the NIH.No funders had any role in the design and conduct ofthe study;collection,management,analysis,or interpretation ofthe 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 NIH 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). can be expected to reduce smoking? 12. 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Cawkwell PB,Lee L,Weitzman M, Tobacco Control Legal Consortium. and regulatory gaps.Drug Alcohol Sherman SE.Tracking hookah bars in State and local tobacco regulation in Depend.2015;156:97-103 Downloaded from www.aappublications.org/news by guest on May 7,2019 8 ASTOR et 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: 10.1542/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 l 73536#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/public_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/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhttnl American Academy of Pediatrics _ DEDICATED TO THE HEALTH OF ALL CHILDREN Downloaded from www.aappublications.org/news by guest on May 7,2019 P DIATRICS OF • U RNAL OF • ICS 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/suppl/2019/01/03/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. �yCAN.q American Academy of Pediatrics _ DEDICATED TO THE HEALTH OF ALL CHILDREN Downloaded from www.aappublications.org/news by guest on May 7,2019 Addictive Behaviors Reports 8(2018)95-101 Contents lists available at ienceDirect Addictive Behaviors Reports ELSMER journal homepage: www.elsevier.com/locate/abrep - - Measurement and predictive value of susceptibility to cigarettes, e-cigarettes, cigars, and hookah among Texas adolescents pdates Felicia R. Carey, Anna V. Wilkinson, Melissa B. Harrell% Elisabeth A. Cohn, Cheryl L. Perry Michael&Susan Dell Center for Healthy Living,University of Texas Health Science Center at Houston,School of Public Health in Austin,1616 Guadalupe S4 Suite 6.300, Austin,TX 78701,United States of America ABSTRACT Susceptibility to cigarette smoking,defined as the lack of a firm commitment not to smoke in the future,begins in childhood and is a phase in the transition from never to ever use of cigarettes.While a consistent and validated predictor of cigarette use,little research has assessed whether the susceptibility construct applies equally well across other tobacco products.Baseline data were collected in 2014-2015 from a representative sample of(n=2844)middle and high school students in five counties surrounding the four largest cities in Texas,(49%female and mean age 13.13 years,with subsequent waves at 6,12,and 18 months.Confirmatory factor analysis examined the appropriateness of a three-item susceptibility measure(product-specific curiosity,intention to use,and peer influence)across product types and ethnic groups (Hispanic versus non-Hispanic). Logistic regression examined whether product specific susceptibility at baseline predicted future product in- itiation. At baseline, 11.5%, 17.0%, 17.4% and 29.4%, of adolescent never users were susceptible to cigars, cigarettes,hookah and e-cigarettes, respectively; significantly more Hispanic than non-Hispanic adolescents were susceptible to e-cigarettes (32.4%versus 26%,p < 0.01) and cigarettes (19.9%versus 13.9%, p < 0.05).Product-specific items were significantly and consistently associated with the respective underlying susceptibility product construct and across ethnic groups(p < 0.001 for all).Susceptibility to e-cigarettes(AOR=2.28-6.64)or any combustible product(cigarettes,hookah,cigars;AOR=3.38-5.20)significantly predicted subsequent ever use.This study confirms the appropriateness of the susceptibility construct across four tobacco product types and ethnic groups,and the utility of susceptibility in predicting future product use among adolescents. 1. Introduction use tobacco products in the future,is a critical construct,predictive of tobacco use and amenable to intervention. Research examining the Use of conventional tobacco products,like cigarettes and cigars,has initial susceptibility construct based on behavioral intentions,peer in- decreased in recent years among adolescents, while use of tobacco fluence, and self-efficacy(Pierce et al., 1996) demonstrated that com- products, like e-cigarettes and hookah, continues to increase (Singh prehensive community anti-smoking media programs, are effective in et al., 2016).These trends and the growing popularity of specific pro- altering and suppressing adolescents' susceptibility to smoking ducts call for identifying risk factors that predict product use initiation. (Meshack et al., 2004). A revised measure of the susceptibility con- Numerous studies have demonstrated susceptibility to cigarettes among struct, which incorporated curiosity with behavioral intentions and never smoking adolescents is associated with increased risk of experi- peer influence, demonstrated little loss in internal consistency, but a mentation with cigarettes and becoming an established smoker reduction in predictive validity and accuracy (Pierce et al., 2005). To (Jackson,1998;Jackson&Dickinson,2004;Nodora et al.,2014;Pierce, date,a few studies have assessed whether the original susceptibility to Choi,Gilpin,Farkas,&Merritt,1996;Pierce,Distefan,Kaplan,&Gilpin, cigarettes construct(Pierce et al.,1996)also can be adapted to measure 2005; Spelman et al., 2009; Strong et al., 2015; Unger, Johnson, susceptibility to other products, like e-cigarettes, hookah, and cigars Stoddard, Nezami, &Chou, 1997). Limited research suggests that sus- (e.g.,Bold et al.,2017;Lechner et al.,2018),and none have examined ceptibility to e-cigarettes or hookah independently predicts future e- the susceptibility construct that includes curiosity. Yet, recent survey cigarette (Bold, Kong, Cavallo, Camenga, & Krishnan-Sarin, 2017) or data suggest that the most common reason for adolescents to try e- hookah use(Lipkus,Reboussin,Wolfson,&Sutfin,2015),respectively, cigarettes is out of curiosity (Kong, Morean, Cavallo, Camenga, & and that susceptibility to cigarettes predicts future e-cigarette and cigar Krishnan-Sarin, 2015; Patrick et al., 2016). Thus, utilizing a suscept- use(Cole,Kennedy,Chaurasia,&Leatherdale, 2017).Still,few studies ibility construct that includes curiosity might be particularly useful to have examined product-specific susceptibility measures in predicting our understanding of susceptibility to non-cigarette tobacco products. future use of products other than cigarettes. Additionally, no studies have assessed whether the susceptibility Susceptibility,which reflects the lack of a firm commitment not to construct (Pierce et al., 2005) functions equally across ethnic groups. *Corresponding author. E-mail address:Melissa.B.Harrell@uth.tmc.edu(M.B.Harrell). https://doi.org/10.1016/j.abrep.2018.08.005 Received 17 April 2018;Received in revised form 3 August 2018;Accepted 16 August 2018 Available online 18 August 2018 2352-8532/©2018 The Authors.Published by Elsevier Ltd.This is an open access article under the CC BY-NC-ND license (http://creativeco mmo ns.orgAicenses/BY-NC-ND/4.O/). ER Carey et d Addictive Behaviors Reports 8(2018)95 101 Table 1 Demographics and susceptibility to e-cigarettes and combustible tobacco products among Hispanic and non-Hispanic never users at baseline,TATAMS(n=2844; N=318,097). Variable Hispanic Non-Hispanic Total %(95%CI) %(95%CI) %(95%CI) Sex Female 47.7(41.1-54.5) 50.3(45.1-55.5) 49.0(43.7-54.3) Male 52.3(45.5-58.9) 49.7(44.5-54.9) 51.0(45.7-56.3) Grade 6 39.8(28.4-52.5) 36.6(23.6-52.0) 38.3(26.9-51.1) 8 35.3(24.4-48.0) 34.4(20.2-51.9) 34.9(23.7-47.9) 10 24.9(15.1-38.3) 29.0(18.4-42.7) 26.9(17.7-38.6) Age(mean,SE) 13.14(0.19) 13.12(0.19) 13.13(0.17) Family SES High 15.8(12.9-19.3) 25.2(18.7-33.0) 20.3(16.2-25.1) Middle 64.4(612-67.5) 61.6(56.2-66.7) 63.1(60.2-65.9) Low 19.8(16.8-232) 13.2(101-17.2) 16.6(14.1-19.6) Susceptibility to e-cigarettes items' Have you ever been curious about smoking/using e-cigarettes? 26.9(23.5-30.7) 22.2(19.0-25.9) 24.7(21.9-27.7)* Do you think you will use e-cigarettes in the next 12 months? 10.5(8.3-13.1) 8.0(6.1-10.4) 9.3(7.6-11.3) If one of your close friends were to offer you an e-cigarette,would you use it? 17.9(15.1-21.1) 13.0(10.7-15.6) 15.6(13.6-17.7)* Susceptibility to e-cigarettes(derived)b 32.4(28.7-36.3) 26.0(22.3-30.1) 29.4(26.2-32.7)** Susceptibility to cigars(large cigars,cigarillos,and little filtered cigars)items' Have you ever been curious about smoking/using cigars? 7.6(5.6-10.3) 7.0(5.3-9.0) 7.3(6.0-8.8) Do you think you will use cigars in the next 12 months? 4.3(2.8-6.5) 3.2(2.2-4.6) 3.8(2.8-5.0) If one of your close friends were to offer you a cigar,would you use it? 7.4(5.0-10.8) 4.5(32-6.2) 6.0(4.6-7.8) Susceptibility to cigars(derived)b 12.8(9.7-16.7) 10.2(7.9-13.0) 11.5(9.5-13.9) Susceptibility to hookah items' Have you ever been curious about smoking/using hookah? 14.7(11.8-182) 12.5(9.6-162) 13.7(11.3-16.4) Do you think you will use hookah in the next 12 months? 6.9(5.0-9.4) 5.3(3.6-7.6) 6.1(4.6-8.1) If one of your close friends were to offer you hookah,would you use it? 9.8(7.6-12.6) 7.8(5.8-10.5) 8.9(72-10.9) Susceptibility to hookah(derived)b 18.8(152-23.1) 15.7(12.1-202) 17.4(14.6-20.6) Susceptibility to cigarettes items' Have you ever been curious about smoking/using cigarettes? 13.3(10.8-16.4) 10.0(8.3-12.1) 11.8(10.1-13.7)* Do you think you will use cigarettes in the next 12 months? 5.1(3.4-7.4) 3.9(2.8-5.4) 4.5(3.5-5.8) If one of your close friends were to offer you cigarettes,would you use it? 8.4(5.8-12.0) 6.2(4.6-8.2) 7.3(5.7-9.3) Susceptibility to cigarettes(derived)b 19.9(15.6-25.0) 13.9(11.5-16.7) 17.0(14.4-20.0)* Susceptibility to any combustible tobacco product(derived)b 29.1(24.5-34.1) 22.9(18.8-27.7) 26.2(22.7-29.9)* Note:CI=confidence interval,SE=standard error.All frequencies and means are weighted to account for complex survey design.Never users represent adolescents who have never used any of the four product types.n represents the observed sample size,N represents the weighted sample size. "Any combustible"includes cigarettes,cigars,and hookah. p < 0.05, *p < 0.01 for Chi-square test of Hispanic versus non-Hispanic across categories of the item. a For set of items,%(95%Cl)represents the proportion of adolescents who said anything other than"not at all curious"to the first item and"definitely not"to the second two items. b For items,%(95%Cl)represents the proportion of adolescents classified as susceptible. Hispanic adolescents who have never smoked report greater intentions cigarettes)and in predicting future initiation of these products among to smoke cigarettes in the future compared to white peers (Bunnell Hispanic and non-Hispanic adolescent never users in grades 6,8,and 10 et al.,2015)and greater curiosity about e-cigarettes(Margolis,Nguyen, in Texas. We hypothesized the measurement of susceptibility would Slavit, & King, 2016). In addition, Hispanic adoles apply equally across products, and each product-specific susceptibility ceptiblellOWarettes (Fulmer et al., 2015; Gritz ct construct would predict future use of each product.We also hypothe- ettes (Singh et al., 2016; U.S. Department of Heal an uman sized the measurement of susceptibility constructs for each product (Trinidad ct al., 2017), compared to non- would apply equally across Hispanic and non-Hispanic subgroups, This is a concern because comparatively, though prevalence of susceptibility to each product may be higher for Hispanics are the youngest ethnic group in the nation, with a large Hispanic adolescents. proportion of the Hispanic population(roughly a third)being under the age of 18 years (Patten, 2016), and Hispanic youth report a higher 2. Methods prevalence of e-cigarette use in middle school in the past 30 days compared to non-Hispanic youth of all races (Singh et al., 2016). 2.1. Study design and participants Considering existing tobacco-related health disparities (Centers for Disease Control and Prevention,2018)and the expected near doubling The Texas Adolescent Tobacco and Marketing Surveillance system of the Hispanic population over the next 30 years(Krogstad,2014),it is (TATAMS) is a rapid response surveillance system that follows three important to determine whether constructs predicting future use, like population-based cohorts of adolescents, to represent developmental susceptibility, are applicable across ethnic groups. Such information changes in tobacco use behaviors. A complex probability design was can inform the development of culturally sensitive interventions and used to recruit 3907 students (n) in 79 middle and high schools in 4 communication campaigns designed to reduce susceptibility and ulti- major metropolitan areas of Texas (Austin, San Antonio, Dallas-Ft. mately product use. Worth, & Houston); when sampling weights are applied in statistical The goal of this study was to evaluate the utility of a three-item data analyses, results are representative of 461,069 (N) students who susceptibility construct adapted from Pierce et al. (2005), assessing were enrolled in the 6th,8th,and loth grades in 1969 middle and high curiosity, intention to use, and peer influence, in measuring suscept- schools in these cities during the 2014-15 academic year. Further de- ibility at baseline to four products (e-cigarettes, hookah, cigars, and tails about TATAMS'sampling methods and recruitment are described 96 RK Carey et al Addictive Behaviors Reports 8(2018)95 101 elsewhere in Perez et al.(2017).Active parental consent was obtained cigars,hookah, and cigarettes,with individuals who were non-suscep- for all surveys,for all students. tible to all three products categorized as non-susceptible, those who Baseline data were collected during the 2014-2015 academic year were susceptible to one or more products categorized as susceptible, from 3907 students via web-based surveys administered on tablets in and those who were missing on susceptibility variables for all three the classroom,with three follow-up data collection periods occurring 6, products labeled as missing. 12, and 18 months after baseline via similarly formatted web-based surveys administered outside the classroom. At 6 months 64% were 2.2.2. Ever use retained,at 12 months 70%were retained,and at 18 months 74%were E-cigarette,cigar,hookah,and cigarette ever use were measured at retained. These retention rates are comparable to other cohorts na- 6,12,and 18 months by one item each asking,"Have you ever smoked/ tionwide with similar data collection schedules and incentive structures used [this product], even one or two puffs?" with "Yes" responses (Cantrell et al., 2018). Survey items were adapted from valid and re- classified as ever users of each product and"No"responses classified as liable measures used for state and national tobacco surveillance, like never users.Ever use of any combustible product was measured based the Population Assessment of Tobacco and Health (PATH) study on whether adolescents were classified as ever users of any of the three (Hyland et al., 2017); cognitive interviewing among students, aged combustible products (cigars,hookah,or cigarettes). 11-18, assessed the reliability and content validity of all survey ques- tions. The final survey included over 340 items assessing socio- 2.2.3. Covariates demographic factors, tobacco use behaviors, cognitive and affective Covariates included sex(male or female), grade level(6,8,or 10), factors, and exposure to tobacco marketing. The median number of age (range: 10-18 years), ethnicity, and family SES. Ethnicity was di- questions received by students was 137,with an average administration chotomized as Hispanic versus non-Hispanic, which includes non- time of 45 minutes. The majority of students (58.1%) answered all Hispanic adolescents of white,black, and other races. Family SES was items,and 92%of students answered 96%or more of the items(Delk, measured by one item asking,"In terms of income,what best describes Harrell, Fakhouri,Muir, &Perry, 2017).Active consent from parents/ your family's standard of living in the home where you live most of the guardians and assent from students were obtained for all data collection time?" with response options categorized as high ("very well off'), waves.TATAMS was approved by the University of Texas Health Sci- middle ("living comfortably"), and low ("just getting by," "nearly ence Center at Houston Institutional Review Board(HSC-SPH-13-0377). poor,"and"poor")(Gore,Aseltine Jr.,&Colten,1992;Romero,Cuellar, The population for this study was limited to 2844 adolescents, or &Roberts,2000;Springer,Selwyn,&Kelder,2006). 72.8% of those enrolled at baseline, classified as never users of any product at baseline (i.e., a never user of e-cigarettes, cigars, hookah, 2.3. Analyses and cigarettes)with complete data on all sociodemographic variables. Sampling weights were utilized, allowing the study population to be The distribution of demographic and susceptibility measures across representative of 318,097 students enrolled in 6th,8th,and loth grades the total study population and by ethnicity were examined, and Chi- at baseline in these five Texas counties.As can been seen in Table 1,at square tests assessed statistically significant differences between baseline,sex was equally distributed(51%male),38.3%of adolescents Hispanic and non-Hispanic adolescents across categories of these items. were in grade 6,and mean age was 13.13(SE=0.17).Most adolescents Confirmatory factor analysis(CFA)assessed the fit of the three-item had a middle range family socioeconomic status (SES) (63.1%). His- susceptibility construct for each of the four products among the total panic adolescents represented 52.4%of the study population.Of note, population and by ethnicity, using a robust weighted least squares the Hispanic(n= 1430) and non-Hispanic (n= 1414)youth included approach with mean and variance adjusted estimation. CFA models in this analysis did not differ in terms of susceptibility to any of the four were evaluated based on significance and size of model parameter es- products examined to those excluded from the analysis due to missing timates, and overall goodness-of-fit parameters, including the root covariates (p < 0.05 for all;data not shown). mean square error of approximation (RMSEA, values<0.06 indicate good fit), the comparative fit index (CFI, values>0.95 indicate good 2.2. Measures fit),the Tucker-Lewis index(TLI,values >0.95 indicate good fit),and the weighted root mean square residual(WRMR,values< 1.0 indicate 2.2.1. Susceptibility good fit) (Hu&Bender, 1999;Yu,2002). Susceptibility to four product classes was examined among never Following confirmation that each susceptibility construct fit ap- users of any product: 1)e-cigarettes, 2)cigars (large cigars, cigarillos, propriately across products and ethnicities,the predictive value of each and little filtered cigars),3)hookah,and 4)cigarettes.Susceptibility to derived susceptibility variable on future use of each product was ex- each product was assessed by three items asking,"Have you ever been amined at 6, 12, and 18 months among the total population and by curious about smoking/using [this product]?", "Do you think you will ethnicity using Chi-square tests. Due to low numbers of ever users of use [this product] in the next 12 months?", and "If one of your close combustible products, ever use of cigars,hookah, and cigarettes were friends were to offer you [this product],would you use it?"Response combined as ever use of any combustible product, and logistic regres- options included "Not at all curious," "A little curious," "Somewhat sion models examined the effect of susceptibility to e-cigarettes and any curious," or "Very curious" for the first item and "Definitely not," combustible product, separately, at baseline on ever use of these pro- "Probably not," "Probably yes," or"Definitely yes" for the other two ducts at follow-up, adjusted for sex,age,family SES, and ethnicity. items.These items are adapted from a four item measure that has de- All analyses were conducted using Stata 14.0(College Station,TX) monstrated good internal consistency in prior studies (a=0.74) and Mplus Version 7(Los Angeles,CA),utilizing complete case analysis (Pierce et al., 2005) and is a strong predictor of future cigarette ex- of never users of any product at baseline. Analyses also incorporated perimentation(Pierce et al., 1996,2005). sampling weights and considered clustering within school districts and Adolescents were categorized as non-susceptible to each individual stratification of schools based on proximity to point of sale tobacco item if they responded"Not at all curious"or"Definitely not,"with any outlets to account for complex design(Perez et al., 2017). other response categorized as susceptible. Derived susceptibility vari- ables were created for each product, with individuals who were non- 3. Results susceptible to all three items categorized as non-susceptible,those who were susceptible to one or more items categorized as susceptible, and 3.1. Descriptive statistics those who were missing on any item labeled as missing. Susceptibility to any combustible product was derived based on susceptibility to At baseline (fable 1), the most commonly endorsed susceptibility 97 ER Carey et d Addictive Behaviors Reports 8(2018)95 101 item across products was curiosity (24.7%for e-cigarettes, 13.7% for among Hispanic and non-Hispanic groups,with two exceptions.Among hookah, 11.8% for cigarettes, and 7.3% for cigars), while the least Hispanic adolescents only,intention to use displayed the largest factor commonly endorsed item was intention to use (9.3% for e-cigarettes, loading(P=0.888,SE=0.090)for cigarette susceptibility,while peer 6.1% for hookah, 4.5%for cigarettes, and 3.8%for cigars). Based on influence displayed the largest factor loading(3 =0.931,SE=0.070) derived susceptibility variables,29.4%of adolescents were susceptible for cigar susceptibility. Additional tests to examine differences in the to e-cigarettes, 17.4%susceptible to hookah, 17.0% susceptible to ci- measurement of each product specific construct when ethnicity is in- garettes, and 11.5% susceptible to cigars; 26.2% were susceptible to cluded in the model, ethnicity was significant to the measurement of any combustible product(hookah,cigarettes, or cigars). susceptibility to e-cigarettes, but not to the measurement of suscept- Significant differences between Hispanic and non-Hispanic adoles- ibility to other products (results not shown). However, the overall cents were observed for family SES,e-cigarette susceptibility,cigarette model fit, as well as factor loadings and the significance of each sus- susceptibility, and susceptibility to any combustible product. For e-ci- ceptibility item,remained consistent with e-cigarette models presented garette susceptibility,Hispanic adolescents, compared to non-Hispanic in Table 2. adolescents, endorsed curiosity (26.9%versus 22.2%) and peer influ- ence (17.9% versus 13.0%) items more often and had a higher pre- valence of being susceptible (32.4%versus 26.0%). For cigarette sus- 3.3. Predictive validity ceptibility, Hispanic adolescents, compared to non-Hispanic adolescents, endorsed curiosity more often (13.3%versus 10.0%)and Among the total population, there were significant differences in had a higher prevalence of being susceptible (19.9% versus 13.9%). ever use at 6, 12, and 18 months based on susceptibility status at Hispanic adolescents had a higher prevalence of being susceptible to baseline for e-cigarettes, cigarettes,hookah, and any combustible pro- any combustible product (29.1%) compared to non-Hispanic adoles- duct (Fig. 1). Specifically, 6.3% of adolescents susceptible to e-cigar- cents(22.9%). ettes at baseline used e-cigarettes at 6 months,11.3%at 12 months,and 13.8% at 18 months, versus 0.9%, 2.1%, and 4.6%of non-susceptible adolescents, respectively (p < 0.05 for all). Of those susceptible to 3.2. Confirmatory factor analysis cigarettes at baseline, 2.6% used cigarettes at 6 months, 6.6% at 12 months, and 9.4% at 18 months, versus 0.7%, 1.5%, and 2.8% of For the CFA among the total population and by Hispanic and non- non-susceptible adolescents, respectively (p < 0.05 for all). Of those Hispanic ethnicity (Fable 2), parameter estimates for each item (curi- susceptible to hookah at baseline,1.3%used hookah at 6 months,2.7% osity,intention to use,and peer influence)were significant(p < 0.001) at 12 months, and 3.8%at 18 months, versus 0%, 0.2%, and 0.4% of and displayed large loadings onto product specific susceptibility latent non-susceptible adolescents, respectively (p < 0.05 for all). Among factors. Goodness-of-fit statistics suggested each susceptibility model adolescents susceptible to any combustible product at baseline, 3.7% was an appropriate fit to the data (RMSEA < 0.06, CFI > 0.95, used any combustible product at 6 months, 7.4% at 12 months, and TLI > 0.95, WRMR < 1.0 for all) among the total population and 12.3% at 18 months, versus 0.7%, 1.7%, and 3.5%of non-susceptible Hispanic and non-Hispanic groups specifically. adolescents, respectively(p < 0.05 for all).There were no significant Among the total population, peer influence displayed the largest differences in cigar ever use at any time point based on susceptibility to factor loading for e-cigarette susceptibility (3=0.980, SE=0.029), cigars at baseline. cigarette susceptibility (3=0.904, SE=0.055), and hookah suscept- When ethnicity was considered as a potential effect modifier of ibility (3=0.951, SE=0.025), while intention to use displayed the these relationships, few differences were noted.Among Hispanic ado- largest factor loading for cigar susceptibility(P=0.928, SE=0.042). lescents, there were no significant differences in cigarette ever use at Curiosity displayed the lowest loading for all susceptibility constructs 6 months based on susceptibility to cigarettes at baseline; significant among the total population (3=0.802, SE=0.036 for e-cigarettes; differences in ever use only emerged at 12 and 18 months(p < 0.05 for 0=0.644, SE=0.070 for cigarettes; 0=0.818, SE=0.043 for both). Among non-Hispanic adolescents, there were significant differ- hookah; 0=0.755,SE=0.052 for cigars). ences in cigar ever use at 12 and 18 months based on susceptibility to Results were consistent overall when examining each construct cigars at baseline, with 4.2% of susceptible adolescents using at Table 2 Confirmatory factor analysis of susceptibility items for each product, total population and by ethnicity among never users at baseline, TATAMS (n=2844; N=318,097). Susceptibility constructs Total Hispanic Non-Hispanic Factor loading S.E. p-Value Factor loading S.E. p-Value Factor loading S.E. p-Value E-cigarettes Curiosity 0.802 0.036 <0.001 0.781 0.050 <0.001 0.824 0.041 <0.001 Intention 0.865 0.029 <0.001 0.825 0.049 <0.001 0.914 0.026 <0.001 Friends 0.980 0.029 <0.001 1.000 0.041 <0.001 0.958 0.031 <0.001 Cigarettes Curiosity 0.644 0.070 <0.001 0.565 0.111 <0.001 0.735 0.079 <0.001 Intention 0.856 0.054 <0.001 0.888 0.090 <0.001 0.831 0.054 <0.001 Friends 0.904 0.055 <0.001 0.858 0.072 <0.001 0.948 0.073 <0.001 Hookah Curiosity 0.818 0.043 <0.001 0.792 0.071 <0.001 0.854 0.053 <0.001 Intention 0.934 0.024 <0.001 0.949 0.032 <0.001 0.912 0.031 <0.001 Friends 0.951 0.025 <0.001 0.959 0.033 <0.001 0.935 0.034 <0.001 Cigars Curiosity 0.755 0.052 <0.001 0.728 0.076 <0.001 0.796 0.052 <0.001 Intention 0.928 0.042 <0.001 0.909 0.064 <0.001 0.943 0.045 <0.001 Friends 0.897 0.049 <0.001 0.931 0.070 <0.001 0.858 0.066 <0.001 Note:SE=standard error.Cigars include large cigars,cigarillos,and little filtered cigars.Factor loadings for each confirmatory factor analysis model are a measure of how well each specific item loads onto the respective factor(i.e.,susceptibility construct),ranging from 0(poor association)to 1(strong association). 98 F.R.Carey et d Addictive Behaviors Reports 8(2018)95 101 ■Ever Use at 6 Months a Ever Use at 12 Months .Ever Use at 18 Months 16 15 13.8 14 13 * 12.3 12 11.3 11 10 9.4 9 Ever 8 * 7.4 Use 7 6.3 6.6 6 5 4.6 4 * * 3.8 3.8 3.5 3.7 3 2.1 2.8 2.6 2.7 2.4 2.3 * 1.5 1.7' 1 , ■- 0.0 002 0.4 ' 0.61.0 1.1� 0.71 ■® ■ 11 Non-Susceptible Susceptible Non-Susceptible Susceptible Non-Susceptible Susceptible Non-Susceptible Susceptible Non-Susceptible Susceptible E-Cigarettes Cigarettes Hookah Cigars Any Combustible Fig.1.Comparison of susceptibility at baseline among never users and subsequent ever use of each product at 6,12,and 18 months.Note:*indicates p < 0.05 for the Chi-square test of group differences in ever use of each specific product at each time point by susceptibility status for each specific product at baseline. 12 months and 5.9%at 18 months, versus 0.9%and 1.7% of non-sus- times higher odds of ever use of any combustible product at 12 and ceptible adolescents,respectively(p < 0.05 for both). 18 months, respectively. Similarly, susceptibility to any combustible In the adjusted logistic regression models (Table 3) examining the product significantly predicted ever use at all time points, with sus- association between susceptibility and ever use at 6,12,and 18 months ceptible adolescents having 5.20(95%Cl: 1.92-14.07), 3.89(95%Cl: for e-cigarettes,age was the only covariate significantly associated with 2.17-6.95),and 3.38(95%Cl:2.03-5.62)times higher odds of ever use ever use at any time point. Each year increase in age was associated of any combustible product at 6, 12, and 18 months, respectively, with 1.46 (95% CI: 1.17-1.82), 1.55 (95% Cl: 1.31-1.84), and 1.33 compared to non-susceptible adolescents. There were no significant (95%CI:1.08-1.64)times higher odds of e-cigarette ever use at 6, 12, interactions between ethnicity and susceptibility to e-cigarettes or any and 18 months, respectively. Similarly, susceptibility to e-cigarettes combustible product at any time point. significantly predicted ever use across time points, with susceptible adolescents having 6.64 (95% CI: 3.39-13.00), 5.01 (95% CI: 2.69-9.34), and 2.88 (95% Cl: 1.66-4.97) times higher odds of a-ci- 4. Discussion garette ever use at 6,12,and 18 months,respectively,compared to non- susceptible adolescents. Among this population of Texas adolescents,we observed the three- For models considering any combustible product, age was sig- item susceptibility measure adapted from Pierce et al. (2005)was ro- nificantly associated with ever use,with each year increase in age being bust across tobacco products and ethnic groups. Consistent with our associated with 1.33(95%Cl:1.09-1.62)and 1.34(95%CI:1.16-1.54) first hypothesis and past research examining susceptibility in the con- text of cigarettes (Nodora et al., 2014; Pierce et al., 1996, 2005), we Table 3 Adjusted logistic regression of susceptibility to each product at baseline on ever use at 6 months,12 months,and 18 months among never users at baseline(n=2844; N=318,097 at baseline). Variable Ever use at 6 months Ever use at 12 months Ever use at 18 months OR 95%CI p-Value OR 95%Cl p-Value OR 95%CI p-Value E-cigarettes Sex(ref:female) Male 1.30 0.61-2.76 0.488 1.08 0.73-1.61 0.700 1.31 0.88-1.96 0.185 Age 1.46 1.17-1.82 0.001 1.55 1.31-1.84 <0.001 1.33 1.08-1.64 0.008 Family SES(ref:middle) High 1.65 0.55-4.98 0.368 1.00 0.45-2.20 0.993 1.24 0.63-2.44 0.521 Low 0.64 0.22-1.89 0.412 0.45 0.18-1.12 0.085 0.83 0.33-2.07 0.682 Ethnicity(ref:non-Hispanic) Hispanic 1.29 0.60-2.76 0.599 0.99 0.60-1.63 0.966 0.93 0.60-1.44 0.740 Susceptible to e-cigarettes(ref no) Yes 6.64 3.39-13.00 <0.001 5.01 2.69-9.34 <0.001 2.88 1.66-4.97 <0.001 Any combustible product Sex(ref:female) Male 0.85 0.33-2.15 0.725 0.97 0.50-1.89 0.920 1.05 0.59-1.87 0.867 Age 1.18 0.88-1.59 0.267 1.33 1.09-1.62 0.005 1.34 1.16-1.54 <0.001 Family SES(ref:middle) High 0.54 0.10-2.81 0.458 1.17 0.58-2.38 0.662 1.30 0.74-2.26 0.356 Low 1.08 0.29-4.03 0.904 1.21 0.49-3.03 0.673 1.19 0.59-2.43 0.620 Ethnicity(ref:non-Hispanic) Hispanic 0.74 0.27-2.14 0.575 0.97 0.48-1.95 0.930 0.99 0.61-1.63 0.983 Susceptible to any combustible(ref:no) Yes 5.20 1.92-14.07 0.001 3.89 2.17-6.95 <0.001 3.38 2.03-5.62 <0.001 Note:OR=odds ratio,Cl=confidence interval,SES=socioeconomic status."Any combustible"includes cigarettes,cigars,and hookah. 99 ER Carey et al Addictive Behaviors Reports 8(2018)95 101 confirmed curiosity,intention to use,and peer influence are significant independent of susceptibility (Pierce et al., 2005), warranting further and appropriate items to consider in measuring susceptibility to e-ci- examination of factors leading Hispanic adolescents to be more curious garettes, cigarettes,hookah, and cigars among this adolescent popula- about these products. Despite a higher reported prevalence of sus- tion.Across products,we observed minor differences in the strength of ceptibility to e-cigarettes and cigarettes among Hispanic adolescents,no each item.Specifically,curiosity had the weakest relationship with the significant interactions were observed between ethnicity and suscept- underlying susceptibility construct across all products, peer influence ibility in predicting future use.Although more Hispanic adolescents are had the strongest relationship with susceptibility to e-cigarettes, ci- susceptible to e-cigarettes and cigarettes than their non-Hispanic peers garettes, and hookah, and future intentions had the strongest re- (and Hispanic adolescents endorse curiosity about products more than lationship with susceptibility to cigars.While all three factors may be non-Hispanic peers), the relationship between the measure of suscept- influential in determining adolescent susceptibility to tobacco products, ibility itself and ever use of e-cigarettes and cigarettes is consistent intervention efforts to alter susceptibility may need to be tailored by across ethnic groups.This suggests that tailoring interventions designed product. to ameliorate susceptibility among Hispanics to address curiosity might We observed almost 30% of adolescents were susceptible to a-ci- be particularly useful. garettes at baseline,a prevalence nearly double that of each individual combustible product.Adolescents may be more susceptible to e-cigar- 4.1. Strengths and limitations ettes than other products, and more research is needed to investigate factors driving increased susceptibility, like the appeal of flavors One study limitation is the low prevalence of ever users at future (Ambrose et al., 2015) or increased television and digital media mar- time points for specific products,like hookah and cigars.This prevented keting(Duke et al.,2014;Mantey,Cooper,Clendennen,Pasch,&Perry, examination of susceptibility to these products separately at baseline 2016;Pierce et al.,2017).As expected,we observed susceptibility to e- regarding future use; thus, we cannot draw conclusions about specific cigarettes and combustible products predicts product use at time points predictive validity of susceptibility to individual combustible products. 6, 12, and 18 months in the future. This is consistent with previous Still, our examination of combustible products as a whole provides research(Bold et al.,2017;Cole et al.,2017;Jackson,1998;Jackson& evidence for susceptibility as a predictor of product use among ado- Dickinson, 2004; Nodora et al., 2014; Pierce et al., 1996, 2005; lescents. Additionally, our three-item construct only includes a single Spelman et al.,2009;Strong et al.,2015;Unger et al., 1997)and sug- measure of intentions to use tobacco in the future, rather than both gests targeting and lessening susceptibility through intervention efforts measures originally considered by Pierce et al.(2005),which may limit remains a significant factor in preventing initiation of multiple forms of the ability to make comparisons between our susceptibility measures product use among adolescents. and those used in other studies.Next,this study population is limited by Of note, the declining magnitude of the odds ratios predicting in- geography,so findings may not be generalizable to adolescents outside itiation from any combustible product over time was not statistically Texas. Finally, despite utilizing measures adapted from established different from each other, based on a comparison of their 95% con- surveys(Hyland et al.,2017)and thorough cognitive testing,self-report fidence intervals.In contrast,the declining odds ratios for susceptibility of data may lead to response bias. to e-cigarette use over time show a significant drop in influence on ever Despite limitations, this study is strengthened by the large,diverse use at 18 months from susceptibility assessed at baseline.This suggests population of Texas adolescents, which provided adequate power to that by 18 months when compared to 6 and 12 months, other factors examine specific associations across ethnic groups and products. The exert a stronger influence on experimentation relative to susceptibility complex survey design and use of analyses accounting for sampling status assessed 18 months earlier. In turn, this suggests that assessing weights and clustering within schools yield results representative of the susceptibility to e-cigarettes more frequently may be necessary to in- overall population of urban Texas adolescents in grades 6, 8, and 10. form the development of targeted long-term interventions, as is iden- This study's longitudinal design and breadth of tobacco products allows tification of other factors that may be proximally related to e-cigarette for investigation of all products concurrently, within the same popu- use. lation and across time points, permitting temporal conclusions about Congruous with our second hypothesis,we found the measurement the role of susceptibility on future initiation, and extending past re- of each susceptibility construct across products applied equally well search,which has yet to examine multiple product types longitudinally across ethnic groups. Results among groups were consistent with the among the same cohort. entire population,with minor differences.Among Hispanic adolescents, intention to use had the strongest relationship with susceptibility to 4.2. Conclusions cigarettes, while peer influence had the strongest relationship among non-Hispanic adolescents.In contrast,peer influence had the strongest Susceptibility is a key construct for predicting future initiation of relationship with susceptibility to cigars among Hispanic adolescents, tobacco;past research has examined its validity relevant to cigarettes, while intention to use had the strongest relationship among non- but not among contemporary adolescent populations and the changing Hispanic adolescents. Additionally, ethnicity was significant to the landscape of tobacco products.This study confirms the appropriateness measurement of susceptibility to e-cigarettes as a whole;the differences of the measurement of susceptibility (Pierce et al., 2005) across four in the model when considering ethnicity suggest that while the mea- products(e-cigarettes,hookah,cigars,and cigarettes)and ethnic groups surement of susceptibility to e-cigarettes is valid across ethnic groups, (Hispanic versus non-Hispanic), and the utility of susceptibility in the meaning of the construct may vary slightly depending on ethnicity. predicting future tobacco product use among adolescents.Implications Thus,while it is appropriate to utilize the same susceptibility measure for intervention and research emphasize the importance of suscept- across ethnic groups, specific influences may be more relevant to pre- ibility in predicting initiation of product use and the need to investigate dicting susceptibility for Hispanics vs. non-Hispanics depending on factors influencing susceptibility to specific products,like e-cigarettes, product type, and specifically, susceptibility to e-cigarettes should be especially among Hispanic adolescents. considered separately by ethnicity. While we expected Hispanic adolescents would have a higher pre- Compliance with ethical standards valence of susceptibility to each product than non-Hispanic adolescents, this was observed only for e-cigarettes and cigarettes, with curiosity Ethical approval about these products endorsed more often among Hispanic adolescents. This is consistent with previous research (Margolis et al., 2016), and TATAMS was approved by the University of Texas Health Science notable, as curiosity predicts future experimentation with smoking Center at Houston Institutional Review Board (HSC-SPH-13-0377).All 100 F.R.Carey et al. Addictive Behaviors Reports 8(2018)95 101 procedures performed in studies involving human participants were in Hyland,A.,Ambrose,B.K,Conway,K.P.,Borek,N.,Lambert,E.,Carusi,C.,...Compton, accordance with the ethical standards of the institutional and/or na- W.M.(2017).Design and methods of the population assessment of tobacco and health(PATH)study.Tobacco Control 26(4),371-378.https://doi.org/10.1136/ tional research committee and with the 1964 Helsinki declaration and tobaccocontrol-2016-052934. its later amendments or comparable ethical standards.This article does Jackson,C.(1998).Cognitive susceptibility to smoking and initiation of smoking during not contain any studies with animals performed by any of the authors. childhood:A longitudinal study.Preventive Medicine,27(1),129-134.https://doi. org/10.1006/pmed.1997.0255. Jackson,C.,&Dickinson,D.(2004).Cigarette consumption during childhood and per- Informed consent sistence of smoking through adolescence.Archives of Pediatrics&Adolescent Medicine, 158(11),1050-1056.https://doi.org/10.1001/arrhpedi.158.11.1050. Kong,G.,Morean,M.E.,Cavallo,D.A.,Camenga,D.R.,&Krishnan-Sarin,S.(2015). Informed consent was obtained from all individual participants in- Reasons for electronic cigarette experimentation and discontinuation among ado- cluded in the study. lescents and young adults.Nicotine&Tobacco Research,17(7),847-854.https://doi. org/10.1093/ntr/ntu257. Krogstad,J.M.(2014).With fewer-new-arrivals-census-lowers-hispanic population projec- Role of funding sources tions.Washington,D.C.:Pew Research Center. Lechner,W.V.,Murphy,C.M.,Colby,S.M.,Janssen,T,Rogers,M.L.,&Jackson,K.M. (2018).Cognitive risk factors of electronic and combustible cigarette use in adoles- This work was supported by the National Cancer Institute (NIH/ cents.Addictive Behaviors,82,182-188.https://doi.org/10.1016/j.addbeh.2018.03. NCI)and the FDA Center for Tobacco Products(CTP)(TATAMS) [grant 006. Lipkus,I.M.,Reboussin,B.A.,Wolfson,M.,&Sutfin,E.L.(2015).Assessing and pre- number 1 P50 CA1809061. The content is solely the responsibility of dicting susceptibility to waterpipe tobacco use among college students.Nicotine& the authors and does not necessarily represent the official views of the Tobacco Research,17(9),1120-1125.https://doi.org/10.1093/ntr/ntu336. National Institutes of Health or the Food and Drug Administration. Mantey,D.S.,Cooper,M.R.,Clendeanen,S.L.,Pasch,K E.,&Perry,C.L.(2016).E- cigarette marketing exposure is associated with e-cigarette use among U.S.youth. Journal of Adolescent Health,58(6),686-690.https://doi.org/10.1016/j.jadohealth. Contributors 2016.03.003. 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Cigarettes and smokeless tobacco are at all-time youth usage lows since the law raising the minimum age of purchase to 21 went into effect and bans of vaping products discourage current smokers from switching to less harmful options. The California Retailers Association is the only statewide trade association representing all segments of the retail industry including general merchandise, department stores, mass merchandisers, fast food restaurants, convenience stores, supermarkets and grocery stores, chain drug, and specialty retail such as auto,vision,jewelry, hardware and home stores. CRA works on behalf of California's retail industry, which currently operates over 164,200 stores and employs around 2,776,000 people— nearly one fifth of California's total employment. Prohibition never works, especially at a local level with a patchwork of ordinances throughout the state—there is a statewide ballot initiative that Californians are already scheduled to vote on next year, addressing this issue at a statewide level. If this ban is approved, consumers can simply go outside the city limits to obtain products, costing the city legal tax revenues. There are currently 89 legal, responsible tobacco retailers in Santa Ana, and 85% are minority-owned. The small business community is still recovering from COVID-19 and with variants like Omicron spreading, a ban like this could put many out of business. Sincerely, Ryan Allain Manager, State and Local Government Affairs California Retailers Association 1121 L Street, Suite 607 • Sacramento, CA 95814 • P: 916/443-1975 • www.calretailers.com Orozco, Norma From: Han Kim <hankiml030wt@gmail.com> Sent: Tuesday, December 21, 2021 9:26 AM To: eComment Subject: Santa ana Tobacco Flavor Ban Hearing Dear Council Member Nelida Mendoza I'm writing as a small business operator in the city of santa ana. I'm extremely concerned that an ordinance is being considered in santa ana that will ban the sale of all flavored tobacco products, including menthol cigarettes,flavored cigars,and flavored smokeless tobacco. If santa ana ban the sale that tobacco products. Customer going to buy that tobacco products next other citys. Customer not going to quit beacuse santa ana ban that tobacco products. Then our sale going to down and business going to suffering. As a responsible retailer in the city, an employer, and a constituent. I strongly urge you to not support this proposal. This legislation will have a devastating impact not only on my small business but also local retail industry in santa ana. Thank you for your consideration. Sincerely Geralds quick stop market Han jin kim i �k NATO December 21, 2021 Mayor Vicente Sarmiento Members of the Santa Ana City Council 22 Civic Center Plaza Santa Ana, CA 92701 RE: Proposed Flavored Tobacco Products Ban Dear Mayor Sarmiento and Councilmembers: As the Executive Director of the National Association of Tobacco Outlets (NATO), a national retail trade association that represents more than 60,000 retail stores throughout the country including many Santa Ana retail stores, I am writing to submit our comments and concerns regarding Ordinance Prohibiting the Sale of Flavored Tobacco Products on your December 21, 2021, agenda. This would ban the sale of all flavored tobacco products, including menthol cigarettes, mint and wintergreen smokeless tobacco products, flavored cigars and flavored pipe tobacco. We would ask that the City Council not adopt this ordinance for the reasons explained below. Three Studies Find that Banning Flavored Tobacco Products Is Associated with Increased Youth and Young Adult Smoking According to a growing number of studies, the banning of all flavored tobacco products can result in increasing the number of underage youth and young adults that start to smoke, or return to smoking, cigarettes. This would result in a new public health issue that policymakers should avoid. Study No. 1: University of Memphis School of Public Health, Science Direct-Addictive Behavior Reports (June 2020): The first study, funded by the National Institute of Drug Abuse of the National Institutes of Health, investigated the impact of the City of San Francisco flavored tobacco ban ordinance after the ban was in force for nearly a year, finding that flavored tobacco product use was reduced, but cigarette smoking among 18-24 year-olds increased by over 35%. The study also found that most consumers of flavored tobacco find other sources for these products. Link: https://www.sciencedirect.com/science/article/pii/S2352853220300134?via%3Dihub Study No. 2: Yale School of Public Health Study, JAMA Pediatrics (May 2021): The second study regarding San Francisco's flavored tobacco ban ordinance was funded by the National Institute on Drug Abuse of the National Institutes of Health and the US Food and Drug Administration Center for Tobacco Products and conducted by the Yale School of Public Health. It compared youth smoking rates among high National Association of Tobacco Outlets,Inc.,17595 Kenwood Trail,Minneapolis,MN 55044 952-683-9270 www.natocentral.org school students in the San Francisco School District to the smoking rates of high school students in seven other metropolitan school districts located in cities that did not have a flavored tobacco ban. According to the study, the smoking rate for San Francisco high school students under the age of 18 increased from 4.7% in 2017 before the adoption of the city's ordinance to 6.2% in 2019,the year after the ordinance was enacted. This is a 32% increase in underage youth cigarette smoking rates in the San Francisco school district. At the same time, the underage smoking rates in the other metropolitan school districts that are located in cities which did not have a flavored tobacco product sales ban continued to decline and averaged 2.8% as of 2019. Link:https://jamanetwork.com/journals/jamapediatrics/fullarticle/2780248?utm source=twitter&utm cam paign=content- shareicons&utm content=article engagement&utm medium=social&utm term=052421&s=03#.YKwb0 ZyP66Y.twitter Study No. 3: Milken Institute School of Public Health, George Washington University, Nicotine & Tobacco Research (July 31, 2021): A third study, funded by the US National Cancer Institute and conducted through the Milken Institute School of Public Health at George Washington University, found similar impacts from flavored vapor bans on young adult tobacco users. The study compiled young adult smoking rates in six major metropolitan cities that enacted a flavored tobacco product ban. The study abstract included the following findings: Moreover, if vape product sales were restricted to tobacco flavors, 39.1% of users reported being likely to continue using e-cigarettes but 33.2% were likely to switch to cigarettes.If vape product sales were entirely restricted, e-cigarette users were equally likely to switch to cigarettes versus not 40%). Link: https://doi.org/10.1093/ntr/ntabl54 Low and Declining Use Rates of Traditional Tobacco Products Require Caution in Flavor Bans: According to California's Healthy Kids Survey for 2020-2021 in Santa Ana Unified School District, only 2% of I Ith graders had ever smoked a whole cigarette and 0% had not done so, even once, in the past 30 days; only 1%had ever tried smokeless tobacco and 0%currently do not use smokeless tobacco. The same survey found that in 2019, 9% of 1 1th graders currently used e-cigarettes. That figure should be considered in the context of recent findings by the FDA that e-cigarette use among youth declined about one-third in 2020,and declined sharply again in 2021,such that nationally,current e-cigarette use among high schoolers is at 11.3%, about a 60% decrease from two years earlier. See E-Cigarette Use Among Middle and High School Students —National Youth Tobacco Survey, United States, 2021, US Department of Health and Human Services, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, October 1, 2021, Vol. 70,No. 39. This means that the empirical data showing essentially no underage use of traditional products in Santa Ana and the national trend of a 60%drop in e-cigarette use does not support the wholesale banning of all flavored tobacco products that legal age adults prefer to use. FDA Intends to Ban Menthol Cigarettes and Flavored Cigars: The City of Santa Ana should not pursue a flavored tobacco ban ordinance because the Food and Drug Administration announced in April of this year that the agency intends to publish a rule banning the sale of menthol cigarettes and all flavored cigars. With such a sweeping regulation, the city council should pause and allow the FDA's proposed regulation process which the agency intends to ban some of the same flavored tobacco products that would be prohibited under the proposed ordinance. National Association of Tobacco Outlets,Inc.,17595 Kenwood Trail,Minneapolis,MN 55044 952-683-9270 www.natocentral.org FDA Actions on Electronic Cigarettes and Other Nicotine Products: The FDA has taken significant actions that have resulted in the removal of a substantial number of flavored electronic nicotine delivery system (ENDS) products from the market. These strong measures should be allowed to work to further reduce youth access to and use of electronic nicotine vapor products. Specifically, in February 2020, the FDA adopted a ban on the sale of all flavored cartridge-based and pod- based electronic cigarettes, except for tobacco and menthol flavored products. This action removed hundreds of ENDS products from the market. In addition, the FDA required that manufacturers of all electronic cigarette products file what is known as a pre-market tobacco product application(PMTA)with the agency by September 9, 2020, to keep their products on the market. The FDA was required to process those PMTAs within one year. That year elapsed in September 2021, and the Food and Drug Administration has thus far completed about 99% of the reviews of the Pre-Market Tobacco Applications it received by its September 2020 deadline.Most of the applications are for electronic smoking devices and products used with them. The FDA has thus far rejected over 6 million electronic smoking devices and has granted exactly one application for an e-cigarette,Vuse Solo,and for two tobacco- flavored cartridges used with that device. The FDA has also granted marketing applications for four flavored modern nicotine products,Verve Discs and Verve Chews in Blue Mint and Green Mint flavors. These are the first non-tobacco flavored products that have been granted marketing authority by the FDA. The significance of the Vuse and Verve decisions should not be lost on the Council. For the FDA to grant those applications, it was required to and did find, after exhaustive scientific studies, that the marketing of those products was "appropriate for the protection of the public health." By granting these applications, for the first time the FDA has stated that electronic smoking devices and modern oral nicotine products, including non-tobacco flavored versions of the latter, could protect public health. As the FDA is still working on the remaining 1% of applications (covering about 55,000 products) filed by the September 2020 deadline, it would be premature for the City to issue a blanket ban on all flavored tobacco products as the FDA may well grant marketing approval of other products,some of which may be flavored,that are"appropriate for the protection of the public health." The city's ban on those products would work against the public health benefits of those products. Voters Want to Decide Whether Flavor Bans Make Sense: California Senate Bill 793, which would have banned most flavored tobacco products statewide, has been referred to the voters who will vote in November 2022 whether to allow the statewide flavor ban bill to go into effect. Voters want their say on flavor bans.We respectfully suggest that deferring action until the voters have spoken is in the best interests of Santa Ana and its retailers. Store Closures and Layoffs May Follow the Proposed Ban: Our convenience store members recently experienced losses of up to 45%in gasoline sales and 20%or more in grocery,snack,beverage,and tobacco product sales during the recent market disruptions, significant numbers because convenience stores usually rely on tobacco product sales for approximately 36% of in-store sales. Tobacco specialty stores that rely on tobacco product sales for up to 90%of total sales will be devastated by the loss of hundreds of products. Additionally, retailers have recently found it difficult to attract and retain employees and combined with the effects of inflation,payroll costs continue to rise. If Santa Ana retailers must remove hundreds of products from their shelves, it will be very difficult to compete with retailers in neighboring localities or with illicit sellers who do not care to whom they sell their products. Employee layoffs and even store closures are real possibilities. National Association of Tobacco Outlets,Inc.,17595 Kenwood Trail,Minneapolis,MN 55044 952-683-9270 www.natocentral.org NATO and its Santa Ana retail members share everyone's interest in keeping tobacco and electronic smoking devices out of the hands of persons under 21 years old but banning all flavored products makes no sense from a health standpoint or economic point of view. Indeed, Santa Ana's retailers are exemplary in keeping tobacco products out of the hands of underage persons; according to the FDA, Santa Ana retailers have a near-perfect 92% compliance record by refusing to sell to underage persons (see attached spreadsheet.) Why would the City Council want to harm these responsible retailers and chase their customers to other jurisdictions or to illicit markets? We urge the City Council not to move forward with the proposed ban on flavored tobacco products. Thank you for your consideration. Sincerely, Thomas A. Briant NATO Executive Director National Association of Tobacco Outlets,Inc.,17595 Kenwood Trail,Minneapolis,MN 55044 952-683-9270 www.natocentral.org 27762 Antonio Pkwy Suite L1-463 Ladera Ranch, CA 92694 ocrtcc www.ochcc.org ORANGE COUNTY HISPANIC CHAMBER OF COMMERCE T: (714) 953-4289 December 17, 2021 Dear Mayor Sarmiento and members of the City Council, The Orange County Hispanic Chamber of Commerce has proudly represented businesses in Orange County ranging from small neighborhood shops to large corporations for over 35 years. We are writing to you today to urge you to continue the hearing on the ban of the sale of flavored tobacco products to a later date, and oppose the ordinance when it comes before you. The minority owned business community is integral to the everyday life of the people of Santa Ana. Small businesses have been on the front lines of the Pandemic since its inception, and are still struggling to recover from the financial burdens they have been faced with as a result. A flavored tobacco ban is an overreaching and irresponsible prohibition on a legal product that is sold by 89 responsible retailers in Santa Ana. Youth usage of cigarettes and flavored tobacco products is at a generational low due to these responsible retailers abiding by the law and only selling to consumers age 21 or older. This ban would inevitably contribute to these hard-working retailers going out of business. We care deeply about Santa Ana and our members that contribute to Santa Ana's business community. We feel that we have not been given enough time to properly review this ordinance and communicate with our members to prepare them for its negative repercussions. With that in mind, we respectfully ask that you continue this ordinance to a later date. We at the OCHCC thank you for your consideration of our collective concerns. Sincerely, Reuben Franco President& CEO Orange County Hispanic Chamber of Commerce December 17, 2021 Honorable Mayor and Members of the Santa Ana City Council, The California Licensed Beverage Association (CALBA) has proudly represented Taverns, Nightclubs, Restaurants, Hotels and on-site and off-site liquor establishments throughout California for over 80 years. We urge you to oppose a more restrictive tobacco ordinance currently being reviewed by your Council which would ban the sale of flavored tobacco products from licensed, regulated city tobacco retailers. Cigarettes and smokeless tobacco products are adult-only products for purchase for those over 21 years old. In our industry,we often see customers who are switching from combustible cigarettes to less harmful options. Banning the sale of flavored tobacco products inadvertently creates a public health risk by taking these options away from adult consumers who are trying to scale-back or quit altogether. In addition to legal tobacco sales, Santa Ana allows for cannabis retail sales for responsible adult-use as well.Yet flavor bans are not being considered for the cannabis industry. Both industries are strictly regulated, with mindful, responsible retailers. We support education and regulation, however we all know that prohibition never works. Small businesses and the community as a whole are still struggling to recover from the burdens and anxieties of COVID and its many variants. We ask that you not penalize the responsible, legally operating tobacco retailers in Santa Ana by banning adult-only products. Instead, we ask that you keep this community of your constituents in mind and find a solution that increases the enforcement of existing tobacco retail regulations rather than taking flavored tobacco products off the market completely. We at CALBA thank you for your time and consideration, 26er-ewe Swamy Beverly Swanson President �Y CALBA CALIrORNIA LICENSED BEVERAGE ASSOCIATION Orozco, Norma From: Jose Manuel Alonzo <ccalonsom@yahoo.com> Sent: Monday, December 20, 2021 3:19 PM To: eComment Subject: CIGARRETE BAN HI IM A MANAGER AT A SANTA ANA CA, AT A 76 GAS STATION„ PASSING THIS ORDINANCE BEFORE THE CITIZENS FO CALIFORNIA VOTE ON THE REFERNDUM FOR SB 793 PUTS SANTA ANA RETAILERS AT DISADVANTAGE BECAUSE COSNSUMERS WILL SIMPLY DRIVE TO FOUNTAIN VALLEY OR HUNGTINGTON BEACH TO ACQUIRE THIER PREFERRED PRODUCTS.. ALSO,TOBACCO CONSUMERS VISIT CONVENIENCE STORES ATA MUCH HIGHER RATE THAN OTHER CUSTOMERS. WHEN TOBACCO CONSUMERS TAKE THEIR BUSINESS OUT OF SANTA ANA LOCAL BUSINESSES WILL ALSO LOSE SALES ON DISCRETIONARY ITEMS LIKE FUEL, SNAKCS,AND VEVERAGES, WE HAVE AROUND 21 EMPLOYEES AND IT WILL IMPACT OUR EMPLOYEES FINANCIALLY SPECIALLY WITH THE PANDEMIC NOW THIS DAYS.. 1