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HomeMy WebLinkAboutCORRESPONDENCE - #27 Orozco, Norma From: Jonathan &Justin Lukoff <lukoffjy@gmail.com> Sent: Tuesday, March 01, 2022 3:39 PM To: eComment Subject: agenda item #27-flavored tobacco The data is clear: Flavored tobacco products attract our children to smoking and vaping, addicting them to nicotine and harming them. Ban all flavored tobacco and tobacco-like products. No exceptions. Protect our children. Jonathan Lukoff, MD DABPediatrics and DABPreventiveMedicine-Informatics 1 Orozco, Norma From: Nicolette Ramirez <nicolettev@gmail.com> Sent: Tuesday, March 01, 2022 3:22 PM To: eComment Subject: Subject: Agenda Item #27 1 encourage the city to support a policy that ends the sale of all flavored tobacco products without delay. Thank you, Nicolette Ramirez 1 Orozco, Norma From: Allison Levy <abtannen@gmail.com> Sent: Tuesday, March 01, 2022 12:31 PM To: eComment; Morris, Angie; Lopez,Jessie Subject: Re: 3/1/22 - Agenda Item #27 As a resident of Santa Ana and a parent of elementary- and middle-school aged children, I am writing to ask the Council to support a policy that ends the sale of all flavored tobacco products without further delays. We know that flavored tobacco is the tobacco product of choice for middle- and high-school children. We know that this is the age when kids are susceptible to their peers, to product marketing, and to impulsive choices based on what's readily available - and when life-long tobacco habits are formed. And we know how devastating those tobacco habits are to the health of our community. Please help ensure that these flavored tobacco products are not readily available for our kids! We have a wonderful, diverse community in Santa Ana with a wide variety of cultural activities and traditions that do *not* promote the use of addictive tobacco products by our youth. The only culture calling out to protect the use of hookahs is the culture of the tobacco industry- who will promote any argument that helps keep its products on our shelves. It's not coming from Santa Ana parents; we are looking to you to make evidence-based policy decisions that protect the health of our children. The past few years have made it clear that we cannot wait for state or national policies to protect our own here in Santa Ana. Tobacco companies have aggressively marketed their menthol and flavored tobacco products to communities of color, low- income, and LGBTQ communities for decades. You can help address the health inequities burdening our community by supporting a policy that ends the sale of all flavored tobacco products today. Allison Levy, Ward 3, Santa Ana i Orozco, Norma From: Thomas Moua <tmoua@p4w.org> Sent: Tuesday, March 01, 2022 12:23 PM To: eComment Subject: LGBT Letter of Support for Restriction of the Sale of Flavored Tobacco Attachments: Partners4Wellness Flavor Tobacco Restriction Letter of Support.pdf; Youth Empowered To Act Letter of Support.pdf, Carr Intermediate Letter of Support.pdf, April Cruze Letter of Support.pdf Dear Mayor Sarmiento and Councilmembers, I am writing to you on behalf of Partners4Wellness regarding the flavor tobacco epidemic targeting our youth. Our agency works directly with the LGBTQ community in the City of Santa Ana to help prevent tobacco use among youth. The LGBTQ youth have a disproportionately higher rate of tobacco use than their heterosexual peers. The tobacco industry continues to target youth with flavored advertisements and products. Thus,we are asking you to help us prevent youth from a lifetime of addiction to sweet candy flavors. I have attached a letter of support from Partners4Wellness Project Manager Marianne along with letters of support from various LGBT serving organizations throughout Santa Ana. Best wishes, Thomas Moua Tobacco Prevention, LGBT Program Coordinator 0 Portner eflness Dt}Or, P 949.770.0847 x I E tmoua@p4w.org Partners4Wellness.org OM' i r 5ANTA AAA YOUTH COALITION Santa Ana Youth vs. Bag Tobacco Campaign Tim Iran l4 TO44"55 MW WiaOarl tnr a KW L,in tnr City al saora Ara an rev,,a r the sale Of llasie,rM T-Macr4 pradum including rnenthul cirryrvllc%w.dhor8 ca rnpkions FlarorLd lcrk�xu producks unckr inc efforts to reduce ta,haL€o uw aniorQ youth and LGBTQ indivdivals..and put a new gerrevation of kids at risk of Nt Mean addislieo arA bohattc--eAuh,-d death and t1,wacw ToMEm cimpanles tray a fen`hDuory at far®ttlr[X INr UGSTQ ufrYfMNWMV thr8ugh ehrlr prrl6f ary Inarlw4lM Mfart4, and Scribing us hooked on their produce.New,ILh Ld labu cu r:living uxd by lhe-w,sarnrr cunh}hanies 1u target and tnlko Aew younytrr 1-68Tt'dtustofien.Flavor.,RL-candy and n! MYhof,tovrr thr har%h hnlr al lohatta,rrialliz*II ea=r to®cL husked n nd has ;r is queL.E;dcclranrr crgarcUn(c-tlgarckLeh)hauc hmn the MmL CDMM-unly Lngd Ict6iccQ product in the,United States since 2014,and ov SAW,of r�igar tto asen.in high school usr'flawom E-adcncc chows khaL ruuLh.ccrUwE i mai! thence groups,and w�Yncn art par4[tAarlyvulnLrablc laaswccL fl.mp'i and nhrnthol arid 3rrrlargrlYd iuinitlhis indrvd',M DMAW aratl lYa4tai[led ux of fla%'dtrd Idibatto prtwluttt.L(34TQ p##rplr= have higtrcR raLv%of tKO tsg r41(c srnvkind.( 2A%sr7.jLl^4ond ur F ctpergttc�ltic than iron I G610 rr",frcinckmly (25A%vs JAJ%6.Snurking nn%amoMLGftMyouth range hehe,aen MK to 5!)l(tornpiredto jra&2AMtt,3E%of nDnLWlIUVQtWi FurttK-rnrxc.at he-,bL+z n 4wwrii Ihut IvWLca rclatk'd dca Eli y arc dial.""Iwna[cly h tow r fur LChll!lil praple and athEr rnarg rrzli wd o rnunrtivr I■nuxarago the City of 5Lxnta tuna to oarrtrdortfia nnotlon to remict the®Ir 43r ttauorod tam.Prairie%that rwdoria tt�A IAW of tlamoree tc-ta=peOdxiets hwlp p^ not only y6ulh but all corYrrnunitild from a~meal al Merton- April CRAB N3 Mm S ijs re NamP+d Ow niPpl_nn or tlucrnasc aprilCFUZ90I•,a)grrkail corn Frn.4, ,rrr�s:. 714642WQ:5 Mme Number 9 fly oWniTatiun is r,da sing this meastiax. i� d t IL J SANTA ANA YOUTH COALITION Santa Ana Youth vs. Big Tobacco Campaign This letter is to express my support for a policy in the City of Santa Ana to restrict the sale of flavored tobacco products including menthol cigarettes without exemptions. Flavored tobacco products undermine efforts to reduce tobacco use among youth and LGBTQ indivdivals, and put a new generation of kids at risk of nicotine addiction and tobacco-caused death and disease. Tobacco companies have a long history of targeting the LGBTQ community through their predatory marketing efforts, and getting us hooked on their products. Now,flavored tobacco is being used by these same companies to target and entice new, younger LGBTQ customers. Flavors, like candy and menthol, cover the harsh taste of tobacco, making it easier to get hooked and harder to quit. Electronic cigarettes (e-cigarettes) have been the most commonly used tobacco product in the United States since 2014, and over 68%of e-cigarette users in high school use flavors. Evidence shows that youth, certain racial/ethnic groups, and women are particularly vulnerable to sweet flavors and menthol and are largely driving this increased uptake and sustained use of flavored tobacco products. LGBTQ people have higher rates of both cigarette smoking (32.4%vs 20.3%) and of e-cigarettes use than non-LGBTQ respondents (25.1%vs 14.3%). Smoking rates among LGBTQ youth range between 38%to 59%compared to just 28%to 35%of non-LGBTQ youth. Furthermore, it has been shown that tobacco-related deaths are disproportionately higher for LGBTQ people and other marginalized communities. I encourage the City of Santa Ana to consider the motion to restrict the sale of flavored tobacco. Policies that restrict the sale of flavored tobacco products help protect not only youth but all communities from a lifetime of addiction. Sandy Ta Name Signature Pride Club, Carr Intermediate School Name of Organization or Business sandy.ta@sausd.us Email Address 714-480-4100 Phone Number € My organization is endorsing this measure. € You may use my name as an endorser, and my organization's name for identification purposes only. SANTA ANA YOUTH COALITION Santa Ana Youth vs. Big Tobacco Campaign This letter is to express my support for a policy in the City of Santa Ana to restrict the sale of flavored tobacco products including menthol cigarettes without exemptions. Flavored tobacco products undermine efforts to reduce tobacco use among youth and LGBTQ indivdivals, and put a new generation of kids at risk of nicotine addiction and tobacco-caused death and disease. Tobacco companies have a long history of targeting the LGBTQ community through their predatory marketing efforts, and getting us hooked on their products. Now,flavored tobacco is being used by these same companies to target and entice new, younger LGBTQ customers. Flavors, like candy and menthol, cover the harsh taste of tobacco, making it easier to get hooked and harder to quit. Electronic cigarettes (e-cigarettes) have been the most commonly used tobacco product in the United States since 2014, and over 68%of e-cigarette users in high school use flavors. Evidence shows that youth, certain racial/ethnic groups, and women are particularly vulnerable to sweet flavors and menthol and are largely driving this increased uptake and sustained use of flavored tobacco products. LGBTQ people have higher rates of both cigarette smoking (32.4%vs 20.3%) and of e-cigarettes use than non-LGBTQ respondents (25.1%vs 14.3%). Smoking rates among LGBTQ youth range between 38%to 59%compared to just 28%to 35%of non-LGBTQ youth. Furthermore, it has been shown that tobacco-related deaths are disproportionately higher for LGBTQ people and other marginalized communities. I encourage the City of Santa Ana to consider the motion to restrict the sale of flavored tobacco. Policies that restrict the sale of flavored tobacco products help protect not only youth but all communities from a lifetime of addiction. Tobias Vasquez Name TPVasquez Signature Youth Empowered To Act Name of Organization or Business tobias.vasquez@lgbtgcenteroc.org Email Address 7149535428 Phone Number € My organization is endorsing this measure. € You may use my name as an endorser, and my organization's name for identification purposes only. C* :W;) Partners Wellness 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: This letter is to express Partner4Wellness' support for a comprehensive restriction of flavor tobacco products, including menthol and hookah, without exemptions in the City of Santa Ana. Flavored tobacco products undermine efforts to reduce tobacco use among youth and LGBTQ individuals, and put a new generation of kids at risk of nicotine addiction and tobacco-caused death and disease. Tobacco companies have a long history of targeting the LGBTQ community through their predatory marketing efforts, and getting us hooked on their products.Now, flavored tobacco is being used by these same companies to target and entice new, younger LGBTQ customers. Flavors, like candy and menthol, cover the harsh taste of tobacco,making it easier to get hooked and harder to quit. Electronic cigarettes (e- cigarettes)have been the most commonly used tobacco product in the United States since 2014, and over 68% of e-cigarette users in high school use flavors. Evidence shows that youth, certain racial/ethnic groups, and women are particularly vulnerable to sweet flavors and menthol and are largely driving this increased uptake and sustained use of flavored tobacco products. LGBTQ people have higher rates of both cigarette smoking (32.4%vs 20.3%) and of e-cigarettes use than non-LGBTQ respondents (25.1%vs 14.3%). Smoking rates among LGBTQ youth range between 38%to 59% compared to just 28%to 35% of non-LGBTQ youth. Furthermore, it has been shown that tobacco-related deaths are disproportionately higher for LGBTQ people and other marginalized communities. Partners4Wellness supports the restriction of the sale of flavored tobacco without exemptions. Policies that restrict the sale of flavored tobacco products help protect not only youth but all communities from a lifetime of addiction. Sincerely, sae Aiu&a Program Manager Partners4Wellness 21068 Bake Parkway Lake Forest, California 949.770.1191 Partners Wellness.org r Providence March 1, 2022 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: On behalf of Providence, I write to you today to ask that you pass a comprehensive ordinance ending the sale of all flavored tobacco,including candy flavored e-cigarettes,sweet cigars,menthol cigarettes and flavored hookah products. In 2020 Governor Newsom signed into law SB 793,representing a monumental shift towards achieving a smoke free state and demonstrating the state's efforts to get these products out of our communities.Unfortunately given the recent qualified referendum,the law to end the sale of flavored tobacco products will not take effect unless and until approved by voters in the November 2022 election.As a result,youth candy-flavored tobacco products have remained on the market for nearly two years to addict young new users. Every day of delay before this law takes effect means more youth being exposed and susceptible to becoming addicted to tobacco. Youth are lured by candy flavors in e-cigarettes which has led to nearly 20%of high schoolers using e-cigarettes nationwide.The original flavored tobacco product,the menthol cigarette,has hooked youth for far too long. Hookah products are also available in a variety of fruit and candy flavors,and they are increasingly popular with youth. From 2011 to 2015,hookah use among high school and middle school students rose by more than 50%.The rapid expansion of hookah means that more retailers will sell to kids. Offering any sort of exemption only opens and increases young people's access to these dangerous and addictive products. For these reasons I urge the City Council to enact a strong ordinance that ends the sale of flavored tobacco products.Your actions will protect many Santa Ana youth from a lifetime of tobacco addiction. I appreciate your consideration and look forward to continue working with you and the City of Santa Ana on ways to improve public health for its residents. Sincerely, Jordan Abushawish Director of Public Affairs Orozco, Norma From: Patricia Boe <patricia.I.boe@gmail.com> Sent: Tuesday, March 01, 2022 12:12 PM To: eComment Subject: Agenda Item #27 As a Santa Ana resident, I'm writing in SUPPORT of the policy to end the sale of all flavored tobacco products without further delay (agenda item 427). Flavored tobacco products are opposed by all major health organizations because they are a significant entry point for youth becoming life-long tobacco users. This policy goes right to the heart of public health. Please support it. Thank you! Patricia Boe Jack Fisher Park, Santa Ana i Orozco, Norma From: Milan Cox <milanmcox@gmail.com> Sent: Tuesday, March 01, 2022 12:07 PM To: eComment Subject: Agenda item #27 Attn: Jessie Lopez I encourage the city to support a policy that ends the sale of all flavored tobacco products without delay. Milan Cox Ward 3 resident i 00 American Heart Association. February 28, 2022 The Honorable Vicente Sarmiento, Mayor Santa Ana City Council 20 Civic Center Plaza Santa Ana, CA 92701 RE: Ending the Sale of Flavored Tobacco in Santa Ana Dear Mayor Sarmiento and Members of the Santa Ana City Council: The American Heart Association supports ending the sale of all flavored tobacco products in the City of Santa Ana to protect youth and communities of color from these addictive and deadly products. We urge you to pass a comprehensive ordinance that ends the sale of all flavored tobacco products without exemptions. With over 30 percent of high school students now using tobacco, the need for a comprehensive policy is clear. The tobacco industry is actively and aggressively working to addict new users with easy access to sweet and candy-flavored tobacco products. All flavored tobacco products, including e-cigarettes, menthol cigarettes, hookah (shisha), and cigars come in kid-friendly flavors and are highly addicting. Flavored hookah (shisha) has become popular among youth and young adults. According to the California Department of Public Health, smoking shisha is most common among individuals between the ages of 18-24 years. Hookah is appealing to young people in large part because of the flavors it comes in, such as gummy bear, horchata, and mango. Ending the sale of all flavored tobacco products without exemptions will reduce access to the products that are the tobacco industry's key strategy for targeting and addicting new smokers, particularly youth and communities of color. While SB 793 was signed by the Governor in the Fall of 2020 to end the sale of most flavored tobacco products in California, 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 to be protected - local action is needed to protect the community 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 will use mint, fruit, and candy-flavored tobacco to addict more life-long customers. Over 70 communities across California protect their residents from nicotine addiction and tobacco-related death and disease by prohibiting the sale of all flavored tobacco products. Santa Ana kids deserve these same protections. We respectfully ask your support for this vital public health policy. Thank you. Sincerely, r Jacqueline Eubany, MD, FACC, FHRS Electrophysiologist, Cardiovascular Wellness Institute Board President, Orange County & Inland Empire Division American Heart Association Orozco, Norma From: Rodriguez, Yaneth <ylr@med.usc.edu> Sent: Tuesday, March 01, 2022 11:15 AM 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; Yaneth Rodriguez (ylr@usc.edu) Subject: Agenda item #27 (Info & Education) Ordinance Options Prohibiting the Sale of Flavored Tobacco Product Attachments: USC Flavor and E-cigarette_Info Sheet_05.22.19 (PDF).pdf, Tobacco Retail Licensing and Youth Product Use.pdf, Measurement and predictive value of susceptibility to cigarettes ecigarettes cigars and hookah among adolescents.pdf; Examining Hookah as an Introduction to Nicotine Products among College Students.pdf Importance: High Dear Mayor and City Council Members of the City of Santa Ana, In your consideration of agenda item#27 "Ordinance Options Prohibiting the Sale of Flavored Tobacco Product" on tonight's agenda, attached is an information sheet which contains research findings from the University of Southern California's Tobacco Center of Regulatory Science (USC TCORS). 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 a strong tobacco retail license to prevent sales to minors was associated with lower rates of youth and adult initiation of combustible and e-cigarette use. A comprehensive ordinance restricting the sale of flavored tobacco products would include traditional combustible menthol cigarettes and cigars, as well as chewing tobacco and 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. • 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 2001 N. Soto St. Office 302N; MC 9239 Los Angeles, CA 90032 1 ylr@usc.edu z 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. Margolis,K A.,Nguyen,A.B.,Slavit,W.L,&King,B.A.(2016).E-cigarette curiosity among U.S.middle and high school students:Findings from the 2014 National Youth FRC and EAC conducted the analysis. FRC led the writing and Tobacco Survey.Preventive Medicine,89,1-6.https://doi.org/10.1016/j.ypmed. completed the initial draft. AVW and MBH conceptualized and su- 2016.05.001. Meshack,A.F.,Hu,S.,Pallonen,U.E.,McAlister,A.L.,Gottlieb,N.,&Huang,P.(2004). pervised the analysis, and provided critical feedback. CLP provided Texas Tobacco Prevention Pilot Initiative:Processes and effects.Health Education critical feedback. Research,19(6),657-668.https://doi.org/10.1093/her/cygO88. Nodom,J.,Hartman,S.J.,Strong,D.R,Messer,K,Vera,L.E.,White,M.M.,...Pierce,J. P.(2014).Curiosity predicts smoking experimentation independent of susceptibility Conflict Of interest in a U.S.national sample.Addictive Behaviors,39(12),1695-1700.https://doi.org/ 10.1016/i.addb eh.2014.06.002. 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Yu,C.(2002).Evaluating cutoff criteria of model fit indices for latent variable models with Hu,L.,&Bentler,P.M.(1999).Cutoff criteria for fit indexes in covariance structure binary and continuous outcomes(Doctoral dissertation)Los Angeles:University of analysis:Conventional criteria versus new alternatives.Structural Equation Modeling California. 6(1),1-55.https://doi.org/10.1080/10705519909540118. 101 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 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 t=Not current USC Research, *=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 (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 t=Not current USC Research, *=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). 2. Leventhal AM,Strong DR,Sussman S,Kirkpatrick MG,Unger 16,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. 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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-year follow-up of a national sample of 12th grade students.Tobacco control.2017;26(e2):e106-e11. 19. Barrington-Trimis JL,Kong G,Leventhal AM,Liu F,Mayer M,Cruz TB,et al.E-cigarette Use and Subsequent Smoking Frequency Among Adolescents.Pediatrics. 2018;142(6). 20. McConnell R,Barrington-Trimis 1L,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.changelabsoIutions.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 Fairworning.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. 2 019;143(2):e 20173 5 36. 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. t=Not current USC Research, *=Both USC and Outside Research Updated 5/22/2019 Orozco, Norma From: America On Track <ontrack@americaontrack.org> Sent: Monday, February 28, 2022 10:11 PM To: eComment Subject: Agenda Item #27: Ordinance Options Prohibiting the Sale of Flavored Tobacco Products Importance: High There is a tremendous amount of community support for Ending the Sale of All Flavored Tobacco Products in Santa Ana! From January 1, 2022 to February 28, 2022, on behalf of the Santa Ana Fights Flavors coalition, America On Track volunteers collected endorsements to determine if Santa Ana residents would support an Ordinance to Eliminate the Sale of All Flavored Tobacco Products in the City of Santa Ana. To date, a total of 812 Santa Ana residents have signed an Endorsement to End the Sale of All Tobacco Products, In All Locations, with No Exemptions Following is a link to see the 812 endorsements: https://www.dropbox.com/scl/fo/rapwwmhe4vu59e4zj'iskd/h?dl=0&rlkey=3 vy643b7afjjtkw6ngvukf 5klo Thank you. Claire Claire Braeburn, Executive Director America On Track 600 W. Santa Ana Blvd, Suite 710 Santa Ana, CA 92701 Tel: 714-531-7144 Fax: 714-531-7773 1 Email: OnTrack@AmericaOnTrack.org Be sure to Like Us on Facebook! www.Facebook.com/AmericaOnTrackOC z 1 March 1, 2022 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. CancerAction AlMetwork- HeartAmerican AATCL C /4550CIQtlOn. i. ivc ;�u• American • �0 P'"D � 7�� Lung Association. AMERIcnNSFOR � F , l ilYlERICA g NONSMUKERS'RIGHiS o • m y ON TRACK California f- m Crear-g Brig!rcr Fru.— C O A L I T I O N for ComvuuririesdYonrl since L9l5 • a` FA'Vm- Partners4WellnessF�-e•tiNCADD0C� � A .NmNw*.E,a„dedS 1 UTQ [ENTER ..... o �_C'rzrn6odian`t m.., '1—At11 Y i�v FIRST � Phoenix 5 BOY SCOUTS House ORANGE COUNTY DELHI CENTER OF AMERICA Building Health and Wealth ORANGE COUNTY COUNCIL CALIFORNIA - -_ ��Ih KAISER COMMUNITY HEALTH INITIATIVE ` �� PERMANENTE, ORANGE COUNTY OF ORANGE COUNTY DENTAL SOCIETY LATI NO HEALTH ACCESS Change the future> March 1, 2022 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 Boy Scouts of America—Orange County Council California Association of Student Councils, Orange County Chapter Community Health Initiative of Orange County Dehli Center First Five Orange County Kaiser Permanente Latino Health Access LGBTQ Center Orange County Orange County Dental Society Orange County Tobacco and Vape Free Coalition Partners 4 Wellness Parents Against Vaping e-cigarettes - PAVe Phoenix House California The Cambodian Family Tobacco Free Kids Action Fund 0 Cancer Action Network— American Cancer Apo society-A' February 28, 2022 The Honorable Vicente Sarmiento Mayor, City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 Re: Agenda Item 27. Ordinance Options Prohibiting the Sale of Flavored Tobacco Products Dear Mayor Sarmiento and Members of the Santa Ana City Council, The American Cancer Society Cancer Action Network's mission is to end suffering and death from Cancer. All individuals should have equitable access to quality cancer care and equal opportunity to live a healthy life. Our ability to continue to make progress against cancer relies heavily on eliminating the inequities that exist in cancer prevention and care, including tobacco policies. We are deeply concerned about the availability of flavored tobacco products, and thank you for considering strong policies to protect the health of our youth. We are writing to urge you to vote tonight in support of an ordinance that end the sale of menthol cigarettes and all other flavored tobacco products, including but not limited to flavored cigars, e-cigarettes, shisha, and smokeless tobacco. Option 1a in the staff report is ideal; we urge you to act without delay. Eliminating the sale of all flavored tobacco products, including menthol cigarettes, is a social justice issue. Tobacco companies have intentionally and aggressively marketed their menthol and flavored tobacco products to communities of color, lower- income, and LGBTQ communities. Disparities resulting from this intentional marketing include higher use of tobacco products in these same communities who already bear a greater burden of many health disparities. Ending the sale of all flavored tobacco products including menthol cigarettes, removes much of the allure of these products and is a key component of a comprehensive strategy to effectively reduce tobacco initiation and subsequent addiction. Lynda Barbour, MPH,Sr. Director,Government Relations,American Cancer Society Cancer Action Network PO Box 910549;San Diego, CA 92191 W:619-624-1517 C:619-742-4861 lVnda.barbour@cancer.org www.FightCancer.org With your yes vote for an ordinance that ends the sale of all flavored tobacco products citywide with no exemptions, you will encourage a generation of tobacco-free kids—potentially saving them from a lifetime of addiction and the deadly consequences of tobacco use. We urge you take immediate action and give Santa Ana youth that equal opportunity to live a healthy life by ending sales of all flavored tobacco products. Sincerely, lyda Barbour, MPH Senior Government Relations Dir, Southern California ACS CAN American Cancer Society Cancer Action Network 5333 Mission Center Rd,Ste.105;San Diego CA 92108 619.682.7416•(F)619.296.0928•Iynda.barbour(@cancer.ore Orozco, Norma From: Phillip Gardiner <gmoney.gardiner@gmail.com> Sent: Tuesday, March 01, 2022 8:24 AM To: eComment Subject: Fwd: End the Sale of Menthol and All Flavored Tobacco Products in Santa Ana! Attachments: Santa Ana Letter of Support.docx (1).pdf, Poilicy Position Statement - Dr. Forouzesh.docx.pdf, Menthol Val Editorial.pdf, Menthol AA Mendez (1).pdf ---------- Forwarded message --------- From: Nicole Turkson <nturkson@amplify.love> Date: Tue,Mar 1, 2022 at 8:00 AM Subject: End the Sale of Menthol and All Flavored Tobacco Products in Santa Anal To: <vsarmiento@santa-ana.org>, <TPhan o,santa-ana.org>, <dpenaloza o,santa-ana.org>, <JessieLopez o,santa-ana.org>, <pbacerra o,santa-ana.org>, <JRyanHernandez@santa-ana.org>, <nmendoza@santa-ana.org> Cc: Phillip Gardiner<gmoneygardiner@gmail.com>, Camille Cummings <ccummings@amplify.love>, Carol McGruder<cmc ruder_,usa.net>, Ernesta<thegreenfoundation333@gmail.com>, Mohammed Forouzesh <Mohammed.Forouzesh@csulb.edu>, Tim Gibbs <tim o,timgibbsconsulting com> Greetings, Attached is a letter of support from the African American Tobacco Control Leadership Council regarding the sale of menthol and other flavored tobacco products in the City of Santa Ana. Additionally, please find a Policy Position Statement submitted on behalf of Dr. Mohammed Forouzesh, Professor of Health Sciences at California State University Long Beach. Menthol, hookah, and other flavored tobacco products cause disease and death, especially in historically targeted groups like the African American community. New research shows that: "menthol cigarettes were responsible for 1.5 million new smokers, 157 000 smoking-related premature deaths and 1.5 million life-years lost among African Americans over 1980-2018. While African Americans constitute 12% of the total US population, these figures represent, respectively, a staggering 15%, 41% and 50% of the total menthol-related harm.." (Mendez & Le, 2021) (the full article and an accompanying editorial are also attached.) Santa Ana can be a leader in putting an end to this outright discriminatory health disparity. Please do not hesitate to reach out to AATCLC with any questions or concerns. Best regards, Nicole Turkson, MPH I Project Coordinator African American Tobacco Control Leadership Council (888) 881-6619, ext 102 1 www.savingblacklives.org i nFINISHING THE FIGHT Knocking Out Commercial Tobacco•AATCLC 2 0 Brief report 0 Consequences of a match made in hell: the harm caused by menthol smoking to the African American population over 1980-2018 CID David Mendez,Thuy T T Le 0 ► Additional supplemental ABSTRACT avoided if menthol cigarettes were banned from the material is published online 3 5-9 W Background For many years,national surveys have market; and while other studies have addressed OW)only.To view,please visit the if journal online(http://dx.doi. shown a consistently disproportionately high prevalence the historical causes that have made menthol the 6 org/10.1136/tobaccocontrol- of menthol smokers among African Americans compared preferred choice of cigarette products among 2021-056748). with the general population.However,to our knowledge, African Americans, to our knowledge, no prior o no prior study has quantified the harm that menthol study has quantified the health harm that menthol 0 Health Management and Policy, smoking has caused on that population. In this work,we smoking has already inflicted on that population. o University of Michigan,Ann estimate the public health harm that menthol cigarettes Following a recent stud 10 that calculated the Arbor,Michigan,USA P 9 g Y N have caused to the African American community over the health damage caused by menthol smoking on the N Correspondence to last four decades. entire US population over 1980-2018, the current o DrThuyTT Le,Department of Methods Using National Health Interview Survey work estimates the share of such harm borne by the Health Management and Policy, data,we employed a well-established simulation model African American community,and its disproportion 41 University of Michigan School of o0 Public Health,Ann Arbor 48109, to reproduce the observed smoking trajectory over compared with the total menthol toll in the USA. o MI,USA;thuyttle@umich.edu 1980-2018 in the African American population.Then,we Our results may be helpful to the Food and Drug repeat the experiment,removing the effects of menthol Administration as they continue evaluating the Received 28April 2021 on the smoking initiation and cessation rates over that benefit of a menthol ban. m Accepted 16August 2021 period,obtaining a new hypothetical smoking trajectory. m Finally,we compared both scenarios to calculate the 3 public health harm attributable to menthol cigarettes METHODS over 1980-2018. We used the same simulation model and calibration o Results Our results show that menthol cigarettes process as in the Le-Mendez article10 with param- o were responsible for 1.5 million new smokers, 157000 eters specific to the African American population. smoking-related premature deaths and 1.5 million life- The model formulation,definition of model param- 0 years lost among African Americans over 1980-2018. eters and how some parameters were calculated 0 While African Americans constitute 12%of the total were thoroughly described in Le-Mendez's work.1' a US population,these figures represent, respectively,a The African American-specific parameters were a staggering 15%,41%and 50%of the total menthol- taken from several data sources described below related harm. and summarised in online supplemental table Al. B Discussion Our results show that menthol cigarettes For our initial year(1980),we obtained the African disproportionally harmed African Americans significantly American population by single year of age from the 7 over the last 38 years and are responsible for Centers for Disease Control and Prevention." For o exacerbating health disparities among that population. subsequent years, we got the African American birth v Removing menthol cigarettes from the market would cohorts from 1981 through 2018 from the National o benefit the overall US population but, particularly,the Vital Statistics Reports.lz 13 The overall age-specific o African American community. death rates for the African American population, o updated every 5years, were extracted from the s 1980-2018 US Life Tables.14 We used relative risks of 3 mortality specific to the African American population, o BACKGROUND derived from Cancer Prevention Study 11(CPS-II data; 3 For over 60 years,tobacco companies have targeted Relative risks for African American current and former o ► http://dx.doi.org/10.1136/ menthol cigarettes to the African American commu- smokers were derived from CPS-II data and provided m tobaccocontrol-2021-056988 nity through aggressive marketing and promo- by Dr Michael Thun from the American Cancer -a tion.1-3 It is well known that a disproportionately Society for the 2011 Tobacco Products Scientific Advi- m Check for updates high number of African Americans smoke menthol sory Committee (TPSAC) Menthol Report.Available cigarettes. According to the 2018 National Survey in online supplemental table A5)to calculate the death N ©Author(s)(or their on Drug Use and Health,85%of African American rates by age for never, current and former smokers employer(s))2021.No N commercial re-use.See rights smokers used menthol versus 39% of those in the following thesame procedure described in Le-Men- 0 and permissions.Published general population. This is not a recent phenom- dez's article. ° Smoking prevalence for current and by BMJ. enon. In 1980, for example, menthol prevalence former smokers and the proportion of menthol use To cite:Mendez D,Le TTT. among African American smokers was 66%vs 33% among smokers in 1980 were estimated using NHIS n Tob Control Epub ahead of among the general population, according to the data. We calculated the overall smoking cessation � print:[please include Day National Health Interview Survey(NHIS). rates for African Americans by adjusting the general Month Year].doi:10.1136/ Several articles have addressed the prospec- population's overall smoking cessation rates presented o tobaccocontrol-2021-056748 tive harm to the black community that could be in Le-Mendez's work10 with the ratio of cessation m BMJ Mendez D,Le TTT Tob Control 2021;0:1-3.doi:10.1 136/tobaccocontrol-2021-056748 1 1 Brief report o n rates between the African American and general populations(0.66) (over 1980-2018) of the corresponding population referred to n reported in ref 15.Then,using the menthol cessation multiplier for on each row, relative to the entire US population. For example, o African Americans estimated by Mills et a116 (0.47, 95% Cl 0.24 the table shows that, among African Americans, menthol was =* to 0.91) and the proportion of menthol smokers among current responsible for 1.5 million extra smokers, 157 000 smoking- African American smokers, we applied the same process used in related premature deaths and 1.5 million excess life-years lost � ref 10 to compute the cessation rates for African American non- during 1980-2018, representing 15%, 41% and 50% of the 6 menthol and menthol smokers.The specific formulation and cessa- total menthol toll, respectively. However, during the sameCD tion values for 1980 are shown in the Supplement to ref 10 and period,African Americans constituted only around 12% of the Q v online supplemental tables A2 and A3. overall US population. v' The annual adult smoking initiation rates for African Amer- The last row of the table shows a hypothetical African Amer- icans were computed by taking the average NHIS smoking ican population that exhibits the same menthol smoking-related w prevalence among 18-24 year-olds, consistent with ref 10. The parameters as the general population.We simulated this scenario switching rates between menthol and non-menthol smokers were by setting the values of menthol-affected parameters for the 6 calculated as in the 2011 menthol report17 (2.29%switching to African American population to those of the general popula- menthol and 1.08% to non-menthol cigarettes). An extensive tion. In this hypothetical group,the estimated menthol smoking o sensitivity analysis (see online supplemental table A4) showed excess initiation, premature deaths and life-years lost would 0 that these parameters exert little influence on the results. The have represented 13%, 16% and 21% of the overall menthol o ratio of yields from experimenter to smoker is 19 and menthol harm, respectively; much more in agreement with the propor- CD ry mortality multiplier for the African American population remains tional(relative to the entire US)size of this population(12%).It r2 as in the Le-Mendez work,10 following their same arguments. is worth noting,though,that the menthol death toll in the low- o As in ref 10, we first used NHIS smoking prevalence data over menthol population is still above its proportional share. This is M 1980-2018 (when the NHIS survey was conducted) to calibrate due to the mortality rates among African American smokers, � the model.Then,we used the calibrated model to replicate African g g population. 00 P which are hi her than in the general o Americans' smoking prevalence trajectory during 1980-2018. n Finally,to quantify the harmful effect of menthol use on the African 8 American population,we repeated the previous step to generate an DISCUSSION m alternative smoking trajectory for African Americans duringthesame Since the 1960s, the tobacco industry has targeted the African m period,eliminating the effect of menthol since 1980. We achieved American community for the consumption of menthol cigarettes 3 this by adjusting the smoking initiation and cessation rates to elimi- through aggressive marketing, including intense advertising m nate the effect of menthol on those parameters(see the Appendices and price discounts. Simultaneously, the industry supported No to the 2011 TPSAC Menthol Report17 and the Le-Mendez paper10). numerous African American organisations to gain the trust of the o Finally, we compared our results from both scenarios (with and African American community. Several publications 9 describe -,O< p without menthol cigarettes)to calculate the impact of menthol on the marketing efforts by the tobacco industry to establish a o smoking prevalence, life-years lost and smoking-related premature special connection between menthol cigarettes and the African o deaths. Additionally, we compared our results with those for the American community. In a fascinating article entitled `The a general population reported in Le-Mendez's work10 and calculated African Americanization of menthol cigarette use in the United a the disproportionate harm inflicted on the African American popu- States',3 Gardiner recounts the long history of, and explains the o lation due to menthol. facts behind, the relationship between African Americans and 3 menthol cigarettes, and how those products became an inte- RESULTS gral part of the African American culture. In essence, the iden- The simulated smoking prevalence for African Americans closely tification of African American smokers with menthol has been 07 captures the NHIS reported smoking prevalence over 1980-2018 purposely orchestrated by the tobacco industry following their with pseudo-W=0.95 (pseudo-W=1—[Errors Sum of Squares]+ goal of maximising their profits. o Total Sum of Squares])(see online supplemental figure Al and A2). Unfortunately, this marketing strategy turned out to be a o Table 1 shows the harm attributable to menthol cigarettes for the huge success for the tobacco industry, but deadly for the black o general population (from Le-Mendez's work10),the African Amer- community. Besides creating a brand with which African Ameri- s ican population and the hypothetical low-menthol African Amer- cans could identify and call their own,the industry exposed this 3. ican population. A complete sensitivity analysis on the values in population to a substance that amplifies the damaging effects of o table 1 is presented in online supplemental table A4. cigarette smoking. Menthol intensifies this harm by increasing 3 The values in the first three columns of the table are self- the chances that individuals transition from experimentation explanatory;the numbers within parentheses show the percent- to regular smoking,is 19 and b increasing dependency, which m P' P g g� Y g ages that those values represent,relative to those for the general leads to delayed cessation.16 These effects increase the number of CD population. The last column shows the average proportion smokers and the amount of time they remain smoking. m N Table 1 Excess smoking initiation,smoking-related deaths and life-years lost due to menthol cigarettes over 1980-2018 for the adult general, o African American and hypothetical low-menthol African American population N Cumulative excess smoking Cumulative excess life-years Average percentage of v initiators(%) Cumulative excess deaths(%) lost(%) population(%) C General population 10137808(100) 377528(100) 2 951 533(100) 100 n W African American population 1 508913(15) 156471 (41) 1476198(50) 12 Hypothetical low-menthol 1 286848(13) 61 132(16) 606840(21) 12 p African American population m m 2 Mendez D,Le TTT Tob Control2021;0:1-3.doi:10.1136/tobaccocontrol-2021-056748 °- Brief report 0 C) The negative impact of menthol cigarettes on the public's health is Competing interests None declared. n significant,as Le and Mendez described in ref 10.For African Amer- Patient consent for publication Not required. E3 ican smokers, though, the harm wrought by menthol smoking is Provenance and peer review Not commissioned;externally peer reviewed. much higher than that for the rest of the population.Despite having a similar overall smoking prevalence as the general population,20 ORCID iD : Thuy T T Le http://orcid.org/0000-0002-3106-4045 6 it is well known that African Americans suffer, proportionally or E disproportionately,more serious smoking-attributable health conse- (D zi REFERENCES 0- quences. Main probable causes for this phenomenon are the high a)1 Food and Drug Administration.Preliminary scientific evaluation ofthepossible a) overall mortality rates due to economic and social conditions and public health effects of menthol versus nonmenthol cigarettes.Food and Drug the high prevalence of menthol among African American smokers, Administration,2013. which causes them to be more addicted and quit less. In fact, our 2 Davis RM,Gilpin EA,Loken B.The role of the media in promoting and reducing w results show that menthol was responsible for 157 000 smoking- tobacco use.USA,2008. rn 3 Gardiner PS.The African Americanization of menthol cigarette use in the United related deaths among African Americans during 1980-2018, over 0 States.Nicotine Tob Res 2004;6 Suppl 1:55-65. v two and a half times their proportional share of menthol deaths 4 Levy DT,Pearson JL,Villanti AC,et al.Modeling the future effects of a menthol ban 0 compared with the general population. And, what is even more on smoking prevalence and smoking-attributable deaths in the United States.Am J 0 n depressing,50%of all the life-years lost to menthol smoking during Public Health 2011;101:1236-40. 0 1980-2018 occurred among African Americans. Additionally, our 5 Anderson SJ.Marketing of menthol cigarettes and consumer perceptions:a review of o tobacco industry documents.Tob Control2011;20 Suppl 2:ii20-8. results(shown in online supplemental figure Al)also indicate that, 6 Sutton CD,Robinson RG.The marketing of menthol cigarettes in the United States: No without menthol,smoking prevalence among African Americans in populations,messages,and channels.Nicotine Tob Res 2004;6 Suppl 1:83-91. 2018 would have been 8.3%,instead of the NHIS reported 14.9% 7 Delnevo CD,Ganz 0,Goodwin RD.Banning menthol cigarettes:a socialjustice issue o (a 44% reduction). We note that our results may be considered long overdue.Oxford University Press US,2020. rn 8 Cadham CJ,Sanchez-Romero LM,Fleischer NIL,et al.The actual and anticipated -r conservative, since we do not take into account the future harm effects of a menthol cigarette ban:a scoping review.BMC Public Health ib that menthol smoking over 1980-2018 will cause to the African 2020;20:1-17. 0 American population. 9 Robert N.Proctor,golden holocaust:origins of the cigarette catastrophe and the case Considering that cigarette smoking is the number one cause of for abolition,2012. rn 10 Le TTT,Mendez D.An estimation of the harm of menthol cigarettes in Cn preventable deaths in the USA,menthol in cigarettes is an important the United States from 1980 to 2018.Tob Control 2021.doi:10.1136/ a factor in creating and exacerbating health disparities in this country. tobaccocontrol-2020-056256.[Epub ahead of print:25 Feb 2021]. m Removing menthol cigarettes from the market will save thousands 11 Population by age groups,race,and sex for 1960-97.centers for disease control and C7 of African American lives per year and help reduce health disparities prevention. m at a time when inequalities among minority and socioeconomically 12 Martin JA,Hamilton BE,Osterman MJ.Births:final data for 2015,2017. N 13 ed-Martin J,Hamilton B,Osterman M.Births:final data for 2018.In:National vital o o N disadvantaged groups are increasingly salient. statistics reports.Services DoHaH,2019. 14 Arias E,Xu J.United States life tables:2017,2019. 0 paperWhat this 15 Babb S,MalarcherA,Schauer G,et al.Quitting Smoking Among Adults-United States,2000-2015.MMWR Morb Mortal Wkly Rep 2017;65:1457-64. 16 Mills SD,Hao Y,Ribisl KM,et al.The relationship between menthol cigarette use, v ► Menthol cigarettes have been disproportionately used among smoking cessation,and relapse:findings from waves 1 to 4 of the population coo African Americans. assessment of tobacco and health study.Nicotine Tob Res 2021;23:966-75. 0 ► Menthol cigarettes exacerbate health inequalities for the 17 Mendez D.Results from a Population Dynamics Model of the Consequences o African American community. of Menthol Cigarettes for Smoking Prevalence and Disease Risks.Appendix ► Removing menthol can have the double effects of saving lives A,2011.Available:http://www fda gov/downloads/AdvisoryCommittees/ CommitteesMeeting Mate ria Is/To baccoProductsScientificAdvisoryCommittee/ and reducing inequalities. UCM247689 pdf 18 Nonnemaker J,Hersey J,Horns!G,et al.Initiation with menthol cigarettes and youth smoking uptake.Addiction 2013;108:171-8. Acknowledgements The authors would like to thank the University of Michigan 19 Nonnemaker J,Feirman SP,MacMonegle A,et al.Examining the role of menthol o Data Analysis and Dissemination Core led by Dr.Jihyoun Jeon for providing us some cigarettes in progression to established smoking among youth.Addict Behav 0 data for this work. 2019;98:106045. Contributors DM and TTTL conceptualised the project.TTTL calibrated the model 20 Cornelius ME,Wang TW,Jamal A,et al.Tobacco Product Use Among Adults-United o and conducted all the analysis.DM supervised the work.Both authors contributed to States,2019.MMWR Morb Mortal Wkly Rep 2020;69:1736-42. 07 21 U.S.Department of Health and Human Services.Tobacco use among U.S.racial/ the writing of the manuscript. ethnic minority Groups African Americans,American Indians and Alaska natives, n Funding The research reported in this publication was supported by the Asian Americans and Pacific Islanders,and Hispanics:a report of the surgeon General. 3 National Cancer Institute of the National Institutes of Health and Food and Drug Atlanta:U.S.Department of Health and Human Services,Centers for Disease Control o Administration Centre for Tobacco Products(award number U54CA229974). and Prevention,Office on Smoking and Health,1998,1998. W m m m N O N O N N C C) W 0 m m Mendez D,Le TTT Tob Control 2021;0:1-3.doi:10.1136/tobaccocontrol-2021-056748 3 0- Editorial o C) total menthol-related harm: 41% the What more evidence is needed? E3 smoking-related premature deaths and o Remove menthol cigarettes from 50% the life-years lost. This anal- _* ysis demonstrates the contribution of menthol cigarettes toward the annihila- c the marketplace now tion of a people already under siege by a En racist society and its myriad of inequities, CD 1,2 governmental policies and political domi- fl Valerie Yerger v nation.l� 18 Institutionalised racism, its cn long historical impact, and the associated, o Tobacco remains the leading cause of prematurely if the exemption of menthol yet unresolved, intergenerational trauma preventable death and disease in the USA is allowed to continue.6 experienced by black people in America and many other countries. However, The disproportionate toll of menthol ciga- have made them vulnerable to the clever 6 among all racial and ethnic groups in the rettes among African Americans compared marketing and predatory dumping of USA, African Americans bear the greatest with the general population is a social injus- mentholated tobacco products in their o burden from tobacco-related morbidity tice. The black community has long been communities. O and mortality.'Every year,45 000 African subjected to the predatory marketing of For decades, the tobacco industry has o Americans prematurely and unnecessarily mentholated tobacco products, particularly exploited social and economic inequities N die from tobacco-caused diseases.An esti- in lower income areas, where there are not to foster the uptake and use of menthol N mated 85% of them smoked menthol only more advertisements,but more promo- cigarettes, and create brand loyalty among o cigarettes.2 tions and cheaper prices for menthol ciga- African Americans. Tobacco companies rn Menthol's sensory properties reinforce rettes when compared with more affluent strategically targeted menthol cigarettes to CD smoking, increase uptake of nicotine and neighbourhoods. Tobacco companies also low-income African Americans, blanketing o toxic smoke components, and discourage heavily rely on their cooptation of commu- inner city communities with marketing, n cessation. Menthol's cooling, anaesthetic nity leaders to defuse tobacco control free samples, and music promotions'19 and 0)and analgesic effects ease initiation among efforts.' Black-led organisations with finan- thereby contributing to the tobacco-related m new smokers by masking the harshness cial ties to the tobacco industry have played health disparities observed today,as Mendez m and irritation of tobacco smoke, reducing a critical role in disseminating misinfonna- and Le have now confirmed. We can no 3 pain sensations in the mouth and throat, tion throughout the black community. Such longer ignore the intersecting, overlapping m and enabling deeper inhalation that facili- misinformation, for example, includes the and distinctive systems of oppression that No rates greater exposure to nicotine.3 idea that local policies prohibiting the sale of shape `being black in America' and how o On 3 March 2009, Representative mentholated tobacco products are racist and menthol cigarettes contribute to sustained 1< p Henry Waxman and 124 congressional will increase the criminalisation of individ- and widening health disparities.20 cc°g cosponsors introduced H.R. 1256—the uals who possess or smoke them,exploiting This paper is compelling on its own o `Family Smoking Prevention and Tobacco legitimate concerns about racist policing to merit; however, read in tandem with the a Control Act. Representative Waxman's defend the tobacco industry's targeted preda- authors' previous paper, one can fully a Committee Report expressed concerns lion on the black community.9 to appreciate the significant role menthol o about the disproportionate use of menthol Authors Mendez and Le,in their article cigarettes have played in addicting 3 cigarettes among African Americans, the `Consequences of a match made in hell: millions of young people to nicotine and targeted marketing of menthol cigarettes the harm caused by menthol smoking to in the deaths of thousands due to tobacco. in black communities, and the higher the African American population over As the authors emphasise, mentholated 07 rates of lung cancer among African Amer- 1980-2018,"' show why none of us can cigarettes have a `significant detrimental ican smokers compared with non-African remain silent and complicit. This paper impact on the public's health and could o American smokers, urging the Secretary should serve as a kick upside the head continue to pose a substantial health risk.' o of Health and Human Services to move for those who are in a position to remove More than a decade after the FDA was n quickly to address the unique public these deadly products from the market- given authority to regulate tobacco products, health issues posed by menthol cigarettes. place. Until this paper, no prior study has long after other flavours favoured by white . Yet, although most other characterising fully quantified the health harm inflicted children were banned from most tobacco 0 flavours in cigarettes were prohibited in on African Americans by menthol ciga- products, and long after the first of several 2009 under the final version of the Family rettes. Yet, for at least three decades, scientific reports found menthol cigarettes to Smoking Prevention and Tobacco Control African American tobacco control activists pose a public health risk above that seen with Cn m Act, menthol was inexplicably excluded.s have been out there resisting the perva- non-menthol cigarettes,22-24 the FDA still has '0 It has been estimated that hundreds of sive presence of the tobacco industry and not acted. The black community has been 3 thousands of African Americans and other their deadly products in black communi- abandoned at the federal level,leaving activCD - menthol smokers are destined to die ties,12-15 including filing a lawsuit to get ists to seek local and state policy changes.So. N the Center for Tobacco Products of the the question for me is: Given the mountains o US Food and Drug Administration (FDA) of evidence, will anything push the federal 0 'Social and Behavioral Sciences,University of California to act on menthol.16 Now the evidence is government to consider social justice and act San Francisco,San Francisco,California,USA v Z irrefutable: menthol cigarettes are killing on its commitment to finally ban menthol African American Tobacco Control Leadership Council, our people at a rate unmatched by any cigarettes and all flavoured cigars?2s z6 n San Francisco,California,USA other assaults on our community. The recent highly publicised killings of C/)-n Correspondence to Dr Valerie Yerger,Social and Though constituting only 12% of black men and women, including George Behavioral Sciences,University of California San Francisco,San Francisco,California 94143-0612,USA; the total US population, African Amer- Floyd, Ahmaud Arbery, Breonna Taylor o Valerie.Yerger@ucsf.edu icans bear an alarming amount of the and many others, brought to the forefront m BM� Yerger V.Tob Control Month 2021 Vol 0 No 0 1 °- Editorial 0 C) of our nation's conscience how pervasively Tob Control 2021;0:1-2. 15 Sutton CD,Robinson RG.The marketing of menthol 0 racism permeates everyday life.Whether one doi:10.1 136/tobaccocontrol-2021-056988 cigarettes in the United States:populations,messages, o and channels.Nicotine Tob Res 2004;6 Suppl 1:83-91. is on the receiving or perpetuating end of ORCID iD 16 African American Tobacco Control Leadership Council racist behaviours or if one benefits from or Valerie Yerger http://orcid.org/0000-0003-2469-402X v.US Department of Health and Human Services,Case is negatively impacted by racist policies,we No.4:20-cv-4012-KAW(N.D.Cal.),2021.Available: htt s//www. ublichealthlawcenter.or /sites/default/ 6 all recently watched how quickly the world REFERENCES p p 9 Fnn, files/AATCLC-v-FDA-Defs-Second-Motion-to-Dismiss. mobilised to support the Black Lives Matter 1 Centers for Disease Control and Prevention,Tobacco pdf a movement.Are we in a moment to leverage use among U.S.racial/ethnic minority groups.A report 17 Alexander M.The newJim Crow:mass incarceration a)this movement? of the surgeon General.Washington,DC,1998.https:// U) www.cdc.gov/tobacco/data-statistics/sgr/l998/ in the age of colorblindness.New York,NY:The New If menthol cigarettes are allowed to stay Press,2012. o complete-report/ 18 Dawes D.The political determinants of health. -' in the marketplace, the lives of African 2 Villanti ACC,,Mowery PD,Delnevo CD .,et al.Changes p -' Americans and others remain at increased in the prevalence and correlates of menthol Baltimore,MD:Johns Hopkins University,2020. to 19 Yerger VB,Przewoznik J,Malone RE.Racialized risk. Conversely, removing these terrible cigarette use in the USA,2004-2014.Tob Control 0 geography,corporate activity,and health disparities: 6 products will benefit not only the black 2016;25:ii14-20. w p y tobacco industry targeting of inner cities.J Health Care 3 KreslakelM,WayneGF,AIpertHR,eta/.Tobacco 0 community but also other racial and ethnic Poor Underserved 2007;18:10-38. 0 industry control of menthol in cigarettes and targeting 20 Kong AY,Golden SD,Berger MT.An intersectional 0 groups, the lesbian, gay,bisexual and trans- of adolescents and young adults.Am J Public Health g g � gender community, youth and those with 2008;98:1685-92. approach to the menthol cigarette problem:what's 4 Family Smoking Prevention and Tobacco Control Act race(ism)got to do with it?Crit Public Health o behavioural health issues,since these groups y 9 N P.L.111e31,2009.Available:https://www.govin 2019;29:616-23. fo. o also disproportionately smoke mentho- 21 Le TT,Mendez D.An estimation of the harm of N gov/content/pkg/PLAW-111 publ31/pdf/PLAW- menthol cigarettes in the United States from lated cigarettes over non-mentholated ciga- 111publ31.pdf 9 6 rettes.27-30 I ask that others stand with us to 5 Family Smoking Prevention and Tobacco Control 1980 to 2018.Tob Control 2021.doi:10.1136/ n repair a wrong done to the black community, Act 21,2009.Available:htt s//www.fda. ov/ tobaccocontrol-2020-056256.[Epub ahead of print: CDp g 25 Feb 2021]. 00 as we stand with you.There is simply ethi- tobacco-products/rules-regulations-and-guidance/ Y P Y no 22 Tobacco Products Scientific Advisory Committee,US 0 call table reason to allow the tobacco 00 family smoking prevention-and-tobacco control act y acceptable overview#:-:text=To%20protect%20the%20pu bl ic% Food and Drug Administration.Menthol cigarettes and industry to continue using a flavouring that 20and,and%20marketing%20of%20tobacco% public health:review of the scientific evidence and rn makes it easier to start smoking and harder to 20products.[Accessed 22 Jun 2009]. recommendations,2011.Available:https:Hwayback. m 6 Lev DT,Pearson JL,Villanti AC,et al.Modeling archive-it.org/7993/20170405201731/https:/Ndww. a quit.Whether we work at the federal,state or y g fda.gov/downloads/AdvisoryCommittees/Committe the future effects of a menthol ban on smoking 3 local level,we are empowered in our collec- esMeetingMaterials/TobaccoProductsScientificAdv prevalence and smoking-attributable deaths � tive work to protect our communities from in the United States.Am J Public Health isoryCommittee/UCM269697.pdf[Accessed 04 Sep our number one killer, a corporate industry 2011;101:1236-40. 20211. No of federally adjudicated racketeers.31 This 7 Henriksen L,Schleicher INC,Dauphinee AL,et al. 23 US Food and Drug Administration.Preliminary o Targeted advertising,promotion,and price for menthol evaluation of the possible public health effects of -0 paper provides us with added ammunition to menthol versus nonmenthol cigarettes.Silver S rin et that vital work done. It is Ion past time cigarettes in California high school neighborhoods. g p g, 0 g g p Nicotine Tob Res 2012;14:116-21. MD:Center for Tobacco Products,Food and Drug for the FDA to get inoculated against what- 8 YergerVB,Malone RE.African American leadership Administration,2013. o ever the hell is keeping it from getting these groups:smoking with the enemy.Tob Control 24 Tobacco Control Legal Consortium et al.Citizen a 2002;11:336-45. Petition to the US Food and Drug Administration, m deadly products out of the marketplace. a 9 Tulloss KW.Community leaders come together against Prohibit menthol as a characterizing flavor in racism and discrimination protesting senate bill 793. cigarettes,2013.Available:https://www.publiche o Contributors As the sole author,VY,I made Available:https:Hlasentine1.net/community-leaders- althlawcenter.org/sites/default/files/resources/tcic- substantial contributions to the conception and design fdacitizen etition-menthol-2013. df of the work.I drafted the work and revised it critical) come-together-against-racism-and-discrimination- P P 7 y protesting-senate-bill-793.html[Accessed 20 Aug 25 FDA commits to evidence-based actions aimed at for important intellectual content.As the sole author, 20201 saving lives and preventing future generations of provided final approval of the version published and 10 Brown SM.Conference expresses opposition to smokers,2021.Available:https://www.fda.gov/news- CT am accountable for all aspects of the work in ensuring proposed Maryland menthol ban.Washington eve nts/press-announcements/fda-commits-evidence- 0 that questions related to the accuracy or integrity of the Informer Newspaper.Available:https://www. based-actions-aimed-saving-lives-and-preventing- 0 work are appropriately investigated and resolved. future future-generations-smokers[Accessed 29A r 2021]. 0 washingtoninformer.com/baltimore-black-baptist 9 P 0 Funding The authors have not declared a specific ministers-conference-expresses-opposition-to- 26 Statement by HHS Secretary Xavier Becerra on FDA grant for this research from any funding agency in the proposed-maryland-menthol-ban/[Accessed 11 Feb tobacco actions on menthol cigarettes and flavored o public,commercial or not-for-profit sectors. 20211. cigars,2021.Available:https://www.hhs.gov/about/ Competing interests None declared. 11 Mendez D,TT Le.Consequences of a match news/2021/04/29/statement-hhs-secretary-xavier- 3 becerra-fda-tobacco-actions-menthol-ci arettes- made in hell:the harm caused by menthol 9 0 Patient consent for publication Not applicable. smoking to the African American population over flavored-cigars.html[Accessed 29 Apr 2021]. 3 Provenance and peer review Commissioned; 1980-2018.Tob Control 2021.doi:10.1136/%20 27 Mukherjea A,Wackowski OA,Lee YO,et al. 0 internally peer reviewed. tobaccocontrol-2021-056748 Asian American,Native Hawaiian and Pacific 12 African American Tobacco Control Leadership Council. Islander tobacco use patterns.Am J Health Behav m ©Author(s)(or their employer(s))2021.No commercial 2014;38:362-9. What's menthol got to do with it?Everything!(Still): m re-use.See rights and permissions.Published by BMJ. the plight ofAfrican Americans and mentholated 28 Delnevo CD,Villanti AC,Giovino GA.Trends in menthol 3 tobacco products.Washington,D.C:International Press and non-menthol cigarette consumption in the U.S.A.: Check for updates Briefing,National Press Club,2019.https://youtu.be/ 2000 2011.Tob Control 2014;23:e154-5. 7wT9Lbn8nmk 29 FallinA,Goodin AJ,King BA.Menthol cigarette No To cite Yerger V.Tob Control Epub ahead of print: 13 Sixfootah the Poet.What menthol cigarettes have smoking among lesbian,gay,bisexual,and ry [please include Day Month Year].doi:10.1136/ taken from me.San Francisco Bayview national black transgender adults.Am J Prev Med 2015;48:93-7. o tobaccocontrol-2021-056988 newspaper.Available:https://sfbayview.com/2020/ 30 Young-Wolff KC,Hickman NJ,Kim R,et al.Correlates 04/what-menthol-cigarettes-have-taken-from-me/ and prevalence of menthol cigarette use among _ [Accessed 05 Apr 2020]. adults with serious mental illness.Nicotine Tob Res C 14 RJ Reynolds new"uptown"targets Blacks,1990. 2015;17:285-91. 0 Advocacy Institute.Available:https://www. 31 Eubanks SY,Glantz SA.Bad acts:the racketeering ► http://dx.doi.org/10.1136/tobaccocontrol-2021- industrydocuments.ucsf.edu/docs/mkvw0005 case against the tobacco industry.Washington,DC: 056748 [Accessed 04 Sep 2021]. American Public Health Association,2013. p m m 2 Yerger V.Tob Control Month 2021 Vol 0 No 0 °- s Mohammed Forouzesh, MPH, PHD Professor Emeritus California State University, Long Beach Mohmmed.forouzesh@csulb.edu 949.292.5888 Introduction As a public health professor for over thirty years, I am here to ask for your support for hookah to be included in new laws that bans flavors in tobacco and e-cigarette products.As someone from a Middle Eastern background, I am well aware of the cultural and social practices associated with hookah. According to the World Health Organization (WHO), waterpipe tobacco smoking was usually associated with elderly men in the Middle East. However in the 1990's, it quickly surged to become an epidemic among young people (WHO, 2015). Flavored hookah tobacco products are considered a major factor in the appeal to young people and is becoming a global water pipe epidemic (WHO, 2015). From 2011 to 2015 the prevalence of hookah use among high school and middle school students in the United States dramatically rose by more than 50%. (Singh et al., 2016). Hookah use poses a serious public health concern. In recent days, all Middle Eastern countries have banned the use of hookah in public places because of the direct transmission of infectious diseases such as the Corona Virus through sharing of the mouthpiece. Unlike cigarettes and pipes, hookah users inhale the tobacco fume directly into the lungs for a longer duration to create more smoke. According to a recent University of California Irvine (UCI) study, this method of deep inhalation versus taking individual puffs enables ultrafine particles (with a diameter smaller than 100 nanometers)to enter deep into the lung tissues causing irreversible damage (Nero, 2019). What is Hookah To use hookah, a form of moist tobacco is placed in the head of the water pipe. The tobacco is covered with perforated aluminum foil while the pieces of charcoal placed on top of the foil act as a heat source. Smokers inhale through a mouthpiece, drawing air over the charcoal and through the heated tobacco to produce smoke. One of the problems posed by the use of flavored charcoal, most commonly used by youth, contains many harmful toxins or additives. One of the big myths about hookah usage is that the water in the bowl will filters out the toxic chemicals,providing a shield for the smoker(Nero, 2019). However this is not the case, for the cooling effects of water actually promotes ultrafine particle formation(Nero, 2019). Hookah is often regarded as less harmful and less addictive than cigarettes. However, a typical 1-hour hookah smoking session is equivalent to the inhalation of 100 or more cigarettes (World Health Organization, 2005). According to the University of Pittsburgh Medical Center(UPMC), compared with a single cigarette, one hookah session delivers approximately 125 times the smoke, 25 times the tar, 2.5 times the nicotine and 10 times the carbon monoxide (Primack, 2016). It was found that 63.8%of high school hookah smokers and 44.3%of middle school hookah smokers chose flavored tobacco (Corey et al., 2014). Although limited in research it has been found that hookah users may have a greater risk for developing adverse health issues that include but are not limited to: lung cancer, respiratory illness,periodontal disease and coronary artery disease (Sibai et al., 2014). Call to Action As public health professionals,we ask for your support for hookah to be included in new laws that ban flavors in tobacco and e-cigarette products.By eliminating all tobacco flavors, including menthol, it is expected that this policy change will be an effective preventative measure aimed at reducing hookah usage among youth. References Cobb, C.,Ward, K. D., Maziak,W., Shihadeh,A. L., and Eissenberg, T. (2010). Waterpipe tobacco smoking: an emerging health crisis in the united states.American Journal of Health Behavior, 34(3), 275-285. Corey, C. G.,Ambrose, B.K.,Apelberg, B. J., and King, B. A. (2014). Flavored tobacco product use among middle and high school students-united states, 2011-2014. HHWR Morbidity and Mortality Weekly Report, 64(38), 1066-1070. Nero, M. (2019). UC Irvine study: hookahs more unsafe than other forms of smoking. Retrieved from:httos://batch.com/califomia/lakeforest-ca/uc-irvine-study-vapin�4-more-unsafe-o ther-forms-smoking Primack,A. B. (2016). One hookah tobacco smoking session delivers 25 times the tar of a single cigarette. Journal of Public Health Reports, 1(15), 1-5. Sibai A. M, Tohme, R. A.,Almedawar, M. M., et al. (2014). Lifetime cumulative exposure to waterpipe smoking is associated with coronary artery disease.Atherosclerosis, 234(2), 454-460. World Health Organization. (2005). Advisory note: waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators. World Health Organization. (2015). Waterpipe tobacco smoking: health effects, research needs and recommended actions for regulations. 2nd edition. Singh T. Arrazola RA, Corey CG, et al. (2016). Tobacco use among middle and high school students—United States, 2011-2015. MMWR Morb Mortal Wkly Rep. 2016:65 (14): 361-367. T'he African mericai- Tobacco � 2aT Control Leadership ound"I March 1, 2022 To: Mayor Vicente Sarmiento, Councilmember Thai Viet Phan, Councilmember David Penaloza, Councilmember Jessie Lopez, Councilmember Phil Bacerra, Councilmember Johnathan Ryan Hernandez, Councilmember Nelida Mendoza From: The African American Tobacco Control Leadership Council Re: Prohibit the Sale of Menthol and all Other Flavored Tobacco Products. No Exemptions:All Flavors,All Products,All Locations! The African American Tobacco Control Leadership Council (AATCLC) strongly encourages the Santa Ana City Council to prohibit the sale of menthol and all flavored tobacco products. No exemptions. We are glad to see that the Council is finally addressing this issue and it couldn't come at a better time. We already know that 80% of youth, 12-17 start smoking using flavored cigarettes (Ambrose et al., 2015). Indeed, in the midst of the COVID 19 pandemic nothing could be more important than getting these products out of our community. We already know that smokers are more susceptible to COVID infection (CDC, 2020). If the Council truly wants a healthier Santa Ana, and we believe that you do, then it is imperative that the sale of menthol and all other flavored tobacco products be prevented and that the predatory marketing of these products be stopped and be recognized as a social injustice; an issue that disproportionately impacts poorer communities, marginalized groups, youths and communities of color. Menthol the Ultimate Candy Flavor; It Helps the Poison Go Down Easier! This is no minor matter. Menthol and flavored tobacco products are driving tobacco-related deaths and diseases nation-wide. While the use of non-flavored tobacco cigarettes has been decreasing, the use of menthol cigarettes is on the rise, among youth and adults; among Latinos, Blacks, and Whites (Villanti, 2016). Let's be clear, the majority of women smokers smoke menthol cigarettes; folks from the LGBTQ community disproportionately smoke these products; 47% of Latino smokers prefer menthol cigarettes, with 62% of Puerto Rican smokers using menthol; nearly 80% of Native Hawaiians; a majority of Filipinos; and a majority of smokers with behavioral health issues smoke menthol cigarettes. Frankly, the most marginalized groups disproportionately use these so-called "minty" products (CDC, 2010; Fallin, 2015; Forbes, 2013; Delnevo, 2011; Hawaii State Dept. of Health, 2009; Euromonitor, 2008; Hickman, 2015). Be appraised that 85%African American adults and 94% of Black youth who smoke are using menthol products (Giovino, 2013). These striking statistics arise from the predatory marketing of these products in the Black Community, where there are more advertisements, more lucrative promotions, and cheaper prices for menthol cigarettes compared to other communities The African. American Tobacco AAT Control Leadership Council -SaO rg Bhwk Liras (Henriksen et al., 2011; Seidenberg et al., 2010). These predacious practices for the past 50 years have led to Black folks dying disproportionately from heart attacks, lung cancer, strokes and other tobacco related diseases (RSG, 2014). Take note that new research,just published this month shows that menthol cigarettes were responsible for 1.5 million new smokers, 157 000 smoking-related premature deaths and 1.5 million life-years lost among African Americans over 1980-2018.While African Americans constitute 12% of the total US population, these figures represent, respectively, a staggering 15%, 41% and 50% of the total menthol-related harm (Mendez & Le, 2021) The Council should be aware that menthol is an anesthetic by definition, and as if to add insult to injury, masks the harsh taste of tobacco and allows for deeper inhalation of toxins and greater amounts of nicotine. The greater the nicotine intake, the greater the addiction. Hence, it is no surprise menthol cigarette users find it harder to quit than non-menthol cigarette users (Ton et al., 2015; Levy et al., 2011). The "cool refreshing taste of menthol" heralded by the tobacco industry is just a guise; ultimately, menthol and all flavors allow the poisons in cigarettes and cigarillos "to go down easier!" Hookah: The Manipulation of Culture for Industry Profits! While we have all become aware of the meteoric rise of E-Cigarette use, especially among kids, another addictive product is growing in popularity: flavored shisha/Hookah. Let's not be fooled: passing tobacco smoke through water does nothing to stop the user from inhaling all the toxins, nicotine and cancer-causing chemicals associated with tobacco smoking. Let's be clear, Hookah is just as deadly as cigarettes, if not more. Studies show that in a single hookah smoking session of 40 minutes, smokers consume 25 times the tar, 125 times the smoke 2.5 times the nicotine and 10 times the carbon monoxide compared to smoking a cigarette (Primack et al., 2016). Moreover, both patrons and employees at Hookah lounges are exposed to elevated levels of 2nd hand smoke an already recognized cause of cancer(Zhou et al., 2016) Then there is the fiction that Hookah smoking is a 1000-year-old tradition in the Middle East. Look, tobacco only made its way the Europe some 500 years ago and only gradually made its way to the Middle East 3 to 4 hundred years ago. Make no mistake about it, it's the Hookah Lounge owner's manipulation of culture argument that is used to attract more business and profits. Flavored shisha like Blue Mist, Irish Kiss and Sex on the Beach has nothing to do with Middle Eastern Culture. Once it was determined in the 1960s that smoking kills, Islamic Leaders deemed tobacco, Hookah and Shisha Forbidden. At bottom, Hookah lounges with their nightclub atmosphere have nothing to do with Middle Eastern Culture, rather it's all about the Benjamin's! It's not about getting rid of all hookahs or all tobacco products, it's about getting rid of all flavors, at all places, in all products, period. The African American Tobacco T Control Leadership oun t. - avj"R fl14wA-LrW1 �- We Can't Wait on the State or the FDA The AATCLC is calling upon the Santa Ana City Council to join a growing number of cities, counties and states around the country that are prohibiting,jurisdiction-wide, the sales of menthol cigarettes and all other flavored tobacco products. In June 2018, San Francisco voters passed the first ever citywide restriction on the sales of all flavored tobacco products, including menthol cigarettes and flavored e-cigarette juices. This "strongest flavor ban law ever" was rapidly replicated in the numerous cities in California and around the Country, including Oakland,Alameda, Hayward, Fremont, Berkeley and Sacramento,just to mention a few. Today over 60 municipalities prohibit the sale of all menthol tobacco products including flavored e juices https:Hno-smoke.or�4/wp-content/uploads/pdf/flavored-tobacco-product-sales.pdf Indeed, in June of 2020, the State of Massachusetts became the first State to prohibit the sale of menthol and all flavored tobacco products state-wide and in August of 2020 California followed suit and became the second state to do so. With the tobacco industry forcing a referendum of SB 793, it becomes even more imperative that local jurisdictions take steps to protect their citizenry. We can't wait on the State, let's take steps to make Santa Ana healthier now! And while it is important that the FDA finally began the rulemaking process in April of 2021 to remove menthol cigarettes and flavored little cigars from the marketplace, this process will take years. First, the proposed rule will not be made public until April of 2022. Then, after 60-day public comment period, the tobacco industry will demand more time for comment, that has been granted in the past. Drawing out the comment period to 90 to 120 days. Once the public comment is over, the "rule" is sent to the Office of Management and Budget(OMB), who's review could take a number of months. Once a final rule is made public and there is more public comment, the industry will sue to stop the process from going forward. And may sue for numerous reasons. The bottom line is that we can't wait of the FDA. Localities, like Santa Ana, must take steps to protect the health of their citizens, lives are at stake. Who Are the Racists: The Tobacco Control Advocates or the Tobacco Industry? We should note that some groups, spurred on and funded by the tobacco industry, have been spreading falsehoods, stating that restricting the sale of menthol and flavored tobacco products, including flavored e juices will lead to the"criminalization" of particularly young Black men. Nothing could be further from the truth. All ordinances adopted around the country would prohibit the sale of flavored products, it would not prohibit the possession of these products. The facts are that the adoption of menthol restrictions will not lead to police having any greater interaction with any youth; it won't be illegal to possess these products,just retailers cannot sell them. Indeed, when these ordinances were passed in Oakland and San Francisco, the Police Chiefs stood with us and said there would be no arrest for possession of these products. T'he African American Tobacco Control Leadership Count_— lov-iw fly wk L4v- These same groups rail about"unintended consequences." We respond: Look at the Intended Consequences! As mentioned before, Black folks die disproportionately from tobacco related diseases of heart disease, lung cancer, and stroke compared to other racial and ethnic groups. (RSG, 2014); menthol cigarettes and flavored little cigars are the agents of that destruction. It is estimated that 45,000 Black folks die each year from tobacco related diseases (RSG, 1998). In this regard, the Council should remove all criminal penalties associated with the purchase, use and possession of all tobacco products. Decriminalize tobacco! Hold retail owners responsible, not clerks, don't punish kids! Still other groups funded by the tobacco industry insist that removing menthol cigarettes and flavored little cigars would be taking away "our" cigarette; we'd be discriminatory; racist. This line of argumentation stands history on its head. As was pointed out earlier, it was and is the tobacco industry that predatorially markets these products in the Black Community. The facts are these: there are more advertisements, more lucrative promotions, and most disturbing is that menthol cigarettes are cheaper in the Black Community compared to other communities (Henriksen et al., 2011; Seidenberg et al., 2010). This is how these flavored death sticks became "our" cigarettes, they pushed it down our throats! The AATCLC Formed in 2008, the African American Tobacco Control Leadership Council is composed of a cadre of dedicated community activists, academics, public health advocates and researchers. Even though based in California, we are national in our scope and reach. We have partnered with community stakeholders, elected officials, and public health agencies, from Chicago, Boston and Minneapolis to Berkeley and San Francisco. Our work has shaped the national discussion and direction of tobacco control policy, practices, and priorities, especially as they affect the lives of Black Americans,African immigrant populations and ultimately all smokers. The AATCLC has been at the forefront in elevating the regulation of mentholated and other flavored tobacco products on the national tobacco control agenda, including testifying at the FDA hearings in 2010 and 2011 when the agency was first considering the removal of menthol cigarettes from the marketplace. In November of 2019 we testified on Capitol Hill in support of HR 2339 (The Pallone Bill), this bill would prohibit the manufacturing and sale of menthol and all flavored tobacco products throughout the United States. This Bill was passed in the House of Representatives in February of 2020 but went nowhere in the Senate. In June of 2020 the AATCLC along with its partner Action on Smoking and Health (ASH) filed a lawsuit against the FDA for dragging their feet by leaving menthol on the marketplace with overwhelming scientific evidence showing that it should be removed immediately. Subsequently and importantly the American Medical Association (AMA) and the National Medical Association (NMA) have joined the lawsuit as plaintiffs. The Afr can American Tobacco T Control Leadership Council "..were: {P.s w1 1;1..5 Call to Action! Now is the time to adopt strong tobacco control measures that can protect our families. We already know that menthol and flavors "makes the poison go down easier." Let's not now allow menthol to make COVID-19 go down easier too! The Council needs to put the health of Santa Ana's residents in the forefront of their thoughts, not the interests and profits of the tobacco industry, the vaping industry and their surrogates. This is not the time for half-steps, like continuing to allow these products to be sold in adult-only venues, rather it is time to take a stand for the public's health and say: No Selling of Menthol Cigarettes and All Other Flavored Tobacco Products, including Flavored E-Juices and Flavored Hookah in Santa Ana! Say "No" to the continued predatory marketing of menthol flavored tobacco products to our youth and say "Yes" to the health and welfare of our kids, who are the most vulnerable. In fact, say "Yes" to the protection for all residents of Santa Ana. We are all counting on you! Sincerely, Phillip Gardiner, Dr. P.H. Co-Chair AATCLC www.savinablacklives.or� rwl C. � A! Carol McGruder, Co-Chair AATCLC Valerie Yerger, N.D., Co-Chair AATCLC February 24, 2022 Mayor Vicente Sarmiento Mayor Pro Tern Phil Bacerra, Council Members Johnathan Ryan Hernandez, Jessie Lopez, Nelida Mendoza, David Penaloza, Thai Viet Phan City of Santa Ana 20 Civic Center Plaza Santa Ana, CA 92701 Dear Mayor Sarmiento, Mayor Pro Tom Bacerra and Councilmembers Hernandez, Lopez, Mendoza, Penaloza and Phan, These past couple of years have been extremely difficult for the retail industry and small businesses in particular. As you probably know, the vast majority of our 7-Eleven stores in our Franchisee Owners Association (which includes Santa Ana, Anaheim, Orange, Garden Grove and parts of other surrounding cities) are small businesses which are individually owned and operated. Despite the challenges from COVID and inflation, we've made every effort to keep our 250+ employees working and safe. We've also donated to many charities and causes to help local neighbors and families through these difficult times. To avoid further economic and emotional harm to our 7-Eleven small business owners, workers and customers, we strongly recommend you vote for "Option 4 on March 1 and take no action at this time and wait to see whether senate bill 793 goes into effect following a statewide referendum vote in November 2022 " We're starting to get questions from our customers in Santa Ana asking if the Mayor and City Council are going to force them to drive to other cities in Orange County to get their tobacco products. We let them know that we're working with you to minimize the impacts to them and preferably continue to work on the issue until later in the year when the statewide ballot measure is voted on. Based on statewide estimates, there are likely to be 20,000+ tobacco product users in Santa Ana. Before the City Council takes final action, we also have some questions that will help us better understand the impacts of the proposed ban and finalize our list of practical changes for the ordinance ban. 1. Will Police department or Code Enforcement department be responsible for enforcing the Council's ban? What's the enforcement timeline? Will the Police or Code Enforcement provide a dedicated period of time for letting all the retail tobacco sellers know the timeline, rules and enforcement? Can they come speak to our store owners in the West Coast Franchisee Owners Area before the Council takes action? Can the enforcement plan be included in the ordinance and shared with the impacted stores and sellers before the Council votes on the tobacco ban? W**4 The 7-Eleven West Coast Franchisee Owners Association (West Coast FOA) was formed in 2015. The West Coast FOA EIEYEn includes over 200 small business members, mainly in central Orange County, and is represented by 19 board members. 2. If the ban were to be implemented now, can stores and sellers be allowed to sell their remaining affected tobacco products through the end of 2022? If not, can the City reimburse stores and sellers for the costs of buying and legally discarding the affected property and merchandise? Federal and state laws heavily restrict the ability of tobacco products to be resold to others or sold back to manufacturers. Have you estimated the value of the property and costs to discard the tobacco products? 3. Since the City is aware of the statewide referendum vote in November that would ban the same tobacco products being discussed by the Santa Ana Council, why would the City want to pass something by itself now since it will hurt Santa Ana small businesses but help surrounding cities like Garden Grove, Orange and Anaheim. Not only would our stores lose the tobacco sales, but also the sales of many other purchases that our customers usually make during the same store visit. Things like coffee, sandwiches, chips, drinks, and many more items. Why is Santa Ana doing this to its 7-Eleven stores and other community stores? It's very unfair and discriminatory and many of our employees who are Santa Ana residents and minorities will be negatively affected. 4. We implore the City to postpone action on this tobacco ban until December, so that our Santa Ana stores don't have to suffer an extra 9 months early before other cities. Can the City postpone this ban ordinance vote until December? We don't understand why there is a rush in Santa Ana. If some type of ban were to be considered before November, can there be an option like with the cannabis stores that allows us to continue to sell our existing products if we use ID scanning technology, fraud detection software and other automated software -based technology like the Council discussed at the last meeting? Mayor, please don't force our Santa Ana customers to drive to other cities in Orange County to get their favorite tobacco products. We strongly recommend that you postpone the ordinance ban issue until later in the year when the statewide ballot measure is voted on. Thank you for your time and consideration. On Behalf of Your Local 7-Eleven Convenience Stores, PAUL GHUMAN Paul Ghuman 7-Eleven Small Business Owner President of 7-Eleven West Coast Franchisee Owners Association 914 North Harbor Avenue Santa Ana, CA 92703