Cigarette tax collections in Ky. jumped, then dropped, after tax increases; state's smoking rate has also been on the decline

Kentucky Health News graph from state data

By Melissa Patrick

Kentucky Health News

Increasing state cigarette taxes has proven to be an effective policy to decrease smoking rates, and it appears that is also true in Kentucky.

Nearly 30 percent of Kentucky adults smoked in 2011, two years after the legislature had doubled the cigarette tax to 60 cents a pack. Following a 50-cent increase to $1.10 in 2018, the state's adult smoking rate fell to 17.4% in 2022, the last year for which a rate is available. 

Shannon Baker, the American Lung Association's advocacy director for Kentucky and Tennessee, said that while she could not point to something definitive to explain why Kentucky's smoking rate has been decreasing, as has also been the case in the nation, she could speak to the impact of raising cigarette taxes:

"When taxes increase, smoking rates decline. We should take advantage of that, for goodness sake, and increase the cigarette tax in Kentucky by at least $1 and then tax all other nicotine products at parity with the cigarette tax." 

After an initial boost in cigarette-tax revenue from the rate hikes in 2011 and 2018, revenue from the tax declined 24% from 2019 to 2024.

The legislature increased the tax to 30 cents from 3 cents in 2005, but smoking rates before 2011 should not be compared with those after that because of a change in survey methodology, says the Behavioral Risk Factior Surveillance System, a continuing federal-state poll of Americans' habits.

Baker stressed that its important to take advantage of all policies that are known to decrease smoking. Beyond raising taxes, she said it's important to fund the state tobacco-control program and enforce the law against underage sales, which she said would result in fewer youth becoming addicted to nicotine and growing up to be lifelong smokers, and all the health issues that come with that. 

The new report on state General Fund receipts for the fiscal year that ended June 30 showed a 1.5% increase in receipts from other tobacco products, such as electronic cigarettes or vapes.

Asked about the impact of vaping on decreasing smoking rates, Baker focused her comments on young people, who are more likely to vape than smoke.

"We really have to get a handle on this youth vaping problem," she said, noting that Kentucky is one of about 10 states that doesn't require tobacco retailers to be licensed. "We don't even know where all of these shops are in order to enforce the law against underage sales."

Baker added, "We really need a better method of enforcing the law against underage sales. And what that looks like is licensure and routine regular enforcement opportunities that result in significant penalties all the way up to license suspension and revocation, for scofflaws that routinely violate the law. We're not talking about any onerous policy on those who are compliant with the law. We're simply talking about those who violate the law and violate it routinely." 

The 2023 Youth Risk Behavior Survey found that 5.3% of Kentucky high-school students said they currently smoked cigarettes and 19.7% said they used electronic vapor products. Among middle schoolers, the 2.2% said they smoked cigarettes and 12.8% used a vapor product. "Current use" is considered having used a product on at least one day during the 30 days prior to the survey.

Asked if she thought the new law that bans retailers from selling unauthorized vapor products would be effective in decreasing youth vaping, as it has been touted to do, Baker said, "House Bill 11 turned into . . . an industry market-share grab and nothing more; it is not a protection for kids. What we saw was a bill passing that, in effect would, if it's upheld in court, remove certain products, primarily imported products, from the market shelves, which in and of itself is not a bad thing. But, it certainly doesn't protect kids who will just switch to the other products that remain on the shelves." 

The law has been challenged in court. If it holds up, it will go into effect January 2025.

Baker also wanted to make sure people know that the funds for the state's tobacco control program come from the Master Settlement Agreement with cigarette manufacturers, not from the cigarette tax.

"We need to increase funding for tobacco control because . . .  Kentucky has the highest lung-cancer incidence and mortality rates in the entire nation and most of that is due to our high smoking rate," Baler said. "So even though the smoking rate may be declining, it isn't gone. It isn't good, even."

Biden administration indefinitely postpones ban on menthol cigarettes amid election-year pushback from Black voters, others

Menthol cigarettes and other tobacco products are displayed at a store in San Francisco on May 17, 2018. For the second time in recent months, President Joe Biden’s administration has delayed a plan to ban menthol cigarettes, a decision that is certain to infuriate anti-smoking advocates but could avoid angering Black voters ahead of November elections. (Associated Press file photo by Jeff Chiu)

By Matthew Perrone and Zeke Miller

Associated Press

President Joe Biden’s administration is indefinitely delaying a long-awaited menthol cigarette ban, a decision that infuriated anti-smoking advocates but could avoid a political backlash from Black voters in November.

In a statement Friday, Biden’s top health official gave no timeline for issuing the rule, saying only that the administration would take more time to consider feedback, including from civil rights groups.

“It’s clear that there are still more conversations to have, and that will take significantly more time,” Health and Human Services Secretary Xavier Becerra said in a statement.

The White House has held dozens of meetings in recent months with groups opposing the ban, including civil-rights organizers, law-enforcement officials and small business owners. Most of the groups have financial ties to cigarette companies.

The announcement is another setback for Food and Drug Administration officials, who drafted the ban and predicted it would prevent hundreds of thousands of smoking-related deaths over 40 years. The agency has worked toward banning menthol across multiple administrations without finalizing a rule.

“This decision prioritizes politics over lives, especially Black lives,” said Yolonda Richardson of the Campaign for Tobacco-Free Kids, in an emailed statement. “It is especially disturbing to see the administration parrot the false claims of the tobacco industry about support from the civil rights community.”

Richardson noted that the ban is supported by groups including the NAACP and the Congressional Black Caucus.

Previous FDA efforts on menthol have been derailed by tobacco industry pushback or competing political priorities. With both Biden and former President Donald Trump vying for the support of Black voters, the ban’s potential impact has been scrutinized by Republicans and Democrats heading into the fall election.

Anti-smoking advocates have been pushing the FDA to eliminate the flavor since the agency gained authority to regulate certain tobacco ingredients in 2009. Menthol is the only cigarette flavor that wasn’t banned under that law, a carveout negotiated by industry allies in Congress. But the law instructed the FDA to continue studying the issue.

More than 11% of U.S. adults smoke, with rates roughly even between white and Black people, but about 80% of Black smokers smoke menthol, which the FDA says masks the harshness of smoke, making it easier to start and harder to quit. Also, most teenagers who smoke cigarettes prefer menthols.

For decades, cigarette companies focused menthol advertising and promotions in Black communities, sponsoring music festivals and neighborhood events. Industry documents released in litigation show companies viewed menthol cigarettes as a good “starter product” because they were more palatable to teens.

The FDA released its draft of the proposed ban in 2022. Officials under Biden initially targeted last August to finalize the rule. Late last year, White House officials said they would take until March to review the measure. When that deadline passed last month, several anti-smoking groups filed a lawsuit to force its release.

“We are disappointed with the action of the Biden administration, which has caved in to the scare tactics of the tobacco industry,” said Dr. Mark Mitchell of the National Medical Association, an African American physician group that is suing the administration.

Separately, Rev. Al Sharpton and other civil rights leaders have warned that a menthol ban would create an illegal market for the cigarettes in Black communities and invite more confrontations with police.

The FDA and health advocates have long rejected such concerns, noting FDA’s enforcement of the rule would only apply to companies that make or sell cigarettes, not to individuals.

An FDA spokesperson said Friday the agency is still committed to banning menthol cigarettes. “As we’ve made clear, these product standards remain at the top of our priorities,” Jim McKinney said in a statement.

Smoking can cause cancer, strokes and heart attacks and is blamed for 480,000 deaths each year in the U.S., including 45,000 among Black Americans.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

Ky. and Okla. lead the nation in adult daily vaping; with additional metrics, Forbes ranks Ky. as the No. 2 vaping state, behind Tenn.

Forbes magazine chart, adapted by Kentucky Health News

Kentucky Health News

Kentucky adults use electronic cigarettes daily at the highest rate in the nation, equaled only by Oklahoma, according to an analysis of Centers for Disease Control and Prevention data by Forbes. 

The magazine says 6 percent of adults in Kentucky vape daily, and another 4.5% vape on "some days," for a totla of 10.5%. In Oklahoma, the rates are 6% and 5% for a total of 11%. 

The magazine used daily and occasional vaping rates, and the increase in those rates among adults from 2016 to 2022, to rank the states in prevalence of vaping. Kentucky was second only to Tennessee, where 5.7% of adults vape daily and another 5.1% vape occasionally, for a total of 10.8%.

In smoking traditional cigarettes, Kentucky adults also rank second, just behind those in West Virginia. Youth smoking has declined as vaping has increased.

The 2021 Youth Risk Behavior Survey found that 4.9% of Kentucky high-school students said they smoked cigarettes and 21.9% said they used electronic vapor products. Among middle schoolers, the 1.6% said they currently smoked cigarettes and 13.8% used a vapor product. "Current use" is considered having used a product on at least one day during the 30 days prior to the survey.

“Kentucky historically has had pretty high tobacco use rates across all forms of tobacco, and we’re still, unfortunately, seeing that with e-cigarettes and vaping not only with youth but also adults,” Dr. Melinda Ickes, assistant dean for research at the University of Kentucky College of Education, told WDKY.

“Even if someone is curious and just tries it a couple of times, the risk of dependency increases significantly. These products are certainly not harmless, and especially for young people, they can have lasting effects like mood disorders, impacting brain development, and things related to mental health.”

Kentucky's high smoking rate affects nonsmokers, by adding to the health-care costs borne by taxpayers and the effects of secondhand smoke.  

Centers for Disease Control and Prevention chart, adapted by Kentucky Health News 

Biden administration again delays menthol-cigarette ban as Black support for Biden drops; anti-smoking advocates push back

Photo from ash.org

Kentucky Health News

The Biden administration has again delayed issuing a decision to eliminate menthol cigarettes, with plans to finalize the final rule next March, according to an updated regulatory agenda posted online by the White House Office of Management and Budget. 

Administration officials told The Washington Post that the delay comes after "fierce lobbying from critics who warn that a prohibition could anger some Black smokers who favor the product and could hurt President Biden's reelection prospects." Biden's support among Black voters has dropped about 20 percentage points in the past year, NBC News reports.

Four other officials told the Post, on the condition of anonymity, that the process could be delayed even further. 

The delay follows intense pressure from tobacco lobbyists, HealthDay reports.

Yolonda C. Richardson, president and CEO of the Campaign for Tobacco-Free Kids, said in a statement that it was "disturbing that this delay comes just two weeks after the tobacco industry and its army of lobbyists met with top officials at the White House." Further, she says the delay "allows the tobacco industry to continue profiting at the expense of Black lives." 

Richardson added, "The scientific evidence shows that menthol cigarettes are more addictive, easier for kids to start smoking and harder for smokers to quit. For decades, the tobacco industry has marketed these products to Black communities, causing devastating and disproportionate harm to the health of Black Americans. . . . Research shows that prohibiting menthol cigarettes will save up to 654,000 lives within 40 years, including the lives of 255,000 Black Americans."

When added to cigarettes and cigars, menthol’s minty taste and cooling effect limit throat irritation, making the products more appealing — especially new and young smokers — and it interacts with nicotine to enhance its addictive effects and makes quitting smoking harder, according to the Centers for Disease Control and Prevention.

According to research published earlier this year in the journal Nicotine and Tobacco Research, 43% of adults who smoked cigarettes in the past month in 2020 used menthol, with use most common among Black adults, at 80%. 

Prior to the announcement of the delay, the rule was widely expected to be published in late 2023 or early January, although it was likely be further delayed by legal challenges.  

The delay set in motion a string of statements from anti-smoking advocates calling on the Biden administration to issue the final rule by the end of this year. 

"Ending menthol cigarettes is pivotal to eliminating the dramatic health inequities in who uses tobacco products in the United States and who is most affected by tobacco-caused disease and death, said Harold Wimmer, president and CEO of the American Lung Association.

"Tobacco use is the number one cause of preventable death in the U.S. and claims 45,000 lives every year among Black Americans alone. A recent study quantified the disproportionate harms from menthol cigarettes to Black Americans, finding 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 Black Americans from 1980 to 2018. Halting the sale of menthol cigarettes lays the groundwork for reversing decades of disparities in tobacco use, disease and death in Black and Brown communities." 

Dr. Karen E. Knudsen, CEO of the American Cancer Society Cancer Action Network, noted that the Food and Drug Administration has had authority to ban menthol cigarettes and flavored cigars for 14 years and that any delay in doing so "only benefits the tobacco industry at the expense of public health. Tobacco is a primary driver of all cancer disparities, and the number one cause of cancer deaths nationwide, and flavors like menthol have been proven to make it easier to start and harder to quit using deadly products. There is no scientific rationale for permitting any flavored tobacco product to remain on the market. FDA stated that a comprehensive end to the sale of menthol cigarettes is projected to result in 324,000 to 654,000 fewer smoking related deaths." 

The FDA is also pursuing a ban on flavored cigars and new limits on nicotine in cigarettes, although the process of finalizing those rules is to be delayed until at least March as well, the Post reports. 

Nancy Brown, CEO of the American Heart Association, also issued a statement of concern, urging the administration to issue "strong final rules without delay." She said, "Each day we wait for the final rules to be released is another day Big Tobacco will hook new users and target communities with menthol cigarettes and flavored cigars."

Tobacco companies continue to oppose the ban, "insisting science shows menthols pose no greater risk than other cigarettes," the Post reports. "R.J. Reynolds, which makes Newport, the nation’s top-selling menthol brand, said in a statement Tuesday that a ban would hurt small businesses, dent tax revenue and contribute to a dangerous illegal market."

Food and Drug Administration sends White House office proposed regulations banning menthol cigarettes and flavored cigars

Ash.org

On Friday, the Food and Drug Administration sent the White House Office of Management & Budget its long-in-the-making regulations that would ban the sale of menthol cigarettes and flavored cigars.

 

OMB "serves as a clearinghouse of sorts for executive actions like this," notes Halfwheel, a cigar site. "While the Biden administration is in favor of both bans, OMB is also likely to add scrutiny to FDA’s plans, including asking the agency questions about the economic impacts of the bans—both for the government and businesses—as well as questioning certain legal aspects of the proposal. Historically, OMB has also been a place where the tobacco industry has lobbied to try to soften the impact of rules."

Ten years ago, citizens petitioned the FDA for impose the bans, and went to federal court to force the agency to act. Ordered to respond by April 29, 2021, the FDA said "it was planning on banning both flavored cigars and menthol cigarettes, plans that it said would be announced within a year," Halfwheel notes. "Nearly a year to the date—April 28, 2022—FDA announced that it was moving forward with both proposed regulations, starting the formal rulemaking process that the agency must follow when it crafts new regulations. This included creating proposed rules, as well as allowing for comments about the proposed rules. The commenting period ended in early August 2022."

Menthol cigarettes made up 36% of all cigarette sales in the U.S. in 2018. Anti-smoking groups have cited research that shows cigarette companies have deliberately targeted African American communities, especially youth, with marketing menthol cigarettes, cigars and other tobacco products. Menthol products also have a strong appeal for youth, since menthol numbs the throat and reduces irritation from smoking and makes it easier for them to start smoking.

Once the rules clear OMB, expected before the end of the year, they would not take effect for a year, FDA has said. "The tobacco industry is likely to sue FDA and will likely ask for an injunction until after those lawsuits are resolved, further delaying the enforcement," Halfwheel reports.

UK gets $19 million to study tobacco-product markets and possible additional federal regulation of them in Kentucky

AppalTRuST draws from UK's colleges of Medicine, Nursing, Public Health, Education and Arts and Sciences, the Markey Cancer Center and Bridging Research Efforts and Advocacy Toward Healthy Environmennts (BREATHE). (Photos by Jeremy Blackburn , UK Research Communications)

Kentucky Health News

The University of Kentucky is one of seven institutions that are getting about $20 million each in federal money over the next four years to examine the potential impact of federal tobacco regulations.

The Appalachian Tobacco Regulatory Science Team, which UK has dubbed AppalTRuST, is funded by $19 million from the National Institute on Drug Abuse of the National Institutes of Health and the Food and Drug Administration Center for Tobacco Products.

"The goal of AppalTRuST is to investigate the impact of federal regulatory policies in rural communities through collaboration, education and pioneering regulatory scientific research," said a UK news release that alluded to Kentucky's longstanding health problems from using what was once its top cash crop.

“This is a state with its own struggles and health disparities associated with tobacco use, particularly in Appalachian Kentucky,” Dr. Seth Himelhoch, chair of the UK Department of Psychiatry and the grant's principal investigator, said in the release. “While America has overall reduced its use of combustible tobacco, Appalachian Kentucky, in particular, has not moved along at the same pace.”

Kentucky's adult smoking rate, 19.6% in 2021, is second only to West Virginia's.

Co-directors Teresa Waters, Seth Himelhoch and Ellen J. Hahn

“It seems very important to me that when the federal government is going to evaluate regulations for tobacco use it should certainly be doing so in a part of the country where decreasing combustible tobacco use is likely to lead to long-term health benefits including reductions in cancer and cardiovascular disease,” Himelhoch said.

UK Vice President for Research Lisa Cassis said, “Tobacco has long been an issue that challenges the health and well-being of Kentucky. It is our mission as scientists and stewards of our land-grant institution to advance the commonwealth beyond any obstacles to its public health. This award offers the team behind AppalTRuST an opportunity to lay a foundation for high-level, innovative and interdisciplinary research to make an impact on our state.”

The co-directors of AppalTRuST are Ellen J. Hahn, an endowed nursing professor and director of the Bridging Research Efforts and Advocacy Toward Healthy Environments (BREATHE), and Teresa M. Waters, dean of public health at Augusta University in Georgia, the former chair of health management and policy in the UK College of Public Health. The project involves that college and the colleges of Nursing, Medicine, Education, and Arts and Sciences, as well as the UK Markey Cancer Center.

Hahn said, “Kentuckians are at a much higher risk for heart disease, lung conditions and cancer due to high smoking rates and weak smoke-free protections. AppalTRuST will learn with and from the community to better understand their use of tobacco, retail marketing of tobacco projects, and consumer behaviors in rural communities. The health and economic burdens from tobacco use in our state is enormous, and we hope to foster sustainable change in our communities through this work.”

The project will focus on two regions — Boyd, Carter and Greenup counties in northeastern Kentucky, partly in a metropolitan area, and a more rural group of counties in southeast Kentucky: Breathitt, Knott, Leslie, Letcher and Perry.

The AppalTRuST team will start its research by looking at how people get tobacco products and provide an overview of the marketplace, including the prevalence and impact of marketing and how FDA regulations may affect tobacco use. It will also use a virtual storefront to evaluate how possible regulations would affect purchases of tobacco products.

“We hope the findings AppalTRuST produces will provide important information to the FDA as they regulate tobacco products in a way that positively impacts the health of Kentucky’s rural communities,” said Hahn, who created UK's Kentucky Center on Smoke-Free Policy.

The other six institutions awarded grants for Tobacco Centers of Regulatory Science are the University of North Carolina at Chapel Hill, the University of Michigan, Pennsylvauia State University, Ohio State University, the University of South Carolina and Yale University.

Studies show that comprehensive smoke-free laws and tobacco taxes are associated with lower rates of youth smoking

Kentucky Health News

Tobacco-control policies such as taxes and comprehensive smoke-free laws are associated with lower rates of youth smoking, according to recent studies. 

The purpose of the first study, published in Sage Journals, was to determine whether the presence and strength of local smoke-free ordinances was associated with cigarette and smokeless tobacco use among high school students in Kentucky, and whether use varied by urban/rural location.

The researchers used data from more than 353,000 10th and 12th graders in the 2004-2018 biennial Kentucky Incentives for Prevention Survey. The smoke-free ordinance data came from the Kentucky Center for Smoke-Free Policy at the University of Kentucky.

The center said in a news release that UK researchers "found that high-school students living in Kentucky counties with a comprehensive smoke-free law are 23% less likely to smoke cigarettes and 16% less likely to use smokeless tobacco compared to those living in counties with a partial smoke-free law or no law." 

Also, "Students in counties with moderate/weak laws did not differ in likelihood of use for either product, compared to those in counties without a law." 

Comprehensive smoke-free laws prohibit smoking inside all workplaces and public places.

The study also found that rural youth may be more likely to smoke. 

"Students in urban counties were 14% less likely to smoke, but there was no difference in likelihood of smokeless use by urban/rural location," says the report.

In conclusion, the researchers write, "Given that nearly half of U.S. youth are not protected by smoke-free laws, advocacy for comprehensive smoke-free workplace laws in all states and municipalities may be an important component in reducing the prospect of youth cigarette and smokeless tobacco use." 

In Kentucky, nearly 5% of high-school students smoke cigarettes and nearly 22% of them use electronic cigarettes, according to data from the Campaign for Tobacco-Free Kids. 

A separate study, published in the American Journal of Preventive Medicine, that looked at how changes in state tobacco-control policies impacted youth e-cigarette use in 2013-19. It found that adolescents were 55% less likely to use e-cigarettes following the enactment of a statewide comprehensive smoke-free law than before the state had a law.

 

The researchers then compared this to the impact of age-of-purchase laws and e-cigarette excise taxes and found that comprehensive smoke-free laws had the biggest impact on youth vaping. 

"Youth were 21% less likely to use e-cigarettes when their state had a minimum age-of-purchase law than when they did not," says the release. 

In addition, the study found that "while changes in tobacco excise taxes did not have a statistically significant impact, adolescents who lived in states with higher average cigarette excise taxes were more likely to use e-cigarettes." 

"This suggests that states need to consider parity and tax all tobacco products including e-cigarettes at the same rate," says the release. "These findings indicate that comprehensive smoke-free laws, tightening restrictions on youth access, and enforcing existing age-of-purchase laws can reduce the likelihood of e-cigarette use among youth."

Lexington marks 20 smoke-free years, but smoking bans still haven't caught on in most of Ky. despite tobacco's toll on health

Lexington Mayor Linda Gorton led a celebration of the 20th anniversary of the city's ordinance banning smoking in indoor workplaces and public spaces. (WEKU photo by Stu Johnson)

Kentucky Health News

Twenty years ago, Lexington became the first city in the South of Midwest to make indoor smoking in public places illegal. It's had a big impact there and in several other Kentucky cities, but only three in eight Kentuckains live in a place with such an ordinance.

“Lexington’s ordinance has had an enormous impact on the health of Lexington citizens,” said Mayor Linda Gorton said at a celebration of the anniversary. “In terms of public health, it is one of the most important, if not the most important, ordinance we have passed in the last 20 years. It has saved countless lives.”

Tom Latek of Kentucky Today reports, “After the measure took effect, there was a reduction in heart attacks and emergency-department visits for asthma, and the smoking rate in Fayette County declined nearly 32%, resulting in 16,500 fewer smokers for an estimated annual health-care cost savings of $21 million.”

In 2014, electronic cigarettes, "addictive and popular among youth, were added to the ban," Latek notes. "In the 20 years since Lexington’s smoke-free law passed, 57 additional Kentucky municipalities have passed smoke-free laws, protecting 38% of Kentuckians."

"The number of people benefiting is considerably higher, as residents of counties that don’t protect against secondhand smoke travel to cities that do in order to work, shop, do business, dine and have fun," writes Jamie Lucke of Kentucky Lantern.

But despite Kentucky's high smoking rate and tobacco's effect on the state's health, bills to enact a statewide indoor-smoking ban couldn't get through the General Assembly even when the House was conrolled by Democrats, and now that it and the Senate are heavily Republican, advocates have given up on the idea, at least for now. So they concentrate on local ordinances.

Ellen Hahn, Ph.D., R.N.

“Policy change takes time, often decades,” says Ellen Hahn, the University of Kentucky nursing professor who has been the leading advocate of smoke-free ordinances. “Policy change is also a team sport. While a few people can make a difference, I could not stick with it without support from others.

“As a nurse, I am naturally a patient advocate, giving voice to the voiceless, and as a public health nurse, my patient is the community. I am willing to wait for effective change. . . . The payoff for society is definitely worth the wait.”

Hahn told Lucke that she wishes for four things: “A comprehensive smoke-free law that covers every community in the state . . . a strong, hard-hitting media campaign” against heavily promoted tobacco products; higher cigarette taxes, which Lucke notes "deter young people from starting and to motivate adults to quit;" and more smoking-cessation services. "Kentucky spends just 3.5% of what the Centers for Disease Control and Prevention recommends on tobacco control and prevention," Lucke notes.

“It’s really not a shock that we have such high smoking rates,” Hahn told Lucke. “We don’t invest in prevention. And the sad part is we know what works to reduce smoking. We’re just not doing it.”

FDA proposes new requirements for makers of tobacco products aimed at minimizing contamination, protecting public health

American Heart Association photo illustration

By Melissa Patrick
Kentucky Health News

The U.S. Food and Drug Administration is proposing new rules that are aimed at minimizing contamination of tobacco products, including electronic cigarettes, and that would create manufacturing specifications to ensure product consistency. 

“While no tobacco product is safe, this proposed rule is intended to minimize or prevent additional risks associated with these products,” Brian King, director of the FDA’s Center for Tobacco Products, said in a news release. “Once finalized, it would establish requirements for tobacco product manufacturers that will help protect public health.”

The proposed regulations aim to see that tobacco products are made according to established specifications and would require manufacturers to take appropriate measures to prevent contamination of the product. 

One regulation says companies that create products that don't meet those specifications will be investigated and be required to institute appropriate corrective actions, such as a recall. 

Another establishes the ability to trace all components or parts, ingredients, additives and materials, including by batch of the finished product, to aid in such investigations. 

"These requirements would help minimize or prevent the manufacture and distribution of tobacco products contaminated with foreign substances—such as metal, glass, and plastics—which have been found in tobacco products," FDA said in its release. "The proposed rule would also help address issues related to inconsistencies between e-liquid product labeling and the actual concentrations in e-liquids; such variability can be misleading to consumers, potentially intensifying addiction and exposure to toxins."

"The FDA says there have been inconsistencies between what’s in e-cigarettes and what’s on the label," CNN reports. Gregory Conley, director of legislative and external affairs for the American Vapor Manufacturers Association, told CNN he was disappointed by the timing of the proposed rule.

“The vaping industry has tried in vain for more than a decade to work with FDA on sensible manufacturing standards, only to be ignored while the agency recklessly vilified nicotine vaping,” Conley told CNN in an email. “It is disappointing, but not at all surprising, that the FDA would wait to propose these regulations until it had already committed itself to banning 99.99 percent of the vaping market. The millions of Americans who rely on vaping to stay off cigarettes could benefit from the FDA’s proposal, but only if the agency stops thumbing its nose at its critics and starts to regulate the category in good faith.”

The FDA will hold a public hearing April 12 about the proposed rule. 

Study: 42% of dual smoker-vapers quit vaping early and kept on smoking; 10% quit both; 15% went back to using both

CDC photo

Adults who vape and smoke at the same time are likely to continue smoking in the long run, counter to the electronic-cigarette industry's message that vaping can help current smokers quit, according to a recent study. 

Data for The George Washington University study came from the Population Assessment of Tobacco and Health Study, which is a nationally representative, longitudinal study of tobacco use. The researchers followed regular users of both cigarettes and electronic cigarettes over five cycles of data, called waves, starting in 2013 with annual follow-up to check on smoking and vaping behavior, says a news release.

The study, published in the journal Tobacco Control, found that over six years, the most common pattern among vapers was quitting vaping early, but continuing to smoke, with 42% of the participants falling into this category; 10% quit both vaping and smoking early, and 15% went on to use both products. The findings were based on self-reported data. 

“This study suggests that at the population level, vaping may not help people kick the smoking habit,” lead researcher Nandita Krishnan said in the release.  “People who concurrently use e-cigarettes and cigarettes experience increased health risks and both products deliver nicotine, which is addictive. We should be trying to help them quit both smoking and vaping.”

Krishnan was a researcher at The George Washington University Milken Institute School of Public Health at the time the study was conducted. She is now a postdoctoral scholar at Stanford University.

She said additional research is needed to find out how to help people quit both smoking and vaping over the long haul and that it will also be important to continue monitoring this data as the vaping marketplace evolves.  Further, she said that the long term health effects of vaping products remain unclear.

FDA orders Juul products off the shelves, and firm asks court to block it; rule to limit level of nicotine in cigarettes is coming

Photo from Juul Labs

UPDATE, June 27: A federal judge blocked the order pending proceedings in Juul's lawsuit.

By Melissa Patrick
Kentucky Health News

The federal government has ordered Juul Labs to stop selling and distributing its products in the United States after denying the company's application to keep selling them, saying the company did not provide adequate data to determine "relevant health risks." 

Meanwhile, the Food and Drug Administration is planning to establish a maximum nicotine level in cigarettes and other combustible tobacco products to reduce the addictiveness of the products, which claim the lives of 480,000 Americans each year, with more than 8,000 in Kentucky.

"While we welcome the ban on Juul -- we think that's a good thing -- it is not nearly enough, and until they actually come to grips with the nicotine problem, they're not going to solve this," said Ben Chandler, president of the Foundation for a Healthy Kentucky. "The central problem here is that we are addicting an entire new generation of young people to nicotine."

The FDA issued marketing denial orders against Juul that require the company to remove its electronic-cigarette products from the U.S. market, or risk enforcement action. 

“Today’s action is further progress on the FDA’s commitment to ensuring that all e-cigarette and electronic nicotine delivery system products currently being marketed to consumers meet our public health standards,” FDA Commissioner Robert M. Califf said in the release. He also noted the role of e-cigarettes in the rise of youth vaping.

The 2020 National Youth Tobacco Survey found Juul was the most popular e-cigarette brand used by adolescents with 25.4% of high school e-cigarette users and 35.1% of middle school users saying Juul was their most used brand.

According to the latest 2019 Youth Risk Behavior Surveillance System report, 26% of Kentucky's high school students had used an electronic vapor product on at least one day in the 30 days prior to the survey, while just 8.9% had smoked cigarettes. A national survey found youth vaping rates have declined during the pandemic, but a separate survey taken in late 2020 found that 34% of the 400 Kentucky youth surveyed believed there had been an increase in tobacco use due to the pandemic.

The FDA said the company's marketing applications “lacked sufficient evidence regarding the toxicological profile of the products to demonstrate that marketing of the products would be appropriate for the protection of the public health.” 

A key public-health issue the FDA looks for in reviewing electronic cigarettes is whether the potential benefit to adult smokers who may be using them to quit smoking is greater than the risks to youth. 

The agency said it didn't see clinical information suggesting there is an immediate risk to using Juul products, but "Some of the company’s study findings raised concerns due to insufficient and conflicting data– including regarding genotoxicity and potentially harmful chemicals leaching from the company’s proprietary e-liquid pods – that have not been adequately addressed."

Joe Murillo, chief regulatory officer at Juul Labs, issued a statement saying the company had "provided sufficient information and data based on high-quality research to address all issues raised by the agency" and that the data meets the standard of being "appropriate for the protection of the public health." He added, "We intend to seek a stay and are exploring all of our options under the FDA’s regulations and the law, including appealing the decision and engaging with our regulator."

UPDATE, June 24: Juul asked a federal court in Washington to block the order.

Juul, which has long been blamed for the surge in teen vaping, had already stopped selling its sweet-flavored e-cigarette pods, but had continued selling tobacco- and menthol-flavored cartridges while it waited on the FDA to review its marketing application. The company had also worked on efforts to stop teens from buying its products, like halting television, print and digital advertising. ”

Anti-smoking advocates praised the FDA's ruling. 

Ellen Hahn, a University of Kentucky nursing professor and the director of the Bridging Research Efforts and Advocacy Toward Healthy Environments (BREATHE) initiative, said in an email that the decision "is long overdue. This move is particularly important [for] our ability to breathe in Kentucky. Kentucky youth smoke e-cigarettes, or vapes, over twice the rate of high school students in the U.S. (26.1% vs. 11.3%). E-cigarette aerosol contains highly addictive nicotine that damages the lungs and the developing brain. Vaping is a cause of serious lung injury and makes it harder for the user to fight infection. Lung damage from vaping is comparable to conventional cigarette use." 

That said, Hahn cautioned that since the FDA's decision to limit flavorings in Juul products, other "disposable" vapes have become more popular because they continue to offer a variety of flavors. "So while today’s decision shows the power of FDA’s premarket review, there are plenty of other e-cigarette products still on the market," she said. 

Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, said the decision "represents the most significant action the FDA has taken to reverse the youth e-cigarette epidemic." 

Harold Wimmer, president and CEO of The American Lung Association, commended the FDA for "following the science and denying Juul the ability to sell its products that are clearly marketed to addict a new generation of youth to tobacco."

Limiting nicotine: The FDA's goal in limiting nicotine in cigarettes and other combusted tobacco products is to reduce youth use, addiction and death, says the FDA news release announcing the effort. 

The FDA notes that while nicotine is not what makes cigarettes so toxic, it is the ingredient that makes it hard to quit. And says if the proposed reduction is successful, it "would make those products minimally- or non-addictive." 

"The U.S. Surgeon General has reported that 87% of adult smokers start smoking before age 18, and about two-thirds of adult daily smokers began smoking daily by 18 years of age. Lowering nicotine levels to minimally addictive or non-addictive levels would decrease the likelihood that future generations of young people become addicted to cigarettes and help more currently addicted smokers to quit," Califf said in the release. 

Inside Health Policy reports that the FDA is expected to publish its proposed rule in December. It was originally scheduled for July.

As FDA moves to ban menthol cigarettes, Enquirer reveals how cigarette makers targeted Blacks in Cincinnati area and Knoxville

Kool's 1960s look

Cigarette makers targeted African Americans in Cincinnati and Knoxville as they pushed menthol brands 50 years ago, The Cincinnati Enquirer revealed Sunday in a story prompted by the Food and Drug Administration's move last month to ban menthol cigarettes, the choice of most Black smokers.

The phenomenon began "after a threat of regulation from the federal government caused tobacco companies to pull out aggressive youth-oriented marketing campaigns," the Enquirer's Brooks Sutherland reports. "The companies shifted to focus to another population. The new targets would become impoverished young Black males in urban cities."

R.J. Reynolds Tobacco Co., which now has the bestselling menthol cigarette brand, Newport, targeted cities with new marketing and advertising approaches, including a new brand called Mr. Menthol "to compete with Kool, the dominant brand of menthol cigarettes at the time," Sutherland reports. The test markets were Cincinnati and Knoxville.

Kool, then owned by Louisville's now-defunct Brown & Williamson Tobacco Co., "began to focus on popular culture, particularly music, for its advertising," Sutherland reports. In 1975, it started the Kool Jazz Festival in Cincinnati and 11 other cities, with "iconic artists such as the O’Jays, the Isley Brothers (Lincoln Heights’ own), Harold Melvin, the Ohio Players and B.B. King in its first year."

Don Williams (Photo by Mark
Cesare, The Cincinnati Enquirer)

“I went down there and got me a couple packs; I started out smoking Kools,” Don Williams of Maysville told Sutherland. “They had the brand everywhere. They were giving out packs of cigarettes. People would come in, they’d give them a pack and if you don’t smoke, then you don’t take it.”

Williams added, “It got a lot of Black people to smoke.” The festival became the Cincinnati Music Festival in 1986.

Dr. O’dell Owens, interim Cincinnati health commissioner and former Hamilton County coroner, recalled "how smoking was much more than a habit to young Black males, particularly because of advertising and the coordination between tobacco companies and popular culture," Sutherland writes, quoting him: “When the guys would light up their cigarettes, it wasn’t just lighting a cigarette, it was how you did it,” he said. “You had to light your cigarette with style. . . . It was an event to light a cigarette, and so people said ‘Man, that’s cool.’ And young kids wanted to smoke.”

The FDA banned flavors in cigarettes in 2009, except menthols; their heavy use by Blacks has made such a move politically fraught. But the FDA's move "has been praised by the National Association for the Advancement of Colored People," Sutherland notes. "According to an Interact for Health adult smoking survey, around 68% of Black smokers in the Cincinnati region smoke menthol cigarettes."

FDA proposes ban on menthol cigarettes and cigars, popular among Blacks, whose leaders are divided on the matter

Photo from ash.org

Last week the U.S. Food and Drug Administration announced its long-anticipated plan to ban menthol cigarettes and all flavors in cigars. 

“The proposed rules would help prevent children from becoming the next generation of smokers and help adult smokers quit,” Health and Human Services Secretary Xavier Becerra said in a news release. “Additionally, the proposed rules represent an important step to advance health equity by significantly reducing tobacco-related health disparities.”

When added to cigarettes and cigars, menthol's minty taste and cooling effect limits throat irritation, thereby making the products more appealing to smokers -- especially new and young smokers. The  release adds that menthol also interacts with nicotine in the brain to enhance nicotine's addictive effects and makes it more difficult to quit smoking. 

One study estimates that banning menthol in cigarettes and cigars in the U.S. would lead to a 15% reduction in smoking as early as 2026 and prevent upwards of 650,000 deaths by 2060.

The Washington Post reports on another study published in the peer-reviewed journal Tobacco Control that "found that if a menthol-cigarette ban in the United States were to have the same effect as a Canadian menthol ban, more than 1.3 million additional smokers would quit, including more than 381,000 African Americans." Nearly 85% of Black smokers smoke menthol cigarettes, compared to 30% of white smokers who smoke menthols, says the FDA. 

The proposed menthol ban has divided Black leaders. Ben Crump, a Black civil-rights attorney, told Politico, “There’s a difference between theory and reality. The reality is, we know once you make laws and such then you have local and state actors who use those as weapons to marginalize Black people.”

FDA says it "cannot and will not enforce against individual consumers for possession or use of menthol cigarettes or flavored cigars" and enforcement will only address the industry, but some Black leaders, including Rev. Al Sharpton and others, disagree that this will be the reality. 

The African American Tobacco Control Leadership Council supports the proposed rule. "This is a major step forward in saving Black lives." Dr. Phillip Gardiner, co-chair of the council, said in a statement.   

Gardiner went on to encourage tobacco control activist to continue to fight to ban the sale of menthol tobacco products at the local, state and federal level, noting that the rule-making process and court challenges by the tobacco industry could mean it will be years before this ban could becomes effective.

Stanton Glantz, who continues to conduct tobacco research even after retiring from the University of California San Francisco in 2020, writes on his blog that "FDA has built a strong foundation to justify prohibiting menthol as a characterizing flavor in cigarettes," but its justification for granting exceptions for heated tobacco products and low nicotine-cigarettes "is very weak" and "should be dropped."  

The New York Times published an essay written by Keith Wailoo, a professor of history and public affairs at Princeton University, that provides a detailed walk through the history of how the tobacco industry hooked black smokers on menthols. He is the author of "Pushing Cool: Big Tobacco, Racial Marketing, and the Untold Story of the Menthol Cigarette." 

"After decades of outcries from communities and public health experts about the health inequities and dangers posed by menthol marketing (with the NAACP now urging a ban), the FDA’s proposed rule that would impose the ban, announced April 28, is a long-awaited step that will save hundreds of thousands of lives in the decades to come," Wailoo writes. "We should not be distracted by those who work on behalf of the tobacco industry while claiming to speak for Black health and well-being. They are part of the web that has maintained the stranglehold, enticing consumers with deceptive promises."

The FDA says that in 2019 there were more than 18.5 million menthol cigarette smokers aged 12 and older in the U.S. which included high rates of youth, young adults, African Americans and other racial and ethnic minorities. In 2020 menthol made up 37% of the cigarette market in in the U.S., up from 26% in 2000, according to The Truth Initiative menthol fact sheet. 

The FDA is accepting public comments on its proposed rules for menthol cigarettes and flavored cigars through July 5. 

Health advocates say state government needs to do a lot more about tobacco, including letting local governments regulate sales

Map by Bridging Research Efforts & Advocacy Toward Healthy Environments, University of Kentucky

As the state legislature ponders allowing local governments to again regulate tobacco sales, the Lexington Herald-Leader has produced a comprehensive report showing the damage done to Kentucky's health by the crop that once accounted for almost half the state's farm income – and politicians' unwillingness to do much to limit the damage.

"The state’s response has been among the most anemic in the country, tobacco control advocates say. The state spends a fraction of what’s recommended to prevent people from starting to smoke and help smokers quit, and its tax rate on cigarettes is among the lowest in the country," Bill Estep reports.

High-school students in Kentucky smoke more than in any other state, 8.9 percent of them, according to the American Lung Association. The adult smoking rate, 21.4 percent, is the nation's second highest, trailing only West Virginia's 22.6%; the national rate is 14%. In Monroe, Metcalfe and Wolfe counties, the adult rate is 45%, 44% and 42%.

Kentucky's lung-cancer rate of 88 annual cases per 100,000 residents is the highest in nation; the U.S. rate is 57. The state also has the highest death rate from lung cancer.

The Campaign for Tobacco-Free Kids estimates that 8,900 Kentucky adults die each year due to smoking, "and that health-care costs tied to smoking total $1.92 billion a year, not counting any impact from secondhand smoke," Estep reports. "The organization said nearly $600 million of that spending is through Medicaid, a taxpayer-funded program. The state and federal tax burden per household in Kentucky from smoking is $874."

But the tobacco industry usually wins in Frankfort. In the mid-1990s, the General Assembly prohibited cities and counties "from having their own rules on the use, display, sale and distribution of tobacco products," Estep notes. "The law means communities can’t limit the visibility of cigarettes in convenience stores, for example, or prevent vape shops from locating close to schools."

Sen. Wil Schroder

The ban would be repealed by Senate Bill 166, filed by Sen. Wil Schroder, a Northern Kentucky Republican. The tobacco industry is against it. David B. Sutton, a spokesman for Altria Group, the nation's leading cigarette maker, "said the state should avoid a confusing patchwork of local rules and taxes," Estep reports. Sutton said a varying rulebook “makes operating a business more complex and confusing for retailers trying to operate within the bounds of the law.”

Last year, when two similar bills were introduced, "Supporters had counted heads and thought they had the votes to pass the bills," Estep writes. "But the bills died a quick death. They didn’t get a hearing, much less a vote. Altria, a leading tobacco company, spent $73,627 on lobbying in the first three months of the legislative session as two bills were bottled up in committee."

As in many other states, the legislature has also refused to spend more money on tobacco cessation and prevention programs, keeping the about at $2 million a year. The state gets tobacco-related revenue of almost $500 million a year, and the Centers for Disease Control and Prevention recommends that it should spend $56 million of it to help people quit and keep others from starting.

The Foundation for a Healthy Kentucky estimates the tobacco industry spent $246 million in 2020 in Kentucky promoting its products, Estep notes.

It all adds up to a need to act on many fronts, said University of Kentucky nursing professor Ellen Hahn, director of a project called BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments) that has led anti-tobacco efforts in the state.

“Tobacco’s an addiction. It’s really rampant across Kentucky, so to fix it we need every tool in the toolbox,” Hahn told Estep. “If local communities have their hands tied and they can’t pass rules for instance that make it harder for youth to purchase tobacco products, it just limits our ability to fix the problem.”

Estep's story is accompanied by others. He has a story about the continued but slow expansion of local governments that ban smoking in workplaces and public indoor spaces, and another one about the benefits of quitting smoking and resources that are available to people who want to quit.

Alex Acquisto writes that the main battle over tobacco in Kentucky has shifted to teenagers' use of electronic cigarettes: "In 2019, the last year the data was available, more than one in four high school-aged students (over 30%) used e-cigarettes, also known as vaping, as did 20% of middle schoolers – the highest rate of any of the 11 states surveyed that year. At least 50% of high school students at each grade level admitted to ever having used tobacco products, and closer to 30% said they vaped frequently." The local-regulation bill is intended partly to enable local governments to discourage youth use of tobacco products.

FDA announces plan to ban menthol-flavored cigarettes and all flavored cigars within the next year; likely to be a long process

Menthol cigarettes (New England Public Media photo)

By Melissa Patrick
Kentucky Health News

The Food and Drug Administration announced a plan Thursday to ban menthol-flavored cigarettes and all flavored cigars within the next year. The proposed ban is likely the beginning of a long process that could take years to implement, CNBC reports.

The agency says the goal is to "reduce tobacco addiction" and curb deaths. "Banning menthol — the last allowable flavor — in cigarettes and banning all flavors in cigars will help save lives, particularly among those disproportionately affected by these deadly products," acting FDA Commissioner Janet Woodcock said in a news release. "With these actions, the FDA will help significantly reduce youth initiation, increase the chances of smoking cessation among current smokers, and address health disparities experienced by communities of color, low-income populations, and LGBTQ+ individuals, all of whom are far more likely to use these tobacco products.”

The ban is not expected to take effect within a year, because it will take years to produce sufficient evidence to support it, and it is likely to face legal challenges from the cigarette industry. The Centers for Disease Control and Prevention reports that as of 2018, sales of menthol cigarettes made up 36% of all cigarette sales in the U.S.

Richmond, Virginia-based Altria Group, which controls about 17% of the menthol market, told CNBC, “We share the common goal of moving adult smokers from cigarettes to potentially less harmful alternatives, but prohibition does not work. Criminalizing menthol will lead to serious unintended consequences," such as illegal sales. 

Imperial Tobacco's ITG Brands, which has about 8% of the market, told CNBC that the FDA’s decision was “disappointing” but expected: “We believe the rulemaking process will reveal that there is no clear scientific evidence to support a federal menthol and flavor ban. We are hopeful that FDA will follow the law and prioritize sound policy and science over political pressure.”

The proposal does not set an effective date. Its next step will be publication of the proposed rules and an opportunity for public comment.

Anti-smoking groups have long called for this ban, supported by research that shows Big Tobacco has deliberately targeted Black communities, especially youth, with marketing menthol cigarettes, cigars and other tobacco products.

Menthol products also have a strong appeal for youth, since menthol numbs the throat and reduces irritation from smoking and makes it easier for them to start smoking.

If implemented, one study suggests that within the first 13 to 17 months of a ban, an additional 923,000 American smokers would quit, including 230,000 African Americans. Another study projected a ban would prevent about 633,000 American deaths, including nearly a quarter million African Americans.

“This ban is a crucial step in preventing youth initiation and addiction to nicotine and will help mitigate some of the health outcome disparities for African Americans,” Ben Chandler, president and CEO of the Foundation for a Healthy Kentucky, said in a press release. “The foundation applauds the FDA for taking this step to improve Americans’ health, save lives and reduce health care costs.”

The proposal also gained the support of Dr. Richard E. Besser, president and chief of the Robert Wood Johnson Foundation, in a op-ed in The Hill: "Together, these actions would provide a monumental victory for public health, a generational advancement in our nation’s efforts to achieve health equity, and a significant step forward to protect ourselves against future pandemics."

About 20 million Americans smoke menthol cigarettes, including nearly 85% of Black smokers and 30% of white smokers, says the release. Tobacco use is the number one cause of preventable death among African Americans. Some 45,000 African Americans die annually from tobacco-related diseases.

If implemented, the regulations would only apply to manufacturers, distributors, wholesalers, importers and retailers to ensure the products do not make their way onto the market. It would not be enforced against individual consumer possession of the products, says the release.

The FDA made the decision to ban menthol products after facing an April 29 court-ordered deadline to respond to a citizen petition sent to the agency in 2013 to ban menthol as a flavor in cigarettes, Reuters reports.