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.

86 percent of Kentucky's school districts have already adopted tobacco-free polices, ahead of state law with opt-out provision

Only 24 of Kentucky's 172 school districts, or 14 percent, have not passed a tobacco-free policy that mirrors a new state law that will take effect next July 1, according to the Foundation for a Healthy Kentucky, which says more districts are expected to enact the policy soon.

The law gives districts the ability to opt out of the law during its first three years, but it seems to have prompted them to opt in. Half of the districts with the policy have enacted it since Gov. Matt Bevin signed the law April 9, the foundation's Bonnie Hackbarth said. When it was signed, only 74 of the state's 172 school districts, or 42 percent, were fully tobacco-free.

Many of the adopters since Aug. 9 were in a swath of counties in the Pennyroyal regions of Southern Kentucky, from Taylor and Cumberland in the east to Lyon in the west; tobacco production remains common in the region, and there is a smokeless tobacco plant in Hopkinsville, the seat of Christian County, which has not adopted the policy. Here are maps showing the increase since April:

Lexington bans tobacco, including smokeless, at city ballfields

By Melissa Patrick
Kentucky Health News

Lexington's 56 city-run baseball parks, including Whitaker Bank Ballpark where the Lexington Legends play, are now tobacco-free. The city prohibits use of cigarettes and smokeless tobacco products at city fields, including dugouts, bleachers, spectator areas, concession areas and restrooms.

Andy Shea, president and CEO of the Lexington Legends;
Ben Chandler, Foundation for a Healthy Ky. president;
and Lexington Mayor Jim Gray. Shea and Gray received
the foundation's Healthy Kentucky Policy Champion award.

"This important move will create a healthier and safer place for the thousands of Legends fans who come to the park each season," Mayor Jim Gray said at the announcement.

Gray noted that Lexington passed Kentucky's first city-wide smoking ban nearly 15 years ago and saw "almost immediate results," including fewer asthma-related emergency room visits and a "big" drop in the smoking rate.

"For the kids and families coming to the parks, we are taking the next step as a city," he said.

This effort is part of a nationwide movement to break the longstanding connection between baseball and smokeless tobacco, often used by baseball players.

The latest Youth Risk Behavior Survey found that 10.6 percent of Kentucky high schoolers used smokeless tobacco in 2017, compared to 5.8 percent nationally in 2016. Many more boys than girls use the product in Kentucky, 17.2 percent versus 3.1 percent.

It's a habit that comes with serious health risk, including oral, pancreatic and esophageal cancer. It can also lead to nicotine addiction, increased risk for death from heart disease and stroke, and diseases of the mouth.

Amy Barkley, regional director,
Campaign for Tobacco-Free Kids

"We applaud the Lexington Legends for taking a strong stand against tobacco and for kids, by making Whitaker Bank Ballpark 100 percent tobacco-free,"said Amy Barkley, regional director of the Campaign for Tobacco-Free Kids. "By taking tobacco use completely out of the game here in Lexington, it sends a strong message to kids that our national pastime should be about promoting a healthy and active lifestyle, not a deadly and addictive product."

The Campaign for Tobacco-Free Kids' "Knock Tobacco Out of the Park" program has been working with professional baseball for several years to "take tobacco out of the game of baseball for good," Barkley said.

Chewing tobacco has been banned among players in minor league baseball at ballparks and during team travel since 1993, but so far only 14 out of 30 Major League teams have similar policies, said Barkley. She added that the last collective bargaining agreement prohibits any new player in Major League ball from using tobacco.

Andy Shea, president and CEO of the Lexington Legends, said in a news release, "We are very proud to be one of the first Minor League Baseball facilities in the country to go tobacco-free."

Foundation for a Healthy Kentucky CEO Ben Chandler Chandler gave Shea and Gray a Health Policy Champions award from the foundation. He called the announcement "an important signal that we're sending here in the commonwealth of Kentucky to everybody about the need to curb our use of tobacco here in Kentucky."

Survey of Kentucky 10th graders finds less use of drugs, alcohol and electronic cigarettes, but use of tobacco remains high

By Melissa Patrick
Kentucky Health News

Kentucky 10th graders are reporting less use of drugs and alcohol, but continue to smoke cigarettes and use smokeless tobacco at a "significantly higher" rate than their national counterparts.

Those are among the findings of a recent survey, which also found that suicide rates among the state's high-school sophomores are slightly higher than they were in 2014.

The biennial "Kentucky Incentives for Prevention" survey is given to students across the state in even-numbered grades starting in the sixth grade, but the report says it only offers statistics from 10th graders "since this is likely the most accurate indicator of levels of use for high-school students."

The 2016 survey includes information from about 28,000 students in 149 of the state's 173 public school districts, but did not include the state's two largest districts. In addition to the Jefferson and Fayette county schools, Meade, Warren, Morgan, Laurel and Martin counties did not participate.

The report found that 13.1 percent of Kentucky high-school sophomores reported smoking cigarettes one or more times in the 30 days prior to the survey, compared to 4.9 percent nationally.

These rates ranged from a high of 16.5 percent in the Kentucky River region (Breathitt, Knott, Lee, Leslie, Letcher, Owsley, Perry and Wolfe counties) to  9.7 percent in the so-called Centerstone region (Bullitt, Henry, Oldham, Shelby, Spencer and Trimble counties).

Smokeless-tobacco use among 10th graders was nearly three times higher than the national rate, 9.7 percent compared to 3.5 percent nationally. However, electronic-cigarette use among saw a decrease, dropping to 11.4 percent in 2016, down almost 5 percentage points from 2014.

Other good news: Alcohol use among Kentucky sophomores continues to drop, although it continues to be the controlled substance they most often use. In 2016, 19.4 percent reported drinking alcohol in the 30 days prior to the survey, down from 21 percent in 2014.

Alcohol use among 10th graders is higher in Western Kentucky. The Pennyroyal region (Caldwell, Christian, Crittenden, Hopkins, Lyon, Muhlenberg, Todd and  Trigg counties) had the highest rate, 24.1 percent, followed by 23 percent in the Four Rivers region (Ballard, Calloway, Carlisle, Fulton, Graves, Hickman, Livingston, Marshall and McCracken counties).

Those western regions also had the highest rates for binge drinking, defined as drinking five or more drinks in a row at one or more times in the two weeks prior to the survey. In Four Rivers it  was 13.2 percent, in the Pennyroyal 12.4 percent.

Statewide in 2016, the rate for binge drinking was 10.4 percent, down from 12 percent in 2014. The poll found that almost 10 percent of the 10th graders in the 2016 survey had gone to school drunk or high at least one time in the year prior to the survey.

Marijuana use among Kentucky sophomores has been declining since 2010, but pot remains the most widely used illegal substance by this age group. The poll found 11.3 percent said they had used marijuana one or more times within the 30 days prior to the survey. The Pennyroyal region, at 14.7 percent, had the highest rate.

The rate of Kentucky 10th graders who abused prescription drugs (using them without a prescription) 30 days prior to the survey dropped to 2.7 percent in 2016, from 3.6 percent in 2014. The Pennyroyal region, which had the highest rate for this measure in 2016, was almost double this rate at 4.8 percent.

Overall, sophomores' use of heroin, cocaine, methamphetamines and ecstasy dropped slightly from 2014 to 2016. Fewer than 1 percent of the state's 10th graders reported using any of the drugs last year.

Bill passes to decrease smoking; one doesn't; lawmakers set to pass resolution for feds to ditch plan to limit tobacco carcinogen

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. – Smoke-free advocates would say that this legislative session's record is 1-2.

That's because Kentucky lawmakers have passed one bill that will increase access to smoking-cessation treatments, but can't find enough support to pass one that would make Kentucky schools 100 percent tobacco-free -- and are poised to pass a resolution that asks federal officials to withdraw a proposal that would reduce the carcinogen levels in smokeless-tobacco products.

Sen. Julie Raque Adams' bill to decrease insurance barriers to smoking-cessation treatments is one of two tobacco-related bills that passed this legislative session and is on its way to the Governor for his signature.

The Patient Protection and Affordable Care Act requires all insurance policies to cover smoking-cessation treatments, but insurance barriers, like co-payments, prior authorization requirements and limits on length of treatment, make them not readily available.

Senate Bill 89 would require barrier-free access to all U.S. Preventive Services Task Force-recommended smoking cessation treatments in all Kentucky health plans, including Medicaid.

The other tobacco bill, sponsored by Sen. Ralph Alvarado, R-Winchester, which would have banned tobacco use on all school properties and at school events, is all but dead in the state House, despite its quick passage in the Senate.

Just over half of Kentucky's public-school students are in school districts with tobacco-free policies: 62 of the state's 173 districts, covering 654 schools.

Kentucky's high school students have a higher smoking rate than the national average, 17 percent compared to 15 percent; and 24 percent of them use electronic cigarettes, according to the 2015 Youth Risk Behavior Survey. The survey also found that 22.5 percent of the state's middle-school students have tried smoking.

Alvarado called Senate Bill 78 "low-hanging fruit" because it involves the health and safety of Kentucky's children and polling shows that 85 percent of Kentuckians support such an effort, but House Speaker Jeff Hoover said, "There was just not enough support in the caucus right now to do it."

Another piece of tobacco-related legislation introduced this session is a resolution that urges the the U.S. Food and Drug Administration to withdraw its proposal to reduce the levels of N-nitrosonornicotine, or NNN, a carcinogen, in all smokeless tobacco products sold in the U.S.

The FDA's proposal states,"NNN is a potent carcinogenic agent found in smokeless tobacco products and is a major contributor to the elevated cancer risks associated with smokeless tobacco. The FDA estimates that, in the 20 years following implementation of its proposed product standard, approximately 12,700 new cases of oral cancer and approximately 2,200 oral cancer deaths would be prevented in the U.S. because of this rule."

The resolution notes that the majority of farmers who raise the dark tobacco that makes up the main ingredient of smokeless tobacco products live in Kentucky and "raise approximately 24,000 acres of the crop with an estimated cash value of approximately $173 million per year."  It also says that the proposed standards in the FDA proposal are "technically unachievable" and that the impact of this rule would be "far-reaching and onerous because of the negative impact on agriculture and on manufacturing jobs in Kentucky."

House Concurrent Resolution 48, sponsored by Walker Thomas, R-Hopkinsville, passed the House 69-3 and is expected to pass the Senate in the final two days of the session, after the veto recess. The FDA is accepting public comment on this proposal until April 10, 2017. Click here for directions. 

Bill to make all Ky. schools tobacco-free is likely dead for this session; only 62 of the state's 173 school districts ban tobacco

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. -- A bill that would ban tobacco use on school properties and at school events has all but died in the state House, despite its quick passage in the Senate and polling that says Kentuckians would support such a mandate.

"We are probably not going to do that this session. . . . unless there is a change of direction in the caucus, we are probably not going to do that," House Speaker Jeff Hoover said. "There is just not enough support in the caucus right now to do it."

Senate Bill 78 would prohibit the use of tobacco products by students, school personnel, and visitors in schools, school vehicles, properties, and activities, allowing schools one year to adopt, implement and enforce the policy. Just over half of Kentucky's public-school students are in school districts with tobacco-free policies: 62 of the state's 173 districts, covering 654 schools.

The bill passed unanimously out of the Senate Education Committee and passed the Senate 25-8, with two members passing. It now resides in the House Education Committee.

The committee chair, Rep. John "Bam" Carney, R-Campbellsville, said he supports the bill, but the decision to put it on his committee agenda or not depends on leaders of the House's Republican majority, who determine the "pulse" of the caucus on the issue.

"Personally, I would be glad to hear it," Carney said. "It is certainly something that I would probably vote for."

Majority Floor Leader Johnathan Shell, R-Lancaster, said the bill isn't a priority.  "We have got so many more important bills that have been coming in and out," he said. "We are just trying to make sure that we are getting everything through the process that we can."

Freshman Rep. C. Wesley Morgan, R-Richmond, concurred with Shell, saying he thought the bill was probably being held up "because there has been a lot of substantial bills related to a lot of things that have been held up for a long time that have really high priority."

Sen. Ralph Alvarado

The bill's sponsor, Sen. Ralph Alvarado, R-Winchester, said Kentucky is missing out on an opportunity to decrease youth smoking -- which would save lives in future generations -- and to decrease the cost of health care in the future.

"I think reducing the youth smoking rate would be the biggest long term investment for us, but it has got to start at some point," he said. Research shows that strictly enforced tobacco-free school policies can reduce youth smoking by 30 percent.

Kentucky's high-school students smoke at a higher rate than the national average, 17 percent compared to 15 percent; and 24 percent of them use electronic cigarettes, according to the 2015 Youth Risk Behavior Survey. The survey also found that 22.5 percent of the state's middle-school students have tried smoking.

Morgan, a former smoker, said he would support such a bill, and had been approached by supporters of the bill, but no one had lobbied him against it.

Rep. Kim P. Moser, R-Walton, who is carrying the bill for Alvarado in the House, also said she had not heard of anyone lobbying against it.

Rep. Stan Lee, R-Lexington, also a former smoker, said he wasn't familiar with the bill, but noted that resistance to bills that restrict tobacco use in Kentucky was often cultural.

"The struggle I have is that I grew up on a tobacco farm. It put food on the table and clothes on my back. . . . I still have that issue that it is a free and legal product, " he said. "I would say probably that the real reason that it is not moving is that it is cultural."

Alvarado, a physician, said he thought one of the reasons the bill has been held up in the House is because of a misconception that it says possession of tobacco products on school grounds would be a violation of the law. That is not true, he said: "If you are consuming tobacco products, that is where it would become an issue on campus."

Alvarado said he was hanging onto a "slim hope" that the bill could be called up in the House. Legislators have two days left in this short session, March 14 and 15, to pass laws without subjecting them to a veto by the governor that wouldn't be overridden.

He called the bill "low-hanging fruit." It does seem to be politically popular, since 85 percent of Kentuckians support tobacco-free schools, according to the 2016 Kentucky Health Issues Poll.

Another tobacco bill: Sen. Julie Raque Adams, R-Louisville, has filed a tobacco related bill, Senate Bill 89, that would require all insurance policies sold in Kentucky to cover all smoking-cessation medications and counseling approved by the U.S. Food and Drug Administration, eliminating many current barriers to treatment, like co-payments and prior authorization. This bill passed 35-2 in the Senate, passed favorably out of its House committee and is awaiting action in the full House.

Study says if Ky. cut its smoking rate to the national average, it could save $1.7 billion in health-care costs the very next year

Illustration from University of California-San Francisco

By Melissa Patrick
Kentucky Health News

If Kentucky could cut its smoking rate to the national average, it would save an estimated $1.7 billion on healthcare the following year, a study says.

Kentucky's smoking rate is 26 percent, and the national average is 18 percent.

The study at the University of California-San Francisco estimates that a 10 percent decline in the national rate would save $63 billion the next year in health-care costs.

"What it adds to our knowledge is that we can save money quickly," Ellen Hahn, University of Kentucky nursing professor and director of its smoke-free policy center, told Kentucky Health News. "We are not talking 18 to 20 years down the road. ... If we reduced our smoking rate at least 10 percent, we would see dramatic reductions in health-care cost in just one year."

The study also found that smoking makes Kentucky spend $399 more per person per year on health care than it would if the state's rate equaled the national rate. That was the highest figure of any state.

Conversely, low rates of smoking save Utah and California, respectively, $465 and $416 per person per year compared to what they would spend if their smoking rates were the national rate.

“Regions that have implemented public policies to reduce smoking have substantially lower medical costs,” the study's authors said in a news release. “Likewise, those that have failed to implement tobacco control policies have higher medical costs.”

Lexington's smoking rates dropped 32 percent in just one year after it enacted its smoking ban, which amounted to an estimated $21 million in smoking-related healthcare costs savings, according to a University of Kentucky study led by Hahn and published in the journal Preventive Medicine.

The UCSF study, published in PLOS Medicine, looked at health-care spending in each state and the District of Columbia from 1992 to 2009, and measured the year-to-year relationship between changes in smoking behavior and changes in medical costs.

Many studies have shown that smoking bans and other smoke-free policies decrease smoking rates, reduce smoking prevalence among workers and the general population, and keep youth from starting to smoke.

These have been some of the arguments for a statewide smoking ban, but efforts to pass one have stalled because new Republican Gov. Matt Bevin opposes a statewide ban and says smoke-free policies should be a local decision.

Bevin won big budget cuts from the legislature to set aside hundreds of millions of dollars for shoring up the state's pension systems, but the study hasn't made the administration look at a smoking ban as a source of savings. A ban passed the House last year but died in the Senate.

Asked how this study might affect the administration's position on a statewide smoking ban, Doug Hogan, acting communications director for the Cabinet for Health and Family Services, said in an e-mail, "Smoking bans are a local issue, rather than a one-size-fits-all solution." Bevin's office and Senate President Robert Stivers did not respond to requests for comment.

Hogan said the cabinet is committed to helping people quit smoking: "Education and proper policy incentives are critical tools that the state can use and as our commonwealth crafts its Medicaid wavier, it is looking very closely at ways to best incentivize smoking cessation to improve health and decrease cost to the commonwealth."

Dr. Ellen Hahn

Hahn said, "Kentucky has the dubious honor of leading the nation in cigarette smoking, and we have for many years. ... it is a major driver of health-care cost. And in a climate where we are trying to save every dollar ... I think that we should pay attention to this study because what it really says is that we can save a boatload of money if we help people quit and we can save it quickly."

Other possible tobacco-control measures include raising cigarette taxes, anti-smoking advertising campaigns and better access to smoking-cessation programs. Hahn said the state gets some money from the federal Centers for Disease Control and Prevention and the tobacco master settlement agreement for prevention and cessation efforts, but the state needs to do more.

"We spend very little on the things that we know work, like helping people quit smoking, like doing widespread media campaigns on television, radio and print," she said. "We just don't do that in our state. We never have. In fact, we spend very little, about 8 percent of what the CDC say we should."

The study says significant health-care savings could occur so quickly because the risks for smoke-related diseases decreases rapidly once a smoker quits.

"For example, the risk of heart attack and stroke drop by approximately half in the first year after the smoker quits, and the risk of having a low-birth-weight infant due to smoking almost entirely disappears if a pregnant woman quits smoking during the first trimester," says the report.

"These findings show that state and national policies that reduce smoking not only will improve health, but can be a key part of health care cost containment even in the short run," co-author Stanton Glantz, director of the UCSF Center for Tobacco Control Research and Education, said in the release.

Hahn said, "People don't realize how effective quitting smoking really is, how much money it really saves. So that is the value of this paper. It is a wake-up call for those of us doing this tobacco control work and for elected officials who are trying to save money and redirect funds and shore up the economic health of Kentucky. ... Doing all we can to reduce smoking saves lives and money. What's better than that?"

UK study finds e-cigarettes aren't replacing traditional cigarettes, but their sales rise as unregulated TV ads for them increase

A study led by a University of Kentucky researcher found that electronic cigarettes have not become a substitute for traditional cigarettes, but their use is increasing, especially as television commercials for the products increase, Carol Lea Spence reports for UK AgNews.

“Cigarette purchases have dropped a bit, from about 90 percent to 80 percent of all tobacco products during the past 15 years, but it’s still a big player. Other tobacco product sales are growing, though—particularly e-cigarettes,” Yuqing Zheng, lead researcher and an agricultural economist in UK's College of Agriculture, Food and Environment, told Spence.

The study, published in The American Journal of Agricultural Economics, looked at the habit formation of non-cigarette products and studied usage in five categories, including: cigarettes, e-cigarettes, smokeless tobacco, cigarillos and cigars, Spence reports.

The study collected data from convenience stores in 30 U.S. markets, looking for evidence to support that e-cigarettes had become a substitute for traditional cigarettes. It also investigated whether consumers purchased products based on cost and advertising.

They found that when the price of e-cigarettes went up, it did not increase the demand for traditional cigarettes. And not surprisingly, it also found that the purchase of e-cigarettes increased with increased TV advertising, but not with increased magazine advertisements.

“This adds to the policy discussion,” Zheng told Spence. “While cigarettes are strictly regulated in terms of advertising, there are no advertising restrictions on e-cigarettes.”

The study also found that based on consumption patterns, all five tobacco products in the study were habit forming, and e-cigarettes had the "highest degree of habit formation," Zheng told Spence.

Zheng attributed that to three things: Most e-cigarettes contain nicotine, which is addictive; they can be used in places where traditional cigarettes are banned; and because they don't burn out, people use them for longer periods of time, Spence reports.

Zheng told Spence that there is no scientific evidence to prove e-cigarettes are less harmful than cigarettes, and noted that the study found that people will generally buy traditional cigarettes regardless of the price, but in general are "more responsive to price increases" of non-cigarette tobacco.

FDA launches its first advertising campaign aimed at rural youth about the dangers of smokeless tobacco

The U.S. Food and Drug Administration today launched a campaign on the dangers of smokeless tobacco among rural teens. FDA is expanding its “The Real Cost” campaign "to educate rural, white male teenagers about the negative health consequences associated with smokeless tobacco use," it says. "For the first time, messages on the dangers of smokeless tobacco use—including nicotine addiction, gum disease, tooth loss, and multiple kinds of cancer—are being highlighted through the placement of advertisements in 35 U.S. markets specifically selected to reach the campaign’s target audience."

FDA’s Population Assessment of Tobacco and Health study found that 31.84 percent of rural, white males ages 12 to 17—629,000 total youths—either experiment with smokeless tobacco or are at-risk, says FDA. "According to the Substance Abuse and Mental Health Services Administration, each day in the U.S. nearly 1,000 males under the age of 18 use smokeless tobacco for the first time—almost as many male teenagers who smoke their first cigarette—making early intervention critical and highlighting a need for targeted youth smokeless tobacco prevention."

The campaign will be conducted through advertisements on television, radio, print, public signs, billboards, the internet and social media, says FDA. The agency is also partnering with Minor League Baseball teams, with stadiums promoting tobacco-free lifestyles "by displaying campaign advertising and providing opportunities for fans to meet and interact with players who support the campaign’s public health messages." (Read more)

Here's a link to the campaign’s bites and B-roll package; the ads are also available on YouTube: https://www.youtube.com/playlist?list=PLgf1d4CujVYYl8IZmTz5hedERt3f19hED

Athletes drive a rise in high schoolers' use of smokeless tobacco

High-school athletes are using more smokeless tobacco, even though overall tobacco use among high-school students has declined, according to a study published by the federal Centers for Disease Control and Prevention.

“We can do more to protect America’s youth from a lifetime of addiction,” Tom Frieden, CDC director, said in a press release. “The fact is, smokeless tobacco products, such as chewing tobacco, snuff or dip, can cause cancer of the mouth, esophagus and pancreas. And the nicotine in these products is harmful to the developing brain. Because we know tobacco-free policies in schools and other public recreational areas work, we must take action now so that our children are safe from these toxins.”

Student responses to the national Youth Risk Behavior Survey from 2001 through 2013 show that the share reporting any tobacco use dropped to 22.4 percent from 33.9 percent, and the rate of those smoking combustible tobacco products dropped to 19.5 percent from 31.5 percent. However, those who reported using smokeless tobacco products increased to 8.8 percent from 8.2 percent.

The increased use of smokeless tobacco was driven by athletes. The rate among non-athletes remained unchanged at 5.9 percent but has "increased significantly" to 11.1 percent from 10 percent in youth athletes.

Researchers suggest that athletes are aware of the adverse consequences of smoking on athletic performance, but may view smokeless tobacco as "less harmful, socially acceptable, or even a way to enhance athletic performance."

The 2013 YRBS found that 26.3 percent of Kentucky's high-school youth reported any use of tobacco; 17.9 percent were smoking cigarettes, and 13.2 percent reported using smokeless tobacco.

“Tobacco use among youth athletes is of particular concern because most adult tobacco users first try tobacco before age 18,” Brian King, deputy director for research translation in the CDC Office on Smoking and Health, said in a press release. “The younger people are when they start using tobacco, the more likely they are to become addicted and the more heavily addicted they can become.”

The reports calls for increased education about the dangers of smokeless tobacco; recognition that the tobacco industry pushes smokeless tobacco as an alternative to smoking where it is prohibited; that the role of professional athletes, many who use smokeless tobacco, must be part of the discussion because they are often considered role models by youth; and that "implementing and enforcing tobacco-free policies that prohibit all tobacco use on school campuses and at all public recreational facilities, including stadiums, parks, and school gymnasiums, by players, coaches, referees, and fans might help reduce tobacco use among student athletes."

A few additional school districts have decided to go tobacco-free next year.

As of September, Kentucky had 47 school districts with comprehensive tobacco free policies. These policies cover 45 percent of Kentucky's students and  represents 27 percent of the school districts in the state, according to the Kentucky 100% Tobacco Free Schools website.

“Creating 100 percent tobacco-free environments is one of the best ways we can set our kids up for a healthy future,” U.S. Surgeon General Vivek H. Murthy said in the release. “It helps them see that being tobacco-free is the way to better health and a longer life.”

Lake Cumberland District Health Department using polls in an effort to get school boards to make campuses tobacco-free

Countywide smoking bans are unlikely to pass anytime soon in most of rural Kentucky, but more county school districts are making their campuses tobacco-free. Now a multi-county health department is trying to get rural school boards to do that, with public-opinion polls showing that county residents overwhelmingly favor the move.

Department logo has been altered to
show Clinton County in yellow.

The Lake Cumberland District Health Department conducted the poll in Clinton County, and said it found that 86.55 percent were in favor and 7.16 percent were opposed. The rest had no opinion.

Making a campus tobacco-free means that members of the public are not free to smoke at school athletic events, so the poll also asked, “Would you like to see our school become tobacco-free at all events?” The results were virtually the same: 85.3 percent answered yes and 8.7 percent answered no, even though one-fourth to one-fifth of the county's residents smoke and it has a long history of raising tobacco.

"The results are perhaps surprising to some, considering the rate of tobacco usage in the county," reports the Clinton County News. The poll of 749 residents has an error margin of plus or minus 3.6 percentage points.

The department also surveyed 100 teachers in the school system and found that 77 percent would "definitely" support making the schools 100 percent tobacco-free.

The health department presented the survey and other findings to the Clinton County Board of Education June 15, but the board took no action. The department noted that a recent survey found that 28 percent of the county's students in eighth through 12th grades had used smokeless tobacco in the previous 30 days. "That level was the highest in the Lake Cumberland District," the Clinton County News reports.

The Casey County Board of Education adopted a smoke-free policy after a poll by the health department showed 70 percent of the county's residents favored it, the Casey County News reported.

UK cancer-center director urges lawmakers to raise cigarette tax and pass a statewide smoking ban to reduce cancer deaths

The Markey Cancer Center at the University of Kentucky supports a statewide smoking ban and an increase in the state cigarette tax to significantly reduce cancer deaths in the state, the center's director told a legislative committee Sept. 3.

“We are highly supportive, and we hope that you will be supportive as well, of (these) initiatives that we think will improve the overall health of Kentuckians,” Dr. B. Mark Evers told the state legislative Tobacco Settlement Agreement Fund Oversight Committee.

A news release from the Legislative Research Commission said Evers presented the numbers to back up his advice: Kentucky is first nationally in percentage of people who get cancer, and in overall cancer mortality. Lung cancer alone accounts for about 35 percent of Kentucky cancer deaths; nationally, lung cancer's share is 28 percent.

Twenty-eight percent of adult Kentuckians smoke, with approximately 8,000 deaths each year from smoking-related illnesses. The greatest incidence of tobacco-related cancers is in Eastern Kentucky.

That is the highest percentage in the U.S., Evers notes, adding that there is an indirect relationship between cigarette taxes and smoking rates. Kentucky has the 12th lowest cigarette tax among the states.

"Raising the cost of cigarettes and a statewide smoking ban could help cut Kentucky cancer deaths by 50 percent," Evers said. That is the Markey Cancer Center's goal over the next five years.

The center has a new strategic plan, "Conquering Cancer in the Commonwealth," that focuses on the state's "major cancer killers" -- lung, head and neck, colorectal, breast, and cervical cancer.

In response to a question about how to decrease the number of smokers in Kentucky, Evers pointed to local smoke-free policies and increased efforts in Appalachia toward smoking cessation.

When asked what it will take to lower the percentage of Kentucky smokers to less than 10 percent, Evers recommended three things: increasing the cigarette excise tax, a statewide smoking ban, and instituting lung-cancer screening projects like those in place at UK and the University of Louisville.

“Those three things are really going to help drive down those numbers,” he said.

Fewer teens report using tobacco and abusing prescription drugs, but some attribute latter trend to increase in heroin use

By Melissa Patrick and Melissa Landon
Kentucky Health News

Fewer Kentucky teenagers said last year that they used prescription drugs without a doctor's direction, or tobacco, than in the last such survey. But some addiction experts worry that prescription-drug abuse has dropped since 2010 because young people are using heroin instead.

According to a state survey of young people in 88 percent of Kentucky's school districts, their improper use of prescription drugs has declined steadily since 2004, with the greatest decrease between 2010 and 2012.

In 2012, prescription-drug abuse among high-school seniors dropped almost a third, to 9 percent from 13.1 percent in 2010. Among sophomores, it dropped to 7.6 from 11.3 percent; among eighth graders, to 2.9 from 5.3 percent; and among sixth graders, to 0.7 from 1.8 percent.

Some feel there's a disconcerting reason for the decline in prescription-drug abuse. "My concern is the unintended consequence is that people have switched to heroin," Karyn Hascal, president of The Healing Place recovery program in Louisville, told Laura Ungar of The Courier-Journal. "The problem is addiction, not the drug of the day." Hascal said The Healing Place has seen addicts who started out using other types of drugs but eventually turned to heroin as a cheaper option.

Although the survey didn't measure heroin use among teens, it asked if any of their four best friends had used illegal drugs in the past year. The results showed a continued slow decline, to 12.2 percent and 15 percent, respectively, among high-school sophomores and seniors.

"Over the past four years we have significantly stepped our efforts to address prescription-drug abuse," Connie Smith, manager of the Substance Abuse Prevention Branch of the state Division of Behavioral Health, said in a news release. "All of our regional prevention centers have been working very hard with their local coalitions to plan and implement effective programs to reduce illegal use of prescription drugs among youth."

The federally funded survey measures use of drugs, tobacco and inhalants; mental health; school safety issues; and gambling. The division said 153 of the 174 school districts at the time took part, with 122,718 students participating. The survey also measures concerns such as school safety issues and gambling. The report said that almost every other area studied had lower numbers in 2012 than in 2008

The survey asked several questions about tobacco. Among high-school seniors, 25.6 percent reported smoking in the previous 30 days, down from 29.4 percent in 2010. Among sophomores, smoking dropped to 18 percent from 21.7 percent; among eighth graders, to 8.7 from 10.7; and among sixth graders, to 2 percent from 2.5 percent in 2010.

Use of smokeless tobacco by high-school students declined in 2012, after rising in each survey from 2006 to 2010. Among seniors, it fell to 15.7 percent from 17.5 percent in 2010; among sophomores, it dropped to 13.4 percent from 15.9 percent. Among younger students, an eight-year decline continued, but at a sharper rate since 2010.

Marijuana use among high-schoolers declined slightly after increasing in 2008 and 2010. The survey also showed a steady decrease in the risk that teenagers associate with occasional use of marijuana. For the full report, click here.

Kentucky Health News is an independent service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

State health-insurance exchange plans to make smokers pay 40 percent more for coverage; varied interests, observers object

By Molly Burchett
Kentucky Health News

Supporters of the Patient Protection and Affordable Care Act have touted its goal to provide health insurance to all Americans without discrimination, such as prohibiting insurers from denying coverage due to pre-existing conditions. But it allows them to charge smokers more for it, and the officials running Kentucky's health-insurance exchange plan to do just that.

When Kynect, the state's online insurance exchange, opens Oct. 1, smokers can expect to pay up to a 40 percent surcharge, not far from the 50 percent limit in the law. That has brought objections from a wide range of observers, including tobacco companies and anti-cancer activists, saying it may be well-intended but is unfair and may backfire.

"Ranked No. 1 in adult smoking and cancer deaths, Kentucky should be doing all it can to bring tobacco users under the care of medical professionals. Yet some Kentucky smokers — perhaps many — will still be unable to afford health insurance, even after historic reforms take effect next year," says a recent Lexington Herald-Leader editorial. In 2011, the last year for which figures are available, 29 percent of adult Kentuckians smoked, and that does not include those who use smokeless tobacco.

UPDATE, Sept. 11: The state Department of Insurance says the 40 percent is a ceiling, and some companies are charging less, but 40 percent is the most common tobacco surcharge on health insurance policies sold in Kentucky. "There are health care costs associated with tobacco use," spokeswoman Ronda Sloan said. "With no tobacco use surcharge, insurers would have raised rates for everyone to offset those costs. . . . Plans will provide benefits for tobacco use cessation."

Seven states (California, Connecticut, Massachusetts, New Jersey, New York, Rhode Island and Vermont) and the District of Columbia will not charge smokers higher premiums. Connecticut voted against a smoking surcharge for individual policies, saying higher individual rates would disproportionately penalize poor people who tend to smoke.

Surchage critics in Kentucky agree. "This penalty is being applied to the working poor and medically indigent," writes Dr. Kevin Kavanagh, chairman of Health Watch USA, in a Herald-Leader op-ed. "Tobacco use is inversely related to education and income. In Kentucky, 48 percent of adults without a high school diploma smoke. These are the working poor."

Since most smokers tend to have lower incomes, the surcharge could discourage them from signing up for coverage at all because they can't afford it, restricting health care access for those that need it most, critics say. Although people with incomes up to four times the federal poverty level will get premium subsidies on the exchanges, the tobacco surcharge will be added to the final rate, reports Sarah Kliff of The Washington Post.

"The smoker's premium alone will account for 24 percent to 29 percent of his salary not counting deductibles and co-pays," Kavanagh writes. "This policy clearly blocks insurability for the low-income worker." Cigarette makers say the policy amounts to discrimination against smokers, reports Kliff.

The surcharge makes sense from a strictly actuarial perspective, and is supported by the insurance industry because smokers have much higher health costs, reports WebMD Health News. Kentucky's health costs attributable to smoking add up to about $1.5 billion a year, and smoking-caused productivity losses total $2.3 billion a year, says the Centers for Disease Control and Prevention.

Read more here: http://www.kentucky.com/2013/09/08/2810231/pricing-smokers-out-of-health.html#storylink=cpy

However, punitive measures like higher premiums have not been proven to reduce smoking, say health organizations opposing the surcharge, such as the American Cancer Society and American Lung Associaton. In addition to being ineffective, higher premiums for smokers could make health insurance coverage unaffordable, leaving tobacco users without coverage for smoking-cessation programs, or any other type of coverage that Obamacare has sought to provide.

"From the longer-term perspective on how to improve people's health and contain medical costs, the tobacco penalty is a policy disaster," says the Sept. 8 Herald-Leader editorial. The Cancer Society says states would see greater public health and economic benefits from increased tobacco taxes, implementation of strong smoke-free laws and the funding prevention efforts, rather than penalizing smokers.

In closing, Kavanagh poses an important question: "Wouldn't it be better to provide these individuals access to the health care system where tobacco withdrawal could be encouraged and assisted and preventative care for other ailments can be provided?" (Read more)

Smoking ban gets 'a good scrubbing' before Judiciary Committee

By Al Cross
Kentucky Health News

The bill for a statewide smoking ban is favored by three-fifths of Kentucky adults, but is dead for this session of the General Assembly. However, its supporters think they made some headway Monday as they laid groundwork for getting it through the state House a year from now.

The House Judiciary Committee held an informational hearing on House Bill 190 to "give it a good scrubbing" before a committee that is more skeptical of it than the Health and Welfare Committee, which approved it early in the session, the bill's sponsor, Rep, Susan Westrom, D-Lexington, said afterward.

Westrom said she was encouraged by the hearing because it exposed weaknesses in the bill that she will correct for the next regular session, beginning in January 2014. For example, she said, Rep. Steven Rudy, R-Paducah, argued that the bill's language would make it illegal to use smoke in barns to cure the dark tobacco grown in Western Kentucky, largely for smokeless consumption.

"This is about vetting," Westrom told Rudy. "You have a different mindset that I do sitting on the Health and Welfare Committee."

Rudy acknowledged that secondhand smoke is not beneficial, but asked, "Has there ever been a death certificate that secondhand smoke killed this person?"

Dr. Sylvia Cerel-Suhl, Central Kentucky president of the American Heart Association, replied that Lexington recorded a significant drop in acute heart attacks after enacting a smoking ban, and said "thousands of studies" of secondhand smoke have shown exposure to it can cause premature death.

"The evidence is absolutely overwhelming," she said, and asked if anyone else had any questions. No one did, but the committee was one member short of a quorum.

Advocates told the legislators that 37 jurisdictions, covering 34 percent of the state's population, limit smoking in some way. Mark Hayden, a trial lawyer and former Campbell County commissioner, said a statewide ban is needed because enacting ordinances, writing regulations and enforcing them is a burden for local officials.

The bill would give local health departments power to enforce the ban. Scott Lockard, president of the Kentucky Health Departments Association and the health director in Clark County, said his agency has issued no court charges, only warning citations, since its board passed a ban, and Woodford County has issued only three citations.

Others appearing at the hearing included Dr. Stephanie Mayfield, commissioner of the state Department of Public Health, and Lt. Gov. Jerry Abramson, who was invited by the Kentucky Smoke-Free Kentucky Coalition. He discussed enforcement of of the ban in Louisville, where he was mayor.

Rep. Tom Riner, D-Louisville, said the ban is "one of the most important pieces of legislation that has been brought before this body, because it literally affects every Kentuckian. . . perhaps the most important piece."

Kentucky Health News is an independent news service of the Institute for Rural Journalism and Community Issues at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.

UK quickens drumbeat of tobacco-free policy through report line

The University of Kentucky promotes compliance and enforcement of its tobacco-free policy through a community report line, among many other measures.  Although the report line was established last spring, its mention in recent campus communications suggests a hightened emphasis on compliance measures. 

The line to report violations of the smoking ban engages the community in developing an environment in which compliance is expected, said Dr. Ellen Hahn, a nursing professor and co-chair of UK's Tobacco-free Taskforce and director of its Kentucky Center for Smoke-free Policy.

"Since these policies are self-enforcing, we need a mechanism by which everyone on campus can easily report violations," Hahn said. "Most people do not feel comfortable approaching a violator, so this is a way to encourage everyone to be involved in promoting compliance." She said the report line was a suggested "best practice" from other campuses with similar policies.

Implementation of the policy, the ultimate goal of the policy is to promote a healthy place to live, work and learn, has been a success, Hahn said: The air is healthier, and exposure to secondhand smoke has decreased. Also, since the policy was established in the fall of 2009, there has been a four-fold increase in the use of nicotine replacement to quit using tobacco, and UK has many low- or no-cost options to help students and employees do so.

Click here to report a violation of the tobacco-free policy, here for a tobacco-free brochure. 

Dollar General to sell tobacco in most of its stores by mid-2013, reflecting 'customer demand' and 'competition pressure'

By the middle of 2013, most of Dollar General's 10,000 U.S. stores will carry cigarettes and other tobacco products.. The company has made the decision in response to “competitive pressures” which came about when Family Dollar Stores, a key competitor, began adding cigarettes to its stores last year. In a press release issued by Dollar General, customer demand also drove the company's decision, citing their perception that their core customers -- mostly based in rural America -- are more likely to smoke than the national average.

A 2012 study by the American Lung Association indicated that while rural Americans do smoke more than urban Americans, geography is less a factor in determining who smokes than socioeconomic status. The study also found that pregnant rural women are far more likely to smoke than their urban counterparts. (See actual numbers from the Centers for Disease Control and the American Lung Association study here.)

G. Chambers Williams III of The Tennessean in Nashville reports that business analysts think the idea is a good one for the company, which tested the product placement last year in Nevada. Analyst Mark Montagna with Avondale Partners in Nashville explained that the company found that the average purchase per customer was $14 where tobacco was sold, versus an average of $11 otherwise. But, he added, the one challenge the company will face with tobacco products, additional shoplifting.
Anti-smoking advocates expressed regret at the business choice. (Read more)

Tobacco use higher in rural areas; several factors include tobacco companies' targeting of rural youth, Lung Assn. says

Tobacco use is higher among rural communities than in suburban and urban areas, and smokeless tobacco use is twice as common. According to the American Lung Association, rural youth are more likely to use tobacco and to start earlier than urban youth, perpetuating the cycle of tobacco addiction, death and disease.

In its latest health disparity report, “Cutting Tobacco’s Rural Roots: Tobacco Use in Rural Communities,” ALA says the increased tobacco use is associated with lower education levels and lower incomes, which are both common in rural areas where there may be fewer opportunities for educational and economic advancement.

The exposure to secondhand smoke is also likely to be higher, since rural communities are less likely to have smoke-free air laws in place, and that probably makes residents less likely to ask individuals not to smoke in their homes or other indoor places they control.

The report also pointed out that the tobacco industry "spends millions of dollars targeting rural youth," and "these young people are less likely to be exposed to tobacco counter-marketing campaigns. Rural tobacco users are also less likely to have access to tobacco-cessation programs and services to get the help they need to quit. Promotion of the availability of state counseling services by phone and online resources also lags in rural communities."

To read the full report, go here.

Smoking ban bill clears House committee for first time; but sponsor says she won't take it farther this session

A measure for a statewide smoking ban passed the House Health and Welfare Committee today, the first time such a bill has cleared committee in legislative history, Deborah Yetter reports for The Courier-Journal.

But House Bill 289 is not expected to be called for a vote this year, said its sponsor Rep. Susan Westrom, right, D-Lexington. "I'm not someone who wants to shove something down someone's throat," she said, adding she plans to reintroduce the measure next year.

Westrom predicts support will continue to grow as "people come to realize local smoking bans have worked well in cities, including Louisville, Lexington and Owensboro. Already, 23 states ban smoking statewide in indoor public spaces," Yetter reports.

Support for the bill was given a significant boost when the Kentucky Chamber of Commerce stepped behind it. President David Adkisson said the majority of business owners the chamber talked to support a ban. "We now feel like it needs to be statewide and not a patchwork," he said.

HB 289 passed with a 10-2 vote. Rep. Addia Wuchner, R-Burlington, a candidate for Congress in the Fourth District, was one of two Republicans to vote against the measure, calling it "well meaning" but too intrusive on people's rights. "It is not the role of the government to go this far," she said. (Read more)

Number of teens and young adults who smoke, use smokeless tobacco is on the rise

A "shocking" number of American teenagers smoke cigarettes and/or use smokeless tobacco, the first U.S. surgeon general's report on youth tobacco since 1994 has found. (Photo by Karen Bleier, AFP/Getty Images)

"The numbers are really shocking," Surgeon General Regina Benjamin said, noting the data show 1 in 4 high school seniors and 1 in 3 young adults under age 26 smoke. "It's a problem we have to solve."

Though there was dramatic progress in reducing youth smoking rates from 1997 to 2003, the 899-page report shows the decline has flattened. "Smokeless tobacco is up among white high school-age boys, and cigar smoking appears to be rising among black high school girls," reports David Brown for The Washington Post.

Data from the 2010 Kentucky Youth Tobacco Survey show that almost 25 percent of the state's high-school students are smokers. Although the prevalence of smoking among youth has declined in the past few years, the smoking prevalence among teenagers and young adults is higher than among other adult populations.

"Two people start smoking for every one who dies from the habit each year," Benjamin said. "Almost 90 percent of those 'replacement smokers' first try tobacco before they are 18."

The findings showed smoking can damage lung function at a very young age. One study of "nearly 700 children from East Boston found that those who started to smoke at age 15 exhaled 8 percent less air in one second — a key measure of lung function — than non-smoking teenagers. The growth of lung capacity stopped a year earlier in smokers — at 17 in girls and 19 in boys — than in non-smokers," Brown reports.

Another study showed how smoking affects the cardiovascular system. Researchers looked at autopsy results of white men ages 25 to 34 who were killed either by trauma or homicide. Smokers were two times as likely to have advanced damage of the abdominal aorta as non-smokers. "They also had somewhat greater damage to the blood vessel most often implicated in acute heart attacks," Brown reports.

Danny McGoldrick of the Campaign for Tobacco-Free Kids told USA Today's Wendy Koch tobacco marketing "is a big cause of the problem." He pointed to his organization's report revealing the tobacco industry's relationship with convenience stores to blatantly advertise and display tobacco products.

The industry's success in fighting increases in tobacco-related taxes is considered to be another factor. But industry officials like Ken Garcia of Altria Group, parent company of Philip Morris USA, said "there's already quite a (tax) burden on adult smokers." (Read more)