The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use

ObjectiveIn the United States, many states have established minimum legal purchase ages for electronic nicotine delivery systems (ENDS) to ban adolescent purchases, but these policies may also affect other related substance use. We explore whether ENDS are substitutes or complements for cigarettes, cigars, smokeless tobacco, and marijuana among adolescents by using variation in state-level implementation of ENDS age purchasing restrictions.MethodsWe linked data on ENDS age purchasing restrictions to state- and year-specific rates of adolescent tobacco and marijuana use in 2007–2013 from the Youth Risk Behavior Surveillance System. This data provides a nationally representative sample of adolescents who attend public and private schools. We performed a fixed effect regression analysis exploring the influence of ENDS age purchasing restrictions on outcomes of tobacco use and marijuana use, controlling for state and year fixed characteristics, age-race cohorts, cigarette excise taxes, and cigarette indoor use restrictions.ResultsFor cigarette use, we separate our results into cigarette use frequency. We found causal evidence that ENDS age purchasing restrictions increased adolescent regular cigarette use by 0.8 percentage points. ENDS age purchasing restrictions were not associated with cigar use, smokeless tobacco use, or marijuana use.ConclusionsWe document a concerning trend of cigarette smoking among adolescents increasing when ENDS become more difficult to purchase.     

Intended and unintended effects of e-cigarette taxes on youth tobacco use

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has contributed to aggressive regulation by state and local governments. Between 2010 and mid-2019, ten states and two large counties adopted ENDS taxes. We use two large national surveys (Monitoring the Future and the Youth Risk Behavior Surveillance System) to estimate the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth ENDS consumption, with estimated ENDS tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may considerably undercut or even outweigh any public health gains.     

Bans on electronic cigarette sales to minors and smoking among high school students

Many states have banned electronic cigarette sales to minors under the rationale that using e-cigarettes leads to smoking traditional combustion cigarettes. Such sales bans would be counterproductive, however, if e-cigarettes and traditional cigarettes are substitutes, as bans might push teenagers back to smoking the more dangerous combustion cigarettes. We provide evidence that these sales bans reduce the incidence of smoking conventional cigarettes among high school seniors. Moreover, we provide evidence suggesting that sales bans reduced e-cigarette usage as well. This evidence suggests that not only are e-cigarettes and smoking regular cigarettes positively related and not substitutes for young people, banning retail sales to minors is an effective policy tool in reducing tobacco use.     

Emerging electronic cigarette policies in European member states,Canada, and the United States

BackgroundIncreased electronic cigarette (ECIG) use has motivated new regulations to address the changing landscape of tobacco use and promote public health.MethodThis policy scan compares ECIG prevalence and regulations in the European Union (EU), Canada, and the United States (US) at the federal- and local-level to foster a policy dialogue around modern tobacco prevention and control regulations.ResultsAmong young adults, 40 % in the US, 29 % in Canada, and 28 % in the EU report ever using an ECIG. Results from the policy scan find significant variation in approach to regulating ECIGs. EU member states are subject to the most stringent requirements regarding nicotine concentration regulations, and several member states have also opted to ban flavors and/or require plain packaging or out of sight retail sales. Among EU and US states, taxation is a popular strategy, though taxing strategies vary widely. Regarding youth use, US states have led the way for increasing the legal age of sale to 21 at the federal level, and in Canada recent federal regulations are innovative in their approach to banning advertising that may appeal to youth.ConclusionStrategies to achieve public health goals related to ECIGs vary widely, with federalism playing an important role in policy innovation, offering opportunities to evaluate their effectiveness and inform future regulations.     

How does electronic cigarette access affect adolescent smoking?

Understanding electronic cigarettes’ effect on tobacco smoking is a central economic and policy issue. This paper examines the causal impact of e-cigarette access on conventional cigarette use by adolescents. Regression analyses consider how state bans on e-cigarette sales to minors influence smoking rates among 12 to 17 year olds. Such bans yield a statistically significant 0.9 percentage point increase in recent smoking in this age group, relative to states without such bans. Results are robust to multiple specifications as well as several falsification and placebo checks. This effect is both consistent with e-cigarette access reducing smoking among minors, and large: banning electronic cigarette sales to minors counteracts 70 percent of the downward pre-trend in teen cigarette smoking for a given two-year period.     

The Impact of Massachusetts�� Smoke-Free Workplace Laws on Acute Myocardial Infarction Deaths

Objectives. We examined the rate of acute myocardial infarction (AMI) deaths in Massachusetts before and after the implementation of a comprehensive smoke-free workplace law in July 2004.Methods. We used Poisson regression models to examine the impact of the state law in cities and towns with and without previous local smoking bans and the effect of the local laws for the period of 1999 through 2006.Results. The AMI mortality rate decreased by 7.4% (95% confidence interval [CI] = 3.3%, 11.4%) after implementation of the state law. The state ban had an impact in cities and towns with no prior local smoking ban (9.2% decrease; P < .001) but not cities and towns with a prior local smoking ban. However, there was a nonsignificant 4.9% (95% CI = −5.0%, 13.9%) decrease associated with the local smoking ban that preceded the effect of the state ban. The effect of the state ban was modest (−1.6%) in the first 12 months after implementation but much larger after the first 12 months (−18.6%; P < .001).Conclusions. Comprehensive statewide smoke-free workplace laws in Massachusetts were associated with an estimated 270 fewer AMI deaths per year. These results add to the evidence suggesting that smoke-free air laws are associated with lower rates of AMI.Comprehensive smoking bans prohibit smoking in workplaces, including public and private worksites, restaurants, and bars. Studies have shown that comprehensive smoking bans reduce exposure to environmental tobacco smoke, whereas smoking restrictions, which permit designated smoking areas or provide separately ventilated sections, are not effective at preventing or eliminating exposure to environmental tobacco smoke.¹In addition to reducing exposure to environmental tobacco smoke, comprehensive smoking bans may change social norms regarding the acceptability of smoking in a community, resulting in fewer people smoking in public places.¹ Comprehensive smoking bans have been shown to reduce smoking prevalence by 3.8% (95% confidence interval [CI] = 2.8%, 4.7%) and to reduce the number of cigarettes smoked per smoker per day by 3.1 (95% CI = 2.4, 3.8).²Both cigarette smoking and exposure to environmental tobacco smoke increase the risk of coronary heart disease (CHD).¹ It is hypothesized that a decrease in these exposures as a result of a comprehensive smoking ban would result in reductions in CHD. The association between comprehensive smoking bans and acute myocardial infarction (AMI) hospital admissions was examined previously in the United States and Europe. Several meta-analyses have been conducted that pooled the results of these studies and found that comprehensive smoking bans were associated with a 17% to 19% lower AMI hospital admission rate.^3–5The first comprehensive workplace smoking ban in Massachusetts was implemented in 1994 in the town of Amherst.⁶ Individual cities and towns enacted comprehensive smoking bans over the next decade. In 2003, Boston, Cambridge, and Somerville implemented comprehensive smoking bans. All residents of Massachusetts were covered by the state comprehensive smoking ban in July 2004, which banned smoking in all workplaces, including restaurants and bars.⁷The experience in Massachusetts, in which local laws introduced comprehensive workplace smoking bans at various times, offers the opportunity to assess the impact of the local and statewide laws both separately and jointly. We examined the AMI mortality rate before and after the Massachusetts smoke-free air law in cities and towns with and without prior local comprehensive smoking bans. We also examined the impact of the local smoking bans before the statewide smoke-free law took effect.     

Banning Tobacco Sales in Massachusetts' Pharmacies

Bans on the sale of tobacco products in pharmacies allow pharmacies to provide health information and services without the conflict of interest posed by concurrent tobacco sales. As health care providers, pharmacies are trusted sources of information for patients. The existence of tobacco products in pharmacies is contrary to their mission as a health care entity. By May 2012, a full 27 Massachusetts municipalities had banned the sale of tobacco products in health care institutions, including pharmacies. These bans covered 30% of the state's population.

Key teaching points:

? Pharmacies play a key role in dispensing health advice.

? Pharmacies are the only remaining health care institutions in Massachusetts that continue to sell tobacco.

? Tobacco products in pharmacies send a conflicting message and are likely to discourage smokers who are trying to quit.

? Bans on the sale of tobacco in pharmacies enjoy broad support in Massachusetts.

? No legal challenges or compliance problems relating to banning the sale of tobacco in pharmacies have been reported in Massachusetts.

     

Enforcement Provisions of Indoor Tanning Bans for Minors: An Analysis of the First 6 US States

Several states have passed legislation banning minors from indoor tanning; however, concern has been raised regarding enforcement. We explored the statutes pertaining to enforcement in the first 6 US states to pass legislation banning minors younger than 18 years from indoor tanning. The findings reflect significant variability in enforcement provisions across the 6 states. Further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce skin cancer incidence.Since 2011, 11 US states have passed indoor tanning bans for minors younger than 18, and many other states are currently considering similar legislation.1 Although there is unprecedented momentum for indoor tanning legislation that protects youths, the recent US Surgeon General’s Call to Action, among others, has raised concerns over whether these new statutes will be enforced.2Policy initiatives for tobacco control can provide important lessons for control of indoor tanning, including enforcement.3 Federal tobacco enforcement policies are set forth in the Synar Amendment, an amendment to the Alcohol, Drug Abuse, and Mental Health Administration Act enacted in 1992 and implemented by the Substance Abuse and Mental Health Services Administration in 1996.4 Notably, the amendment tasks US states with enacting and enforcing legislation aimed at prohibiting the sale and distribution of tobacco to minors younger than 18 years.4 In addition to laws banning tobacco sales to people younger than 18 years, states have enacted legislation requiring licensure of tobacco retailers; random, unannounced inspections; specification of state enforcement authority; and creation of a graduated system of civil or criminal penalties for outlet owners and clerks.4Similar to age restrictions on tobacco sales, legislation banning minors from indoor tanning may play an important role in educating the public about the risks posed by indoor tanning and may denormalize indoor tanning by children. Legislation can also counter the indoor tanning industry’s history of deceptive marketing claims that tend to understate risks and broadly overstate any potential benefits of tanning.5     

Preface

Abstract

Background: Out of 143 countries that consumed asbestos between 2003 and 2007, only 44 have banned asbestos. This study tried to explain why some countries have banned asbestos while others have not, based on a synthesis that asbestos ban policy of a country will rely on a process of cognition of threats and exploration of safer alternatives.

Method: As we hypothesized that increased social cost of mesothelioma, capacity of health-related infrastructures, and policy diffusion from adjacent countries were related to asbestos ban adoption, published databases of asbestos ban years, mesothelioma mortality, country rankings in health care and human rights standings, and distribution of banning countries over 14 regions were analyzed accordingly.

Results: The average mesothelioma death rate was significantly higher for countries with asbestos bans than in those with no ban (4·59 versus 1·83/million). No-ban countries had less well-developed health-related infrastructures. Among European countries, there was a tendency toward geographical diffusion of asbestos ban policy from Nordic to Western and then other European countries over the years. Even though aberrant cases were also noted where bans were instituted even without mesothelioma database, these were rather exceptions than rules.

Conclusion: Risk cognition is a complex process, but the presence of well-functioning health infrastructures, as well as the increased social cost of mesothelioma, that can make the plight of asbestos victims visible to the eyes of public and policy makers, may have contributed to this process. Asbestos ban policy from adjacent countries might have facilitated the adoption of alternative solutions.     

Public support for selected e-cigarette regulations and associations with overall information exposure and contradictory information exposure about e-cigarettes: Findings from a national survey of U.S. adults

ObjectiveWe assessed public support for six e-cigarette regulations and examined whether self-reported exposure to e-cigarette information and contradictory e-cigarette information were associated with support.MethodWe conducted an online survey among a nationally representative sample of 527 U.S. adults in July 2014. Weighted, fully adjusted multinomial logistic regression models predicted support for banning e-cigarettes in smoke-free areas, prohibiting e-cigarette sales to youth, requiring addiction warnings, banning flavors, requiring labeling nicotine and harmful ingredients, and banning youth-targeted marketing.ResultsBetween 34% and 72% supported these six policies (disagreed 6–24%; no opinion 18–38%). We found higher support for policies to protect youth (prohibit sales to youth and youth-targeted marketing) and to require labeling e-cigarette constituents (nicotine and harmful ingredients). Banning the use of flavors in e-cigarettes was the least supported. Overall information exposure predicted lower relative risk of support for three policies (prohibit sales to youth, nicotine and harmful ingredient labeling, addiction warnings). In comparison, contradictory information exposure predicted lower relative risk of support for two policies (prohibit sales to youth, nicotine and harmful ingredient labeling).ConclusionsExposure to overall and conflicting information about e-cigarettes in the public sphere is associated with reduced support for certain proposed e-cigarette policies. These findings are important for policymakers and tobacco control advocates involved in promulgation of e-cigarette policies. The results provide insights on which policies may meet some public resistance and therefore require efforts to first gain public support.     

Compliance and support for bans on smoking in licensed venues in Australia: findings from the International Tobacco Control Four‐Country Survey

Objective: To examine attitudes towards and compliance with the recent Australian bans on smoking in licensed venues, and to explore effects on smoking behaviour. Methods: Three Australian states (Queensland, Tasmania and Western Australia) implemented a total ban on smoking in all enclosed licensed premises in 2006, and two others (Victoria and New South Wales) did so in mid‐2007. We used data from smokers residing in these states for each of the six waves of the ITC‐4 country survey (2002–2007; average n=1,694). Results: Consistent with the majority of international findings, observed compliance was reported by more than 90% of smokers from a pre‐ban situation of indoor smoking being the norm. Attitudes became more positive in the year before the ban, but more than doubled in the year the bans were implemented. The associations found for the leading states were replicated by the lagging states a year later. We found no evidence for any increase in permitting smoking inside the home after the bans took effect. Further, we were unable to find any evidence of reductions in daily cigarette consumption or any increase in quitting activity due to the bans. Implications: These results add to a growing body of international research that suggests that smokers are readily able to comply with, and increasingly support, smoke‐free bars, though the bans may have limited effect on their smoking habits.     

Examining how changes in provincial policy on vape marketing impacted the distribution of vaping advertisements near secondary schools in London,Ontario

ObjectivesOn January 1, 2020, the Government of Ontario passed a regulation banning vaping advertisements by retailers, apart from specialty shops. A motivation for this ban was to limit youth exposure to vaping advertisements. The primary goal of this research was to evaluate the impact of this ban on the number and density of vaping advertisements surrounding secondary schools. Additionally, we examined whether the number of vaping advertisements varied by school socio-demographic characteristics.MethodsThis study used a pre-post design. Audits were conducted December 2019 (pre-ban) and again January to February 2020 (post-ban), to identify vaping advertisements within 800 m surrounding secondary schools (n = 18) in London, Ontario.ResultsPrior to the ban, there were 266 vaping advertisements within 800 m of secondary schools. After the ban, this was reduced to 58, a 78.2% reduction. The mean number of vaping advertisements surrounding schools significantly decreased from 18.1 before the ban to 3.6 after the ban (p < 0.001). A significant positive correlation was found, prior to the ban, between the number of vaping advertisements surrounding schools and school-level residential instability (r = 0.42, p = 0.02). After the ban, no significant correlations were found between the number of vaping advertisements and school socio-demographic characteristics.ConclusionThe provincial ban of vaping advertisements in select retail settings significantly reduced the number of vaping advertisements in the areas surrounding secondary schools in London, Ontario. The ban also reduced socio-demographic inequities in youths’ potential exposure to marketing of vaping products. Continued monitoring of the geographic accessibility and promotion of vaping products is warranted.     

Electronic Cigarettes: Smoke-Free Laws,Sale Restrictions,and the Public Health

Consumer use of e-cigarettes is rising despite a lack of rigorous safety testing, manufacturing controls, and a well-understood risk profile. Many states and municipalities have prohibited e-cigarette sale to minors or amended their smoke-free laws to restrict public use. I discuss the public health impact of e-cigarettes and the current lack of Food and Drug Administration regulation, and advocate that states and localities reexamine their smoke-free laws and sale restrictions to appropriately regulate public use and youth access.Smoking consistently accounts for nearly 5.4 million deaths worldwide1 and approximately 443 000 in the United States each year.2 Heeding the significant health warnings and deadly statistics, smokers are increasingly turning to a new mode of nicotine intake: the electronic cigarette, or e-cigarette. Public awareness and use of e-cigarettes is skyrocketing as a result of targeted marketing tactics.3 The Centers for Disease Control and Prevention (CDC) report that e-cigarette use quadrupled in a 1-year period and continues to rise.4 Twenty-one percent of adult smokers in the United States have used e-cigarettes, 6% of all adults have tried e-cigarettes, and general awareness of e-cigarettes has risen to 60% of all adults, up from 40% the previous year.4 The CDC also report that use among US youths is staggering, having doubled among high-school students between 2011 and 2012.5 This most recent figure has led many nonsmoking advocates and health officials to question whether a troubling gateway effect of e-cigarettes for subsequent youth cigarette smoking is emerging after decades of decline in cigarette use by minors.6A core feature of the e-cigarette is that it looks and feels like a cigarette, satisfying psychological and behavioral stimuli for users who smoke. E-cigarettes, however, are smokeless, consisting of a replaceable nicotine cartridge, an atomizer that vaporizes the nicotine when the user inhales, and a battery that powers the device. The nicotine cartridge contains nicotine and various secondary chemical ingredients. When screwed together, the nicotine liquid from the cartridge contacts the atomizer and is carried to a metal coil heating element. The intake of air triggers a current from the battery through the atomizer, which heats up the nicotine liquid. Often, a light-emitting diode at the base mimics the burning ash at the end of traditional cigarette as the user inhales. Many products resemble a traditional cigarette, yet some are marketed in the shape of other household accessories such as pipes, pens, and lipstick. A single cartridge can hold the nicotine equivalent of an entire pack of cigarettes or more, and there is tremendous variation in the composition, strengths, and flavoring of the nicotine liquid.7E-cigarette advertisements, and the celebrities that frequent them, have emphasized the freedom to smoke anywhere; a lack of smell, tar, smoke, or toxic chemicals; an absence of social stigma; cost savings; and health advantages, often specifically reaching out to smokers aiming to quit or cut down.8 Some distributors also advertise their products as not emitting secondhand smoke or as ecologically friendly.8 The accuracy of these claims is unclear and contested. In fact, the Food and Drug Administration (FDA) and health care professionals alike have raised concern about the novel method of nicotine delivery, product ingredients, nicotine levels, safety of the various mechanical and electrical parts, dearth of data on product performance, and both explicit and implicit messages to users regarding health benefits.9 Scientific and clinical publications have only begun to target issues related to e-cigarette use.Consumer use, marketing and promotional claims, and technological characteristics of e-cigarettes have also raised decades-old questions of when the FDA can assert authority over particular products as drugs or medical devices. The 2010 DC Circuit case of Sottera v. FDA limited the FDA’s authority to regulate e-cigarettes as drugs or medical devices to instances where the manufacturer makes explicit health or disease-prevention claims for its products.10 Examining the language and congressional intent of the Family Smoking Prevention and Tobacco Control Act of 2009 (TCA), the court held that e-cigarettes fall within the literal definition of tobacco products because nicotine is “derived from tobacco,” as set forth in the TCA definitions. The FDA declined to appeal that decision and is currently assessing appropriate regulation and enforcement activities; the agency has issued a statement that it plans to assert regulatory authority over e-cigarettes as tobacco products.11While the FDA struggles to determine how to regulate these products at the federal level, state and local governments also have a role to play. The TCA, coupled with previous legislative authority, gives broad latitude to states and localities to enact laws and regulations relating to the sale, distribution, possession, and use of tobacco products.12 State and local regulatory efforts have focused on smoke-free laws and restrictions on use and sale. Thirty-six states and 3931 municipalities have laws in place restricting or prohibiting smoking in public places and workplaces.13 The scope of the laws varies, commonly directed at a combination of locations such as nonhospitality workplaces, restaurants and bars, and public areas. The overwhelming majority of the laws were drafted with cigarettes and traditional tobacco products in mind, with many specifically using the word “smoke” or “smoking” to define the restricted or prohibited action. However, e-cigarettes do not produce smoke; they produce vapor. States and localities must reexamine their smoke-free laws and access restrictions to appropriately regulate the use of e-cigarettes.As of September 2013, 27 states and localities have amended their smoke-free laws to explicitly include e-cigarettes within the ban on smoking in public places.14 For example, the New Jersey Smoke-Free Air Act prohibits smoking in indoor public places, workplaces, and in buildings or grounds of any public or nonpublic elementary or secondary school. It was amended in 2010 to include within the scope of smoking “the inhaling or exhaling of smoke or vapor from an electronic smoking device.”15 An electronic smoking device is further defined as “an electronic device that can be used to deliver nicotine or other substances to the person inhaling from the device, including, but not limited to, an electronic cigarette, cigar, cigarillo, or pipe.”15 Likewise, New York bans e-cigarette use within 100 feet of entrances and exits to public or private schools.16 In addition to the state laws, Somerset, Massachusetts; King County, Washington; Madison County, Kentucky; Savannah, Georgia; and Petaluma, California, are just a few cities and counties, among others, that have passed ordinances explicitly including e-cigarettes within the scope of their smoking bans.14 Both California and Oregon have settled in court with leading e-cigarette manufacturers and distributors, making the sale of their specific e-cigarette products unlawful in those states.14Thirty-four states and municipalities have also enacted laws banning sales of e-cigarettes to minors, although the age limitations vary from younger than 18 to younger than 21 years.14 Dozens of states include both a ban on smoking in public settings and a ban on sale to minors, and other laws contain individual nuances.14 For example, Hawaii prohibits the sale of e-cigarettes to minors younger than 18 years, and also requires in-person sales rather than sales through the Internet.14 Tacoma–Pierce County, Washington, includes a ban on free sampling unless within an e-cigarette retail store.14 In a September 2013 letter to the FDA, lawmakers joined the call, urging the agency to act swiftly at the federal level to address the epidemic of youths’ use of e-cigarettes.17 Federal legislators have also advocated hearings on the health risks and scope of FDA authority.17These state and local laws are merely a stopgap measure and fail to establish a uniform national policy for e-cigarettes. The best outcome to ensure the protection of the public health, and youths in particular, would be for the FDA to initiate rulemaking proceedings to deem e-cigarettes within the definitional scope of the TCA. This would allow the FDA to develop manufacturing requirements, reporting mechanisms, product standardization, ingredient listings, limitations on marketing claims, and various other procedures to install proper oversight of product development and distribution. As with any effort at content regulation, First Amendment challenges may arise. However, states and local governments also have a role in regulation and should proactively reassess their existing smoking bans, sale to minors, and other restrictions and decide whether to amend the language to include e-cigarettes. Failing to include a clear statutory definition leaves use and access to e-cigarettes as a significant loophole, and may thwart even the most well-intended public health laws.     

Investigating the Impact of the New York State Flavor Ban on e-Cigarette–Related Discussions on Twitter: Observational Study

BackgroundOn May 18, 2020, the New York State Department of Health implemented a statewide flavor ban to prohibit the sales of all flavored vapor products, except for tobacco or any other authorized flavor.ObjectiveThis study aims to investigate the discussion changes in e-cigarette–related tweets over time with the implementation of the New York State flavor ban.MethodsThrough the Twitter streaming application programming interface, 59,883 e-cigarette–related tweets were collected within the New York State from February 6, 2020, to May 17, 2020 (period 1, before the implementation of the flavor ban), May 18, 2020-June 30, 2020 (period 2, between the implementation of the flavor ban and the online sales ban), July 1, 2020-September 15, 2020 (period 3, the short term after the online sales ban), and September 16, 2020-November 30, 2020 (period 4, the long term after the online sales ban). Sentiment analysis and topic modeling were conducted to investigate the changes in public attitudes and discussions in e-cigarette–related tweets. The popularity of different e-cigarette flavor categories was compared before and after the implementation of the New York State flavor ban.ResultsOur results showed that the proportion of e-cigarette–related tweets with negative sentiment significantly decreased (4305/13,246, 32.5% vs 3855/14,455, 26.67%, P<.001), and tweets with positive sentiment significantly increased (5246/13,246, 39.6% vs 7038/14,455, 48.69%, P<.001) in period 4 compared to period 3. “Teens and nicotine products” was the most frequently discussed e-cigarette–related topic in the negative tweets. In contrast, “nicotine products and quitting” was more prevalent in positive tweets. The proportion of tweets mentioning mint and menthol flavors significantly increased right after the flavor ban and decreased to lower levels over time. The proportions of fruit and sweet flavors were most frequently mentioned in period 1, decreased in period 2, and dominated again in period 4.ConclusionsThe proportion of e-cigarette–related tweets with different attitudes and frequently discussed flavor categories changed over time after the implementation of the New York State ban of flavored vaping products. This change indicated a potential impact of the flavor ban on public discussions of flavored e-cigarettes.     

Perceptions About the Impact of Cigarette Filters on the Environment and Smoking-Related Behaviors

PurposeExamine adolescents’ and young adults’ (AYAs) knowledge and perceptions about the composition and environmental harms of cigarette filters and determine how perceptions are associated with support for policy interventions.MethodsCross-sectional, convenience sample from 10 California schools. AYAs (N = 429; 70% < 21 years) were surveyed about tobacco use, perceptions of cigarette filters, their impact on the environment, and cigarette sales bans.ResultsMost agreed that filters are harmful to the environment and not biodegradable (89%, n = 383 respectively); fewer knew filters are made of plastic (43%, n = 185). AYAs who agreed that filters are harmful to the environment were more supportive of cigarette sales bans (OR = 2.78 [95% CI: 1.18, 6.58]).ConclusionsKnowledge of the environmental harms of cigarettes among AYAs may strengthen support for tobacco control. More research is needed to further understand the knowledge and attitudes about the environmental impact of tobacco and to clarify how this might add support for tobacco-related policies.     

Impact of a smoking ban on restaurant and bar revenues--El Paso, Texas, 2002

Smoke-free indoor air ordinances protect employees and customers from secondhand smoke exposure, which is associated with increased risks for heart disease and lung cancer in adults and respiratory disease in children. As of January 2004, five states (California, Connecticut, Delaware, Maine, and New York) and 72 municipalities in the United States had passed laws that prohibit smoking in almost all workplaces, restaurants, and bars. On January 2, 2002, El Paso, Texas (2000 population: 563,662), implemented an ordinance banning smoking in all public places and workplaces, including restaurants and bars. The El Paso smoking ban is the strongest smoke-free indoor air ordinance in Texas and includes stipulations for enforcement of the ban by firefighting and law enforcement agencies, with fines of up to $500 for ordinance violations. To assess whether the El Paso smoking ban affected restaurant and bar revenues, the Texas Department of Health (TDH) and CDC analyzed sales tax and mixed-beverage tax data during the 12 years preceding and 1 year after the smoking ban was implemented. This report summarizes the results of that analysis, which determined that no statistically significant changes in restaurant and bar revenues occurred after the smoking ban took effect. These findings are consistent with those from studies of smoking bans in other U.S. cities. Local public health officials can use these data to support implementation of smokefree environments as recommended by the Task Force on Community Preventive Services.     

Area-level differences in the prices of tobacco and electronic nicotine delivery systems — A systematic review

ObjectiveTo examine associations between area-level characteristics (socioeconomic status, racial or ethnic characteristics, age, and any other characteristics that may be associated with vulnerability) and the prices of tobacco products and electronic nicotine delivery systems (ENDS).Data sourcesWe searched MEDLINE, EconLit and Scopus, unpublished and grey literature, hand-searched four specialty journals, examined references of relevant studies, and contacted key informants.Study selectionWe considered all studies that quantitatively examined area-level variations in the prices of tobacco products and ENDS. We included all studies that examined any area-level measures regardless of the geographic location, language or time of publication. At least two reviewers independently screened the articles. We identified 20 studies.Data extractionAt least two reviewers independently extracted the characteristics, methods, and main results and assessed the quality of each included study.Data synthesisOverall, cigarette prices were found to be lower in lower socioeconomic status neighbourhoods, and in neighbourhoods with a higher percentage of youth, and Blacks or African Americans. We identified too few studies that examined price differences for cigarillos, chewing tobacco, roll-your-own, and ENDS to reach any conclusions.ConclusionsOur findings are in keeping with tobacco industry documents that detailed how manufacturers used race, class, and geography to target vulnerable populations and suggest that regulations that can limit industry price manipulation such as minimum, maximum, and uniform prices, and high specific excise taxes should be considered. More frequent and systematic monitoring of tobacco prices and ENDS is warranted.     

Secondhand smoke in hospitals of Catalonia (Spain) before and after a comprehensive ban on smoking at the national level

ObjectiveTo assess changes in secondhand smoke exposure by means of airborne nicotine concentrations in public hospitals of Catalonia (Spain) before and after a comprehensive national smoking ban.MethodsWe monitored vapor-phase nicotine concentrations in 44 public hospitals in Catalonia (Spain) before the smoking ban (September–December 2005) and one year after (September–December 2006). We installed 5–7 sampling devices per hospital for 7 days in different places (228 pairs of samples), and 198 pairs of samples were available for the final analysis.ResultsThe median nicotine concentration declined from 0.23 μg/m³ (interquartile range: 0.13–0.63) before the law to 0.10 μg/m³ (interquartile range: 0.02–0.19) after the law (% decline = 56.5, p < 0.01). We observed significant reductions in the median nicotine concentrations in all hospital locations, although secondhand smoke exposure was still present in some places (main hospital entrance, emergency department waiting rooms, fire escapes, and cafeterias).ConclusionsSecondhand smoke in hospitals has decreased after the ban. Assessment of airborne nicotine concentrations appears to be an objective and feasible system to monitor and reinforce the compliance of smoke-free legislations in this setting.     

Environmental and Economic Evaluation of the Massachusetts Smoke-free Workplace Law

An environmental and economic evaluation of the smoke-free law in Massachusetts provides a broad appreciation of how a state-wide smoking ban affects the health of patrons and workers as well as the industries that are commonly concerned about the effects of smoking bans on business. The aim of this study is to evaluate environmental and economic effects of the statewide Massachusetts statewide Smoke-Free Workplace Law. Before and after the smoking ban, air quality testing was conducted in a sample (n = 27) of hospitality venues and state-wide economic changes were assessed. Compliance, in terms of patronage was measured by person-counts. Environmental outcomes were respirable suspended particles (RSP) less than 2.5 microns in diameter (PM_2.5). Economic outcomes were meals tax collections, employment in the food services and drinking places and accommodations industries. On average, levels of respirable suspended particles (RSPs) less than 2.5 microns in diameter (PM_2.5) decreased 93% in these venues after the Massachusetts Smoke-free Workplace Law went into effect. No statistically significant changes were observed among the economic indicators. This evaluation demonstrates that the state-wide Massachusetts law has effectively improved indoor air quality in a sample of Massachusetts venues and has not negatively affected several economic indicators. Support for this report was provided by the Flight Attendant Medical Research Institute.