The State of Tobacco Control

Albert A. Rizzo, MD

This podcast series highlights clinical advancements in pulmonology, sleep medicine, and critical care medicine. Moderator, Albert Rizzo, MD, interviews prominent health professionals to help our community gain insight into leadership lessons.

In this episode, Dr Rizzo interviews Scott D Siegel, PhD, MHCDS, and Thomas Carr about issues surrounding the most preventable cause of lung disease: tobacco, including the American Lung Association’s “State of Tobacco Control” annual report and research on the impact of smoking on communities of color.

Additional Resources:

Thomas Carr

Thomas Carr is the National Director of Policy at The American Lung Association (Washington DC).

Scott D. Siegel, PhD, MHCDS

Scott D Siegel, PhD, MHCDS, is the Director of Population Health Research at ChristianaCare's iREACH and a licensed psychologist at ChristianaCare (Newark, DE).

Albert Rizzo, MD

Albert A. Rizzo, MD, is the chief medical officer of the American Lung Association and a member of ChristianaCare Pulmonary Associates (Newark, Delaware).



Speaker 1:

Hello and welcome to Critical Observations in Pulmonary Medicine, led by Chief Medical Officer of the American Lung Association, Dr Albert Rizzo. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.

Dr Albert Rizzo:

This podcast is another in the series, Critical Observations in Pulmonary Medicine. Today's topic is not about a specific disease entity, but importantly about issues surrounding the most preventable cause of lung disease: tobacco. We're going to hear about important aspects about advocating for tobacco control that the practicing physician should be aware of in understanding issues related to their patients.

To take a deeper dive into the area of tobacco control in this country, we have two guests with us, with unique perspectives and experiences. We have Thomas Carr from the American Lung Association, and Dr. Scott Siegel from ChristianaCare in Newark, Delaware. Thank you both for joining me today.

Dr Scott D Siegel:

Thank you for having me.

Thomas Carr:

Yeah, thanks for having me.

Dr Albert Rizzo:

The American Lung Association's Annual State of Tobacco Control reports and evaluates states and the federal government on actions taken to eliminate the nation's leading cause of preventable death: tobacco use and save lives with proven, effective, and urgently needed tobacco control laws and policies. The Lung Association proudly marked the 20th anniversary of releasing its State of Tobacco Control report back in early 2022, and a new report will be coming out in 2023. That last report reflected on the progress made over the past 20 years, and it's looking ahead to the significant amount of work that remains to be done to end tobacco-caused death and disease in this country.

I'd like to start with Thomas Carr. Thomas has been the Director of National Policy at the American Lung Association since October 2010, and held the title of Manager, National Policy, and Policy Analyst with the Lung Association prior to that. In this role, he directs state and local tobacco control advocacy efforts for the Lung Association, and is the primary author and editor of the Lung Association's annual State of Tobacco Control report. He also oversees the American Lung Association's State Legislated Actions on Tobacco Issues project, which is an online database and website for state tobacco control laws. Mr Carr is one of the country's most knowledgeable experts on state tobacco control laws and policies.

First, I'd like to address the new generation of tobacco products, including e-cigarettes, and the threat they have made over the last several years as more and more individuals, now up to two and a half million middle and high school students have reported using e-cigarettes in 2022. In response to the youth vaping epidemic, new public policies including ending the sale of all flavored tobacco products have risen in importance as well.

Could you give us an overview of what the State of Tobacco Control in 2022 showed us and what has happened since then? I'd like you to touch on these three specific areas: one is the FDA opportunities that were achieved or missed in 2021 and 2022 to help reduce tobacco use, and also what efforts were prominent at the state level, and then again, the ongoing concern of health inequities and disparities related to tobacco use in our society.

Thomas Carr:

Great. Thanks again, Dr. Rizzo, for having me on the podcast. State of Tobacco Control 2022 was an especially fun report to do because of the 20th anniversary of the report, we were able to look back over the past 20 years to document some of the tobacco control successes and missed opportunities over that time period.

Under a law passed in 2009, called the Tobacco Control Act, the U.S. Food and Drug Administration gained comprehensive authority over the manufacturing, marketing, and sale of tobacco products. The Lung Association strongly supported the passage of this law and had high hopes for strong policies and regulations to prevent and reduce tobacco use we hoped would follow.

However, I think it is fair to characterize FDA authority over tobacco products as a mostly missed opportunity. It was certainly not entirely the FDA's fault, as the tobacco industry will strongly oppose and sue FDA over any regulation that'll meaningfully reduce tobacco use, and they need the support of the presidential administration in office to proceed. But there have also been a number of unforced errors. One specific example of a missed opportunity has been the FDA not moving forward to end the sale of menthol cigarettes and other flavored tobacco products, which play a major role in youth initiation of these products, and in the case of menthol cigarettes in particular, make it harder for smokers to quit.

The reports produced by FDA's Tobacco Products Scientific Advisory Committee in 2011 and the FDA itself in 2013, found removing menthol cigarettes from the marketplace would benefit public health. There's been progress on this issue recently, with FDA pledging in 2021, then proposing rules in 2022 to end the sale of menthol cigarettes and flavored cigars. But the delay in acting caused additional and needless death and disease to occur, especially among Black Americans, given that over 80% of Black persons who smoke use menthol cigarettes.

Turning to the state level, in its State of Tobacco Control report, the Lung Association grades states in five areas, state funding for tobacco prevention and cessation programs, state smoke-free laws in public places and workplaces, state tobacco taxes, access to tobacco cessation treatments and services, and state flavored tobacco product laws. There has been some change in the policies graded during the 20 years of the report. All of the first three policies I mentioned have been graded over the entire 20 years.

Overall, what we found in the 2022 report is that we saw more forward progress over the decade, 2000 to 2010, than from 2011 to 2022. One notable example of this was smoke-free laws, where the number of states of comprehensive laws prohibiting smoking in public places and workplaces, including restaurants and bars, rose from two states in 2002 to 28 states by 2012. But no state has passed a law since then.

Medicaid coverage of tobacco cessation treatments and services is an area we did see continuous improvement in, both from improved state coverage under the traditional Medicaid program and more people being covered in many states due to the Medicaid expansion under the Affordable Care Act. This is good news because Medicaid enrollees smoke at significantly higher rates than people that have private health insurance, and we have to make sure people have help to end their addiction.

This is a good segue to some of the ongoing disparities in tobacco use that continue to be present in the U.S. and that contribute to health inequities in this country. On the positive side, adult cigarette smoking and tobacco use data from 2020, released in March 2022, saw the lowest cigarette smoking rate among adults ever recorded. Only 12.5% of adults smoked in 2020, a significant decline from 14% in 2019. Overall adult tobacco use and adult e-cigarette use also registered declines from 2019 to 2020.

However, these overall rates mask significant disparities in tobacco use among races and ethnicities, and due to socioeconomic factors. Smoking remains alarmingly high among Native Americans and Alaskan natives at 27.1%, and lesbian, gay, and bisexual adults at 16.1%. Smoking has also been found to be higher if a person's income or education is lower, and if they enrolled in Medicaid or are uninsured.

Populations disproportionately exposed to secondhand smoke include children ages 3 to 11, Black Americans, persons living in poverty, and people with a high school education or less. In addition to the extremely high rates of menthol cigarette use among Black Americans who smoke, menthol cigarettes are used at elevated levels among LGBTQ Americans, women, and Hispanic Americans who smoke.

The tobacco control community must address these disparities. The good news is both the policies addressed in the Lung Association State of Tobacco Control report and the policies like those your next guest will address can make a difference, but we need policymakers at all levels of government to pass, fund, and implement them to see progress.

Dr Albert Rizzo:

So, it sounds like there's certainly a comprehensive approach from the Lung Association at both certainly federal and state levels, and certainly, there is a lot of work still to be done. And you're right, I think there's a good segue now to talk a little bit more about local action. Communities are beginning to address tobacco-related health inequities as a social justice issue, and local data inequities at the point of sale can be valuable in garnering support for policies to change the retail environment.

Dr Scott Siegel is a licensed psychologist and director of population health research within the Institute for Research on Equity and Community Health, or abbreviated iREACH, at ChristianaCare in Newark, Delaware. In his immediate prior role, Dr Siegel served as the director of psychosocial oncology and cancer survivorship at the Helen F. Graham Cancer Center & Research Institute, where he provided counseling services to people affected by cancer and led a team of psychologists, social workers, nurses, and research staff.

He's here today to discuss his research that unearthed new insights about the impact of smoking on Delaware's communities in particular, and in particular, those of color, and discuss some potential new solutions to this disparity issue. This work, which is the first study of its kind, performed by Dr Siegel and colleagues at ChristianaCare's iREACH, was published in the peer-reviewed journal, Cities & Health, and involved the use of geospatial analysis.

Dr Siegel, thank you for joining us today. Please tell us about how you came to have your interest in population health research and your recent research findings.

Dr Scott D Siegel:

Thank you again for having me, and thank you also to Thomas for really setting the table quite well in terms of the work that needs to be done. My interest was really born out of the work I did, working directly with people affected by cancer. As I think many know, lung cancer is the leading cause of cancer mortality by a lot. And by far the leading risk factor for lung cancer is tobacco use. But it was working up close with people who were living with cancer, dying from cancer, and their families who are left behind after that really motivated me to want to think about what could we do differently.

I think like many, I used to think that we as a country had solved the tobacco problem. We've seen dramatic decreases in the rates of smoking, where about half of the male adult population in the 1950s was smoking. As we just heard, now it's about 12% of the adult population. But that overall statistic really doesn't tell the whole story. In terms of reducing the overall rates, there's more to do to think about how we reach all groups. And we really do need to take additional action, because the trajectory we're on, we won't actually solve that with the existing policies.

So one of the questions that I really became quite interested in is what are the mechanisms by which some of these subgroups continue to smoke at rates that we see maybe 20, 30 years ago for other majority groups. And what we realized is that because of residential segregation in this country by socioeconomic status and by race and ethnicity, that in areas that are higher poverty and predominantly minority, we see a completely different landscape with respect to the retail environment. Much higher rates of retailers licensed to sell tobacco products. And this is even after adjusting for population density.

It's within these communities where the tobacco retailers are not just selling the tobacco products, but they're the primary way that the tobacco industry is marketing. We made it illegal to market by TV and billboards and near schools and sporting events, but we didn't regulate the marketing at the point of sale and on the window front of stores, and this is really where the tobacco industry reallocated their marketing funds. And then they are able to reduce pricing within these low-income communities to offset the tax increases that have also proven to be so effective at reducing smoking rates.

So between the shifting in marketing, the reducing prices, and then just the social norms that it creates and perpetuates in these communities, that smoking is a normal thing to do, all of that goes a long way towards creating new customers among youth and maintaining existing customers among adults. Even, and maybe even especially, among adults who very much would like to stop using tobacco, but when you're constantly bombarded by the cues to smoke and the marketing and just the social norms, it becomes very, very difficult to discontinue. So that was really the basis for why we started to look at this.

We're certainly not the first to recognize the link between the retail environment and smoking rates among disadvantaged groups, but what we realized is that some of the initial attempts through policy to regulate this have not necessarily had the outcomes we're looking for. So we sought to understand what was it about those policies that maybe could be improved upon.

What our research did in Delaware, just like we've seen in other parts of the country, we first established that there were higher rates of tobacco retailers, a higher density in these disadvantaged communities, communities of lower income and predominantly minority groups. But we went further when we looked by zoning type. What we saw is that there's a very high rate of tobacco retailers in residentially zoned areas of these communities, meaning that these stores are within walking distance of where someone lives. These are the stores that they pass on their way to work or the stores that the kids pass on their way to school. It's the same stores that they go to on the corner to buy their bread for the week. It's unavoidable.

When you look into other communities, not only are there lower rates of tobacco retailers, but they're also segregated into commercially zoned areas. You don't see them nearly at the rate as in residential areas. So unless you're seeking out cigarettes in more advantaged areas, it's easy to go through life without even thinking about it, let alone being prompted to take up smoking or to continue smoking.

So, the main insight we gained from our work locally as you have to think about the neighborhoods where people live. And prior research has shown that even living within a block or two of smoking decreases by half the likelihood that someone will discontinue smoking in the next year. So just that proximity alone is very important and points to some potential policy implications.

Dr Albert Rizzo:

I think there's no question that the marketing at the local level is probably underappreciated, but I think you point out the fact that that's a big loophole the tobacco industry has utilized. And the proximity issue, I guess also has to do with... Thomas can tell us. There are laws about tobacco sales near schools, or not?

Thomas Carr:

Certainly not in most states. In a few places, there may be community-level laws, but certainly not the state level in most cases, no.

Dr Albert Rizzo:

I mean, you've really set the stage for what's going on, and I wanted to talk a little bit more about some of the hurdles and things that we can maybe do to start making progress. I know you alluded to a little bit of lack of momentum, Thomas, as far as state laws being enacted recently. So maybe if you could talk maybe at the national and state level about some hurdles that remain, and then we'll ask Scott to talk more about the municipality hurdles that we may face.

Thomas Carr:

I would say, I mean, in large part, it's really a political problem. We certainly have a set of policies that have been proven to reduce tobacco use that we can draw from, and promising practices like Dr. Siegel is talking about as well, that we can employ. I think it's in large part a how do we get our political leaders and certainly then in all parts of the country as well too, to do this. And especially in some of the Southern and Appalachian and other states, we've seen a real lack of these tobacco renewal policies being implemented. I think that leads and that you see it in the smoking rate data as being higher.

Dr Albert Rizzo:

Scott, anything at the municipality level you foresee as a hurdle we can try to address?

Dr Scott D Siegel:

Yeah, there are a few barriers, I think, we really want to focus on. One is because like I mentioned earlier, just the way things are segregated, this is out of sight out of mind for a lot of people. They don't realize the stark difference in exposure to marketing and just access to tobacco. That varies quite a bit from community to community.

So I think from a policymaker standpoint, some general awareness is important. And connecting the dots on what this does to the overall health, the constituents as well as healthcare costs at a state level, whether through Medicaid or state employees, of course, there are competing interests. So the tobacco industry itself as well as business owners of the stores that are selling these tobacco products are not necessarily in favor of any additional regulation or new policy, and will often point to the economic benefits of leaving things status quo.

Local politicians are very sensitive to these messages. And unless there is an organization or some effort to organize the community to offer a different perspective, most political leaders are going to be responsive to local business owners as well as messages from industry who are very, very good at working with state legislatures and other policymakers in terms of advancing their message.

So, I agree with Thomas completely that largely this is political. There are some economic issues we want to think about. It hearkens back to the days of where we were helping farmers who grew tobacco to move to different crops so that they could still pay their bills. And that may require some proactive thinking on our part, investments, and helping local economies.

But there are a also a lot of resources available if we wanted to think about that. We collect a lot of excise taxes on tobacco. There continues to be funds from the master settlement. And typically in most states, it's just a small fraction of those dollars that actually get back into tobacco control. So there are resources if we wanted to think progressively about how we could help transition the economies of these local communities, but it's going to take effective messaging and working with political leaders for sure.

Thomas Carr:

If I could, one other thing I'll add on the local level, and this kind of is a state and local combination is laws that preempt or prevent local communities from being able to pass stronger policies at the state level. And we've been seeing an uptick in the tobacco industry pushing for these laws, especially as states and communities get into flavored tobacco product laws, in particular. And it's unfortunate because what it does is it also precludes policies like Dr Siegel's talking about and things like that too. Or in some cases, it does.

Dr Albert Rizzo:

Having practiced at ChristianaCare for many years and still doing so, I know Delaware was fairly aggressive early on with regard to clean indoor air laws. I think we passed one of the earliest strongest indoor air laws back when, I think, Governor Minner was governor and fought a lot to make sure that casinos were smoke-free. And it is just a lot of work ahead of us.

I guess the message is changing this requires action on the part of the public, the voting public to put people into place who will look at these issues. And you're right, Scott, there are competing interests, and certainly business is going to push back with regard to restrictions of some retail locations and retail business. But again, we always have to put the health of the community on a balance between what business can or cannot support.

So, I don't know what your sense of, is Delaware continuing to be fairly progressive as far as trying to control tobacco? I know you're not a politician, we're not politicians. We don't want to support one or the other. But what do you foresee anything in the legislature this coming year or two?

Dr Scott D Siegel:

Well, the encouraging news is like you said, Delaware has traditionally been progressive and has taken multiple steps over the years. There was also not that long ago, another tax increase. But in light of what's been going on in public health in the last few years with COVID and other related issues, there's a lot of focus on opioid overdose and death, that I think the spotlight has come off of tobacco. And again, it can feel like an issue that we dealt with before. It's not a priority.

But we also know that tobacco use is certainly related to COVID outcomes, and the same can be said about opioids, where people who currently smoke have a much harder time getting off of opioids or getting into treatment because of the smoking. So I think that the tobacco control world has to continue to adapt.

The tobacco industry is very good at adapting. So just even the preemption strategy is one that they learned the hard way, but now they're using effectively. So we need to respond to that as well.

And also from a public health standpoint, we have to realize that there are lots of different competing priorities. And if we ever get into the position of trying to compete against other issues, we come at a disadvantage. But where we can show that by working together, for example, addressing tobacco use to improve both opioid overdose deaths and also issues like COVID, then it's not a matter of divide and conquer, but it's really how do we join together and allocate resources in ways that really benefit ultimately the public, as you said, which we have to put first. So it can't be a pet-cause approach. It really has to be one that evolves over time and where we look for opportunities to work across sectors.

Dr Albert Rizzo:

So Thomas, when is the next Tobacco Control report due to come out from the American Lung Association?

Thomas Carr:

The next State of Tobacco Control report will be coming out on Wednesday, January 25th at 12:00 AM Eastern Time. So pretty soon. So, we look forward to kind of sharing the results we've seen over the past year. And I will note in regards to Delaware, there has been a bit of an increase in their funding for tobacco control programs in this past year. So that's kind of a preview. Something we already knew because they were kind of in their fiscal year already. So that was good news, but obviously, how that funding is applied is important.

Dr Albert Rizzo:

So that comprehensive report, I guess would be the best place to get information on past and upcoming tobacco control issues and the state of tobacco control.

Thomas Carr:

Yeah, absolutely. is kind of the vanity link to the State of Tobacco Control. And you'd see 2022 up there, the 2022 report up there right now, but once 2023 comes out, it'll be updated automatically.

Dr Albert Rizzo:

Right. And Scott, where can people learn more about your work at ChristianaCare?

Dr Scott D Siegel:

Well, they can certainly visit our website, the iREACH website at ChristianaCare. The paper that you cited earlier is open-access. That's certainly something we can provide information on. People can readily access it.

I also just... If I could kind of bring this back into the clinician's room for a moment, for the physician or the other type of clinician who may be working with a patient to know that there are a number of resources available. There are national and state quitlines. But some of the work that we're discussing here in terms of thinking about the local environment that people live in and what that does at a population level, there are also implications when you're counseling a patient about smoking cessation. And namely, a lot of times we take a patient who continues to smoke as evidence that they don't care, that they're not motivated. But we're not fully appreciating, necessarily, all the challenges that they have, including the fact that maybe they live with people who smoke or that they've tried, but they just haven't succeeded. So it's more a question of self-efficacy than it is a question of motivation.

So taking into account the social determinants of health, the retail environment, the full picture helps us to better understand all the challenges that people are up against, and making sure that we're really doing everything on our end that we can to understand that and then maximize their chances of success if they do choose to make a quit attempt.

Dr Albert Rizzo:

Yeah, no question that smoking addiction is real. The majority of smokers, when surveyed, want to quit. And on average, 9, 10, 11 times is what's needed to have somebody successfully quit. And a lot of it is based on, as you said, it's the support that they get from their families, their physicians, and also it's their ability to maybe zone out from the marketing cues that are all around them in some of these neighborhoods. So it's an ongoing issue. Certainly, the Lung Association looks at smoking cessation as just as important as tobacco control. I mean, they're both parts of the same way to improve public health.

Dr Scott D Siegel:


Dr Albert Rizzo:

So there's a lot of work to be done, and I think the important thing is that we keep educating individuals, educate the public about what laws may need to be changed locally as well as state and federally. So I want to thank you both for the time you took today and encourage our listeners to get more information at the sites that were mentioned and hopefully tune in for our next podcast next month. So thank you both again.

Dr Scott D Siegel:

Thank you.

Thomas Carr:

Thank you.

Speaker 1:

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