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Home My WebLink AboutCOM 0593.017 2022-2024 P[Pcr4cw CAMPAIGN g11.t (02_ dal' TogAQ.o-FREE ��M` S�3 Kck° c C) December 4th, 2023 r Dear Councilmembers, A 3 The Campaign for Tobacco-Free Kids strongly supports Bill 102 to end the sale of flavored a;=, mow: tobacco products in the County of Hawai'i. The Campaign for Tobacco-Free Kids &the Tobacco-Free Kids Action Fund are pleased to submit this letter in support of a comprehensive ban on the sale of flavored tobacco products in the city and county of Honolulu to reduce tobacco use, particularly among youth.The Campaign for Tobacco-Free Kids is the nation's largest non-profit, non-governmental advocacy organization solely devoted to reducing tobacco use and its deadly toll by advocating for public policies that prevent kids from using tobacco and help smokers quit. It is encouraging to see cities and counties continue to take thoughtful, evidence-based steps to reduce the number of kids who start using tobacco and help tobacco users quit. We understand that this bill would not take effect unless the state repealed the preemption on tobacco sale regulation by the counties.The counties of Hawai'i have a long history of enacting tobacco control before the state takes action and we hope that the state will allow the counties to resume their role in protecting their residents against pernicious actors like Big Tobacco. While Hawai'i has made great strides in reducing tobacco use, tobacco use remains the number one preventable cause of premature death and disease in Hawai'i and the nation, killing 480,000 Americans annually, including 1,400 in Hawai'i. As you discuss policy options,we stand with dozens of other national health organizations to urge you to end the sale of all flavored tobacco products including candy flavored e-cigarettes, sweet-flavored cigarillos, menthol cigarettes, and hookah products. Prohibiting the sale of all flavored tobacco products in all tobacco retailers is a critical step that will help protect children living in Hawai'i from the unrelenting efforts by the tobacco industry to hook them to a deadly addiction. Flavored tobacco products are designed to alter the taste and reduce the harshness of tobacco products so they are more appealing and easy for beginners, who are almost always kids.These products are pervasive and are marketed and sold in a variety of kid-friendly flavors. With their colorful packaging and sweet flavors,flavored tobacco products are often hard to distinguish from the candy displays near which they are Comm. No. _ T b•� Ref. To: Ref. Date nEC ® 5 2023 CAMPAIGN ToBAQ.o-FREE Kick• frequently placed in retail outlets. Eight out of ten youth who have ever used a tobacco product started with a flavored product.! Flavored Tobacco Products Are Pervasive A 2009 federal law, the Family Smoking Prevention and Tobacco Control Act, prohibited the sale of cigarettes with characterizing flavors other than menthol or tobacco, including candy and fruit flavors. While overall cigarette sales have been declining since the 2009 law, the proportion of smokers using menthol cigarettes (the only remaining flavored cigarette) has been increasing.2 Menthol cigarettes comprised 37 percent of the market in 2020.3 The Tobacco Control Act's prohibition on characterizing flavors did not apply to other tobacco products, and as a result,tobacco companies have significantly stepped up the introduction and marketing of flavored non-cigarette tobacco products. In fact,the overall market for flavored tobacco products is actually growing. In recent years, there has been an explosion of sweet-flavored tobacco products, especially e-cigarettes and cigars.These products are available in a wide assortment of flavors—like mango, blue razz, pink punch and mint for e-cigarettes and chocolate, watermelon, and cherry dynamite for cigars.Tobacco companies are making and marketing deadly and addictive products that look and taste like a new line of flavors from a Ben and Jerry's ice cream store. Flavors are not just a critical part of the product design, but are a key marketing ploy for the industry.The 2016 Surgeon General Report on e-cigarettes concluded, "E-cigarettes are marketed by promoting flavors and using a wide variety of media channels and approaches that have been used in the past for marketing conventional tobacco products to youth and young adults.i4 The 2021 National Youth Tobacco Survey found that 70.3%of middle and high school 1 Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association,published online October 26,2015. 2 Villanti,A.,et al.,"Changes in the prevalence and correlates of menthol cigarette use in the USA,2004-2014,"Tobacco Control, 25(Suppl 2):ii14-ii20,2016. 3 U.S.Federal Trade Commission(FTC),Cigarette Report for 2020,2021, httos://www.ftc.eov/system/files!documents/reports/federal-trade-comm fission-cigarette-report-2020-smokeless-tobacco-repo rt-2020/o114508fv20cigarettereoort.odf [data for top 4 manufacturers only]. 4 HHS,E-Cigarette Use Among Youth and Young Adults.A Report of the Surgeon General.Atlanta,GA:U.S.Department of Health and Human Services,Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health,2016. CAMPAIGN Eov ToAco-FREE Kick• students-17.77 million youth—had been exposed to e-cigarette advertisements from at least one source.' Sales of cigars (i.e., large cigars, cigarillos, and small cigars) have more than doubled between 2000 and 2020, and much of the growth is attributable to smaller types of cigars, many of which are flavored and inexpensive.' Nielsen convenience store market scanner data showed that over half(53.3%) of cigar sales in 2020 were for flavored cigars. Among flavored cigars sold in these stores in 2020,the most popular flavors were sweet or candy(30.6%) and fruit(29.5%).' Earlier data show the number of unique cigar flavor names more than doubling from 108 to 250 over the same time period.'The top five most popular cigar brands among 12-to 17-year olds who have used cigars—Black& Mild, Swisher Sweets, White Owl, Backwoods, and Dutch Masters—all come in flavor varieties.'These products are often sold singly or can be priced as low as 3 or 4 for 99 cents, making them even more appealing to price-sensitive youth. Note that cigar smoke is composed of the same toxic and carcinogenic constituents found in cigarette smoke.10 Although tobacco companies claim to be responding to adult tobacco users' demand for variety, it's clear that flavored tobacco products play a key role in enticing new users, particularly kids, to a lifetime of addiction.This growing market of flavored tobacco products is undermining progress in reducing youth tobacco use. Flavored Tobacco Products Are Popular Among Youth These sweet products have fueled the popularity of e-cigarettes and cigars among youth. A government study found that eight out of ten kids who have ever used tobacco products started with a flavored product.' Across all tobacco products,the data is clear:flavored 5 Gentzke,A,et al.,"Tobacco Product Use and Associated Factors Among Middle and High School Students—National Youth Tobacco Survey,United States,2021,"MMWR 71(5):1-29,March 10,2022, httos://www.cdc.eov/mmwr/volumes/71/ss/odfs/ss7105a1-H.odf. 6 U.S.Alcohol and Tobacco Tax and Trade Bureau(TTB),Tobacco Statistics. 'Delnevo,CD,et al."Cigar Sales in Convenience Stores in the US,2009-2020,"JAMA 326(23):2429-2432. 'Delnevo,CD,Giovenco,DP,&Miller,EJ,"Changes in the Mass-merchandise Cigar Market since the Tobacco Control Act," Tobacco Regulatory Science,3(2 Suppl 1):S8-516,2017. 9 SAMHSA's public online data analysis system(PDAS).National Survey on Drug Use and Health,2015, httos://odas.samhsa.eov/#/survey/NSDUH-2015-DS0001/crosstab/?row=CGR3OBR2&column=CATAG2&weight=ANALWT C&rel ults received=trs P. 10 National Cancer Institute(NCI),Cigars:Health Effects and Trends.Smoking and Tobacco Control Monograph No.9,1998, htto://cancercontrol.cancer.gov/Bro/tcrb/monograohs/9/m9 complete.odf.Chang,CM,et al.,"Systematic review of cigar smoking and all cause and smoking related mortality,"BMC Public Health,2015. 11 Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association,published online October 26,2015. CAMPAIGN ToACco B -FREE Kick tobacco products are overwhelmingly used by youth as a starter product, and preference for flavors declines with age. Nationally, e-cigarettes have been the most commonly used tobacco product among youth since 2014.Today,youth e-cigarette use remains a serious public health concern,with over 2.5 million youth, including 14.1%of US high schoolers, reporting current e-cigarette use in 2022, according to the National Youth Tobacco Survey(NYTS).'2 According to the 2019 Hawai'i Youth Risk Behavior Survey, 30.1%of Hawai'i high school students and 17.7%of middle school students are current e-cigarette users.13 Kids are not just experimenting with e-cigarettes, but are using them frequently, leading to an addiction that is difficult to break.According to the 2022 NYTS, 46%of high school e-cigarette users reported vaping on 20 or more days/month, and 30.1% reported daily use.14 This youth addiction crisis has been fueled by the growth of high nicotine e-cigarettes--many contain as much or more nicotine as a pack of twenty cigarettes. Nicotine is a highly addictive drug that can have lasting damaging effects on adolescent brain development—the brain keeps developing until about age 25. In particular, nicotine use can harm the parts of the adolescent brain responsible for attention, learning, mood and impulse control.'The Surgeon General concluded that, "The use of products containing nicotine in any form among youth, including in e-cigarettes, is unsafe."" Youth e-cigarette users are also at risk of smoking cigarettes. A 2018 report from the National Academies of Science, Engineering& Medicine found that "There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and 12 Cooper,M et al.,"E-Cigarette Use Among Middle and High School Students—United States,2022,"MMWR,71(40): 1283-1285,October 7,2022,httos://www.cdc.gov/mmwr/volumes/71/wr/ndfs/mm7140a3-H.odf. 13 Centers for Disease Control and Prevention(CDC).2019 High School Youth Risk Behavior Survey Data. Available at http://nccd.cdc.gnv/vouthonline/. 14 Cooper,M et al.,"E-Cigarette Use Among Middle and High School Students—United States,2022,"MMWR,71(40): 1283-1285,October 7,2022,httos://www.cdc.eov/mmwr/volumes/71/wr/ndfs/mm7140a3-H.odf. 15 HHS,The Health Consequences of Smoking:50 Years of Progress.A Report of the Surgeon General,CDC,Office of Smoking and Health(OSH),2014,htto://www.surgeoneeneral.gov/library/reports/50-vears-of-progress/index.html.See also:CDC Office on Smoking and Health,"Quick Facts on the Risks of E-cigarettes for Kids,Teens,and Young Adults,"March 2019.Accessed August 9,2019. 16 HHS,E-Cigarette Use Among Youth and Young Adults.A Report of the Surgeon General.Atlanta,GA:U.S.Department of Health and Human Services,Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health,2016. CAMPAIGW ToBAQo-FREE young adults."17 More recent research confirms this finding.'8 Therefore, it is critical for any policy restricting sales of flavored tobacco products to include e-cigarettes. In February 2020,the FDA restricted some flavors in cartridge-based e-cigarettes, but exempted all menthol-flavored e-cigarettes and left flavored e-liquids and disposable e-cigarettes widely available in every imaginable flavor, including flavors that uniquely appeal to Hawaii's children— like luau punch and lychee ice. New data show that the market share of these products has grown substantially and that youth quickly migrated to the flavored products that were exempt from the FDA's policy. In 2022, 55.3%of US youth e-cigarette users reported using disposable e-cigarettes and 26.6%of users of flavored e-cigarettes reported using menthol e-cigarettes.19 While the FDA recently announced that it had denied marketing applications for certain flavored e-cigarettes, many of the flavored products most popular among kids, like Juul, are still on the market. Every day these products remain on the market, our kids remain in jeopardy. Because of the delays and gaps in the FDA's actions, it is critical that states and cities step up their efforts to eliminate ALL flavored e-cigarettes, as well as other flavored tobacco products. The evidence is also clear that as long as any flavored e-cigarettes—including menthol-flavored products—are on the market, kids will shift to them and we will not end this public health crisis. Hawai'i must close the gaps left by the FDA and protect our kids from these dangerous and addictive products. Menthol Cigarettes and Flavored Cigars Increase Youth Smoking and Exacerbate Health Disparities No other flavored product contributes more to the death and disease caused by tobacco use than menthol cigarettes. Menthol cools and numbs the throat, reducing the harshness of cigarette smoke,thereby making menthol cigarettes more appealing to youth who are initiating smoking. As the only flavored cigarette left on the market, it's also no surprise that menthol cigarettes are popular among youth. About half of youth who have ever tried smoking started with menthol-flavored cigarettes.Z°The FDA's Tobacco Product Scientific Advisory Committee (TPSAC) has reported that: 17 National Academies of Sciences,Engineering,and Medicine(NASEM),Public Health Consequences of E-Cigarettes,2018, http://nationalacademies.ore/hmd/Reports/2018/oublic-hea Ith-conseauences-of-e-cigarettes.asox. 18 Berry,KM,et al.,"Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths,"JAMA Network Open,2(2),published online February 1,2019;Pierce,JP,et al.,"Use of E-Cigarettes and Other Tobacco Products and Progression to Daily Cigarette Smoking,"Pediatrics,147(2),published online January 11,2021. 19 Cooper,M et al.,"E-Cigarette Use Among Middle and High School Students—United States,2022,"MMWR,71(40): 1283-1285,October 7,2022,https://www.cdc.eov/mmwr/volumes/71/wr/odfs/mm7140a3-H.pdf. 2°Ambrose,BK,et al.,"Flavored Tobacco Product Use Among US Youth Aged 12-17 Years,2013-2014,"Journal of the American Medical Association,published online October 26,2015. CAMPAIGN ok- Toi3P o-FREE Kick. • Menthol cigarettes increase the number of children who experiment with cigarettes and the number of children who become regular smokers, increasing overall youth smoking. • Young people who initiate using menthol cigarettes are more likely to become addicted and become long-term daily smokers. According to the 2019 Hawaii Youth Risk Behavior Survey, 59%of Hawaii's high school cigarette smokers and 38%of middle school cigarette smokers used menthol cigarettes. In addition, cheap, flavored cigars—sold in hundreds of flavors like cherry dynamite, tropical twist and chocolate—have flooded the market in recent years and fueled the popularity of these products with kids.The 2022 National Youth Tobacco Survey shows that cigars are the second most popular tobacco product(after e-cigarettes) among all high school students and are especially popular among Black high school students.21 Tobacco companies have a long history of targeting communities with menthol marketing. Tobacco industry marketing, often targeted at minority communities, has been instrumental in increasing the use of menthol products and in the disproportionate use of menthol products by minority groups and youth.TPSAC concluded that menthol cigarettes are marketed disproportionately to younger smokers and Black Americans.22 Dating back to the 195Os,the tobacco industry has targeted these communities with marketing for menthol cigarettes through sponsorship of community and music events, targeted magazine advertising,youthful imagery, and marketing in the retail environment. Nationwide, as a result of this targeting, 85% of Black smokers smoke menthol cigarettes, compared to 29%of White smokers.23 Nationally, menthol is also disproportionately high among Asian and Hispanic smokers, LGBTQ+smokers, smokers with mental health problems, socioeconomically disadvantaged populations, and pregnant women.24 21 Park-Lee E,et al."Tobacco Product Use Among Middle and High School Students—United States,2022."MMWR 71(45):1429-1435, November 11,2022,https://www.cdc.qov/mmwr/volumesl71/wr/pdfs/mm7145a1-H.pdf. 22 TPSAC,Menthol Cigarettes and Public Health:Review of the Scientific Evidence and Recommendations,July 21,2011. 23 Delnevo,CD,et al.,"Banning Menthol Cigarettes:A Social Justice Issue Long Overdue,"Nicotine&Tobacco Research,22(10): 1673-1675,2020. 24 Delnevo,CD,et al.,"Banning Menthol Cigarettes:A Social Justice Issue Long Overdue,"Nicotine&Tobacco Research,22(10):1673-1675, 2020. CAMPAIGN rov TotAQo-FREE � dls There is also evidence that the industry has targeted the Hawaiian population. In the 1980s, a marketing group strategized how to reach native Hawaiians with Kool cigarettes, a popular menthol brand.The agency recommended that Kool employ "ethnic advertising" in Hawai'i, recommending the use of models that were "fun, happy-go-lucky young people in their 20s...[who have] full social calendars and spend a lot of time outdoors at the beach... people who display what islanders call the aloha spirit.i25 An assessment of tobacco advertising in Hawaii found that Kool, a popular menthol brand, was the most heavily advertised brand across Hawai'i in the early 2000s.26 The 2020 Behavioral Risk Factor Surveillance System shows that prevalence is high among ethnic groups that comprise a significant proportion of Hawaii's population, with 79%of Filipino smokers, 78%of Native Hawaiian smokers, and 69%of Japanese smokers usually smoking menthol cigarettes. Menthol cigarettes are a major reason why Black Americans suffer disproportionately from tobacco use. The tobacco industry's "investment" in the African American community has had a destructive impact. In 2013,the FDA released a report finding that menthol cigarettes lead to increased smoking initiation among youth and young adults, greater addiction, and decreased success in quitting smoking.27 Tobacco use is the number one cause of preventable death among Black Americans, claiming 45,000 Black lives every year.28 Tobacco use is a major contributor to three of the leading causes of death among Black Americans- heart disease, cancer and stroke.29 The higher rates of some tobacco-caused diseases among Black Americans result, in part,from their greater use of menthol cigarettes,which are associated with reduced 25 Anderson,SJ,"Marketing of menthol and consumer perceptions:a review of tobacco industry documents,"Tobacco Control, 20(Suppl 2):ii20-ii28;2011. 26 Glanz,K.et al.,"Operation Storefront Hawaii:Tobacco Advertising and Promotion in Hawaii Stores,"Journal of Health Communication,11(7):699-707,2006. 27 FDA,Preliminary Scientific Evaluation of the Possible Public Health Effects of Menthol versus Nonmenthol Cigarettes,2013. 28American Cancer Society,"Cancer Facts&Figures for African Americans,2016-2018,"2016, htto://www.cancPcorg/acs/grouu)s/content/aOeditorial/documents/document/acspc-047403.odf;.American Heart Association, "African Americans and Cardiovascular Diseases:Statistical Fact Sheet,2012 Update," htto://www.heart.ore/idc/groups/heart-public/Owcm/(a)soo/esmd/documents/downloadable/ucm 319568.odf.HHS, "Tobacco Use Among US Racial/Ethnic Minority Groups—African Americans,American Indians and Alaskan Natives,Asian Americans and Pacific Islanders,and Hispanics:A Report of the Surgeon General,"1998, htta://www.cdc eov/tobacco/data statistics/serL1998/complete report/odfs/comolete report.udf 29 HHS,"Tobacco Use Among US Racial/Ethnic Minority Groups—African Americans,American Indians and Alaskan Natives, Asian Americans and Pacific Islanders,and Hispanics:A Report of the Surgeon General,"1998;CDC,National Vital Statistics Report,Vol.68,No.9.Table 10,2019 httos://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68 09-508.odf. CAMPAIGN ToBAko-FREE K��• cessation.30 Researchers estimate that among the Black community, 157,000 smoking-related premature deaths and 1.5 million excess life-years between the years 1980 and 2018 can be attributed to menthol cigarettes.31 Action to prohibit menthol cigarettes is long overdue. In 2011,TPSAC concluded that "Removal of menthol cigarettes from the marketplace would benefit public health in the United States."32 Over a decade after TPSAC issues its report—in April 2022—the FDA issued proposed rulemaking to prohibit menthol cigarettes and flavored cigars. However, until any FDA action is finalized, states and cities should continue their growing efforts to end the sale of menthol cigarettes and other flavored tobacco products. It will take time for the FDA to finalize and implement the necessary regulations to prohibit menthol cigarettes and flavored cigars, and tobacco industry lawsuits could cause more delays. States and cities have an obligation to protect the health of their citizens and must act now to stop tobacco companies from targeting kids and other groups with menthol cigarettes and other flavored products. We can't afford more delay in taking action to protect kids and save lives. The scientific evidence leaves no doubt that menthol cigarettes and other flavored tobacco products increase the number of people, particularly kids,who try the product, become addicted and die a premature death as a result. Prohibiting the sale of menthol cigarettes and other flavored tobacco products is an important step toward protecting our children from the tobacco industry's aggressive efforts to hook children to a deadly, addictive product. This issue is about protecting our kids, saving lives, and advancing health equity. Thank you for considering a strong and comprehensive policy without exemptions.This ordinance will save lives in Hawai'i. Sincerely, Liza Ryan Gill 3°HHS,"Tobacco Use Among US Racial/Ethnic Minority Groups—African Americans,American Indians and Alaskan Natives, Asian Americans and Pacific Islanders,and Hispanics:A Report of the Surgeon General,"1998;HHS,Reducing the Health Consequences of Smoking:25 Years of Progress:A Report of the Surgeon General,2014.See also Alexander,LA,et al.,"Why we must continue to investigate menthol's role in the African American smoking paradox,"Nicotine&Tobacco Research,18(S1): 591-5101,2016. 31 Mendez,D and Lee,TT,"Consequences of a match made in hell:the harm caused by menthol smoking to the African American population over 1980-2018,"Tobacco Control,published online September 16,2021. 32 Tobacco Products Scientific Advisory Committee(TPSAC),Menthol Cigarettes and Public Health:Review of the Scientific Evidence and Recommendations,July 21,2011 htto://www.fda.eov/downloads/AdvisorvCommittees/CommitteesMeetingMaterials/TobaccoProductsScientificAdvisorvCommittee /UCM269697.odf. CAMPAIGN ToBAco-FREE Kick Campaign for Tobacco-Free Kids, Hawaii