Key Findings

"State of Tobacco Control" 2021: Preventing and Reducing Tobacco Use During the Time of COVID-19

The 19th annual American Lung Association “State of Tobacco Control” report 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 COVID-19 pandemic was clearly the main story of 2020, causing hundreds of thousands of deaths and disrupting the lives of everyone in the country. The U.S. Surgeon General has conclusively linked smoking to suppression of the immune system, and smoking can cause more severe COVID-19 symptoms, according to the Centers for Disease Control and Prevention (CDC). With the threat of COVID-19 in addition to the numerous tobacco-caused diseases, it is imperative to prevent youth from starting to use tobacco and to help everyone quit.

Much like COVID-19 has a disproportionate impact on certain communities, especially communities of color, so does tobacco use and exposure to secondhand smoke. Menthol cigarettes remain a key vector for tobacco-related death and disease in Black communities, with over 80% of Black Americans who smoke using them. Menthol cigarette use is also elevated among LGBTQ+ Americans, pregnant women and persons with lower incomes. A recent study showed that while overall cigarette use declined by 26% over the past decade, 91% of that decline was due to non-menthol cigarettes.¹ This underscores what an FDA scientific advisory committee already found:² menthol cigarettes are hard to quit, and that disproportionately affects Black communities.³ In addition, secondhand smoke exposure also occurs most often in hospitality establishments such as bars and casinos where people from Black and Brown communities more often work.⁴

Menthol in cigarettes plays a significant role in youth becoming addicted to cigarettes, masking the harsh taste of tobacco smoke and making the smoke easier to inhale. Menthol cigarettes, which are disproportionately used by Black persons who smoke, are also more difficult to quit.

The public policies called for in “State of Tobacco Control” can play an important role in helping achieve health equity in tobacco control by providing equal protection from exposure to secondhand smoke and ending predatory tobacco industry marketing practices in all communities. Prohibiting the sale of all flavored tobacco products, including menthol cigarettes and eliminating smoking in all public places and workplaces, including bars and casinos are particularly important to accomplish these goals. Unfortunately, 2020 came and went, and once again the U.S. Food and Drug Administration (FDA) did not act to remove all flavored tobacco products from the marketplace.

In a major step forward for public health, the U.S. House of Representatives took important action in February 2020, passing legislation to prohibit the sale of all flavored tobacco products. However, the Senate did not take up the bill during the remainder of 2020.

Removing all flavored tobacco products is one of the top tobacco control priorities for the American Lung Association. In response, the Lung Association introduced a new state grade for flavored tobacco products to “State of Tobacco Control” 2021. This new category replaces the state Tobacco 21 grade, which became a nationwide law in 2019. The other four state grades, Tobacco Control Program Funding, Smokefree Air, Tobacco Taxes and Access to Cessation Services, remain.

Action to end the sale of flavored products occurred at the state level in 2020 with California passing legislation prohibiting the sale of most flavored products, including menthol cigarettes. Once again, no state has passed a comprehensive smokefree law since 2012.

The American Lung Association’s 12-Point Plan to End the Tobacco Epidemic

“State of Tobacco Control” 2021 report makes clear that it is critical for states, communities and the federal government to do more to decrease tobacco use and save lives. To supplement and simplify the key actions needed by federal, state and local policymakers to accomplish this, the American Lung Association released its 12-point advocacy plan to end the tobacco epidemic in November 2019. Implementation of these key actions would lead to drastically lower rates of tobacco use, and the many lung diseases it causes or makes worse.

The Biden Administration Has a Golden Opportunity to Act on COVID-19 and Future Pandemics; Take Action on Policies Called for in “State of Tobacco Control”

The lack of investment in public health infrastructure adversely impacted the United States’ response to COVID-19. 2020 has made clear that federal and state governments need to be better prepared to deal with infectious disease pandemics, and other public health threats including tobacco.  

Tobacco remains the leading cause of preventable death and disease in America, killing 480,000 people each year. In addition, 16 million Americans live with a tobacco-related disease.⁵

This provides the Biden Administration a golden opportunity to restore our nation’s public health infrastructure and increase investments in public health. It is critical that the new administration take important actions that remain unfinished from the past two administrations. At the top of the list in 2021 is ensuring FDA correctly implements and enforces pre-market tobacco product authorization (PMTA) requirements for all tobacco products, including e-cigarettes.

As the result of a lawsuit filed by the American Lung Association and several public health partners, FDA was ordered by a federal district court judge to follow the Family Smoking Prevention and Tobacco Control Act and require tobacco product manufacturers submit PMTA applications to FDA by September 9, 2020. The products for which manufacturers submitted applications are allowed to remain on the market for up to a year while FDA reviews them. Ultimately, the PMTA process provides an important opportunity to FDA to remove products from the marketplace that are not appropriate for the protection of the public health. 

The Lung Association and several partners issued a set of principles for FDA to consider as it reviews these PMTA applications. Of particular importance is the recommendation that no flavored tobacco product be given a PMTA and allowed to remain on the market. Flavors are a key driver of youth tobacco use, and therefore cannot meet the public health standard that the law requires.

Another lawsuit filed by the Lung Association and its partners, resulted in FDA issuing the final graphic warning labels for cigarette packs on March 15, 2020. However, the tobacco industry quickly filed multiple lawsuits in Texas and Washington, D.C., seeking to stop the warnings from being implemented. The warnings are now on hold until resolution of these court cases. The Lung Association urges the Biden Administration to vigorously defend these warnings, which will increase awareness and knowledge of the dangers of tobacco products.

Finally, in 2020, FDA authorized several “modified risk” tobacco products, including Philip Morris International’s product IQOS, marketed in the U.S. by Altria. During FDA’s deliberation on whether to approve the IQOS application, Altria failed to present evidence on how the proposed modified risk claims would impact youth uptake of the product – a key requirement of the Tobacco Control Act.  Despite this, FDA authorized Altria to make a modified exposure claim, allowing the company to say IQOS reduces exposure to dangerous chemicals and hazards as compared to cigarettes.

Youth Tobacco Use including Vaping Declines in 2020; But Kids Follow the Flavors

Youth vaping registered a promising decline in 2020 after two years of massive increases moving from 27.5% in 2019 to 19.6% among high school students and from 10.5% to 4.7% among middle school students, according to data from CDC’s 2020 National Youth Tobacco Survey (NYTS).⁶ The decline may be due to the removal of most of Juul’s flavors in 2019, and the attention paid to youth vaping after the declaration of an epidemic by the Surgeon General. However, nearly 3.6 million middle and high school students still use e-cigarettes, an increase of 68% from three years ago.⁷  Due largely to the decline in youth vaping, overall tobacco use among high school students declined from 31.2% in 2019 to 23.7% in 2020.⁸

The changes in youth vaping over the past year reveal that kids will follow the flavors that are available to them.  The Trump Administration’s January 2020 flavored e-cigarette guidance was inadequate as it left menthol flavored e-cigarettes (including JUUL), all disposable flavored products (including Puff Bar), and any flavored product sold in vape stores on the market. Not surprisingly, the NYTS data show that these flavored e-cigarettes saw the biggest increases in use by teens in 2020.

The NYTS 2020 survey revealed that teens made several notable changes in how they used e-cigarettes in 2020. Disposable e-cigarette use skyrocketed by 1,000% among high school e-cigarette users (from 2.4% to 26.5%) and 400% among middle school e-cigarette users (from 3% to 15.2%). Flavored e-cigarette use among current e-cigarette users also increased from 71.7% to over 82.9% among high school students and from 59.9% to 73.9% among middle school students. In addition, higher levels of menthol e-cigarette use were observed with 37% of high school students and 23.5% of middle school students using menthol flavored products.⁹ The percentage was even higher among kids who used cartridge-based e-cigarettes.

To help address the continuing youth e-cigarette epidemic and achieve its mission focal point of reducing youth vaping to 15% by 2025, the American Lung Association launched its End the Youth Vaping Epidemic initiative on September 1, 2020. It is an integrated, multi-component campaign to support parents, schools and students. A major component of the campaign is the “Get Your Head Out of the Cloud” youth vaping awareness campaign from the American Lung Association and the Ad Council to provide parents with a discussion guide to address the dangers of vaping with their kids, while they’re still willing to listen.

Recent State Level Successes Provide a Blueprint for Newly Elected State Governments 

Political control of state legislatures largely stayed the same during the November 2020 elections. However, states should look to recent successes by states in 2020 as a blueprint for action, including:

• Increasing state tobacco taxes. Colorado and Oregon voters approved significant increases in their state cigarette taxes of $1.10 and $2.00 per pack respectively. In both cases, passage of these measures is expected to result in significant increases in funding for their state tobacco control programs too.
• Making More Workplaces Smokefree.  Across the country, more than 200 tribal and non-tribal casinos re-opened smokefree¹⁰ after being closed due to COVID-19. The Lung Association urges states and tribal casinos to make these changes permanent to protect their workers from secondhand smoke. Nebraska also passed legislation adding e-cigarettes to its state smokefree law.
• Expanding Medicaid and Tobacco Cessation Coverage. Missouri and Oklahoma voters approved ballot measures allowing Medicaid expansion to move forward in each state. This will result in the new enrollees in Medicaid having access to a comprehensive quit smoking benefit and other essential coverage. Ohio passed legislation requiring all state Medicaid plans to cover a comprehensive quit-smoking benefit, including all FDA-approved medications and counseling.

Pharmacists Prescribing Quit Smoking Treatments: While most health insurance plans cover tobacco cessation treatment without cost-sharing giving pharmacists the authority to prescribe or having a state standing order for tobacco cessation medications can make it easier for smokers to get the treatment they need to quit. While 13 states have laws that allow for pharmacists to prescribe or allowing a standing order, more states are looking at these policies to make it easier for smokers to quit.

• Prohibiting Flavored Tobacco Products, Including Menthol Cigarettes. California became the second state in the country to pass a law prohibiting the sale of most flavored tobacco products, including menthol cigarettes. However, days after the legislation was signed into law, the tobacco industry filed a referendum to overturn the law, which if enough signatures are collected will delay implementation until November 2022 at the earliest. The states of New York and New Jersey as well as the city of Chicago all passed laws prohibiting the sale of flavored e-cigarettes.
• Reducing the Availability, Accessibility and Discounting of Tobacco Products. New York became the second state to prohibit tobacco sales in all its pharmacies. New Jersey and New York became the first two states to eliminate the redemption of coupons and other tobacco industry discounts by retailers. In addition, Louisville, KY, passed an ordinance limiting where new retailers selling tobacco products can be located, including preventing them from being located near schools and other locations predominantly used by kids. These policies should be considered promising practices that the Lung Association urges states and local communities to adopt.

In 2021, given the budget deficits that many states will be facing due to COVID-19, the Lung Association expects that many state tobacco control programs will face potential cuts or even complete loss of state funding. However, given the clear linkages between smoking and more severe disease from COVID-19,¹¹ these programs are more important than ever to enable people to quit and prevent kids from starting. The Lung Association will actively encourage states to significantly increase tobacco taxes in 2021 as a way to prevent youth from starting, help smokers quit and provide much needed state revenues.

Overall Adult Tobacco Use Increases; More Action Needed to End Disparities in Tobacco Use

The recent decline in adult cigarette smoking rates stopped in 2019 remaining essentially flat compared to the previous year at 14%. Overall adult tobacco use registered an increase from 19.7% in 2018 to 20.8% in 2019. This means 50.6 million Americans currently use tobacco products.¹²

The adult tobacco use rate also masks significant disparities among races/ethnicities and due to socio-economic factors. Use of commercial tobacco products remains particularly high among Native Americans and Alaskan Natives at 29.3% and Lesbian, Gay and Bisexual adults at 29.9%.¹³ Adults with mental illness and substance abuse also endure significantly higher rates of smoking. According to the National Survey on Drug Use and Health:¹⁴

• Overall smoking rates among adults with any behavioral health condition in 2019 were 28.9% vs. 14.6% without a behavioral health condition.
• Among adults with a serious mental illness resulting in serious functional impairment the rate was 33.0% in 2019 vs. 17.3% among adults without a serious mental illness.
• Rates are even higher among adults with substance use disorders at 42.0% vs. 16.1% for adults without a substance use disorder. In addition, smoking has declined more rapidly over time among adults with mental illness than adults with a substance use disorder.

In addition, the recent overall decline in cigarette smoking rates has been due almost entirely to non-menthol cigarettes. Menthol cigarettes are predominantly used by Black Americans and disproportionately by pregnant women, youth and LGTBQ Americans.¹⁵ These disparities in menthol cigarette use are primarily the result of targeting by the tobacco industry.

These disparities in tobacco use highlight the importance of properly funding state tobacco control programs, which can bring additional attention and resources to alleviate these disparities and achieve health equity in tobacco control. People from disproportionately affected communities should be empowered to lead the effort to address these disparities, including providing funding to organizations that directly serve the communities. The Lung Association is encouraged that the Centers for Disease Control and Prevention’s Office on Smoking and Health put a high priority on addressing these tobacco use disparities and achieving health equity in tobacco control in its recent five year funding awards to states. Recognizing these federal funding awards are relatively small, it is now incumbent on states to invest their own funding to ensure funding investments at CDC-recommended levels.

Successes and Challenges in 2020 and What States and the Federal Government Need to do in 2021

States:

Overall, states still have a lot of work to do to put in place the proven policies called for in “State of Tobacco Control” that would help significantly reduce the 480,000 lives lost to tobacco each year. Due to states focusing almost entirely on the effects of COVID-19 in 2020, many states had less of a chance to pass the proven policies called for in the report, but 2021 presents opportunities for progress. In 2021, it is critical that states:   

• Increase Tobacco Taxes and Equalize Taxes Across All Tobacco Products – During 2020, Colorado and Oregon approved increases in their state cigarette taxes by an amount that has been shown to reduce tobacco use and initiation, over $1.00 per pack. Virginia also increased its cigarette tax in 2020, but by only 30 cents per pack, missing a golden opportunity to accelerate declines in smoking rates for adults and youth. The average state cigarette tax is now $1.88 per pack – with the District of Columbia having the highest cigarette tax ($4.50 per pack) and Missouri having the lowest (17 cents per pack). The District of Columbia was the only jurisdiction to earn an “A” grade in this category for having high tobacco taxes across most or all products.

Significantly increasing tobacco taxes is one of the most effective ways to reduce tobacco use, especially among youth. Bringing parity to (equalizing) tobacco taxes across all products, including cigars, little cigars and roll-your-own cigarettes, discourages initiation and eliminates any financial incentive for people to switch to a cheaper product, thereby encouraging people to quit tobacco entirely. In 2020, California, Maine, Utah, Vermont and Wyoming were the only states to have equalized taxes across all tobacco products, including e-cigarettes.

• Expand Comprehensive Cessation Coverage – Nicotine addiction is a serious disease, regardless of what tobacco product is being used. Data shows while nearly seven out of 10 smokers want to quit, only 10% quit successfully in the past year.¹⁷ In 2020, Ohio passed legislation requiring all Medicaid plans in the state and the state employee health plan to cover a comprehensive quit smoking benefit, including all seven FDA-approved quit smoking medications and three forms of counseling. Also in 2020, voters in Oklahoma and Missouri voted to expand Medicaid to 138% of the federal poverty level or just under $30,000 per year for a family of three. This expansion of coverage will help thousands of low-income Americans access cessation. 

Currently, 13 states have a comprehensive tobacco cessation benefit for all standard Medicaid enrollees, covering all seven tobacco cessation medications and all three forms of counseling to help smokers quit. However, states should ensure that both standard Medicaid and Medicaid expansion programs offer comprehensive quit smoking coverage without barriers such as copays, prior authorization or stepped therapy (where a patient must try and fail with one product before using others). For example, there are six states that allow all Medicaid enrollees to have two quit attempts per year, for at least 90 days each, without any additional barriers. All other states are more restrictive with other barriers or have fewer or shorter quit attempts. 

As a result of the COVID-19 pandemic, many healthcare providers and patients turned to telehealth to continue needed medical treatment, while limiting in-person interactions; states and the federal government have made temporary changes to make it easier for providers to help smokers quit through telehealth. States and the federal government should work to ensure tobacco cessation via telehealth is made permanent.

Medicaid covers some of the most vulnerable groups in society including poor families, low-income pregnant women and people with disabilities. Medicaid enrollees smoke at a higher rate than the general population (24.9% vs. 10.7%).¹⁸ Additionally, Medicaid is the largest single payer for behavioral health services in the United States.¹⁹

• Increase Funding for Tobacco Control Programs and Focus These Programs on Disproportionately Affected Populations – During 2020, five states – Florida, Hawaii, Illinois, Maine and Utah saw significant increases in tobacco control program funding of $1 million or more, and passage of tobacco tax increases in Colorado and Oregon should result in increases in future years. However, several states also saw cuts in funding, including Kentucky by $1 million, Wyoming by $1.5 million and Tennessee re-directing all of its state funding. Alaska, Maine and Utah earned “A” grades in the report for funding their programs at or close to CDC-recommended levels.

Connecticut and Tennessee were the only states that provided no state funding at all for tobacco prevention and quit smoking programs, severely hampering their state’s ability to respond to the youth vaping epidemic and tobacco use disparities. The total amount spent by states on tobacco prevention and cessation in fiscal year 2021 is $668 million, less than three cents of every dollar of the close to $26.9 billion states collected from tobacco settlement payments and tobacco taxes in fiscal year 2021.

• The Remaining 22 States Pass Comprehensive Smokefree Laws – No new states approved comprehensive laws prohibiting smoking in all public places and workplaces in 2020, continuing the disturbing lack of state progress since 2012. Nebraska added e-cigarettes to its comprehensive smokefree law, in total 16 states and DC have taken this important step. In addition, more than 200 tribal and non-tribal casinos have re-opened smokefree²⁰ after being closed due to COVID-19 either voluntarily or being required to do so by executive order or state gaming control boards.

Smokefree Casinos: In 2020, casinos around the country have adopted new smokefree policies as they reopen after the COVID-19 closing this spring. Smoking requires people to remove masks, making it an unnecessary risk. The Lung Association is encouraged by this trend and is hopeful it will continue into 2021.

Secondhand smoke is a serious health hazard causing or making worse many diseases and conditions, including lung cancer, heart disease, stroke and asthma. It causes over 41,000 deaths per year.²⁰ While many workplaces in the 22 states that have not yet passed comprehensive laws are smokefree, people working in the hospitality (i.e., restaurants, bars and gaming establishments) and manufacturing sectors may be and often are exposed to secondhand smoke at work daily. Certain racial/ethnic groups are disproportionately represented in the hospitality sector and are therefore more likely to be exposed to secondhand smoke.²²

• Pass Laws Prohibiting the Sale of all Flavored Tobacco Products – During 2020, California became the second state to pass a law eliminating the sale of most flavored tobacco products, including menthol cigarettes. New Jersey and New York also passed laws prohibiting the sale of all flavored e-cigarettes, and Rhode Island implemented a permanent rule doing the same. This year’s “State of Tobacco Control” report features a new state grade on flavored tobacco products, and Massachusetts was the only state to earn an “A” grade in the category.

Flavors are one of the main reasons kids use tobacco products and have played a big role in the youth vaping epidemic the country is currently experiencing. The 2020 National Youth Tobacco Survey found that over 80% of kids who use e-cigarettes use a flavored product, including high rates of use of fruit, mint and menthol flavors.²³ In addition, over half of youth cigarette smokers start their use by smoking menthol cigarettes.²⁴

Federal Government:
Another year has passed, and we have yet to see meaningful FDA action on a variety of fronts, including flavored tobacco products and a product standard reducing nicotine levels in tobacco products. The September 9, 2020 date for e-cigarettes and certain other tobacco products to submit their pre-market tobacco authorizations (PMTA) to FDA has passed and we await action by FDA to take non-compliant products off the market.

In November 2020, the American Lung Association issued its 2021 Federal Action Plan, which outlines our tobacco control priorities for the federal government.

“State of Tobacco Control” 2021 provides a blueprint that states, and the federal government can follow to put in place proven policies that will have the greatest impact on reducing tobacco use and exposure to secondhand smoke in the U.S. The real question is: Will the Biden Administration and state lawmakers seize this opportunity and make 2021 the year significant progress is made in passing meaningful tobacco control policies, including addressing tobacco-related health disparities?