The youth vaping epidemic showed no signs of abating in 2019 with high school e-cigarette use increasing by a staggering 135% over the past two years. Important steps forward were taken to address this public health challenge in 2019 such as increasing the tobacco sales age to 21 – first in many states and then nationwide – but overall the country failed to do what was necessary to avert the crisis. This year’s “State of Tobacco Control” report poses an urgent question for the country, will 2020 be the year that lawmakers prioritize public health over the tobacco industry?

Report Overview

“State of Tobacco Control” 2020: Will 2020 Be the Year the Federal Government, States and Communities Pass Meaningful Tobacco Control Policies and Prioritize Public Health over the Tobacco Industry?

The 18th 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 youth e-cigarette or vaping epidemic showed no signs of abating in 2019 after the extremely troubling 78% rise in high school e-cigarette use and 48% rise in middle school e-cigarette use from 2017 to 2018.1 High school e-cigarette use continued its dramatic rise in 2019 to 27.5% and middle school use was at 10.5% in 2019. Overall, about 6.2 million middle and high school students now currently use tobacco products, an increase of close to three million kids in just the past two years.2 Almost all of that increase is due to youth use of e-cigarettes.

The dramatic rise in youth e-cigarette/tobacco use over the past two years, is a real-world demonstration of the failure of the U.S. Food and Drug Administration (FDA) to properly oversee all tobacco products, especially e-cigarettes. In particular, the delay by FDA in reviewing products, including e-cigarettes and cigars, over which they asserted authority under the 2016 “deeming” rule played a big part in the problems the country is experiencing now. This failure places the lung health and lives of Americans at risk.

In addition, the country faced a second crisis: the emergence of E-cigarette, or Vaping, Product Use Associated Lung Injury (EVALI), which has resulted in dozens of deaths and thousands of injuries caused by vaping. Large numbers of the illnesses were among youth and young adults, which makes them particularly alarming. According to the Centers for Disease Control and Prevention (CDC), one chemical of concern and likely cause of the outbreak is Vitamin E acetate, a chemical used in THC/marijuana vaping products. Additional chemicals or ingredients causing lung injuries, including in nicotine-containing products have not been ruled out.

However, 2020 could and must be the year the health of our nation is prioritized over the tobacco industry. As the result of lawsuits filed by the American Lung Association and several public health partners, FDA will be required by a federal district court judge to review all tobacco products introduced to the market after February 15, 2007. Originally supposed to have happened in 2018, this review is now required to happen by May 12, 2020 — assuming no further delays in the legal process. This would provide another opportunity for FDA to remove products from the market that do not meet FDA’s public health standard.

Graphic warning labels will also appear on cigarette packs by June 2021 as the result of another lawsuit against FDA won by the Lung Association and partners. A proposed rule with new graphic warning labels was issued by FDA in August 2019, and a final rule is required to be in place by March 15, 2020.

The Trump Administration failed to prioritize public health over the tobacco industry with its January 2, 2020 announcement that will leave thousands of flavored e-cigarettes on the market. This was a dramatic reversal of the Administration’s September 2019 announcement that it would “clear the market” of all flavored e-cigarettes, prohibiting their sale unless and until they can meet FDA’s public health standard. Instead, they issued a substantially weaker version that leaves menthol flavored e-cigarettes and the thousands of non-closed pod flavored products, including any product sold in vape shops on the market. According to results from the CDC’s 2019 National Youth Tobacco Survey, among high school students who used only e-cigarettes, over 72% used flavored e-cigarettes, including 66% who used fruit flavors and over 57% used mint and menthol flavors in 2019.4 These data demonstrate how shortsighted the Trump Administration’s unfortunate decision was.

In what could only be described as unimaginable even two years ago, in December 2019, Congress passed bipartisan legislation to raise the minimum age of sale for tobacco products to 21. This legislation took effect in December 2019. The Lung Association urged Congress to do much more to address youth tobacco use by including a prohibition on all flavored tobacco products, a prohibition of online sales and codifying the May 2020 court-ordered deadline for premarket review applications to be filed with FDA. Congress failed to move forward with these items.

House Energy and Commerce Committee Chairman Frank Pallone (NJ) introduced the Reversing the Youth Tobacco Epidemic Act in 2019, separate legislation from the Tobacco 21 legislation that passed Congress in December. This legislation offered a comprehensive solution to the youth tobacco use crisis by prohibiting the sale of all flavored tobacco products and stopping the online sale of all tobacco products, in addition to increasing the tobacco sales age to 21. This measure passed out of the House Energy and Commerce Committee but did not reach the full House of Representatives for a vote in 2019.

In the absence of strong federal action, the state of Massachusetts is leading the way in putting the health of its citizens ahead of the tobacco industry by becoming the first state to prohibit the sale of all flavored tobacco products, including e-cigarettes and menthol cigarettes. The legislation that passed in November of 2019 contained several other strong provisions as well, including a 75% of the wholesale price tax on e-cigarettes, equivalent to the tax on cigarettes.

What the “State of Tobacco Control” 2020 report makes clear is that more needs to be done by states, communities and the federal government to stop the increase in youth tobacco use brought on by the youth e-cigarette use epidemic. Sadly, the U.S. may have squandered a golden opportunity to make the current generation of kids the first tobacco-free generation. The country must redouble its efforts for the sake of future generations.

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

The Lung Association’s “State of Tobacco Control” report has for the past 18 years offered policymakers a road map of the public policies needed to prevent and reduce tobacco use. 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 plan for ending the tobacco epidemic. Implementation of these key actions would lead to drastically lower rates of tobacco use, and the many lung diseases it causes or makes worse.

Tobacco 21 Laws Go Nationwide

2019 saw a massive increase in the number of states passing laws to increase their age of sale for tobacco products to 21 or Tobacco 21 laws. As of January 1, 2020, 19 states and the District of Columbia passed Tobacco 21 laws. This is an increase from only six states and DC at the beginning of 2019. However, several of the state laws passed in 2019, including in Arkansas, Texas and Virginia had provisions that will make them less effective in preventing and reduce tobacco use. These provisions were often pushed for by the tobacco industry and their allies.

Tobacco 21 legislation was also introduced in both houses of Congress and importantly passed into law as part of a year-end funding package signed into law in December 2019. This is remarkable progress on an issue that saw the first state, Hawaii, pass this important policy to prevent youth tobacco use just four short years ago in 2015.

However, to truly end the tobacco epidemic in this country, all the public policies called for in the Lung Association’s “State of Tobacco Control” report and in the Lung Association’s 12-point plan to end the tobacco epidemic need to be put in place. Much has been made of the tobacco industry switching from opposing to supporting Tobacco 21 laws, but it is a strategic and public relations choice by them with a goal to forestall action in other areas such as increased tobacco taxes or prohibiting flavored tobacco products. And at the state level, the tobacco industry is also supporting preemptive provisions in these laws that would prevent local action on other tobacco sales laws.

More Action by FDA Still Needed

FDA has full authority over the manufacture, marketing and sale of tobacco products in the U.S. under a law passed by Congress in 2009 and through its 2016 “deeming” rule. However, in many cases over the past two administrations, the agency has failed to implement the law and use its comprehensive authority to put meaningful restrictions on tobacco products, including e-cigarettes, in place. This lack of action continued to earn the federal government an “F” grade for FDA Regulation of Tobacco Products in the 2019 “State of Tobacco Control” report.

One clear consequence of FDA’s inaction has been the meteoric rise in the use of JUUL, an e-cigarette that looks like a USB flash drive, which contains high amounts of nicotine, comes in several kid-friendly flavors (sale of all flavors except menthol are suspended currently) and is particularly popular with youth and young adults. The product also manipulated the chemistry of nicotine making it easier to inhale and acts faster, potentially making addiction easier,5 according to the U.S. Surgeon General. JUUL has claimed the largest share of the overall e-cigarette market6 in a very short time period and has inspired a number of other companies to create similar types of e-cigarettes.

FDA is being compelled, as the result of court decisions, to move forward with its review of tobacco products that it asserted authority over in 2016 such as cigars and e-cigarettes, and to put graphic warning labels on cigarettes. However, given the scale of flavored tobacco product use among youth, one major item that must be on FDA’s agenda is to remove all flavored tobacco products, including mint and menthol from the marketplace. The Trump Administration put forward a proposal to clear the market of all flavored e-cigarettes in September 2019, but bowing to tobacco industry pressure, announced a substantially weaker proposal on January 2, 2020 that leaves thousands of flavored e-cigarettes on the market. Congress also missed an opportunity to act on flavored tobacco products as part of legislation passed in December 2019.

Research shows that 97% of current youth e-cigarette users used a flavored product in the past month, and 70% cite flavors as a key reason for their use.7 More broadly, an article released by the Centers for Disease and Control and Prevention (CDC) in October 2019 showed that 64% of high school students who used tobacco products used a flavored product in the past 30 days in 2018.8 Menthol in cigarettes also plays a significant role in youth becoming addicted to cigarettes, masking the harsh taste of tobacco smoke and making the poison go down easier. Menthol cigarettes are also disproportionately used by African-Americans and make it more difficult to quit smoking.

In 2019, FDA’s nationwide media campaign, “The Real Cost,” focused on reducing e-cigarette use among youth ages 12-17 and was expanded to appear on TV further increasing its reach.

Surgeon General Spotlights Importance of Quitting Smoking

On January 23, 2020, U.S. Surgeon General Jerome Adams released a new report on tobacco, “Smoking Cessation: A Report of the Surgeon General,” highlighting and making new conclusions about quitting smoking and the health benefits of quitting. Major report conclusions include:

  • Insurance coverage for smoking cessation that is comprehensive, barrier-free and widely promoted increases the use of these treatments, leads to higher rates of quitting and is cost effective; and
  • Smoking cessation can be increased by raising the price of cigarettes, adopting comprehensive smokefree policies, implementing mass media campaigns, requiring pictorial health warnings and maintaining comprehensive statewide tobacco control programs.9

All of the public policies shown to increase smoking cessation in the Surgeon General’s report are called for in “State of Tobacco Control.”

One policy that could have a big impact on increasing insurance coverage and therefore quitting smoking is expanding the Medicaid program under the Affordable Care Act to 138% of the federal poverty level, which has already provided healthcare to millions of Americans. Several studies released this year have reinforced how important having healthcare is to quitting smoking. One notable study showed Medicaid enrollees in Medicaid expansion states are utilizing tobacco cessation treatment at a higher rate than their peers in non-expansion states.10

More Positive News

Despite the very negative news regarding youth use of e-cigarettes, through the implementation of policies that the Lung Association has long-called for in “State of Tobacco Control,” adult and youth cigarette smoking rates are at an all-time low, with 5.8% of high school students11 and 13.7% of adults smoking cigarettes.12 This is the lowest adult cigarette smoking rate ever recorded in CDC’s National Health Interview Survey.13

2019 also saw several important actions taken by states and the federal government to curb tobacco use and exposure to secondhand smoke:

  • California, Illinois, Maine and Nevada saw significant increases in funding for their state tobacco prevention and control programs in fiscal year 2020. Maine now funds its program near CDC-recommended levels making it one of only three states to earn an “A” grade in “State of Tobacco Control.”
  • Illinois approved a significant increase in its state cigarette tax of a $1.00 per pack. Maine equalized its tax on tobacco products, including e-cigarettes with its tax on cigarettes, and Vermont added e-cigarettes to its tax on other tobacco products.
  • Colorado and New Mexico closed several loopholes in their state smokefree workplace laws along with adding e-cigarettes to their laws. Minnesota and South Dakota also added e-cigarettes to their smokefree laws.
  • Arkansas passed legislation requiring state Medicaid plans to cover all FDA-approved tobacco cessation medications.
  • Massachusetts became the first state in the country to pass a law prohibiting the sale of all flavored tobacco products, including menthol, despite intense and well-funded tobacco industry opposition. Several larger jurisdictions, including Los Angeles County also passed comprehensive flavored tobacco laws.
  • The Centers for Disease Control and Prevention (CDC)’s Office on Smoking and Health received a much needed $20 million increase in funding to help fight the youth e-cigarette use epidemic in the fiscal year 2020 federal budget.
2019 State Trends and 2020 State Opportunities

Successes and Challenges in 2019 and What States Need to Do in 2020

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. States made notable progress on Tobacco 21 laws this year, but policies beyond those that restrict access to tobacco must be prioritized.

  • States Must Increase Tobacco Taxes and Equalize Taxes Across All Tobacco Products — During 2019, Illinois was the only state to increase its cigarette tax by an amount that has been shown to reduce tobacco use and initiation, $1.00 per pack. New Mexico also increased its cigarette tax in 2019, but by only 34 cents per pack, missing a golden opportunity to accelerate declines in smoking rates for adults and youth. The average state cigarette tax is now $1.81 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).

    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, discourages initiation and eliminates any financial incentive for people to switch to a cheap product, thereby encouraging people to quit tobacco entirely. In 2019, Maine and Vermont joined California as the only states to have equalized taxes across all tobacco products, including e-cigarettes.
  • States Must Expand Comprehensive Cessation Coverage in All Medicaid Programs — Smoking is a serious addiction, and while nearly seven out of 10 smokers want to quit, only 10% quit successfully in the past year.14 During 2019, Arkansas passed legislation requiring all Medicaid plans in the state to cover all seven FDA-approved quit smoking medications. Currently, 12 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, 49 states still have barriers for Medicaid enrollees to access this treatment. States must 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).
  • States Must Increase Funding for Tobacco Control Programs and Focus These Programs on At-Risk Populations — During 2019, Maine saw a close to $7 million increase in funding for its state tobacco prevention program in fiscal year 2020 as the result of an increase in the state budget and revenue from an increase in taxes on other tobacco products. California also saw a large increase in tobacco control program funding due to tobacco tax revenues coming in higher than expected. Alaska, California and Maine all earned “A” grades in the report for funding their programs at close to CDC-recommended levels.

    In addition, Florida, Illinois, and Nevada all saw $1 million or more increases in funding to tobacco prevention programs in fiscal year 2020. Tennessee and West Virginia also allocated $2 million and $500,000 respectively to their tobacco prevention programs this year after providing no state funding last year. Connecticut was the only state that provided no state funding at all for tobacco prevention and quit smoking programs, severely hampering the state’s ability to respond to large increases in youth tobacco use. The total amount spent by states on tobacco prevention and cessation is over $746.2 million, less than three cents of every dollar of close to $27.2 billion states collect from tobacco settlement payments and tobacco taxes.
  • The Remaining 22 States Must Pass Comprehensive Smokefree Laws — No additional states approved comprehensive laws prohibiting smoking in all public places and workplaces in 2019, continuing the disturbing lack of progress at the state level on passage of these laws since 2012. Colorado and New Mexico closed several smaller loopholes in their already comprehensive statewide smokefree laws, in addition to adding e-cigarettes to their laws. However, Colorado then turned around and created a new loophole in its smokefree law for so-called “marijuana hospitality establishments.” Minnesota and South Dakota also added e-cigarettes to their comprehensive smokefree laws, and Florida passed legislation adding e-cigarettes to its current secondhand smoke protections as required by a constitutional amendment approved by voters in November 2018. At the local level, the city of Atlanta approved a comprehensive smokefree law, one of the last major U.S. cities not to have such a law in the country.

    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.18 Since 2006, the U.S. Surgeon General has concluded that there is no safe level of exposure to secondhand smoke. 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.19
  • States and Communities Should Pass Laws Prohibiting the Sale of all Flavored Tobacco Products — During 2019, Massachusetts became the first state to pass a comprehensive law eliminating the sale of all flavored tobacco products, and communities in California, Colorado, Minnesota and New York also passed laws. Governors in nine states starting with Michigan Gov. Gretchen Whitmer in September 2019 used their executive authority to temporarily prohibit or restrict the sale of flavored or all e-cigarettes. As of December 2019, eight of these states had been sued by the e-cigarette industry, and the prohibitions in five were on hold.

    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. Research shows that 81% of kids who have ever used tobacco products started with a flavored product, including 81% who have ever tried e-cigarettes and 65% who have ever tried cigars. Youth also cite flavors as a major reason for their current use of non-cigarette tobacco products, with 81.5% of youth e-cigarette users and 73.8% of youth cigar users saying they used the product "because they come in flavors I like.20
2019 Federal Trends and 2020 Federal Opportunities

Successes and Challenges in 2019 and What the Federal Government Needs to Do in 2020

Will 2020 be the year that FDA finally takes several steps forward in providing meaningful oversight over all tobacco products? Due to court decisions, FDA is scheduled to proceed with reviewing all newly deemed tobacco products, including e-cigarettes, cigars, pipe tobacco and hookah, that entered the market after February 15, 2007. FDA has also been required by a federal court to issue a final rule by March 15 that will require graphic warning labels to appear by June 2021 on 50% of the front and back of all cigarette packs. The Trump Administration squandered a golden opportunity to “clear the market” of all flavored e-cigarettes during 2019. Congress passed important legislation to increase the tobacco sales age to 21 nationwide but missed an opportunity to do more in 2019 to address the youth tobacco use epidemic.

  • FDA Must Fully Implement the Deeming Rule — Due to a successful lawsuit by the American Lung Association and its public health partners, barring any additional legal delays, FDA must require all manufacturers to submit product applications by May 2020 to remain on the market. The dramatic increase in rates of youth e-cigarette use from 2017 to 2019, with over five million kids now using e-cigarettes,21 makes this overdue review even more critical.
  • FDA Must Move Forward with Graphic Warning Labels on Cigarettes — In August 2018, a U.S. District Court judge ruled FDA unreasonably delayed finalizing a new rule requiring graphic warning labels on cigarettes. Under the approved timeline as part of the judge’s order, FDA issued a proposed rule with new graphic warning labels on August 15, 2019 and is scheduled to issue a final rule on March 15, 2020. The lawsuit compelling FDA to act was filed by the American Lung Association and other public health groups.

    FDA previously met a Tobacco Control Act-mandated timeline of 2011 by finalizing a rule requiring graphic warning labels on 50% of the front and back of cigarette packs. However, after the cigarette companies sued FDA and a judge sided with the industry and tossed out the specific warnings in 2012, FDA failed to move forward with proposing new graphic warning labels, despite it being required by law. The lawsuit compelling FDA to act was filed by the American Lung Association and other public health groups, aimed at forcing action by FDA on this important public policy, which could have a substantial impact on smoking rates.
  • The Trump Administration and Congress Must Remove All Flavored Tobacco Products, Including Menthol Cigarettes, from the Marketplace — The Trump Administration and Congress failed to address flavored tobacco products, one of the main drivers of the youth e-cigarette epidemic, despite several opportunities to do so. Flavors in all tobacco products play a key role in hooking our kids on tobacco, and a product standard by FDA eliminating all flavored tobacco products, including all e-cigarettes and menthol cigarettes is still desperately needed.

    House Energy and Commerce Committee Chairman Frank Pallone’s “Reversing the Youth Tobacco Epidemic Act of 2019” that would prohibit all flavored tobacco products also remains alive and should receive a vote in the House in 2020. The bill also takes other important steps to reduce youth tobacco use, including severely restricting online sales of all tobacco products. A Senate companion was introduced in early January by Senator Sherrod Brown (OH).
  • Federal Government Must Do More to Help Smokers Quit — U.S. Surgeon General Jerome Adams issued an important report “Smoking Cessation: A Report of the Surgeon General,” on January 23, 2020 exploring the trends and science behind and emphasizing the health benefits that accrue to people from quitting smoking. It also detailed tobacco control policies that can impact a person’s ability to quit smoking, which include virtually all of the policies evaluated in “State of Tobacco Control.” Increased access to tobacco cessation as part of insurance coverage was one important policy recommended in the report.

    Recognizing the importance of a comprehensive tobacco cessation benefit, the Office of Management and Budget (OMB), in their 2019 Federal Employee Health Benefits Carrier Call letter, is requiring a comprehensive cessation benefit with no barriers. OMB is also asking carriers to ensure all tobacco users, including e-cigarette users, have access to the benefit and that the benefit is promoted to enrollees to help smokers quit.

    Despite an ongoing federal court case regarding the constitutionality of the Affordable Care Act, key quit smoking policies required in the Affordable Care Act remain in effect while the case makes its way through the courts. However, the Administration put forward new rules that expand “skimpy” plans that are not required to cover quit smoking treatments. The U.S. Department of Health and Human Services has also approved a tobacco surcharge for Medicaid enrollees who smoke in Indiana and Wisconsin. The American Lung Association opposes tobacco surcharges as there is no evidence that they help smokers quit.
  • CDC and FDA Must Continue Their Successful and Cost-Effective Mass Media Campaigns — The fiscal year 2020 spending bill for CDC’s Office on Smoking and Health approved by the House of Representatives and Senate provided a much-needed $20 million increase in funding for CDC’s Office on Smoking and Health. This will allow the office to continue its “Tips From Former Smokers” campaign, a highly effective media campaign that features stories of people living with smoking-related diseases. It will also enable more activity by CDC and states on addressing the youth e-cigarette epidemic.

    In September 2018, FDA launched an extension of its “The Real Cost” media campaign to address the risks of youth use of e-cigarettes, targeting youth ages 12-17 who have used e-cigarettes or are open to trying them. And in 2019, FDA expanded the reach of this campaign by placing some of the ads on TV, a move the American Lung Association wholeheartedly supported. Given e-cigarettes are now at “epidemic” levels among high school youth at 27.5% in 2019 and the rise of JUUL, it is critical that this media campaign be maintained and expanded.23
  • Congress Must Increase Taxes on All Tobacco Products — The federal government has not increased taxes on cigarettes and other tobacco products since 2009 and is long overdue for a significant increase. The $0.62 increase in 2009 had a significant impact on smoking rates and increasing tobacco taxes is one of the most significant actions Congress could take to prevent and reduce tobacco use. Equalizing taxes between cigarettes and other tobacco products is also important to help tobacco users quit for good. For the first time in 2019, multiple bills were introduced in Congress that would tax e-cigarettes.

“State of Tobacco Control” 2020 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 lawmakers seize this opportunity and make 2020 the year the federal government, states and communities pass meaningful tobacco control policies and prioritize public health over the tobacco industry?

Sources

  1. Centers for Disease Control and Prevention. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students—United States, 2011–2018. Morbidity and Mortality Weekly Report. Nov. 16, 2018; 67(45):1276-1277.
  2. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019. MMWR Surveill Summ 2019;68(No. SS-12):1–22.
  3. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA, 2014.
  4. Cullen KA, Gentzke AS, Sawdey MD et al. E-Cigarette Use Among Youth in the United States, 2019. JAMA. Published online November 5, 2019. doi:https://doi.org/10.1001/jama.2019.18387.
  5. U.S. Department of Health and Human Services. Surgeon General’s Advisory on E-Cigarette Use Among Youth. Atlanta, GA, Dec. 2018.
  6. King BA, Gammon DG, Marynak KL, Rogers T. Electronic Cigarette Sales in the United States, 2013-2017. JAMA. 2018;320(13):1379-1380; see also U.S. Department of Health and Human Services. Surgeon General’s Advisory on E-Cigarette Use Among Youth. Atlanta, GA, Dec. 2018.
  7. Ambrose, BK, et al., Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014, JAMA, published online October 26, 2015.
  8. Cullen KA, Liu ST, Bernat JK, et al. Flavored Tobacco Product Use Among Middle and High School Students — United States, 2014–2018. MMWR Morb Mortal Wkly Rep 2019;68:839–844. DOI: http://dx.doi.org/10.15585/mmwr.mm6839a2.
  9. U.S. Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General— Executive Summary. 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, 2020 https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.
  10. Maclean, J. C., Pesko, M. F. and Hill, S. C. (2019), Public Insurance Expansions and Smoking Cessation Medications. Econ Inq, 57: 1798-1820. doi:10.1111/ecin.12794.
  11. Cullen KA, Gentzke AS, Sawdey MD et al. E-Cigarette Use Among Youth in the United States, 2019. JAMA. Published online November 5, 2019. doi:https://doi.org/10.1001/jama.2019.18387
  12. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults — United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68:1013–1019. DOI: http://dx.doi.org/10.15585/mmwr.mm6845a2external icon
  13. Ibid.
  14. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults — United States, 2000–2015. MMWR Morb Mortal Wkly Rep 2017;65:1457–1464.
  15. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults — United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68:1013–1019. 
  16. Centers for Medicare and Medicaid Services. Medicaid.gov, Behavioral Health Services. Available at: https://www.medicaid.gov/medicaid/benefits/bhs/index.html
  17. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2017. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  18. U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA, 2014.
  19. U.S. Bureau of Labor Statistics. BLS Reports. Labor force characteristics by race and ethnicity, 2015. September 2016; Report 1062. https://www.bls.gov/opub/reports/race-and-ethnicity/2015/home.htm
  20. 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.
  21. Wang TW, Gentzke AS, Creamer MR, et al. Tobacco Product Use and Associated Factors Among Middle and High School Students — United States, 2019. MMWR Surveill Summ 2019;68(No. SS-12):1–22.
  22. Maclean, J. C., Pesko, M. F. and Hill, S. C. (2019), Public Insurance Expansions and Smoking Cessation Medications. Econ Inq, 57: 1798-1820. doi:10.1111/ecin.12794.
  23. Cullen KA, Gentzke AS, Sawdey MD et al. E-Cigarette Use Among Youth in the United States, 2019. JAMA. Published online November 5, 2019. doi:https://doi.org/10.1001/jama.2019.18387





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