Dr. Kevin Most: Youth and Tobacco
The Illinois House voted a few weeks ago to raise the age allowed to purchase tobacco to 21, you may remember in the past a similar bill was put to Governor Rauner and he vetoed it. Currently in Illinois we have 35 towns, including Chicago, where the age has been moved to 21. Currently there are seven states that limit the sale to those over the age 21 across the entire state. The concern Rauner cited at that time was that this would push young smokers over state lines to buy cigarettes or increase the black market sales of these products. This bill does remove the penalty for possession of tobacco related items by underage individuals.
Studies have shown that individuals are less likely to start smoking if they have not taken it up by age 21. We have had essentially a pilot running in Chicago after the city raised the age to purchase tobacco to 21 in 2016. Chicago Department of Public Health said they saw a 36% decline in tobacco use in that age group in the first full year after restrictions were put in place. However the state spends only 9% of the recommended CDC amount on tobacco prevention.
The financial impact on the state may show a decrease in tax revenue as the full tax on a pack of cigarettes in Illinois is $2.42 per pack. It is probably no surprise that the states with the lowest tax on cigarettes include Virginia, North Carolina, South Carolina and Georgia. The range of tobacco tax in the US is wide, from $4.35 in Connecticut to $0.17 in Missouri. The health improvement of individuals who quit should be the focus. Illinois Medicaid spends close to $2 billion dollars a year treating illnesses directly related to smoking, now multiply that across the country.
Opponents say that if you are old enough to vote and old enough to join the army you should be old enough to buy cigarettes. The counter argument is this is based on studies that show that delaying the opportunity to smoke until the age of 21 has a great impact on an individual never smoking. We also have to remember that there is a billion dollar industry made on helping people stop this activity, that alone should tell individuals that postponing the ability to legally purchase tobacco is a good idea. There are so many people that smoke now that say, “I wish I could quit but it is not that easy” many others say “I wish I had never started smoking”
We all know the impact tobacco smoking has on our health. Each year more than 480,000 people in the US die from illnesses directly related to smoking. Smoking also shortens the lives of smokers by 11 years. We have discussed the increase risk of all heart diseases, many cancers as well as lung disease. We probably have not touched on two other aspects as much. Chewing tobacco and e cigarettes. Let’s take a minute and touch on those and the health impact they may have.
Recently a study came out that showed that e cigarettes or vaping was twice as effective as conventional nicotine replacement in those who wanted to quit smoking. Many now are asking themselves if this is good news. On the surface one would say, of course it is good news, it works twice as good as other nicotine replacement, what is not good about that. Well, let’s make sure we understand that the rates for those who can quit for greater than 6 months are not good. Smoking cessation is extremely difficult, the addiction to nicotine can be as fast as one to two cigarettes and the addiction is very strong.
Cessation of smoking is still a major initiative for physicians and patients. The failure rate for smoking cessation is very high. The encouraging news is that young adults that really want to quit have had higher rates of success. This is thought to be true because of smoke free homes, smoke free restaurants, smoke free workplaces being more popular and mandated. Couple this with lower levels of dependence at a younger age and the change in social norms, allows for some higher success with young adults. The biggest impact on someone trying to quit was living in a smoke free home. We are also seeing that generation taking a closer look at their personal health.
You may have noticed a large push by the company juul in recent newspaper advertising. They have been taking out full page ads for months now. The play for them is to convince you this is a great way to quit smoking but they are also looking to increase their sales and kids are definitely a focus. Experts say that the amount of nicotine in a single juul cartridge is the equivalent amount of nicotine in a pack of cigarettes. The nicotine is delivered to kids and unfortunately doctors are seeing youths, using Juul and other e-cigarettes, showing up with symptoms that are consistent with nicotine toxicity. They still are not sure what the long term effects of e cigarettes are on teens, the early reports were that it is less harmful than cigarettes but they are not based on any scientific studies.
Although the vaping companies are promoting the fact that use of e cigarettes is the best way to stop smoking, more disturbing news came out last week that should damper our enthusiasm. The CDC reported last week that teen smoking rates have risen in the past year and this was after several years of steady decline. In 2018, 27.1 percent of high school students reported using tobacco products within the past month. Compare that to the less than 20 percent the year before. Even more disturbing is middle school student rates of tobacco use rose as well to 7.2 percent.
This backslide on high school tobacco use has brought us back to levels we saw close to 10 years ago. This has raised concerns across the country and the concern has shown some disturbing trends. E cigarettes have been around for many decades, however since 2003, they became commercially available. This product was designed by a Chinese pharmacist inventor who had his father pass away from lung cancer. He built this as a smoking cessation tool and an alternative for the tobacco which took his father’s life.
The use of e cigarettes now, for the most part, is not being used as a smoking cessation tool but instead a way to start or continue a nicotine habit.
The gadget alone is attractive to kids who have grown up in this high tech world. This high tech also has some downsides. The ability to add flavor and remove some of the harshness of cigarettes allows the vapors to get much deeper in the lungs. This results in more exposure of the healthy lung tissue to chemicals as well as increases the amount of nicotine that is absorbed. The technology, the flavor and the thought it is safer than cigarettes coupled with peer pressure to try it has led to an 80% increase in teen use of vaping. The thought that vaping would decrease the use of cigarettes may in fact backfire as the number of kids now vaping has increased to a point well beyond where we saw youth cigarette use rates, thus the opportunity to transition to cigarettes is still high. The fact that we do not know the long term effects of vaping is the major concern.
Another concern that is being raised is the increase use of marijuana and the use of vaping units to smoke marijuana based oils. This is a concern for identifying youths who are using marijuana, as the classic odor is not present and is masked by the flavored oil. Marijuana is in an oil base versus the classic leaf based and again the ability to inhale more deeply is noted as well.
Also recently we had the first death from the explosion of a vaping pen. There have been many cases of the pens battery exploding and causing harm and burns to individuals but recently a pen exploded and a portion cut a major blood vessel in the neck of a user and he died.
So the take home message is we do not know the long term health effects of vaping. Vaping is becoming very popular for children, and thought to be a gateway to cigarette use in the future. Counsel your children on the negative aspects of all forms of smoking.
Hookah or water pipe smoking has also seen gains in popularity as many feel this is safer than smoking cigarettes. Many feel it is a less harmful product than regular cigarettes but this has been proven to be false. This type of smoking contains harmful chemicals and may be more serious than cigarettes as like vaping this can be flavored with candy and mint flavors which appeal to younger smokers. This is seen as a gateway to cigarettes and in many cases marijuana use as well. An international study showed that water pipe use was higher than smoking cigarettes among youths in almost all of the countries studied. This way to smoke also delivers high concentrations of nicotine, these pipes also deliver 35 times the more Carbon monoxide as does a single cigarette.
The health effects from using a water pipe to smoke are actually magnified as the user is inhaling tobacco as well as charcoal smoke. Those who use water pipes exclusively were found to have higher blood pressure than nonsmokers. They have also been found to have higher mortality, more frequent heart attacks when compared to cigarette smokers. So anyone who thinks water pipes are safer is incorrect.
Many think of baseball players and cowboys when we are asked about chewing tobacco. We visualize that pouch of tobacco and the individual grabbing a handful and placing it in their mouth. Although that is still around, tobacco companies have stepped up their game to make this type of tobacco use more socially acceptable. The companies have added flavors, some are now placed in small paper pouches instead of the loose leaf, the marketing and names are made to attract that age group. We have moved well past that pouch of “Red Man”
Historically chewing tobacco is the oldest method of consuming tobacco and for many years was more popular than smoking tobacco. In the 1940’s RJR had 84 different brands of chewing tobacco to complement the 12 brands of smoking tobacco.
The health impact of chewing tobacco is a very high risk of cancers of the mouth, throat, tongue and neck. Babe Ruth died from Cancer of the throat and was a heavy user of chewing tobacco. The baseball industry has tried to distance its players from oral tobacco, as it is being blamed for the increased use of this product in teens. We have seen a decrease in smoking tobacco but like vaping, chewing tobacco has seen a rise in use.
Chewing tobacco like cigarettes have been treated with chemicals that are known to cause cancer. Chewing tobacco also increases your risk of heart disease, high blood pressure, gum disease and dental illness. Another often overlooked concern is that the pouches have been mistaken for candy by young children and caused death as children watch their parents use.
Smokeless tobacco can be just as addicting as cigarettes and the same techniques are used to help them quit. Nicotine patches, gum, Chantix and other behavioral modifications can help.
Youths need to know that chewing tobacco is not safer than smoking, nor is less addictive.