Prevention of Youth Initiation of Tobacco Use: National

Novel dissolvable tobacco or other nicotine-containing products—that are not approved by the Food and Drug Administration (FDA) as nicotine replacement therapies—have the potential to increase adolescent nicotine addiction and even cause nicotine toxicity in small children. These products are frequently marketed in flavors appealing to children. This category of product also includes e-cigarettes, which are devices that vaporize a liquid nicotine-containing substance. These products should be regulated appropriately to ensure safety and public health benefit. 

Clinicians and other private citizens can submit public comments to the FDA regarding specific tobacco regulation issues during open comment periods. Comments can include peer-reviewed articles citing evidence on a topic, and/or anecdotal evidence from clinical practice. Note that comments made by AAP members must be made as individuals, and not on behalf of the AAP. 

Recommended by: 

• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• Surgeon General report– The Health Consequences of Smoking— 50 Years of Progress, 2014- page 827 

For more information: 

• AAP State Government Affairs– Issue Brief: Tobacco Product Control 
• AAP Statement to Tobacco Products Scientific Advisory Committee– July 22, 2011 
• Campaign for Tobacco-Free Kids– Public health community comments to FDA on dissolvable tobacco products, September 20, 2010 
• FDA Tobacco Product Regulation– Making Your Voice Heard 
• Regulations.gov– Docket ID: FDA-2011-N-0467 Submitted Comment 
• U.S. Court of Appeals– Public health community amicus brief, Smoking Everywhere, Inc. v. FDA, May 24, 2010 

Research has demonstrated that there is a high likelihood that flavored tobacco increases the risk of tobacco initiation. Flavored cigarettes (other than menthol) were banned by the 2009 Family Smoking Prevention and Tobacco Control Act. The law did not extend the ban to other tobacco products, but did give the Food and Drug Administration (FDA) the authority to do so. When one type of flavored tobacco product is banned and others aren't, there is room for re-branding. 

Following the ban on flavored cigarettes by the Family Smoking Prevention and Tobacco Control Act, some brands of flavored cigarettes changed how they were made and were re-released as flavored cigars— perfectly legal under the terms of the law. Prohibiting all flavored tobacco products would ensure that re-branding can't happen and that the rates of tobacco use initiation would decrease. Laws should include menthol-flavored products, which are popular with youth. 

Recommended by: 

• AAP policy statement– Electronic Nicotine Delivery Systems 
• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• Centers for Disease Control and Prevention (CDC)– Health Equity in Tobacco Prevention and Control 
• Surgeon General report– The Health Consequences of Smoking— 50 Years of Progress, 2014- page 827 
• Surgeon General report– Preventing Tobacco Use Among Youth and Young Adults, 2012- page 205 

For more information: 

• Campaign for Tobacco-Free Kids– Not Your Grandfather’s Tobacco: A New Generation of Cheap and Sweet Cigars Threatens a New Generation of Kids 
• Tobacco Control Legal Consortium– Regulating Flavored Tobacco Products 
• Tobacco Control Legal Consortium– The Problem with Menthol: A Backgrounder 
• Tobacco Control Legal Consortium– Regulating Menthol Tobacco Products 
• Tobacco Control Legal Consortium– Regulating Menthol Flavored Tobacco Products: Lessons Learned 
• Tobacco Control Legal Consortium– Chicago’s Regulation of Menthol Flavored Tobacco Products: A Case Study 

Since menthol masks the harshness of smoking, it could increase youth smoking initiation. An advisory committee to the Food and Drug Administration (FDA) has determined that the public health would benefit if menthol cigarettes were removed from the market. Clinicians and other private citizens can submit public comments to the FDA regarding specific tobacco regulation issues during open comment periods. 

Comments can include peer-reviewed articles citing evidence on a topic, and/or anecdotal evidence from clinical practice. Note that comments made by AAP members must be made as individuals, and not on behalf of the AAP. 

Recommended by: 

• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• Centers for Disease Control and Prevention (CDC)– Health Equity in Tobacco Prevention and Control 
• Surgeon General report– The Health Consequences of Smoking— 50 Years of Progress, 2014- page 827 

For more information: 

• AAP Statements to Tobacco Products Scientific Advisory Committee– March 31, 2010 and November 18, 2010 
• FDA Tobacco Product Regulation– Making Your Voice Heard 
• FDA Tobacco Product Scientific Advisory Committee– Menthol Report, March 2011 
• Regulations.gov– Docket ID: FDA-2011-N-0467 Submitted Comment 

The United States has signed but not ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). The FCTC is the first global public health treaty designed to foster international cooperation to protect persons around the world from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to secondhand tobacco smoke.

The treaty commits nations to implement policies on tobacco price and tax increases, eliminating or restricting tobacco advertising and sponsorship, labeling tobacco packaging with more prominent health warnings, reducing exposure to secondhand smoke, expanding access to tobacco cessation treatments and curbing illicit trade. Over 165 countries have ratified the framework convention. 

Recommended by: 

• U.S. Department of Health and Human Services– Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the US Department of Health and Human Services- Strategic Action 4 

For more information: 

• American Cancer Society– Global Advocacy for the WHO Framework Convention on Tobacco Control 
• WHO– Framework Convention on Tobacco Control 

Raising taxes has been shown to deter the purchase and use of tobacco, prompt cessation attempts, and decrease youth initiation. In turn, revenue from these taxes can be used to support evidence-based tobacco control programs in the community and state to prevent youth initiation, secondhand smoke exposure and decrease the prevalence of tobacco use.

States with excise tobacco product tax rates below the level imposed by the top quintile of states should substantially increase their rates to reduce consumption, smuggling and tax evasion. All tobacco products should be taxed the same, including smokeless tobacco, hookah, cigars and electronic nicotine delivery systems. 

Recommended by: 

• AAP policy statement– Electronic Nicotine Delivery Systems 
• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• National Academy of Medicine report– Ending the Tobacco Problem: A Blueprint for the Nation, 2007- Recommendation 3 
• Surgeon General report– The Health Consequences of Smoking— 50 Years of Progress, 2014- page 827 
• World Health Organization (WHO)– WHO Report on the Global Tobacco Epidemic 2008: The MPOWER Package- Intervention R 

For more information: 

• AAP Issue Brief– Tobacco Control Funding 
• AAP Issue Brief– Tobacco Product Control 
• Campaign for Tobacco-Free Kids– Raising Cigarette Taxes Reduces Smoking, Especially Among Kids (AND THE CIGARETTE COMPANIES KNOW IT) 
• WHO– The Economic and Health Benefits of Tobacco Taxation 

No youth-rated movie, TV show or video game should include tobacco product imagery. Let movie production companies, directors, television studios, video game companies, movie theater companies and the Motion Picture Association of America (MPAA) know that tobacco imagery in media portrayals can impact how children view tobacco use, and may actually influence whether or not a child experiments with tobacco. Tobacco products are so highly addictive that one use is all it takes to become a regular user.

Seeing characters in the media use tobacco has been shown to influence children to view tobacco use in a more favorable light. Write letters, make phone calls and partner with national advocacy organizations to reach these organizations. Encourage production companies to not accept any money from tobacco companies, and to include a disclaimer that they have not accepted tobacco funding or gifts during any point in the creation of the film, show or game. Encourage the MPAA to give an R rating to any production that contains tobacco use imagery unless the tobacco use depicts a historical portrayal or shows the consequences of use, and to include a strong anti-smoking ad (not produced or funded by a tobacco company) prior to the start of the film, show or game. Tobacco-free movie policies should include nicotine delivery systems (e-cigarettes). 

Recommended by: 

• AAP policy statement– Electronic Nicotine Delivery Systems 
• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• National Academy of Medicine report– Ending the Tobacco Problem: A Blueprint for the Nation, 2007- Recommendations 37-38 
• Surgeon General report– Preventing Tobacco Use Among Youth and Young Adults, 2012- page 602 
• Surgeon General report– Reducing Tobacco Use, 2000- pages 20-21 
• U.S. Department of Health and Human Services– Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the US Department of Health and Human Services- Strategic Action 2 
• World Health Organization (WHO)– WHO Report on the Global Tobacco Epidemic 2008: The MPOWER Package- Intervention E 

For more information: 

• AAP Julius B Richmond Center– Smoke-free Movies and Media 
• AAP Issue Brief– Tobacco Product Control 
• Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Review, July 15, 2011– Smoking in Top-Grossing Movies-- United States, 2010   
• President’s Cancer Panel Annual Report, 2006-2007– Part 3: Reducing Cancer Risk by Eliminating Exposure to Tobacco Use and Exposure- pages 88-90, 114 
• Smoke Free Movies 

The United States has signed but not ratified the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC). The FCTC is the first global public health treaty designed to foster international cooperation to protect persons around the world from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to secondhand tobacco smoke.

The treaty commits nations to implement policies on tobacco price and tax increases, eliminating or restricting tobacco advertising and sponsorship, labeling tobacco packaging with more prominent health warnings, reducing exposure to secondhand smoke, expanding access to tobacco cessation treatments and curbing illicit trade. Over 165 countries have ratified the framework convention. 

Recommended by: 

• U.S. Department of Health and Human Services– Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the US Department of Health and Human Services- Strategic Action 4 

For more information: 

• American Cancer Society– Global Advocacy for the WHO Framework Convention on Tobacco Control 
• WHO– Framework Convention on Tobacco Control 

Children and adolescents need to hear messages that discourage tobacco use, resist peer influences and counter aggressive tobacco industry advertising tactics. Tobacco use prevalence declines when adequately funded mass-media counter-marketing campaigns are combined with other strategies in multi-component tobacco control programs. Counter-advertising media campaigns can be effective in increasing negative beliefs and attitudes about the tobacco industry and lead to lower levels of youth tobacco use initiation. The evidence shows that youth exposure to images that create a positive association with smoking is also associated with a likelihood of smoking initiation. 

Warning: The tobacco industry is well-known for its effective marketing schemes and hidden-meaning campaigns. The industry frequently releases youth prevention and adult cessation programs that appear to be benign, but have been shown to do more harm than good. Be aware of these programs when looking to take action on this recommendation. 

Recommended by: 

• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• Centers for Disease Control and Prevention (CDC)– Best Practices for Comprehensive Tobacco Control Programs, 2014- page 31 
• National Academy of Medicine report– Ending the Tobacco Problem: A Blueprint for the Nation, 2007- Recommendation 15 
• Surgeon General report– The Health Consequences of Smoking— 50 Years of Progress, 2014- page 875 
• Surgeon General report– Preventing Tobacco Use Among Youth and Young Adults, 2012- pages 602, 812 
• U.S. Department of Health and Human Services– Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the US Department of Health and Human Services- Strategic Action 2 
• World Health Organization (WHO)– WHO Report on the Global Tobacco Epidemic 2008: The MPOWER Package- Intervention W 

For more information: 

• AAP Issue Brief– Tobacco Control Funding 
• Campaign for Tobacco-Free Kids– Kick Butts Day 
• Food and Drug Administration (FDA)– The Real Cost 
• Institute for Global Tobacco Control– The MPOWER framework and United Nations human rights treaties: An additional argument for the promotion of tobacco control goals 
• Truth Initiative– Truth Campaign 

For more information about tobacco industry tactics: 

• Americans for Nonsmokers’ Rights– Tobacco’s Dirty Tricks 
• Campaign for Tobacco-Free Kids– Big Surprise: Tobacco Company Prevention Campaigns Don’t Work; Maybe It’s Because They Are Not Supposed To 
• The Rise and Fall of Tobacco Media Campaigns, 1967-2005 

The Master Settlement Agreement (MSA), a result of litigation between 46 state attorneys general and the four largest U.S. tobacco companies, eliminated sponsorship or hosting of events with a large youth audience and events with underage participants. The MSA also limited brand name sponsorship of athletic, musical, artistic and other cultural or societal events by the four participating tobacco companies to one per year.

These restrictions were strengthened by the 2009 Family Smoking Prevention and Tobacco Control Act Regulations Restricting the Sale and Distribution of Cigarettes and Smokeless Tobacco to Protect Children and Adolescents, which stated that no cigarette or smokeless tobacco brand can sponsor these types of events. By having a sponsorship restriction on any tobacco product company, including electronic nicotine delivery system companies, the tobacco industry will lose a major method of product promotion. 

Corporations which manufacture tobacco product brands may still sponsor these types of events so long as: the corporation was registered and in use in the US prior to January 1, 1995; and that the corporate name does not include any brand name, logo, motto, symbol, recognizable color or color pattern, or other product identifier used for the brand identification or cigarettes or smokeless tobacco. 

Recommended by: 

• AAP policy statement– Electronic Nicotine Delivery Systems 
• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• U.S. Family Smoking Prevention and Tobacco Control Act, 2009 
• U.S. Tobacco Master Settlement Agreement, 1998 

For more information: 

• AAP Issue Brief– Tobacco Product Control 
• Federal Register Docket No. FDA-1995-N-0259: Regulations Restricting the Sale and Distribution of Cigarettes and Smokeless Tobacco to Protect Children and Adolescents 
• FDA– Regulations Restricting the Sale and Distribution of Cigarettes and Smokeless Tobacco 

Because 90% of smokers begin by age 18, it is crucial to prevent adoption of smoking in young populations. Since some high school students are 18 and legally able to buy cigarettes in some places, it is easy for those students to purchase cigarettes and give them to younger students who cannot buy cigarettes themselves. Pushing back the age of tobacco purchase to 21 helps keep products like cigarettes, hookah, cigars, smokeless tobacco and electronic nicotine delivery systems out of the hands of younger potential smokers- the majority of people who purchase for distribution to minors are between the ages of 18 and 20, and younger students likely do not share social circles with 21 year olds. 

Critics of Tobacco 21 laws use a variety of arguments to voice concerns about these laws. One of the most frequently heard arguments against Tobacco 21 laws is that eliminating tobacco sales from those under 21 will cause convenience stores to lose business. The total loss of revenue is only 2.12% of total tobacco sales. In addition, not a single convenience store in Needham, MA went out of business when the Tobacco 21 law was implemented in 2005. Another concern for implementation of these laws is that underage smokers will go to a neighboring town to buy cigarettes. However, this has not been the case in Needham since 2005, and there is no evidence that it will occur. Most high school students have limited mobility, and each town that raises its sales age increases the likelihood that surrounding towns will do the same. 

Additional concerns center around the added burden this would place on retailers. However, current FDA policy requires that retailers check the ID of anyone attempting to purchase tobacco who appears to be under age 27. Raising the purchase age to 21 would make things consistent with alcohol regulations- in some states, driver’s licenses for people under 21 are different than for those over 21. Compliance protocols can easily be modified to match those of alcohol sales. If the minimum age of legal access for tobacco products were raised to 21 now, it estimated that by the time today’s teenagers were adults, there would be a 12% decrease in prevalence of tobacco use among those adults. 

Recommended by: 

• AAP policy statement– Electronic Nicotine Delivery Systems 
• AAP policy statement– Public Policy to Protect Children From Tobacco, Nicotine, and Tobacco Smoke 
• Centers for Disease Control and Prevention (CDC)– Health Equity in Tobacco Prevention and Control 
• National Academy of Medicine report– Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products 

For more information: 

• AAP Issue Brief– Tobacco Product Control 
• Campaign for Tobacco-free Kids– Increasing the Sale Age for Tobacco Products to 21 
• Campaign for Tobacco-free Kids– Increasing Minimum Legal Sale Age for Tobacco Products to 21 
• Tobacco21.org