Protecting the Health of our Young People, and our State’s Future, by Raising the Minimum Sales Age of Tobacco Products from 18 to 21

Op-ed by Karyl T. Rattay, MD, MS, Director, Division of Public Health, Delaware Department of Health and Social Services

It’s a fact that most smokers start using tobacco as youth: Eighty-nine percent of current adult Delaware smokers started before the age of 21; and slightly over 17 percent started between the ages of 18 and 20, according to 2017 Delaware Adult Tobacco Survey (ATS) data.

Nicotine addiction keeps young people using tobacco products which increases the risk of physical damage to their bodies. Exposure to nicotine can have lasting effects on adolescent brain development, and can disrupt the formation of brain circuits that control attention, learning, and susceptibility to addiction. Youth and young adults who use tobacco are also at risk for developing early abdominal aortic atherosclerosis, which affects the flow of blood to vital organs; reduced lung growth, which increases the risk of chronic obstructive pulmonary disease (COPD) later in life; and reduced lung function. Adolescent girls and young women who become addicted to nicotine and use tobacco during pregnancy increase the risk of a premature birth or even the death of their child.

An emerging policy intervention to help reduce youth and young adult initiation of, and access to, tobacco products is to increase the legal age for the sale of these products from 18 to 21 years old. These are known as “Tobacco 21 or T21 laws.” Research shows that youth often turn to older friends and classmates as sources of cigarettes. Increasing the tobacco age to 21 in Delaware would reduce the likelihood that a high school student will be able to legally purchase tobacco products for themselves, other students, or underage friends. Adolescents age 15-17 would also have a harder time passing themselves off as 21-year-olds. As many tobacco users between 18 and 21 move from experimental use to regular, daily use, a T21 law would prevent this as well. The Institute of Medicine (IOM) estimates that increasing the age of sale to 21 would decrease long-term tobacco use by about 12 percent. And, it could decrease tobacco-related deaths by 10 percent.

Sen. Bryan Townsend introduced T21 legislation in Delaware last week. SB25, which has the support of Gov. John Carney, additionally imposes a civil penalty for sales to 18- to 21-year-olds, prohibits parents and guardians from purchasing tobacco products for minors, and prohibits individuals under age 21 from entering vapor establishments.

Seven states, including our neighboring states of New Jersey and Virginia, have passed T21 laws. Seventy percent of Delawareans surveyed by the 2017 ATS support a T21 law. A majority of current tobacco product users surveyed also support such a law.

As the Director of the Division of Public Health (DPH) and a board-certified pediatrician, I support SB25 because it is a population-based health initiative that promotes health, prevents disease, averts a lifelong addiction to nicotine and steers Delawareans away from the dangers of tobacco use.

The toll of tobacco use is staggering. Tobacco use is still the leading cause of preventable death and disability in Delaware and the United States. Our latest cancer data report lists tobacco use or smoking as risk factors for 16 cancers.

Of particular concern to us here in Delaware is lung cancer. Our most recent cancer statistics indicate lung cancer accounted for 14 percent of all newly diagnosed cancer cases and 30 percent of all cancer deaths. An estimated 85 to 90 percent of all lung cancer cases are caused by tobacco use, according to the U.S. Department of Health and Human Services.

Additionally, secondhand smoke is a known cause of low birthweight, Sudden Infant Death Syndrome, and lung problems, asthma, and ear infections among children.

Every year, nearly 1,400 adult Delawareans die from smoking-related illnesses, according to Centers for Disease Control and Prevention estimates. The U.S. Surgeon General warns that an estimated 17,000 Delaware youth who are now under age 18, will ultimately die prematurely from smoking-related illnesses if current trends continue.

Despite our great strides in reducing tobacco use, especially reducing youth smoking rates, we still have a long way to go. We are seeing an alarming increase in the use of electronic cigarettes. Although only 6.2 percent of Delaware high school students smoked regular cigarettes in 2017, nearly 20 percent used some type of tobacco product. Also, a 2018 Institute of Medicine report indicates young people who begin with e-cigarettes are more likely to transition to combustible cigarette use, and are at risk for suffering associated health burdens. We must take innovative actions.

For more than 30 years, Delaware has been a national leader in establishing tobacco prevention interventions that help protect the health of all Delawareans. We all breathe easier in public places and workplaces thanks to the Delaware General Assembly’s passage of the Clean Indoor Air Act. Our legislators created the Delaware Health Fund which helps the state maintain a comprehensive tobacco prevention and cessation program. The creation of the Delaware Cancer Consortium led to a large group of dedicated people who continuously make our cancer prevention, detection, and treatment system work better. The DCC recommends enacting legislation to increase the age to 21 to purchase cigarettes and other tobacco products.

DPH and our health partners have worked hard to save lives and safeguard Delawareans from a diminished quality of life by guiding them toward healthy behaviors. Delaware should join the states that are passing T21 laws – and remain a national leader in protecting the health of our citizens.

DOVER – The Division of Public Health (DPH) is advising parents and teachers to be aware of a recent trend among youth known as “JUULing.” JUUL is a brand of e-cigarette that looks similar to a flash drive and can be charged in the USB port of a computer.

JUULs can be appealing to youth for a variety of reasons. Pods come in a variety of fruit and candy flavors, the devices can be difficult to distinguish from a real flash drive, and the vapor dissipates quickly instead of hanging in the air like a smoke trail. This has caused concern am

ong school administrators across the country as youth have taken to “JUULing” on school property, even in class.

A Truth Initiative study found that 37 percent of 15 to 24-year-old JUUL users are uncertain whether the product contains nicotine. The study also found that JUUL users don’t refer to use of these products as “e-cigarette use” or “vaping” but rather as “JUULing, which leads them to believe it is safer.

“There is no safe form of tobacco,” said DPH Director Dr. Karyl Rattay. “Students are under the impression that “JUULing” is safe and that these products don’t have nicotine, however, that is not the case. We believe it is important to educate parents and teachers about this trend, and e-cigarettes in general, and that it is critical that students understand the dangers posed by JUULs and nicotine as well.”

According to the product label, just one pod used in a JUUL allows for 200 puffs and contains the same amount of nicotine as one pack of cigarettes. Nicotine is highly addictive and can affect the developing brains of youth. In less than five years, e-cigarettes and vape products have become the fastest-growing sector of the American tobacco industry. Nationally and in Delaware, e-cigarettes are the most commonly used tobacco product among youth.

Among teenagers, experimentation with electronic or e-cigarettes became popular in 2015. According to the 2015 Delaware Youth Risk Behavior Survey (YRBS), 23.5 percent of public high school students had used e-cigarettes in the past month, and 2.3 percent were smoking or “vaping” e-cigarettes daily. Dual use of tobacco products is also a concern. In Delaware, 32.5 percent of high school e-cigarette users reported also using cigars, and 27 percent reported also using cigarettes. In addition, 37 percent of e-cigarette users reported never smoking cigarettes before starting to use e-cigarettes.

In 2014, Delaware banned the sale of e-cigarettes to minors, and a year later the state expanded the Delaware Clean Indoor Air Act to include prohibiting the use of e-cigarettes and other electronic vapor devices in workplaces and indoor public place.

While research is under way to determine the health effects of e-cigarette usage, the aerosol from e-cigarettes contains harmful substances such as nicotine, lead products and cancer-causing agents, according to the Centers for Disease Control and Prevention (CDC).

DPH is reaching out to schools, school nurses and wellness centers, and pediatrician’s offices with a Health Alert on the topic of “JUULing” and has increased social media messaging around the issue. The Division has previously developed targeted outreach campaigns to address e-cigarette use overall, and will continue to provide education in schools and the community. For more information on “JUULing” visit Tobacco Free Kids at: Tobacco-Free Kids on “JUULing”:  https://www.tobaccofreekids.org/assets/factsheets/0394.pdf. For more information e-cigarettes, visit https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm or for more information on what Delaware is doing to address youth tobacco and e-cigarette use, visit http://www.thedirtytruth.com or https://www.healthydelaware.org/Individuals/Tobacco/Vaping.

A person who is deaf, hard-of-hearing, deaf-blind or speech-disabled can call the DPH phone number above by using TTY services. Dial 7-1-1 or 800-232-5460 to type your conversation to a relay operator, who reads your conversation to a hearing person at DPH. The relay operator types the hearing person’s spoken words back to the TTY user. To learn more about TTY availability in Delaware, visit http://delawarerelay.com.

Delaware Health and Social Services is committed to improving the quality of the lives of Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. DPH, a division of DHSS, urges Delawareans to make healthier choices with the 5-2-1 Almost None campaign: eat 5 or more fruits and vegetables each day, have no more than 2 hours of recreational screen time each day (includes TV, computer, gaming), get 1 or more hours of physical activity each day, and drink almost no sugary beverages.

DOVER – You’d like to quit smoking. Maybe you’ve tried before. But it can feel hard. The American Cancer Society estimates it takes between eight to ten attempts for the average person to quit smoking. When trying to quit, support can make all the difference. That’s why the Cancer Society has set Thursday Nov. 16, 2017, as the date for the annual Great American Smoke Out. Each year, thousands of people across the county use the Great American Smoke Out as their date to quit.

If you or someone you care about smokes, the Division of Public Health (DPH) asks you to use Nov. 16, 2017 as your quit date, and use the days leading up to it to create a plan to do so. A good first step is to call the Delaware Quitline (1-866-409-1858) for advice. By quitting, smokers take an important step toward reducing their risk of heart disease, cancer and lung diseases. And, even quitting for one day can put smokers on the path to recovery.

In Delaware, rates of cigarette use continue to decline. Cigarette smoking by adults dropped again to an all-time low of 17.7 percent, according to the 2016 Behavioral Risk Factor Survey (BRFS). But total tobacco use among Delaware adults in 2016 was 24.2 percent or approximately one in four Delawareans. Total tobacco use includes cigarettes, cigars, little cigars, smokeless tobacco products, e-cigarettes, and all other tobacco products.

Smoking is the leading cause of preventable death. Eighty-five percent to 90 percent of lung cancer cases are caused by smoking, and lung cancer makes up one-third of all cancer deaths.

About 36.5 million Americans still smoke cigarettes, and tobacco use remains the single largest preventable cause of disease and premature death in the world. Nationally, while cigarette use also declined (from 42 percent in 1965 to 15 percent in 2015), cigar, pipe, and hookah – other dangerous and addictive ways to smoke tobacco – are very much on the rise.

“Smoking kills people – there is no “safe” way to consume tobacco,” said Department of Health and Social Services Secretary Dr. Kara Odom Walker. “Delaware has been a leader in the effort to create healthy, smoke-free, indoor workplaces and public places for our citizens, yet there is still more we can do to reduce smoking and save lives.”

Secondhand smoke can aggravate the symptoms of chronic diseases such as asthma and COPD. DPH continues to remind smokers of the dangers of secondhand smoke, both to children and other adults, particularly pregnant women.

While smoking makes it harder for a woman to get pregnant, those who are pregnant and continue to smoke face:

• increased risk of miscarriage;
• potential problems with the placenta – the oxygen and food supply for the baby;
• increased risk of birth defects;
• increased risk of Sudden Infant Death Syndrome (SIDS); and
• potentially preterm or low birthweight babies.

Delaware data from a recent Women of Childbearing Age Report shows that an estimated 1,400 women smoked during the last three months of pregnancy. Women who smoked during that time frame were approximately three times more likely to deliver a low birthweight baby as compared to those who did not smoke

“If you are pregnant and are smoking, talk to your doctor immediately about ways to safely quit,” said DPH Director Dr. Karyl Rattay. “You can have fewer health problems, breathe better and have more energy. Your baby will have fewer problems too, such as wheezing, fewer coughs, colds and ear infections, and a reduced risk of SIDS.”

The Division of Public Health has a variety of resources to help you start and be successful in your journey to leading a tobacco-free life. The Delaware Quitline provides free tobacco cessation counseling services for Delaware Residents who are 18 years of age and older. When a person calls the toll-free Quitline (1-866-409-1858), they have the option to receive cessation counseling over the phone and, unique to Delaware, can opt to receive counseling in person by a local health care professional trained in cessation. Some participants may qualify for free pharmaceutical cessation aids such as patches, gum, nasal spray and prescription medicine such as Chantix. The Delaware Quitline also has special materials for pregnant smokers trying to quit.

For those who may need some assistance and don’t feel the Quitline is right for them, QuitSupport.com offers a free web-based option. This online cessation counseling service makes Quit Coaches available to provide tips on quitting tobacco. For individuals under the age of 18, NOT on Tobacco (NOT) is a cessation service available at most school wellness centers. Contact 1-800 LUNGUSA for more details on the NOT program.

Research shows that most people try to quit smoking several times before they succeed. (It’s called a relapse when smokers go back to smoking like they were before they tried to quit.) If a relapse happens, think of it as practice for the next time. Studies show that most people who don’t succeed in quitting are ready to try again in the near future. Things a person learns from a failed attempt to quit may help them quit for good next time. It takes time and skills to learn to be a non-smoker.

In 2014, Delaware banned the sale of e-cigarettes to minors and in 2015, Delaware’s Clean Indoor Air Act was expanded to include prohibiting the use of e-cigarettes and other electronic vapor devices in workplaces and indoor public places. Additionally, smoking is not permitted on State property.

For more information about tobacco cessation, visit DPH’s Tobacco Prevention and Control Program at http://www.dhss.delaware.gov/dhss/dph/dpc/tobacco.html.

A person who is deaf, hard-of-hearing, deaf-blind or speech-disabled can call the DPH phone number above by using TTY services. Dial 7-1-1 or 800-232-5460 to type your conversation to a relay operator, who reads your conversation to a hearing person at DPH. The relay operator types the hearing person’s spoken words back to the TTY user. To learn more about TTY availability in Delaware, visit http://delawarerelay.com.

Delaware Health and Social Services is committed to improving the quality of the lives of Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. DPH, a division of DHSS, urges Delawareans to make healthier choices with the 5-2-1 Almost None campaign: eat 5 or more fruits and vegetables each day, have no more than 2 hours of recreational screen time each day (includes TV, computer, gaming), get 1 or more hours of physical activity each day, and drink almost no sugary beverages.

DOVER – The Division of Public Health (DPH) is helping the Delaware Quitline celebrate a major milestone this month. The Quitline has now been helping Delaware smokers break their addiction for the past 15 years.

The Delaware Quitline is a toll-free tobacco cessation hotline (1-866-409-1858) that provides tobacco users (including e-cigarette users) the option of receiving counseling by phone or in person. Health care professionals trained in cessation counseling are available statewide for in-person counseling. All Quitline services are free to Delaware residents 18 years of age and older.

For eligible smokers, the Quitline also provides Food and Drug Administration-approved prescription cessation aids and non-prescription nicotine-replacement therapy such as patches, gum, and lozenges. To celebrate the 15-year anniversary, while supplies last, cessation aids will be available, free, to all participants who enroll in one of the Quitline counseling programs.

“This is a significant event in our tobacco prevention efforts and we are so pleased to be able to offer additional assistance to those who want to engage in healthier lifestyles and stop smoking,” said Dr. Karyl Rattay, DPH Director. “Quitting smoking is one of the most important things a person can do to reduce their cancer risk. Additionally, we must continue to work with Delawareans on making overall healthier lifestyle choices, such as getting regular physical activity, and eating healthy diets, especially those high in fruits, vegetables and whole grains and low in added sugars like sugar sweetened beverages.”

Since it began in February 2001, the Delaware Quitline has served more than 49,000 Delaware adults. Of those, more than 36,000 received telephone counseling, and almost 13,000 received face-to-face counseling. Additionally, 25 percent of those who responded to the follow-up survey, conducted seven months after services are provided, reported that they had not smoked in the past month.

During the past decade, Delaware has implemented the comprehensive Tobacco Prevention and Control Program statewide, and youth smoking rates have declined. High school students reporting “current cigarette smoking” is at an all-time low of 9.9 percent according to the 2015 Delaware Youth Risk Behavior Survey. This is a 69.3 percent decrease since 1999. However, the percentage of Delaware adults who reported that they currently smoke was 19.9 percent, according to the 2014 Behavioral Risk Factor Survey. This percentage has remained statistically unchanged for the past four years.

Lisa Moore, the Division’s Tobacco Prevention and Control Program manager, said, “While the high school data is still promising, we must be diligent in addressing tobacco use at all ages – and we must do everything possible to help smokers who want to quit. Tobacco use is still the leading cause of preventable death in Delaware and the United States,” Moore said. “Prevention is key, however, the Delaware Quitline is a useful resource for those who already smoke and need help quitting.”

The Quitline also has special programs for pregnant smokers and smokeless tobacco users and has counselors who speak Spanish. The Delaware Quitline is a Division of Public Health program managed through a contract with Alere Wellbeing. It is funded in part by grants from the U.S. Centers for Disease Control and Prevention (CDC) and the Delaware Health Fund. For more information about the Delaware Quitline, visit: http://www.dhss.delaware.gov/dhss/dph/dpc/quitline.html.

A person who is deaf, hard-of-hearing, deaf-blind or speech-disabled can call the DPH phone number above by using TTY services. Dial 7-1-1 or 800-232-5460 to type your conversation to a relay operator, who reads your conversation to a hearing person at DPH. The relay operator types the hearing person’s spoken words back to the TTY user. To learn more about TTY availability in Delaware, visit http://delawarerelay.com. Delaware Health and Social Services is committed to improving the quality of the lives of Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. DPH, a division of DHSS, urges Delawareans to make healthier choices with the 5-2-1 Almost None campaign: eat 5 or more fruits and vegetables each day, have no more than 2 hours of recreational screen time each day (includes TV, computer, gaming), get 1 or more hours of physical activity each day, and drink almost no sugary beverages.