After a detailed briefing on the premature deaths and diseases linked to tobacco among residents, Multnomah County Chair Deborah Kafoury on Tuesday directed the Health Department to return with recommendations on how the County can reduce youth access to nicotine products.
The Health Department’s recommendations – including restrictions on flavored products that attract young people and can set them up for lifelong addictions – will be presented in September. Chair Kafoury has created an online form for those who wish to comment on any proposed flavor restrictions.
She acknowledged the difficulty in reducing the use of nicotine products, both for users and for businesses. “But at some point,” she said, “we have to say enough.”
“And especially after two years of a deadly respiratory virus that is exacerbated by smoking – I am ready to say, ‘Enough.’”
In an important part of Tuesday’s briefing, Multnomah County Health Officer Dr. Jennifer Vines told the Board of Commissioners that tobacco and COVID-19 have “serious interplay,” explaining that smokers who were hospitalized with COVID-19 were linked to higher risks of complications and death.
Data from the American Heart Association published in July 2022 found those who smoked were 45% more likely to die and 39% more likely to be treated by a ventilator.
The American Lung Association dubbed COVID-19 and tobacco as “creating a crisis within a crisis.”
Attracting the next generation of tobacco users
The main concern with flavored nicotine and tobacco products comes from a high number of preventable deaths and health issues – including cancers and heart risks – associated with their use. In Multnomah County, those are the two leading causes of death.
Vines said young people especially tend to use flavored nicotine and tobacco products, primarily in the form of e-cigarettes or vapes – calling them starter products for nicotine addiction.
“Almost all of them are using flavored products,” said Dr. Vines.
She said there’s a clear reason for that. Dr. Vines showcased a number of flavored tobacco products, like vapes and cigars, all boasting attractive flavors similar to candy: gummy bear, chocolate and vanilla, banana ice cream, pineapple and rainbow Skittles.
“Hard to tell the difference, right?” said Dr. Vines, as she held up a vape pen with colorful packaging – a flavored tobacco product.
The Oregon Health Authority reported that in 2017, 57% of Oregon 8th graders using tobacco or vaping sought out flavored products, with that share climbing to 65% among 11th graders who use tobacco or vape. That compares to just 21% of adults using flavored tobacco or nicotine products.
This candy-like flavoring of tobacco has a historic precursor: menthol.
Dr. Vines explained how menthol flavoring can mask the irritating sensation of inhaling cigarette smoke, and give smokers a less harsh feeling. Menthol was also coined for adults, at one point, as an alternative to smoking cigarettes.
“Like you’re breathing fresh air through your menthol cigarettes, which we know is not true,” she said.
Tobacco flavoring is strategic, Dr. Vines said. Flavoring like menthol can lead to smokers inhaling more deeply, not feeling the irritation – and therefore making it harder to quit.
Dr. Vines reported 99.6% of retailers assessed in Multnomah County sold at least one type of flavored tobacco product, such as menthol cigarettes, e-cigarettes, cigarillos or smokeless tobacco.
Low prices for these flavored tobacco products also makes them attractive and easily attainable for young people. In Multnomah County, 67% of retailers who sold cigarillos or small cigars advertised them for less than a dollar. And even for products that cost more than a dollar, 73% of retailers offered discounts or price promotions.
“When it’s cheap, tastes good and is widely available, kids are going to use it,” said Dr. Vines.
Marketing efforts saturate Black, LGBTQ+ communities
Dr. Vines talked about the longstanding disparities related to nicotine and tobacco use. The African American community, along with the LGBTQ+ community, have traditionally been targets of the tobacco industry.
The tobacco industry’s marketing tactics target Black neighborhoods, which often have 10 times as many tobacco ads. That saturated advertising has led to more youth and adults in those communities using those products. According to Tobacco Control, Black smokers use menthol at a higher rate – 85% – than smokers of any other race.
LGBTQ+ youth use cigars, e-cigarettes or vaping products at higher rates than other youth. Dr. Vines reported that among high school students who report smoking e-cigarettes, 30% identify as bisexual, 27% as lesbian/gay, and 23% as heterosexual.
Multnomah County first to limit youth access, license retailers
Multnomah County has consistently led efforts to address the health impacts of tobacco and nicotine use.
In September 2019, the Multnomah County Public Health Advisory Board recommended the Board of Health, made up of the Board of Commissioners, consider a flavored tobacco and nicotine ban. This was based on an outbreak of vaping-related lung disease and a steady rise in the rates of teen vaping. That effort came just before Multnomah County faced COVID-19 and focused its immediate public health resources on battling the pandemic.
Dr. Vines has long pushed for Multnomah County to do more, recounting recent policy changes made in efforts to make tobacco products less accessible to youth and young adults. In April 2017, Multnomah County Public Health urged the Board to raise the legal tobacco purchase age to 21 in April, and shortly after, Governor Kate Brown signed SB 754 into law, raising the legal purchase age to 21.
In October 2015, the Racial and Ethnic Approaches to Community Health (REACH) program and the Action Communities for Health, Innovation and Environmental Health (ACHIEVE) Coalition, identified flavored tobacco as a major contributor to health disparities, specifically affecting the Black and African American communities.
Commissioner Sharon Meieran, who is also a practicing emergency physician, said this was an issue “near and dear” to her heart.
“I see those impacts in the ER with my patients,” she said.
Commissioner Susheela Jayapal said tobacco and flavored products’ health effects are clear, but said she also wanted to make sure the impact of regulations “doesn’t land on already vulnerable communities.”
“We know that a lot of the vaping nicotine products are candy flavors that are attractive and used by many youth,” said Commissioner Jessica Vega Pederson, who said she was eager to continue learning about other health impacts of tobacco and nicotine products in September.