Restrict sale of flavored tobacco products — including menthol — health officials ask Board of Commissioners

October 4, 2019

Health officials, parents and community advocates on Thursday, Oct. 3, asked the Board of Commissioners to ban the sale of flavored e-liquids and tobacco products, including menthol cigarettes.

Public Health Director Rachael Banks details more than a decade of tobacco prevention, asks Board to consider flavor ban.

The request comes as the federal government investigates an outbreak of vaping-related lung disease and as states order temporary bans on vaping. Many jurisdictions have already banned flavored e-liquids, which are most popular among teens, and a few have expanded that ban to include flavored tobacco products and menthol cigarettes, most commonly used by youth and African American smokers. On Friday, Oct. 4, Oregon Gov. Kate Brown ordered a six-month statewide ban on sales of flavored vaping products.

Vape business owners sued the state, and on Oct. 17, the Oregon Court of Appeals placed a temporary stay on the ban on tobacco-based products to give the plaintiffs an opportunity to make their case.

The Multnomah County Board of Commissioners last month asked the Public Health Division to bring forward a proposal on banning flavored products. Chair Deborah Kafoury said the Board will hold a series of public hearings before deciding.  

Those who cannot attend a hearing but wish to comment may submit written comments online.

Leading Cause of Death

The rate of smoking traditional cigarettes has been dropping for years. But that decline masks emerging risks and ongoing health disparities, Deputy Health Officer Dr. Jennifer Vines told the Board of Commissioners during the Oct. 3, 2019 briefing.

Health officials have watched in alarm as teens take up vaping at staggering rates. And they remain frustrated that rates of menthol cigarette use remain stubbornly constant. Tobacco remains the leading cause of preventable death in Oregon and Multnomah County. More than 100,000 people smoke and more than 1,000 people a year die in Multnomah County from tobacco-related illness. 

Just in Multnomah County, that adds up to more than $300 million in medical costs and another $272 million in lost productivity

“As a physician, I think the suffering in terms of disease and death is enough,” Vines said. “But you’re also stewards of public money. You might hear a business argument from tobacco retailers. But at the end of the day, we all pay for tobacco-related illness.”

Vines held up a pack of Jackpot brand, blueberry-flavored cigars as she spoke; she bought the pack for 99 cents at the corner store. She also showed off a pack of caramel M&Ms. The candy was more expensive, with the smallest bag selling for  $1.29.

Tobacco use always comes down to cost and flavor, she said. Among smokers, teens are most likely to choose menthol. Among vaping products, flavors are more popular the younger you get. Recent data suggests one-in-four teens vaped in the last 30 days, but Vines said that’s an undercount.

“If you talk to a teen, they’ll laugh and say everybody vapes,” she said. “This notion that youth use of nicotine is skyrocketing is born out in our best science.”

The long-term risks of vaping are unknown. After all, e-cigarettes have been on the shelves for less than a decade. But the long-term risks from nicotine are well-documented, showing a link between nicotine use as a teen and substance abuse as an adult. 

And consumers shouldn’t believe marketing that touts liquids as “nicotine-free,” Vines said. Almost all vaping liquids — 99 percent — contain nicotine whether they’re labeled as having it or not.

But, Vines said, “menthol tobacco deserves special mention here.”

Menthol, added in varying degrees to about 90 percent of cigarettes, makes it easier to smoke and harder to quit. It has a cooling and anesthetic effect, which allows a smoker to breath deeper and absorb more nicotine. 

Among cigarette smokers, menthol use is more common among 12 to 17 year olds, and least common among older adults. And menthol use is vastly more common among African American smokers than white smokers, largely because of effective advertising campaigns and low-cost deals in traditionally African American neighborhoods.

The Health Department launched a campaign in 2013 to raise awareness about flavored tobacco.

A roadmap

Jurisdictions across the nation are considering bans on e-cigarettes and flavored e-liquids to protect the public from the outbreak of vape-related lung disease and to prevent teens from picking up vaping. Multnomah County Public Health is asking the Board of Commissioners to consider a broader ban that includes flavored tobacco — and specifically menthol — to reverse health disparities that lead African American residents to die at higher rates.

In 2009, before vaping had surged to prominence, Congress banned flavors from traditional tobacco products. Menthol was exempt. 

Last month the FDA vowed to propose action on flavored e-liquids. 

“Three weeks ago the FDA said they would come back in two weeks with a plan to ban flavored e-cigarettes. We’re still waiting to understand what that plan is,” said Public Health Director Rachael Banks. “We do know they don’t intend to include flavored tobacco or menthol.”

Oregon Gov. Kate Brown on Friday issued a temporary ban on all flavored vaping products and ordered the Oregon Health Authority to propose legislation to permanently ban flavored e-liquids. The order doesn’t include flavored tobacco products such as menthol cigarettes.

“We need a permanent solution that will not leave communities of color behind again,” Banks told the Board on Thursday. “The state and federal proposals would not provide permanent solutions to stop a new generation of youth from becoming addicted. And they would not provide solutions to the racist policies or save the communities who literally paid with their lives — from the slave fields picking tobacco to the aggregation of health disparity we see today.

Banks proposed a comprehensive ban on flavored products, similar to laws passed in other major metropolitan areas. San Francisco banned all flavored products in 2017. Sacramento did the same this year. 

Banks’ proposed ban would include flavored liquids and tobacco products, including menthol, and would prohibit the sale of mint-flavored e-liquids. Banks said at least one company has tried to differentiate mint from other flavored e-liquids, calling mint a “modest adult flavor” similar to menthol.

“Mint and menthol are not adult flavors. As a 12-year-old who began with menthol, I can tell you those are not modest adult flavors,” she said.

Commissioner Susheela Jayapal thanked Banks and Vines for their testimony. Jayapal said the County must continue pushing different strategies to keep kids from using tobacco.

“There’s no question of the urgency of stopping this tide. Raising the age limit hasn’t done the trick. It’s important we did that, to reduce use,” she said. But “the one question I have is what’s the most effective way to do it.”

Jayapal said she’d heard raising taxes was the best way to stop youth from using unhealthy products. 

“We would love nothing more than to increase tobacco taxes,” Chair Deborah Kafoury said. But Oregon law preempts counties from taxing tobacco products. “For many [legislative] sessions, we have sought to remove that preemption. Ultimately it wasn’t possible. There will be a ballot measure to do that this session. This County has made it clear it would be an avenue to consider.”

A long time coming

Health workers have tried for years to help Black residents stop smoking. In 2007 LifeWorks NW began its tobacco prevention work, focusing on African American smokers and menthol. Two years later, a group of government and community nonprofits formed the ACHIEVE Coalition to “end health inequities in chronic diseases” for African Americans in Multnomah County. That effort also addressed smoking and menthol cigarettes.

Meanwhile, a new front was forming in public health’s war on addiction.

Until then, a child of any age could purchase e-cigarettes. A person could vape anywhere — at work, at school, at the doctor’s office. And the County struggled to enforce existing tobacco because it lacked a registry of tobacco vendors.

Multnomah County held a series of public hearings in 2014. Health Officer Vines warned of an increasing number of youth using electronic cigarettes locally. And the Multnomah County Environmental Health Division recommended the County ban sales of e-cigarettes to minors. The division also recommended the County ban e-cigarette use anywhere cigarettes are banned under the Oregon Clean Air Act.

The Board answered with an ordinance in March 2015 that prohibited minors from buying and using inhalant delivery systems, and then restricted the use of e-cigarettes to match the treatment of cigarettes under the Oregon Clean Air Act.

Later in 2015, Gov. Kate Brown adopted state law that did the same things, following Multnomah County.

Since then, youth, health officials and the Public Health Advisory Board have asked the Board of Commissioners to “do me a favor and ban the flavor,” including in a March 2019 presentation on the leading causes of death in Multnomah County.

Then, last month, the Board of Health, as it issued a warning on vaping, asked for long-term recommendations on flavors. 

“It might seem like the timeline is moving quickly,” Public Health Director Banks said. “But I can tell you, as a tobacco prevention manager here a decade ago, these discussions are not new. And it’s not new that the community is asking us to do something about tobacco.”

Despite efforts to curb kids’ access to nicotine, youth vaping rates continue to rise, from 1 in 26 youths in 2013 to one in four today. Most vape for the flavors, and research suggests that kids who vape are more likely to transition to cigarettes. And when they do, they prefer menthol. 

Nearly 800 retailers sell tobacco and e-cigarette products in Multnomah County. And every single retailer in a recent state survey said they sold flavored products. Despite strict enforcement of tobacco laws, vendors still sell tobacco products to underage youth inspectors 17 percent of the time. And that number is worse in businesses for people 21 and older, where more than half the time, vendors sell illegally to youth.

“All those steps have not been enough to stop the increasing rates of youth vaping,” said Chair Kafoury. “So if we are to consider action to stop addiction before it starts, we must consider banning the flavors that attract kids to e-cigarettes in the first place. And we must also consider including flavored cigarettes and other tobacco products, which also attract youth.”

Public testimony

The Board of Commissioners is scheduling public hearings and has invited residents who cannot attend to submit written comments online. Commissioners on Thursday heard from parents, advocates, health professionals and one vape shop owner.

Marcus Nettles, owner of Rose City Vapors, said if the board bans ban flavored products, consumers will turn to the black market instead. He acknowledged youth vaping is a problem, but told the board that vape shops like his are doing what they can to keep teens from buying e-cigarette products. He said the state’s recent decision to raise the minimum tobacco sale age from 18 to 21 will help, too.

Amanda Court, a nurse practitioner first at George Middle School and now at Madison High, told the story of a 12-year-old boy who frequently came to the health center at George. “We talked about anxiety, family stress, girl trouble,” she said. Then he came in with his vape pen. 

“He wanted my help convincing his mother that it’s not bad for you,” she recalled. It’s just juice, he told her, and he liked the flavor. 

“He had no concept that this was a potentially toxic compound. Back then I didn’t know the risk either. But we’re unable to ignore the risk any longer,” Court said. “Flavor makes them seen innocent, more like a treat than a drug. I strongly support a flavor ban. Nicotine is addictive enough as it is. There’s no need to make it more appealing.”

Alyshia Macaysa says county's Public Health Advisory Board has focused on tobacco and nicotine for years,

Cheryl Carter sits on the Multnomah County Public Health Advisory Board. 

“We identified a local ban on flavored e-liquids and tobacco products as a top policy action. We are here again to express our support for the ban. As members of this community we will not tolerate the continued profiting the industry makes off our people, particularly young people of color. We urge the County to move forward with a local ban and to provide communities most impacted with access to the quality of life they deserve.”

Alyshia Macaysa, who also sits on the advisory board,. said the group has focused on tobacco and nicotine for years, precisely because of its mandate to address health risks that disproportionately affect people of color.

“A local ban or any restriction is not about shaming or punishing those most affected Black and indigenous communities,” she said. “We won’t tolerate Black, indigenous and people of color being used in marketing tactics by companies that benefit from our early deaths.”

Yugen Rashad is the coalition coordinator for the County’s Racial and Ethnic Approaches to Community Health program, also known as REACH. REACH focuses on narrowing health disparities in the black community. It targets smoking in campaigns and outreach, and in partnership with other organizations. Rashad has worked on tobacco prevention for more than a decade

“The tobacco prevention network was created here, recruiting from the community. This is not new. When we started the work in 2006, big tobacco was advertising menthol products to poor people and African Americans in particular. They promoted the lifestyle of menthol. In Jet, in Ebony. This is not new.”

Daniel Morris, Ph.D., is a public health researcher who sits on the Public Health Advisory Board. 

“I’ve done research on tobacco for more than 10 years. It’s the only product that I can think of that kills its users when it's used as intended,” he said. “The existential problem is they need to recruit new users to replace the ones they kill off.”

Haika Mushi, who works with African immigrants and refugees at the African Family Holistic Health Organization, said her husband smoked until she became pregnant and the doctor warned them their baby would be at risk. “Weeks before our daughter was born, he quit,” Mushi said. “He never used vaping to stop. He just made a decision..” But her clients, many who don’t yet read or speak English, aren’t getting the message about the risks from tobacco and vaping. 

“We have seen a high number of youth who migrated here, by age 12 they’re starting to experiment,” she said. “I’m afraid we’re raising a population who will be unhealthy in the future.”  

She asked the Board to include menthol in any flavor ban to keep youth from transitioning to menthol cigarettes once flavored e-liquids are pulled from the shelf. 

Daniel Morris, Ph.D., is a public health researcher who sits on the Public Health Advisory Board

Liuba Vega, mom of an 11-year-old boy, said no one at home smokes or vapes. But her son has long been attracted to the smell of flavored vapor. 

“When he was 8, I was walking with my son down the street and he smelled bubble gum. He was really excited,” she told the Board.  

“What is that?” she said he asked. Vega didn’t want to tell him about e-cigarettes, but he kept smelling sweet flavors in the air, so she explained, cautioning that the vapor contained harmful chemicals. 

“It smells delicious. Maybe it’s not that bad,” she recalled him saying. “Now he’s in middle school. All the kids have access to vapes. It’s appealing to him. It’s so easy for kids to get access to these. I’m really scared, and I want them to be banned.”

Robyn Stowers, a board member of Beyond Black CDC, talks with Black families in east Multnomah County about the risk of smoking. But tobacco has affected her own life, she said. She lost her grandma when she was a child because of smoking. Both of her parents smoked. Now she has a nephew in 10th grade who vapes.

“There was nothing you could do to convince him that e-cigarettes were dangerous,” she said. “We know tobacco kills. Children know tobacco kills. But that doesn’t keep the industry from spending $1 million an hour targeting youth and the Black community. We need to do a better job protecting our community. Government needs to prioritize the health of vulnerable populations.”

She pointed to the community health advocates who asked the Board in 2015 to ban flavored tobacco products. 

“Four years later menthol is still available. This is despite knowing menthol is more dangerous than other products. Despite knowing menthol disproportionately impacts black communities,” she said. “I urge you to move forward with the recommendation to ban all flavored products including menthol.”

Shanaquewa Finney, a community health worker with the Urban League of Portland, is a mother and grandmother. Several members of her family smoke at home. They prefer menthol and flavored Swisher Sweets, she said. That’s caused a lot of health problems over the years, she said, both for smokers and the rest of the family forced to breathe in secondhand smoke.

“The thing that really gets me is I have grandchildren and a 12-year-old daughter,” she said. “She has access to these products. She has tried smoking with friends. I am asking that flavored tobacco and menthol are banned.”