Key Informants' Perceptions of Health Equity and Racial Justice Impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control.

INTRODUCTION: The Massachusetts legislature passed An Act Modernizing Tobacco Control in November 2019 to restrict retail sales of flavored commercially manufactured tobacco products including menthol products, increase penalties for violating the law's provisions, and provide health insurance coverage for tobacco treatment. AIMS AND METHODS: This study explores key informants' perceptions of intended and unintended impacts of implementation of the 2019 Massachusetts statewide law through a health equity and racial justice lens. We conducted in-depth interviews with 25 key informants from three key informant groups (public health officials and advocates, clinicians, and school staff) between March 2021 and April 2022. Using deductive codes on unintended impacts of the implementation of the law's policies, we conducted a focused analysis to identify impacts that were perceived and observed by informants from different key informant groups. RESULTS: Perceived or observed impacts of the law were identified across multiple levels by key informants and included concerns related to three broad themes: 1) intended impacts on health equity and racial justice, 2) ongoing availability of restricted products undermining the intended impact of the law, and 3) inequitable targeting by the policies and enforcement among communities of color. CONCLUSIONS: Future evaluation is needed to assess the intended and unintended impacts of implementation of the Massachusetts law to maximize the potential of the policies to reduce tobacco-related health disparities. We discuss implications and recommendations for achieving a national policy and equitable enforcement of flavored tobacco sales restrictions. IMPLICATIONS: This qualitative study among 25 key informants including public health and tobacco control advocates, clinicians, and school staff obtained perspectives of intended and unintended health equity and racial justice impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control. Findings and recommendations from this study can inform monitoring efforts to assess the law's impacts in Massachusetts and the adoption of similar flavored tobacco sales restrictions and other tobacco control policies in other states to maximize the health equity benefits and minimize unintended impacts.

The role of chain pharmacies to promote healthy food retail: Current trends, legal limits, and policy opportunities.

Chain drug stores have increased their health care role through expanded pharmacy services and retail health clinics. They also are major food retailers. This creates a tension between health promotion and sales of unhealthy foods and beverages to pharmacy customers. This article explores opportunities to improve the nutritional quality of foods sold at chain drug stores that differ from general healthy food retail approaches. It considers the legal limits on marketing to pharmacy customers; the potential roles of health insurers, pharmacy benefit managers and retail health clinics to voluntarily improve food offerings; and formal policymaking legal considerations and approaches.

Reduction in emergency department visits for children's asthma, ear infections, and respiratory infections after the introduction of state smoke-free legislation.

Despite the benefits of smoke-free legislation on adult health, little is known about its impact on children's health. We examined the effects of tobacco control policies on the rate of emergency department (ED) visits for childhood asthma (N=128,807), ear infections (N=288,697), and respiratory infections (N=410,686) using outpatient ED visit data in Massachusetts (2001-2010), New Hampshire (2001-2009), and Vermont (2002-2010). We used negative binomial regression models to analyze the effect of state and local smoke-free legislation on ED visits for each health condition, controlling for cigarette taxes and health care reform legislation. We found no changes in the overall rate of ED visits for asthma, ear infections, and upper respiratory infections after the implementation of state or local smoke-free legislation or cigarette tax increases. However, an interaction with children's age revealed that among 10-17-year-olds state smoke-free legislation was associated with a 12% reduction in ED visits for asthma (adjusted incidence rate ratios (aIRR) 0.88; 95% CI 0.83, 0.95), an 8% reduction for ear infections (0.92; 0.88, 0.97), and a 9% reduction for upper respiratory infections (0.91; 0.87, 0.95). We found an overall 8% reduction in ED visits for lower respiratory infections after the implementation of state smoke-free legislation (0.92; 0.87, 0.96). The implementation of health care reform in Massachusetts was also associated with a 6-9% reduction in all children's ED visits for ear and upper respiratory infections. Our results suggest that state smoke-free legislation and health care reform may be effective interventions to improve children's health by reducing ED visits for asthma, ear infections, and respiratory infections.

Public support for raising the age of sale for tobacco to 21 in the United States.

OBJECTIVES: The vast majority of tobacco users began before the age of 21. Raising the tobacco sales age to 21 has the potential to reduce tobacco use initiation and progression to regular smoking. Our objective was to assess the level of public support nationally for 'Tobacco 21' initiatives in the USA. METHODS: The Social Climate Survey of Tobacco Control, a cross-sectional dual-frame survey representing national probability samples of adults was administered in 2013. Respondents were asked to state their agreement level with, 'The age to buy tobacco should be raised to 21.' RESULTS: Of 3245 respondents, 70.5% support raising the age to buy tobacco to 21. The majority of adults in every demographic and smoking status category supported raising the tobacco sales age to 21. In multivariable analyses, support was highest among never smokers, females, African-Americans and older adults. CONCLUSIONS: This national study demonstrates broad public support for raising the sales age of tobacco to 21 and will help facilitate wide dissemination of initiatives to increase the legal purchase age at national, state and local levels. Increasing public awareness about the susceptibility and rapid addiction of youth to nicotine may further increase public support for raising the tobacco sale age to 21.

Tobacco industry use of personal responsibility rhetoric in public relations and litigation: disguising freedom to blame as freedom of choice.

We examined the tobacco industry's rhetoric to frame personal responsibility arguments. The industry rarely uses the phrase "personal responsibility" explicitly, but rather "freedom of choice." When freedom of choice is used in the context of litigation, the industry means that those who choose to smoke are solely to blame for their injuries. When used in the industry's public relations messages, it grounds its meaning in the concept of liberty and the right to smoke. The courtroom "blame rhetoric" has influenced the industry's larger public relations message to shift responsibility away from the tobacco companies and onto their customers. Understanding the rhetoric and framing that the industry employs is essential to combating this tactic, and we apply this comprehension to other industries that act as disease vectors.

Enforcement Provisions of Indoor Tanning Bans for Minors: An Analysis of the First 6 US States.

Several states have passed legislation banning minors from indoor tanning; however, concern has been raised regarding enforcement. We explored the statutes pertaining to enforcement in the first 6 US states to pass legislation banning minors younger than 18 years from indoor tanning. The findings reflect significant variability in enforcement provisions across the 6 states. Further investigations are needed to determine whether the statutes are successful in curbing indoor tanning among youths and ultimately whether indoor tanning bans among minors help to reduce skin cancer incidence.

Fast-food fights: news coverage of local efforts to improve food environments through land-use regulations, 2001-2013. [corrected].

Zoning and other land-use policies are a promising but controversial strategy to improve community food environments. To understand how these policies are debated, we searched existing databases and the Internet and analyzed news coverage and legal documentation of efforts to restrict fast-food restaurants in 77 US communities in 2001 to 2013. Policies intended to improve community health were most often proposed in urban, racially diverse communities; policies proposed in small towns or majority-White communities aimed to protect community aesthetics or local businesses. Health-focused policies were subject to more criticism than other policies and were generally less successful. Our findings could inform the work of advocates interested in employing land-use policies to improve the food environment in their own communities.

Trends in Electronic Cigarette Use Among U.S. Adults: Use is Increasing in Both Smokers and Nonsmokers.

OBJECTIVES: We assessed trends in use of electronic cigarettes among U.S. adults, demographic predictors of use, and smoking status of current electronic cigarette users. METHODS: Mixed-mode surveys were used to obtain representative, cross-sectional samples of U.S. adults in each of 4 years. RESULTS: Sample sizes for 2010, 2011, 2012, and 2013 were 3,240, 3,097, 3,101, and 3,245, respectively. Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18-24 (14.2%) was higher than adults 25-44 (8.6%), 45-64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers. CONCLUSIONS: There has been rapid growth in ever and current electronic cigarette use over the past 4 years. Use is highest among young adults and current cigarette smokers. Although smokers are most likely to use these products, almost a third of current users are nonsmokers, suggesting that e-cigarettes contribute to primary nicotine addiction and to renormalization of tobacco use. Regulatory action is needed at the federal, state, and local levels to ensure that these products do not contribute to preventable chronic disease.

The debate on regulating menthol cigarettes: closing a dangerous loophole vs freedom of choice.

The Family Smoking Prevention and Tobacco Control Act exempted menthol from a flavoring additive ban, tasking the Tobacco Products Safety Advisory Committee to advise on the scientific evidence on menthol. To inform future tobacco control efforts, we examined the public debate from 2008 to 2011 over the exemption. Health advocates regularly warned of menthol's public health damages, but inconsistently invoked the health disparities borne by African American smokers. Tobacco industry spokespeople insisted that making menthol available put them on the side of African Americans' struggle for justice and enlisted civil rights groups to help them make that case. In future debates, public health must prioritize and invest in the leadership of communities most affected by health harms to ensure a strong, unrelenting voice in support of health equity.

Cigarettes become a dangerous product: tobacco in the rearview mirror, 1952-1965.

Tobacco control's unparalleled success comes partly from advocates broadening the focus of responsibility beyond the smoker to include industry and government. To learn how this might apply to other issues, we examined how early tobacco control events were framed in news, legislative testimony, and internal tobacco industry documents. Early debate about tobacco is stunning for its absence of the personal responsibility rhetoric prominent today, focused instead on the health harms from cigarettes. The accountability of government, rather than the industry or individual smokers, is mentioned often; solutions focused not on whether government had a responsibility to act, but on how to act. Tobacco lessons can guide advocates fighting the food and beverage industry, but must be reinterpreted in current political contexts.

Retail impact of raising tobacco sales age to 21 years.

The majority of tobacco use emerges in individuals before they reach 21 years of age, and many adult distributors of tobacco to youths are young adults aged between 18 and 20 years. Raising the tobacco sales minimum age to 21 years across the United States would decrease tobacco retailer and industry sales by approximately 2% but could contribute to a substantial reduction in the prevalence of youths' tobacco use and dependency by limiting access.

The origins of personal responsibility rhetoric in news coverage of the tobacco industry.

The tobacco industry consistently frames smoking as a personal issue rather than the responsibility of cigarette companies. To identify when personal responsibility framing became a major element of the tobacco industry's discourse, we analyzed news coverage from 1966 to 1991. Industry representatives began to regularly use these arguments in 1977. By the mid 1980s, this frame dominated the industry's public arguments. This chronology illustrates that the tobacco industry's use of personal responsibility rhetoric in public preceded the ascension of personal responsibility rhetoric commonly associated with the Reagan Administration in the 1980s.

"Tobacco-free nicotine" electronic cigarette perceptions and use among adolescents and adults in five New England states.

Introduction: More brands are using tobacco-free nicotine (TFN) in electronic cigarettes (e-cigarettes) and these products are becoming increasingly popular. The term TFN and claims about its properties can mislead consumers about the harms and addictiveness of TFN e-cigarettes, which may increase initiation of these products among non-smokers or influence current smokers' decisions to adopt TFN e-cigarettes as a harm reduction measure. Methods: We conducted an observational, cross-sectional survey of 777 adolesc aged 13-17 and 655 current adult cigarette smokers residing in Massachusetts, Connecticut, New Hampshire, Rhode Island, or Vermont about their TFN e-cigarette awareness, use, perceptions, and susceptibility. We examined the association between prior awareness of TFN and use, perceptions, and susceptibility. Results: One-third of adolescents and adults reported being aware of TFN. TFN e-cigarette use was less common than tobacco-derived nicotine (TDN) e-cigarette use among adolescents (8.9 % vs. 30.5 %) and adults (21.1 % vs. 79.4 %). Compared to unaware adolescents, adolescents who were aware of TFN more frequently reported being more likely to use TFN compared to TDN e-cigarettes and that TFN e-cigarettes are more addictive than those containing TDN. Aware adult smokers more frequently reported that TFN e-cigarettes are more addictive than TDN e-cigarettes, TFN e-cigarettes cause some harm, TDN e-cigarettes cause little harm, and that TFN and TDN e-cigarettes are equally harmful than those who were unaware previously. Conclusion: Public health education campaigns are needed to educate consumers about the harms and addictiveness of TFN e-cigarettes.

Impacts of the Massachusetts 2019 An Act Modernizing Tobacco Control on tobacco retailer settings: A multi-methods study.

BACKGROUND: In November 2019, the Massachusetts legislature passed An Act Modernizing Tobacco Control and became the first state to restrict retail sales of all flavored (including menthol) cigarettes, e-cigarettes, and other tobacco products. Our study aims to provide the retailer experience of the new law from the perspectives of multiple stakeholders, including tobacco retailers themselves, public health officials, and Massachusetts residents. METHODS: We conducted in-depth interviews with seven tobacco retailers and ten public health officials from March 2021 to April 2022. Monthly repeated cross-sectional surveys were administered through the online survey panel Prodege from April 2021 to August 2022 (adult sample: N = 765; adolescent sample: N = 900). Themes from interviews were identified by drawing on deductive codes informed by the interview guide, followed by inductive coding of data. Survey data were descriptively analyzed in R. RESULTS: Key themes included retailer frustration over loss of sales to neighboring states, factors associated with retailer compliance, and the need for increased education regarding the law. Survey results showed that a minority of adolescents (13.3%) and adults (26.1%) who vaped in the past 30-days were traveling to border states to purchase vape products. Less than one-quarter of adolescent participants and less than half of adult participants could correctly identify which products Massachusetts did not sell. CONCLUSIONS: Evidence from the retailer, public health, and end-user perspectives support mutual benefits of adjacent states enacting flavored tobacco sales restrictions, improved policy education for retailers and the public, and improved retailer enforcement.

Allying tobacco control with human rights: invited commentary.

The recognition that tobacco control and human rights concerns overlap is quite recent. This commentary reflects upon tobacco control's growth through allying with other domains, and details a particular effort to build alliances between tobacco control and human rights practitioners.

The First State Tobacco Flavor Ban: High School Tobacco Control Needs in a Changing Landscape.

BACKGROUND: Despite recent tobacco control efforts, adolescent vaping remains an epidemic in the United States. The purpose of our study was to understand high school student vaping behaviors using the perceptions of Massachusetts school personnel during the critical window from when the Massachusetts statewide flavor ban legislation was passed in November 2019 through the first year of the COVID-19 pandemic. METHODS: High school personnel throughout Massachusetts were invited to complete a cross-sectional survey. Analysis of survey responses was conducted in R. RESULTS: A total of 162 respondents completed the survey representing 137 schools that draw enrollments from 216 (61%) of the 352 cities and towns in Massachusetts. The most popular products that respondents believed their students were using were JUULs (95.7%), other e-cigarettes (85.3%), and disposable vapes (79.6%). Following the flavor ban, the majority (90.7%) did not report an increase in combusted tobacco product use. All participants (100%) reported wanting more access to prevention and treatment resources. CONCLUSIONS: Our findings suggest that a comprehensive flavor ban may be an effective tobacco control policy that does not appear to promote student switching from vaping products to combusted tobacco products. These data also indicate that schools report needing additional resources to address the vaping epidemic.

Promotion of Meal Premiums in Child-Directed TV Advertising for Children's Fast-food Meals.

BACKGROUND: Fast-food intake is a modifiable obesity risk factor in early childhood, and child-directed fast-food marketing is common. Per self-regulatory guidelines regarding deception, premiums (ie, incentives or toy giveaways) in child-directed advertisements must be secondary to the advertised product. METHODS: Content analyses were performed of all child-directed fast-food television (TV) advertisements aired on four national US children's TV networks, February 1, 2019, through January 31, 2020, to assess the emphasis of premiums relative to food. We quantified the percent of the audio transcript (word count) and visual airtime (seconds) that included premiums or food and the on-screen size of premiums relative to food in randomly selected frames from each advertisement. RESULTS: There were 28 unique child-directed advertisements for children's fast-food meals in the study year; 27 advertisements were from one restaurant and accounted for nearly all (99.8%) of the total airtime for the 28 advertisements. Premiums were present in 27 of the 28 unique advertisements. On average, premiums (versus food) accounted for 53.0% (vs 16.0%) of words in the audio transcript and 59.2% (vs 54.3%) of the visual airtime per advertisement. In the random subset of frames that includes both premiums and food imagery, imagery of premiums accounted for 9.7% (95% CI: 6.4%-13.0%) of the on-screen area, whereas imagery of food accounted for 5.7% (95% CI: 4.4%-7.0%), an average ratio of 1.9:1 within each frame when excluding one large outlier. CONCLUSIONS: Child-directed fast-food TV advertisements emphasize premiums over food in violation of self-regulatory guidelines, counter to childhood obesity prevention efforts.