Smoking is the leading cause of preventable death and disability in the United States. More than 16 million Americans are living with a serious disease caused by smoking. The vast majority of smokers start smoking as teenagers. Youth smoking causes nicotine addiction, asthma and reduced lung function, and greatly increases the risk of cancer and cardiovascular disease. The rise of e-cigarettes and other vaping devices also creates new challenges, as youth often do not recognize the health risks of these smokeless products.
Baylor College of Medicine has taken a multidimensional, multidisciplinary approach to study and help prevent the harms of smoking and vaping, including researching the health risks, examining tobacco control and screening efforts, establishing tobacco cessation programs, and providing national and state-level public opinion data and ethical arguments to support policymaking and public dialogue.
The key elements of our position on preventing nicotine addiction include the following:
1. Youth addiction to tobacco and e-cigarettes is a complex societal problem that must be recognized and stopped. Unfortunately, rates of nicotine product use among middle and high school students have increased in recent years, driven primarily by an increase in e-cigarette use. High school student e-cigarette use climbed 78% from 2017 to 2018, with more than 3.6 million youth nationally reportedly using e-cigarettes.
2. Laws should be passed nationwide that prevent the sale of tobacco products and e-cigarettes to anyone under the age of 21 (Tobacco 21 laws). Nine in 10 smokers start before the age of 18. If an individual hasn’t started smoking by age 18, he or she very likely won’t ever do so. Raising the minimum age of sale for tobacco and nicotine products to 21 has been shown to reduce use among youth. Texas recently passed Tobacco 21 legislation. By passing Tobacco 21 laws nationwide, we could save 223,000 Americans every year from premature death associated with smoking.
3. There is bipartisan support for Tobacco 21 laws, and professional societies are supportive. Baylor faculty were the first to show that there is no difference in support for Tobacco 21 laws by political party and that support in “red” states was as high as support in “blue” states. Baylor faculty also helped mobilize professional societies, including the American Academy of Pediatrics and the American Thoracic Society, to publicly support Tobacco 21 laws and other policies to prevent youth smoking and vaping.
4. Stronger enforcement mechanisms, including signiﬁcant penalties for retailers who illegally sell tobacco and nicotine to minors, are critical to the success of Tobacco 21 laws. In March 2019, the FDA called out 15 national retailers who allegedly were found selling tobacco and nicotine products to minors. A recent study found tobacco and vape shops in California failed to check IDs for teens purchasing e-cigarettes and other nicotine products, despite a state law raising the legal age for purchasing such products to 21. Consequently, laws alone are not enough; they must be reinforced by such measures as compliance checks and strong penalties for retailer violations.
5. Stronger action needs to be taken to limit the marketing and sale of these products. Congress is investigating a leading vaping company’s business practices and its role in the youth nicotine epidemic. The FDA has taken action by more strictly regulating the marketing and sale of both traditional and e-cigarettes, and various advocacy organizations have called for restricting the use of flavorings that make these products especially appealing to children and teenagers. We support these actions, and urge the FDA and Congress to take additional steps to protect youth, including banning flavors in cigars and cigarillos, which have a disproportionate impact on minority and low-income populations.
6. Continued investment in research and implementation of prevention and cessation treatment strategies can have an impact. Data suggests increased implementation of proven tobacco control interventions can increase the number of smokers who make a quit attempt and who succeed in quitting. Baylor faculty have been on the frontlines studying the value of counseling to protect youth from tobacco and nicotine addiction. Additionally, the Dan L Duncan Comprehensive Cancer Center at Baylor St. Luke’s Medical Center is one of only two sites in the state of Texas that has recently begun implementing a National Cancer Institute-funded tobacco cessation program for patients with cancer. The goal is to help ensure that after patients leave their doctor’s office, they are equipped with the tools and steps they need to stop their tobacco use habits. More is needed to improve tobacco cessation counseling and treatment in both inpatient and outpatient facilities, and as part of lung cancer screening programs.
7. We must continue to examine research gaps with the goal of translating these into patient-care solutions. Baylor faculty are working to better understand the risks of tobacco and nicotine and perceptions about their use, especially in pregnant patients and among teens. Through our work at the Baylor Airways Clinical Research Center and in our clinical work at our affiliated hospitals, we also are leading efforts to study and care for patients suffering from asthma, lung cancer and chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis. Through our Office of Government Affairs and proactive media outreach, Baylor strives to provide timely and accurate information about the harms of smoking and the importance of regulation to prevent the harms of tobacco and of nicotine addiction.
While the national smoking rate has fallen to historic lows, the socioeconomic gap has never been bigger and e-cigarette use among our youth is rapidly on the rise. Baylor College of Medicine is leading efforts to prevent another generation from the harms of tobacco and nicotine addiction. We need to work together to educate legislators, policy makers and our communities to prevent tobacco and nicotine product use and tobacco smoke exposure.
Contributors: Stephanie Morain, Clarice Jacobson, Harold Farber, Roger Zoorob, Nicola Alexander Hanania, Melissa Suter, Kjersti Aagaard, Farrah Kheradmand, and Amy McGuire on behalf of the Center for Medical Ethics and Health Policy at Baylor College of Medicine.