Local leadership on tobacco prevention


To mark the World Health Organization’s World No Tobacco Day 2019, we sat down with Dr. Sara H. Cody, Health Officer for the County of Santa Clara and Public Health Department Director, to ask her about her the importance of banning flavors in e-cigarettes, her career in public health, and the value of cities’ public health departments working together.

Why are you passionate about banning flavors in vaping and e-cigarette products?

Banning flavors in e-cigarettes is our best strategy to prevent an entire generation of teens from taking up the nicotine habit. A decade ago, the public health community felt rightfully proud of preventing so much disability, disease and death through tobacco prevention programs and campaigns. Then e-cigarettes entered the marketplace, touted as less harmful than cigarettes and an aid for smokers who want to quit. We are now seeing increasing rates of e-cigarette use among youth in our county. While use of cigarettes among youth is down to 3 percent, at least 10 percent of youth now report using e-cigarettes.  With over 15,000 flavor options, such as Cotton Candy and Gummy Bears, it’s no wonder that more than 8 in 10 youth who use e-cigs report starting with a flavored product.

What we now understand is that e-cigarettes are essentially nicotine-delivery devices enshrouded in tasty sweet and minty flavors that hold a special appeal for middle and high school age youth.  The evidence is growing that while e-cigarettes do provide an off-ramp from the combustible tobacco highway, they entice a much larger and more vulnerable adolescent population onto the tobacco highway.  We know that the teenage brain is still developing, that nicotine is a highly addictive drug, and that nicotine poses a unique risk of long-lasting harmful effects for teenagers.

Preventing exposure to e-cigarettes will also prevent exposure to the chemicals found in these products as there’s so much we don’t yet know about their health impacts. Vaping and e-cigarette companies have successfully preyed on middle and high school students, targeting them with ads and flavors, and developing a market for their product for decades to come.  Nationwide, almost a third of youth who vape report doing so because the products are flavored, the same strategy the tobacco industry used to get kids hooked on cigarettes.

The FDA is currently considering action against e-cigarette makers like Juul. Why is it important for the ban to go nationwide?

Currently, the FDA’s actions don’t match the urgency of the problem. The proportion of youth becoming addicted to nicotine is rising at an alarming rate; it’s quickly becoming a public health failure of huge proportions. Our country will suffer the consequences for years to come, and quite frankly the FDA is simply not doing enough.

Like many local jurisdictions, we’ve had to fill the vacuum and take action to address the growing vaping epidemic. Not only does smoking cause thousands of preventable deaths from secondhand smoke exposure and other smoking-related illnesses, smoking costs the County of Santa Clara millions of dollars every year.  The tobacco industry is targeting our kids with the same tactics they used to hook their parents and grandparents on cigarettes, and all levels of government need to step up.  

Tell us about why you first got involved in public health.

When I was a resident taking care of patients in an internal medicine primary care clinic, I remember one patient in particular. I was ostensibly seeing her for hypertension and hypercholesterolemia, but her chief complaints were chronic headaches, stomach pain, and neck pain. As I would soon discover, she was struggling with unstable housing, unstable employment, and a teenage son with untreated mental health issues who was setting small fires around their apartment building. In short, the prescriptions I had to offer seemed so trivial, and so wildly mis-matched to what she really needed to be well.

I think about her when I think about our public health charge to create the conditions in which people can be healthy. To connect this back to the history of tobacco prevention and the accelerating epidemic of teen vaping, we can’t solve this problem by telling youth not to vape, or by developing nicotine addiction recovery tools and programs. It’s our job to keep these products from being attractively marketed to youth in the first place. And yes, we can eliminate flavored vaping products in our county, but unless there is meaningful and timely action at the national level, we cannot realistically curb the vaping epidemic. 

Tell us about one of the greatest challenges of your career in public health and how you grew from it.

The greatest challenge that I experience is an ongoing one that I face almost every day, and that is the challenge of articulating the value of public health. My world of upstream prevention: changing social norms, changing policy, changing the social and physical environment, or even more basic public health prevention like HIV and syphilis screening, or ensuring PrEP for those at risk, regularly collides with the world where most of my health colleagues are living: how do we get more healthcare services to more sick people and pay for it. Yes, of course we need robust healthcare services of all kinds, but it should not be to the exclusion of investment in primary prevention. I don’t know if I’ve grown from this challenge, but I have found allies in my local public health law colleagues, and kindred spirits in health officials across the country.

Are there any other counties that have led on an issue you care about? Tell us about what you took from that.

The work done by the City and County of San Francisco on the issue of flavored tobacco, including e-cigarettes, is very impressive. The Board of Supervisors, championed by then Supervisor Malia Cohen, adopted a complete restriction on the sale of flavored products at all stores, going farther than most local cities and counties at that time. The law was swiftly challenged through a referendum (Prop E), that was placed on the ballot by the tobacco industry. Widespread community awareness and support for protecting youth fueled San Francisco voters, who ultimately upheld the city’s law, ending the sale of candy-flavored tobacco by a 68-32 percent margin. This set a foundation for other local cities and counties to move efforts forward. In the absence of federal action, local public health experts and elected officials must step in and lead on tobacco prevention.

Innovating to Reduce Harm in Las Vegas

The costs of the opioid crisis are a top concern among policymakers in Washington, DC, and continue to dominate headlines daily. The cost in human life, family suffering and finances is sobering. In 2017, the nation lost more than 47,000 Americans to opioids, and in my home state, Nevada Department of Health and Human Services Office of Analytics reports that there were 401 opioid-related overdose deaths. This week, a new study estimated that the federal tax revenue lost to the opioid epidemic totals $26 billion, nationally. Diseases related to drug use have also surged, with Hepatitis C increasing 133 percent between 2004 and 2014, tracking with the growth of opioid injection hospital admissions. Reports of dangerous, dirty needles littering public parks and neighborhoods are common.

A Standardized Approach is Needed to Address Social Determinants of Health

By Dr. Colleen Bridger, MPH, PhD.
San Antonio Metropolitan Health District

America leads the world in medical research and medical care and for all we spend on health care, we should be the healthiest people on earth. Yet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and Jordan. There is growing recognition that health starts – long before illness – in our homes, schools and jobs. In fact, only about 20 percent of a person’s health happens in the doctor’s office – the rest happens out in the world and things like healthy air and water may not be in a person’s control.

Now is the Time to Tell Policymakers that Trauma Matters to Our Health

By Kelly Colopy, MPP, BCHC Chair and Director, Long Beach Health Department Director
Amanda Merck, MPH, Senior Research Area Specialist, Salud America!, UT Health San Antonio  

Public health professionals all over the country are leveraging practice and policy strategies to address the issue of trauma, including incorporating a “trauma-informed” point of view into the way they conduct business. In recent years, public health science and practice has become more cognizant of the evidence of, and action needed, to support those who suffer from trauma. This awareness and response is starting to transform the field.

Wrapping Up the Highs and Lows of Urban Public Health in 2018

By Chrissie Juliano, Director, Big Cities Health Coalition

As 2018 winds down, I am celebrating my four year anniversary with the Big Cities Health Coalition, which has been a leader in the urban public health field for 16 years. While our membership, staffing, location, and infrastructure have changed over the years, our mission, vision, and goals remain the same: to protect health of those who live in America’s big cities for present and future generations.

Guarding against viral misinformation this flu season

By Joseph P. Iser, MD, DrPH, MSc
Chief Health Officer
Southern Nevada Health District

As a clinician and a public health professional, I see every day how technology can help providers give patients useful information, better care, and drive better outcomes. As doctors, we use online toolkits to help treat our patients, eReferrals to provide more efficient access to smoking cessation resources, and electronic health records can make everything more accessible for both providers and patients. In my role as the Chief Health Officer of the Southern Nevada Health District, I’ve also come to see what a valuable public health tool technology and social media can be. In our agency, we use Twitter, Facebook, and YouTube throughout the year to educate and motivate our community on public health issues from violence, to STDs, and of course, the flu. We created a new video earlier this year about the importance of the flu vaccine and have a Twitter account dedicated to information about the flu.

World AIDS Day 2018: Progress Continues, Disparities Remain

By Kim Rodgers, Communications Specialist, National Association of County and City Health Officials

World AIDS Day, observed annually on December 1, provides the opportunity to highlight our accomplishments, remember those who have lost their lives to HIV and AIDS, and refocus our efforts on what still needs to be done to end the epidemic. Local health departments are in the forefront of these efforts, working on initiatives to address the prevention and treatment of HIV and AIDS and support work towards a cure.

Child Development-Community Policing: How One Local Health Department Joins Local Police on The Front Line in The War on ACEs

By Stacey Butler, LCSW, Child Development-Community Policing Director
and Gibbie Harris, Director
Mecklenburg County Public Health

Gunshots ring out at a Charlotte, North Carolina apartment complex, and a five-year-old girl is struck in the leg by a stray bullet. Charlotte-Mecklenburg Police (CMPD) arrive on scene.  Recognizing the potential psychological trauma for the child and her family, they call the Child Development-Community Policing (CD-CP) on-call clinician. She responds within minutes, providing acute trauma intervention alongside her officer partner, who is beginning the work of helping the child and her family feel safe again. This officer-clinician team continues to visit the family over the next few days and weeks to assess progress and needs, providing targeted interventions, and helping reestablish a sense of safety both inside and outside their home.

Ten lessons we learned about how to deploy teams into post-hurricane settings

By Mitch Stripling, MPA, Assistant Commissioner, Bureau of Agency Preparedness and Response; Colin Stimmler, MA, Senior Director for Agency Preparedness and Response at the New York City Department of Health and Mental Hygiene

Disasters like Hurricane Michael show how severe the public health impacts from a coastal storm can be.  When disasters like this strike, many local and state health workers are often willing to help in another jurisdiction, but they aren’t quite sure how.  

New Report: Shortage of “Disease Detectives” in Local Health Departments Puts Cities at Risk

By Big Cities Health Coalition and Council of State and Territorial Epidemiologists staff

Epidemiologist, noun
epidemiologist \ˌe-pə-ˌdē-mē-ˈä-lə-jist
An expert scientist who studies, detects and tracks injuries and disease in our communities.

Epidemiologists serve on the front lines of public health, protecting Americans and the global community. When health threats emerge, these “disease detectives” investigate. They identify the causes, factors and patterns associated with illness, determine who is at risk, collect evidence to recommend preventive actions, and rapidly implement control measures. Epidemiologists also respond to major health hazards including emerging threats such as Zika and Ebola, as well as natural disasters such as floods and hurricanes. They also work on chronic issues facing communities including obesity, diabetes, cancer, HIV/AIDS and motor vehicle crashes.

Big Tobacco is marketing vapes to our kids, so our city took them on and won — it’s the FDA’s turn now

By Tomás Aragón, MD, DrPH, Health Officer and Director, Population Health Division, Derek Smith, MSW, MPH, Tobacco Free Project Director, San Francisco Department of Health

This blog originally appeared here in the Hill.

The FDA recently announced that it considers a new surge in teen e-cigarette use to be an epidemic, and will give e-cigarette manufacturers 60 days to prove that they are not marketing to kids. This is a very welcome move for those of us who have been pushing to prevent teen tobacco use. Our city recently took on the makers of e-cigarettes and won. The FDA should take San Francisco's lead and do everything it can to protect kids from Big Tobacco.

Hurricane Harvey: In the Eye of the Storm

By Big Cities Health Coalition Staff

It’s been one year since Hurricane Harvey hit Houston and the surrounding area with record-breaking rain and devastating floods which inflicted injuries, infectious diseases, chemical exposures and mental trauma on residents. Public health officials from the Houston Health Department, a member of the Big Cities Health Coalition, were on the front lines in the lead up to the hurricane and its aftermath. Today, many are reflecting on the events of those four historic days in August 2017 and what lessons were learned, and can still be learned, from the disaster.

Let schools be places for learning—not “JUULing”

By Brian A. King, PhD, MPH, Deputy Director for Research Translation, Office on Smoking and Health, Centers for Disease Control and Prevention

Remember your high school bathroom? If it was anything like mine, the bathroom was a fairly foul-smelling place that you wanted to leave as quickly as possible.

But things are changing. Kids are flocking to school bathrooms across the country faster than the cafeteria on pizza day. School bathrooms have become places where students gather to socialize and use e-cigarettes—in particular, e-cigarettes shaped like USB flash drives that deliver a high level of nicotine.

Minneapolis Health Department Supports a Young Food Entrepreneur

By Dan Huff, Director of Environmental Health, and Gretchen Musicant, Commissioner of Health, Minneapolis Health Department

This blog originally appeared here on The National Association of County & City Health Officials (NACCHO) Essential Elements Blog.

Jaequan Faulkner, 13, started selling hot dogs in front of his Minneapolis home in 2016, calling his establishment “Mr. Faulkner’s Old Fashioned Hot Dogs.” His food stand came back this summer bigger and better than before, and it grew popular with customers in the neighborhood.

Recently, his business came to the attention of local officials when someone complained that he did not have official permits.

To make sure people are safe from food-borne illnesses, all events that serve food to the public in Minneapolis must be permitted, and violators are subject to an immediate shutdown.

Our Top Takeaways from NACCHO Annual 2018

By Big Cities Health Coalition Staff

We just returned to D.C. from the NACCHO Annual Conference, a summer pilgrimage for public health enthusiasts, which took place this year in New Orleans. The theme of this year’s conference was Unleashing the Power of Public Health. Our time in The Big Easy was especially frenetic this year, with lots and lots of sessions that we found fascinating. Below is a collection of our top takeaways from some of the most engaging sessions we participated in. Tell us which moments you thought were most important in the comment box below, or on Twitter at @BigCitiesHealth.

Public Health and Medical Community Pledge to Decrease Gun Violence

By Dr. Jeff Duchin, Health Officer for Public Health – Seattle & King County

This blog originally appeared here in the Public Health - Seattle & King County blog Public Health Insider

Firearm-related injury and death, from suicide to accidental injury and homicide – is a major public health problem and a leading cause of premature death in King County and nationally. In 2016, 663 adults and 20 children died from a firearm injury in Washington state, including 144 adults and 7 children from King County.

Firearm-related injuries have very high personal and financial costs to individuals, families and society – and that’s why prevention is essential.  In 2015, the cost of firearm fatalities alone (not counting non-fatal injuries) in King County was almost $200 million from medical costs and lost productivity, and nationally the cost is in the hundreds of billions of dollars each year.

LGBTQ Pride and Public Health

By Ginger Lee, MPH, Bureau Manager, Collective Impact & Operations,
Long Beach Department of Health and Human Services

June is LGBTQ Pride month.  Pride is a time when lesbian, gay, bisexual, transgender, queer and questioning people join together to further strengthen community by celebrating joyously, with parades and other events.  Pride is also a time when the LGBTQ community remembers its history. And for public health professionals, Pride is a time to reflect on what we can do to address social conditions that negatively affect the health of LGBT people, and to strengthen conditions that support health within our LGBTQ communities.

Hepatitis Awareness Month 2018: Addressing Hepatitis A

By Meghan McGinty, PhD, MPH, MBA, Deputy Director of the Big Cities Health Coalition, and Michelle Cantu, MPH, Director of Infectious Diseases and Immunization, NACCHO

This blog originally appeared here on The National Association of County & City Health Officials (NACCHO) Essential Elements Blog.

The month of May is designated as Hepatitis Awareness Month in the United States and May 19th is Hepatitis Testing Day. During this month, NACCHO will highlight the role of local health departments (LHDs) in responding to this silent epidemic and work to bring increased attention to viral hepatitis. Through a series of three blog posts, NACCHO will focus on the most common types of viral hepatitis, which are hepatitis A, hepatitis B, and hepatitis C. This series seeks to raise awareness of the importance of vaccination for hepatitis A and B, testing for hepatitis B and C, and the availability of effective care and treatments that, in the case of hepatitis C, result in a cure for most people. Additionally, the series will highlight current events related to viral hepatitis – such as outbreaks of hepatitis A in jurisdictions across the country and soaring rates of hepatitis B and C associated with increased injection drug use that is being fueled by the opioid epidemic – and how LHDs are on the frontlines of responding to these worrying trends.