Local leadership on tobacco prevention

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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.