Issues in Respiratory Therapy: How New Legislation Can Help Tackle America’s Addiction to Nicotine

In December 2019, Congress passed a provision that would raise the legal age to purchase tobacco products to 21, as part of a $1.4 trillion spending bill. The provision was the culmination of a five-year process, wherein 19 states and over 500 towns and cities had passed similar rules. And it comes as one part of a much-needed response to rising youth addiction to nicotine through vaping, e-cigarettes, and other flavored forms of nicotine consumption.

“The basic dynamic on tobacco legislation, ever since about the ‘50s, has been that the public overwhelmingly supports doing something about the tobacco epidemic, and the tobacco companies fight it,” says Dr. Stanton Glantz, director of the UCSF Center for Tobacco Control Research and Education.

Some experts, including Dr. Glantz, had initially worried that the Republican-led bill was something of a trap and that the bill’s language could support an industry blitzkrieg that would implement weaker laws in several different states at once.

“One of the tobacco industry’s strategies is when it’s clear they can’t stop something, they’ll start supporting bad legislation, so the politicians can claim they solved the problem while still protecting the industry,” Dr. Glantz says.

Examples of that behavior have been seen in Big Tobacco’s support of state laws with wording that emphasized the purchase of tobacco products, thereby placing fault on the youth and/or clerk engaging in a transaction, while shielding owner/operators, manufacturers, and distributors. But, thanks to the efforts of pro-health activists, the new provision’s wording is largely focused on promoting public health—and it gives little back to Big Tobacco.

The Great American Smokeout

In addition to legislation, one way to combat smoking addiction and help with quitting are public events such as the Great American Smokeout. Celebrated on the third Thursday every November, the Great American Smokeout is the day Americans are encouraged to quit smoking. This year, it is celebrated on November 18, 2021.

While quitting smoking can be difficult, the Great American Smokeout doesn’t ask people to stop smoking in one day but instead make this day the start of the journey to a smoke-free life. There is a lot of community and camaraderie on this day as there are thousands of Americans that make the Great American Smokeout their first day being tobacco-free. This event is sponsored by the American Cancer Society as quitting smoking dramatically reduces the risk of several forms of cancer.

To help people quit smoking, the Great American Smokeout and the American Cancer Society have published numerous resources, including research, cancer screening guidelines, current news, and more. However, information alone is rarely enough to help people quit.

Americans that truly succeed at quitting have done so because of the support they have received. The American Cancer Society encourages people to find help and, if necessary, treatment. Services that can be accessed to help with quitting include support phone lines, nicotine anonymous meetings, or a quitting counselor or coach. In fact, the American Cancer Society has a 24-hour quitting hotline people can call at any time to receive support.

Meet the Expert: Stanton Glantz, PhD

Dr. Stanton Glantz—now retired—is the former Director of the UCSF Center for Tobacco Control Research and Education (CTCRE) and Program Director of the CTCRE Postdoctoral Training Program. His research covers a wide range of topics, including the health effects of e-cigarettes and secondhand smoke (particularly on the cardiovascular system) and the efficacy of different tobacco control policies.

Dr. Glantz is the author and co-author of numerous publications on tobacco control, including secondhand smoke, e-cigarettes, and heated tobacco products. In the 1990s, working with the UCSF Library, Dr. Glantz helped publicize over 90 million pages of previously secret documents from the tobacco industry.

He graciously shared his perspective on prospective changes to tobacco regulations.

T21 Laws and Banning Flavored Tobacco Products

The US Surgeon General has said that youth use of nicotine in any form is unsafe. Nicotine has adverse effects on the developing teenage brain, and a large majority of smokers pick up the habit before they turn 20. A 2015 study by the National Academy of Medicine estimated that raising the legal age to purchase tobacco products to 21 (via rules known as T21 laws) could lead to a 12 percent reduction in tobacco use by the time teenagers become adults, with the largest impact being on 15- to 17-year-olds. Further studies have shown that T21 laws significantly reduce smoking amongst youth.

While T21 laws are a win, they don’t go far enough. Smoking is still responsible for nearly half a million deaths per year in the US, according to the Centers for Disease Control and Prevention (CDC). One of the next legislative steps in fighting back is banning flavored tobacco products, including menthol cigarettes, as the European Union did in a 2016 law that went into effect in 2020.

Menthol cigarettes and other forms of flavored tobacco mask the product’s taste, smell, and astringency. Youth smokers are more likely to use menthol cigarettes than any other age group; over half of smokers between the ages of 12 and 17 use menthol cigarettes, compared with just a third of smokers over the age of 34. Menthol cigarettes are also more addictive. A 2014 clinical trial of smoking cessation products found that smoking menthol cigarettes reduced the likelihood of quitting smoking.

“Menthol is much more than a flavor,” Dr. Glantz says. “Menthol interacts with nicotine, and you can tune the menthol-nicotine ratio in order to increase the addictive potential of cigarettes. It’s a local anesthetic, so it makes it easier to get the smoke down. It’s the most important additive in tobacco products.”

Since the EU law banning menthol cigarettes, similar legislation has been passed in Canada. Progress has been more scattershot in the US, with Massachusetts, San Francisco, Sacramento, and Los Angeles passing their own bans. In February of 2020, the US House of Representatives narrowly approved a bill that would ban all flavored tobacco products, including menthol cigarettes, at the federal level.

The American Civil Liberties Union (ACLU) and nearly two-dozen Democrats argued that the bill unfairly targets African Americans. The prevalence of menthol cigarettes is extremely high among African American communities: 70 percent of African American youth smokers use menthol cigarettes, and 85 percent of all African American smokers use menthol cigarettes, compared to 29 percent of whites. The bill’s opposition points to the unintended consequence of further policing on African American communities that a menthol ban could create.

But others, including Dr. Glantz, have argued that keeping menthol cigarettes on the shelves is unfairly targeting African Americans, too. From the 1950s up until the mid-2000s, tobacco companies heavily targeted the marketing of menthol cigarettes to African Americans, youth, and other minority communities. And, while they’re no longer sponsoring music festivals, they are still actively promoting the use of menthol cigarettes within the youth and minority demographics. A 2011 study of cigarette prices found that menthols were significantly less expensive in areas with a large African American community, where menthol advertising also continues to be higher than average.

In 2016, the African American Tobacco Control Leadership Council (AATCLC) and Action on Smoking and Health (ASH) sued the Food and Drug Administration (FDA) for continued inaction on menthol products. And inaction does seem particularly callous, given that the FDA has also stated that it’s likely menthol cigarettes pose a greater public health risk than non-menthol cigarettes. Banning or further restricting the sale of menthol cigarettes would have a positive health impact on a demographic that quits smoking less often and has higher rates of lung cancer than their White counterparts.

Sadly, once the bill was passed on to the Senate it was referred to committee and has not reemerged. According to Dr. Glantz, that’s largely because of pushback from the tobacco industry, which has a history of co-opting not only politicians but also legitimate organizations like the ACLU in order to support their agenda.

“In general, what I’ve found is that the higher up you go in the political system, the stronger the tobacco industry is—and the weaker the public is,” Dr. Glantz says.

Local legislators tend to be more sensitive to public opinion than those at the federal level. And the local level is where most of the recent progress in tobacco legislation has taken place. When the federal level has failed to implement laws such as T21 or flavor bans, local and state legislators have stepped in. The result of that local action eventually rippled back upwards into a federal T21 provision.

“At some point, there becomes an overwhelming enough level of pressure from all this local action that it generates action at higher levels,” Dr. Glantz says.

The FDA has some leeway, however. In 2009, the Tobacco Control Act gave the FDA control over the manufacturing, distribution, and marketing of tobacco products. Right away, the FDA banned all flavors in cigarettes except menthol, although they still allowed flavors in other tobacco products. In April 2021, the FDA announced that they are working on new product standards that will ban menthol in cigarettes and all flavors in cigars. The rules will soon be published in the Federal Register and will be open for public comment.

Banning menthol and other flavors of tobacco is just one scrum in the larger fight pro-health lobbyists are waging against America’s addiction to nicotine. Indoor clean-air legislation remains a top priority. The rise of legal marijuana, the production of new heated tobacco products, the industry’s expansion into low- and middle-income countries, and the continued proliferation of smoking in entertainment all require continued attention at the local, state, and federal levels. And while Dr. Glantz knows how difficult the task can be, he remains hopeful.

“The tobacco industry is very powerful, and they’re a tough opponent, there’s no question, but the fact is, they’re losing.” Dr. Glantz says. “We don’t have to match the industry dollar for dollar, because we’ve got the truth and public opinion on our side. It’s easier to sell the truth than a lie.”

Matt Zbrog

Matt Zbrog


Matt Zbrog is a writer and researcher from Southern California. Since 2018, he’s written extensively about trends within the healthcare workforce, with a particular focus on the power of interdisciplinary teams. He’s also covered the crises faced by healthcare professionals working at assisted living and long-term care facilities, both in light of the Covid-19 pandemic and the demographic shift brought on by the aging of the Baby Boomers. His work has included detailed interviews and consultations with leaders and subject matter experts from the American Nurses Association (ASCA), the American College of Health Care Administrators (ACHCA), and the American Speech-Language Hearing Association (ASHA).

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