美国肺脏协会+2022年烟草控制状况报告-136正式版

2022“StateofTobaccoControl”2022:20Yearsof“StateofTobaccoControl”—CelebratingtheProgressMadeandRecognizingtheWorkthatRemainstobeDoneExecutiveSummaryTheAmericanLungAssociation’sannual“StateofTobaccoControl”reportevaluatesstatesandthefederalgovernmentonactionstakentoeliminatethenation’sleadingcauseofpreventabledeath—tobaccouse—andsaveliveswithproven-effectiveandurgentlyneededtobaccocontrollawsandpolicies.TheLungAssociationproudlymarksthe20thanniversaryofreleasingits“StateofTobaccoControl”reportin2022byreflectingontheprogressmadeoverthepast20yearsandlookingaheadtothesignificantamountofworkthatremainstobedonetoendtobacco-causeddeathanddiseaseinthiscountry.Anewgenerationoftobaccoproducts,includinge-cigarettes,threatenstheprogressmade,asmorethantwomillionmiddleandhighschoolstudentsreportedusinge-cigarettesin2021.1Inresponsetotheyouthvapingepidemic,newpublicpolicies,includingendingthesaleofallflavoredtobaccoproducts,haveriseninimportanceaswell.Keythemesin“StateofTobaccoControl”thisyearinclude:FDAOpportunitiesin2021toReduceTobaccoUse:TheU.S.FoodandDrugAdministration(FDA)tookseveralactionsin2021thatcouldsignalabeginningtomeaningfulactioninitsoversightoftobaccoproducts.OnApril29,2021,FDAmadeanimportantannouncementindicatingitsintentiontoissueproposedrulesnolaterthanApril2022toremovementholcigarettesandmostflavoredcigarsfromthemarketplace.IfFDAfollowsthroughonitscommitment,itwillbeanhistoricachievementforpublichealthintheU.S.giventhedisproportionateimpactmentholcigarettesandflavoredcigarshaveonmanydifferentcommunitiesandpopulations,especiallyBlackAmericans.FDAhadanopportunitytoremovee-cigarettesandothertobaccoproductsfromthemarketthatdidnotmeetitspublichealthstandardthroughitspre-markettobaccoauthorization(PMTA)authorityundertheFamilySmokingPreventionandTobaccoControlAct.FDAwasunderacourt-ordereddeadlineofSeptember9,2021,toreviewmillionsofPMTAssubmittedbye-cigarettesandothertobaccoproductcompaniesin2020.Unfortunately,asoftheendof2021,FDAhadnotactedontheproductsmostresponsiblefortheyouthe-cigaretteepidemicsuchasJUUL,leavingthemonthemarket.HealthDisparitiesRelatedtoTobaccoUse:Anunfortunateconstantoverthepast20yearsistheunequalburdenoftobaccouseandexposuretosecondhandsmokeonsomecommunitiesandpopulations.Theoveralladultsmokingratehasdeclinedsignificantlyfrom21.6%in2003to14.0%in2019,a35%decline.2However,thisoverallratemaskssignificantdisparitiesamongraces/ethnicitiesandduetosocio-economicfactors.SmokingremainsparticularlyhighamongNativeAmericansandAlaskanNativesat20.9%andLesbian,GayandBisexualadultsat19.2%.3Smokingamongpersonswithlowerincomesandlowerlevelsofeducationalso2 L AmericanLungAssociation“StateofTobaccoControl”2022MoreAbout“StateofTobaccoControl”“StateofTobaccoControl”2022isfocusedonprovenpoliciesthatfederalandstategovernmentscanenacttopreventandreducetobaccouse.Theseinclude:Tobaccopreventionandquitsmokingfunding,programsandrobustinsurancecoverage;Comprehensivesmokefreelawsthateliminatesmokinginallpublicplacesandworkplaces;Increasedtobaccotaxes;Eliminatingthesaleofallflavoredtobaccoproducts;FullimplementationoftheU.S.FoodandDrugAdministration’s(FDA)FamilySmokingPreventionandTobaccoControlAct;andHardhittingfederalmediacampaignstoencouragesmokerstoquitandpreventyoungpeoplefromstartingtousetobacco.ThereportassignsgradesbasedonlawsandregulationsdesignedtopreventandreducetobaccouseineffectasofJanuary2022.Thefederalgovernment,all50stategovernmentsandtheDistrictofColumbiaaregradedtodetermineiftheirlawsandpoliciesareadequatelyprotectingcitizensfromtheenormoustolltobaccousetakesonlives,healthandtheeconomy.

2022remainshigh.4Certainpopulationsarealsodisproportionatelyexposedtosecondhandsmoke,including:childrenages3-11,BlackAmericans,personslivinginpovertyandpeoplewithahighschooleducationorless.5Partsofthecountry,especiallymanySouthernandAppalachianstatesremainunprotectedfromsecondhandsmokeinpublicplacesandworkplacesaswell.StateProgresstoReduceTobaccoUse:Thecountryhasmadesubstantialprogressonseveralofthestatepublicpoliciesmeasuredin“StateofTobaccoControl”overthepast20years.Theseinclude:Progressingfrom2to28smokefreestates;Increasingtheaveragestatecigarettetaxfrom$0.62inJanuary2003to$1.91inJanuary2022;andImprovingstateMedicaidprogramcoverageofquitsmokingtreatmentssince“StateofTobaccoControl”firstbegantrackingthesedatain2008.In2021,thetobaccoindustrybroughtbacktotheforefrontanoldroadblockithasusedformorethan30years:preemption,orlobbyingstatelegislaturestopasslawsthatpreventlocalcommunitiesfrompassingtobaccocontrolpoliciesstrongerthanstatelaw.Thisseverelyhamperstheabilityoflocalcommunitiestopreventandreducetobaccouse.Unfortunately,thetobaccoindustrywassuccessfulininstitutingnewpreemptivestatelawsonsalesoftobaccoproductsinFloridaandMontanain2021.TheCOVID-19pandemic’simpactontobaccouseisstillbeingassessed.AccordingtoaFederalTradeCommissionreportin2020,cigarettesalesincreasedforthefirsttimein20years.6Itisunclearifthissignalshigheradultsmokingrates,orexistingsmokerssmokingmorecigarettes.Inaddition,therateofyouthvapingintheCentersforDiseaseControlandPrevention’s2021NationalYouthTobaccoSurveyvariedsignificantlyifastudenttookthesurveyathomeorinaschoolbuilding.7Therefore,itisunclearifthelevelofyouthvapingseenin2021willbeaone-yearbliporadurabletrend.During2020,manycasinosbothtribalandnon-tribalre-openedsmokefreeafterbeingclosedinitiallyduringtheCOVID-19pandemic.Unfortunately,2021sawsomebackslidinginthisareawithsmokingreturningtocasinosinNewJerseyandPennsylvaniaafteremergencyordersissuedbygovernorspreventingthemfromallowingsmokingexpired.Activityontobaccotaxincreasesendedupbeingmuchslowerthanexpectedin2021aswell,duetomanystatebudgetsbeingmorerobustthanexpected.In2022,thecountryneedstoredoubleitseffortstopasstheprovenpoliciescalledforin“StateofTobaccoControl.”Thiswillrequireanongoingpartnershipatthefederal,stateandlocallevelstorestartdeclinesinadultandyouthtobaccouseratesandreducethe480,000liveslosttotobaccoeachyear.Ourelectedofficialsmusttakestrongeractionstoputthecountryonapathtofinallyendtobaccouseoverthenext20years.Park-LeeE,RenC,SawdeyMD,etal.NotesfromtheField:E-CigaretteUseAmongMiddleandHighSchoolStudents—NationalYouthTobaccoSurvey,UnitedStates,2021.MMWRMorbMortalWklyRep2021;70:1387–1389.DOI:/10.15585/mmwr.mm7039a4.CDC.NationalHealthInterviewSurvey.Variousyears.CorneliusME,WangTW,JamalA,LoretanCG,NeffLJ.TobaccoProductUseAmongAdults—UnitedStates,2019.MMWRMorbMortalWklyRep2020;69:1736–1742.Ibid.3 L AmericanLungAssociation“StateofTobaccoControl”20222022TsaiJ,HomaDM,NeffLJ,SosnoffCS,WangL,BlountBC,MelstromPC,KingBA.TrendsinSecondhandSmokeExposure,2011-2018:ImpactandImplicationsofExpandingSerumCotinineRange.AmJPrevMed.2021Sep;61(3):e109-e117.doi:10.1016/j.amepre.2021.04.004.FederalTradeCommission.“CigaretteReportfor2020.”ReleasedOctober2021.Park-LeeE,RenC,SawdeyMD,etal.NotesfromtheField:E-CigaretteUseAmongMiddleandHighSchoolStudents—NationalYouthTobaccoSurvey,UnitedStates,2021.MMWRMorbMortalWklyRep2021;70:1387–1389.DOI:/10.15585/mmwr.mm7039a4.4 L AmericanLungAssociation“StateofTobaccoControl”2022202220thAnniversaryof“StateofTobaccoControl”ShowsPolicymakersatAllLevelsofGovernmentHaven’tFullyEmbracedImportanceofPreventingandReducingTobaccoUseTobaccoremainstheleadingcauseofpreventabledeathanddiseaseinAmerica,killing480,000peopleeachyear.Inaddition,16millionAmericanslivewithatobacco-relateddisease.3

SincetheAmericanLungAssociationfirstlaunchedits“StateofTobaccoControl”reportinJanuary2003,thecountryhas,overall,madetremendousprogressinitseffortstopreventandreducetobaccouse.Adultcigarettesmokingrateshavedeclinedfrom21.6%in2003to14%in2019.1Youthcigarettesmokingrateshavefallenevenfasteramonghighschoolstudentsfrom22.5%in2002to4.6%in2020.2Atthestatelevel,thecountryhasseensignificantprogressonseveraltobaccocontrolpolicies,including:1)smokefreeworkplacelaws,2)tobaccotaxesand3)Medicaidcoverageoftobaccocessationtreatments.Atthefederallevel:1)theU.S.FoodandDrugAdministration(FDA)gainedcomprehensiveauthorityoverthemanufacture,marketingandsalesoftobaccoproducts;2)flavoredcigarettes,withtheglaringexceptionofmenthol,wereprohibited;and3)thefederalageofsalefortobaccoproductswasincreasedto21nationwide.However,inotherways,federal,stateandlocalpolicymakershaveyettotakethestepsnecessarytoeliminatetobaccouseorprotectanothergenerationofyouthfrombecomingaddicted.Significantsocial,racial,geographicandsexualorientationdisparitiesinwhousestobaccoproductsandwhoisexposedtosecondhandsmokeintheU.S.haveonlybecomemorepronouncedasoveralltobaccouserateshavedecreased.WhiletherehavebeensomepromisingannouncementsandactionstakenbyFDAin2021,unnecessaryaddiction,diseaseanddeathcouldhavebeenpreventedbymoreassertivefederalgovernmentactiononflavoredtobaccoproducts.Stateprogressoncomprehensivesmokefreeworkplacelawsappearssuccessfuloverthecourseof20yearsbuthascompletelystalledsince2012.Tobaccotaxincreaseshaveslowedintermsoffrequencyoverthepastfewyears,andonlyonestate,Maryland,increaseditstobaccotaxesin2021.Thecountrycontinuestoendurethemostsignificantpublichealthcrisisofthelast100years,COVID-19,andyetithasfailedtoconvinceofficialsthattheymustsufficientlyinvestinpublichealthinfrastructureandprioritizepoliciesthatwillprotectpeopleduringapublichealthepidemic.TheLungAssociation’s“StateofTobaccoControl”2022reportcontinuestoofferaroadmapwithsolutionsformanyofthesechallenges,butthecountryneedsfederal,stateandlocallawmakerstoimplementthemtofurtherdrivedownsmokingandtobaccouserates.FDACrawlsForwardTowardsMoreComprehensiveRegulationofTobaccoProducts;LeavesProductsMostResponsiblefortheYouthE-CigaretteEpidemicontheMarketFacingacourt-ordereddeadline,in2021,FDAfinallybegantoimplementandenforcepre-markettobaccoauthorization(PMTA)requirementsfore-cigarettes,hookah,pipetobacco,mostcigarsandothertobaccoproductsaftermanyyearsofdelay.ThisprogresswasduetoacourtdecisioninalawsuitfiledbytheLungAssociationandseveralpublichealthpartnersorderingtobaccoproductmanufacturerstosubmitPMTAapplicationstoFDAbySeptember9,2020,andforFDAtoreviewandmakedecisionsonthoseapplicationsbySeptember9,2021.5 L AmericanLungAssociation“StateofTobaccoControl”20222022FDAdidissuemarketingdenialordersformanynon-mentholflavorede-cigarettesin2021.However,whenitcametothee-cigaretteproductswiththehighestmarketshareandthatarethemostresponsiblefortheyouthvapingepidemicsuchasJUULandVuse,FDAdelayeddecisionontheirPMTAsforasignificantperiodoftimeafterthecourt’sdeadline.FDAalsoissuedmarketingordersforseveralhighnicotineVusetobacco-flavorede-cigarettesandtooknoactiononanyPMTArelatedtomenthole-cigarettes.TheLungAssociationhasrepeatedlycalledforallflavoredtobaccoproducts,includinge-cigarettes,toberemovedfromthemarketplace.Flavorsareakeydriverofyouthtobaccouse,andnoevidencehasbeenpresentedthatflavoredproductscanmeetthepublichealthstandardthatthelawrequires.Anew,potentiallylargeloopholeemergedin2021intheformofsyntheticnicotine,astheFDA’sCenterforTobaccoProductsassertsitsauthorityonlycoversnicotinederivedfromtobacco.E-cigarettecompanies,includingPuffBar,themostusede-cigaretteproductamongteens,appeartobeexploitingthislegalloophole.Syntheticnicotineflavorede-cigarettesarebeingusedtoattempttoevadetheTobaccoControlAct.TheLungAssociationhascalledforFDAtoregulatesyntheticnicotineasadrug;ifitistoberegulatedasatobaccoproduct,itwillrequireactionbyCongress.InResponsetoSignificantDisparitiesinTobaccoUseinU.S.,FDAMakesanImportantAnnouncementonMentholOverall,adultcigarettesmoking,andtobaccouseratesremainedlevelfromthepreviousyearin2019,thelatestyearofdata.Ashasbeenthecasesince“StateofTobaccoControl”wasfirstpublished20yearsagothough,theoverallratesmasksignificantdisparitiesamongracial,ethnic,socio-economicandLGBTQ+communities.UseofcommercialtobaccoproductsremainsparticularlyhighamongNativeAmericansandAlaskanNativesat20.9%andlesbian,gayandbisexualadultsat19.2%.4Adultswithlowerincomes,lowerlevelsofeducationandexperiencingmentalillnessorsubstanceabusealsoenduresignificantlyhigherratesofsmoking.Whileregular,nationaldataislackingonthistopic,studieshaveshownthatsmokingandtobaccousecanvarysignificantlyamongstsub-populationsofHispanicandAsianAmericansaswell.Inaddition,thedeclinesincigarettesmokingratesobservedinrecentyearshasbeenduealmostentirelytonon-mentholcigarettes.Mentholcigarettesareusedbycloseto81%ofBlackAmericans5anddisproportionatelybypregnantwomen,youthandLGBTQAmericans.6Infact,astudyreleasedin2021foundthatmentholcigaretteswereresponsiblefor1.5millionnewsmokers,157,000smoking-relatedprematuredeathsand1.5millionlifeyearslostamongAfricanAmericansfrom1980–2018.7Thesedisparitiesinmentholcigaretteusearelargelytheresultoftargetedmarketingbythetobaccoindustry.ThismakesanApril2021announcementbyFDAofitsintentiontoissueproposedrulesremovingmentholcigarettesandmanyflavoredcigarsfromthemarketplaceanimportantdevelopment.However,FDAhassaiditwilltakeuntilApril2022justtoproposerules.Thenitmaytakeseveralyearstofinalizetheruleanddefendagainsttheinevitableindustrylawsuits.ThisisontopofyearsofdelayfromwhenFDA’sTobaccoProductScientificAdvisoryCommitteein2011andFDAitselfin2013issuedseparatereportssayingitwouldbebeneficialtopublichealthtoremovementholcigarettesfromthemarket.TheAmericanLungAssociationapplaudedthislongoverdue6 L AmericanLungAssociation“StateofTobaccoControl”20222022announcementandurgesFDAtoactwithurgencyonthisissueinlightoftheyearsofdelayandthedisproportionateburdenmentholcigarettesplaceonmanycommunitiesexperiencinghealthdisparities.20YearsofUnevenChangeinStateTobaccoPreventionPoliciesThepast20yearsinstatetobaccopreventionpoliciescanbestbesummarizedasunevenprogresswithsignificantdifferencesbypolicy,decadeandgeographicregion.Thecountrysawsignificantprogressonsmokefreeworkplacelawsandtobaccotaxesduringthe2000s,onlytoseethatprogressstallcompletelyduringthe2010s.Certainpartsofthecountrycontinuetolagsignificantlybehindinputtinginplacetheprovenpoliciescalledforin“StateofTobaccoControl,”includingstatesintheSouth,AppalachiaaswellaspartsoftheMidwestandGreatPlains.Stateswheretobaccoisorwaspreviouslygrownandhavesignificanttobaccoindustrypresences,suchasNorthCarolinaandVirginia,remainparticularlychallenging.IncreasingStateTobaccoTaxes:Increasingtobaccotaxesby$1.00perpackormoreisoneofthemosteffectivewaystoreducetobaccouse,especiallyamongkids.Manystateshavesignificantlyincreasedtheirtaxesoncigarettesandothertobaccoproductsoverthepast20years.However,thishascreatedawidedisparityincigarettetaxrates,withtheloweststatecigarettetaxinMissouriatameager17centsperpackandtheDistrictofColumbiathehighestat$4.50perpack.Marylandwastheonlystatetoincreaseitscigarettetaxin2021,to$3.75perpack,5thhighestinthecountry.SmokefreePublicPlacesandWorkplaces:From2003to2012,therewasasignificantexpansionofthenumberofstateswithlawsprohibitingsmokinginpublicplacesandworkplaces,howevernoadditionalstateshavepassedsuchlawssincethen.Somestateswithcomprehensivesmokefreelawshaveclosedadditionalloopholesintheirlaws,includingConnecticutin2021.Ohioalsoaddede-cigarettestoitscomprehensivesmokefreelawin2021.During2020,morethan200tribalandnon-tribalcasinosre-openedsmokefree8afterbeingclosedduetoCOVID-19.During2021,manytribalcasinoskepttheirsmokefreepoliciesinplacebuttherewassomebackslidingamongstate-regulatedcasinoswhenstateCOVID-19emergencyordersexpired.Inaddition,theNavajoNationapprovedlegislationin2021aftera12plusyeareffortthatmadeallpublicplacesandworkplaces,includingtribalcasinossmokefree.ExpandingMedicaidandTobaccoCessationCoverage.Since2009,the“StateofTobaccoControl”reportbeganreportingonstates’tobaccocessationcoverage.Overthepast13years,stateMedicaidprogramshaveincreasedthenumbertreatmentstheycovered,andbecauseofprovisionsintheAffordableCareAct(ACA)haveincreasedthenumberofpeopleeligibleforMedicaidcoverage.The2009reportshowedonly20statescoveringall7FDA-approvedcessationmedications.Thisyear’sreportshowsthat43statesnowprovidethatcoverage.ThereporthastrackedtheprogressstateshavemadeinprovidingthesetreatmentsnotonlytoMedicaidenrollees,butalsotoStateEmployeesthroughtheirhealthplans.Thereportalsorecognizestheimportanceofadequatelyfundingstatequitlinesinhelpingsmokersquit.Whilethelast13yearsof“StateofTobaccoControl”reportshaveshownprogressinpoliciestoaccessquitsmokingservices,thereisstillmoreworktobedone.7 L AmericanLungAssociation“StateofTobaccoControl”2022MedicaidExpansionandTobaccoCessationTheAffordableCareActexpandedMedicaidcoveragetoindividualsat138%ofthefederalpovertylevel($30,305peryearforafamilyofthree)orlower.In2022,38statesandtheDistrictofColumbiahaveallexpandedtheirMedicaidprograms.Individualswithincomeslessthan$35,000ayearsmokeatrateof21.4%,higherthanthegeneralpopulation(14%).Itisnotsurprisingthatincreasingaccesstohealthcarecoverage,includingacomprehensivecessationbenefit,resultsinmorepeoplemakingquitattempts.ResearchshowsMedicaidquitattemptsinexpansionstatesincreasedbyover20%.“Tohelpaddressthecontinuingyouthe-cigaretteepidemicandachieveitsmissionfocalpointofreducingyouthvapingto15%by2025,theAmericanLungAssociationlauncheditsEndYouthVapinginitiativeonSeptember1,2020.Itisanintegrated,multi-componentcampaigntosupportparents,schoolsandstudents.MajorcomponentsofthecampaignincludeourVape-FreeSchoolsInitiative,whichhelpsschoolsnavigatethispublichealthemergencywithtoolstoprotectandsupportbothschoolsandstudentsandthe“GetYourHeadOutoftheCloud”youthvapingawarenesscampaignfromtheAmericanLungAssociationandtheAdCounciltoprovideparentswithadiscussionguidetoaddressthedangersofvapingwiththeirkids,whilethey’restillwillingtolisten.”

2022FundingforStateTobaccoPreventionandCessationPrograms.Thisissuehasseentheleastprogressamongthefourareasthatstateshavebeengradedonlongestinthe“StateofTobaccoControl”report.Themajorityofstateshavekepttheirlevelsoffundingsteadyfromyeartoyear,butmoststatesremainfarshortofthefundinglevelsrecommendedbyCDC.Properlyfundingstatetobaccocontrolprogramscanbringcrucialfocusandresourcestoalleviatedisparitiesinwhousestobaccoproductsandhelpachievehealthequityintobaccocontrol.Peoplefromdisproportionatelyaffectedcommunitiesshouldbeempoweredtoleadtheefforttoaddressthesedisparities,includingprovidingfundingtoorganizationsthatdirectlyservethecommunities.Inthecurrentstatefiscalyear,fiscalyear2022,twostates—AlaskaandOregonfundedtheirstatetobaccocontrolprogramsatorclosetothelevelrecommendedbyCDC.NewTobaccoProductsandNewPublicPoliciesRisetotheForefrontOverthe20yearsof“StateofTobaccoControl,”bothnewtobaccoproductsandnewpublicpoliciestopreventandreducetobaccousehaveemerged.Themostprominentandconcerningofthenewtobaccoproductstocomeontothemarkethavebeene-cigarettes,whichhavebeensoldintheU.S.since2007.TheAmericanLungAssociationhasbeenconsistentlywarningofthepotentialdangersoftheseproductssincetheirdebut.Ourfearswereunfortunatelyvalidatedwhenyouthuseofe-cigarettesrosesubstantiallyfrom2011to2015andthentoanevengreaterdegreefrom2017to2019.ThiscausedtheU.S.SurgeonGeneraltodeclareyouthvapinganepidemicin2018.In2021,youthvapingrateswere11.3%amonghighschoolstudentsand2.8%amongmiddleschoolstudents.9However,withsomeschoolsclosedforin-personlearningduetotheCOVID-19pandemic,somekidshadlessaccesstoe-cigarettes.Youthvapingratesin2021variedsubstantiallybasedonwhetherastudenttookthesurveyatschool(15.0%)orhome/someotherplace(8.1%).10OthernewtobaccoandnicotineproductsintroducedtotheU.S.marketinthepastfewyearsincludeheatedtobaccoproductssuchasPhilipMorrisInternational’sIQOSproduct,andnicotinepouches,suchasVelo.YouthuseofthesenewproductswillneedtobemonitoredcloselyandFDAmustbepreparedtoremovetheseproductsfromthemarketplace.Onethingisclear:kidsoverwhelminglypreferflavoredtobaccoproducts.11Inthe2021NationalYouthTobaccoSurvey,85.8%ofhighschoolstudentsand79.2%ofmiddleschoolstudentswhousede-cigarettes,usedflavoredproducts.Thishasledtoanewpublicpolicyrisinginimportance,prohibitingthesaleofallflavoredtobaccoproducts,includingmentholcigarettes,flavoredcigarsandflavorede-cigarettes.Startingwiththe“StateofTobaccoControl”2021report,statesarenowgradedonwhethertheyprohibitthesaleofallflavoredtobaccoproducts,andtheFDAremovingflavoredtobaccoproductsfromthemarketplacehasbeenincorporatedintothefederalgovernment’sgradesforcloseto10years.WithremovalofmentholcigarettesandflavoredcigarsbyFDAseveralyearsinthefutureataminimum,itisimperativethatstatesandlocalitiesacttoendthesaleofallflavoredtobaccoproducts.In2021,theDistrictofColumbiaapprovedalawthatwouldprohibitthesaleofallflavoredtobaccoproductsinvirtuallyalllocations.However,fundingwillneedtobeprovidedinthecity’sbudgetin2022forthelawtotakeeffect.ImplementationofCalifornia’sflavoredtobaccoproductlawwasalsodelayeduntil2022attheearliestduetoasuccessfulballotreferendumonthemeasurefiledbythetobaccoindustry.8 L AmericanLungAssociation“StateofTobaccoControl”20222022Othernewpublicpolicieshavebecomemoreprominentatthestatelevelinrecentyears,including:IncreasingtheTobaccoSalesAgeto21Startingin2015withthestateofHawaii,closeto20states,andthenthefederalgovernmentinDecember2019,increasedtheageofsalefortobaccoproducts,includinge-cigarettes,to21.A2015reportfromtheNationalAcademyofMedicinefoundthatincreasingtheminimumsalesageto21nationwidecouldprevent223,000deathsamongpeoplebornbetween2000and2019,including50,000fewerdyingfromlungcancer,thenation’sleadingcancerkiller.12Ahandfulofstatescontinuedtopasslegislationin2021,aligningtheirstateminimumageswiththeincreasedfederalminimumage.ReducingtheAvailabilityandAccessibilityofTobaccoProducts.OnequestionthaturgentlyneedstobeanswerediswhytherearesomanytobaccoretailersintheUnitedStates.Astudyoftobaccoproductretailersin30cities,foundthatthereare31timesmoreretailersthanMcDonaldsand16timesmoreretailersthanStarbucks.Inaddition,inmostcities,tobaccoproductretailerswereconcentratedinthelowest-incomeneighborhoods.13Statesandcommunitiesshouldenactlegislationtoreducethenumberoftobaccoproductretailersandprohibitthemfrombeingclusteredtogetherornearyouth-focusedlocationslikeschoolsandchildcarefacilities.Alongtheselines,atthestatelevel,twostates—MassachusettsandNewYork—haveprohibitedtobaccosalesinpharmacies,andUtahhasprohibitednewretailtobaccospecialtybusinessesfromlocatingincertainareas.AnOldThreattoStatePoliciesRe-Emergesin2021In2021,legislationwasintroducedinmanystatesthatwouldpreventlocalgovernmentsfrompassingstro