Community Voices: A Qualitative Study Exploring Perceptions of Menthol Cigarette Sales Restrictions in Los Angeles County Among Black Adults Who Smoke Menthol Cigarettes.

INTRODUCTION: The commercial tobacco industry has long targeted Black communities by making menthol cigarettes not only appealing but affordable through marketing, advertising, and pricing strategies, particularly in the retail environment. Policies that focus on restricting the sale of menthol cigarettes have the potential to significantly reduce the death toll from smoking while also mitigating health inequities and advancing racial equity. However, limited qualitative research exists on the perceptions of menthol cigarette sales restrictions, including local policies, among Black adults who smoke menthol cigarettes. AIMS AND METHODS: In-depth semi-structured interviews were conducted between January and September 2021 with self-identified non-Hispanic Black adults who reported current menthol cigarette use (n = 26). Participants were asked open-ended questions about awareness and perceptions of the Los Angeles County law banning the retail sale of menthol cigarettes in unincorporated communities, including how it influences their smoking and purchasing behaviors. RESULTS: We used three thematic categories to structure the results: (1) Are People Aware of Local Menthol Cigarette Sales Restrictions? Levels of Awareness and Strategies to Increase Awareness, (2) Why Ban Menthol? Concerns About Equity and Fairness, and (3) Will Menthol Cigarette Bans Decrease Smoking? Mixed Perceptions About Potential Impact. Most participants (88.5%) had heard about the menthol ban in their communities. Participants described ambivalence towards the ban and identified several factors that hinder support, participation, and well-being, including uncertainty regarding the rationale for banning menthol cigarettes; perceptions that the ban specifically targets Black communities; and concerns regarding government overreach and constraining individual choice. Participants had differing views on whether the ban would likely help them and others who smoke menthol cigarettes reduce or quit smoking. Participants also described situations in which they would purchase menthol cigarettes in another state, country, online, or in the illicit market. Furthermore, participants often viewed the ban as perpetuating criminalization and over-policing of Black communities-arguments used by the commercial tobacco industry to oppose menthol bans. CONCLUSIONS: Our community-based sample of Black adults who smoke menthol cigarettes face challenges and concerns about local menthol bans. Community-centered interventions, messages, and materials about racial equity in menthol bans, access to free cessation services, and countering commercial tobacco industry interference, in addition to measurable steps toward rectifying injustice from the commercial tobacco industry and repeated exemptions of menthol cigarettes from federal legislation through tangible reparations, would be helpful to this community. IMPLICATIONS: We sought to add to the literature on flavored nicotine and commercial tobacco policies in the United States by centering the voices of Black adults who smoke menthol cigarettes regarding their awareness, perceptions, and opinions of local laws restricting menthol cigarette retail sales and how such polices influence their smoking and purchasing behaviors. Our findings suggest that Black adults who smoke menthol cigarettes are aware of local laws restricting menthol cigarette retail sales and are ambivalent about the rationale. Our findings have implications for the development and delivery of equity-focused strategies and resources to increase awareness of and rationale for the ban; counter commercial tobacco industry interference; and facilitate smoking cessation among Black adults who experience more combustible tobacco-related morbidity and mortality than their racial/ethnic counterparts. By understanding this relevance, we can also recognize how individual awareness and perceptions are moored within and contextualized by broader social structures and systemic inequities that warrant policy considerations.

Flavored Tobacco Sales Restrictions and Youth E-cigarette Behavior: Impact by Tobacco Retailer Density in Diverse Communities in California.

INTRODUCTION: Factors that impact flavored tobacco sales restriction (flavor restrictions) effectiveness on youth e-cigarette behavior are unclear. Tobacco retailer density (retailer density) is a health equity issue with greater retailer density in high-minority, low-income areas. We examined the association between flavor restrictions and youth e-cigarette behavior by retailer density across diverse communities in the California Bay Area. AIMS AND METHODS: We analyzed data from the California Healthy Kids Survey using a difference-in-differences (DID) strategy. We compared pre- and post-policy changes in e-cigarette access and use one-year post-implementation among high school students in the Bay Area with a flavor restriction (n = 20 832) versus without (n = 66 126). Separate analyses were conducted for students in cities with low and high retailer density, with a median cutoff of 3.3 tobacco retailers/square mile. RESULTS: Students with high retailer density were more likely to identify as a minority and have parents with lower education. Among students with low retailer density, flavor restrictions were associated with 24% lower odds in the pre- to post-policy increase in ease of access relative to unexposed students (DID = 0.76, 95% CI: 0.58, 0.99). Among students with high retailer density, flavor restrictions were associated with 26% higher odds in ease of access (DID: 1.26, 95% CI: 1.02, 1.56) and 57% higher odds of current use (DID = 1.57, 95% CI: 1.31, 1.87). CONCLUSIONS: Flavor restrictions had positive impacts on youth e-cigarette access in low, but not high retailer density cities. From a health equity perspective, our results underscore how flavor restrictions may have uneven effects among vulnerable groups. IMPLICATIONS: In diverse communities in the California Bay Area, our results suggest a protective association between flavored tobacco sales restrictions and youth access to e-cigarettes in low, but not high tobacco retailer density cities one-year post-implementation. These results underscore how flavor restrictions may have uneven effects, and when implemented in high retailer density areas, may disproportionately place already vulnerable groups at heightened exposure to e-cigarette use and access. In high retailer density areas, additional tobacco control efforts may need to be included with flavor restriction implementation, such as increased education, youth prevention and cessation programs, policies to reduce tobacco retailer density, or stronger tobacco retailer enforcement or compliance monitoring.

Commercial Tobacco Retailers Need to Be Included in Research on Policies Restricting the Sale of Menthol Cigarettes.

INTRODUCTION: Menthol cigarettes are disproportionately marketed and advertised in the commercial tobacco retail environment in Black communities across the United States, contributing to menthol cigarette-related disparities and lower likelihood of successful quitting among Black people who smoke. Policies restricting retail sales of menthol cigarettes are aimed at preventing initiation, promoting quitting, and reducing related disparities. METHODS: Structured phone interview surveys were conducted from January to July 2021 with commercial tobacco retailers in Los Angeles County, California, unincorporated communities with a high percentage of Black residents, eight months after a local policy restricting retail sales of menthol cigarettes and other flavored nicotine and commercial tobacco products became effective on May 20, 2020. Interviews examined menthol cigarette sales restrictions-related knowledge, attitudes, and practices. RESULTS: Among 22 retailers interviewed, most (86.4%) reported having knowledge of the local ban on menthol cigarettes, and more than half (54.5%) reported offering price promotions for menthol cigarettes. Additionally, more than half (54.5%) reported believing customers who buy menthol cigarettes would stop smoking altogether following the ban. CONCLUSIONS: Most retailers reported having knowledge of the menthol ban, yet half reported offering price promotions for menthol cigarettes. Findings suggest retail availability of menthol cigarettes in Los Angeles County unincorporated communities with a high percentage of Black residents, post ban. Public health and policy implications are discussed.

Key Informants' Perceptions of Health Equity and Racial Justice Impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control.

INTRODUCTION: The Massachusetts legislature passed An Act Modernizing Tobacco Control in November 2019 to restrict retail sales of flavored commercially manufactured tobacco products including menthol products, increase penalties for violating the law's provisions, and provide health insurance coverage for tobacco treatment. AIMS AND METHODS: This study explores key informants' perceptions of intended and unintended impacts of implementation of the 2019 Massachusetts statewide law through a health equity and racial justice lens. We conducted in-depth interviews with 25 key informants from three key informant groups (public health officials and advocates, clinicians, and school staff) between March 2021 and April 2022. Using deductive codes on unintended impacts of the implementation of the law's policies, we conducted a focused analysis to identify impacts that were perceived and observed by informants from different key informant groups. RESULTS: Perceived or observed impacts of the law were identified across multiple levels by key informants and included concerns related to three broad themes: 1) intended impacts on health equity and racial justice, 2) ongoing availability of restricted products undermining the intended impact of the law, and 3) inequitable targeting by the policies and enforcement among communities of color. CONCLUSIONS: Future evaluation is needed to assess the intended and unintended impacts of implementation of the Massachusetts law to maximize the potential of the policies to reduce tobacco-related health disparities. We discuss implications and recommendations for achieving a national policy and equitable enforcement of flavored tobacco sales restrictions. IMPLICATIONS: This qualitative study among 25 key informants including public health and tobacco control advocates, clinicians, and school staff obtained perspectives of intended and unintended health equity and racial justice impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control. Findings and recommendations from this study can inform monitoring efforts to assess the law's impacts in Massachusetts and the adoption of similar flavored tobacco sales restrictions and other tobacco control policies in other states to maximize the health equity benefits and minimize unintended impacts.

Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity.

INTRODUCTION: This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017). AIMS AND METHODS: Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol. RESULTS: Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories. CONCLUSIONS: After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity. IMPLICATIONS: Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

Facilitators and Barriers to Passing Local Policies That Prohibit the Sale of Flavored Tobacco Products: Qualitative Analysis of Strategies Implemented by 36 Communities in California, 2017-2021.

To reduce youth access to tobacco products, the California Tobacco Prevention Program funded local tobacco prevention programs from July 2017 through December 2021 to address its Communities of Excellence Indicator 3.2.9: "the number of jurisdictions with a policy eliminating or restricting the sale and/or distribution of any mentholated cigarettes and other flavored tobacco products, and paraphernalia." We examined the strategies by which community coalitions attempted to limit the number of stores selling flavored tobacco across California. Thirty-six final evaluation reports (FERs) were used for our analysis. We examined certain elements or factors as primary areas of interest because of their apparent link to successful outcomes in analyses of FERs in the past. Over half (19 of 36) of FERs reported successfully passing at least 1 policy to regulate the sale of flavored tobacco products. Urban communities passed more policies (16 of 18) compared with rural communities (3 of 18). Successful campaigns tended to involve youth, demonstrate illegal sales to minors and public support for a ban, and identify a champion. Barriers included the COVID-19 pandemic, California wildfires, staffing shortages, and conservative political climates. This evaluation offers insights into the successes and challenges faced by local coalitions seeking policy changes for tobacco use prevention, which can be different for urban and rural communities. The evaluation also indicates the necessity of adopting flexible tactical plans for overcoming environmental factors that affected intervention and evaluation activities.

Community Engagement, Jurisdictional Experience, and Previous Tobacco-Related Ordinances in Neighboring Communities as Drivers of Flavored Tobacco Bans in Los Angeles County.

We examined whether a community engagement approach and jurisdictional attributes were associated with local action to restrict the sale of flavored tobacco products in Los Angeles County during 2019-2022. We estimated crude and adjusted risk ratios to examine these associations. Jurisdictions that used an active community engagement approach to adopt a flavored tobacco ban ordinance, those with previous experience adopting other tobacco-related ordinances, and those located next to communities that have an existing tobacco retail license ordinance were more likely than jurisdictions without these attributes to adopt a new ordinance to restrict the sale of flavored tobacco products. Efforts to adopt such an ordinance were generally more successful in jurisdictions where community members were engaged and policy makers were familiar with the adoption of public health ordinances.

Pursuing a smoke-free generation.

The United Kingdom may soon become a world leader in forging a smoke-free generation. Last month, the country passed a bill that bans the sale of cigarettes to anyone born in 2009 or later. The prime minister claims the policy will "phase out smoking in young people almost completely as early as 2040." A final vote by Parliament is expected next month. Tobacco claims 8 million lives every year, and could claim a billion lives over this century-mostly in low- and middle-income countries. For every person that dies, at least 30 more suffer from smokingrelated chronic disease. The benefits of a tobacco-free society would be transformational.

Tobacco policies and changes in the tendency of smoking cessation in cigarette users in Chile: a longitudinal cross-sectional study.

OBJECTIVE: To assess the impact of tobacco control regulations and policy implementation on smoking cessation tendencies in cigarette users born between 1982 and 1991 in Chile. DESIGN: Longitudinal cross-sectional study. SETTING: National level. PARTICIPANTS: Data from the National Survey of Drug Consumption (Service of Prevention and Rehabilitation for Drug and Alcohol Consumption). A pseudo-cohort of smokers born between 1982 and 1991 (N=17 905) was tracked from 2002 to 2016. PRIMARY AND SECONDARY OUTCOMES MEASURES: Primary outcome was the tendency to cease smoking conceptualised as the report of using cigarettes 1 month or more ago relative to using cigarettes in the last 30 days. The main exposure variable was the Tobacco Policy Index-tracking tobacco policy changes over time. Logistic regression, controlling for various factors, was applied. RESULTS: Models suggested a 14% increase in the smoking cessation tendency of individuals using cigarettes 1 month or more ago relative to those using cigarettes in the last 30 days (OR 1.14, CI 95% CI 1.10 to 1.19) for each point increment in the Tobacco Policy index. CONCLUSIONS: Our study contributes to documenting a positive impact of the implementation of interventions considered in the MPOWER strategy in the progression of smoking cessation tendencies in smokers born between 1982 and 1991 in Chile.

Would banning menthol cigarettes, flavored cigars, and flavored e-cigarettes prompt users to seek illicit channels for obtaining them in the United States?

BACKGROUND: Banning flavors in tobacco and nicotine products may reduce youth initiation and prompt quit attempts but such bans may lead to illicit markets. We examined how likely current users would be to seek flavored products from illicit channels under various ban scenarios. METHODS: Cross-sectional surveys of 2552 current users of menthol cigarettes or flavored cigars and 2347 users of flavored e-cigarettes were conducted between 2021 and 2022 in the United States. For each ban scenario, respondents reported if they would have intentions to seek the banned flavored products from any illicit channels and identified the specific illicit channel they would consider. Logistic regressions were used to estimate how the likelihood of having intentions to seek illicit channels was associated with demographics, ban scenarios, and status of tobacco use. RESULTS: Under various ban scenarios, 24-30% of people who smoked said they would seek illicit channels to obtain the banned products compared with 21-41% of dual users and 35-39% of users of flavored e-cigarettes. Online retailers were favored by people who smoked while users of flavored e-cigarettes favored local retailers. Heavy users were more likely to say they would try illicit channels. Under bans restricting more types of flavored tobacco products, users would be less likely to try illegal channels. CONCLUSIONS: A significant proportion of users of flavored tobacco and nicotine products would not reject using illicit banned products. Tailored programs are needed to apply to the groups with a higher risk of seeking illicit channels for banned products.

Smoking out Australia's growing illicit tobacco market: Current trends and future challenges.

Data from the Australian Taxation Office and Australian Border Force show notable recent increases in illicit tobacco seizures across Australia. The illicit tobacco market results in substantial losses in tax revenue, funds organised crime, and perpetuates tobacco use, threatening to undermine Australia's ability to achieve its national commercial tobacco endgame goal of 5 % or less smoking prevalence by 2030. This commentary discusses recent trends in Australia's illicit tobacco trade, reasons why this is of concern, potential drivers of Australians' illicit tobacco use, and policy measures that could be implemented to mitigate increasing illicit tobacco trade such as implementing a track and trace system, increased investment in the Australian Border Force to enhance detection of illicit tobacco shipments at Australia's borders, and encouraging public tip-offs of illicit tobacco sales.

Beyond the smoke: Historical analysis of the revenue implications of state cigarette tax policies, 1989 to 2019.

INTRODUCTION: While cigarette taxes are a vital tobacco control tool, their impact on cigarette tax revenue has been largely understudied in the extant literature. This study examines how the level of cigarette taxes affects the revenue generated from cigarettes in the United States over a thirty-year period. METHODS: We obtained the Tax Burden Data from the Centers for Disease Control and Prevention (1989-2019). Our dependent variables were gross cigarette tax revenue and per capita gross cigarette tax revenue, and our independent variable was state tax per pack. We used two-way fixed effects to estimate the relationship between state cigarette tax revenue and cigarette taxes, adjusting for state-level sociodemographic characteristics, state-fixed effects, and time trends. RESULTS: The study reveals that raising cigarette state tax by 10 % led to a 7.2 % to 7.5 % increase in cigarette tax revenue. We also found state and regional variation in taxes and revenue, with the Northeast region having the highest taxes per pack and tax revenues. In 2019, most states had low or moderate taxes per pack and tax revenues per capita, while a few states had high taxes per pack and tax revenues per capita. CONCLUSIONS: Our research demonstrates the positive impact of increased cigarette taxes on state tax revenue over three decades. Not only do higher taxes aid in tobacco control, but they also enhance state revenues that can be reinvested in state initiatives. Some states could potentially optimize their tax rates.

Multisectoral action to address noncommunicable diseases: lessons from three country case studies.

Introduction: Multisectoral action is a central component of the global response to the rising prevalence of non-communicable diseases (NCDs). In this paper we aimed to unpack the definition of multisectoral action and provide an overview of the historical context, challenges, and recommendations alongside three country case studies: salt reduction in the UK, tobacco legislation in Nigeria, and regulation of edible oils in Iran. Methods: We used an iterative review process to select three country case studies from a list of 20 potential cases previously identified by WHO. At our third round of review we unanimously agreed to focus on salt reduction in the UK, tobacco regulation in Nigeria, and edible oil regulation in Iran as these represented rich cases on diverse risk factors from three different world regions that we felt offered important lessons. We conducted literature reviews to identify further data for each case study. Results: Across the three studies a number of important themes emerged. We found that multisectoral approaches demand the often difficult reconciliation of competing and conflicting values and priorities. Across our three chosen cases, commercial interests and free trade agreements were the most common obstacles to successful multisectoral strategies. We found that early consultative stakeholder engagement and strong political and bureaucratic leadership were necessary for success. Discussion: The complex multi-rooted nature of NCDs requires a multisectoral approach, but the inevitable conflicts that this entails requires careful navigation.

Should tobacco sales be restricted to state-run alcohol outlets? Perspectives from 10 US alcohol control states.

BACKGROUND AND AIMS: The ubiquity of tobacco retailers helps to sustain the tobacco epidemic. A tobacco retail reduction approach that has not been tried is transitioning tobacco sales to state-controlled alcohol stores (TTS), which are limited in number and operate under some restrictions, e.g. regarding opening hours or marketing materials. This study summarizes policy experts' and advocates' views of TTS, including (1) advantages and disadvantages; (2) feasibility; and (3) potential implementation obstacles. DESIGN: This study was a qualitative content analysis of semi-structured interviews. SETTING: Ten US states with alcoholic beverage control systems were included. PARTICIPANTS: The participants comprised a total of 103 tobacco control advocates and professionals, public health officials, alcohol policy experts and alcohol control system representatives, including two tribal community representatives. MEASUREMENTS: Interviewees' perspectives on their state's alcoholic beverage control agency (ABC, the agency that oversees or operates a state alcohol monopoly) and on TTS were assessed. FINDINGS: Interviewees thought TTS offered potential advantages, including reduced access to tobacco products, less exposure to tobacco advertising and a greater likelihood of successful smoking cessation. Some saw potential long-term health benefits for communities of color, due to the smaller number of state alcohol stores in those communities. Interviewees also raised concerns regarding TTS, including ABCs' limited focus on public health and emphasis on revenue generation, which could conflict with tobacco use reduction efforts. Some interviewees thought TTS could enhance the power of the tobacco and alcohol industries, increase calls for alcohol system privatization or create difficulties for those in recovery. CONCLUSIONS: In the United States, transitioning tobacco sales to state-controlled alcohol stores (TTS) could have a positive public health impact by reducing tobacco availability, marketing exposure and, ultimately, tobacco use. However, tensions exist between alcohol control system goals of providing revenue to the state and protecting public health. Should a state decide to pursue TTS, several guardrails should be established, including building into the legislation an explicit goal of reducing tobacco consumption.