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A comprehensive policy approach to nicotine addiction requires a health equity lens

woman vaping
REUTERS/Kai Pfaffenbach
The tobacco industry, which includes e-cigarette manufacturers, uses menthol, candy and fruit-flavored tobacco products to attract the next generation of smokers.
While the media continue to report on the alarming health fallout of the vaping or e-cigarette epidemic and its impact on youth and young adults, it’s important to remind Minnesotans that the leading cause of preventable disease and premature death continues to be commercial tobacco use.

Every year, cigarettes, cigars and smokeless tobacco still kill more than 6,000 Minnesotans and cost $7.5 billion in excess health care costs and lost productivity, according to a 2017 Blue Cross and Blue Shield of Minnesota study.

Recently, the House DFL Caucus announced the intention to introduce a package of bills during the 2020 legislative that would address youth access to tobacco products, including e-cigarettes. The package would include a ban on all flavored tobacco products, which includes menthol tobacco and e-cigarettes. Rep. Kelly Morrison, DFL-Deephaven, and Rep. Alice Mann, DFL-Lakeville, wrote a MinnPost commentary about this package as a comprehensive approach to curbing youth nicotine use.

Insidious impact on marginalized communities

The narrative around this policy agenda focuses on youth and the alarming rise of youth vaping, which is quite valid. We also want to continue to highlight the insidious impact of commercial tobacco use on marginalized communities – including African-Americans, American Indians, LGBTQ people, and people with mental illness or substance-use disorders, just to name a few.

Dr. Mark Steffen
Dr. Mark Steffen
Commercial tobacco use has dramatically decreased in the past 20 years, with the Minnesota adult smoking rate falling to 14 percent, from a high of 22 percent in 1999. Behind these numbers, though, is the continued disproportionate impact of commercial tobacco.

According to the most recently available data, 59 percent of American Indians in Minnesota reported smoking cigarettes. Those on Medical Assistance or MinnesotaCare, the state health insurance programs for low-income families and individuals, smoke at twice the statewide average – 30 percent.

Because of the higher prevalence of commercial tobacco use, American Indians have a higher risk of tobacco-related disease and death, such as cardiovascular disease. (Tobacco use here refers specifically to the use of manufactured, commercial tobacco products, and not to the sacred, medicinal and traditional use of tobacco by American Indians and other groups.)

People with mental illness or substance-use disorders die 5 years earlier, many due to commercial tobacco use.

Menthol and candy flavors

The tobacco industry, which includes e-cigarette manufacturers (such as Altria, which has a 35 percent ownership stake in leading e-cigarette brand Juul), uses menthol, candy and fruit-flavored tobacco products to attract the next generation of smokers. Their targets are undeniably young people, but because of predatory marketing by the tobacco industry, they also attract African-Americans, American Indians and LGBTQ individuals. Nine out of ten African American adult smokers use menthol tobacco, compared to 22 percent of white adult smokers.

Blue Cross has led the country as a health business in standing up for Minnesotans against the harms of commercial tobacco, filing the first lawsuit of its kind in 1994 with the State of Minnesota against the tobacco industry. It’s out of the settlement proceeds that we continue to invest in improving the health of Minnesota communities through the Center for Prevention and as co-chair of the statewide coalition Minnesotans for a Smoke-free Generation. Blue Cross also strives to improve the health of our communities by providing resources, support and partnership to those who have experienced the greatest health inequities.

We applaud Minnesota lawmakers for tackling youth nicotine use and its harms on a new generation. Certainly, the proposal to ban all flavored and menthol tobacco products, including e-cigarettes, will also benefit marginalized communities. By expanding the narrative around who benefits from a comprehensive policy approach to nicotine and tobacco addiction, we can ensure that all Minnesotans are seen and heard.

Mark Steffen, M.D., MPH, is the vice president and chief medical officer of Blue Cross and Blue Shield of Minnesota.


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Comments (1)

  1. Submitted by Russell Booth on 12/04/2019 - 12:09 am.

    An intelligent person might google “trauma nicotine” or “medicinal uses of nicotine” and, after studying up, wonder whether this article that purports to promote equity among among marginalized communities is oppressive of those communities.

    I am an adult. My life counts. I quit smoking 7 years ago. Thank you for your belated concerns. Thanks also for the smoking cessation drug I tried long ago, a potential side effect of which is suicide. I survived it.

    I buy my vapes from a local, reputable manufacturer. They know what’s in it and nobody appears intelligent if they claim that nobody knows what is in it. The manufacturer knows.

    I ask if I can get it without flavoring. I cannot. The government could do something about that.

    My vapes contain four things. The two chemicals that are the base in asthma inhalers. Nicotine. FDA-approved flavorings. (Maybe water too.)

    Chemicals in asthma inhalers are not harmful to health. Nicotine in moderate doses raises the risk of heart attack and stroke by 5%. The effect of inhaling FDA-approved flavorings at higher concentrations than was studied is not known.

    I’m okay with a 5% long-term risk considering that nicotine helps me to manage the acute and immediate symptoms of my LEGAL DISABILITY. If I could buy my vapes without flavoring, I would. The flavoring is the only heath unknown.

    Adults like fruit flavors. Doctors actually recommend that adults eat fruit. Adults also eat candy. If the only vape flavors available were tobacco flavors, I would wonder why the government was grooming kids to smoke tobacco.

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