Federal Priorities for the 117th Congress: Tobacco

The CDC Office on Smoking and Health (OSH) must continue to receive robust funding to help combat the tobacco-caused diseases that are burdening the nation. Public health interventions supported by CDC OSH, such as the funding provided to state tobacco control programs and Tips from Former Smokers media campaign, are proven to reduce tobacco use. The American Lung Association urges that $310 million be appropriated to OSH for FY21. On March 9, 2020, the Lung Association and our partners sent letters to the House of Representatives and Senate Appropriations subcommittees on Labor- Health and Human Services requesting an increase in funding for CDC’s OSH. 

The Food and Drug Administration should continue its investments in “The Real Cost” campaign, a youth prevention mass media campaign which is proven effective at reducing youth tobacco use.  Within “The Real Cost” there are efforts aimed at reducing youth use of cigarettes, smokeless and e-cigarettes.  In its first two years, “The Real Cost” prevented almost 600,000 youth from starting smoking.

Following the removal of almost all flavored cigarettes from the marketplace, cigarette smoking rates among youth dropped to historically low levels. However, the remaining flavored tobacco products, including menthol cigarettes, cigars and e-cigarettes, on the market are attracting and addicting another generation, leading to a significant increase in overall youth tobacco use. Over half of youth cigarette smokers ages 12-17 started with menthol cigarettes, and in 2019, close to 70% of youth who used tobacco products used a flavored product.  In addition, in 2020 over 80% of current high school e-cigarette users, used flavored e-cigarettes. The Lung Association submitted comprehensive comments to the Food and Drug Administration (FDA) in July 2018 outlining our position on flavored tobacco products. To address the nation’s youth e-cigarette epidemic, the Lung Association calls on Congress and FDA to eliminate all flavored tobacco products from the marketplace, including menthol cigarettes, flavored cigars and e-cigarettes.

In May 2016, the FDA extended its tobacco regulatory authority to other tobacco products (deeming rule). However, in many cases since 2009, the FDA has failed to implement the Tobacco Control Actand use its comprehensive authority to put meaningful restrictions on tobacco products, including e-cigarettes, in place. One clear consequence of FDA’s inaction has been the meteoric rise in the use of e-cigarettes among youth and young adults. Most tobacco products, including all e-cigarettes, were required to submit a product application to FDA by September 9, 2020 to determine whether they should be permitted to stay on the market. The FDA must publish the application status of all new products.  The FDA must adhere to the principles established by the Lung Association and our partners in reviewing these applications and require the removal of all tobacco products that came onto the market illegally after August 8, 2016.  FDA must remove all products that failed to file an application. 

Nicotine is the addictive drug in tobacco products. Reducing nicotine in tobacco products to below levels that sustain addiction will make it easier for smokers to quit and harder for youth to become addicted. FDA must not limit its focus solely to cigarettes; FDA must reduce nicotine levels in all tobacco products, including cigars and e-cigarettes.

The 2009 Tobacco Control Act requires FDA to issue a rule requiring all cigarette packs have graphic warning labels on the 50% of the front and back of all cigarette packs.   Tobacco industry lawsuits have delayed this requirement.  A 2020 ruling in a federal lawsuit brought by the American Lung Association and public health partners resulted in FDA releasing final graphic warnings by March 15, 2020.   A lawsuit filed by a tobacco company has temporarily blocked the implementation of the warning labels, delaying the rule that would require them to appear on all cigarette packs by June 2021. FDA and the Department of Justice must strongly defend graphic warning labels in the federal courts. 

Congress and/or FDA must prohibit online sales of all tobacco products. Studies have shown that many tobacco products are sold online with limited or no age verification requirements. Prohibiting online sales will shut off an easy way for youth to buy e-cigarettes and other tobacco products online. The Protecting American Lungs and Reversing the Youth Tobacco Epidemic Act, which passed the House in February 2020, includes this provision.

The 2009 Tobacco Control Act calls for the FDA to create a comprehensive track and trace system to counter the threat of illicit markets and maximize the public health benefits of strong oversight, which the agency has failed to do thus far. The tobacco industry has a history of being complicit in supplying illicit markets, repeatedly opposing taxation proposals to protect public health and financially benefitting from the illicit diversion of their own products. The Lung Association calls on the FDA to implement “track and trace” technology on all tobacco products to prevent black market, counterfeit and smuggling activities. 

With no consequences, E-cigarette manufacturers advertise their products as smoking cessation aids and have falsely claimed their products can help smokers quit. These unproven health claims confuse adult consumers as well as youth. FDA’s Center for Drug Evaluation and Research must crack down on e-cigarette manufacturers to stop unproven health claims about their products. 

The tobacco industry has a long history of marketing its addictive products to young people. These advertisements are reaching young people through numerous social media platforms and target youth with their bright colors, young influencers and enticing flavors. The Federal Trade Commission must halt advertising and marketing to youth, including on social media. The American Lung Association and partners submitted a petition to FTC in August 2018 asking them to take action on this issue.

According to the Affordable Care Act and the FAQ guidance, Medicaid expansion plans and most private health insurance plans, including health insurance plans sold on the exchange, must cover a comprehensive tobacco cessation benefit – all seven medications and all three forms of counseling. Plans also cannot impose cost-sharing or prior authorization. Data shows that states can still improve their coverage. In 2016, only 9 of the 32 expansion states covered all seven medications and group and individual counseling. In 2019, data showed that only 11 out of 36 states provided this coverage. The Centers for Medicare and Medicaid Services (CMS) must work with states to enforce the comprehensive tobacco cessation benefit in all exchange and Medicaid expansion plans.  

Traditional Medicaid is required to cover all tobacco cessation medications, however there is no requirement for counseling coverage for non-pregnant adults. State Medicaid programs may impose barriers, including cost-sharing, prior authorization and stepped care therapy. In 2018, data showed that 15 states covered all seven medications as well as group and individual counseling, and only two states did not impose barriers to access the coverage. Congress should pass H.R.2125/S.2622, the Quit Because of COVID-19 Act, to expand coverage to a comprehensive tobacco cessation benefit for all traditional Medicaid plans. This would include all seven medications and all three forms of counseling. Plans should also remove cost-sharing or prior authorization barriers, which make it more difficult for smokers to access this help to quit.  

Beyond counseling, there is very little research on what is effective in helping youth quit tobacco products.  In 2020, the US Preventive Services Task Force gave an “I” or incomplete grade to primary care interventions for the cessation of tobacco use among school-aged children and adolescence. The Task Force outlined what criteria a study would need to have to be considered as part of the evidence base for future recommendations. Research looking into youth cessation interventions, including pharmacotherapies, must be prioritized for funding.

Certified Tobacco Treatment Specialists (CTTS) provide specialized and intensive interventions, freeing up time for physicians and other healthcare providers to work to the top of their licensure. Although their training and field experience is extensive, CTTS are currently unable to bill for the cessation counseling they provide through Medicare, as they are not included in the definition of a Medicare Qualified Provider. The American Lung Association urges CMS to change its policy to allow individuals with a CTTS certification to bill for tobacco cessation counseling as part of a patient care team. The Lung Association also urges Congress to update policy to clarify individuals with a CTTS can bill for tobacco cessation counseling as part of a patient care team.    

The “Tips From Former Smokers” campaign is a highly effective media campaign that features stories of people living with smoking-related diseases, but funding only permits it to be on the air 27 weeks a year. Over the first seven years, over one million Americans have successfully quit smoking because of “Tips,” and millions more have made quit attempts. The “Tips” campaign has an incredible return on investment that continues to generate positive outcomes. The Lung Association supports extending “Tips” to a year-round mass media campaign. 

The federal government has not increased taxes on cigarettes and other tobacco products since 2009 and a significant increase is long overdue. The $0.62 increase in 2009 helped reduce smoking rates. Increasing tobacco taxes is one of the most important actions Congress could take to prevent and reduce tobacco use. Congress should equalize the tax rate on all products. The Lung Association supports the Tobacco Tax Equity Act (H.R. 2786/S.1314), which will double the federal tax rate on cigarettes and equalize the federal tax rate for all other tobacco products. This legislation will help reduce youth initiation and incentivize tobacco users to quit for good.