Video Abstract

Video Abstract

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Electronic nicotine delivery system use contributes to the epidemic of youth vaping. Regulations to curtail or prohibit the sale of flavored nicotine products aim to disrupt initiation of child nicotine use by reducing access to enticing nicotine flavorings. A total of 6 states and >300 localities have restricted or banned flavored nicotine product sales. In this case study, we outline the use of a localized town-based strategy, which offered 2 potential bills to incrementally restrict or prohibit sale of flavored vape products when county or state legislation was not politically feasible. Over the course of 18 months, these bills reduced the number of municipalities where these products could be sold or advertised until county, city, and statewide bans were effectively in place, ultimately making the passage of a bill in the statehouse palatable. Strong partnerships with officials who had expertise in local town government, local American Academy of Pediatrics chapter physician champions, and a diverse coalition were instrumental in motivating smaller governments, which often pass legislation faster than larger legislatures, to create child-protective tobacco policies.

Although use of combustible cigarettes has steadily decreased, exclusive use of electronic cigarette and associated nicotine delivery systems (ENDSs) has increased dramatically in the general young adult population. Between 2013 and 2014, the US Surgeon General reports 6.1% of young adults used ENDSs exclusively in the past 30 days.1  Exponential increases in vaping among middle and high school–aged children have also been observed. More than one-quarter (27.5%) of high school–aged children reported electronic cigarette use within 30 days in 2019.2  Although recent enforcement of Food and Drug Administration restrictions have been associated with a reduction in high school vape use from 27.5% to 19.6% in 2020, use of these products remains at epidemic levels.3  Approximately 5% of middle schoolers also use these devices.3  ENDSs often contain toxicants with known adverse health effects, such as formaldehyde, propylene glycol and acrolein: products that may increase cancer risk.4  Childhood ENDS use is also a gateway to combustible cigarette use because youth are at increased risk of initiating traditional cigarette use within 2 years of the onset of vaping.5,6  In addition, adolescent use of vape products, which may contain levels of nicotine far beyond those of traditional cigarettes, renders younger users more susceptible to nicotine addiction than if vaping begins at a later age.7,8  One ENDS can contain levels of nicotine equivalent to 20 traditional cigarettes, and, in the form of nicotine salts, the substance may increase potency of nicotine available to the adolescent brain.9 

Tobacco promotion is an important contributor to youth tobacco and vape use.7,8  Given these data, tobacco companies, therefore, may be incentivized to focus marketing toward adolescents and youth, both through advertising and the creation of child-oriented flavors.911  Middle and high school students are frequently exposed to e-cigarette advertising, creating interest in experimenting with the products.9,10  Per the Centers for Disease Control and Prevention, advertising for ENDS products reached 80% of students in 2016, an increase of 10% in 2 years.12  Over 10.6 million children viewed e-cigarette advertising on the Internet and 17.7 million were exposed to ads in retail stores.12  In addition to advertising and promotion, the use of ENDS flavorings is a potent recruitment tool. Flavored vape products are particularly appealing to children, with 80% of youth nicotine users inhaling a flavored ENDS product and 60% citing specific flavors as the reason for continued use.13  Fruit and candy flavors, such as bubblegum, jelly bean, birthday cake, chocolate, and both mint and menthol facilitate youth tobacco initiation and dependence.11 

The American Academy of Pediatrics (AAP) called for restrictions on tobacco advertising to children, including point-of-sale advertising, in 2015.10  These restrictions assist in decoupling the reality of nicotine addiction from the favorable images and social acceptability depicted in tobacco promotion. The AAP also recommended a ban on the sale of flavoring agents, including menthol.10  Epidemiological data comparing similar counties revealed such a prohibition could reduce current use of both flavored and unflavored products in children within 6 months of implementation.14 

New York Chapter 2 is one of 3 New York State–based AAP chapters, encompassing the counties of Nassau (population: 1.35 million) and Suffolk (population: 1.47 million) as well as the New York City boroughs of Brooklyn (population: 2.65 million) and Queens (population: 2.24 million). Nassau County consists of several towns, including the Town of Hempstead (population: 768 000), Town of North Hempstead (population: 231 000), and Town of Oyster Bay (population: 298 000) as well as municipalities of Long Beach (population: 33 000) and Glen Cove (population: 27 000).

Local pediatricians first provided testimony on tobacco control policies such as “Tobacco 21,” which raises the age of tobacco purchase to 21 years, in 2008 (and has since become federal law). From 2015 to 2018, with vigorous testimony by pediatricians and other stakeholders, Tobacco 21 legislation passed in both New York City and Suffolk County in 2015 and in Nassau County in 2018, before ultimately being enacted statewide in 2019.15,16 

Region-specific data from 2017 to 2018 revealed the rates of past-week, flavored e-cigarette use were 14.3% among 12 to 21 year olds, with 7.7% of children in the same age group reporting using PODS, a new generation of ENDS which feature disposable cartridges.17,18  Thus, Tobacco 21 policies alone were locally ineffective in reducing the teenager e-cigarette epidemic.

The main purpose of this advocacy work was to obtain passage of legislation to prohibit the sale of flavored vape products chapter-wide or, alternatively, advocate for “compromise” legislation to prohibit advertising of these products within 1000 feet of schools, parks, playgrounds, libraries, and other locations where young children congregate. After an initial failed attempt to prohibit the sale of flavored vape products in Suffolk in late 2018, we shifted our goal. Our revised goal was to create a region with restrictive local policies toward the sale of flavored nicotine products, constructed by passing multiple laws in the towns that comprise the counties. The proposed outcome included passing local legislation at the town level throughout 2019, and to create a patchwork of antitobacco regulations, creating momentum for larger municipal governments at the county, city, and state level, to enact these policies.

We describe our shift to a town-based strategy across the chapter’s region and completed the following advocacy steps to reach our goal:

  1. Codrafted and attempted passage of a county-wide ban on the sale of flavored tobacco products.

  2. Developed a targeted, ultra-local legislative strategy focused on drafting a primary bill to prohibit the sale of flavored vape products and a “compromise bill” to limit their advertising within 1000 feet of “child-friendly” locations, such as schools, parks, playgrounds, etc. Bills were introduced in towns known to be more receptive toward antitobacco legislation.

  3. Formed a broad-based coalition of antivaping and antitobacco advocates to coalesce around this ultra-local strategy and provide testimony at these smaller legislative venues.

  4. Educated legislators at all levels of government about the dangers of vaping via briefings and coordinated testimony.

The proposed outcome included drafting and passing local legislation in smaller towns.

To achieve these goals, physician members of the chapter, including the chapter president, legislative chair, and legislative committee members implemented a wide-ranging advocacy campaign including networking with like-minded organizations (Parents Against Vaping e-cigarettes, Campaign for Tobacco-Free Kids, Coalition Against Substance Abuse, etc; Table 1), social media, and opinion and editorial postings in local newspapers.

TABLE 1

Coalition members Over Time for Town-Based Advocacy Aimed at Restricting Sale of Electronic Nicotine Delivery System Flavors

December 2018June 2019July to November 2019
Original coalition Additional Additional 
AAP NY Chapter 2 Committee Against Substance Abuse School superintendents 
Campaign for Tobacco-Free Kids Parents Against Vaping e-cigarettes American Lung Association 
Local hospitals Various school district PTA members American Heart Association 
High school principal  American Cancer Society 
  Middle school–aged children 
December 2018June 2019July to November 2019
Original coalition Additional Additional 
AAP NY Chapter 2 Committee Against Substance Abuse School superintendents 
Campaign for Tobacco-Free Kids Parents Against Vaping e-cigarettes American Lung Association 
Local hospitals Various school district PTA members American Heart Association 
High school principal  American Cancer Society 
  Middle school–aged children 

List of antitobacco and/or antivaping organizations over time during advocacy to implement antitobacco restrictions in towns throughout AAP New York Chapter 2.

At the outset of this advocacy on nicotine flavorings in December 2018, physician members of the chapter codrafted legislation in Suffolk County to prohibit the sale of flavored vape products. The draft left exceptions for mint and menthol products as a concession to certain members of the Suffolk County Legislature. The chapter convened an initial coalition of community pediatricians, pediatric residents, the chapter president, a local high school principal, and members of the Campaign for Tobacco-Free Kids to testify at a December 2018 committee hearing. This coalition would expand over the year (Table 1). Testimony was coordinated to prevent repetition, and the bill was referred unanimously to the entire county legislature (see Supplemental Information). A rally of pediatricians and health advocates was held in conjunction with the legislative vote.19  The day of the full Suffolk County Legislature vote included a large contingent of pro-vape advocates from the New York State Vapor Association as well as vape shop owners and former combustible cigarette users. The protests against this bill, which included a “vape-in,” made statewide headlines, led local newscasts, and resulted in the bill being tabled without a formal vote19  (Fig 1). The accompanying social media campaign by pro-vape advocates, the state vaping association, convenience store owners, the Better Business Bureau, and established combustible cigarette users resulted in wariness by other large municipal governments (including New York City and the neighboring Nassau County), to consider similar legislation.

FIGURE 1

Timelines of selected local advocacy events related to local antitobacco advocacy. Town-based events and the ability to have 2 simultaneous bills restricting access to flavored tobacco products to children accelerated county and city adoption (at the AAP chapter level) and, ultimately, state adoption of these policies. Symbols (ie, star, circle, open circle, triangle, and open triangle) match the geographic location of the region of interest with the advocacy actions along the time line.

FIGURE 1

Timelines of selected local advocacy events related to local antitobacco advocacy. Town-based events and the ability to have 2 simultaneous bills restricting access to flavored tobacco products to children accelerated county and city adoption (at the AAP chapter level) and, ultimately, state adoption of these policies. Symbols (ie, star, circle, open circle, triangle, and open triangle) match the geographic location of the region of interest with the advocacy actions along the time line.

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Chapter members, in cooperation with county legislative staff, pivoted to a town-based legislative approach, beginning in January 2019. The strategy was two-pronged: sequentially approaching town boards to pass rules prohibiting the sale of flavored vape products and, if a board raised concerns, rapidly proposing the compromise bill to prohibit advertising of tobacco products in areas highly-trafficked by children. The latter bill relied heavily on published testimony from pro-vape advocates, who repeatedly expressed concern about the rise in teenager vaping but disagreed with enacting a “flavor” ban. By providing alternatives for wary legislators, this step created stronger chapter-wide antitobacco policy and maintained attention on the dangers of flavored nicotine products in children (Fig 1).

Local government staff facilitated growth of an enlarging “antivaping” coalition using the existing relationships with organizations with similar child-health goals (Table 1). For example, 12 advocates appeared before the local Town of Hempstead Board to speak in support of the compromise bill, prohibiting tobacco product advertising near parks, playgrounds, libraries, pools, and community centers, resulting in unanimous passage in June 2019 (Fig 1).

Now considered palatable, given one local township had passed legislation and created local precedent, pediatricians and coalition members next met with the supervisor of a neighboring town (officially named the Town of North Hempstead; Fig 1), who drafted a bill within 6 weeks based on the compromise legislation passed in the adjacent town. Efforts to pass town-based legislation escaped detection by the vape industry lobby, who only routinely monitored bills in high-population counties and the New York State Legislature and were thus not aware of these smaller government efforts, resulting in little or no organized opposition. Ultimately, members of this group spoke at 6 local town councils and multiple county hearings in favor of either a complete prohibition on the sale of flavored nicotine products or the compromise legislation to restrict tobacco advertising in child-friendly areas. Before a town hearing, e-mail “legislative alerts,” including sample text were sent to the Listserv of organizations to share with members, inviting them to e-mail or call relevant government representatives expressing support (see Supplemental Information).

Throughout multiple hearings and private meetings, coalition members educated legislators about the dangers flavored vape products pose to children. Chapter member pediatricians appeared 10 times before various local boards to testify in support of proposed legislation. To complement these efforts, the chapter assigned 2 pediatricians to deliver remarks to local parent–teacher association (PTA) groups in the towns where any antitobacco legislation was being proposed. These physician chapter members, which included one elected school board member, educated local PTAs about the dangers of ENDS and built community-wide support for local bills. Attendees left with a sample letter and instructions to call their town representative (see Supplemental Information). Five education sessions occurred at local PTA meetings or school auditoriums. In addition, a comprehensive policy letter on vape flavorings, specific to the region, was produced and delivered to legislators. Two press conferences, convened by the county executive and attended by AAP chapter advocates, the county health commissioner, and school board members of 4 major districts, were held to increase the visibility of the issue, emphasizing only the compromise bill. The goal was to raise awareness without telegraphing our intent to ultimately pass a prohibition on the sale of any flavored nicotine product, which would antagonize pro-vape advocates.

The compromise bill on the restriction on advertising of tobacco products near child-friendly areas passed unanimously in Nassau County in August 2019: 2 months after the Town of Hempstead legislation and 2 weeks after being proposed in the Town of North Hempstead (Fig 1). Speaking in support of the measure was a now well-rehearsed, experienced, broad coalition of 20 antitobacco advocates, including 9 pediatricians, 2 pediatric subspecialists, 2 PTA members, 2 children from local middle schools, a former local high school valedictorian currently performing oncology research, 3 teachers, and 2 grandparents.

In August 2019, the Town of Hempstead now proposed a full-scale prohibition on the sale of all flavored vape products, consistent with National AAP policy and expanding the breadth of the antitobacco legislation beyond the compromise bill, which this town passed in June 2019 (Fig 1). A complete ban on flavored vape products passed in the town in September of 2019. The next month, a county-wide ban was introduced. With heavy opposition from the vape industry, the bill failed to pass. Despite this setback, the legislative minority, county executive, and local AAP chapter continued targeted, individual meetings with legislators who had reluctantly voted against the bill. The chapter also consolidated its list of members who live or practice in the county and merged it with PTA attendance sheets from pediatrician-led antivaping information sessions to create a list-serve to be activated should the bill be reintroduced.

On November 25, 2019, the Nassau County Legislature convened to hear testimony again on a complete prohibition on the sale of all flavored ENDSs. Despite failing 2 months previously, the legislation passed unanimously, aided by targeted e-mails via the Listserv (Fig 1). At the time, the county was the largest statewide region to enact such a prohibition. Within a month, New York City, whose health committee chair was closely following the events in the neighboring county, proposed and passed a complete flavor ban encompassing all of New York City in December of 2019. Similar bills were subsequently introduced in Westchester County (population: 970 000), the City of Yonkers (population: 200 000; AAP Chapter 3), and Albany County (population: 305 000; AAP Chapter 1). With the majority of the state already now living under this public health policy, statewide legislation passed in March 2020.

This report demonstrates how highly localized advocacy can spur broader legislative change by setting precedent. Although significant AAP advocacy is focused at the state level, chapters should consider targeting smaller, local governments to enact child-friendly policies if state legislation is not feasible. There are several advantages to working with local governments. Given their smaller scale, meeting with all members of a board is relatively easy, compared with the state level. In addition, the pace of enacting legislation is often faster than at the county, state, or federal levels. Finally, compared with higher levels of government, less direct outreach to legislative offices may be required. In some towns, 20 to 30 calls from residents may create an outsize impact. In addition, town governments in our Chapter are often one-party dominated, making it easier to target which local governments will be receptive to our proposals. Our strategy provides a template for how to reduce the burden of child nicotine addiction, even in states with “tobacco-friendly” legislatures, and our strategy may be a model to enact other policies.

Several factors contributed to this strategy. Partnering with county officials who knew the idiosyncrasies of town government was essential. County legislative staff provided key contact personnel in town governments and suggested the town board members most likely to be supportive. They also provided increased networking with like-minded organizations and advocates with whom we had not previously worked, facilitating coalition building. Increased social media, op-ed use, and press conferences attended by legislators from multiple levels of government maintained the relevancy of this issue against the backdrop of increased flavored vape product use, facilitating the ultimate passage of laws at every level of town, county, and state government.20 

Reducing access to alluring flavored nicotine products is an evidenced-based strategy to lower rates of teenager vaping and early combustible cigarette use.7,8,10,11  Legislative prescriptions are one element of reducing the harm of tobacco on children. A localized approach that offers several bills allows for incremental progress, when sweeping legislative change is politically infeasible. Subsequent to passage of these 2019 measures, state and local data reported a decrease in current e-cigarette use from 27.5% to 19.6% among high schoolers.3,21  Further studies are needed to assess further policy mechanisms to reduce child nicotine use.

We acknowledge the work of scores of members of New York Chapter 2 of the AAP for their work calling legislators, appearing for testimony, and conducting educational sessions with multiple parent-teacher groups about the dangers of vaping. These actions were essential to achieve passage of these laws.

Dr Shah conceptualized the article, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Siddiqui made critical revisions of the manuscript, assisted significantly in the advocacy outlined in the article, and reviewed the manuscript; Dr Krief made critical revisions of the manuscript, assisted significantly in the advocacy outlined in the article, and reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • AAP

    American Academy of Pediatrics

  •  
  • ENDS

    Electronic Nicotine Delivery System

  •  
  • PTA

    parent–teacher association

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Competing Interests

POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data