American Association of Public Health Physicians

Guardians of the Public's Health

Information for AAPHP members attending the AMA Interim Meeting

AAPHP Delegatie Dave Cundiff, Charles Lee, Anna Yao (RFS AAPHP Sectional Delegation), Alternative Delegate Arlene Seid

APHP Resident and Fellow Sectional Delegate ANNA YAP MD (center), with AAPHP’s AMA Delegate DAVE CUNDIFF MD MPH and with AAPHP Associate Member MARYANNE MURRAY DNP EdD (Dave’s wife) — AMA Ambassador Mixer, San Diego, 2019-11-15.

down to see submitted resolutions inclduing:

1) MAINTAINING PUBLIC FOCUS ON LEADING CAUSES OF NICOTINE-RELATED DEATH

2) LEGISLATION TO FACILITATE CORRECTIONS-TO-COMMUNITY HEALTHCARE CONTINUITY VIA MEDICAID

3) REGULATING MARKETING AND DISTRIBUTION OF TOBACCO PRODUCTS AND VAPING-RELATED PRODUCTS

Submitted Resolution:

Title: MAINTAINING PUBLIC FOCUS ON LEADING CAUSES OF NICOTINE-RELATED DEATH

Introduced by: American Association of Public Health Physicians

WHEREAS our AMA is dedicated to the protection of the public’s health; and

WHEREAS the protection of the public’s health always requires due consideration of quantitative risks, and often requires comparison of competing risks as well; and

WHEREAS direct and indirect exposure to combustible cigarette smoke continues to cause approximately 480,000 deaths each year in the USA, and that number has not decreased significantly for many years [footnote 1]; and

WHEREAS as of early October 2019, the U.S. outbreak of “vaping-associated pulmonary illness” has risen to approximately 1,080 cases and 19 deaths have been attributed to this outbreak so far [footnote 2]; and

WHEREAS Americans’ rates of combustible cigarette smoking have dropped at an accelerated rate since 2010, since electronic nicotine delivery systems (ENDS) became widely available in the U.S. market [footnotes 3, 4]; and

WHEREAS a 2013 Gallup survey of former smokers in the USA, with no attempt to weight the sample by year of quitting, showed that 3% of former smokers in the USA stated that electronic cigarettes were the primary stop-smoking method associated with their successful quitting of combustible cigarettes [footnote 5], and no updates of these data since 2013 are available; and

WHEREAS the only large randomized controlled trial of e-cigarettes as a smoking cessation aid was done in Britain, and it showed that British e-cigarettes (used in context of British stop-smoking counseling and cultural context) had stop-smoking results that were clearly superior to those of pharmaceutical nicotine replacement products [footnotes 6, 7); and

WHEREAS there is spirited debate on the real-world effects of e-cigarettes on smoking cessation in the USA (footnote 8); and

WHEREAS Public Health England’s 2019 update notes that 4.1% of quit attempts assisted by the National Health Service involve the use of electronic cigarettes, and notes on page 95 that, “In every region, quit rates involving the use of an EC were higher than any other type of pharmacotherapy used” [footnote 9]; and

WHEREAS on August 30, 2019, the U.S. Centers for Disease Control and Prevention (CDC) issued public guidance discouraging use of all ENDS products, regardless of prior nicotine dependence or the purpose of the individual’s ENDS use [footnote 10]; and

WHEREAS our AMA’s public statements during September 2019 basically copied CDC guidance that everyone should stop all use of ENDS products, also regardless of prior nicotine dependence or the purpose of the individual’s ENDS use [footnotes 11, 12]; and

WHEREAS In late September 2019, CDC modified their guidance to state that, “Adults who use e-cigarettes because they have quit smoking should not return to smoking combustible cigarettes.” [footnote 13]. However, because this aspect of the CDC recommendation was buried in page three of a five-page report, it seems to have received very little attention in mainstream media or in public consciousness; and

WHEREAS in early October 2019, the Atlantic published an analysis by James Hamblin MD noting that the news value of a small number of VAPI-associated deaths is far higher than the news value of a huge number of smoking-associated deaths, reminding us that those trying to save lives by stopping smoking must stay vigilant that this part of our message is not drowned out by other messages [footnote 14]; and

WHEREAS in early October 2018, a highly respected tobacco industry analyst (who is compensated for the accuracy of her predictions, not for raising the value of any industry stock), cautiously predicted, “While still too early to call, we believe further negative news and an FDA-mandated removal of non-tobacco e-cigarette flavors from the market could result in improved combustible cigarette volumes as vapers potentially return to the cigarette category.” [footnote 15]; and

WHEREAS a significant increase in the number of Americans smoking combustible cigarettes, regardless of the cause of this increase, would result in a public health catastrophe; therefore be it

RESOLVED that in public statements on nicotine issues, and in discussions with government officials, our AMA will seek every reasonable opportunity to remind the American public about (1) the massive ongoing death toll from combustible cigarettes; (2) the large and solidly demonstrated death toll from environmental tobacco smoke; and (3) the ongoing need for every smoker to find the best possible way to achieve and maintain abstinence from combustible cigarettes.

*** FOOTNOTES ***

((1)) https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm, accessed September 20, 2019.

((2)) https://www.nytimes.com/2019/10/03/health/vaping-illnesses-cdc.html, accessed October 4, 2019.

((3)) https://www.cnbc.com/2018/11/08/cdc-says-smoking-rates-fall-to-record-low-in-us.html, accessed October 4, 2019.

((4)) http://tobaccoanalysis.blogspot.com/2019/09/e-cigarettes-are-gateway-to-smoking-so.html, accessed September 12, 2019.

((5)) https://news.gallup.com/poll/163763/smokers-quit-tried-multiple-times.aspx, accessed October 4, 2019.

((6)) https://www.nejm.org/doi/10.1056/NEJMoa1808779, accessed October 4, 2019.

((7)) https://www.health.harvard.edu/blog/can-vaping-help-you-quit-smoking-2019022716086, accessed October 4, 2019.

((8)) https://www.cnn.com/2019/07/15/health/e-cigarettes-quit-smoking-study/index.html, accessed October 4, 2019.

((9)) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/821179/Vaping_in_England_an_evidence_update_February_2019.pdf, accessed October 7, 2019.

((10)) https://emergency.cdc.gov/han/han00421.asp?deliveryName=DM8038, accessed October 4, 2019.

((11)) https://www.ama-assn.org/press-center/ama-statements/ama-urges-public-avoid-e-cigarette-use-amid-lung-illness-outbreak, accessed September 9, 2019.

((12)) https://www.npr.org/2019/09/12/760077445/trump-calls-for-ban-on-non-tobacco-flavored-vaping-products, accessed September 16, 2019.

((13)) https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6839e1-h.pdf?deliveryName=USCDC_921-DM9775, accessed September 27, 2019.

((14)) https://www.theatlantic.com/health/archive/2019/10/how-dangerous-vaping/599209/, accessed October 2, 2019.

((15)) https://www.journalnow.com/business/e-cigarette-sales-begin-to-cool-as-public-health-warnings/article_3eb0c42e-2e70-5bbe-84ae-7e2835c7ebea.html, accessed October 3, 201

LEGISLATION TO FACILITATE CORRECTIONS-TO-COMMUNITY HEALTHCARE CONTINUITY VIA MEDICAID

Submitted by: American Association of Public Health Physicians

WHEREAS our AMA has established policy in item 6 of Health Care While Incarcerated H-430.986 to “urge the Center for Medicare and Medicaid Services (CMS) and state Medicaid agencies to provide Medicaid coverage for health care, care coordination activities and linkages to care delivered to patients up to 30 days before the anticipated release from correctional facilities”; and

WHEREAS Medicare and Medicaid are legally prohibited by the inmate exclusion provision, section 1905(a)(29)of the Social Security Act¹, from paying for expenses incurred while a beneficiary is incarcerated, thus requiring Congressional action before CMS and states can implement the policy that our AMA supports in H-430.986; and

WHEREAS a bipartisan Congressional bill, H.R. 1329, introduced to the 116^th Congress by Rep. Paul Tonko (D-NY) & Rep. Michael Turner (R-OH)² and known as the Medicaid Reentry Act, would amend the inmate exclusion provision to grant states flexibility to restart benefits for Medicaid-eligible incarcerated individuals during the 30 day period preceding the date of release; and

WHEREAS the American Medical Association has not yet announced support for the Medicaid Reentry Act as of October 13, 2019; therefore be it

RESOLVED that our AMA amend item #6 of HoD Policy H-430.986 to add the word "Congress", with necessary punctuation, to read as follows:

6. Our AMA urges Congress, the Centers for Medicare & Medicaid Services (CMS), and state Medicaid agencies to provide Medicaid coverage for health care, care coordination activities and linkages to care delivered to patients up to 30 days before the anticipated release from correctional facilities in order to help establish coverage effective upon release, assist with transition to care in the community, and help reduce recidivism. [Amend Current HoD Policy]

References

(1) https://www.ssa.gov/OP_Home/ssact/title19/1905.htm, accessed October 14, 2019.

(2) H.R. 1329, The Medicaid Reentry Act, https://www.congress.gov/bill/116th-congress/house-bill/1329, accessed October 14, 2019.

REGULATING MARKETING AND DISTRIBUTION OF TOBACCO PRODUCTS AND VAPING-RELATED PRODUCTS

Introduced for I-19 by: American Association of Public Health Physicians

WHEREAS the 2019 outbreak of “E-cigarette and Vapor Associated Pulmonary Illness” (EVAPI) has so far been almost entirely associated with the use of illicit, illegal, and/or user-modified “electronic cigarette” products, especially those containing THC; and

WHEREAS nicotine is highly addictive; and

WHEREAS it is important to decrease the rates of nicotine use and dependence in all age groups, especially youth; and

WHEREAS it is important to decrease the morbidity and mortality from nicotine products by all appropriate means; and

WHEREAS it is unclear whether prohibition of legal e-cigarette and “vaping” products would increase or decrease the use of illicit, illegal, and/or user-modified products; and

WHEREAS the net effect of e-cigarette flavoring bans on adult smokers is unclear; and

WHEREAS there is an urgent need to decrease the addictiveness of electronic nicotine delivery systems (ENDS); therefore be it

RESOLVED that our AMA supports strict marketing standards to prevent all nicotine-related products from being marketed to, or attractive to, children, adolescents, and young adults, including but not limited to the following measures:

Banning print advertising except in adult-only publications or media (adults are >85% of audience).
Banning advertising and/or sponsorship at stadiums, concerts, sporting or other public events that are not primarily targeted to adults;
Banning offers of any school or college scholarships by any company selling tobacco products.
Banning television advertising of any tobacco products, including any vapor products.
Banning advertising, marketing and sale of tobacco products that:
- Uses the terms "candy" or "candies" or variants in spelling, such as "kandy" or "kandeez," "bubble gum," "cotton candy," and "gummi bear", and "milkshake."
- Uses the terms "cake" or "cakes" or variants such as "cupcake."
- Uses packaging, trade dress or trademarks that imitate those of food or other products primarily targeted to minors such as candy, cookies, juice boxes or soft drinks.
- Uses packaging that contains images of food products primarily targeted to minors such as juice boxes, soft drinks, soda pop, cereal, candy, or desserts.
- Imitates a consumer product designed or intended primarily for minors
- Uses cartoons or cartoon characters.
- Uses images or references to superheroes.
- Uses any likeness to images, characters, or phrases that are known to appeal primarily to minors, such as "unicorn".
- Uses a video game, movie, video, or animated television show known to appeal primarily to minors.

Banning advertising and marketing of tobacco products, including vapor products, that:
- Does not accurately represent the ingredients contained in the products.
- Uses contracted spokespeople or individuals that do not appear to be at least 25 years of age.
Banning advertising on outdoor billboards near schools and playgrounds.
Requiring labels to include warnings protecting youth such as "Sales to Minors Prohibited" or "Underage Sales Prohibited" and/or "Keep Out of Reach of Children".
Requiring all advertising to be accurate and not misleading.

And be it further

RESOLVED that our AMA supports the use of the most up-to-date and effective technology for verifying the age of would-be purchasers of tobacco products and vaping-related products, both online and in bricks-and-mortar retail outlets; and be it further

RESOLVED that our AMA opposes sales of tobacco products or vaping-related products on any third-party marketplace such as Alibaba, Amazon, eBay, et al, where the third-party marketplace does not take full responsibility for verifying age; blocking unregulated cannabis and THC products; identifying and prohibiting all counterfeit products; and forbidding packaging and other materials that allow illicit sales of any tobacco product; and be it further

RESOLVED that our AMA supports licensing and frequent inspections of all retail outlets selling any tobacco products or vaping-related products, with loss of license for repeated violations (e.g., three violations in a three year period); and be it further

RESOLVED that our AMA supports limitations on the concentration, chemical form, and vehicle chemistry of all nicotine-related products, with special attention to the European product standards which seem to lead to much lower addictiveness than many of the ENDS products sold in the USA; and be it further

RESOLVED that our AMA supports a ban on all self-service displays of tobacco products, which would require all tobacco products and vaping-related products to be behind a counter or in a locked display and accessible only to a store employee; and be it further

RESOLVED that our AMA supports a ban on sales of all tobacco products and vaping-related products except in stores that display signage indicating that (a) "Unaccompanied Minors Are Not Allowed on Premises" or (b) "Products are Not for Sale to Minors" or (c) "Underage Sale Prohibited", and that enforce these rules consistently; and be it further

RESOLVED that our AMA supports a ban on “straw man” sellers, which would make it illegal for any person who is not a licensed tobacco product dealer or vaping-related product dealer to sell, barter for, or exchange any tobacco product or vaping-related products; and be it further

RESOLVED that our AMA supports legislation that would discourage “straw man” distribution by prohibiting the retail sale of quantities likely intended for more than one consumer, such as the retail sale to one customer of (a) more than two electronic-cigarette or vape devices; (b) more than five standard packages of e-liquids; (c) more than 20 packs of cigarettes; or (d) similarly determined quantities of other tobacco products and/or vaping-related products.

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