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1、“State of Tobacco Control”2022:20 Years of“State of Tobacco Control”Celebrating the Progress Made and Recognizing the Work that Remains to be Done Executive SummaryThe American Lung Associations annual“State of Tobacco Control”report evaluates states and the federal government on actions taken to el
2、iminate the nations leading cause of preventable deathtobacco useand save lives with proven-effective and urgently needed tobacco control laws and policies.The Lung Association proudly marks the 20th anniversary of releasing its“State of Tobacco Control”report in 2022 by reflecting on the progress m
3、ade over the past 20 years and looking ahead to the significant amount of work that remains to be done to end tobacco-caused death and disease in this country.A new generation of tobacco products,including e-cigarettes,threatens the progress made,as more than two million middle and high school stude
4、nts reported using e-cigarettes in 2021.1 In response to the youth vaping epidemic,new public policies,including ending the sale of all flavored tobacco products,have risen in importance as well.Key themes in“State of Tobacco Control”this year include:FDA Opportunities in 2021 to Reduce Tobacco Use:
5、The U.S.Food and Drug Administration(FDA)took several actions in 2021 that could signal a beginning to meaningful action in its oversight of tobacco products.On April 29,2021,FDA made an important announcement indicating its intention to issue proposed rules no later than April 2022 to remove mentho
6、l cigarettes and most flavored cigars from the marketplace.If FDA follows through on its commitment,it will be an historic achievement for public health in the U.S.given the disproportionate impact menthol cigarettes and flavored cigars have on many different communities and populations,especially B
7、lack Americans.FDA had an opportunity to remove e-cigarettes and other tobacco products from the market that did not meet its public health standard through its pre-market tobacco authorization(PMTA)authority under the Family Smoking Prevention and Tobacco Control Act.FDA was under a court-ordered d
8、eadline of September 9,2021,to review millions of PMTAs submitted by e-cigarettes and other tobacco product companies in 2020.Unfortunately,as of the end of 2021,FDA had not acted on the products most responsible for the youth e-cigarette epidemic such as JUUL,leaving them on the market.Health Dispa
9、rities Related to Tobacco Use:An unfortunate constant over the past 20 years is the unequal burden of tobacco use and exposure to secondhand smoke on some communities and populations.The overall adult smoking rate has declined significantly from 21.6%in 2003 to 14.0%in 2019,a 35%decline.2 However,th
10、is overall rate masks significant disparities among races/ethnicities and due to socio-economic factors.Smoking remains particularly high among Native Americans and Alaskan Natives at 20.9%and Lesbian,Gay and Bisexual adults at 19.2%.3 Smoking among persons with lower incomes and lower levels of edu
11、cation also 2022American Lung Association“State of Tobacco Control”20222 Lung.orgremains high.4 Certain populations are also disproportionately exposed to secondhand smoke,including:children ages 3-11,Black Americans,persons living in poverty and people with a high school education or less.5 Parts o
12、f the country,especially many Southern and Appalachian states remain unprotected from secondhand smoke in public places and workplaces as well.State Progress to Reduce Tobacco Use:The country has made substantial progress on several of the state public policies measured in“State of Tobacco Control”o
13、ver the past 20 years.These include:Progressing from 2 to 28 smokefree states;Increasing the average state cigarette tax from$0.62 in January 2003 to$1.91 in January 2022;and Improving state Medicaid program coverage of quit smoking treatments since“State of Tobacco Control”first began tracking thes
14、e data in 2008.In 2021,the tobacco industry brought back to the forefront an old roadblock it has used for more than 30 years:preemption,or lobbying state legislatures to pass laws that prevent local communities from passing tobacco control policies stronger than state law.This severely hampers the
15、ability of local communities to prevent and reduce tobacco use.Unfortunately,the tobacco industry was successful in instituting new preemptive state laws on sales of tobacco products in Florida and Montana in 2021.The COVID-19 pandemics impact on tobacco use is still being assessed.According to a Fe
16、deral Trade Commission report in 2020,cigarette sales increased for the first time in 20 years.6 It is unclear if this signals higher adult smoking rates,or existing smokers smoking more cigarettes.In addition,the rate of youth vaping in the Centers for Disease Control and Preventions 2021 National
17、Youth Tobacco Survey varied significantly if a student took the survey at home or in a school building.7 Therefore,it is unclear if the level of youth vaping seen in 2021 will be a one-year blip or a durable trend.During 2020,many casinos both tribal and non-tribal re-opened smokefree after being cl
18、osed initially during the COVID-19 pandemic.Unfortunately,2021 saw some backsliding in this area with smoking returning to casinos in New Jersey and Pennsylvania after emergency orders issued by governors preventing them from allowing smoking expired.Activity on tobacco tax increases ended up being
19、much slower than expected in 2021 as well,due to many state budgets being more robust than expected.In 2022,the country needs to redouble its efforts to pass the proven policies called for in“State of Tobacco Control.”This will require an ongoing partnership at the federal,state and local levels to
20、restart declines in adult and youth tobacco use rates and reduce the 480,000 lives lost to tobacco each year.Our elected officials must take stronger actions to put the country on a path to finally end tobacco use over the next 20 years.More About“State of Tobacco Control”“State of Tobacco Control”2
21、022 is focused on proven policies that federal and state governments can enact to prevent and reduce tobacco use.These include:Tobacco prevention and quit smoking funding,programs and robust insurance coverage;Comprehensive smokefree laws that eliminate smoking in all public places and workplaces;In
22、creased tobacco taxes;Eliminating the sale of all flavored tobacco products;Full implementation of the U.S.Food and Drug Administrations(FDA)Family Smoking Prevention and Tobacco Control Act;andHard hitting federal media campaigns to encourage smokers to quit and prevent young people from starting t
23、o use tobacco.The report assigns grades based on laws and regulations designed to prevent and reduce tobacco use in effect as of January 2022.The federal government,all 50 state governments and the District of Columbia are graded to determine if their laws and policies are adequately protecting citi
24、zens from the enormous toll tobacco use takes on lives,health and the economy.1.Park-Lee E,Ren C,Sawdey MD,et al.Notes from the Field:E-Cigarette Use Among Middle and High School Students National Youth Tobacco Survey,United States,2021.MMWR Morb Mortal Wkly Rep 2021;70:13871389.DOI:http:/dx.doi.org
25、/10.15585/mmwr.mm7039a4.2.CDC.National Health Interview Survey.Various years.3.Cornelius ME,Wang TW,Jamal A,Loretan CG,Neff LJ.Tobacco Product Use Among Adults United States,2019.MMWR Morb Mortal Wkly Rep 2020;69:17361742.4.Ibid.2022American Lung Association“State of Tobacco Control”20223 Lung.org5.
26、Tsai J,Homa DM,Neff LJ,Sosnoff CS,Wang L,Blount BC,Melstrom PC,King BA.Trends in Secondhand Smoke Exposure,2011-2018:Impact and Implications of Expanding Serum Cotinine Range.Am J Prev Med.2021 Sep;61(3):e109-e117.doi:10.1016/j.amepre.2021.04.004.6.Federal Trade Commission.“Cigarette Report for 2020
27、.”Released October 2021.7.Park-Lee E,Ren C,Sawdey MD,et al.Notes from the Field:E-Cigarette Use Among Middle and High School Students National Youth Tobacco Survey,United States,2021.MMWR Morb Mortal Wkly Rep 2021;70:13871389.DOI:http:/dx.doi.org/10.15585/mmwr.mm7039a4.2022American Lung Association“
28、State of Tobacco Control”20224 Lung.org20th Anniversary of“State of Tobacco Control”Shows Policymakers at All Levels of Government Havent Fully Embraced Importance of Preventing and Reducing Tobacco UseSince the American Lung Association first launched its“State of Tobacco Control”report in January
29、2003,the country has,overall,made tremendous progress in its efforts to prevent and reduce tobacco use.Adult cigarette smoking rates have declined from 21.6%in 2003 to 14%in 2019.1 Youth cigarette smoking rates have fallen even faster among high school students from 22.5%in 2002 to 4.6%in 2020.2 At
30、the state level,the country has seen significant progress on several tobacco control policies,including:1)smokefree workplace laws,2)tobacco taxes and 3)Medicaid coverage of tobacco cessation treatments.At the federal level:1)the U.S.Food and Drug Administration(FDA)gained comprehensive authority ov
31、er the manufacture,marketing and sales of tobacco products;2)flavored cigarettes,with the glaring exception of menthol,were prohibited;and 3)the federal age of sale for tobacco products was increased to 21 nationwide.However,in other ways,federal,state and local policy makers have yet to take the st
32、eps necessary to eliminate tobacco use or protect another generation of youth from becoming addicted.Significant social,racial,geographic and sexual orientation disparities in who uses tobacco products and who is exposed to secondhand smoke in the U.S.have only become more pronounced as overall toba
33、cco use rates have decreased.While there have been some promising announcements and actions taken by FDA in 2021,unnecessary addiction,disease and death could have been prevented by more assertive federal government action on flavored tobacco products.State progress on comprehensive smokefree workpl
34、ace laws appears successful over the course of 20 years but has completely stalled since 2012.Tobacco tax increases have slowed in terms of frequency over the past few years,and only one state,Maryland,increased its tobacco taxes in 2021.The country continues to endure the most significant public he
35、alth crisis of the last 100 years,COVID-19,and yet it has failed to convince officials that they must sufficiently invest in public health infrastructure and prioritize policies that will protect people during a public health epidemic.The Lung Associations“State of Tobacco Control”2022 report contin
36、ues to offer a road map with solutions for many of these challenges,but the country needs federal,state and local lawmakers to implement them to further drive down smoking and tobacco use rates.FDA Crawls Forward Towards More Comprehensive Regulation of Tobacco Products;Leaves Products Most Responsi
37、ble for the Youth E-Cigarette Epidemic on the MarketFacing a court-ordered deadline,in 2021,FDA finally began to implement and enforce pre-market tobacco authorization(PMTA)requirements for e-cigarettes,hookah,pipe tobacco,most cigars and other tobacco products after many years of delay.This progres
38、s was due to a court decision in a lawsuit filed by the Lung Association and several public health partners ordering tobacco product manufacturers to submit PMTA applications to FDA by September 9,2020,and for FDA to review and make decisions on those applications by September 9,2021.Tobacco remains
39、 the leading cause of preventable death and disease in America,killing 480,000 people each year.In addition,16 million Americans live with a tobacco-related disease.32022American Lung Association“State of Tobacco Control”20225 Lung.orgFDA did issue marketing denial orders for many non-menthol flavor
40、ed e-cigarettes in 2021.However,when it came to the e-cigarette products with the highest market share and that are the most responsible for the youth vaping epidemic such as JUUL and Vuse,FDA delayed decision on their PMTAs for a significant period of time after the courts deadline.FDA also issued
41、marketing orders for several high nicotine Vuse tobacco-flavored e-cigarettes and took no action on any PMTA related to menthol e-cigarettes.The Lung Association has repeatedly called for all flavored tobacco products,including e-cigarettes,to be removed from the marketplace.Flavors are a key driver
42、 of youth tobacco use,and no evidence has been presented that flavored products can meet the public health standard that the law requires.A new,potentially large loophole emerged in 2021 in the form of synthetic nicotine,as the FDAs Center for Tobacco Products asserts its authority only covers nicot
43、ine derived from tobacco.E-cigarette companies,including PuffBar,the most used e-cigarette product among teens,appear to be exploiting this legal loophole.Synthetic nicotine flavored e-cigarettes are being used to attempt to evade the Tobacco Control Act.The Lung Association has called for FDA to re
44、gulate synthetic nicotine as a drug;if it is to be regulated as a tobacco product,it will require action by Congress.In Response to Significant Disparities in Tobacco Use in U.S.,FDA Makes an Important Announcement on MentholOverall,adult cigarette smoking,and tobacco use rates remained level from t
45、he previous year in 2019,the latest year of data.As has been the case since“State of Tobacco Control”was first published 20 years ago though,the overall rates mask significant disparities among racial,ethnic,socio-economic and LGBTQ+communities.Use of commercial tobacco products remains particularly
46、 high among Native Americans and Alaskan Natives at 20.9%and lesbian,gay and bisexual adults at 19.2%.4 Adults with lower incomes,lower levels of education and experiencing mental illness or substance abuse also endure significantly higher rates of smoking.While regular,national data is lacking on t
47、his topic,studies have shown that smoking and tobacco use can vary significantly amongst sub-populations of Hispanic and Asian Americans as well.In addition,the declines in cigarette smoking rates observed in recent years has been due almost entirely to non-menthol cigarettes.Menthol cigarettes are
48、used by close to 81%of Black Americans5 and disproportionately by pregnant women,youth and LGBTQ Americans.6 In fact,a study released in 2021 found that menthol cigarettes were responsible for 1.5 million new smokers,157,000 smoking-related premature deaths and 1.5 million life years lost among Afri
49、can Americans from 19802018.7 These disparities in menthol cigarette use are largely the result of targeted marketing by the tobacco industry.This makes an April 2021 announcement by FDA of its intention to issue proposed rules removing menthol cigarettes and many flavored cigars from the marketplac
50、e an important development.However,FDA has said it will take until April 2022 just to propose rules.Then it may take several years to finalize the rule and defend against the inevitable industry lawsuits.This is on top of years of delay from when FDAs Tobacco Product Scientific Advisory Committee in
51、 2011 and FDA itself in 2013 issued separate reports saying it would be beneficial to public health to remove menthol cigarettes from the market.The American Lung Association applauded this long overdue 2022American Lung Association“State of Tobacco Control”20226 Lung.organnouncement and urges FDA t
52、o act with urgency on this issue in light of the years of delay and the disproportionate burden menthol cigarettes place on many communities experiencing health disparities.20 Years of Uneven Change in State Tobacco Prevention PoliciesThe past 20 years in state tobacco prevention policies can best b
53、e summarized as uneven progress with significant differences by policy,decade and geographic region.The country saw significant progress on smokefree workplace laws and tobacco taxes during the 2000s,only to see that progress stall completely during the 2010s.Certain parts of the country continue to
54、 lag significantly behind in putting in place the proven policies called for in“State of Tobacco Control,”including states in the South,Appalachia as well as parts of the Midwest and Great Plains.States where tobacco is or was previously grown and have significant tobacco industry presences,such as
55、North Carolina and Virginia,remain particularly challenging.Increasing State Tobacco Taxes:Increasing tobacco taxes by$1.00 per pack or more is one of the most effective ways to reduce tobacco use,especially among kids.Many states have significantly increased their taxes on cigarettes and other toba
56、cco products over the past 20 years.However,this has created a wide disparity in cigarette tax rates,with the lowest state cigarette tax in Missouri at a meager 17 cents per pack and the District of Columbia the highest at$4.50 per pack.Maryland was the only state to increase its cigarette tax in 20
57、21,to$3.75 per pack,5th highest in the country.Smokefree Public Places and Workplaces:From 2003 to 2012,there was a significant expansion of the number of states with laws prohibiting smoking in public places and workplaces,however no additional states have passed such laws since then.Some states wi
58、th comprehensive smokefree laws have closed additional loopholes in their laws,including Connecticut in 2021.Ohio also added e-cigarettes to its comprehensive smokefree law in 2021.During 2020,more than 200 tribal and non-tribal casinos re-opened smokefree8 after being closed due to COVID-19.During
59、2021,many tribal casinos kept their smokefree policies in place but there was some backsliding among state-regulated casinos when state COVID-19 emergency orders expired.In addition,the Navajo Nation approved legislation in 2021 after a 12 plus year effort that made all public places and workplaces,
60、including tribal casinos smokefree.Expanding Medicaid and Tobacco Cessation Coverage.Since 2009,the“State of Tobacco Control”report began reporting on states tobacco cessation coverage.Over the past 13 years,state Medicaid programs have increased the number treatments they covered,and because of pro
61、visions in the Affordable Care Act(ACA)have increased the number of people eligible for Medicaid coverage.The 2009 report showed only 20 states covering all 7 FDA-approved cessation medications.This years report shows that 43 states now provide that coverage.The report has tracked the progress state
62、s have made in providing these treatments not only to Medicaid enrollees,but also to State Employees through their health plans.The report also recognizes the importance of adequately funding state quitlines in helping smokers quit.While the last 13 years of“State of Tobacco Control”reports have sho
63、wn progress in policies to access quit smoking services,there is still more work to be done.2022American Lung Association“State of Tobacco Control”20227 Lung.orgFunding for State Tobacco Prevention and Cessation Programs.This issue has seen the least progress among the four areas that states have be
64、en graded on longest in the“State of Tobacco Control”report.The majority of states have kept their levels of funding steady from year to year,but most states remain far short of the funding levels recommended by CDC.Properly funding state tobacco control programs can bring crucial focus and resource
65、s to alleviate disparities in who uses tobacco products and help achieve health equity in tobacco control.People from disproportionately affected communities should be empowered to lead the effort to address these disparities,including providing funding to organizations that directly serve the commu
66、nities.In the current state fiscal year,fiscal year 2022,two statesAlaska and Oregon funded their state tobacco control programs at or close to the level recommended by CDC.New Tobacco Products and New Public Policies Rise to the ForefrontOver the 20 years of“State of Tobacco Control,”both new tobac
67、co products and new public policies to prevent and reduce tobacco use have emerged.The most prominent and concerning of the new tobacco products to come onto the market have been e-cigarettes,which have been sold in the U.S.since 2007.The American Lung Association has been consistently warning of th
68、e potential dangers of these products since their debut.Our fears were unfortunately validated when youth use of e-cigarettes rose substantially from 2011 to 2015 and then to an even greater degree from 2017 to 2019.This caused the U.S.Surgeon General to declare youth vaping an epidemic in 2018.In 2
69、021,youth vaping rates were 11.3%among high school students and 2.8%among middle school students.9 However,with some schools closed for in-person learning due to the COVID-19 pandemic,some kids had less access to e-cigarettes.Youth vaping rates in 2021 varied substantially based on whether a student
70、 took the survey at school(15.0%)or home/some other place(8.1%).10 Other new tobacco and nicotine products introduced to the U.S.market in the past few years include heated tobacco products such as Philip Morris Internationals IQOS product,and nicotine pouches,such as Velo.Youth use of these new pro
71、ducts will need to be monitored closely and FDA must be prepared to remove these products from the marketplace.One thing is clear:kids overwhelmingly prefer flavored tobacco products.11 In the 2021 National Youth Tobacco Survey,85.8%of high school students and 79.2%of middle school students who used
72、 e-cigarettes,used flavored products.This has led to a new public policy rising in importance,prohibiting the sale of all flavored tobacco products,including menthol cigarettes,flavored cigars and flavored e-cigarettes.Starting with the“State of Tobacco Control”2021 report,states are now graded on w
73、hether they prohibit the sale of all flavored tobacco products,and the FDA removing flavored tobacco products from the marketplace has been incorporated into the federal governments grades for close to 10 years.With removal of menthol cigarettes and flavored cigars by FDA several years in the future
74、 at a minimum,it is imperative that states and localities act to end the sale of all flavored tobacco products.In 2021,the District of Columbia approved a law that would prohibit the sale of all flavored tobacco products in virtually all locations.However,funding will need to be provided in the city
75、s budget in 2022 for the law to take effect.Implementation of Californias flavored tobacco product law was also delayed until 2022 at the earliest due to a successful ballot referendum on the measure filed by the tobacco industry.Medicaid Expansion and Tobacco CessationThe Affordable Care Act expand
76、ed Medicaid coverage to individuals at 138%of the federal poverty level($30,305 per year for a family of three)or lower.In 2022,38 states and the District of Columbia have all expanded their Medicaid programs.Individuals with incomes less than$35,000 a year smoke at rate of 21.4%,higher than the gen
77、eral population(14%).It is not surprising that increasing access to healthcare coverage,including a comprehensive cessation benefit,results in more people making quit attempts.Research shows Medicaid quit attempts in expansion states increased by over 20%.“To help address the continuing youth e-ciga
78、rette epidemic and achieve its mission focal point of reducing youth vaping to 15%by 2025,the American Lung Association launched its End Youth Vaping initiative on September 1,2020.It is an integrated,multi-component campaign to support parents,schools and students.Major components of the campaign i
79、nclude our Vape-Free Schools Initiative,which helps schools navigate this public health emergency with tools to protect and support both schools and students and the“Get Your Head Out of the Cloud”youth vaping awareness campaign from the American Lung Association and the Ad Council to provide parent
80、s with a discussion guide to address the dangers of vaping with their kids,while theyre still willing to listen.”2022American Lung Association“State of Tobacco Control”20228 Lung.orgOther new public policies have become more prominent at the state level in recent years,including:Increasing the Tobac
81、co Sales Age to 21 Starting in 2015 with the state of Hawaii,close to 20 states,and then the federal government in December 2019,increased the age of sale for tobacco products,including e-cigarettes,to 21.A 2015 report from the National Academy of Medicine found that increasing the minimum sales age
82、 to 21 nationwide could prevent 223,000 deaths among people born between 2000 and 2019,including 50,000 fewer dying from lung cancer,the nations leading cancer killer.12 A handful of states continued to pass legislation in 2021,aligning their state minimum ages with the increased federal minimum age
83、.Reducing the Availability and Accessibility of Tobacco Products.One question that urgently needs to be answered is why there are so many tobacco retailers in the United States.A study of tobacco product retailers in 30 cities,found that there are 31 times more retailers than McDonalds and 16 times
84、more retailers than Starbucks.In addition,in most cities,tobacco product retailers were concentrated in the lowest-income neighborhoods.13 States and communities should enact legislation to reduce the number of tobacco product retailers and prohibit them from being clustered together or near youth-f
85、ocused locations like schools and childcare facilities.Along these lines,at the state level,two statesMassachusetts and New Yorkhave prohibited tobacco sales in pharmacies,and Utah has prohibited new retail tobacco specialty businesses from locating in certain areas.An Old Threat to State Policies R
86、e-Emerges in 2021In 2021,legislation was introduced in many states that would prevent local governments from passing stronger tobacco control laws,which is referred to as preemption.These types of laws are a favorite tactic of the tobacco industry and its allies as it denies local governments the ab
87、ility to pass meaningful public policies to prevent and reduce tobacco use,including addressing the youth vaping epidemic.Unfortunately,legislation was approved in two statesFlorida and Montanathat prevents communities from passing almost anything stronger than state law to regulate tobacco product
88、sales.The Lung Association expects the tobacco industry to continue its full court press on this issue in 2022.On its 20th anniversary,“State of Tobacco Control”2022 continues to provide a blueprint that states,and the federal government can follow to put in place proven policies that will have the
89、greatest impact on reducing tobacco use and exposure to secondhand smoke in the U.S.The real question is:Will federal and state lawmakers put us on a path to end the death and disease caused by the tobacco use over the next 20 years?1.CDC.National Health Interview Survey for 2003 and 2019.2.CDC.Nati
90、onal Youth Tobacco Survey for 2002 and 2020.3.U.S.Department of Health and Human Services.The Health Consequences of Smoking:50 Years of Progress.A Report of the Surgeon General.Atlanta,GA,2014.4.Cornelius ME,Wang TW,Jamal A,Loretan CG,Neff LJ.Tobacco Product Use Among Adults United States,2019.MMWR
91、 Morb Mortal Wkly Rep 2020;69:17361742.5.Substance Abuse and Mental Health Services Administration.National Survey on Drug Use and Health,2020.2022American Lung Association“State of Tobacco Control”20229 Lung.orgAnalysis by the American Lung Association Epidemiology and Statistics Unit.6.Delnevo CD,
92、Ganz O,Goodwin RD,Banning Menthol Cigarettes:A Social Justice Issue Long Overdue.Nicotine Tob Res,2020 Oct 8;22(10):1673-1675.https:/doi.org/10.1093/ntr/ntaa1527.Mendez D,Le TTT.Consequences of a match made in hell:the harm caused by menthol smoking to the African American population over 19802018.T
93、ob Control 2021;0:13.doi:10.1136/tobaccocontrol-.8.Americans for Nonsmokers Rights Foundation.“Reopening Casinos Smokefree:The New Normal.”Accessed 11/22/2020.9.Park-Lee E,Ren C,Sawdey MD,et al.Notes from the Field:E-Cigarette Use Among Middle and High School Students National Youth Tobac
94、co Survey,United States,2021.MMWR Morb Mortal Wkly Rep 2021;70:13871389.DOI:http:/dx.doi.org/10.15585/mmwr.mm7039a4.10.Ibid11.Ibid12.Institute of Medicine,Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products,Washington,DC:The National Academies Press,2015,http:/w
95、ww.nationalacademies.org/hmd/Reports/2015/TobaccoMinimumAgeReport.aspx.13.ASPire Center.“Tobacco Retailers.”Available at:Tobacco Retailers-ASPiRE Center.Accessed 11/11/2021.2022American Lung Association“State of Tobacco Control”202210 Lung.orgTobacco Prevention and Cessation Funding Overview CDC-Per
96、centage State Tobacco Tobacco Other Total Federal Recommended of CDC-Tobacco Settlement Tax State State Funding Total Spending Recommended Related State Name Funding Funding Funding Funding to States Funding Level Level Revenue GradeAlabama$939,631$0$798,339$1,737,970$1,682,740$3,420,710$55,900,000
97、6.1%$290,900,000 FAlaska$0$0$9,140,000$9,140,000$1,284,919$10,424,919$10,200,000 102.2%$81,100,000 AArizona$0$17,500,000$0$17,500,000$1,708,792$19,208,792$64,400,000 29.8%$422,900,000 FArkansas$12,040,814$0$0$12,040,814$1,522,930$13,563,744$36,700,000 37.0%$284,000,000 FCalifornia$208,013,081$39,637
98、,000$3,600,000$251,250,081$3,571,588$254,821,669$347,900,000 73.2%$2,838,500,000 BColorado$0$22,711,711$360,000$23,071,711$1,692,350$24,764,061$52,900,000 46.8%$370,100,000 FConnecticut$0$0$0$0$1,177,808$1,177,808$32,000,000 3.7%$471,300,000 FDelaware$7,103,800$0$0$7,103,800$991,511$8,095,311$13,000
99、,000 62.3%$139,900,000 CDistrict of$1,000,000$0$900,000$1,900,000$1,031,660$2,931,660$10,700,000 27.4%$63,100,000 F Columbia Florida$73,988,595$0$354,466$74,343,061$2,883,131$77,226,192$194,200,000 39.8%$1,486,900,000 FGeorgia$750,000$0$0$750,000$2,127,823$2,877,823$106,000,000 2.7%$405,600,000 FHaw
100、aii$6,582,277$0$836,542$7,418,819$1,156,607$8,575,426$13,700,000 62.6%$148,900,000 CIdaho$3,485,800$159,000$0$3,644,800$1,171,888$4,816,688$15,600,000 30.9%$75,300,000 FIllinois$10,100,000$0$0$10,100,000$2,241,976$12,341,976$136,700,000 9.0%$1,218,300,000 FIndiana$7,500,000$0$0$7,500,000$1,832,809$9
101、,332,809$73,500,000 12.7%$542,600,000 FIowa$0$0$4,020,894$4,020,894$1,137,971$5,158,865$30,100,000 17.1%$265,200,000 FKansas$1,001,960$0$0$1,001,960$1,516,090$2,518,050$27,900,000 9.0%$181,400,000 FKentucky$2,000,000$0$0$2,000,000$1,656,354$3,656,354$56,400,000 6.5%$495,100,000 FLouisiana$500,000$3,
102、838,246$1,198,000$5,536,246$1,635,696$7,171,942$59,600,000 12.0%$442,400,000 FMaine$4,286,575$4,100,000$0$8,386,575$1,169,002$9,555,577$15,900,000 60.1%$187,900,000 CMaryland$10,853,869$11,302$0$10,865,171$1,694,510$12,559,681$48,000,000 26.2%$565,400,000 FMassachusetts$0$0$5,618,793$5,618,793$1,902
103、,654$7,521,447$66,900,000 11.2%$686,700,000 FMichigan$0$0$1,830,900$1,830,900$2,347,639$4,178,539$110,600,000 3.8%$1,159,400,000 FMinnesota$0$0$12,891,875$12,891,875$1,596,128$14,488,003$52,900,000 27.4%$723,400,000 FMississippi$7,420,000$0$1,275,000$8,695,000$1,341,100$10,036,100$36,500,000 27.5%$2
104、50,600,000 FMissouri$0$0$477,435$477,435$1,949,182$2,426,617$72,900,000 3.3%$257,200,000 FMontana$0$0$0$0$1,408,205$1,408,205$14,600,000 9.6%$105,800,000 FNebraska$0$0$2,570,000$2,570,000$1,187,754$3,757,754$20,800,000 18.1%$99,800,000 FNevada$0$0$3,554,015$3,554,015$1,384,475$4,938,490$30,000,000 1
105、6.5%$225,200,000 FNew Hampshire$0$0$589,166$589,166$1,144,210$1,733,376$16,500,000 10.5%$285,900,000 FNew Jersey$0$0$7,445,467$7,445,467$1,855,458$9,300,925$103,300,000 9.0%$838,200,000 FNew Mexico$0$0$3,898,300$3,898,300$1,142,861$5,041,161$22,800,000 22.1%$137,600,000 FNew York$39,769,600$0$0$39,7
106、69,600$2,905,769$42,675,369$203,000,000 21.0%$1,887,000,000 FNorth Carolina$11,000,000$0$2,399,600$13,399,600$2,353,231$15,752,831$99,300,000 15.9%$458,100,000 FNorth Dakota$0$0$5,684,000$5,684,000$1,055,244$6,739,244$9,800,000 68.8%$51,600,000 COhio$0$0$14,780,000$14,780,000$2,464,914$17,244,914$13
107、2,000,000 13.1%$1,267,300,000 FOklahoma$22,703,765$1,172,541$0$23,876,306$1,618,668$25,494,974$42,300,000 60.3%$526,700,000 COregon$0$36,900,000$0$36,900,000$1,556,750$38,456,750$39,300,000 97.9%$468,600,000 APennsylvania$16,001,000$0$0$16,001,000$2,399,303$18,400,303$140,000,000 13.1%$1,663,100,000
108、 FRhode Island$0$0$396,732$396,732$1,383,858$1,780,590$12,800,000 13.9%$205,700,000 FSouth Carolina$0$5,000,000$0$5,000,000$1,720,878$6,720,878$51,000,000 13.2%$229,900,000 FSouth Dakota$0$0$4,500,000$4,500,000$1,046,792$5,546,792$11,700,000 47.4%$83,000,000 FTennessee$0$0$2,000,000$2,000,000$1,664,
109、198$3,664,198$75,600,000 4.8%$411,600,000 FTexas$0$0$3,682,166$3,682,166$3,349,957$7,032,123$264,100,000 2.7%$1,870,900,000 FUtah$3,292,900$3,150,000$7,674,240$14,117,140$1,256,406$15,373,546$19,300,000 79.7%$133,600,000 AVermont$0$0$2,500,000$2,500,000$1,101,504$3,601,504$8,400,000 42.9%$103,400,00
110、0 FVirginia$13,181,451$0$0$13,181,451$1,847,658$15,029,109$91,600,000 16.4%$395,100,000 FWashington$0$0$1,555,942$1,555,942$1,828,532$3,384,474$63,600,000 5.3%$513,400,000 FWest Virginia$0$0$445,000$445,000$1,229,006$1,674,006$27,400,000 6.1%$232,600,000 FWisconsin$0$0$5,315,000$5,315,000$1,588,681$
111、6,903,681$57,500,000 12.0%$747,400,000 FWyoming$4,408,951$0$214,884$4,623,835$1,021,016$5,644,851$8,500,000 66.4%$39,100,000 C*Information in this chart covers state fiscal year 2022,which is July 1,2021 to June 30,2022 for all states except Alabama,Michigan,New York and Texas as well as the Distric
112、t of Columbia.2022American Lung Association“State of Tobacco Control”202211 Lung.orgSmokefree Air Grading Chart Casinos/Recreational/Government Private Childcare Gaming Retail Cultural E-Cigarettes Total State Worksites Worksites Schools Facilities Restaurants Bars Establishments stores Facilities I
113、ncluded Penalties Enforcement Score GradeAlabama 2 0 2 2 0 0 0 2 2-2 4 2 14 FAlaska 5 5 4 4 4 4 N/A 4 4 0 4 4 42 BArizona 4 4 5 4 4 4 4 4 4-2 4 4 43 AArkansas 4 3 4 4 3 1 1 4 4-2 4 3 33 CCalifornia 5 4 4 4 4 4 4 4 4 0 4 2 43 AColorado 5 3 4 4 3 3 4 4 4-1 4 2 39 BConnecticut 5 5 5 4 4 3 4 4 4 0 3 3 4
114、4 BDelaware 4 4 4 4 4 5 4 4 4 0 4 4 45 ADistrict of Columbia 4 4 5 4 4 2 N/A 4 4 0 3 4 38 AFlorida 4 4 4 4 4 1 4 4 4 0 3 4 40 BGeorgia 4 3 4 4 3 1 N/A 3 4-2 1 2 27 DHawaii 5 5 4 4 4 5 N/A 4 4 0 4 3 42 AIdaho 4 3 4 4 4 0 4 4 4-2 3 2 34 CIllinois 5 5 4 4 4 5 4 4 4-2 4 4 45 AIndiana 4 4 4 4 3 1 0 4 4-2
115、 4 3 33 CIowa 4 4 5 4 4 4 1 4 4-2 4 4 40 AKansas 5 5 4 4 4 4 1 4 4-2 3 4 40 AKentucky 2 0 4 0 0 0 0 0 0 0 1 0 7 FLouisiana 4 4 4 4 4 0 1 4 4-2 3 4 34 CMaine 5 5 5 4 5 4 3 4 4-1 4 4 46 AMaryland 4 4 4 4 4 5 4 4 4-2 2 4 41 AMassachusetts 4 4 4 4 4 3 4 4 4 0 4 3 42 AMichigan 4 4 4 4 4 4 1 4 4-2 4 4 39
116、CMinnesota 3 3 4 4 4 5 4 4 4 0 3 4 42 AMississippi 3 0 4 4 0 0 0 0 0-2 1 2 12 FMissouri 2 1 3 4 1 0 0 1 1-2 3 1 15 FMontana 4 4 4 4 4 5 4 4 4-2 3 4 42 ANebraska 4 4 4 4 4 3 4 4 4 0 4 3 42 ANevada 4 4 5 4 4 1 1 4 4 0 2 2 35 CNew Hampshire 2 2 4 4 4 2 2 2 2 0 4 4 32 DNew Jersey 4 4 5 4 4 2 2 4 4 0 3 4
117、 40 ANew Mexico 5 4 4 4 4 3 0 4 4 0 3 4 39 BNew York 4 4 5 4 4 2 4 4 4 0 4 4 43 ANorth Carolina 2 0 4 3 4 3 N/A 0 0-2 2 4 20 FNorth Dakota 5 5 4 4 4 5 4 4 4 0 3 3 45 AOhio 4 4 4 4 4 5 4 4 4 0 3 4 44 AOklahoma 3 3 5 4 3 0 3 4 4-2 3 3 33 DOregon 5 5 4 4 4 3 4 4 4 0 4 4 45 APennsylvania 4 4 4 4 3 0 2 4
118、 4-2 3 4 34 DRhode Island 4 4 4 4 4 3 2 4 4 0 3 4 40 ASouth Carolina 1 0 2 4 0 0 N/A 0 1-2 3 1 10 FSouth Dakota 4 4 4 4 4 4 4 4 4 0 3 2 41 BTennessee 4 3 4 4 3 1 N/A 4 4 0 2 4 33 CTexas 0 0 1 4 0 0 0 0 1 0 3 1 10 FUtah 4 4 5 4 4 5 N/A 4 4 0 4 4 42 AVermont 4 4 4 4 4 4 N/A 4 4 0 3 3 38 AVirginia 1 0
119、3 3 2 2 0 1 1-2 2 3 16 FWashington 5 5 4 4 4 5 4 4 4-2 3 4 44 AWest Virginia 1 0 4 1 0 0 0 0 0-2 1 0 5 DWisconsin 4 4 4 4 4 4 4 4 4-2 2 4 40 AWyoming 0 0 0 0 0 0 0 0 0 0 0 0 0 F*An N/A in the Casinos/Gaming Establishments category means either the state only has such establishments located on sovere
120、ign tribal lands,which are not subject to state smokefree laws or does not allow commercial gaming2022American Lung Association“State of Tobacco Control”202212 Lung.orgTobacco Taxes Grading Chart Tax on Tax on Tax on Tax on Smokeless Pipe/RYO Tax on State Cigarette Tax Little Cigars Large Cigars Tob
121、acco Tobacco E-Cigarettes Total Score GradeAlabama 6 1 1 0 0 0 8 FAlaska 18 2 2 2 2 0 26 DArizona 18 1 1 0 0 0 20 FArkansas 12 2 1 2 2 0 19 FCalifornia 24 2 2 2 2 2 34 BColorado 18 2 2 2 2 1 27 DConnecticut 30 2 1 0 1 0 34 BDelaware 18 1 1 0 1 0 21 FDistrict of Columbia 30 2 0 2 2 2 38 AFlorida 12 0
122、 0 2 2 0 16 FGeorgia 6 1 2 2 2 0 13 FHawaii 24 2 1 2 2 0 31 CIdaho 6 2 2 2 2 0 14 FIllinois 24 2 1 0 1 1 29 CIndiana 12 2 2 0 2 0 18 FIowa 12 2 1 1 2 0 18 FKansas 12 1 1 1 1 0 16 FKentucky 12 1 1 0 1 1 16 FLouisiana 12 1 1 1 2 0 17 FMaine 18 2 2 2 2 2 28 CMaryland 24 2 1 1 1 1 30 CMassachusetts 24 2
123、 1 2 1 2 32 BMichigan 18 1 1 1 1 0 22 FMinnesota 24 2 1 2 2 2 33 BMississippi 6 2 2 2 2 0 14 FMissouri 6 2 2 2 2 0 14 FMontana 12 2 2 0 2 0 18 FNebraska 6 2 2 0 2 0 12 FNevada 12 1 1 1 1 1 17 FNew Hampshire 12 2 0 2 2 0 18 FNew Jersey 18 1 1 0 1 0 21 FNew Mexico 18 2 1 1 1 1 24 DNew York 30 2 1 0 1
124、1 35 BNorth Carolina 6 2 2 2 2 0 14 FNorth Dakota 6 2 2 0 2 0 12 FOhio 12 2 1 1 1 0 17 FOklahoma 18 2 1 2 2 0 25 DOregon 24 2 1 0 2 2 31 CPennsylvania 18 2 0 0 0 1 21 FRhode Island 30 2 1 0 2 0 35 BSouth Carolina 6 1 1 1 1 0 10 FSouth Dakota 12 2 2 2 2 0 20 FTennessee 6 2 1 1 1 0 11 FTexas 12 0 0 2
125、2 0 16 FUtah 12 2 2 2 2 2 22 FVermont 24 2 2 2 2 2 34 BVirginia 6 2 2 0 2 0 12 FWashington 24 2 1 0 2 0 29 CWest Virginia 12 1 1 1 1 0 16 FWisconsin 18 2 1 2 2 0 25 DWyoming 6 2 2 2 2 2 16 F2022American Lung Association“State of Tobacco Control”202213 Lung.orgAccess to Cessation Services Grading Cha
126、rt Medicaid SEHP Investment Private Medicaid Medicaid Barriers to Medicaid SEHP SEHP Barriers to Per Insurance Tobacco Total State Medications Counseling Coverage Expansion Medications Counseling Coverage Smoker Mandate Surcharge Score GradeAlabama 14 6 3-8 4 2 1 0 0 0 22 FAlaska 14 4 10 0 4 3 1 20
127、0 0 56 BArizona 14 8 12 0 4 2 2 10 0 0 52 CArkansas 14 8 14 0 2 2 1 5 0 1 47 DCalifornia 14 12 12 0 2 2 1 15 0 2 60 BColorado 14 12 13 0 4 3 1 20 2 1 70 AConnecticut 14 12 13 0 4 4 1 0 0 1 49 CDelaware 12 8 9 0 4 4 2 20 1 0 60 BDistrict of Columbia 14 4 12 0 0 0 0 20 0 2 52 CFlorida 14 8 12-8 4 1 1
128、15 0 0 47 DGeorgia 11 8 7-8 4 2 1 0 0-2 23 FHawaii 11 8 11 0 3 3 1 20 0 0 57 BIdaho 14 4 12 0 4 2 2 15 0 0 53 CIllinois 14 12 9 0 3 1 1 10 1 0 51 CIndiana 14 8 12 0 4 2 2 5 0-2 45 DIowa 14 6 8 0 4 2 2 0 0 0 36 FKansas 14 12 14-8 4 0 2 0 0 0 38 FKentucky 14 12 14 0 4 3 1 0 5 1 54 CLouisiana 14 8 10 0
129、 4 2 1 5 1 0 45 DMaine 14 12 12 0 4 2 1 20 0 0 65 AMaryland 14 8 12 0 4 2 2 15 2 0 59 BMassachusetts 14 12 14 0 3 2 1 5 2 2 55 CMichigan 14 8 13 0 4 3 1 0 0 0 43 DMinnesota 12 10 13 0 4 4 2 20 0 0 65 AMississippi 14 2 12-8 4 2 1 5 0 0 32 FMissouri 14 12 14 0 4 3 2 0 0 0 49 CMontana 14 8 13 0 3 3 2 1
130、5 0 0 58 BNebraska 14 8 10 0 3 3 2 5 0 0 45 DNevada 9 6 13 0 2 3 1 0 0 0 34 FNew Hampshire 14 8 12 0 4 3 1 5 0 0 47 DNew Jersey 14 0 0 0 0 0 0 0 3 2 19 FNew Mexico 14 8 14 0 2 4 1 20 3 0 66 ANew York 14 8 12 0 4 2 2 10 1 2 55 CNorth Carolina 14 8 10-8 4 2 1 5 0 1 37 FNorth Dakota 14 4 13 0 4 3 1 20
131、1 0 60 BOhio 14 12 13 0 4 4 1 10 0 0 58 BOklahoma 14 8 14 0 3 3 1 20 0 0 63 AOregon*14 12 12 0 0 0 0 0 2 0 40 IPennsylvania 12 6 11 0 2 2 2 5 0 0 40 FRhode Island 14 12 13 0 4 4 2 0 5 2 56 BSouth Carolina 14 12 14-8 3 2 1 20 0 0 58 BSouth Dakota 4 2 9-8 4 2 2 20 0 0 35 FTennessee 14 6 5-8 4 4 1 0 0
132、0 26 FTexas 14 10 11-8 4 3 2 0 0 0 36 FUtah 14 8 8 0 4 2 1 20 1 0 58 BVermont 14 12 12 0 1 2 1 20 3 2 67 AVirginia 14 12 14 0 2 1 1 0 0 0 44 DWashington 14 6 11 0 3 3 2 0 0 0 39 FWest Virginia 14 4 8 0 4 2 1 0 0 0 33 FWisconsin 14 10 14-8 4 3 1 0 0-2 36 FWyoming 14 8 7-8 2 0 2 20 0 0 45 D*Oregon ear
133、ned an I for Incomplete grade this year for being unable to provide several pieces of information necessary for the grade before the report went to print.2022American Lung Association“State of Tobacco Control”202214 Lung.orgFlavored Tobacco Product Laws GradesState GradeAlabama FAlaska FArizona FArk
134、ansas FCalifornia*IColorado FConnecticut FDelaware FDistrict of Columbia FFlorida FGeorgia FHawaii FIdaho FIllinois FIndiana FIowa FKansas FKentucky FLouisiana FMaine FMaryland FMassachusetts AMichigan FMinnesota FMississippi FMissouri FMontana FNebraska FNevada FNew Hampshire FNew Jersey DNew Mexic
135、o FNew York DNorth Carolina FNorth Dakota FOhio FOklahoma FOregon FPennsylvania FRhode Island DSouth Carolina FSouth Dakota FTennessee FTexas FUtah FVermont FVirginia FWashington FWest Virginia FWisconsin FWyoming F*California earned an I for Incomplete grade because their flavored tobacco product l
136、aw is not in effect and will be voted in a ballot measure this year2022American Lung Association“State of Tobacco Control”202215 Lung.org“State Of Tobacco Control”2022 MethodologyThe American Lung Associations“State of Tobacco Control”2022 is a report card that evaluates state and federal tobacco co
137、ntrol policies by comparing them against targets based on the most current,recognized criteria for effective tobacco control measures,and translating each state and the federal governments relative progress into a letter grade of“A”through“F.”A grade of“A”is assigned for excellent tobacco control po
138、licies while an“F”indicates inadequate policies.The primary reference for all state tobacco control laws is the American Lung Associations State Legislated Actions on Tobacco Issues on-line database.The American Lung Association has published this comprehensive summary of state tobacco control laws
139、since 1988.Data for the state cessation section is taken from the American Lung Associations State Tobacco Cessation Coverage database.Calculation of Federal Grades Tobacco control and prevention measures at the federal level are graded in five areas:federal regulation of tobacco products;federal co
140、verage of tobacco cessation treatments;federal excise taxes on tobacco products;federal mass media campaigns;and federal minimum age of sale for tobacco products.The sources for the targets and the basis of the evaluation criteria are described below.Federal Regulation of Tobacco ProductsSince the p
141、assage of the Family Smoking Prevention and Tobacco Control Act giving the U.S.Food and Drug Administration the authority to regulate tobacco products in June 2009,the grading system for this category has been based on how the federal government is implementing its new authority,and whether Congress
142、 is providing full funding to FDA with no policy riders to limit the agencys authority.The American Lung Association has identified three important items that FDA was required by the Tobacco Control Act to implement,that FDA indicated they would take action on or would significantly improve the publ
143、ic health:1)implementation of a rule asserting authority over all other tobacco products besides cigarettes,smokeless tobacco and roll-your-own tobacco also known as the“deeming”rule;2)requiring large,graphic cigarette warning labels that cover the top 50%of the front and back of cigarette packs;and
144、 3)issuing at least one product standard to reduce the toxicity,addictiveness and/or appeal of tobacco products,including removal of flavored tobacco products from the marketplace.Points were awarded based on how the federal government has implemented these three items as well as whether Congress fu
145、nded FDAs Center for Tobacco Products at the levels called for in the Family Smoking Prevention and Tobacco Control Act.The Federal Regulation of Tobacco Products grade breaks down as follows:Grade Points EarnedA 15 or 16 Total PointsB 13 or 14 Total PointsC 12 Total PointsD 10 or 11 Total PointsF U
146、nder 10 Total Points2022American Lung Association“State of Tobacco Control”202216 Lung.orgImplementation of Final“Deeming”Rule Giving FDA Authority over All Tobacco Products(4 points)Target is implementation of final rule that gives FDA authority over all tobacco products in addition to cigarettes a
147、nd smokeless tobacco.+4 points:Deeming rule fully implemented;pre-market review of all deemed tobacco products complete;products without PMTA are removed from marketplace.+3 points:FDA has begun the PMTA process for all deemed tobacco products.+2 points:FDA only implementing portions of deeming rule
148、+0 points:FDA postpones implementation of the entire ruleGraphic Cigarette Warning Labels(4 points)Target is FDA requires large,graphic cigarette warning labels that cover the top 50%of the front and back of cigarette packs.+4 points:FDA requires large,graphic cigarette warning labels that cover the
149、 top 50%of the front and back of cigarette packs.+1 points:FDA proposes large,graphic cigarette warning labels that cover the top 50%of the front and back of cigarette packs.+0 points:No graphic warning label requirement is issued.Product standards to address toxicity,addictiveness and appeal of tob
150、acco products,including removal of Flavored Tobacco Products such as Menthol Cigarettes(4 points)Target is FDA takes action to reduce the toxicity,addictiveness and/or appeal of tobacco products,including removing flavored tobacco products from the marketplace.+4 points:Strong product standard is fi
151、nalized that will be appropriate for the protection of public health,including eliminating all flavored tobacco products.+3 points:Strong product standard is finalized,including removing some but not all flavored tobacco products.+2 points:Strong product standard is proposed that will be appropriate
152、 for the protection of public health,including eliminating all flavored tobacco products.+1 points:Product standard is proposed,including removing some but not all flavored tobacco products from the marketplace+0 points:No product standard is issued and all flavored products remain on the marketplac
153、e.Funding for FDA Center for Tobacco Products(4 points)Target is Congress provides funding for FDA Center for Tobacco Products at levels called for in Family Smoking Prevention and Tobacco Control Act without attaching limiting policy riders.+4 points:Congress provides full funding without attaching
154、 limiting policy riders.+2 points:Congress provides full funding but with policy riders.+1 points:Congress provides funding at a level inconsistent with the Tobacco Control Act+0 points:No funding at all provided.2022American Lung Association“State of Tobacco Control”202217 Lung.orgFederal Cessation
155、 Treatment CoverageThe cessation treatment coverage criteria used in the American Lung Associations“State of Tobacco Control”2022 report is based on the coverage of tobacco cessation treatments provided by the federal government through its four main public insurance programs:1)Medicare(for American
156、s over age 65),2)Medicaid(for low-income and/or disabled Americans),3)TRICARE(for members of the military and their families),and 4)Federal Employee Health Benefits Program(for federal employees and their families).A fifth category covers federal requirements for tobacco cessation treatment coverage
157、 in state health insurance marketplaces under the Patient Protection and Affordable Care Act or health care reform law.Providing help to quit through these programs and state health insurance exchanges will reach large numbers of tobacco users,improve health,prevent unnecessary death,save taxpayer m
158、oney and set an example for other health plans.The federal government must lead by example and cover a comprehensive benefit for everyone to whom it provides health care.The definition of a comprehensive tobacco cessation benefit used in these criteria follows the recommendations in the Clinical Pra
159、ctice Guideline entitled Treating Tobacco Use and Dependence.In this Guideline,published in 2008 the U.S.Public Health Service recommends the use of seven medications and three types of counseling as effective for helping tobacco users quit.This definition has been reaffirmed in the 2015 United Stat
160、es Preventive Services Task Force(USPSTF)recommendation.The Federal Cessation Coverage grade breaks down as follows:Grade Points EarnedA 18 to 20 Total PointsB 16 to 17 Total PointsC 14 to 15 Total PointsD 12 to 13 Total PointsF Under 12 Total PointsMedicare(4 points)Target is all Medicare recipient
161、s have easy access to a comprehensive cessation benefit.+4 points:All Guideline-recommended medications and counseling are covered.+3 points:At least 4 medications and 1 type of counseling are covered.+2 points:At least 2 medications and 1 type of counseling are covered.+1 point:At least 1 treatment
162、 is covered.+0 points:No coverage.Medicaid(4 points)Target is all Medicaid enrollees have easy access to a comprehensive cessation benefit.+4 points All Guideline-recommended medications and counseling are required to be covered.+3 points:At least 4 medications and 1 type of counseling are required
163、to be covered.2022American Lung Association“State of Tobacco Control”202218 Lung.org+2 points:At least 2 medications and 1 type of counseling are required to be covered.+1 point:At least 1 treatment is required to be covered.+0 points:No required coverage.TRICARE(4 points)Target is all TRICARE enrol
164、lees have easy access to a comprehensive cessation benefit.+4 points:All Guideline-recommended medications and counseling are covered.+3 points:At least 4 medications and 1 type of counseling are covered.+2 points:At least 2 medications and 1 type of counseling are covered.+1 point:At least 1 treatm
165、ent is covered.+0 points:No coverage.Federal Employee Health Benefits(FEHB)(4 points)Target is all federal employees&dependents have easy access to a comprehensive cessation benefit.+4 points:All Guideline-recommended medications and counseling are covered.+3 points:At least 4 medications and 1 type
166、 of counseling are covered.+2 points:At least 2 medications and 1 type of counseling are covered.+1 point:At least 1 treatment is covered.+0 points:No coverage.Federal Requirements for State Health Insurance MarketplacesTarget is all plans in marketplaces cover a comprehensive tobacco cessation bene
167、fit.+4 points:All Guideline-recommended medications and counseling are required to be covered.+3 points:Administration releases guidance outlining coverage of a comprehensive tobacco cessation benefit as a preventive service.+2 points:Administration requires that all plans sold in the State Health I
168、nsurance Marketplaces cover tobacco cessation treatment as part of the preventive services requirement.+1 points:Administration proposes new regulations that no longer require all plans in the State Health Insurance Marketplaces to provide tobacco cessation.+0 points:Administration finalizes new reg
169、ulations or issues guidance that no longer require all plans in the State Health Insurance Marketplaces to provide tobacco cessation.Bonus Points:1 bonus point in each category is awarded if coverage is provided with minimal barriers to access.Federal Tobacco Excise Taxes Criteria for the federal to
170、bacco excise taxes grade are identical to the state tobacco excise tax grade.For more information,see the State Tobacco Excise Taxes section on p.25.2022American Lung Association“State of Tobacco Control”202219 Lung.orgThe Federal Tobacco Excise Tax grade breaks down as follows:Grade Points EarnedA
171、36 to 40 pointsB 32 to 35 pointsC 28 to 31 pointsD 24 to 27 pointsF 23 and below pointsFederal Mass Media Campaigns Health communications interventions,including mass media campaigns designed to encourage tobacco users to quit or discourage youth from starting to smoke have been found to be an effec
172、tive intervention to prevent and reduce tobacco use,according to the U.S.Surgeon General and U.S.Centers for Disease Control and Prevention(CDC).More information on health communications interventions and their effectiveness can be found in CDCs Best Practices for Comprehensive Tobacco Control Progr
173、ams 2014.Two agencies of the federal government ran mass media campaigns for part or all of 2021 that seek to reduce or prevent tobacco use among different populations:1)CDCs Tips from Former Smokers media campaign,which targets adults who use tobacco and 2)FDAs Real Costs campaign,which targets you
174、th ages 12 to 17 with tobacco prevention messages.Both mass media campaigns will continue to run in 2022.The federal mass media campaign grade criteria are based off the reach,duration and frequency of these mass media campaigns as well as if the campaign refers people to available services that can
175、 help them quit.The Federal Mass Media campaign grade breaks down as follows:Grade Points EarnedA 22 to 24 pointsB 20 to 21 pointsC 17 to 19 pointsD 15 to 16 pointsF Under 15 pointsReach(3 points for each campaign,6 points total)Target:Advertising from each mass media campaign reaches 75%or more of
176、its target audience each quarter the campaign is running.+3 points:Ads reach 75%or more of target audience each quarter+2 points:Ads reach 55-74%of target audience each quarter+1 point:Ads reach 1-54%of target audience each quarter+0 points:No ad campaignDuration(3 points for each campaign,6 points
177、total)Target:Each mass media campaign runs for 12 months of the year.+3 points:Ads run 9-12 months per year+2 points:Ads run 6-8 months per year+1 point:Ads run 1-5 months per year+0 points:No ad campaign2022American Lung Association“State of Tobacco Control”202220 Lung.orgFrequency(3 points for eac
178、h campaign,6 points total)Target:Each campaign has an average gross rating point of 1,200 for the 1st quarter the campaign is running and 800 or higher rating points for subsequent quarters.+3 points:Average targeted rating point of 1,200 or higher for 1st quarter of campaign;average targeted rating
179、 point of 800 or higher for subsequent quarters+2 points:Average targeted rating point of 1,000 or higher for 1st quarter of campaign;average targeted rating point of 600 or higher for subsequent quarters+1 points:Average targeted rating point of 800 or higher for 1st quarter of campaign;average tar
180、geted rating point of 400 or higher for subsequent quarters+0 points:No ad campaignPromotion of Available Services(3 points for each campaign,6 points total)Target:Media campaign refers people to available resources that can help them.+3 points:Media campaign refers people to available resources dir
181、ectly+1 points:Media campaign refers people to location where available resources can be accessed+0 points:Campaign does not refer people to additional resourcesFederal Minimum Age of Sale for Tobacco ProductsIn March 2015,the National Academy of Medicine(formerly the Institute of Medicine)issued a
182、report looking at the impact increasing the age of sale for tobacco products could have on youth tobacco use rates.The report concluded that increasing the age of sale for tobacco products to 21 nationwide could prevent 223,000 deaths among people born between 2000 and 2019,including 50,000 fewer dy
183、ing from lung cancer,the nations leading cancer killer.1A grade was awarded in this category based on whether the federal government increased the age of sale for tobacco products to 21 and issued the regulations as required by statute.The letter grade received deductions based on if groups,like act
184、ive-duty military,were exempted from the age of sale of 21.The federal government would receive an automatic F grade if some tobacco products,such as e-cigarettes were exempted from the age of sale increase,preemption on state or local governments from raising the age of sale was imposed or the age
185、of sale was 19 or 20 years old.Grade breaks down as follows:A=age of sale for all tobacco products is 21 years of age with no exceptions;B=age of sale for all tobacco products is 21 years of age,but certain groups,such as active-duty military are exempted;F=age of sale for tobacco products is below
186、21 years of age,some tobacco products are exempted from the age of sale to 21 increase or preemption on state or local governments concerning tobacco sales age increases is imposed.2022American Lung Association“State of Tobacco Control”202221 Lung.orgCalculation of State Grades State level tobacco c
187、ontrol policies are graded in five key areas:tobacco prevention and cessation funding,smokefree air laws,state tobacco excise taxes,access to tobacco cessation treatments and services and state laws to end the sale of flavored tobacco products.The sources for the targets and the basis of the evaluat
188、ion criteria are described below.State Tobacco Prevention and Cessation Program FundingIn January 2014,the Centers for Disease Control and Prevention(CDC)published an updated version of its Best Practices for Comprehensive Tobacco Control Programs,which was first published in 1999,and previously upd
189、ated in 2007.Based on“Best Practices”as determined by evidence-based analysis of state tobacco control programs,this CDC guidance document recommends that states establish programs that are comprehensive,sustainable and accountable.The CDC lists five components as crucial in a comprehensive tobacco
190、control program:State and Community Interventions,Mass-Reach Health Communication Interventions,Cessation Interventions,Surveillance and Evaluation and Infrastructure,Administration and Management.The CDC also recommends an overall level of funding for each states tobacco control program based on a
191、variety of state-specific factors such as prevalence of tobacco use,the cost and complexity of conducting mass media to reach targeted audiences and the proportion of the population that is below 200%of the federal poverty level.For the tobacco prevention and control spending area,the CDC recommenda
192、tion for state funding of comprehensive programs served as the denominator in the percentage calculation to obtain each states grade.Each states total funding for these programs(including federal funding from the CDC given to states for tobacco prevention and cessation activities)served as the numer
193、ator.After calculating the percentage of the CDC recommendation each state had funded,grades were assigned according to the following formula.Percent of CDCGrade Recommended LevelA 80%or moreB 70%to 79%C 60%to 69%D 50%to 59%F Less than 50%Limitation of Grading System on State Tobacco Control Expendi
194、turesThe American Lung Association bases its tobacco prevention and cessation program funding grades on the total amount allocated to tobacco control programs,including applicable federal funding,in each state,but does not evaluate the expenditure in each of the CDC-recommended categories.The Lung A
195、ssociation does not evaluate the efficacy of any element of any states program.Therefore,a state may receive a high grade but be significantly underfunding a component or components of a comprehensive program.It also may be true that a state with a low grade is adequately funding a specific componen
196、t or program in one community.2022American Lung Association“State of Tobacco Control”202222 Lung.orgHowever,the CDC recommends a comprehensive program and explains that simply funding an element of the program will not achieve the needed results.The CDC explicitly calls for programs that are compreh
197、ensive,sustained and accountable.The American Lung Association agrees with the CDC and believes that the total funding is a fair basis for grading state programs and a states tobacco control funding performance.State Smokefree Air LawsThe smokefree air laws grading system is based on criteria develo
198、ped by an advisory committee convened by the National Cancer Institute with some modification to reflect the current policy environment.The criteria were presented in the article,“Application of a Rating System to State Clean Indoor Air Laws(USA)”(Chriqui JF,et al.Tobacco Control.2002;11:26-34).This
199、 approach provides scoring in nine categories:Government Workplaces,Private Workplaces,Schools,Child Care Facilities,Restaurants,Retail Stores,Recreational/Cultural Facilities,Penalties and Enforcement.All laws are open to interpretation and our analysis may differ from those of the authors noted in
200、 the above study.To reflect the current policy environment,two additions have been made to the advisory committees recommended categories of smokefree establishments.An additional category for bars has been added to all states.A second category,Casinos/Gaming Establishments,was added to the states w
201、hich allow casinos or gaming establishments.Adding these categories became necessary after the committee made its recommendations in 2002,because a number of states have prohibited smoking in bars and casinos/gaming establishments since then,and states need to be recognized in the grading system for
202、 protecting workers in these places from secondhand smoke.In addition,in“State of Tobacco Control”2019 a penalty was added to the grade for states that have not included e-cigarettes in their laws restricting or prohibiting smoking.A state that has not included e-cigarettes in their laws or only has
203、 included them in select locations receives a-2 point penalty;a state that has included e-cigarettes in many but not all public places and workplaces covered by state law gets a-1 point penalty;and no penalty is applied for states that have included e-cigarettes in all places where smoking is prohib
204、ited by state law.The smokefree air grade for each state is based on a total of all points received in all categories.The grades are based on a maximum score of 40 if the state has no casinos or gaming establishments,or 44 if the state has casinos or gaming establishments.Both these high scores have
205、 been attained by states in this years report.The maximum score of 40 or 44 becomes the denominator,and the states total points serve as the numerator.The percentage was calculated,and grades were assigned following a standard grade-school system.States receiving scores in the top 10%of the range(90
206、 to 100%)earned an“A.”Those receiving scores falling between 80 and 89%got a grade of“B,”between 70 and 79%a“C”and between 60 and 69%a“D.”Those that fell below 60%received an“F.”The points break down as follows:2022American Lung Association“State of Tobacco Control”202223 Lung.orgAssigned No State C
207、asino/State Casino/Gamin Grade Gaming Establishments Establishments PresentA 36 to 40 40 to 44B 32 to 35 36 to 39C 28 to 31 31 to 35D 24 to 27 27 to 30F 23 and below 26 and belowThere are two situations that create exceptions to the grading system:Preemption or Local opt-out:State preemption of stri
208、cter local ordinances or states that have a provision in its law allowing communities to opt-out of the law is penalized by a reduction of one letter grade.States with preemption that have a score of 40 points or higher(or 44 points or higher dependent on whether the Casinos/Gaming Establishments ca
209、tegory is applicable for that state)are not penalized for preemption.Local Ordinances:States without strong statewide smokefree laws may be graded based on local ordinances or regulations.Strong local smokefree air ordinances/regulations that include most workplaces,all restaurants and bars are cons
210、idered according to the percentage of population covered in the state.States with over 95%of their population covered by comprehensive local smokefree ordinances will receive an“A,”over 80%a“B,”over 65%a“C”and over 50%a“D.”Local ordinances that cover less than 50%of the population will not be consid
211、ered for evaluation under this exception.2Key to Smokefree Laws Ratings by CategoryFor all categories,laws that require that smoking be permitted or laws without any restrictions for the category receive a score of zero(0).1.Government Workplaces(4 points):Target is“state and local government workpl
212、aces are 100%smokefree,no exemptions.”Score is lowered if restriction depends on type of ventilation,location of smoking area and/or number of employees.A bonus point(+1)is available if the laws meet the target criteria and require the grounds or a specified distance from entries or exits to be smok
213、efree.2.Private Workplaces(4 points):Target is“private workplaces are 100%smokefree,no exemptions.”Score is lowered if restriction depends on type of ventilation,location of smoking area and/or number of employees.A bonus point(+1)is available if the laws meet the target criteria and require the gro
214、unds or a specified distance from entries or exits to be smokefree.3.Schools(4 points):Target is“no smoking permitted in public and non-public schools during school hours or while school activities are being conducted.”Score is lowered if restriction depends on type of school,school hours,type of ve
215、ntilation and/or location of smoking area.A bonus point(+1)is available if the laws meet the target criteria and extend the law/policy to any time in school facilities,on school grounds,and at school-sponsored activities.4.Child Care Facilities(4 points):Target is“no smoking permitted during operati
216、ng hours in childcare facilities(explicitly including licensed,home-based facilities).”Score is lowered if restrictions depend on ventilation standards,location of smoking areas and/or exemptions for certain types of facilities.2022American Lung Association“State of Tobacco Control”202224 Lung.org5.
217、Restaurants(4 points):Target is“restaurants(explicitly including bar areas of restaurants)are 100%smokefree.”Score is lowered if restriction depends on type of ventilation,location of smoking areas and/or exemptions for some restaurants.A bonus point(+1)is available if the laws meet the target crite
218、ria and extend the law/policy to outdoor seating areas of restaurants.6.Bars/Taverns(4 points):Target is“bars/taverns and similar types of establishments are 100%smokefree.”Score is lowered if restriction depends on ventilation standards,location of smoking area and/or if laws only applied to some b
219、ut not all bars/taverns.A bonus point(+1)is available if the laws meet the target criteria and extend the law/policy to private clubs or similar establishments at all times.7.Casinos/Gaming Establishments(4 points):Target is“casinos/gaming establishments are 100%smokefree.”Score is lowered if restri
220、ction depends on ventilation standards,location of smoking area and/or if laws only apply to some but not all casinos/gaming establishments.This category does not apply to states that do not have casinos/gaming establishments or only casinos/gaming establishments on sovereign tribal lands.8.Retail S
221、tores(4 points):Target is“retail stores or retail businesses open to the public are 100%smokefree.”Score is lowered if restriction depends on ventilation standards and/or location of smoking area,and if laws only apply to some but not all retail stores or businesses.9.Recreational/Cultural Facilitie
222、s(4 points):Target is“recreational and cultural facilities are 100%smokefree.”Score is lowered if restriction depends on ventilation standards,location of smoking area and/or if laws only apply to some but not all recreational/cultural facilities.Note:state law does not apply to recreational/cultura
223、l facilities on sovereign tribal land.10.Penalties(4 points):Target is“graduated penalties or fines,applicable to smokers and to proprietors or employers,for any violation of clean indoor air legislation.”Score is lowered if penalties included possibilities for delay,exceptions for either smokers or
224、 proprietors/employers,or penalties that only apply to some but not all offenses.An intent requirement or affirmative defense against violation reduces the score by one(1)point.11.Enforcement(4 points):Target is“designate an enforcement authority for clean indoor air,require sign posting and have a
225、phone number and/or online location to report violations.”Score is lowered if there is no requirement for sign posting,there is no phone number or online location to report violations,enforcement authority only applies to some sites,or an enforcement authority or sign requirement exists,but not both
226、.A bonus point(+1)is available if the laws meet the target criteria and require the enforcement authority to conduct compliance inspections.State Tobacco Excise TaxesThe U.S.Surgeon General,in The Health Consequences of Smoking 50 Years of Progress,released in January 2014 to commemorate the 50th an
227、niversary of the first Surgeon Generals report on smoking in 1964,concluded that“increases in the prices of tobacco products,including those resulting from excise tax increases,prevent initiation of tobacco use,promote cessation and reduce the prevalence and intensity of tobacco use among youth and
228、adults.”32022American Lung Association“State of Tobacco Control”202225 Lung.orgResearch has clearly demonstrated that as the price of cigarettes increases,consumption decreases.For each 10%price increase,it is estimated that consumption drops by about 7%for youth and 3 to 5%for adults.4 Increasing t
229、axes on tobacco products other than cigarettes is also important as while rates of cigarette smoking are declining,rates of cigar smoking,and smokeless tobacco use are stagnant or increasing.In a number of states,rates of cigar smoking among youth exceed rates of cigarette smoking.Starting with“Stat
230、e of Tobacco Control 2015,”taxes on tobacco products other than cigarettes were incorporated into the grading system.The grading system also was switched to a points-based system,with the level of states cigarette tax worth up to 30 possible points and taxes on other tobacco products worth up to 10
231、possible points,for a total of 40 points available in the grading category.The 30 points for the level of a states cigarette tax will continue to be based on the average(mean)of all state taxes as the midpoint,or the lowest“C.”The average cigarette tax was chosen because it is often seen as an indic
232、ation of where states are in their cigarette taxing policies.The average state excise tax on January 1,2022 was$1.91 per pack.The range of state excise taxes($0.17 to$4.50 per pack)is divided into quintiles,and a state is assigned 6 points for attaining each quintile.The score earned for the level o
233、f a states cigarette tax is broken down as follows:Score Tax30 points$3.82 and over24 points$2.866 to$3.81918 points$1.91 to$2.86512 points$0.955 to$1.9096 points Under$0.955For taxes on tobacco products other than cigarettes,a state is evaluated on whether the tax on five specific types of tobacco
234、products is a)equivalent to the states tax on cigarettes and b)the tax on the specific type of tobacco product is not based on the weight of the product.Taxing tobacco products other than cigarettes by weight is inadequate because it means the tax level does not keep pace with inflation and tobacco
235、industry or other price increases.The five specific types of tobacco products other than cigarettes which states are evaluated on are:1)little cigars,2)large cigars,3)smokeless tobacco,4)pipe/roll-your-own tobacco and 5)e-cigarettes.In“State of Tobacco Control”2020,e-cigarettes replaced dissolvable
236、tobacco products as one of the five categories.States can earn up to 2 points total for each type of other tobacco product;1 point if the tax is equivalent to the cigarette tax and 1 point if the tax is not weight-based.States will not be penalized for having a weight-based tax if they also have a m
237、inimum tax that is equal to the current cigarette tax or the weight-based tax is equivalent to the cigarette tax.2022American Lung Association“State of Tobacco Control”202226 Lung.orgThe overall grade breaks down as follows:Grade Points EarnedA 36 to 40 pointsB 32 to 35 pointsC 28 to 31 pointsD 24 t
238、o 27 pointsF 23 and below pointsState Access to Cessation Services The Access to Cessation Services grading system sets targets for states and awards points in three areas:1)State Medicaid coverage of tobacco cessation treatments,2)State Employee Health Plan coverage of tobacco cessation treatments
239、and 3)the Investment per Smoker each state makes in its quitline,a service available in all states that provides tobacco cessation counseling over the phone.Bonus points are available in two other target areas,Standards for Private Insurance and Tobacco Surcharges.In 2008,the U.S.Department of Healt
240、h and Human Services Public Health Service published an update to its Clinical Practice Guideline on Treating Tobacco Use and Dependence.This Guideline,based on a thorough review of scientific evidence on tobacco cessation,recommends several treatment options that have proven effective in helping pe
241、ople quit smoking.These options include the use of five nicotine-replacement therapies(gum,patch,lozenge,nasal spray,inhaler),bupropion and varenicline(non-nicotine medications),and three types of counseling(individual,group and phone).It also recommends that all public and private health insurance
242、plans cover the cessation treatments recommended in the Guideline.In 2020,the U.S.Surgeon General reiterated the need for this comprehensive cessation benefit without barriers in“Smoking Cessation:A Report of the Surgeon General.”Targets established in the Medicaid,State Employee Health Plan and Sta
243、ndards for Private Insurance categories were based on these Public Health Service Guideline and U.S.Surgeon General recommendations for cessation treatments.In the 2014 Best Practices for Comprehensive Tobacco Control Programs document,discussed previously in the Tobacco Prevention and Control Spend
244、ing section above,the CDC establishes benchmarks for quitlines that are funded at the recommended levels.Grading in this section is based on the amount of funding provided to the state quitline for services divided by the number of smokers in the state.In 2015,the Lung Association incorporated infor
245、mation on what tobacco cessation treatments are provided to the Medicaid expansion population into this grade.Points awarded in the Medicaid Coverage section below incorporate this information.Points available in the Medicaid coverage section were 40 to represent new Medicaid expansion enrollees.If
246、a state has not opted to expand Medicaid up to the levels established in the Affordable Care Act(ACA),the state receives an automatic deduction of 8 points to represent the substantial number of tobacco users that do not have access to cessation treatments because of this decision.The Lung Associati
247、on will deduct up to 2 points for any state that implements a policy to charge Medicaid enrollees a tobacco surcharge or that has policies that charge Medicaid enrollees that smoke more for coverage than 2022American Lung Association“State of Tobacco Control”202227 Lung.orgnon-tobacco user Medicaid
248、enrollees.The Lung Association also added 2 bonus points available to states who prohibit or limit tobacco surcharges,or health insurance policies that charge tobacco users more in premiums than non-tobacco users.States can limit or remove these surcharges.All data in the Cessation section of“State
249、of Tobacco Control”2022 was collected and analyzed by the American Lung Association.The cessation grades are based on the maximum number of total points,a score of 70,assigned according to the categories described in detail below.Over half of the points(40 points total)under the Access to Cessation
250、Services section are awarded for coverage under a states Medicaid program.This weighting is due to the higher smoking rates among the Medicaid population than among the general population,as well as the need to cover treatments to help people of lower income who smoke quit.Twenty points total are aw
251、arded for the investment per smoker in the states quitline and 10 points total are awarded for State Employee Health Plan coverage.The score of 70 serves as the denominator,and the states total points serves as the numerator to calculate a percentage score.Grades were given following a standard grad
252、e-school system using that percentage score.The grades break down as follows:Grade Points EarnedA 63 to 70B 56 to 62C 49 to 55D 42 to 48F 41 and underKey to Cessation Coverage Ratings by Category:Medicaid Coverage(40 points):5 Target is barrier-free coverage of all Guideline-recommended medications
253、and counseling for the states entire Medicaid population(including the Medicaid expansion population).1.States receive up to 14 points for coverage of medications:2 points for coverage for all enrollees of each of the 7 medications.If coverage of a medication varies by plan or pregnancy status,1 poi
254、nt is awarded for each medication covered in this way;2.States receive up to 12 points for coverage of counseling:4 points for each type of counseling covered(individual,group and phone).If a counseling coverage varies by plan or pregnancy status,2 points is awarded for each type of counseling cover
255、age;3.States receive up to 14 points for providing coverage without barriers:1 to 3 points are deducted for each barrier to coverage that exists in a state.Deductions vary based on type of barrier and severity.4.If a state has not expanded Medicaid coverage up to the levels established in the Afford
256、able Care Act(138%of the federal poverty level for all eligibility categories),8 points are automatically deducted from the Medicaid coverage score.5.State that impose a tobacco surcharge or charge tobacco users higher premiums than non-tobacco users for Medicaid coverage will have 2 points deducted
257、 from the Medicaid coverage score.2022American Lung Association“State of Tobacco Control”202228 Lung.orgState Employee Health Plan Coverage(10 points):Target is barrier-free coverage of all Guideline-recommended medications and counseling for all of a states employees and dependents.1.0 to 4 points
258、are given for coverage of medications;deductions were made if only some health plans/managed care organizations provide coverage;2.0 to 4 points are given for coverage of counseling;deductions were made if only some health plans/managed care organizations provide coverage;3.0 to 2 points are given i
259、f coverage is free of barriers.Quitlines(20 points):States are graded based on a curve set by the median investment per smoker,which in fiscal year 2021 was$2.41 per smoker.Points are awarded based on the scale below:$/smoker$4.82 20 points$/smoker$3.62-$4.81 15 points$/smoker$2.41-$3.61 10 points$/
260、smoker$1.21-$2.40 5 points$/smoker$1.21 0 pointsStandards for Private Insurance Coverage(up to 5 bonus points):Target is a legislative or regulatory standard requiring coverage of all PHS-recommended medications and counseling in private insurance plans within the state.1.1 point given for the prese
261、nce of a legislative or regulatory private insurance standard or if a state insurance commissioner issues a bulletin on the enforcement of the tobacco cessation FAQ issued by the federal government;62.0 to 2 points given for required coverage of medications;3.0 to 2 points given for required coverag
262、e of counseling.Tobacco Surcharges(up to 2 bonus points):Target is a state policy prohibiting small group and individual health insurance plans from charging tobacco users higher premiums than non-tobacco users.States can prohibit this practice or limit these surcharges to amounts smaller than feder
263、al law allows,which is 50%.1.2 points given if state prohibits tobacco surcharges;OR2.1 point given if state limits tobacco surcharges to less than 50%of the premium charged to non-tobacco users.State Flavored Tobacco Product LawsFlavored tobacco products have long played an important role in youth
264、starting to use tobacco products and in the case of menthol keeping people,particularly Black Americans,addicted.According to CDCs 2021 National Youth Tobacco Survey,over 85%of high school students and close to 80%of middle school students who use e-cigarettes use a flavored product.7 And the latest
265、 data available from the 2019 National Youth Tobacco Survey found that close to 70%of youth tobacco users used a flavored product.8Menthol cigarettes play a key role in addicting youth smokers and keeping people hooked.About half of youth smokers ages 12-17 smoke menthol 2022American Lung Associatio
266、n“State of Tobacco Control”202229 Lung.orgcigarettes.9 Black Americans are disproportionately impacted with over 80%of Black persons who smoke using menthol cigarettes.10 Menthol cigarette use is also elevated among LGBTQ+Americans,pregnant women and persons with lower incomes.A recent study showed
267、that while overall cigarette use declined by 26%over the past decade,91%of that decline was due to non-menthol cigarettes.11Given the key role that flavors play in getting and keeping people addicted to tobacco products,and the slow pace of action by the federal government on the topic,a new grade w
268、as added to“State of Tobacco Control 2021”evaluating states on whether they have prohibited the sale of all flavored tobacco products.This grade replaced the Minimum Age grade from“State of Tobacco Control”2020 and earlier years.Grades are based on the strength of a states restrictions on flavored t
269、obacco products with exemptions for certain products or in certain locations decreasing the grade.Grades break down as follows:A=the sale of all flavored tobacco products is prohibited;B=the sale of most flavored tobacco products,including menthol cigarettes,is prohibited with some narrow exemptions
270、;C=the sale of all flavored tobacco products,including menthol cigarettes,is limited to over age 21 stores/locations;D=the sale of one type of flavored tobacco product is completely prohibited(i.e.flavored e-cigarettes or flavored tobacco product restrictions that completely exempt menthol cigarette
271、s);F=No state law on flavored tobacco products or the sale of one type of flavored tobacco product restriction that exempts menthol.There is one situation that creates an exception to the grading system:Local Ordinances:States without a statewide law or weaker statewide restrictions on flavored toba
272、cco products may be graded based on local ordinances.Local ordinances that prohibit the sale of all flavored tobacco are considered according to the percentage of population covered in the state.States with over 95%of their population covered by local flavored tobacco product ordinances will receive
273、 an“A,”over 80%a“B,”over 65%a“C”and over 50%a“D.”Local ordinances that cover less than 50%of the population will not be considered for evaluation under this exception.State Statistics Used in the ReportAdult smoking rates are taken from the CDCs 2020 Behavioral Risk Factor Surveillance System.Adult
274、smoking means having used cigarettes on one or more of the past 30 days.High school smoking and tobacco use,and middle school smoking rates are taken from CDCs 2019 Youth Risk Behavior Survey,state youth tobacco surveys or other state-based surveys that measure youth smoking or tobacco use rates.Hig
275、h school tobacco use includes having used cigarettes,cigars,smokeless tobacco or electronic vapor products on one or more of the past 30 days for most states.In states where the tobacco products covered by the survey used are different,a sentence has been added to the state-specific footnotes on eac
276、h state page describing the tobacco products included.Health impact and economic information is taken from CDCs Smoking Attributable Mortality,Morbidity and Economic Costs(SAMMEC)software.2022American Lung Association“State of Tobacco Control”202230 Lung.orgSmoking attributable deaths reflect averag
277、e annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older.Smoking-attributable health care expenditures are based on 2004 smoking-attributable fractions and 2009 personal health care expenditure data.Deaths and expenditures should not be compared by state.Sta
278、te-by-state tobacco-related revenue data(revenue from state tobacco settlement payments and tobacco taxes)is provided by the Campaign for Tobacco-Free Kids.1.Institute of Medicine,Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products,Washington,DC:The National Aca
279、demies Press,2015,http:/www.nationalacademies.org/hmd/Reports/2015/TobaccoMinimumAgeReport.aspx.2.Data to calculate percent of state populations covered by local ordinances is obtained from the Americans for Nonsmokers Rights Foundation.3.U.S.Department of Health and Human Services.The Health Conseq
280、uences of Smoking50 Years of Progress:A Report of the Surgeon General.Atlanta,GA:U.S.Department of Health and Human Services,Centers for Disease Control and Prevention,National Center for Chronic Disease Prevention and Health Promotion,Office on Smoking and Health,2014.4.There is general consensus a
281、mong tobacco researchers that every 10 percent increase in the price of cigarettes decreases cigarette consumption by about 4 percent in adults and about 7 percent in children.Tauras J,et al.Effects of Price and Access Laws on Teenage Smoking Initiation:A National Longitudinal Analysis,Bridging the
282、Gap Research,ImpacTeen.April 24,2001.5.As of January 1,2014,the Affordable Care Act(ACA)required that state Medicaid programs no longer exclude coverage of tobacco cessation medications.In State of Tobacco Control 2020 a state was only given credit for covering tobacco cessation medications if there
283、 is documentable evidence that the Medicaid program is covering that medication,regardless of the federal requirement.6.On May 2,2014,the U.S.Departments of Labor,Health and Human Services and Treasury issued an FAQ that clarified what health insurance plans under the Affordable Care Act should cove
284、r in terms of tobacco cessation medications and counseling,https:/www.cms.gov/cciio/resources/fact-sheets-and-faqs/aca_implementation_faqs19.html(see question 5).7.Park-Lee E,Ren C,Sawdey MD,et al.Notes from the Field:E-Cigarette Use Among Middle and High School Students National Youth Tobacco Surve
285、y,United States,2021.MMWR Morb Mortal Wkly Rep 2021;70:13871389.8.Wang TW,Gentzke AS,Creamer MR,et al.Tobacco Product Use and Associated Factors Among Middle and High School Students United States,2019.MMWR Surveill Summ 2019;68(No.SS-12):122.9.Substance Abuse and Mental Health Services Administrati
286、ons public online data analysis system(PDAS).National Survey on Drug Use and Health,2020.10.Ibid.11.Delnevo CD,Ganz O,Goodwin RD,Banning Menthol Cigarettes:A Social Justice Issue Long Overdue.Nicotine Tob Res,2020 Oct 8;22(10):1673-1675.https:/doi.org/10.1093/ntr/ntaa1522022American Lung Association
287、“State of Tobacco Control”202231 Lung.orgTobacco Taxes FCIGARETTE TAX:Tax rate per pack of 20:$1.01OTHER TOBACCO PRODUCT TAXES:Little Cigars:Equalized:Yes;Weight-Based:YesLarge Cigars:Equalized:No;Weight-Based:NoSmokeless Tobacco:Equalized:No;Weight-Based:YesPipe/RYO Tobacco:Equalized:No;Weight-Base
288、d:YesE-cigarettes:Equalized:N/A;Weight-Based:N/AMass Media Campaigns ATIPS FROM FORMER SMOKERS MEDIA CAMPAIGN:Reach:Meets TargetDuration:Under TargetFrequency:Meets TargetPromotion of Services:Meets TargetFDA“REAL COSTS”MEDIA CAMPAIGN:Reach:Meets TargetDuration:Meets TargetFrequency:Meets TargetProm
289、otion of Services:Under TargetMinimum Age I*Minimum Age of Sale for Tobacco Products:21*The federal government gets an“I”for Incomplete because FDA has not issued implementing regulations that were required by statute to be issued by June 17,2020.Federal Regulation D of Tobacco ProductsImplementatio
290、n of Rule Asserting Authority over All Tobacco Products:Rule partially implemented Graphic Cigarette Warning Labels:Warning labels finalized,but not in effect*Product Standards,including Flavored Tobacco Products:No product standard proposed or finalized Funding for FDA Center for Tobacco Products:O
291、perating on continuing resolution until February 2022*FDA has finalized graphic warning labels for cigarettes,due to a federal court order the effective date for the rule is January 9.2023.Cessation Coverage DMedicaid Coverage:Partially Required Medicare Coverage:Partially Covered TRICARE Coverage:C
292、overed Federal Employee Health Benefits Coverage:Covered State Health Insurance Exchanges:Partially Required DThumbs down for the federal government for undermining healthcare access to comprehensive tobacco cessation coverage.United States Report CardUNITED STATESFederal Highlights:The American Lun
293、g Association has identified four key actions for the Biden Administration and Congress to take in 2022 that will help ultimately eliminate the death and disease caused by tobacco use:1.FDA must adhere to the Tobacco Control Act and reject product marketing applications(PMTAs)for any product that fa
294、ils to prove it is appropriate for the protection of the public health,including all flavored products;2.The Biden Administration must propose and finalize rules that will remove all menthol cigarettes and flavored cigars from the marketplace;3.Congress must increase federal funding for the Centers
295、for Disease Control and Prevention(CDC)s Office on Smoking and Health to help states combat the youth e-cigarette epidemic and to further strengthen its“Tips from Former Smokers”Campaign;and4.The U.S.Department of Health and Human Services(HHS)must clarify and ensure that most health plans,including
296、 state Medicaid expansion plans,cover a comprehensive tobacco cessation benefit without barriers and cost-sharing:and Congress must pass the“Quit Because of COVID-19”Act.2022American Lung Association“State of Tobacco Control”202232 Lung.orgUNITED STATESlegislation has bipartisan support in the House
297、 and the Senate.In 2021,the House passed the Build Back Better act that which for the first time ever,taxed e-cigarettes.However,the tax on e-cigarettes was dropped in the Senate in December.The lawsuits brought by Altria and RJ Reynolds in two separate federal courts continue to hold up the graphic
298、 warning labels for cigarette packs.As a result of the delays,FDA will not finalize the proposed rules until at least 2023.The Lung Association and our partners are supporting FDAs legal efforts to push back against the industrys cases.United States FactsEconomic Costs Due to Smoking:$289,500,000,00
299、0Adult Smoking Rate:14.0%Adult Tobacco Use Rate:20.8%High School Smoking Rate:4.6%High School Tobacco Use Rate:23.6%Middle School Smoking Rate:1.6%Middle School Tobacco Use Rate:6.7%Smoking Attributable Deaths per Year:480,320Smoking Attributable Lung Cancer Deaths per Year:163,700Smoking Attributab
300、le Respiratory Disease Deaths per Year:113,100Adult smoking and tobacco use rates are taken from the 2019 National Health Interview Survey.High school and middle school smoking and tobacco use rates are taken from the 2020 National Youth Tobacco Survey.Health impact information is taken from the Smo
301、king Attributable Mortality,Morbidity and Economic Costs(SAMMEC)software.Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for persons aged 35 years and older.Smoking-attributable health care expenditures are based on 2004 smoking-attributable f
302、ractions and 2009 personal health care expenditure data.Deaths and expenditures should not be compared by state.Key highlights from 2021 and Items for 2022 include:In response to a court-ordered deadline,in April 2021,the Biden Administration announced that by April 2022,it would propose two new rul
303、es to remove menthol cigarettes and flavored cigars from the marketplace.The Lung Association eagerly anticipates the proposed rules and strongly encourages comprehensive regulations.To meet the September 9,2021,court-ordered deadline,FDA began to review and issue denial orders to some of the millio
304、ns of e-cigarettes that submitted premarket tobacco marketing applications.While FDA denied millions of applications,it has not acted on the applications from e-cigarette manufacturers with the largest market shares,nor has the agency appeared to issue any marketing orders denial orders to manufactu
305、rers for their menthol flavored e-cigarettes.We are also unaware of FDA action on any marketing orders for tobacco products other than e-cigarettes such as cigars and hookah.While the Lung Association is frustrated with FDAs lack of progress with the remaining deeming applications,we are supporting
306、the agencys authority over these products in amicus briefs filed with the courts in lawsuits brought by e-cigarette companies whose products were denied marketing orders.The House-passed appropriations bill increased funding for CDCs Office on Smoking and Health(OSH)to$250 million for fiscal year(FY
307、)2022;the Senate Appropriations committee bill includes an increase to$247.5.OSH was funded at$237.5 million in FY2021.However,it is unclear whether OSH will receive any increase,as the federal government is operating under a continuing resolution through February 18,2022.OSH funding provides suppor
308、t for critical efforts to reduce tobacco use such as CDCs“Tips from Former Smokers”campaign.This campaign,which is celebrating its 10th anniversary this year has led to more than 1 million smokers quitting.The Administration has not yet acted on limiting non-compliant health plans which are not requ
309、ired to cover treatment to help people quit tobacco use,to remain on the market.These“skimpy”plans compete with plans that are required to cover treatments to help people quit tobacco use.The Lung Association continues to urge Congress to pass the“Quit Because of COVID-19 Act”which would ensure all
310、Medicaid enrollees have access to a comprehensive tobacco cessation benefit.The 2022American Lung Association“State of Tobacco Control”202233 Lung.orgTobacco Taxes:FCIGARETTE TAX:Tax Rate per pack of 20:$0.675OTHER TOBACCO PRODUCT TAXES:Tax on little cigars:Equalized:No;Weight-Based:NoTax on large c
311、igars:Equalized:No;Weight-Based:NoTax on smokeless tobacco:Equalized:No;Weight-Based:YesTax on pipe/RYO tobacco:Equalized:No;Weight-Based:YesTax on e-cigarettes:Equalized:N/A;Weight-Based:N/AAccess to Cessation Services:FOVERVIEW OF STATE CESSATION COVERAGE:STATE MEDICAID PROGRAM:Medications:All 7 m
312、edications are coveredCounseling:Some counseling is coveredBarriers to Coverage:Substantial barriers exist to access coverageMedicaid Expansion:NoSTATE EMPLOYEE HEALTH PLAN(S):Medications:All 7 medications are coveredCounseling:Some counseling is coveredBarriers to Coverage:Some barriers exist to ac
313、cess coverageSTATE QUITLINE:Investment per Smoker:$1.18;the median investment per smoker is$2.41OTHER CESSATION PROVISIONS:Private Insurance Mandate:No provisionTobacco Surcharge:No prohibition or limitation on tobacco surchargesCitation:See Alabama Tobacco Cessation Coverage page for coverage detai
314、ls.Flavored Tobacco Products:FRestrictions on Flavored Tobacco Products:No state law or regulationTobacco Prevention and F Control Program Funding:FY2022 State Funding for Tobacco Control Programs:$1,737,970FY2022 Federal Funding for State Tobacco Control Programs:$1,682,740*FY2022 Total Funding for
315、 State Tobacco Control Programs:$3,420,710CDC Best Practices State Spending Recommendation:$55,900,000Percentage of CDC Recommended Level:6.1%State Tobacco-Related Revenue:$290,900,000*Includes tobacco prevention and cessation funding provided to states from the Centers for Disease Control and Preve
316、ntion.Smokefree Air:FOVERVIEW OF STATE SMOKING RESTRICTIONS:Government Worksites:RestrictedPrivate Worksites:No provisionSchools:RestrictedChild Care Facilities:RestrictedRestaurants:No provisionBars:No provisionCasinos/Gaming Establishments:No provisionRetail Stores:RestrictedRecreational/Cultural
317、Facilities:RestrictedE-Cigarettes Included:NoPenalties:YesEnforcement:YesPreemption/Local Opt-Out:NoCitation:ALA.CODE 22-15A-1 et seq.(2003).Alabama Report CardALABAMA2022American Lung Association“State of Tobacco Control”202234 Lung.orgALABAMAIn 2022,the American Lung Association in Alabama will ad
318、vocate for the implementation of a comprehensive tobacco retail licensing program to ensure enforcement and compliance with tobacco control statutes while continuing to educate state legislators on best practices for tobacco control,including the benefits of a statewide smokefree law.In order to red
319、uce the death and disease caused by tobacco use in Alabama,state legislators will need to recognize the health and economic burden of tobacco use and secondhand smoke exposure by enacting public health protections and investing in evidence-based tobacco prevention programs.The Lung Association will
320、continue to work with partners in the Coalition for a Tobacco Free Alabama to ensure successful passage and preservation of comprehensive local smokefree ordinances.Alabama State FactsHealthcare Costs Due to Smoking:$1,885,747,576Adult Smoking Rate:18.5%Adult Tobacco Use Rate:N/AHigh School Smoking
321、Rate:7.1%High School Tobacco Use Rate:26.7%Middle School Smoking Rate:3.4%Smoking Attributable Deaths:8,650Adult smoking data come from CDCs 2020 Behavioral Risk Factor Surveillance System.High school smoking and tobacco use rates are taken from the 2019 Youth Risk Behavior Surveillance System.Middl
322、e school smoking rates are taken from the 2016 Youth Tobacco Survey.Health impact information is taken from the Smoking Attributable Mortality,Morbidity and Economic Costs(SAMMEC)software.Smoking attributable deaths reflect average annual estimates for the period 2005-2009 and are calculated for per
323、sons aged 35 years and older.Smoking-attributable healthcare expenditures are based on 2004 smoking-attributable fractions and 2009 personal healthcare expenditure data.Deaths and expenditures should not be compared by state.Tobacco use remains the leading cause of preventable death and disease in t
324、he United States and in Alabama.To address this enormous toll,the American Lung Association calls for the following actions to be taken by Alabamas elected officials:1.Implement a comprehensive tobacco retail licensing program to ensure enforcement and compliance with tobacco control statutes;2.Pass
325、 a comprehensive statewide smokefree law that protects all workers and patrons from secondhand smoke;and3.Increase funding for the Alabama tobacco prevention and control program.In 2021,Representative Drummond introduced House Bill 273 to reduce kids access to e-cigarettes and protect them from a li
326、felong addiction to tobacco and nicotine.House Bill 273 aligned Alabamas statute with federal law increasing the sales age of tobacco products to 21 years of age while also adding some additional provisions to tobacco control statutes.Unfortunately,House Bill 273 did not adequately update state toba
327、cco control laws to restrict youth access to tobacco,including e-cigarettes and expressly exempts non-nicotine products from being regulated by adjusting the definition of electronic nicotine dispensing devices.The Lung Association and other public health partners advocated for updating provisions f
328、or licensing,enforcement and compliance of tobacco products,including e-cigarettes,and removing youth penalties as polices that would have effectively reduced youth tobacco and nicotine use.Many local municipalities were inundated with needs to respond to their community as a result of the COVID-19
329、pandemic and were unable to focus on other issues,such as implementing strong smokefree ordinances.Tobacco control partners continue to be engaged with community education on the dangers of tobacco use and secondhand smoke across Alabama.The Lung Association plays a prominent role by offering techni
330、cal assistance on the best practices of tobacco prevention and control.The Alabama Department of Public Health continues to affect social norm change around tobacco use,address the marketing of tobacco products to youth,and promote policies that eliminate exposure to secondhand smoke through the Tob
331、acco Prevention and Control Program.Alabama State Highlights:2022American Lung Association“State of Tobacco Control”202235 Lung.orgTobacco Taxes:DCIGARETTE TAX:Tax Rate per pack of 20:$2.00OTHER TOBACCO PRODUCT TAXES:Tax on little cigars:Equalized:Yes;Weight-Based:NoTax on large cigars:Equalized:Yes
332、;Weight-Based:NoTax on smokeless tobacco:Equalized:Yes;Weight-Based:NoTax on pipe/RYO tobacco:Equalized:Yes;Weight-Based:NoTax on e-cigarettes:Equalized:N/A;Weight-Based:N/AAccess to Cessation Services:BOVERVIEW OF STATE CESSATION COVERAGE:STATE MEDICAID PROGRAM:Medications:All 7 medications are cov
333、eredCounseling:Some counseling is coveredBarriers to Coverage:Some barriers exist to access careMedicaid Expansion:YesSTATE EMPLOYEE HEALTH PLAN(S):Medications:All 7 medications are coveredCounseling:Most counseling is coveredBarriers to Coverage:Some barriers exist to access careSTATE QUITLINE:Investment per Smoker:$6.49;the median investment per smoker is$2.41OTHER CESSATION PROVISIONS:Private I