Cancer Answers: Legislative Opportunities for Cancer Control
July 25, 2019Information
Legislative Opportunities for Cancer Control with guest Bryte Johnson, June 16, 2019
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- 00:00Support for Yale Cancer Center Answers comes from AstraZeneca, proud partner in personalized medicine, developing tailored treatments for cancer patients. Learn more at astrazeneca-us.com. 00:13.700 --> 00:42.200 Welcome to Yale Cancer Answers with doctors Anees Chagpar and Steven Gore. Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancer. This week, it is a conversation about legislative opportunities for cancer control with Bryte Johnson, the Connecticut Director of Government Relations at the American Cancer Society Cancer Action Network. Dr. Chagpar is a Professor of Surgery at the Yale School of Medicine. 00:42.200 --> 00:54.000 Chagpar So, Bryte, maybe we can start off big picture talking about what exactly is the cancer action network and what does that do? 00:54.000 --> 01:12.900 Johnson Well, my job is quite frankly just to make sure that cancer remains the top priority among our state legislators. There are hundreds of bills raised every year that relate to our issue areas and I am needed to make sure that the voice of cancer patients are heard in Hartford. 01:12.900 --> 01:26.400 Chagpar Excellent. So, on that kind of backdrop then, what are some of those bills that are currently in the legislature that you are trying to advocate for in terms of cancer patients? 01:26.400 --> 01:47.900 Johnson Sure. Well, the biggest bill right now is one that would increase the sale age of tobacco products to 21. That is an issue that we have been working on for many years now, this is the third year the bill has been raised and there is a growing and visible momentum behind the bill this year and I think we are confident that we may achieve passage. 01:47.900 --> 01:57.400 Chagpar And so, by raising, you said that this is now the third year that it has been presented. And so, has it had issues getting through the legislature? 01:57.400 --> 02:44.900 Johnson Well, a lot of the challenges that we faced have been around just educating legislators as to what the problem and what this potential solution will achieve. It has been a very alarming evolution over the last 3 years. The first year we raised it, both educators as well as the public were confused. E-cigarettes, what! What is this? Last year, it kind of evolved to concern as some of the problems that the state is facing with respect to e-cigarette usage started to come to light, but this year, it has been about fear and fear tends to drive a lot of action at the State House. We have seen some very, very alarming numbers over the last year that show just an explosion in e-cigarette usage across Connecticut and frankly across the country. 02:44.900 --> 02:58.300 Chagpar So, let's talk a little bit more about that. When you said that the bill is really focused on raising the age at which tobacco products can be sold, were you talking about regular cigarettes or e-cigarettes or both? 02:58.300 --> 03:02.500 Johnson We are talking about both. All tobacco products, including electronic cigarettes. 03:02.500 --> 03:16.400 Chagpar And so, you know, some people might wonder why that is such a big deal, like what would raising the age to 21 do, really? 03:16.400 --> 04:18.500 Johnson Well, there are a number of very alarming statistics that still affect us here in Connecticut. There are 4900 people that are expected to die from tobacco use here in Connecticut, just this year alone. Tobacco use brings over 2 billion in healthcare-related costs to Connecticut and as you know, this is a state that cannot afford those types of things. With respect to the 4900 deaths, that is 13 a day. This is still a staggering issue and while we are very pleased that the smoking rate has declined over the years, the e-cigarette use rate has skyrocketed. And in fact, it has increased by over 50% just from 2017 to 2018. Additionally, disciplinary actions at high schools increased from 349 in 2017 to 2160 in 2018, which is a six-fold increase. This is a major problem, and tobacco 21 is a potential solution because it is going to hopefully reduce access to these products for folks under the age of 21. 04:18.500 --> 04:26.900 Chagpar And so, when you were talking about that increase in disciplinary actions at high schools, those were disciplinary actions with regards to smoking? 04:26.900 --> 04:29.400 Johnson With regards to using e-cigarettes. 04:29.400 --> 05:02.200 Chagpar And so, clearly, this bill will make it more difficult for high school students, kids really, anybody under the age of 21 to get their hands on e-cigarettes or regular cigarettes. So, certainly, it will affect that population. Some of our listeners, however, might be a little bit skeptical thinking that if people want cigarettes, there is a black market or bootleg where you can get cigarettes for people who are older than 21, how have you thought about addressing that? 05:02.200 --> 05:51.900 Johnson Well, the black market exists regardless. What this bill will hopefully do is, there are 56,000 kids alive in Connecticut that are going to die prematurely from tobacco use and this bill addresses them. We are not going after the 18, 19 and 20-year-olds. We are trying to prevent the 14, 15 and 16-year-olds from ever having access to these products in the first place. And most of these kids are getting these products from their friends that are 18 but still in high school. The friends pick them up, the 18-year-olds pick them up and then make sure that the younger kids have access to them or sell them to the younger kids and that is an enormous problem and that is what feeding this. And so, by making it more difficult for the younger kids to get access to this, we are hopeful that it will prevent them from ever starting an addiction to nicotine in the first place. 05:51.900 --> 06:40.000 Chagpar Right. One would think that education must play a big part in terms of the fact that e-cigarettes are not cool. Because one can always think, especially if you are skeptic that by making it harder to get, like you can only smoke if you are 21, like this is really an adult thing to do, that kids who may be struggling with the whole getting through adolescence and trying to be a "adult" might think that that is something that is "cool" because you can only get it after you are 21. How has the ACS really thought about educating kids that smoking e-cigarettes, regular cigarettes, tobacco is totally not cool. 06:40.000 --> 07:48.700 Johnson Well, addressing the normalization of the addiction is a huge concern of ours, and we are challenged because the tobacco industry spends almost 70 million dollars annually marketing their products, including electronic cigarettes here in Connecticut and we do not have any response to that. We do not have any funding available to counter-market that. And so, that plus just seeing the activities covered in movies and on TV shows and glamorized using marketing techniques that are illegal for combustible tobacco products but are not illegal for e-cigarettes has been another challenge. Leonardo DeCaprio was caught on camera at the Academy Awards vaping and things like that are a huge problem and we need to be able to addressed that. And so, on the one hand, we have got legislation like increasing the sale age here in Connecticut, but we are also dependent upon actions taken by the federal government to not only potentially increase the age of tobacco products federally but also to address various marketing and licensing issues that are widespread. 07:48.700 --> 08:45.400 Chagpar Right. So, I know for example in Canada, when they were really addressing their tobacco industry, they mandated things like having half of the cigarette package with a realistic but terrible picture of somebody who has got oropharyngeal cancer and a big black block sign that said cigarettes cause oropharyngeal cancer or cigarettes cause death, and increasing the taxation. So, they not only made it an age restriction but they made it unaffordable so that the 18-year-old or the 21-year-old in this case who might be an age to buy cigarettes could not afford to buy cigarettes so that the cycle of starting tobacco use was really cut at the knees. 08:45.400 --> 10:32.200 Johnson Indeed. That's another challenge that we have here. Right now, e-cigarettes are not taxed anything other than the sales tax and so they are significantly cheaper than combustible cigarettes are. Connecticut is tied with New York for having the highest cigarette tax in the country at 435 a pack, but other tobacco products do not come anywhere near that taxation, so while we are seeing a reduction in combustible cigarette use, we are not seeing a reduction in tobacco use because they are simply moving from cigarettes which are expensive over to other tobacco products, which are cheaper and e-cigarettes since they have no tax at all other than the sales tax are cheaper still. What we seeing in Canada and frankly across the world with respect to marketing restrictions and as you mentioned the really alarming photos and warnings that are on the cigarette packs, that has been caught up in litigation for over 20 years now here in the United States. The Master Settlement Agreement, which was an agreement between big tobacco and the states, one of the provisions of that agreement was the addition of those types of photos and those types of warnings on cigarette packs, but unfortunately while we are celebrating the 20th anniversary of the passage of the Master Settlement Agreement, we are also celebrating the 20th anniversary of a number of ancillary law suits that have been in effect ever since. And because of that, we have not gotten to a point where even though the agreement requires those types of displays on the cartons, they are caught up in law suits, so that actually has not been implemented yet. I am happy to say though, it looks like some of those law suits are starting to come to an end and so we may start to see those graphic warnings and those graphic photos on tobacco products here in America before too long. 10:32.200 --> 10:56.100 Chagpar What about the taxation though. I mean when you talk about the fact that cigarette use, combustible cigarette use has declined partly related to the fact that Connecticut has one of the highest tax rates and certainly Canada saw a huge plummeting of cigarette use when the taxes on these packs were insanely expensively, what about translating that to e-cigarettes? 10:56.100 --> 12:10.200 Johnson Well, it is certainly something that we have been advocating for. Our position is that all tobacco products should have parity with the cigarette tax and be linked to the cigarette tax, so that if that tax is ever increased in the future, all of the other taxes would be increased the same amount. That is the best way to eliminate it. My organization views tobacco control sort of like a three-legged stool and each leg serves a purpose: The first leg is regular and significant increases in the price of tobacco products through taxation. The second leg is providing a robust smoke-free environment without exemptions, and the third is providing tobacco control. We have a fairly strong first leg, the second leg is a little wobbly and we are missing the third leg altogether. We do not have any funding for tobacco control. So, as such, the only population that has access to FDA approved quit devices is the Medicaid population because to Governor Malloy's great credit and Governor Lamont's great credit, they have funded cessation activities through Medicaid to the tune of about 3.5 million dollars annually and that has had a huge effect. 12:10.200 --> 12:24.600 Chagpar And so, is it on the legislative agenda in Hartford to increase taxes on all tobacco products or is that something that has just been kind of left to the side as we focus on the age limits to begin with? 12:24.600 --> 13:08.100 Johnson Well, I think they are taking a broad look at anything, everything is on the table right now given that we are still faced with pretty significant budget deficits and a cloudy economic future. So, I know that they are taking a strong look at establishing a tax for electronic cigarettes and vaping products. I am not sure what that tax is going to look like at this point, but we are involved and hopeful that it will serve a number of purposes -- the first of course being that the revenue raise could be used to help restore funding for tobacco control programs across the state, which have been proven to be effective. Additionally, we are hopeful that if tax rate will result in a reduction in use. 13:08.100 --> 13:46.600 Chagpar Yeah absolutely. So, Bryte, maybe the other thing that would be helpful because a lot of people have talked about e-cigarettes, vaping as an alternative to cigarette. The idea being the public's mind that they may be less dangerous, not as addictive, but you had mentioned that you consider all tobacco products to really have significant health effects. We have to take a quick break for a medical minute. So, I will let you ponder that, but right after the break, we are going to find out more about electronic cigarettes, the effects that it has on cancer and other legislative agendas that are going on in cancer control. 13:46.600 --> 14:00.600 Medical Minute Support for Yale Cancer Answers comes from AstraZeneca, proud supporter of the many individuals and organizations who are working together to end cancer as a cause of death. Learn more about the Your Cancer Movement at yourcancer.org. 14:00.600 --> 14:41.000 This is a medical minute about colorectal cancer. When detected early, colorectal cancer is easily treated and highly curable. And as a result, it is recommended that men and women over the age of 50 have regular colonoscopies to screen for the disease. Tumor gene analysis has helped improve management of colorectal cancer by identifying the patients most likely to benefit from chemotherapy and newer targeted agents resulting in more patient-specific treatments. More information is available at YaleCancerCenter.org. You are listening to Connecticut Public Radio. 14:41.000 --> 15:46.000 Chagpar Welcome back to Yale Cancer Answers. This is Dr. Anees Chagpar, and I am joined tonight by my guest Bryte Johnson. We are talking about legislative action to help with cancer control and one of the big issues that Bryte has been working on in addition to helping the Hartford Legislators think about in terms of tobacco control is increasing the age for tobacco products, whether they be combustible or e-cigarettes to 21. So, Bryte, before the break, we were talking about misperceptions with regards to vaping and e-cigarettes. The idea that some think that these are that "healthier version" of cigarettes, that they are less addictive, that they are less likely cause cancer, but you mentioned that the American Cancer Society really considers all tobacco products kind of in the same boat. Can you help us to kind of clarify some of those perceptions and misperceptions? 15:46.000 --> 16:38.000 Johnson Sure, absolutely. I think the jury is in many respects still out on electronic cigarettes - one of the challenges that we face is that for over 60 years, we have been doing research on combustible tobacco products and even now we are still finding links to various ailments because of tobacco use. Well, e-cigarettes have only been around for 10 years. There are no long-term studies because they have not been around long term yet. So, we have no earthly idea what sort of long-term effects they may have. On the surface, they do appear to be less harmful, but I would point out the less harmful does not mean safe and less harmful does not mean they should not be regulated. I think that we can agree that driving into a wall while wearing a seatbelt is probably less harmful than driving into the wall without wearing the seatbelt, but I think we would also agree that perhaps the better option will be to not drive into the wall at all. 16:38.000 --> 16:59.500 Chagpar And so, the idea is really that the connection between e-cigarettes and cancer is not as strong as the connection between regular cigarettes and cancer, but the ACS still considers tobacco as a potential carcinogen and there is tobacco in e-cigarettes? 16:59.500 --> 17:56.000 Johnson Nicotine is an addictive substance, and again, we just do not know yet, we are not there yet, but what is concerning is that the use of e-cigarettes has led to an increase in the use of combustible products. The e-cigarettes themselves are being marketed not as an alternative necessarily but as an addition to. The marketing has slogans like don't quit, switch; meaning, just to switch to a different product, and switching from one bad product to another bad product is not necessarily the best public policy push that we should be making. Additionally, again since we do not know what the long-term effects are and we do know that e-cigarettes are addictive and that there are no regulations pertaining to what is in them, we are very concerned that we could be hooking an entire new generation of kids into what is actually a very dangerous addiction. 17:56.000 --> 18:25.600 Chagpar Right. So, really trying to avoid the potential harms that may be there, albeit that we do not have all of the most robust data, rather than letting us continue with the "safer option" and then 20, 50, 80, 100 years down the line saying oops! now that we know all of the negative effects, trying to get people to quit is going to be kind of like getting people to quit cigarettes now. 18:25.600 --> 19:17.100 Johnson It is an enormous challenge. It is a bit like catching water in a net because we have no regulations again over the items themselves. Ten years ago, there were just a couple hundred items out there, now there are over 15,000 flavors alone and we have no mechanism, none in place to be able to review each one of those flavors. E-cigarettes are not like combustible products where you use it and you are done. E-cigarettes are refillable. So, one cartridge could have a benign substance in it, the next cartridge could not. So, how do you weigh that, how do you measure that in terms of safety or in terms of danger for all the folks that are going around and saying that e-cigarettes are a healthier alternative, I would point out that it is possible to vape illegal drugs and how does that make it safer. 19:17.100 --> 19:33.600 Chagpar Yeah. So, certainly, I can imagine that part of this gets to be rather contentious when people say you do not have the data, you are now trying to regulate without having data that there is harms there, get your big government out of my life. 19:33.600 --> 20:23.500 Johnson We have enough data to show that this is a serious problem. The federal government is calling it an epidemic. We have seen, like I said earlier, we have seen an over 50% increase in e-cigarette use between 2017 and 2018, and as high as that is, that is nothing compared to what we are seeing nationwide. Nationwide, the increase was 78%. Kids are moving to these products. The reality is that nicotine is an addictive substance and we should not be opening the door for our kids to have access to addictive substances. It could lead to further problems and further addictions and massive healthcare costs down the line. And so our view is, it is better to air on the side of caution, regulate these now and control this now before it gets completely out of hand and I am afraid that we are getting close to that already anyway. 20:23.500--> 20:34.900 Chagpar Right. What other issues are on the legislative agenda in terms of cancer aside from the one that you mentioned with regards to tobacco and age? 20:34.900 --> 21:40.700 Johnson Well, as you know, preventative services are a crucial component in cancer care and we are very interested in making sure that number of existing programs that are available to folks in the state continue to be funded through the state budget, including the state breast and cervical cancer early detection program, which I am very happy to say and I give Governor Lamont full credit has been proposed to be funded at the same level as last year, actually with a small increase which is I think incredibly beneficial. Governor Lamont has also followed Governor Malloy's cues and provided 11 million dollars for access for all 11 and 12-year-olds to have access to the HPV vaccine, which is also crucial. And then finally as I mentioned earlier, the budget does contain 3.5 million dollars for Medicaid's Tobacco Cessation Access, which also is key given that the Medicaid population tends to use tobacco products at about a 50% greater rate than the general population and tobacco use costs our state Medicaid program just over 500,000 million dollars annually. 21:40.700 --> 22:36.200 Chagpar So, let’s take that last one first. So, in terms of the tobacco cessation program for Medicaid recipients, clearly it is beneficial in terms of the Medicaid population being perhaps disproptionately higher users of tobacco. And there is no question, I think everybody can understand that tobacco is linked with heart disease, cancers, stroke, I mean the leading causes of death, the leading causes of healthcare expenditure, can be pretty much directly related to tobacco. My question is, the money that is expended on this program, that is, geared towards tobacco cessation, does it work? Do we have data that this is money well spent, that people are actually quitting smoking as a result of these funds, which are coming out of taxpayer dollars? 22:36.200 --> 24:07.100 Johnson Yes, we do. Tobacco Control Programs have been proven to be effective across the country. I can give you a few examples. In Washington, they had a robust program there for a number of years. They achieved a 5:1 savings through 2000 to 2009 and they cut their smoking rate by a third and their youth rate by 50%. Florida has seen a reduction in their youth smoking rate to 6.9%. California cut lung cancer rates by a third between 1988 and 2011. Alaska cut its high school smoking rate by 70% since 1995. Maine has reduced its youth smoking rate by two-thirds. All of this through Tobacco Control Program funding. Unfortunately, most of that funding has been redirected in recent years as each state has been experiencing budget deficits. The great challenge with the Master Settlement is that while the intent of it was that the money that the big tobacco companies would give to the states was supposed to be used to offset the healthcare costs related to the use of those products. It does not say it has to be used for that, it says may, not shall, and so as states have hit deficits and fiscal problems, unfortunately some of those tobacco funds are among the first to be redirected, and here in Connecticut that has unfortunately been a very common issue and as a result, we do not have a robust tobacco control, state-wide tobacco control program. 24:07.100 --> 24:14.200 Chagpar And so the program that we do have for Medicaid patients, do we have data that that has been successful for Medicaid patients? 24:14.200 --> 24:53.800 Johnson We do. There has been a marked reduction in use and more importantly, Connecticut is one of only a handful of states that does provide funding for access to all 7 of the FDA approved methods and that is crucial, and so to that end, I think we have seen a little bit higher of success rate here in Connecticut because not everybody reacts the same way to the same types of treatments; for example, some people one-on-one counseling might not work with them. Some people might need more than one counseling and perhaps the patch or something in addition. So, by having access to all of those, I think more people are able to take advantage of it and we are seeing some beneficial results. 24:53.800 --> 25:13.100 Chagpar Right and certainly, I mean, healthcare insurers should really follow the lead of the government in terms of the cost savings associated with smoking cessation programs. So, while this program is really only for Medicaid patients, one would hope that those who are at least privately insured should be able to get the same kind of health. Is that right? 25:13.100 --> 26:53.500 Johnson Indeed. We have seen some pretty startling examples over the years, even here in Connecticut. About 10 years ago, there was just about a million and a half dollars that were dedicated to the state quitline, so folks can call in to the quitline and they would be provided with nicotine replacement therapies. The idea was that million six would last for the fiscal year that it was appropriated for. They ran out of that money in 3 weeks. Calls went from about 8 a week to dozens and dozens and dozens, and they just got swamped and they ran out of that money in less than a month, which I think follows polling that we have seen over the years that roughly 70% of tobacco users would like to quit and about half of those try to quit, but only about 5% of those are actually successful in quitting for any length of time, and part of that is again because more often than not, right now at least, they do not have any place to turn. They want to quit, who do they talk to, what is available to them, what can help them quit. It is not easy to quit cold turkey and in fact some doctors would argue that quitting nicotine is tougher than quitting heroin. And so, there needs to be robust programs available for the public across the state. Someone should not be punished who lives in Canton that cannot get access to a program because the program is in Norwich. They should not have to drive all the way across the state, it should be available to them where they live and hopefully they will be able to take advantage of it and hopefully will be able to see a reduction not only in the number of deaths per year, but also the staggering costs related to healthcare through tobacco use. 26:53.500--> 27:34.400 Chagpar Yeah. But I think at least for our listeners who may not be on Medicaid, who may be in that pool of smokers who want to quit, I think the message is the first things first, talk to your doctor. There likely can be some support that you can avail yourself of, whether it is one-on-one counseling, whether it is nicotine replacement, whatever; talk to your doctor and many cancer centers -- Yale and other places have smoking cessation programs that you can avail yourself of. And so, if cost is an issue, call your cancer center. 27:34.400 --> 27:55.500 Johnson I would also argue that your second caller should be to your legislator. Because the legislature holds the purse strings and if they are hearing from their constituents, their constituents need this and want this and would benefit from this, then I think that that would help move momentum in Hartford to be able to restore funding for these vital programs. 27:55.500 --> 28:10.500 Chagpar And I think if there are any people who work for any of the major insurers out there, it seems to me to be a cost-effective strategy to get your pool of covered lives smoke free because certainly that can reduce healthcare costs. 28:10.500 --> 28:18.000 Johnson Certainly cheaper to prevent someone from ever starting or help them quit than to deal with the ramifications when it is too late. 28:18.000 --> 28:33.500 Chagpar Right. Which brings us to prevention in general. The other piece of legislation that you were talking about was HPV vaccination for 11 and 12-year olds. Now, was that legislation only for girls or also for boys? 28:33.500 --> 28:56.400 Johnson No, it is for all 11 and 12-year-old boys and girls across the state. It does not mandate that they take the vaccine, it just makes it available to them through the Connecticut Immunization Program, and this is I think key because this vaccine works and this vaccine will reduce cancer in the future and we are very gratified that the Governor has opted to include it in his budget. 28:56.400 --> 29:22.800 Bryte Johnson is the Connecticut Director of Government Relations at the American Cancer Society Cancer Action Network. If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We invite you to join us next week to learn more about the fight against cancer here on Connecticut Public Radio.