Oregon bill would ban all flavored tobacco products

A bill in the Oregon House of Representatives would ban the sale of all flavored tobacco products, including menthol cigarettes, flavored e-cigarettes and hookah. Five states have enacted similar bans, including California, which allows an exception for hookah sales. In Oregon, Washington and Multnomah counties both voted to ban flavored tobacco sales, but a state circuit court judge ruled in 2022 that only the state has that authority.

Here to tell us more about the bill is Dr. James Bishara, a pediatric cardiologist at OHSU’s Doernbecher Children’s Hospital.

This transcript was created by a computer and edited by a volunteer.

Dave Miller:  This is Think Out Loud on OPB. I’m Dave Miller. A bill in the Oregon House of Representatives would ban the sale of all flavored tobacco products including menthol cigarettes, flavored e-cigarettes and Shisha which is used in hookah pipes. Five states have now enacted similar bans including California which allows an exception for hookah sales. Washington and Multnomah counties have tried to put bans on flavored tobacco in place. A judge struck down Washington County’s ban saying only the state has that authority. The Multnomah County ban is facing its own legal challenge. James Bishara is a pediatric cardiologist at OHSU’s Doernbecher Children’s Hospital. He’s been pushing for these bands at the local and state levels and he joins us now to talk about it. James Bishara, welcome to the show.

James Bishara:  Hi. Thank you for having me.

Miller:  Thanks for joining us. I want to start with the overall societal reasons for this proposal, this ban. What are the health consequences of tobacco overall in the US right now?

Bishara:  So I think everyone knows that tobacco is a dangerous drug that causes a lot of disease and death. But they may not quite understand how significant the impact tobacco has on our health. Tobacco kills half of the people who use it as directed and that’s not an exaggeration. And in those it doesn’t kill, it’s going to cause severe diseases like cancer, lung disease, heart disease and affects literally every organ in your body. It’s an extremely dangerous substance. And that calls for really significant measures to protect children from developing tobacco related diseases.

Miller:  What does tobacco use among youth look like right now?

Bishara:  Well, most kids start with flavored products. In fact, eight out of 10, start with a flavored product. And they’re, overall, using e-cigarettes as a grand majority. We’re seeing significant increases in the number of kids who are using tobacco products, up into the nearly 20 to 25% range for 11th graders using e-cigarettes. So nearly one in four kids are using these products at some sort of level.

Miller:  Say like once a month or something? What does one out of four refer to?

Bishara:  So one out of four is going to be at least once a month. Although there is a significant portion of those who are using at least 20 days and then they break it down to daily use as well, which is a little bit less than that. But about 60% to 80% are using many times a month.

Miller:  You mentioned that eight out of 10 young people who are using tobacco products or some kind of nicotine delivery system, use flavored ones. What is the significance of flavor when it comes to their choices?

Bishara:  So I think when we think about flavors, we have to realize that the primary purpose of flavors is that they’re designed to attract kids to start using. And that’s because addiction starts in children. The tobacco industry knows that we need to get the kids addicted because nine out of 10 adults start using before they are age 18. The kids are attracted to the flavors and it’s what eventually gets them hooked to the tobacco products.

Miller:  I can imagine a tobacco company saying, ‘no, no, no, we’re not. The flavors are not intended to attract kids. They’re intended to provide different flavorful opportunities for responsible adults who are making their own choices.’ I mean, I know that’s what they would say in response to what you just said. How would you respond?

Bishara:  Well, I think we have plenty of testimony and evidence over the past several decades that the tobacco industry has been using flavors to attract kids. We’ve got testimony from various executives saying these sorts of things. So we know that that’s true. And while there may be secondary effects, you know, yes, adults like flavors too, the primary purpose is to attract kids.

Miller:  What are the kinds of flavors that are out there right now?

Bishara:  Oh, there’s thousands and thousands of flavors. There’s cereal based flavors, like Lucky Charms, there’s Skittles, there’s strawberry watermelon Ice. If you can think of it you can find it. And there’s ones that look exactly like the candies that we’re used to, the cereals we’re used to as kids. And that’s why they’re so attractive to kids to say, ‘hey, I want to try what Lucky Charms tastes like.’

Miller:  It does seem like it’s harder to argue with a straight face that these are intended for adults making adult decisions if it’s based on candies and sugared cereals.

Bishara:  Certainly.

Miller:  Another argument that the marketers of vaping products or e-cigarettes say is that vaping is safer than smoking cigarettes. This is the harm reduction argument. How do you respond to it?

Bishara:  Well, I look at it from a pediatric perspective. What we’re seeing in kids is that they’re developing an addiction and there’s no harm reduction for them. And we know that this causes disease in kids. There are many chemicals in vaping products that are harmful. We know that the flavoring agents can cause disease, at least some of the flavoring agents can cause disease in kids when used in the long term. And there’s virtually no testing for flavors for chronic inhalational use. So we are really concerned about the long term effects of vaping, particularly for the population of people for whom there is no harm reduction. There’s only harm for kids who are starting to vape.

Miller:  What’s your best understanding of the reduction in teen or even younger kid vaping use or tobacco product use if there were no flavors? Because the ban that lawmakers are considering is not on all tobacco products. It’s simply on flavored ones. How much of a reduction do you think that would lead to if it were actually put in place?

Bishara:  That’s a really hard thing to predict. But what our kids tell us can inform us a lot. And also looking at historical data tells us a lot. What we’ve seen over the past 30 years is that cigarette use has gone down significantly even before e-cigarettes were on the market. And what kids tell us about vapes is that over seven out of 10 say they would try to quit if there were no flavors. So I think it’s really clear knowing that they would quit if there were no flavors and they’re starting because of flavors, that we would see an incredibly positive effect on the health of our kids and future generations if we were to restrict the sale of flavored tobacco products.

Miller:  In the last few years in various places, including in Oregon, another argument against a flavored tobacco ban has come forward. It’s that hookah bars which use flavored tobacco known as Shisha, that they’re a part of Middle Eastern culture and that banning flavored tobacco would undermine a cultural practice. How do you approach that argument?

Bishara:  Well, I think it’s important to consider the impact that policy may have on our diverse communities and hear their perspectives. My perspective as a physician is that whether it’s hookah or a traditional combustible cigarette, tobacco will cause disease in all of its users and kill half of its users, regardless of your ethnicity, your gender, your nationality or your culture. So I care about the health of all of our communities and believe that the children in each community have the right to a healthy life. We should not support policies that will increase the risk of tobacco related diseases in certain communities.

Miller:  How are young people accessing flavored nicotine products these days? I mean, they’re not allowed to go into a store and buy them. So how are they getting them?

Bishara:  Kids have multiple options on how to get e-cigarettes. And it’s certainly an important thing to have policies in place to limit access to tobacco. But what’s important to know is that kids want the flavored tobacco products and that seven out of 10 would quit if there were no flavors. And most won’t even start if there are no flavors. So there’s a lot of things, a lot of ways they can get them. But if we prevent them, if we have products that they’re not interested in starting or using, then they won’t use them at all.

Miller:  Where do you see the most organized or serious opposition to this bill coming from?

Bishara:  Well, there’s many of the tobacco industry stakeholders that are involved, whether it’s the very large tobacco companies that provide funding, as well as some of the more local shops that sell tobacco products. That’s where the majority of the opposition comes from.

Miller:  You’ve been working on this bill and related tobacco use cessation, public policy issues for a number of years now. What’s driving you?

Bishara:  When we think about kids, we know that the addiction starts with them. So if we can prevent addiction, we can prevent all of those really terrible diseases that we see in adults. When I think back to medical school, when I was still taking care of adult patients, the 50 year-old who was a smoker was often many, many times sicker than the 70 or 80 year old who might have been really hard of hearing. Overall, we’re just so much healthier. We know how terrible this disease is and I know that tobacco is going to rob them of an adulthood that they would want to have.

Miller:  You are a cardiologist not a lobbyist or a professional political watcher. But what do you see as this bill’s chances right now?

Bishara:  Well, I’m hopeful. I know there’s a lot of support. And I know that a lot of Oregonians have shown support for legislation that improves the health of our people. We’ve had recent bills passed, we had the referendum for Washington County, we had the tobacco tax several years back that had overwhelming support as well. I think the people of Oregon overall support policies that are going to be helpful and hopefully our legislators will hear that and act on this.

Miller:  James Bishara, thanks very much for joining us.

Bishara:  Thank you.

Miller:  James Bishara is a pediatric cardiologist at OHSU Doernbecher Children’s Hospital. He joined us to talk about the Oregon legislature’s bill. They are considering a ban on flavored tobacco and nicotine products.

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