After decades of public-health efforts, the rate of cigarette smoking among Americans is declining. But behind that progress lurks a disturbing trend: A growing number of people, especially young people, are turning to alternative tobacco products — everything from e-cigarettes and smokeless tobacco to cigars and the smaller cigarillos.
New research suggests these products could be fueling two distinct public-health concerns: one for minority and low-income communities, and the other for higher-income, predominantly white communities.
The study, published last month in the journal Nicotine and Tobacco Research, shows that the prevalence of different tobacco products varies significantly by neighborhood. Retailers in minority and low-income neighborhoods are 20 percent more likely to sell and advertise cigars and cigarillos, while those in higher-income and mostly white neighborhoods are nearly three times more likely to sell e-cigarettes.
The results are based on in-person store audits of nearly 800 tobacco retailers in New York City.
Daniel Giovenco, an author of the study and assistant professor of sociomedical sciences at Columbia University, said it is likely the trends are similar in other East Coast cities.
Though Philadelphia has not studied tobacco products by neighborhood, statistics on youth tobacco use and retailer density suggest the same patterns exist here.
“The fact that kids aren’t smoking cigarettes is deceptive,” said Cheryl Bettigole, director of chronic disease prevention for the Philadelphia Department of Public Health. “Total tobacco use is up.”
City data show that youth cigar use (including cigarillos) doubled from 2011 to 2015. Among black teens specifically, it nearly tripled. On the other hand, white teens were nearly twice as likely to have used vaping products.
“The difference is probably poverty,” Bettigole said.
Cigars and cigarillos, which are often sold for as little as 99 cents, are more accessible for people in low-income communities. E-cigarette kits cost about $30 to $60, and refill cartridges cost $7 to $10.
The tobacco industry has long been known to target low-income communities. In Philadelphia, nearly half of all tobacco retailers are in low-income neighborhoods, with three times as many in North Philadelphia as Center City, according to the health department.
“But no nicotine product is safe for teens,” Bettigole said. So the health department is using different strategies to curb each trend.
For e-cigarettes, the focus is on getting more information to parents, teachers, and school administrators. Many don’t know what e-cigarettes look like, Bettigole said. The most popular brand, Juul, could be mistaken for a thumb drive and creates a very small plume, making it difficult to notice.
“A lot of kids could be vaping at home or school, and people wouldn’t know,” she said. “If they’re looking for kids smoking in the bathroom, they won’t find it.”
It’s also important to make sure teens know that e-cigarettes contain nicotine, Bettigole said. One study found 63 percent of young people who used Juul products weren’t sure if they always contained the addictive substance. Research shows teens who use e-cigarettes are more likely to start smoking cigarettes.
But when it comes to cigars and cigarillos, “that’s a different strategy,” Bettigole said.
Educating teens about their harm is one component, especially since the fruit and candy flavors can make kids think they’re safe, she said. But a larger problem is “the rampant promotion of these products in corner stores.”
The health department has tried to address that through regulations passed in 2016 and recently upheld by City Council to decrease the density of tobacco retailers over time. Department data show this is starting to have an effect, with the number of tobacco retailers dropping about 18 percent over the last two years.
The fact that cigars and cigarillos are most prevalent in low-income minority communities is especially concerning because they are riskier products, said study author Giovenco. While no tobacco products are safe, combustible products deliver carbon monoxide, tar, and smoke, which are among the main drivers of cancer and lung disease.
“Buckling down on those products will have the best effect in terms of minimizing disparities,” Giovenco said.
The U.S. Food and Drug Administration recently announced plans to ban flavored cigars, but the proposal is expected to face strong industry opposition.
“We have to think about youth who don’t use the products yet but may be heavily influenced by advertising done at the point of sale,” Giovenco said.
Research shows repeated exposure to advertising makes kids more likely to try smoking and adults less likely to quit.
“These are not bad choices individuals make in a vacuum,” Bettigole said. “They are determined by the environments people live in.”