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The NATION S HEALTH A PUBLICATION OF THE AMERICAN PUBLIC HEALTH ASSOCIATION

The official newspaper of APHA | Read this full issue online Aug. 1 at www.thenationshealth.org August 2016

Attacks injure 1,500 people over two years WHO: Emergency health workers, facilities intentionally targeted

ARLIERTHIS YEAR, Doctors Without Borders

wanted to reopen a clinic in southern Syria

that had been destroyed during bombings. In

response, local residents cam e out to protest — with health facilities being intentionally attacked, they feared that a new

clinic would make the community a target for m ore violence

“T his k in d o f b o m b in g ta rg e ts th e last sp a c e s o f h u m a n ity in w a r,” M arine B u isso n n iere, s e n io r c o o r­ d in a to r a t D o cto rs W ithout B orders, to ld The Nation's Health. “Clearly, in certain areas, it’s a b o u t m ak in g

life im p o ssib le fo r p e o p le . W h e n th e m edical infra­ s tru c tu re is d e stro y e d a n d it’s co m p letely o r p artially o u t o f service, it n o t only

See HEALTH ATTACKS, Page 2 6

Protecting youth

States, cities raising their minimum age for tobacco sales to 21

N EW measures that can pro­

tect health and

prevent potential smokers from lighting up are catching

fire across the country. At the center of that work is

a tactic that is growing in popularity: reevaluating the

age at which consumers

can purchase tobacco.

O n J u n e 9, California b ecam e th e seco n d state to restrict th e sale o f tobacco p ro d u cts to th o se 21 years o ld a n d u p , an increase from its form er 18-and-up law. For th e first tim e, th e state in clu d ed electronic cigarettes a n d o th e r vaping p ro d u cts in its definition o f tobacco p ro d u cts as well. T he restrictions w ere sig n ed into law by Gov. Jerry B row n o n May 4.

T he law is m aking

See TOBACCO, Page 14

P h o to b y W a k il K ohsa r, c o u rte s y A F P /G e tty Im a g e s

A wounded staff member o f Doctors W ithout Borders receives treatment Oct. 6 following a U.S. airstrike on a Kunduz, Afghanistan, hospital. That attack mistakenly targeted a hospi­ tal, according to U.S. officials. But 62 percent o f attacks on health workers and facilities during emergencies are intention­ ally aimed a t health targets, a new W H O analysis finds.

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Middle-school students at Knowledge is Power Program Acad­ emy take notes in October 2 0 0 0 in N ew York City. The amount and quality o f education children receive can influence how healthy they are as adults and how long they live.

Exploring social determ inants o f health Education attainment linked to health throughout lifespan Second in a series on the role o f social determinants of health. Visit www.thenationshealth.org/sdoh for related content.

I SSUES SUCH AS equal access to affordable housing and incom e redistribution may have their political foes, but Anthony Iton said he is hard-pressed to find anyone against high-quality education for everyone.

“Education is th e single m ost im p o rtan t m odifiable social d e term in an t o f h e a lth ,” Iton, MD, JD, MPH, sen io r vice p re sid e n t for healthy com m unities at th e California E n d o w m en t an d an APHA m em ber, to ld The Nation's Health. “Incom e a n d ed u catio n are th e

tw o big o n es th a t correlate m o st strongly w ith life exp ectan cy a n d m ost h e alth status m easu res.”

Social d eterm in an ts o f health are th e social, eco ­ nom ic a n d physical envi-

See E D U C A TIO N , Page 18

P h o to b y D re w A n g e re r, c o u r te s y G e tty Im a g e s

Mass shooting in Florida spurs public health to call fo r action on US gun violence epidemic Mourners hold candles in Orlando, Florida, in June fol­ lowing a shooting at a nightclub that killed 49. APHA called for measures to end such violence. See Page 2.

California, Hawaii raise tobacco-buying age PHOHIBITM for S A tih h u w w .

U M D IR 21; Cigarettes, cigars, c h e w in g tobacco, powdered

to b a c c o , o th e r tobacco products o r e le c tro n ic cigarettes

and PROHIBITED for SALE to PERSONS

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Photo courtesy Stephanie Vallejo

A smoke shop in lower M anhattan dis­ plays a sign in June declaring N ew York City's tobacco restrictions. States and cities are passing laws and regulations that prevent people younger than 21 from buying tobacco products.

T O B A C C O ,

Continued from Page 1

waves, as the state has 240.000 people ages 18 to 20 who smoke, said April Roeseler, MSPH, branch chief of the California Tobacco Control Program with the California Depart­ ment of Public Health. And 34.000 people die each year from smoking-related diseases in the state.

A 2014 U.S. surgeon general report, “The Health Consequences of Smoking: 50 Years of Progress,” showed that 98 percent of U.S. smokers started smok­ ing by age 26, and 87 per­ cent started before they turned 18. The report sug­ gested several measures, such as increasing taxes on tobacco products, to keep them out of young people’s hands. With substantial sci­ ence on its side, the 21- and-up movement is picking up steam.

To ready California’s 34.000 licensed tobacco retailers for the restrictions, the department created and distributed educational materials, including an ID

checking guide, a fact sheet, window clings and other signage. Roeseler said that while retailers had many questions about the restrictions at first, the new law is easier to enforce than the previous 18-and- up law: Drivers’ licenses for those under 21 are vertical, so they are easy to spot.

“In California, the ID checking just got so much simpler,” Roeseler told The Nation's Health. “We are harmonizing this law with the alcohol product laws. They already know how to check for alcohol.”

California’s law is not the first of its kind: Hawaii enacted the first statewide 21-and-up tobacco law on Jan. 1. Spurred by evidence that such measures can help stem youth smoking, more than 170 municipali­ ties nationwide have already enacted similar laws as of July.

Needham, Massachu­ setts, was the first city in the U.S. to raise its tobacco purchasing age to 21, grad­ ually from 2005 to 2008. In subsequent youth risk behavior studies,

researchers found that the city’s teen smoking rates dropped by 50 percent, said Rob Crane, MD, presi­ dent of the Preventing Tobacco Addiction Founda­ tion, authors of the Tobacco 21 project.

“Others had dropped some (over the same time period), but Needham just jumped off the page,” Crane, an APHA member, told The Nation's Health. “There was a two-thirds reduction in kids who smoked every day.”

Once the results of Needham’s increase were published, other localities started to enact their own laws. In Massachusetts, more than 100 cities and towns, including Boston, have raised their tobacco purchasing age to 21. Other major cities, including New York City, Cleveland, Chicago and Kansas City, Missouri, have done the same. Massachusetts is con­ sidering a state-wide increase, and legislation has been passed by New Jersey legislative bodies.

Even though the national legal tobacco pur­ chasing age is 18 — thus not allowing most teens to use the products —21-and- up laws protect younger teens, according to a 2015 Institute of Medicine report. “Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products” con­ cluded that the increase has the greatest impact on teens ages 15 to 17.

“The parts of the brain most responsible for deci­ sion making, impulse con­ trol, sensation seeking and susceptibility to peer pres­ sure continue to develop and change through young adulthood, and adolescent brains are uniquely vulner­ able to the effects of nico­ tine,” the report said. “In addition, the majority of underage users rely on social sources, like family and friends, to get tobacco.”

John Schachter, director of state communications at the Campaign for Tobacco- Free Kids, said eliminating the chance of youth getting tobacco products from their friends can “really make an impact.”

“If we can keep you from smoking when you’re a kid, then the odds are incredibly high that you

will never smoke,” Schachter told The Nation's Health.

The numbers add up: According to the IOM report, if the minimum legal age were raised to 21 nation­ ally, estimates show there would be 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer and 4.2 mil­ lion fewer years of life lost for people bom between 2000 and 2019.

Public health is taking a strong stance in making sure increased tobacco purchasing age laws are enforced. In Boston, the city’s board of health enacted its 21-and- up tobacco regulation in December. Nikysha Hard­ ing, MPH, director of the Boston Public Health Com­ mission’s Tobacco Preven­ tion and Control Program, and three regulators work to enforce the regulation, as well as Boston’s smoke- free workplace regulations. For the city’s 21-and-up regulation, Harding’s team had 60 days to educate retailers, via mailings and educational visits to the city’s 830 tobacco retailers, before it started to do com­ pliance inspections, for both signage and actual sales of the products, she told The Nation's Health.

Part of strong enforce­ ment is knowing what to look out for, said Margaret Reid, RN, MPA, director of the Division of Healthy Homes and Community Supports with the Boston Public Health Commission. Boston started regulating e- cigarettes in 2011, but while those are gaining in popularity across the coun­ try — and in Boston, where 5 to 6 percent of teens report using the products — the city’s youth are more likely to buy small, flavored cigars, at 21 percent.

Nationally, nearly twice as many teens report using e-cigarettes than those who report using cigarettes, according to the Centers for Disease Control and Pre­ vention. But 73 percent of high schoolers and 56 per­ cent of middle schoolers who had used a tobacco product in the past 30 days had used a flavored one.

“The biggest impact would be if we got rid of the cigars,” Reid told The Nation's Health. “At the same time we passed the 21 law, we passed a flavor regulation.”

The California Depart­ ment of Public Health is working on a similar pro­ gram to help retailers com­ ply with the state’s new law, including age-of-sale warning signs, window clings for shops and tip- sheets to help clerks check identification.

Public health’s enforce­ ment of 21-and-up regula­ tions are more than advocates walking the walk — they are opportunities to promote efforts supported by the public. June research from the Univer­ sity of North Carolina at Chapel Hill and East Car­ olina University showed that most adults support increasing the minimum legal age for tobacco prod­ uct sales, and that most support increasing the age to 21, rather than 19 or 20.

“It’s surprisingly well received by local politicians and thought leaders” as well as voters, Crane told The Nation's Health. “The public both understands and supports 21. It’s not a difficult sell.”

For more on 21-and-up tobacco laws and regula­ tions, visit www.tobacco21. org. For more on APHA’s tobacco advocacy and other resources, visit www.apha. org/tobacco. ■

— Lindsey Wahowiak

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