Author: Will Humble

AzPHA Members will be voting on the following Resolution at our September 28, 2017 Annual Meeting

Background and Summary

Tobacco use poses serious public health problems.  Over the past 50 years, tobacco control in the United States has led to an estimated 8 million fewer premature deaths. However, tobacco use continues to significantly affect public health, and more than 40 million Americans still smoke.

Nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age.  The parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices (electronic cigarettes).

In 2009, the Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration broad authorities over tobacco products but prohibited the FDA from establishing a nationwide minimum age to buy tobacco above 18.  The law directed the FDA to convene a panel of experts to conduct a study on the public health implications of raising the minimum age to purchase tobacco products and electronic nicotine delivery devices. 

At FDA’s request, the Institute of Medicine published a report entitledPublic Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products.  The report literature on tobacco use initiation, developmental biology and psychology, and tobacco policy and predicted the likely public health outcomes of raising the minimum legal age for tobacco products.

The report concluded that: “… Increasing the minimum age of legal access to tobacco products will prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan”.  The report also quantifies the immediate and long term accompanying public health outcome improvements.  The report concludes that there would be a 12% decrease in the prevalence of smoking among the cohort if the minimum age of purchase were moved to 21 years old from the current 18.

The analysis concluded that raising the minimum age to 21 will “… likely immediately improve the health of adolescents and young adults by reducing the number of those with adverse physiological effects such as increased inflammation and impaired immune functioning caused by smoking, as these could potentially lead to negative health consequences, including increased hospitalizations and lessened capacity to heal wounds. Adverse maternal, fetal, and infant outcomes—including preterm births, low birth weight, and sudden infant death—will also probably decrease due to reduced tobacco exposure in mothers and infants. Raising the minimum legal age will also lessen the population’s exposure to secondhand smoke and its associated health effects, both now and in the future.”

Over time, the report concludes that raising the minimum legal age for buying tobacco will likely lead to substantial reductions in smoking-related mortality observed for 30 years.  If the minimum legal age to purchase tobacco were raised to 21 nationally, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Several jurisdictions have already raised the minimum legal age to buy tobacco.  New York City raised the age to 21, in 2013.  Hawaii did it in 2015, becoming the first state to go to the 21 (the Hawaii Public Health Association was instrumental in that effort). California followed suit in 2016, and New Jersey and Oregon did so in 2017.  In Arizona, Douglas and Cottonwood have passed local ordinances restricting the sale of tobacco to people 21 and older.

Proposed AzPHA Resolution – September 2017

Whereas, the Arizona Public Health Association recognizes that tobacco use poses serious public health problems; and

Whereas, nearly all adults who have ever smoked daily first tried a cigarette before 21 years of age; and

Whereas, the parts of the brain most responsible for cognitive and psychosocial maturity continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine, including nicotine from electronic nicotine delivery devices; and

Whereas, increasing the minimum age of legal access to tobacco products and electronic nicotine delivery devices will prevent or delay initiation of tobacco use by adolescents and young adults and improve the health of Americans across the lifespan; and

Whereas, if the minimum legal age were raised to 21 in Arizona, there would be approximately 4,460 fewer premature deaths, 1,000 fewer deaths from lung cancer, and 840,000 fewer years of life lost for those born between 2000 and 2019;

Therefore, be it resolved that the Arizona Public Health Association supports raising the minimum legal age to purchase tobacco and electronic nicotine delivery devices in Arizona to 21 years old.

One of the things that’s most important to remember when you’re a public health practitioner is to look for your leverage.  By that I mean it’s important to set your priorities and use your resources in a way that creates the biggest long-term change with the resources that you have. 

Sometimes that means looking to statutory levers to improve health outcomes.  A good example of that is the Smoke Free Arizona Act, a voter initiative that banned tobacco smoking in workplaces, bars and restaurants.  By all accounts, it has had a profound impact on public health by limiting secondhand exposure and reducing smoking rates. High return on investment.

Sometimes a policy change does the trick.  For example, Maricopa County Department of Public Health worked hard with the community colleges to make their campuses smoke free.  Again, a smart move as it uses policy leverage to influence public health outcomes.

Sometimes it’s changing a rule or regulation.  A few years ago, the Arizona Department of Health Services overhauled their licensing regulations for health care institutions to make it easier to integrate acute care and behavioral health services in order to improve public health outcomes. 

Sometimes leverage means using your contracting authority as a payer of services to drive a public health intervention.  An example of that is the Executive Order issued last year directing AHCCCS to leverage contracts with their Medicaid managed care plans to limit the first fill of addictive prescription opioids to 7 days except for cancer, chronic disease and trauma.

Fortunately, the Substance Abuse and Mental Health Services Administration also recognizes that it has leverage in helping to reduce the opioid painkiller epidemic by releasing grant funds to states to implement interventions that reduce the number of people with Opioid Use Disorders and to reduce the number of opioid-related deaths. 

Earlier this year Arizona received a $24M Opioid State Targeted Response (STR) grant to implement a series of projects and interventions to stem the tide of opioid addiction and deaths.  AHCCCS is administering the grant, and is implementing prevention and treatment activities and working with other state agencies, Regional Behavioral Health Authorities, and contractors to increase access to Opioid Use Disorder treatment and coordinate and integrate care, recovery support services and prevention activities to reduce Opioid Use Disorders and opioid-related overdose deaths. 

The project plan includes developing and supporting state, regional, and local level collaborations and service enhancements to develop and implement best practices to comprehensively address the full continuum of care related to opioid misuse, abuse and dependency.

There are several core areas of work underway including:

• Increasing use of data-driven decision-making;

• Improving access, participation, and retention in comprehensive Medication Assisted Treatment services;

• Increasing prevention activities to reduce Opioid Use Disorder and opioid-related deaths; and

• Purchasing Rx drug drop boxes, toolkit trainings, technical assistance, and implementing Screening, Brief Intervention and Referral to Treatment (SBIRT) in targeted areas.

Of course, each of these elements are complex to implement and have all sorts of activities and collaborative projects underway.  If you’re interested on reading more you can explore their website materials including their Arizona Opioid STR Fact Sheet and the detailed 52-page Opioid STR Project Narrative Arizona.

Shana Malone from AHCCCS is the project lead for the STR grant and will be serving as the moderator in our “Payer” breakout sessions at our upcoming Fall Conference and Annual Meeting on September 28 entitledArizona’s Opioid Epidemic: Evidence – Interventions – Policy.  

In addition, our keynote speaker will be Jon Perez, Regional Administrator for SAMHSA who will share his perspective on where SAMHSA is headed regarding the epidemic.

We look forward to you joining us at this important and timely conference.  You can View our Agenda, register, and check our sponsorship opportunities on our www.azpha.org website.

Whether or not the federal government continues to pay the cost sharing subsidies for health insurance premiums under the ACA is causing consternation in the health insurance industry- big time.  That’s because the President has implied that he may direct the Executive Branch to stop paying the subsidies… and the subsidies are a big factor in setting premium rates.

Cost-sharing subsidies are paid directly to insurers by the fed’s to help cover out-of-pocket costs like deductibles and copayments for people that earn between 100 and 250% of the federal poverty level who buy a marketplace “silver plan”.  A Congressional Budget Office analysis published this week found that if the federal government stops paying the subsidies, the price for “silver plans” on the Marketplace would go up by an average of 20% next year.  

Interestingly, stopping the payments would also increase the federal budget deficit.  How could that be?

People earning up to 400% of the poverty level qualify for advance premium tax credits, which are different from the cost sharing subsidies.  Because health insurance premiums would increase by an average of 20% without the cost sharing subsidies, the federal government would be responsible for paying out more in advance premium tax credits because the premiums will be higher than they would have been had they continued the subsidies.

The CBO report found that the net result would be a $194 billion increase in the federal budget deficit over the next decade.

Just sayin’

8/17/17 Update: A White House Spokesperson is reported to have said yesterday that HHS will make the CSR payments in August, but declined to state whether future months’ CSR will be distributed.

Before leaving for their August Recess, the House Appropriations Committee passed an appropriations bill that will substantially cut funding for the CDC (a $163 million cut) and HRSA (a $397.62 million cut).  The bill would entirely eliminate HRSA’s family planning programs and decrease funding for key CDC immunization and tobacco control efforts. If these cuts go through as planned there would undoubtedly be reductions to our state’s grants from CDC and HRSA.

APHA issued a statement expressing its disappointment with the proposed cuts and urged the House to work in a bipartisan manner to restore the cuts.  The Senate Appropriations Committee won’t be taking any action on the budget bill until after the August recess.

107 years ago Arizona’s founders protected ordinary voters with a state constitution that guaranteed AZ residents the power of referendum, recall and initiatives.  Many of the bold moves to improve public health policy have come via citizens initiatives. A few examples are:

• The Smoke Free Arizona Act;
• The TRUST Commission for tobacco education and prevention;
• First Things First;
• Proposition 204 (from 2000) which extended Medicaid eligibility to 100% of federal poverty

This legislative session, Arizona’s legislative and executive branches passed and signed two bills (HB2244 and HB2404) that will impair our ability to use voter initiatives to improve public health in the future.  HB 2404 prevents signature gatherers from getting paid by the signature (for voter initiatives) and HB2244 changes the citizen’s initiative compliance standard from “substantial compliance” to “strict compliance” with the requirements for putting initiatives on the ballot.

More than a dozen AzPHA members circulated petitions for a non-partisan political committee called The Voters of Arizona that soiught to challenging these new limits on voter initiatives. Their goal had been to collect 75,000 signatures by this week in an effort to keep these new laws on hold (called a referendum) until the Arizona voters have an opportunity to weigh in during the November 2018 election.

Sadly, they recently canceled their Referendum effort to focus on a lawsuit- and they will not be using the signatures that team AzPHA gathered.  A Superior Court judge yesterday ruled that the court will not take action to stop implementation, but perhaps the case will be appealed.

Thank you team AzPHA for your participation in the signature gathering effort.  Sorry that our effort was in vain. 

Last week the federal Commission on Combating Drug Addiction and the Opioid Crisis released their Interim Report.  It’s just a 10 page report- so it’s not a huge commitment like most federal documents.  The main recommendation is to declare a national emergency under either the Public Health Service Act or the Stafford Act. 

Such a declaration would mobilize and provide the authority for federal agencies (e.g. HHS) to take additional policy steps to address the opioid epidemic and put pressure on Congress to focus on funding interventions.  The recommendations range from wonky kinds of things like the Institutes for Mental Diseases exclusion in Medicaid programs to broader issues like medically assisted treatment to state-type issues like state Naloxone distribution laws.  A final report is due later in the year. 

The President and HHS Secretary talked about the report at a media conference Tuesday morning.  The conference quickly turned to a discussion about North Korea.  Sadly, the President and Secretary announced that they don’t intend to take the Commission’s advice and declare a national emergency.

Last week the Arizona Attorney General certified new emergency rules established by the state health department to address the ongoing opioid epidemic.  The regulations apply to the facilities that the agency regulates like skilled nursing facilities, outpatient treatment clinics, hospitals and the like. 

Basically, the new regulations require the health care facilities that they license to adopt and implement policies and procedures relating to the prescribing and administration of opioids.  There are a few webinars scheduled to help facilities understand & implement the new regulations. The ADHS also began expanded blood screening for suspected opioid overdose cases in order to better characterize the epidemic.

There seems to be no end to the damage that opioid painkillers are having in our society.  The latest sign that the epidemic is causing widespread public health damage is highlighted in this abstract published in the American Journal of Public Health where the researchers found a huge increase in the number of drivers killed while under the influence of prescription painkillers. 

The prevalence of prescription opioids detected in fatally injured drivers analyzed in the six study states increased from 1.0% in 1995 to 7.2% in 2015.  The researchers looked at drivers who died within 1 hour of a crash in California, Hawaii, Illinois, New Hampshire, Rhode Island and West Virginia. Those states routinely test for drugs in people who have died in car crashes.

It’s no secret that Arizona and the U.S. are in the midst of an unprecedented opioid epidemic. Public health professionals, healthcare providers, managed care organizations and first responders have been implementing interventions to improve prescribing practices, better manage addiction, and quickly intervene during overdoses to mitigate the epidemic- yet the crisis has worsened. Policy makers in Arizona and across the nation, including the governor, have taken note and are prioritizing resources and policy directives to mitigate the crisis. 

Our Fall AzPHA Conference and Annual Meeting (September 28) will focus on this critical public health crisis.  The conference, titled Arizona’s Opioid Epidemic: Evidence – Interventions – Policy, will present recent Arizona opioid epidemic data and will explore interventions and future policy initiatives within public health, healthcare and managed care systems, first responders, state government, and county health departments to mitigate the epidemic. 

Sign up today at www.azpha.org and take advantage of our early bird registration rates.

 SB 1080 kicks into action next week… and Arizona will finally join the 47 other states that have laws on the books restricting the use of smart phones while driving.  It’ll ban brand-new teen drivers from using their smart phone while driving for the first 6 months of their license (if they’re under 18).  Using the phone in an emergency will still be OK.  Tickets can only be issued if the driver committed another violation.  Prior to this, the only other limitation in AZ to this kind of distraction applied to school bus drivers. 

We supported SB 1080 because of the evidence that this would be an effective public health intervention.  Data in this NHTSA summary document that shows that teens are the largest age group reported as distracted at the time of fatal crashes and have the highest prevalence of cell phone use while driving.  A 2003 study of US crash data called Driver distraction and crashes: An assessment of crash databases and review of the literature found that driver distraction is a contributing factor in 8% to 13% of crashes including cell phone distractions of between 1.5 to 5%.

Between now and our Fall Conference & Annual Meeting on September 28, our Public Health Policy Committee will be discussing proposing a member Resolution at the Conference that will urge Arizona lawmakers to go further and put in place a law restricting the use of cell phones while driving for all ages of drivers- not just minors in their 1st 6 months of driving.

The Governor in his signing statement for SB 1080 suggested he might be supportive of extending the restrictions to all minors (not just minors in their 1st 6 months of driving).  In part, the signing statement said:

“…Distracted driving is a growing problem in Arizona and nationally. I generally believe that public awareness and education campaigns are a more effective remedy to prevent accidents and save lives than blanket laws that let politicians feel like they’ve checked the box, and then move on to the next issue. For that reason, I am skeptical of large-scale bans on texting while driving — I just don’t think they work. But this bill is different. The state already regulates a number of things when it comes to early driving by teens. And for good reason. For our youth, these laws can act as a teacher. In fact, I’d be in favor of a law that goes further, banning texting while driving for all minors.  Driving is a privilege for our youth, and they are still the responsibility of their parents, financially and otherwise, before the age of 18.”

This signing statement suggest that we have some executive branch support for extending the restrictions to at least all drivers under 18.  Not the full intervention (restrictions for all ages) as is in the case in most other states, but a start.

July 28, 2017

The Honorable John McCain

RE: Thank You

Dear Senator McCain:

I write on behalf of myself and the membership and Board of the Arizona Public Health Association (AzPHA) to thank you for your statesmanship.

Throughout the debate in the U.S. Senate regarding the repeal and replacement of the Patient Portability and Affordable Care Act you have been the voice of reason and a primary advocate for ensuring that this important policy decision includes a cross section of perspectives. 

Your commitment to that principle is a testament to your fidelity toward developing public policy that will work for the people of Arizona.

Thank you for your service to the people of Arizona and for your unwavering commitment the United States of America.

Sincerely,

Will Humble, MPH

Executive Director,

Arizona Public Health Association