Regulating nicotine is a cat and mouse game

 Attempts to regulate (and tax) cigarettes and related nicotine-addicting products are a cat and mouse game. Many laws regulate "tobacco," "nicotine," or "flavorings," and all of these have close substitutes that might fall outside of the law, such as synthetic (non-tobacco) nicotines, and coolants other than menthol that might not be considered flavorings.  California legislators are amending laws to fill those gaps.

California’s Visionary Tobacco Bill—Will the FDA Follow?  by Sven E. Jordt, PhD1,2; Sairam V. Jabba, DVM, PhD, JAMA, 2024

"The state of California has been a consistent leader in tobacco control, with one of the lowest smoking rates in the nation. On September 28, 2024, Gavin Newsom, governor of California, signed Assembly Bill 3218, which will further strengthen tobacco control in the state.1 The signed legislation will close 2 loopholes left open by California’s 2022 legislation that restricts sales of most flavored tobacco products, including menthol cigarettes and youth-appealing flavored e-cigarettes. The tobacco industry immediately exploited these loopholes to continue selling flavored tobacco products in the state. Similar loopholes remain in the legislation of other states and in federal regulations. Are other states and the US Food and Drug Administration (FDA) set to follow California’s example, or will California’s advance result in an even wider divide in tobacco control in the US?

...

"The tobacco industry argued that California’s flavor ban does not apply to non-menthol cigarettes because the cooling sensations imparted by odorless cooling agents do not represent a banned “characterizing flavor,” meaning a distinguishable taste, aroma, or both. However, current scientific definitions of the term flavor, also adopted by the flavor chemical industry, include the entire range of sensations perceived during product consumption, including physical traits such as cooling sensations.4 In California’s new bill, legislators adopted this definition, clarifying the term characterizing flavor to include “a cooling sensation distinguishable by an ordinary consumer during the consumption of a tobacco product.”

...

"The second loophole addressed by California’s new bill pertains to emerging e-cigarette products in which nicotine is replaced with chemical analogues such as 6-methyl nicotine.5,6 In both state and federal regulatory statutes, a tobacco product is narrowly defined as being derived from tobacco or nicotine. Manufacturers claim that this definition does not apply to products containing 6-methyl nicotine, because its chemical formula differs from that of nicotine. Manufacturers advertise that FDA review of their products is not required, flavor bans do not apply, and that the products are exempt from tobacco taxes, offering them in youth-appealing flavors such as rainbow fruit, blue razz ice, or strawberry apple lemon.5,6 California’s new legislation closes this loophole by extending the legal definition of nicotine, adding “and includes nicotinic alkaloids and nicotine analogs.”

Gambling as a public health issue (Lancet)

 Here's a warning about gambling from the Lancet:

The Lancet Public Health Commission on gambling   October 24, 2024

"Executive Summary: Gambling is not an ordinary kind of leisure; it can be a health-harming, addictive behaviour. The harms associated with gambling are wide-ranging, affecting not only an individual's health and wellbeing, but also their wealth and relationships, families and communities, and deepening health and societal inequalities. By examining these harms, the Commission unveils the intersections between the social, commercial, legal, and political determinants of health. The Commission sheds light on the increasingly complex commercial ecosystem for gambling and its digital transformation which offer unparalleled capacities for gambling. The Commission calls on governments and policymakers to treat gambling as a public health issue—just as for other addictive and health-harming commodities, such as alcohol and tobacco—and provides recommendations to prevent and mitigate the broad range of harms associated with gambling.

Oregon ends decriminalization of drugs, continues to experiment

 Here's the story in the Washington Post

Hard drugs illegal again in Oregon as first-in-nation experiment ends

"Sunday marks the end of an experiment that drug-reform advocates called a pioneering and progressive measure to better help people. Oregon legislators reassessed Measure 110 this year and decided to again make it a misdemeanor to possess a minor amount of drugs — essentially anything besides marijuana. Selling and manufacturing illicit drugs was and is still illegal in Oregon.

...

"On Feb. 29, the Oregon House of Representatives voted 51-7 to recriminalize drugs, with bipartisan support. The Oregon Senate did the same by a vote of 21-8 the next day. Gov. Tina Kotek (D) signed recriminalization into law April 1.

"Data shows how the [decriminalization] law was used in practice. The Oregonian reported that circuit court data collected by the Oregon Judicial Department from when the law went into effect Feb. 1, 2021, to Aug. 26, 2024, showed that the state’s circuit courts imposed just under $900,000 in fines under the measure but collected only $78,000 of those fines.

"The conviction rate for the 7,227 people cited was 89 percent, with most of those because people didn’t show up to court, the Oregonian reported. Data showed that 85 people completed the substance abuse screening in lieu of a conviction.

"The most commonly cited drug was methamphetamine, accounting for 54 percent of citations. Fentanyl and other Schedule II drugs, the Oregonian reported, ranked second at 31 percent."

#########

And here's the Guardian's coverage:

Oregon: drug possession to be a crime again as decriminalization law expires. First-in-nation trial comes to an end, as new law gives those caught with hard drugs option of charges or treatment

"The new recriminalization law, HB4002, will give those caught with illicit drugs – including fentanyl, heroin and meth – the choice to either be charged with possession or treatment, which includes completing a behavioral health program and participating in a “deflection program” to avoid fines.

"Personal-use possession would be a misdemeanor punishable by up to six months in jail. It aims to make it easier for police to crack down on drug use in public and introduced harsher penalties for selling drugs near places such as parks.

"The recriminalization law encourages, but does not mandate, counties to create treatment alternatives to divert people from the criminal justice system and toward addiction and mental health services."

Dealing with the harms of harm reduction

 Some of the jurisdictions that pioneered harm reduction measures to reduce drug overdose deaths are dealing with problems of public drug use.

The NYT has this story:

Bold Experiment or Safety Risk? Canada Is Divided on How to Stop Drug Deaths.  British Columbia’s partial retreat from an experiment to decriminalize drug possession reveals a political shift in Canada over combating the opioid crisis. By Vjosa Isai

"decriminalization, a policy introduced as a way of alleviating the opioid crisis, has instead been blamed for deepening it. Scenes of people openly using drugs on city streets have led several elected leaders, other critics and even some supporters to say that decriminalization is contributing to a sense of public disorder.

...

"In May, the federal government, which regulates controlled substances, approved a provincial request to reverse the policy and again make public drug use and possession in British Columbia a crime.

"The shift came not long after a similar experiment in Oregon ended in April, following a vote by the state Legislature to re-criminalize drugs amid soaring overdose deaths.

...

"practices, collectively known as harm reduction, are driven by a strategy meant to keep drug users alive rather than getting them to quit.

"Services that fall under this category include needle exchanges, safe injection sites, the distribution of naloxone, a drug used to reverse overdoses, and the testing of street drugs to reveal the presence of any other harmful substances.

...

"Safe injection sites, along with decriminalization, are among the harm reduction measures that have come under attack from critics who claim they lead to crime and perpetuate a cycle of drug abuse.

"In British Columbia, critics say the province should not have pursued decriminalization without also bolstering other services that drug users need, like housing and addiction treatment.

...

"Many residents, he added, complained of increased drug use on public transit, near schools and in entrances to businesses.

...

"Some frontline workers say harm reduction practices are being targeted to score political points at a time when death tolls are reaching new highs and different approaches are necessary to keep users alive."

Do e-cigarettes lead to combustables? (Two NBER papers).

 Two NBER working papers on flavor bans for e-cigarettes, and possible migration to combustables:

The Effect of E-Cigarette Flavor Bans on Tobacco Use. by Chad D. Cotti, Charles J. Courtemanche, Yang Liang, Johanna Catherine Maclean, Erik T. Nesson & Joseph J. Sabia  NBER working paper 32535, DOI 10.3386/w32535,  June 2024

Abstract: Advocates for sales restrictions on flavored e-cigarettes argue that flavors appeal to young people and lead them down a path to nicotine addiction. This study is among the first to examine the effect of state and local restrictions on the sale of flavored electronic nicotine delivery system (ENDS) products on youth and young adult tobacco use. Using data from the State and National Youth Risk Behavior Surveys, we find that the adoption of an ENDS flavor restriction reduces frequent and everyday youth ENDS use by 1.2 to 2.5 percentage points. Auxiliary analyses of the Behavioral Risk Factor Surveillance System show similar effects on ENDS use for young adults ages 18-20. However, we also detect evidence of an unintended effect of ENDS flavor restrictions that is especially clear among 18-20-year-olds: inducing substitution to combustible cigarette smoking. Finally, there is no evidence that ENDS flavor restrictions affect ENDS use among adults aged 21 and older or non-tobacco-related health behaviors such as binge drinking and illicit drug use.

########

Comprehensive E-cigarette Flavor Bans and Tobacco Use among Youth and Adults by Henry Saffer, Selen Ozdogan, Michael Grossman, Daniel L. Dench & Dhaval M. Dave NBER working paper 32534, DOI 10.3386/w32534,  June 2024

Abstract: The vast majority of youth e-cigarette users consume flavored e-cigarettes, raising concerns from public health advocates that flavors may drive youth initiation into and continued use of e-cigarettes. Flavors drew further notice from the public health community following the sudden outbreak of lung injury among vapers in 2019, prompting several states to enact sweeping bans on flavored e-cigarettes. In this study, we examine the effects of these comprehensive bans on e-cigarette use and potential spillovers into other tobacco use by youth, young adults, and adults. We utilize both standard difference-in-differences (DID) and synthetic DID methods, in conjunction with four national data sets. We find evidence that young adults decrease their use of the banned flavored e-cigarettes as well as their overall e-cigarette use, by about two percentage points, while increasing cigarette use. For youth, there is some suggestive evidence of increasing cigarette use, though these results are contaminated by pre-trend differences between treatment and control units. The bans have no effect on e-cigarette and smoking participation among older adults (ages 25+). Our findings suggest that statewide comprehensive flavor bans may have generated an unintended consequence by encouraging substitution towards traditional smoking in some populations.

Nicotine is hard to ban: Juul wins a reprieve from the FDA, and illegal vapes flood the market

 Here are two stories by Jennifer Maloney at the WSJ:

FDA Rescinds Juul Ban, Opening Door for Federal Clearance. E-cigarette maker’s products have stayed on market pending appeal of 2022 ban.. By  Jennifer Maloney

"The Food and Drug Administration rescinded its 2022 ban on Juul Labs’s e-cigarettes. The agency hasn’t yet reached a final determination on whether they can stay on the U.S. market, but the move opened the possibility for federal clearance.

The FDA in 2022 ordered Juul to halt its sales, then stayed the order pending the vaping company’s appeal. The agency said Thursday that it was placing Juul’s products back under scientific review, essentially moving them back to their regulatory status before the ban. 

...

"Juul’s products remain on the market. The FDA didn’t give a timeline for a final decision on whether they can stay there. Juul is the No. 2 e-cigarette maker in the U.S.

Juul and other e-cigarette manufacturers in 2020 were required to submit scientific research to demonstrate that their vaping products exposed users to fewer carcinogens than cigarettes and that the benefit of helping adult smokers switch to a safer alternative outweighed the potential harm of hooking young people on nicotine.

...

"The FDA ban, though it was quickly put on hold, sent Juul into a financial tailspin. The company narrowly averted bankruptcy. Juul has since submitted next-generation vaping products for FDA review. They aren’t yet for sale in the U.S."

###########

U.S. Pledges Crackdown on Illegal E-Cigarettes. FDA and DOJ form task force to go after fruity, disposable vapes flooding the market.  By Jennifer Maloney

"Big tobacco companies and their critics agree on at least one thing: The illegal, fruit-flavored, disposable vapes that are popular among teenagers have flooded the U.S. market and federal regulators haven’t done enough to stop it.

"The Food and Drug Administration and Justice Department said Monday they are stepping up enforcement by forming a multiagency task force to go after the illegal distribution and sale of e-cigarettes.

"Disposable vaping devices, almost none of which are authorized for sale by the FDA, represent more than 30% of U.S. e-cigarette sales in stores tracked by Nielsen, according to an analysis by Goldman Sachs. Many of them are imported from China. Breeze Pro and Elfbar, both of which were ordered off the market last year by the FDA, remain the top two disposable e-cigarette brands in the U.S.

"Njoy is the only disposable vaping brand authorized for sale by the FDA." 

Marijuana policy and use in the U.S., 1979-2022, by Jonathan Caulkins, in Addiction

 Here's a paper forthcoming in the journal Addiction:

Changes in self-reported cannabis use in the United States from 1979 to 2022, by Jonathan P. Caulkins, published online 22 May 2024, https://doi.org/10.1111/add.16519 

"Abstract

Background and aims: Multiple countries are considering revising cannabis policies. This study aimed to measure long-term trends in cannabis use in the United States and compare them with alcohol use.

Design and setting: Secondary analysis of United States general population survey data.

Participants: The national surveys had a total of 1 641 041 participants across 27 surveys from 1979 to 2022.

Measurements: Rates of use reported to the US National Survey on Drug Use and Health and its predecessors are described, as are trends in days of use reported. Four milepost years are contrasted: 1979 (first available data and end of relatively liberal policies of the 1970s), 1992 (end of 12 years of conservative Reagan-Bush era policies), 2008 (last year before the Justice Department signaled explicit federal non-interference with state-level legalizations) and 2022 (most recent data available).

Findings: Reported cannabis use declined to a nadir in 1992, with partial recovery through 2008, and substantial increases since then, particularly for measures of more intensive use. Between 2008 and 2022, the per capita rate of reporting past-year use increased by 120%, and days of use reported per capita increased by 218% (in absolute terms from the annual equivalent of 2.3 to 8.1 billion days per year). From 1992 to 2022, there was a 15-fold increase in the per capita rate of reporting daily or near daily use. Whereas the 1992 survey recorded 10 times as many daily or near daily alcohol as cannabis users (8.9 vs. 0.9 M), the 2022 survey, for the first time, recorded more daily and near daily users of cannabis than alcohol (17.7 vs. 14.7 M). Far more people drink, but high-frequency drinking is less common. In 2022, the median drinker reported drinking on 4–5 days in the past month, versus 15–16 days in the past month for cannabis. In 2022, past-month cannabis consumers were almost four times as likely to report daily or near daily use (42.3% vs. 10.9%) and 7.4 times more likely to report daily use (28.2% vs. 3.8%).

Conclusions: Long-term trends in cannabis use in the United States parallel corresponding changes in cannabis policy, with declines during periods of greater restriction and growth during periods of policy liberalization. A growing share of cannabis consumers report daily or near daily use, and their numbers now exceed the number of daily and near daily drinkers."

Daily and Near Daily (DND) use

...

"That is still not as high as for cigarettes. The 2022 NSDUH survey finds that 58.7% of PM ["Past Month"] cigarette smokers smoked ‘daily’—defined as ‘smoked one or more packs of cigarettes per day’ [8]. Therefore, there are more daily cigarette smokers than DND PM marijuana users (24.1 vs 17.7 million). 3 Still, patterns of marijuana consumption have shifted from being like alcohol to being closer to cigarette use. It is also no longer a young person's drug. In 2022, people 35 and older accounted for (slightly) more days of use than did those under the age of 35."

Gambling addiction

 When gambling opportunities were rare and often illegal in the U.S., gambling addiction was a less visible problem than it is becoming today.

Here's a story from the NYT, about a sports news broadcaster who went to prison after pursuing fraudulent schemes to raise money to pay his gambling debts:

Saturday Mornings With the ‘Voice of Problem Gambling’  Craig Carton, the bombastic sports broadcaster, shows a different side on a weekly show that focuses on the stories of gambling addicts like himself.  By Zach Schonbrun

“There’s a preconceived notion of the kind of guy or gal that is a gambling addict,” Mr. Carton said. “And now you’re listening to schoolteachers and doctors and lawyers and first responders and librarians — normal people who went down a road never having any expectation of having a problem.”

...

"The show’s arrival coincided with an explosion in gambling as 38 states legalized sports betting. The National Council on Problem Gambling estimates that 1 percent of U.S. adults meet the criteria for a gambling disorder, and that an additional 2 to 3 percent are “experiencing problems” due to “moderate” gambling behavior.

"That suggests that most Americans are capable of gambling responsibly, and Mr. Carton believed he could, too. He had gambled his whole life.

...

"The incident that he says “accelerated” his descent into problematic gambling didn’t come until 2014, when Mr. Carton, in his typical bombastic fashion, proclaimed on the air with Mr. Esiason that he could take $10,000 and turn it into $25,000 overnight playing blackjack. To his surprise, Mr. Esiason handed him $10,000 in cash a few weeks later during a special taping at the Borgata, a casino hotel in Atlantic City. Mr. Carton backed up his boast, winning $80,000 playing blackjack.

"But the seeds of compulsion were planted. Almost immediately, Mr. Carton began receiving calls from listeners eager to test his magic touch. Soon he was being handed duffel bags of cash and ushered into private parlors at casinos.

“That just gave me access to more money,” Mr. Carton said. “And when you’re already going down a road where you want to gamble all the time anyway, if you’re betting $100 a hand, and now you’re betting $1,000 a hand, you can’t go back to $100. It just became progressive.”

He won a lot, but at the rate he was going, the odds weren’t in his favor. Debts snowballed; then the federal agents arrived. The judge at his sentencing, Colleen McMahon, introduced herself to him as “Colleen from New York — first time, long time,” echoing a common phrase used by callers into WFAN’s shows. She then told Mr. Carton, “You have indeed descended into a hell of your own making.”

"Mr. Carton’s public disgrace resonated with Dan Trolaro, a former investment adviser for Prudential who spent four and a half years in state prison in New Jersey for stealing $1.9 million in client money. He had committed the thefts to feed an online gambling addiction.

"Mr. Trolaro went on to work for the nonprofit Council on Compulsive Gambling of New Jersey, which is the home of the 1-800-GAMBLER addiction hotline.

...

"On a recent Monday evening, Mr. Carton stood with a microphone in a lecture hall at the LaPenta School of Business at Iona University in New Rochelle, N.Y. For an hour, he implored the 40 or so students in attendance not to follow in his footsteps.

“I’m not here to tell you not to gamble,” he said. “But I am here to tell you that, if you allow it, gambling can ruin your life.”

"The event was presented by FanDuel, the largest online sports book in the country. Mr. Carton is on his second contract as the company’s paid ambassador for “responsible gaming,” a relationship that, he admits, carries the appearance of conflict with his efforts to combat addiction. He insists the arrangement allows him to carry his message to a wider audience."

#####

See also Gamblers Anonymous  https://www.gamblersanonymous.org/ga/

Gambling in video games--entry level gambling for minors?

 In-game gambling for video game tools has become an unregulated form of online gambling that may provide minors with their first gambling fix...

The Guardian has the story:

‘It’s rotting young people’s brains’: the murky world of gambling in video games. In-game purchases of bonus items have long been available. But now gamers are being lured into casino-style betting to win them.  by Rob Davies

"For the uninitiated, “skins” are virtual items within a computer game that can be bought for money, or won as a reward for gameplay. Skins might be devastating weapons, a snazzy uniform for a character or – in a football game – a player who could be the missing link to complete an all-conquering team.

...

"Typically, skins are contained in “loot boxes” or “cases”, which gamers pay small sums for without knowing what they will get.

"Loot boxes have already become a lightning rod for controversy due to their gambling-style mechanism, although the UK government has refused to recognise them as gambling products.

"While skins can be found in loot boxes, they can also be bought in the online marketplace operated by online gaming platform Steam – the medium through which many games such as CS:GO are played.

"Through that marketplace, skins can also be transferred between players and into the game. There, competitors can use them to gain an advantage, or just for cosmetic effect.

"What bothered Jeff [a professional video gamer], however, was not so much the loot boxes or the skins in themselves but another phenomenon that they have spawned: skins gambling.

'This works like any other casino. You load up your account with funds, place a bet, watch the graphics spin and either win or lose.

"The big difference in this case is that the casino taking your bet has no gambling licence and, in some cases, no reliable mechanism to stop under-18s getting their first taste of gambling – via an online ecosystem that is, to many parents, a total mystery

...

"Some skins carry enormous price tags in the real world. One website that tracks skin prices values a “Gungnir” sniper rifle, available in the CS:GO game, at more than $18,000. A knife – a “factory new, case-hardened Karambit, pattern 387 (blue gem)” – is reputedly the most expensive CS:GO skin in history, attracting a $1.5m offer that its owner turned down. Further down the scale, guns, outfits, stickers and knives sell for hundreds of dollars.

...

"it can be literally child’s play to turn skins into hard cash. To use sites such as KeyDrop, players must have an account on the Steam platform, which was created by the maker of CS:GO, US-based game developer Valve.

"Steam has its own marketplace, where gamers can trade skins. Gift cards to help gamers buy such skins are big business at Christmas, an obvious choice for anyone with a relative or a friend who loves nothing more than spending hours in front of a game.

"The Steam marketplace is self-contained, at least initially. You can load cash into your wallet and use those funds to buy skins from Steam or from other gamers. You cannot, however, withdraw the funds. In ­theory, therefore, the marketplace is not somewhere you could properly cash out any winnings.

"But an industry has sprung up: third-party marketplaces such as SkinBaron and Skinwallet, where you can sell skins, including those won on gambling sites, for real money."

The NFL embraces sports gambling for fans but not for players

 The Superbowl is in Las Vegas, and gambling is being embraced by the NFL for fans, but not for players and other NFL employees.

The NYT has the story:

N.F.L.’s Rapid Embrace of Gambling Creates Mixed Signals. The league is pushing to popularize and benefit from sports betting while still trying to guard against the potential pitfalls for its players, employees and fans.  By Jenny Vrentas

"Since the Supreme Court struck down, in 2018, a federal law that effectively banned sports betting outside Nevada — a prohibition once backed by the N.F.L.’s commissioner, Roger Goodell — the N.F.L. has embraced the gambling industry. It has forged partnerships reportedly worth nearly $1 billion over five years with sports betting companies, and permitted a sports book to operate inside one of its stadiums. Now it even has a team in Las Vegas, which the league shunned for decades because any affiliation was seen as a threat to the integrity of the game.

"Yet the embedding of sports gambling so quickly into the culture of the league has resulted in jarring contradictions. The N.F.L. is pushing to popularize and benefit from sports betting while still guarding against the potential pitfalls that it long condemned. While the league donates money to promote responsible gambling, its broadcasts are peppered with advertisements for sports betting companies. The N.F.L. is part of a growing apparatus that encourages casual fans to regularly place wagers on games, while punishing league employees — most notably players — who might do the same.

...

"Americans legally wagered more than $115 billion on sports in 2023, according to the American Gaming Association, the national trade group for the gambling industry. Nearly 25 million more Americans bet on sports last year than in 2018, the group said, and the number of states where betting on sports is legal will reach 38 this year.

...

"[A] report projected that around $1.5 billion would be legally wagered on next Sunday’s Super Bowl, more than 1 percent of the money bet legally on all sports last year.

...

"n 2021, the year the N.F.L. struck deals with its three sports book partners, it gave the National Council on Problem Gambling a three-year, $6.2 million grant that was used in part to modernize the help line that appears at the bottom of betting ads. The league’s contribution is a small fraction of what gambling companies pay to be part of the N.F.L.’s marketing apparatus, but it is the largest grant in the council’s history and exceeded the nonprofit’s grant total over the previous four years, according to tax filings.

...

"The league’s approach to gambling violations within its own ranks, though, remains punitive. For decades, sports leagues have believed that gambling could damage the integrity of results — with worries over a player’s throwing a game because of a bet, for instance — so the focus has been on enforcement and punishment over prevention and treatment.

"The N.F.L. prohibits league and team personnel from betting on any sport, while players are allowed to bet on sports other than the N.F.L., as long as they do not do so at the team facility or while on team or league business. While in Las Vegas for the Super Bowl, members of the Kansas City Chiefs and the San Francisco 49ers and the hundreds of league employees, many staying at Caesars Palace, are not permitted to play casino games and may enter a sports book only if passing through to another part of the hotel."

Drug addiction: not just opioids

 Consumption of addictive drugs seems to come in deadly cocktails these days, which is making interdiction of drugs, and treatment of addiction more complicated.

The NYT has the story:

‘A Monster’: Super Meth and Other Drugs Push Crisis Beyond Opioids. Millions of U.S. drug users now are addicted to several substances, not just opioids like fentanyl and heroin. The shift is making treatment far more difficult.  By Jan Hoffman

"The United States is in a new and perilous period in its battle against illicit drugs. The scourge is not only opioids, such as fentanyl, but a rapidly growing practice that the Centers for Disease Control and Prevention labels “polysubstance use.”

Over the last three years, studies of people addicted to opioids (a population estimated to be in the millions) have consistently shown that between 70 and 80 percent also take other illicit substances, a shift that is stymieing treatment efforts and confounding state, local and federal policies.

“It’s no longer an opioid epidemic,” said Dr. Cara Poland, an associate professor at the Michigan State University College of Human Medicine. “This is an addiction crisis.”

...

"The incursion of meth has been particularly problematic. Not only is there no approved medical treatment for meth addiction, but meth can also undercut the effectiveness of opioid addiction therapies. Meth explodes the pleasure receptors, but also induces paranoia and hallucinations, works like a slow acid on teeth and heart valves and can inflict long-lasting brain changes.

"The Biden administration has been pouring billions into opioid interventions and policing traffickers, but has otherwise lagged in keeping pace with the evolution of drug use. There has been comparatively little discussion about meth and cocaine, despite the fact that during the 12-month period ending in May 2023, over 34,000 deaths were attributed to methamphetamine and 28,000 to cocaine, according to provisional federal data.

...

"Like opioids, which originally came from the poppy, meth started out as a plant-based product, derived from the herb ephedra. Now, both drugs can be produced in bulk synthetically and cheaply. They each pack a potentially lethal, addictive wallop far stronger than their precursors."

Fentanyl

 The NY Times has the story:

Some Key Facts About Fentanyl. It’s lowering American life expectancy and influencing the nation’s politics. By Josh Katz, Margot Sanger-Katz and Eileen Sullivan

"Overdose deaths have been increasing in the United States for decades, but the introduction of fentanyls has led to a staggering rise, accounting for the vast majority of overdose deaths in recent years.

"Around 77,000 Americans died from overdoses involving synthetic opioids like fentanyl in the 12-month period ending in April of this year, according to provisional estimates from the Centers for Disease Control and Prevention. In 2022, the most recent year with complete data, this number was around 74,000. Those three wars  [Vietnam, Iraq and Afghanistan] killed a little over 65,000 Americans combined.

"For comparison, around 55,000 Americans died in 1972 from car crashes, the year with the most such deaths. Around 49,000 died from guns in 2021 (including suicide), the year with the most such deaths.

"Fentanyl alone has become a leading cause of U.S. deaths. It was responsible for a third of deaths among Americans 25 to 34 in 2022, according to a New York Times analysis of C.D.C. mortality data.

...

"Most of the fentanyl sold in the United States is coming from Mexico, where drug cartels synthesize the drugs from precursor chemicals believed to come from factories in China. Some fentanyls are also shipped directly from China into the United States."

Supervised drug use sites to be banned in Pennsylvania

 Statnews has the story:

Pennsylvania set to ban supervised drug use sites, in setback for harm reduction  By Lev Facher

"Pennsylvania lawmakers are set to pass a new ban on supervised drug consumption, effectively ending a Philadelphia nonprofit’s long-running effort to offer a sanctioned substance-use site meant to prevent overdose and death.

"A bill outlawing sites that “knowingly” provide a space for drug consumption passed a committee vote by a wide margin on Tuesday. It now advances to the full state senate, where it is also expected to pass. Gov. Josh Shapiro, a Democrat, has expressed strong opposition to supervised injection sites in the past, and is expected to sign the legislation.

...

"While the Biden administration has expressed unprecedented support for harm reduction, many Americans remain hostile to the approach.

"Some harm-reduction tools, like syringe exchanges and fentanyl test strips, have gained a degree of acceptance, but supervised consumption is still largely taboo. Pennsylvania advocates had high hopes for a planned site in Philadelphia, however, and say the legislation would deal a demoralizing blow to local efforts to avert overdoses and save lives.

...

"Offering medical supervision as people consume drugs that can cause overdose, like heroin and fentanyl, is among the most controversial tactics employed to prevent overdoses. But in recent years, as U.S. drug deaths have surpassed 100,000 annually, the strategy has gained support among some public health advocates. While critics argue that supervised injection condones drug use, studies from cities including Vancouver and Barcelona show that offering the service can lead to a marked reduction in overdose deaths.

...

"Currently, only a few supervised consumption sites are in operation around the U.S. — and none have formally received the federal government’s blessing. Most notably, the nonprofit OnPoint NYC opened two supervised consumption sites in Manhattan late last year. Rhode Island has legalized supervised consumption sites as well, though it’s unclear when a planned site in Providence will open. "

Opioids and Appalachia by Sally Satel

 Sally Satel, who has treated patients in Appalachia, writes movingly of the drug addiction problem there. Here's a paragraph that sets the stage.

"The history of opioid pain relievers in Appalachia is a prime illustration of the fact that drug epidemics rarely burst onto the scene out of nowhere. Instead, they find their place in regions that are already home to an established base of individuals who abuse similar drugs. Thus illicit OxyContin, a more potent opioid, efficiently gained popularity over Percocet and Vicodin in the same way heroin would substitute for prescription opioids as the latter grew scarce after 2010."

That's from Opioids and Appalachia by Sally Satel, in the current issue of National Affairs.

The whole thing is well worth reading; here are a few more paragraphs that caught my eye.

"The churn of pills — diverting, using, and selling them — soon had eastern Kentucky, southeastern Ohio, and West Virginia pulsing with crime. Realtors routinely told home sellers not to leave pills in their medicine chests during open houses. Funeral directors and hospice nurses cautioned the bereaved not to mention in obituaries that their loved ones had succumbed to cancer — a red flag signaling that huge bottles of pills were likely on the premises. In eastern Kentucky, local law enforcement was often stymied by close ties between people within communities. Loyalty within large families and fear of retaliation by neighbors made it hard to cultivate informants and to impanel neutral juries that would convict when prosecutors proved their case.

...

"Appalachians seemed to take the corruption in grudging stride. In one survey, 90% of over 100 Kentuckians working in law enforcement, health, and community governance said the rural OxyContin problem in the early 2000s was "fueled by a cultural acceptance of drug misuse." Indeed, many residents tolerated unlawful activity, since it generated revenue for the community from sales of pills to outsiders. This happened in places like Williamson, West Virginia — dubbed "Pilliamson" — where the local Wellness Center was a hub of reckless prescribing. Cash-laden out-of-staters flocked there to buy painkillers and, in a small area near the center, trade and sell those pills.

"Pablo Escobar and El Chapo couldn't have set things up any better," wrote Eyre. "The coal barons no longer ruled Appalachia. Now it was the painkiller profiteers."

...

"Today, opioid pills are no longer pouring into Appalachia as they once did; highly lethal products like fentanyl-laced heroin, methamphetamine, and counterfeit fentanyl pills are what people are selling."

Canada experiments with decriminalization of opioids and other drugs in British Columbia

 From the CBC:

What you need to know about the decriminalization of possessing illicit drugs in B.C.  B.C. granted exemption by federal government in November 2022; pilot will run until 2026  by Akshay Kulkarni ·

"it is no longer a criminal offence to possess small amounts of certain illicit drugs in B.C. for people aged 18 or above.

"It's part of a three-year pilot by the federal government, which granted B.C. an exemption from the Controlled Drugs and Substances Act (CDSA) on May 31, 2022. 

...

"Under the exemption, up to 2.5 grams of the following four drug types can be legally possessed:

"Cocaine (crack and powder). Methamphetamine. MDMA. Opioids (including heroin, fentanyl and morphine).

"Fentanyl and its analogues were detected in nearly 86 per cent of drug toxicity deaths from 2019 until 2022, according to the latest report from the B.C. Coroners Service."

Selling flavored cigarettes after California's ban

 It's hard to regulate tobacco. The NY Times brings us up to date on California's ban on flavored tobacco products.

R.J. Reynolds Pivots to New Cigarette Pitches as Flavor Ban Takes Effect. Now that California’s tobacco prohibitions are in place, some Camel and Newport items are billed as newly “fresh” or “crisp” non-menthol versions. By Christina Jewett and Emily Baumgaertner

"R.J. Reynolds has wasted no time since California’s ban on flavored tobacco went into effect in late December. “California, We’ve Got You Covered,” the company declared in bold letters on a flier mailed to its cigarette customers.

"The law prohibits flavors, odors or “tastes” in tobacco products, including menthol cigarettes. But antismoking experts argue that R.J. Reynolds, the maker of Camel and Newport brands, is trying to circumvent the ban by luring smokers with a suite of what it says are new non-menthol versions offering “a taste that satisfies the senses” and “a new fresh twist.”

"The campaign is viewed by critics as a provocation of California authorities who are supposed to enforce the ban, which includes a provision outlawing packaging or claims that suggest a product has a flavor. The Food and Drug Administration also is moving forward with a national plan to take menthol cigarettes off the market.

...

"Dr. Robert Jackler, a professor at Stanford Medicine who provided the ads to The New York Times, called the new marketing “outrageous.”

“The thing that surprises me is there’s no camouflage,” said Dr. Jackler, who received the mailers along with staff members of Stanford’s program on tobacco advertising. “They’re saying, ‘This is our menthol replacement. And by the way — wink, wink — it is not really menthol.’”

...

"Worldwide, tobacco companies have discovered loopholes to bans on menthol or flavored tobacco, studies show. In Canada, flavor cards and additive drops have been used to supplement unflavored products. In Denmark, smokers now have access to menthol sprays, capsules and tubes."

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Earlier:

Tuesday, December 27, 2022

Suppressing vaping is hard

Nicotine will be with us for a long time--survey of middle school use

 Sales of tobacco products to minors are generally illegal in the U.S., but a survey shows that doesn't stop children from smoking and vaping.  Here's a report from the Centers for Disease Control and Prevention, in JAMA

Tobacco Use Remains High in Middle and High Schools by Bridget M. Kuehn, MSJ

JAMA. 2022;328(24):2389-2390. doi:10.1001/jama.2022.20058

"Nearly 1 in 9 US middle and high school students reported tobacco product use in the past 30 days—most commonly e-cigarettes—according to a CDC and US Food and Drug Administration analysis of data from the 2022 National Youth Tobacco Survey (NYTS). The researchers estimated that approximately 3.08 million students in 6th to 12th grade currently use tobacco products.

...

"The data show that 16.5% of high school students and 4.5% of middle school students reported using a tobacco product in the past 30 days. About 14% of high school students and about 3% of middle school students used electronic cigarettes. Nearly 4% of all those surveyed reported using any combustible tobacco product.

"Several subgroups of students reported even higher rates of tobacco product use. About 16% of students who identified as lesbian, gay, bisexual, or transgender reported current use of these products. The 2022 NYTS survey was the first to provide data on tobacco product use among American Indian or Alaska Native, Asian, multiracial, or Native Hawaiian or other Pacific Islander youths. It found that American Indian or Alaska Native youth reported the highest rate of a tobacco product use of any racial or ethnic group, at 13.5%.

"The report also found a link between social determinants of health and tobacco product use. For example, students who had experienced severe psychological distress or were from less affluent households were more likely to report current tobacco product use. More than a quarter of students with low academic achievement reported current use. "

Suppressing vaping is hard

 The WSJ has the story:

Major effort needed to remove illegal vaping products, review finds. Group says FDA regulators are overwhelmed and reactive  By Laurie McGinley

"An independent review of the Food and Drug Administration’s tobacco regulators described them as overwhelmed, reactive and fatigued by an oppressive workload involving e-cigarettes and called for a major effort, by several parts of the Biden administration, to remove millions of illegal vaping products from the market.

"The report, by the Reagan-Udall Foundation for the FDA, also said the agency’s Center for Tobacco Products, created by federal law in 2009, has fallen short in laying out clear priorities and has been besieged by lawsuits brought by tobacco and vaping companies, on the one hand, and public health groups on the other.

"The review said there are millions of illegal vaping products on the market — involving companies that should have applied for FDA authorization and never did, or others that had their applications rejected — and that a major effort is needed to remove them."

Opioids and pain management: revised CDC guidelines

 Concerned over the opioid addiction epidemic in the U.S., and the increasing number of overdose related deaths, the CDC issued the 2016 CDC Opioid Prescribing Guideline, which led to reduced opioid prescriptions by doctors. Sometimes this led to the undertreatment of pain, which in turn may have led to patients accessing opioids on the black market, where they are less safe. It may also have led to suicides of patients with unbearable pain.

The CDC has now issued some updated guidelines that appear aimed at balancing concerns with over-prescription against concerns with under-treatment.

Here are the updated guidelines:

CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022

"This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1–49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain.

...

"CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

A central tenet of this clinical practice guideline is that acute, subacute, and chronic pain needs to be appropriately and effectively treated regardless of whether opioids are part of a treatment regimen. 

...

"To avoid unintended consequences for patients, this clinical practice guideline should not be misapplied, or policies derived from it, beyond its intended use (67). Examples of misapplication or inappropriate policies include being inflexible on opioid dosage and duration, discontinuing or dismissing patients from a practice, rapidly and noncollaboratively tapering patients who might be stable on a higher dosage, and applying recommendations to populations that are not a focus of the clinical practice guideline (e.g., patients with cancer-related pain, patients with sickle cell disease, or patients during end-of-life care)

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Earlier post:

Tuesday, March 15, 2022

Opioid prescription reductions and suicides

Lobbying for sports gambling, with cigars and whisky

 Do addictions go together?  The NY Times has the story of how legalized (online, sports) gambling lobbyists wooed state legislators with whisky and cigars (and campaign contributions, which I guess can be addictive too...). Maybe Thanksgiving football can draw in more of the gathering if there's betting involved? (Not to mention whisky...)

Gambling has long been a repugnant transaction because the consequences of gambling addiction can be destructive for individuals and families. And betting on sports has been repugnant because of the danger that athletes will be drawn into fixing matches (even in once genteel sports like tennis).  Lobbying is a competitive sport too:

Cigars, Booze, Money: How a Lobbying Blitz Made Sports Betting Ubiquitous By Eric Lipton and Kenneth P. Vogel

"Less than five years ago, betting on sports in the United States was prohibited under federal law except in Nevada casinos and a smattering of venues in other states. Sports leagues argued that the ban safeguarded the integrity of American sports, while consumer watchdogs warned that legal gambling could turn fans into addicts. In countries like Britain, sports gambling free-for-alls had left trails of addiction.

"But in 2018, the Supreme Court ruled that the federal prohibition was unconstitutional.

"DraftKings and FanDuel, giants in the fast-growing field of fantasy sports, had already mobilized an army of former regulators and politicians to press for sports betting in state capitals. Soon, in a crucial reversal, sports leagues overcame their antipathy toward gambling, which they came to see as a way to keep increasingly distracted audiences tuned in. Casino companies also hopped on board.

...

"The results of the lobbying campaign have been stunning: 31 states and Washington, D.C., permit sports gambling either online or in person, and five more have passed laws that will allow such betting in the future.

...

"In May 2018, the Supreme Court struck down the federal ban on sports gambling, ruling it infringed on states’ rights."

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Here's a map:

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The NYT has these related stories:

Key Findings From The Times’ Investigation of Sports Betting. By David Enrich

"Four years ago, it was illegal to gamble on sports in most of the United States. Today, anyone who turns on the television or visits a sports website or shows up at a stadium is likely to be inundated with ads to bet, bet, bet."

How Colleges and Sports-Betting Companies ‘Caesarized’ Campus Life. by  Anna Betts, Andrew Little, Elizabeth Sander, Alexandra Tremayne-Pengelly and Walt Bogdanich

"Ever since the Supreme Court’s decision in 2018 to let states legalize such betting, gambling companies have been racing to convert traditional casino customers, fantasy sports aficionados and players of online games into a new generation of digital gamblers. Major universities, with their tens of thousands of alumni and a captive audience of easy-to-reach students, have emerged as an especially enticing target.

"So far, at least eight universities have become partners with online sports-betting companies, or sportsbooks, many in the last year, with more expected."

Desperate for Growth, Aging Casino Company Embraced ‘Degenerate Gambler’

Image By Emily Steel

"Mr. Portnoy rarely if ever mentions the bankruptcy. Yet he and his company, Barstool Sports, are urging their tens of millions of followers to dive into the fast-growing and lightly regulated world of online sports betting."

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And here's a story about gambling addiction from The Times of London, which points to online, in-game gambling as a particularly addiction-prone activity (especially during the current World Cup):

Big rise in gambling addictions putting suicidal young men in hospital. NHS lambasts ‘predatory’ betting firms amid 42% increase in demand for specialist clinics by Eleanor Hayward (Ungated summary here).

"The NHS is “picking up the tab” of the online betting industry, with a surge in suicidal gambling addicts turning up to A&E, doctors have warned."

...

"“People start gambling as soon as they wake up in the morning; they’re gambling in the shower, gambling while they’re driving to work.

...

"Gaskell suggested that doctors' surgeries should routinely ask new patients whether they gambled--in the same way they asked how much alcohol people drank in a week.

...

"Figures from the Gambling Commission show the majority of online betters place bets in play...Customers are able to wager lare sums of money multiple times in a matter of seconds on unfolding events.

...

"There are 400 suicides a year in England lnked to gambling."