HHS Agencies Begin to Engage on E-Cigarette Lung Injuries... and what’s the Root Policy Cause of the Vaping Epidemic?

Late last week the CDC issued an Advisory about their investigation of a multi-state outbreak of severe pulmonary disease associated with e-cigarette product (devices, liquids, refill pods, and/or cartridges) use. As of September 6, 2019, over 450 possible cases of lung illness associated with the use of e-cigarette products have been reported to CDC from 33 states. As of Friday, there had been 5 deaths have been confirmed in California, Illinois, Indiana, Minnesota, and Oregon.

CDC also developed a case definition to classify cases consistently.  State and county health departments will now be able to use the new case definition to determine if cases are confirmed or probable (after examining the medical records of suspected cases and consulting with the clinical care team to exclude other possible causes).

Unlike nationally reportable conditions like communicable diseases, these cases require clinicians and public health to interview patients to determine product use and individual behaviors- which means that there’s no active surveillance system to look for injuries like these.  With more health departments and emergency departments actively looking, it’s certain that more cases will be identified, and we should be able to learn more about what’s actually happening and why pretty soon.

There aren’t enough data yet to determine what specifically might be causing the cases but many of the samples tested by the states contained significant amounts of Vitamin E acetate. Vitamin E acetate is in topical consumer products or dietary supplements, but data are limited about its effects after inhalation.

While the FDA and CDC don’t have enough data presently to conclude that Vitamin E acetate is the cause of the lung injury, they urged consumers to not use vaping products that might contain Vitamin E acetate (but I couldn’t find out how consumers would be able to tell that). The statement also said that “… no youth should be using any vaping product, regardless of the substance”.

FDA “Intends to” Better Regulate Flavored Vaping Products

Today the US Department of Health and Human Services Secretary announced that: “… the FDA intends to finalize a compliance policy in the coming weeks that would prioritize the agency’s enforcement of the premarket authorization requirements for non-tobacco-flavored e-cigarettes, including mint and menthol, clearing the market of unauthorized, non-tobacco-flavored e-cigarette products. The FDA plans to share more on the specific details of the plan and its implementation soon.”  I guess we’ll learn more about that the Federal Register in the weeks to come.

Today’s announcement that FDA intends to do more came out after preliminary numbers from the National Youth Tobacco Survey showed a continued rise in the rates of youth e-cigarette use, especially among the non-tobacco flavors that appeal to kids.  In particular, the preliminary data showed that more than 25% of high school kids are current (past 30 day) e-cigarette users in 2019 and the overwhelming majority cited the use of popular fruit and menthol or mint flavors.

Sadly, nothing in the HHS or FDA materials from today suggested that they intend to use any of their authority to tightly regulate the advertising and marketing of e-cigarettes. That fact that they were silent on that makes me believe that that might not be in the cards.

Arizona Policy Interventions Last Legislative Session were Unsuccessful

One of the key public health policy interventions that could make a dent in the vaping epidemic here in Arizona was last year’s SB 1363 Tobacco Product Sales (Tobacco 21) sponsored by Senator Heather Carter.  The bill would have classified electronic cigarettes as a tobacco product (allowing it to be regulated like tobacco – including covering it in the Smoke Free Arizona Act) and moving the buying age for cigarettes and electronic cigarettes to 21 years old.  Sadly, that bill never got a hearing at the Legislature.

So, What’s the Root Policy Cause of the Vaping Epidemic?

In short, it’s judicial branch interpretations of the FDA’s authority to regulate e-cigarettes under the Family Smoking Prevention and Tobacco Control Act.

In June 2009, President Obama signed into law the Family Smoking Prevention and Tobacco Control Act, which gave the FDA the power to regulate the tobacco industry. Under the Act, nicotine and cigarettes can’t be banned but flavorings like fruit or mint can.  Additionally, the law required new tobacco products seeking to enter the market to meet FDA pre-market standards (including electronic cigarette regulation). The statutory language left open the possibility that electronic cigarettes may be able to be regulated as a nicotine delivery device- and as such could have required a prescription.

The FDA exercised that authority by directing the U.S. Customs and Border Protection to reject the entry of electronic cigarettes into the US on the basis they were unapproved drug delivery devices.

A series of lawsuits then followed FDA’s decision. In a December 2010 landmark decision in the Smoking Everywhere v. FDA case, the U.S. Court of Appeals in Washington ruled the FDA can only regulate e-cigarettes as a tobacco product (e.g. that e-cigs can’t be regulated as a nicotine delivery device- which could have included a prescription requirement). The court said that if therapeutic claims are made then the FDA might be able to regulate e-cigs as a nicotine delivery device.  That order is here and the 25-page decision is here.

In a subsequent ruling in December 2010, the appeals court also ruled against the FDA in a 3–0 unanimous decision, finding that the FDA can only regulate e-cigarettes as tobacco products. The judges ruled that such devices would only be subject to drug legislation if they are marketed for therapeutic use – E-cigarette manufacturers had successfully proven that their products were targeted at smokers and not at those seeking to quit.

Editorial Note: Here lies the root cause of why we are where we are right now.  Had the judges found that the FDA had the authority to regulate e-cigarettes as a nicotine delivery device- they could have required a prescription (for smoking cessation purposes) on e-cigs and the marketing wildfire that resulted in the addiction of a generation of young people to high levels of nicotine could have been averted. 

Following those court rulings, in April 2011 the FDA announced it will regulate e-cigarettes like traditional cigarettes and other tobacco products under the Food Drug and Cosmetics Act, however, they never exercised their authority to regulate the marketing and advertising of e-cigarettes, and here we are…  in the middle of a teen and young adult vaping epidemic.

Aligning the Roles of Medicaid and Public Health

Aligning the Roles of Medicaid and Public Health

Medicaid and public health partnerships play an important role in advancing a statewide approach to improving health and reducing health disparities. Collaboration and shared priorities between agencies can play a super important role in improving outcomes.

The Association of State and Territorial Health Officials recently put together this interesting and easy to listen to 30 minute podcast that highlights opportunities to  leverage each agency's respective roles and resources through the CDC’s 6|18 Initiative.  Here are some links to additional resources regarding these kinds of partnerships:

Here's Why We Endorse the Clean Energy for a Healthy Arizona Initiative

The AzPHA Board of Directors has endorsed Proposition 127- the Clean Energy for a Healthy Arizona ballot initiative. Proposition 127 would increase the state's renewable portfolio standard (RPS) which is a mandate that electric utilities acquire a minimum amount of electricity from renewable energy sources. Here's the actual  Proposition 127 Ballot Language

As of 2018, Arizona's renewable portfolio standard (RPS) is 15% renewable by 2025. Proposition 127 would increase our RPS each year until reaching 50% in 2030.

The Initiative defines renewable energy as electricity generated by  solar, wind, certain hydropower, geothermal, and landfill gas energy.  The definition of renewable energy under the initiative doesn’t include nuclear power. For our state, most of the new renewable energy that would be created would probably mostly be solar.

APS reports it currently generates about 12% of its energy from renewable sources which includes utility-owned plants and power being generated by customers through rooftop solar.  Tucson Electric Power reports 13%. Right now, Arizona gets 6% of its electricity from solar power.

It’s no secret that Arizona Public Service (APS) doesn’t want Proposition 127 to pass.  Their current strategic plan  is to mostly meet future electricity needs by building new gas-fired power plants.  You can see the resource plan APS filed at the Arizona Corporation Commission in 2017 and APS’ recent RFP for new power plants to get an idea about their current strategic plan.

This is an over-simplification- but the public policy question posed by Prop 127 is whether it’s in the public’s best interest to meet future generation demand with mostly natural gas plants or solar.

There are compelling health reasons why Proposition 127 makes sense from a public health perspective. Burning fossil fuel, including natural gas, creates air emissions (oxides of Nitrogen and volatile organic compounds) that form ozone. Ozone adversely affects human health by increasing cardiovascular and respiratory disease.  It can decrease lung function and causes more people to visit emergency rooms or even be admitted to the hospital because of asthma or allergy related illnesses. Some studies have even linked preterm birth to air pollution.

But, if it turns out that the health benefits from cleaner air come at the cost of higher electricity prices- then the health gains from the improvement in air quality would need to be weighed against the public health costs to low income folks who already struggle to pay their electric bills- worsening the social determinants of health for low income people.

Before we took a position on Proposition 127, I and our Board carefully examined what impact the initiative might have on future electricity prices.  After all, income is a primary driver of health status, and if the Initiative were to increase electricity prices more rapidly than under the current RPS standard, then it could end up having a net negative impact on public health among low income Arizonans.  That’s why we carefully examined the cost issue before taking a position.

One of the best and most objective sources of information about the relative costs of generating electricity I found is the US Energy Information Administration’s 2018 report entitled  ”Levelized Cost and Levelized Avoided Cost of New Generation Resources in the Annual Energy Outlook 2018”.   The report examines capital, operational and transmission costs as well as off sets from the tax credits.  It takes a little time to read but worth the effort.

The bottom line is that solar energy generated using photovoltaic cells is on par or slightly cheaper than energy generated with natural gas.  Solar plants have a higher capital cost but lower variable (operational cost) because they don’t need fuel (free photons are the fuel).  Solar also benefits from tax credits- which is part of the cost equation.

One of the reasons why solar power is now slightly cheaper than natural gas energy is that the cost of solar panels has decreased rapidly in recent years (in part because of increased global solar panel manufacturing capacity in China).  The cost of utility-scale solar has fallen 77% since 2009.  The cost of battery storage fell 79% between 2010 and 2017.  Another reason why solar costs less in the long run is because of the federal tax credits that are available to utilities that use solar to generate electricity.

Prop 127 also requires 20% of renewable energy eventually be “decentralized” - basically roof-top solar.  That means incentives will be created to encourage solar installation. Done thoughtfully, that could provide an opportunity to prioritize installation of panels on homes in lower income areas, relieving pressure on monthly budgets of families who most need that relief while increasing the value of their property.

The bottom line is that after reviewing as many objective facts as we could find, we concluded that Proposition 127 provides net health and environmental benefits.  That's why we’re supporting Proposition 127.

Substance Abuse Prevention Needs Assessment

AHCCCS is conducting a Statewide Substance Abuse Prevention Needs Assessment to better understand what prevention activities are going on and what the prevention needs in our communities are and about the experiences of folks who work or volunteer in substance abuse prevention. 

If you fit the bill, it would be great if you could take 10 minutes to support this important effort by taking this Arizona Substance Use Prevention Workforce Survey

AzPHA Public Health Policy Update

Save the date

90th annual azpha fall conference and annual meeting

Integrating Care to Improve Public Health Outcomes:

Primary Care | Behavioral Health | Public Health

October 3, 2018 

Desert Willow Conference Center

There’s widespread support for the goals of the Triple Aim: To deliver the highest quality care with an optimal care experience at the lowest appropriate cost. The key is developing systems of care that best achieve these goals. 

Our 90th Annual Fall Conference and Annual Meeting Integrating Care to Improve Public Health Outcomes: Primary Care | Behavioral Health | Public Health will explore efforts currently underway to integrate care and improve outcomes in Arizona as well as initiatives on the horizon to develop systems of care that best achieve the goals of the Triple Aim.

We’ll kick off our Conference with a presentation of the latest academic research that evaluates the outcomes of co-located and integrated models of behavioral care as part of primary care as well as evidence-based toolkits to assist practices including ways to measure progress. We’ll also be exploring how providers are implementing new strategies to integrate care via AHCCCS’ “Targeted Investment” program which provides financial incentives to eligible providers to develop systems for integrated care.

We’ll conduct a short AzPHA Annual Meeting over a delicious buffet lunch followed by our keynote address from the American Public Health Association President Joseph Telfair, DRPH, MSW, MPH.  In our afternoon sessions, we’ll learn about new initiatives to work with managed care in two key areas that impact health outcomes: tobacco use and housing and homelessness.

We’ll close with a panel discussion of key leaders among Arizona’s Managed Care Organizations as they discuss priorities and strategies for improving outcomes under the new integrated Medicaid contracts which will begin October 1, 2018.  The new contracts will require better coordination between providers which can mean better health outcomes for members.

After the conference we'll have a hosted reception as we celebrate AzPHA’s 90th Anniversary!

I’m still working on the agenda, but I expect to have it fleshed out in a couple of weeks and have our registration site up and sponsorship packets out by the 3rd week in June. A summary of the conference is up on our homepage at


American Cancer Society Changes Colon Cancer Screening Recommendation

The American Cancer Society changed their recommendation for colon cancer screening by moving down the standard recommendation 5 years- suggesting that most people get screened at age 45. There are a couple of ways people can get screened, either using a sensitive test that looks for signs of cancer in a person’s stool or with an exam that looks at the colon and rectum (a colonoscopy).  The reason they changed the recommendation is because new data shows that cases of colorectal cancer for people under age 55 increased 50% between in the last 20 years (1994-2014).

However, just because the recommendation from the ACS changed doesn’t necessarily mean that insurers will begin paying for it between 45 and 49 years old.  For that to happen, the United States Preventive Services Task Force would need to recommend the change and list it as a Category A or B preventive health service.

In recent years, a prevention model of health has woven its way into the fabric of traditional models of care. With the passage of the Affordable Care Act the role preventive services has expanded significantly in the US health care delivery system.  Preventive health care services prevent diseases and illnesses from happening in the first place rather than treating them after they happen.

Category A & B” preventive services recommended by the United States Preventive Services Task Force  are now included (at no cost to consumers) in all Qualified Health Plans offered on the Marketplace. In addition, many employer-based and government-sponsored health plans have included Category A & B preventive services in the health insurance plans they offer to their respective members.

Currently, the United States Preventive Services Task Force recommends 49 Category A & B Preventive Health Services that include screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children.  The Task Force consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

You can also browse the USPHS website and check out the preventive services that they have evaluated but don’t recommend. Most of the services are broken down by age, gender and other risk factors.


Medicaid Program Scorecard Released by Feds

The Centers for Medicare & Medicaid Services released a new Medicaid program scorecard this week.  It includes some quality metrics along with federally reported measures in a Scorecard format.

The data that’s built into the state by state scorecard only uses information that states voluntarily submit.  There are 3 main categories (state health system performance; state administrative accountability; and federal administrative accountability) and lots of subcategories.

The most interesting part of the Scorecard I think are the State Health System Performance Measures portion.  Some of the subcategories that are reported in that category on a state by state basis are things like well child visits, mental health conditions, children’s preventive dental services and vaccination rates, and other chronic health conditions.

It looks like a good and valuable tool that will (if they continue to populate the scorecard) provide more transparency into the effectiveness of state Medicaid programs over time. The data that are submitted are voluntary - not compulsory - so that hurts the number of measures that states turn in.  It might be something that you’ll want to bookmark for reference in the future.


Federal “Right to Try” Law Passed and Signed

Congress passed and the President signed a new law this week that gives people with a terminal illness new options for treatment by allowing those folks a way to independently seek drugs that are still experimental and not fully approved by the US Food and Drug Administration.

The new law basically gives terminally ill patients the right to seek drug treatments that remain in clinical trials and "have passed Phase 1 of the FDA’s but haven’t been fully approved by the FDA.  

Arizona voters have already approved a similar law (by a wide margin).  In 2014 AZ voters approved Proposition 303  (referred to the ballot by the Legislature) that makes investigational drugs, biological products or devices available to eligible terminally ill patients. The AZ law has uses the same definition of an "investigational" drug that the new federal law uses.


Western Region Public Health Training Center Grant Renewed

The Western Region Public Health Training Center was awarded a renewed grant as a center for the Regional Public Health Training Centers Program.  They’ll continue to be housed in the University of Arizona Mel and Enid Zuckerman College of Public Health and we will continue to assess the training needs and strengthen the skills of the public health workforce with their partners in Arizona, California, Hawaii, Nevada, and the Pacific Islands.

The training center has literally hundreds of trainings that focus on all sorts of health professionals and the public health workforce.  So no matter what your public health workforce training needs are – the thing to do first is to check the centers website to see if they have the course that you need.  Most likely they will.


I’m doing my best to populate the “upcoming events” part of our AzPHA website.  If you have an upcoming public health related event- please let me know and I’ll get it up on our website at:

AzPHA Public Health Policy Update- December 6

Newborn Screening Policy Success Story

In 2014 a bipartisan group of AZ lawmakers passed a bill charging the ADHS with expanding their newborn screening program to include newborn pulse oximetry screening in hospitals. The test gives the baby’s doctors quick information about whether the newborn might have a congenital heart abnormality. Quick info like that gives them a chance to do early interventions that can save lives and improve outcomes. The agency and hospitals collaborated to implement the new testing and reporting procedures in 2015.

A new study this week in the Journal of the American Medical Association found that states that had our kind of congenital heart disease screening program (based on pulse oximetry) had 33% fewer infant deaths from critical congenital heart disease compared to states without screening policies.

Kudos to our public health partners at the American Heart Association in AZ for raising awareness with our legislators and for that body to recognize and pass this important evidence-based intervention.  This new study demonstrates that it's saving lives.


Medicaid Work Requirements & 5 Year Limit on Horizon

An AZ law (from 2015) requires AHCCCS to annually ask the Centers for Medicare and Medicaid Services (CMS) for permission to require work (or work training) and monthly income reporting for “able bodied adults” as well as a 5-year lifetime limit on AHCCCS eligibility. 

The work requirement and 5 year limit requests that were turned in during the Obama Administration were denied, but the new administrator CMS has publicly said (and written) that she’s receptive to proposals from states to require work or community engagement for people who want to receive Medicaid.

We’re getting closer to having these requirements become part of AZ’s Medicaid program with a transmission of a concept letter from AHCCCS to CMS about the upcoming 2017 request.

A few months ago, AHCCCS floated a draft waiver for public comment that outlined the following requirements for “able-bodied adults” receiving Medicaid services:

  • A requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program;
  • A requirement for able-bodied adults to monthly verify compliance with the work requirements and any changes in family income;
  • The authority to ban people from enrollment for 1 year if they fail to report a change in family income or lie about compliance with the work requirements; and
  • Limit lifetime coverage for all “able-bodied” adults to 5 years (except for certain circumstances). 

Hundreds of comments were turned in urging AHCCCS to change the initial waiver request.  AzPHA submitted a response letter back in February.  Several hundred people and organizations turned also in comments.  

While AHCCCS hasn't released the content of their final waiver request, they did issue a letter last week outlining what they intend to include in the Waiver (after considering the public comments).  

It's a lengthy letter and I can't summarize it all here - but interestingly - it includes a wider list of persons that would be exempt from the eligibility restrictions and the 5 year benefit limit (which already included folks with disabilities) including:

  • People over age 55
  • Women for three months after a pregnancy
  • Former foster youth up to age 26
  • People diagnosed with a serious mental illness
  • People receiving temporary or permanent long-term disability benefits
  • Full-time high school students over age 18
  • Full-time college or graduate students
  • Victims of domestic violence
  • Homeless individuals
  • People impacted by a death of family members in their immediate household
  • A parent or caregiver of a child under age 13
  • A caregiver of a family member in the Arizona Long Term Care System
  • People considered medically frail under state law
  • American Indians

There are other areas covered in the letter that go beyond the requirements of the 2015 law including:

  • Freezing the current base payment rates for community health centers and choosing an alternative inflation factor for future payments; and

  • Limits on paying for emergency medical transportation.

If some (or all) of the items in the waiver are approved (which appears likely) how AHCCCS implements the reporting requirements, coordinates with other agencies like ADES, and determines compliance with the eligibility requirements will have a profound impact on access to care for this population.

We'll continue to track this when the actual waiver request is turned in.


Community Health Worker Training Program Accredited

The Arizona Community Health Worker Association (AzCHOW) approved Central Arizona College’s CHW curriculum and training program last week, a key milestone toward building a robust CHW workforce in Arizona.

Their CHW program is approved for 5 years, at which time the program will be reviewed for renewal. The CHW curriculum provides the core competencies and skills students need for employment opportunities. Students are introduced to community and public health topics like chronic disease management, health communication, health literacy, counseling and motivational interviewing, wellness and health advocacy. 

The program can be completed in 1 year through distance learning and includes a 90- hour internship which can be completed.

The CHW training program was implemented in August of 2016 and the first cohort of students graduated in August of this year.  The second cohort of students is working towards the CHW certificate, and will graduate in August of 2018. 

For more information on the Community Health Worker Certificate Program and application form, please visit or call Kim Bentley at 480-677-7780.  


Tax Bill Could Have Public Health Implications

The Senate approved their version of tax reform by a 51-49 vote last week. Last month, the House approved their version by a 227-205 vote. In the next couple of months, they’ll resolve differences between the two bills and produce a conference bill.

The Senate version repeals the individual mandate for people to have health insurance or pay a fine.  The Congressional Budget Office estimates that repealing of the individual mandate could increase the number of uninsured by 4 million by 2019 and 13 million in 2027. They also estimate that the repeal will increase health insurance premiums by 10% per year but also save the federal government $338 billion (e.g. fewer advance premium tax credits).

The Pay-As-You-Go Act of 2010 (PAYGO) requirement could threaten the Prevention and Public Health Fund and other public health programs. Congress will need to waive the PAYGO requirements separately to prevent these cuts from moving forward. Senator McConnell reportedly assured Senator Collins that the PAYGO waiver will happen, but waiving it will take 60 votes in the Senate.


Affordable Care Act – too big to fail and too big to ignore

By: Jana Granillo in the November 30, 2017 AZ Capitol Times 

How does the Affordable Care Act affect me and my community? Well, that is a big question with a big answer. ACA is big, it is more than the marketplace and mandates – which, by the way, is still the law. It is a whole system of care and infrastructure and problem solving intended to make us healthier as a nation.

When I think of the ACA, what churns to the top of my thoughts are vulnerable populations, my neighbors, my own insurance, and where I live.

When I hear students playing in the schoolyard, I know many are economically disadvantaged. We have a shockingly large percentage of students on Free and Reduced Lunch. How many of those children are on AHCCCS/Medicaid or participate in the ACA Marketplace?

When I commute, I drive by community health centers, also known as Federally Qualified Health Centers. ACA funding impacts these clinics.

When I grocery shop, I see seniors counting their pennies with clipped coupons. Which seniors will endure a fall or become victim to MRSA, a staph infection?  How many of them are Medicare and Medicaid dual eligible?

When I hear a first-responder siren, I think about behavioral health.  According a recent report on the opioid crisis, my community is on a data map and it is colored red. Does the siren tell of another victim? Does that victim have behavioral health options or even a treatment bed for evaluation?

When I choose doctors, I wonder if they were part of the National Service Corp.

What about treatment options? Is there a new medication on the horizon for a chronic condition or disease by the National Institute of Health? Will my elderly relative have to travel to Phoenix to get treatment that is not available in the rural areas?

Will the county hospital financially be in the “green” this year or do we take a hit on our property taxes to support the district? Will they receive Disproportionate Share Payments  for serving the underserved? What funding will be available?

What about all those medically served by the fire department, especially those who don’t have a point of care – who pays for that?

Finally, I ponder, will our family (employer) insurance be there tomorrow? I can’t afford a premium without help.

So, does ACA affect me, my family and my community? Answer: BIG yes!

How do we go forward? The answer is to include experts from multiple health disciplines to define reform around a common goal: affordable quality health care systems that are responsible, provide short-term stabilization and long-term solutions that protect all us.

— Jana Lynn Granillo is a AZPHA member and community health