At the Phillips 66 gas station near the corner of Troost Avenue and East 59th Street in Kansas City, Missouri, you can see bright, colorful ads for tobacco products on sale.
From that very spot, you can also see the brick walls of Troost Elementary.
Forty percent of Kansas City’s public schools are located within 1,000 feet of a tobacco retailer, and tobacco retailers are 10 times more concentrated in Kansas City’s poorest neighborhoods, according to a new study from the ASPiRE Center, which looked at locations of tobacco retailers in Kansas City, Missouri, along with 29 other U.S. cities.
“The pattern looks like continued targeting of youth and disadvantaged people that has been a pattern of the tobacco industry for decades,” said Lisa Henriksen, a senior research scientist on the study from the Stanford University School of Medicine. “It’s a reminder that this placement and targeting persists and is really dangerous for young people.”
The link between tobacco product advertising and youth tobacco use has been well-documented; tobacco manufacturers give price discounts to retailers in order to make their products more affordable, which in turn affects youth smoking.
“Research shows that higher concentrations of retailers makes it more likely for kids to start tobacco use and discourages users from quitting. In part because of access, and in part because of marketing inside of these stores, which makes tobacco products seem more attractive and affordable,” Henriksen said.
In Missouri, 10.9% of high school students use e-cigarettes and 9.2% smoke traditional cigarettes. E-cigarette use in teens has risen dramatically in recent years. In 2019, vaping received a significant increase in media coverage, with focus on an outbreak of lung injuries associated with e-cigarette use.
In recent months, COVID-19 has shifted attention away from other health issues, such as smoking.
“Tobacco use and prevention hasn’t been our priority programming recently,” a spokesperson for Kansas City Public Schools told The Beacon. KCPS is currently meeting completely via distance learning, with no plans to return to in-person learning until Kansas City has seen a consistent decline in new COVID-19 cases for 14 days.
However, the COVID-19 pandemic is having adverse impacts on those who smoke: A recent study from Stanford University found that teens and young adults who vaped were five to seven times more likely to be infected by COVID-19 than their peers who don’t use e-cigarettes. An analysis of multiple studies by the World Health Organization suggests that smoking is associated with increased severity of disease and death in hospitalized COVID-19 patients.
“COVID-19 has taken the spotlight off of the health effects of vaping, but it makes action on vaping more important,” said Matt Myers, president of Tobacco-Free Kids, a nonprofit organization that advocates for reduced tobacco use. “There has never been a time where it is more urgent, if you smoke or use e-cigarettes, to quit.”
Tobacco retailers target low-income neighborhoods
The ASPiRE Center study also showed a tenfold difference in the number of tobacco retailers in Kansas City’s lowest-income neighborhoods versus the highest. Tobacco retailers were congregated in the historic Northeast neighborhood, midtown and downtown.
“That difference was about twice the national findings,” Henriksen said. “Tobacco retailers are really ubiquitous, there are 18 for every McDonald’s restaurant. But even though they are ubiquitous, they are not equally distributed.”
Kansas City has well-known racial and economic segregation, which contributes to longstanding health disparities that have most recently been reflected in testing and treatment related to the COVID-19 pandemic.
“In a time where we are seeing such serious problems with health disparities and health inequity, the tobacco industry can no longer be allowed to target our low-income, particularly African American, neighborhoods, as this survey says they are doing,” Myers said.
Tobacco companies have historically targeted Black communities with a higher concentration of ads. And although Black smokers smoke less than white smokers, they experience more smoking-related disease and death.
“African Americans are more likely to want to quit smoking but are less likely to be successful in those attempts,” said Nikki Nollen, a professor in population health at the University of Kansas Medical Center.
Nollen says one reason is that smoking cessation products aren’t always covered by insurance and can be expensive. Another is that Black smokers tend to smoke menthol cigarettes, which are linked to a lower likelihood of quitting.
But most of all, it comes down to individual disadvantages, such as income, education and neighborhood. Nollen says that when Black and white smokers at the same advantage level are provided the same medications and counseling to quit, there is no disparity.
“What’s causing the disadvantage is all of these systems that have been set up that makes it harder for (Black people) to get access to treatments, and once they have access to treatments, it’s the environments that they live in that are more stressful,” Nollen said.
“Structures have been put in place in our society that take advantage of people who are poor and also poor and of color.”
Decreasing targeting by tobacco retailers
In 2019, Missouri adopted federal laws to help prevent tobacco use by minors. The laws prohibited the sale of tobacco products to anyone under the age of 21 and banned flavors of e-cigarettes other than tobacco or menthol. However, the law banning most flavored e-cigarettes still allows the popular menthol flavoring in pod-based systems and flavors in tank-based systems and disposable e-cigarettes. In July, the Food and Drug Administration called for a removal of fruity-flavored disposable e-cigarettes from the market.
“We know that youth are using flavored tobacco products,” Myers said. “Ninety-seven percent of kids who start with an e-cigarette start with a flavored cigarette. More than 50% of kids who smoke cigarettes use menthol cigarettes. And among high school boys, more use flavored cigars than actually use cigarettes.”
“The very first step is to eliminate those flavored tobacco products that appeal to our kids and that aren’t essential for any other purpose.”
“The federal ban that came out is not near strong enough,” said Erin Gabert, a community impact director with the Kansas City American Heart Association. “Only basing it on the pod-based systems leaves a lot of interpretation for other products to come in that are used the same way as pods, that can still have those flavors and still be used by young people.”
The American Heart Association currently has a task force that is looking into the sales of flavored tobacco products and finding ways that local policy could fill in gaps left by the federal flavor law.
Some communities have already turned to more extensive bans of flavored tobacco products. Last year, Massachusetts’ flavor ban included menthol-flavored products, tobacco-flavored products and flavored chewing tobacco. However, the law does allow the products to be sold at smoking bars for on-site consumption. Many localities in California, such as Los Angeles County, San Francisco and San Diego County, have banned flavored tobacco products, including flavored cigarettes and little cigars. So have cities like Chicago; Aspen, Colorado; and Minneapolis.
Other options that Myers and Henriksen support to prevent youth use of tobacco products, especially in low-income areas, include banning tobacco retailers near schools, limiting the number of tobacco retailers within a certain region or capping the number of tobacco retailers in the city. Rules involving density of retailers could be especially effective in low-income areas of Kansas City, where retailers are highly concentrated.
The county of Santa Clara, in California, passed a law banning new tobacco retailers from selling tobacco products if they were within 1,000 feet of a school or within 500 feet of another tobacco retailer. Researchers found that the law immediately reduced the number of tobacco retailers near schools and the density of tobacco retailers overall.
In January, the American Heart Association hosted a focus group with young people in Kansas City of different races, ages and socioeconomic backgrounds to learn more about their experiences with vaping.
“That was a really awesome engagement opportunity that we had, and it confirmed what we felt, that it really was a crisis in schools,” Gabert said.
The American Heart Association hopes to work with Kansas City-area school districts in the future to help them enact better vaping policies at their schools and find resources to enact those policies.
“We can’t afford to drag our feet,” Gabert said. “If we’re not careful, an entire new generation is going to be addicted to nicotine.”
Brittany Callan is the health and environment reporter at The Beacon and a Report for America corps member. You can reach Brittany at firstname.lastname@example.org. Funding for this reporting was provided in part by the Health Forward Foundation.