State lawmakers are expected to file a tobacco-control bill next year. Healthcare advocacy groups and local elected officials say communities must have the right to implement their own, stronger smoke-free protections.

Since 1996, Kentucky and a dozen other states have enacted so-called preemption laws, which bar cities and counties from deciding how tobacco products are marketed, sold and distributed at the local level.

Meanwhile, more than one third of Kentucky students report the pandemic has increased their use of e-cigarettes and vapes. McCracken County high school student Katharine Morrison said she sees her friends relying on tobacco to cope with stress and isolation during the COVID-19 crisis.

"I feel like people used it more because they were depressed and they thought that it was helping them," said Morrison.

Kentucky's rates of tobacco use are among the highest in the nation, and lawmakers have responded by implementing a statewide tobacco-free school policy, increasing tobacco taxes and raising the legal minimum age to buy tobacco products to 21.

The tobacco and vaping industries and some retailers continue to oppose local control, arguing it hurts sales and independent businesses.

Mayor of Prestonsburg Les Stapleton said he'd like the opportunity to implement measures to reduce smoking and improve the health of residents in his community.

"And I understand that a lot of laws have to be statewide," said Stapleton. "But it's a lot easier for some communities to be able to govern themselves on some issues."

State Sen. Paul Hornback - R-Shelbyville - said nicotine addiction will continue to be a costly public health issue if the cycle of tobacco use among young kids isn't stopped.

"And they're getting their hands on them in some way and go out and resell them to other kids," said Hornback. "There needs to be better control on that, you know. The flavors and everything else need to be eliminated."

In its "2022 Blueprint for Kentucky's Children," the group Kentucky Youth Advocates calls on the state to allow city and county governments to regulate the display, sale and distribution of tobacco products.

According to state data, last year, tobacco and e-cigarette companies spent more than $788,000 lobbying Kentucky lawmakers.

The American Lung Association has released its 2022 State of Lung Cancer report, which shows Indiana has some work to do.

The leading cause of lung cancer is smoking, and the state ranks high in the Lung Association report with 19% of Hoosiers doing so. Indiana also ranks high with the second leading cause of lung cancer, as 40% of home radon tests are at or above the Environmental Protection Agency action level. With early detection, the five-year lung cancer survival rate is 61%.

Tiffany Nichols, Indiana director of advocacy for the American Lung Association, said many people don't realize treatments are possible.

"Many Hoosiers don't understand that there are lifesaving treatments out there," Nichols observed. "I think we need to do a better job at letting people that are at risk of getting lung cancer know there are things out there. They don't necessarily have to die from lung cancer."

She encouraged people to ask their doctors to find out if they are eligible for a lung-cancer screening.

Indiana ranks 20th in the nation in early screenings, but it still represents only 7% of high-risk patients, and nationally only 5% are screened. The Lung Association maintains states should mandate coverage of lung-cancer screenings "in all fee-for-service and managed-care plans without any financial or administrative barriers in their Medicaid programs."

Nichols added health professionals need to advocate for screenings.

"I think health professionals need to make it known that there are screening things that are out there that can help to diagnose and to check for lung cancer early," Nichols urged.

In March of last year, the U.S. Preventive Services Task Force updated the recommendations around lung cancer screenings to include a larger age range and more current and former people who smoke.

A new report from Stanford University finds tobacco companies continue to directly target African Americans, women, and young people with their advertising, creating a larger market for a product which has been linked for years to cardiovascular disease and cancer.

It comes as efforts are underway at the state and federal levels to remove menthol cigarettes from the market.

Dr. Robert K. Jackler, professor at the Stanford University School of Medicine and the report's lead author, said the preference among the targeted groups for menthol cigarettes is the product of a concerted campaign.

"Urban heavily Black-populated areas got carpeted by billboards and signs in store windows, discount coupons," Jackler explained. "The companies would have vans that would give out free samples of cigarettes in poor neighborhoods."

In 2020, the California Legislature prohibited most flavored tobacco products, but the law was put on hold when the industry gathered signatures to force a referendum. In November, voters will consider Proposition 31, which upholds the restrictions. And the industry is funding the "No on 31" campaign, arguing blocking adults from buying menthol products would lead to a drop in sales-tax revenue and create an illegal market, increasing crime.

Jackler predicted voters will pass the ballot initiative, reaffirming the California Legislature's intention to remove most forms of flavored tobacco from the market.

"The tobacco industry is very cynical," Jackler asserted. "They used the initiative petition to buy a couple of more years of profit off of California. They knew they were going to lose this, I think, in the election."

The report finds tobacco companies market menthol to youth because it makes it easier to smoke, masking the taste and numbing the throat. It also noted menthol encourages deeper inhalation and thus, greater exposure to nicotine.

Dr. Jessica Sims, medical director of managed care at UCLA Health and an American Heart Association volunteer expert, thinks removing menthol cigarettes and flavored vaping products from the market will improve public health.

"Nicotine itself has been demonstrated to cause permanent harm to the teenage brain that's still developing," emphasized. "It causes difficulties with attention and memory, and can impact someone's trajectory in life."

In April, the FDA proposed to remove menthol cigarettes and flavored cigars from the market but no final rule has been issued. In 2009, Congress passed the Family Smoking Prevention and Tobacco Control Act, which prohibited all flavors other than tobacco and menthol in cigarettes.

After an investigation found the e-cigarette maker Juul Labs deliberately targeted young people using a variety of marketing practices, Tennessee is among the states that will benefit from the court settlement.

Juul has said its aim has been to "transition adult smokers away from cigarettes," but states argued that its advertising showed otherwise. Tennessee is one of 34 states that will share more than $438 million.

In addition to explicit advertising to kids, said Tennessee Attorney General Jonathan Skrmetti, the company is required to stop even so-called "subtle" forms of marketing through social media and other avenues "such as funding education programs, which let them put their name and the existence of their product in front of kids. They're not allowed to use people under the age of 35 in their marketing. So, they can't pay influencers; they can't use celebrities who are younger, who appeal to younger people."

He added that the company can no longer sell flavors that aren't approved by the Food and Drug Administration, or misrepresent the nicotine content in its products. Juul also will have to verify the age of its followers on Twitter and Instagram. Skrmetti said the settlement money will go into the Office of the Attorney General's Reserve Fund, to support ongoing consumer-protection efforts.

Skrmetti said the company's tactics, like those of big tobacco in previous generations, were aimed at creating a new crop of long-term customers.

"If they're adults and they choose to use these products, that is their choice," he said. "But when they're younger - when they're more vulnerable, when they're not in a position to make that informed decision - this settlement will protect them from the subtle manipulation that could otherwise turn them into lifelong consumers."

According to the Centers for Disease Control and Prevention, as of last year, around 2 million middle- and high-school students said they recently had used e-cigarettes.