The American Lung Association gives a federal agency and individual state governments poor marks in a new report card evaluating tobacco prevention programs.

The federal government is failing to act to protect kids from e-cigarettes, which can lead to a potential addiction, according to the association’s 17th annual State of Tobacco Control report. Tobacco, the leading cause of preventable death and disease in the nation, kills 480,000 people in the United States each year, while an additional 16 million are living with a tobacco-related disease.

North Carolina received an “F.”

NC report card on tobacco from ALA

In the report, the ALA “calls for the following actions to be taken by North Carolina’s elected officials to reduce tobacco use and exposure to secondhand smoke:”

  • Restore funding for tobacco use prevention and cessation programs, including QuitlineNC;
  • Increase the state cigarette tax to the national average of $1.78 per pack; and
  • Resist attempts to weaken the smokefree restaurants and bars law and expand the law to include all public places and private worksites

[The full report can be read online.]

Some of the harshest criticism is reserved for the US Food and Drug Administration, which received a grade of “F” from the lung association, primarily due to a “lack of action,” said Thomas Carr, an author of the new report and national director of policy at the American Lung Association.

The inaction, in particular the FDA’s passivity regarding vaping, is “putting the lives and health of Americans at risk,” said Carr, who noted the “staggering 78% increase among high school students and e-cigarette use in 2017-18.”

Regulation of e-cigarettes is the responsibility of the FDA, yet 20.8% of high school students are currently using e-cigarettes, said Carr. The escalation of vaping has “led both the US surgeon general and FDA commissioner to call teen e-cigarette use an ‘epidemic,’ ” he added. “That is a direct result of lack of regulation of the products.”

‘Lack of regulation’ resulted in high levels of teen e-cig use

Carr noted that the FDA said it would regulate e-cigarettes in 2011.

“Back then, e-cigarette use was at 1.5% among high school students, so that really was the time for action,” he said.

In fact, the FDA began regulating e-cigarettes in 2016, when it set 18 as the minimum sales age, while introducing additional requirements for retailers, and established standards for manufacturers.

More recently, the FDA has taken an “escalating series of unprecedented actions” to stop youth use of tobacco products, especially e-cigarettes, the agency stated. The FDA would not comment specifically on the Lung Association report and instead supplied a general statement to CNN.

“In the last year alone, the agency has advanced work to render cigarettes minimally or non-addictive, announced historic plans to ban menthol in cigarettes and cigars, and is exploring additional product standards,” according to the FDA.

US surgeon general warns of teen risks from e-cigarettes

“They’ve made a lot of announcements this [past] year, but there hasn’t been a lot of concrete action,” Carr said. “Yes, there has been an investigation of [e-cigarette giant] Juul, but that hasn’t led to a lot of meaningful policy change.”

The agency has also “advanced policies to increase access to, and use of, medicinal nicotine products to help people quit smoking, and has launched several adult and youth-focused tobacco public education prevention and cessation campaigns.” The FDA believes it “has made tremendous progress” on tobacco and nicotine regulation “with ambitious public health goals for 2019.”

Carr doesn’t buy it. The government’s general lack of action has “emboldened” the tobacco industry, which has become “very aggressive” in opposing or delaying state tobacco control measures, Carr believes. “They spent over $22 million opposing tobacco tax ballot measures in Montana and South Dakota, for example. If you know the populations of Montana and South Dakota, that’s a lot of money in those states. They clearly think tobacco taxes will reduce smoking among kids and adults.”

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Michael Shannon, a spokesman for R. J. Reynolds Tobacco Company, told CNN in an email that “some newspaper accounts incorrectly reported” that his company contributed to campaigns opposing tobacco tax ballot measures. “We had spent limited funds initially but did not contribute to the campaign,” he said. “Generally, we do oppose higher taxes on tobacco products as higher taxes are unfair to our consumers, who already pay over $40 billion in taxes and fees in the United States.”

Shannon added that R. J. Reynolds does not market to minors.

“Furthermore, we have provided FDA additional steps we are taking to address youth usage, such as supporting laws to raise the legal age of purchase to 21, and commit to work with FDA to combat youth use of tobacco,” said Shannon.

Altria and industry groups contacted by CNN did not respond to requests for comment.

How the association graded the federal government

The association graded the federal government in four areas.

The first grade specifically targets the FDA: “FDA regulations of tobacco products is how well they’re implementing the 2009 law that gave them authority over the manufacture, marketing and sale of tobacco products and also whether Congress is providing the funding to accomplish that,” Carr said.

A second grade assesses the effectiveness of the federal tobacco tax. The third grade evaluates quit-smoking coverage and examines the requirements of the four major health insurance programs that the federal government runs — Tricare, Medicaid, Medicare and federal employee health benefits — as well as those of the Affordable Care Act state marketplaces, Carr explained.

Finally, government-run mass media campaigns were ranked by the association: the CDC’s Tips from Former Smokers campaign, which is aimed at adults, and the FDA’s Real Cost campaign, aimed at kids 12 to 17.

Though the feds get a big A when it comes to media campaigns, they earn a D in coverage for quit-smoking programs and Fs for both taxation and regulation policies.

How the association graded states

The report card also lists five grades for each state: tobacco program funding, smoke-free air, tobacco taxes, access to cessation and “Tobacco 21.”

Even the best-performing states — Alaska, California, Hawaii, Maine, Massachusetts and District of Columbia — failed to get straight As in the five categories graded by the association, while the four states worst performing states scored Fs across the board: Mississippi, Missouri, Texas and Virginia.

The tobacco program funding grade is based on how much a state spends on programs intended to prevent kids from starting and to help people quit smoking, as compared to the funding levels recommended by the CDC for each state.

Smoke-free air is based on whether a state has prohibited smoking at work and public places, including restaurants and bars, and whether e-cigarettes are included in the law is factored into the grade, he said.

Similarly, the tobacco taxes grade takes into account the level of each state’s cigarette tax and whether the state taxes other tobacco products, including cigars and snuff but not e-cigarettes, Carr explained.

Access to cessation is “a bit of a complicated grade,” said Carr, who noted that this assessment includes whether a state’s Medicaid program and employee health plans cover quit-smoking treatments as well as the investment per smoker.

Finally, “some states have moved to increase the minimum age of sale of tobacco products to 21, so that’s what the ‘Tobacco 21’ grade looks at,” he said.

The lung association report also finds that no state is funding its tobacco prevention efforts at levels recommended by the US Centers for Disease Control and Prevention.