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Devils Lake Park Board: Tobacco use policy to be drawn up

The Devils Lake Park Board is one step closer to solidifying guidelines for the use of tobacco products at its outdoor facilities.

By Harry Lipsiea, Devils Lake Journal Reporter

The Devils Lake Park Board is one step closer to solidifying guidelines for the use of tobacco products at its outdoor facilities.

At Monday’s regularly-scheduled meeting, the board voted unanimously to have director Terry Wallace write up a proposed policy and present it to the board for its approval.

Last month, Liz Bonney, Ramsey County Tobacco Prevention Coordinator with Lake Region District Health, brought the idea of a policy to limit areas in which tobacco products could be used at city parks.

The board looked at models currently placed in communities throughout the state of North Dakota. Ultimately, one seemed to jump out to board members as a policy that could fit well in Devils Lake.

“I like what Williston has done with its policy,” board member Kale Stromme stated. “It’s pretty cut and dry specifically when it talks about banning cigarettes in any area where youth are playing.”

The board agreed noting that the policy should include a ban of tobacco products near playground equipment. The board also felt that at baseball and softball diamonds, tobacco will be off limits during youth activities.

The only concern about such a policy was how to enforce the rules.

“There is no way to police the use of tobacco products at the park 100 percent of the time,” Bonney stated.

She pointed out that the policy would inform the public of rules in place. Bonney feels signage, to potentially be provided by Lake Region District Health, would be extremely beneficial.

“I don’t expect anyone to be out there at all times and stop what they are doing if they see someone smoking. That’s not realistic,” Bonney added. “This is a self-policing policy. I think the public will be compliant once they know there are guidelines in place.”

The board then voted for Wallace to form a policy similar to the one in Williston. It is expected to be presented for board approval at a future meeting.

In other business, the park board looked over an initial agreement proposal for the Creel Bay Golf Course. The golf course committee is set meet to go over items on a one-on-one basis later this week.

Also, the newly-added viewing area at the Mike Dosch Memorial Pool has been a hit, manager David Kerlin told the board.

“We have a gotten a lot of positive comments on it,” he stated.

http://www.devilslakejournal.com/article/20150616/NEWS/150619231

Cases of kids poisoned by e-cigs increasing in Minnesota

By Andy Rathbun / St. Paul Pioneer Press
Minnesota has seen a jump in the number of children poisoned by e-cigarettes and their liquid refillables, the Minnesota Department of Health said Wednesday.
From 2013 to 2014, the number of e-cigarette and e-liquid poisonings among Minnesota children 5 and younger rose 35 percent — the second year the Minnesota Poison Control System has seen a significant increase of nicotine poisonings related to e-cigarette products, the health department said in a news release. Poisonings from these products rose from three in 2012 to 62 in 2014.
E-cigarette products can contain a fatal amount of nicotine for a child, and about half of the cases last year were treated at emergency departments. Children can confuse the products, which are often flavored, with a candy or drink, the department of health said.
In January, a new state law took effect requiring child-resistant packaging for e-liquid products.
“This past year Minnesota took a big step to keep kids from accidently ingesting these potentially fatal e-liquids,” Minnesota Health Commissioner Ed Ehlinger said in a statement. “But parents should still use caution and store the products out of the reach of children.”
The symptoms that can result from nicotine poisoning include nausea, seizures, diarrhea, vomiting and difficulty breathing.
The department of health issued a nicotine heath advisory Wednesday that also warns teens and pregnant women of possible nicotine effects.
The drug can harm brain development during adolescence and harm fetal brain and lung development, the department said.
http://www.inforum.com/news/3763762-cases-kids-poisoned-e-cigs-increasing-minnesota

Star Tribune: Mpls. considers restrictions on flavored tobacco products

By Eric Roper Star Tribune

The sale of flavored cigars in convenience stores could soon come to an end in Minneapolis, where city officials are mulling the state’s first ban on the products at most traditional locations to curb youth tobacco use.

Anti-smoking advocates and small retailers squared off at a packed City Council hearing Monday over a proposal that would restrict sales of flavored tobacco products from more than 300 allowed locations to just under two dozen specialty tobacco shops. Similar bans have been enacted in New York City and Providence, R.I.

A council committee delayed a vote on the proposal, which targets flavored cigars, smokeless tobacco, shisha for hookahs and e-cigarette juice — but excludes menthol flavors. It would also set a minimum price on all cigars at $2.60 — echoing measures passed in Bloomington, St. Paul, Maplewood and Brooklyn Center.

Supporters said low-cost flavored cigars, sold under brands like White Owl and Swisher Sweets, are especially harmful because they entice young people to start smoking. A recent study of 530 underage youth in north Minneapolis found that more than half of the 313 who had used tobacco reported at one point smoking a cigar or cigarillo.

“Luring people to an addictive product with cheap prices and candy flavors before they’re old enough to know better doesn’t … give kids much choice,” testified Latrisha Vetaw of Northpoint Health and Wellness Center. Some of the non-tobacco flavors mentioned in the ordinance include chocolate, honey and vanilla, as well as fruits, herbs and candy.

City records show that 362 businesses are currently authorized to sell tobacco products in Minneapolis, though about a quarter of them are bars that largely sell cigarettes. The proposal would limit flavored tobacco sales to approximately 21 “tobacco products shops,” which generate 90 percent of their revenue from tobacco-related sales. It also clarifies that customers must be 18 to enter those stores.

Convenience store owners at Monday’s hearing challenged the necessity of the change, noting that it is already illegal for them to sell tobacco to minors. City records show that out of more than 350 undercover compliance checks each year, only about 6 to 7 percent result in violations for selling to a minor.

They also said that restricting tobacco sales threatens one of their core revenue streams. “Forty percent of our sales in the convenience store industry comes from tobacco. … That’s the industry average: 40 percent,” said Steve Williams, owner of Bobby and Steve’s Auto World, which has several locations. “So we’re affecting the viability of a lot of convenience stores.”

Ahmad Al-Hawari, who owns four convenience stores around the city, said while flavored cigars account for less than 5 percent of their business, the change could result in lost customers.

“A customer will walk or drive to a smoke shop, buy his flavored tobacco as he wishes … and then he’s going to buy cigarettes and pop from there,” Al-Hawari said. “He’s not going to go back to the convenience store.”

The federal government banned all flavored cigarettes except for menthol in 2009, but did not apply the same restrictions to cigars. Cigars may also be sold individually, versus in packs like cigarettes, making a common price about 99 cents each, according to a city staff report.

Paul Pentel, an internist at Hennepin County Medical Center, said their low cost also makes cigars an appealing option for adults who already smoke.

“In my clinic, I am very alarmed by the number of patients I see who have switched to cheap cigars because of the cost of cigarettes,” Pentel said. “For these patients, cheap cigars are a missed opportunity to quit smoking.”

New York City banned the sale of flavored tobacco products in 2009, except for at a handful of tobacco bars. A ban in Providence, R.I., went into effect in 2013. The state of Maine has also enacted a ban on small, flavored cigars.

Four Minnesota cities have already established minimum cigar prices. The minimum is $2.10 in St. Paul and Brooklyn Center, and $2.60 in Bloomington and Maplewood, city staff said.

Council Member Blong Yang, a cosponsor of the ordinance change, said he was drawn to the issue after seeing in the recent study from Breathe Free North, a program of Northpoint, that children have too much access to flavored tobacco. It also appears to be disproportionately affecting minority communities, he said.

“Every single convenience store that you go to it seems has all this stuff right in front of people, basically,” Yang said. “And it’s screaming for people to buy it because it’s there.”

The council’s health, environment and community engagement committee is expected to vote on the measure in two weeks, with a final vote before the full council possible in July.

http://www.startribune.com/minneapolis-mulls-restrictions-on-flavored-tobacco-products/306572261/

LA Times: California Senate votes to restrict e-cigarettes as tobacco products

By PATRICK MCGREEVY

The state Senate on Tuesday approved a bill that would ban electronic cigarettes from restaurants, theaters and other public places in California where smoking is prohibited to address health concerns.

Sen. Mark Leno (D-San Francisco) said his bill would treat e-cigarettes, also known as “vaping” devices, as tobacco products because they often use nicotine and are popular with teenagers.

Youth e-cigarette use rising; heart group calls for regulation

“Of great concern is that the fastest growth segment of new users is among middle and high school students who are now smoking electronic cigarettes,” Leno told his colleagues. “They are advertised on television. They are advertised on billboards.”

The measure, which would also subject e-cigarettes to the same licensing requirements as tobacco, was approved by a 24-12 vote, with Sen. Jeff Stone of Murrietta the only Republican to vote for the bill.

Senate Republican leader Bob Huff of Diamond Bar said e-cigarettes work on vapor that does not spread as much as tobacco smoke, so they should be treated differently in public.

“E-cigs are used by people trying to kick the tobacco habit,” Huff said. He voted against the bill, saying the state should wait until the federal government takes action.

Stone noted that his mother was a former smoker who died of cancer. He said the tobacco and vaping industries are marketing e-cigarettes to young people with flavors including watermelon, tutti frutti and cotton candy while the vapor has nicotine derived from tobacco. He said “vaping” is a gateway to cigarette smoking.

“Now we are exposing a whole new generation of millenials to this fashionable way of smoking tobacco in a way that is going to jeopardize their lives,” Stone said. The measure next goes to the Assembly for consideration.

http://www.latimes.com/local/political/la-me-pc-california-senate-votes-to-restrict-ecigarettes-like-tobacco-products-20150602-story.html

Reuters: California Senate votes to raise smoking age to 21 from 18

LOS ANGELES | BY ALEX DOBUZINSKIS
The California Senate voted on Tuesday to raise the legal smoking age in the most populous U.S. state to 21 from 18, in a move that could make California one of the states with the highest smoking age.
The measure was approved by the Senate 26-8 and must now be approved by the state Assembly.
“We will not sit on the sidelines while big tobacco markets to our kids and gets another generation of young people hooked on a product that will ultimately kill them,” Senator Ed Hernandez, a Democrat and the bill’s author, said.
“Tobacco companies know that people are more likely to become addicted to smoking if they start at a young age,” Hernandez added in a statement.
The Institute of Medicine, the health arm of the National Academy of Sciences, has said that increasing the smoking age to 21 would result in more than 200,000 fewer premature deaths nationally for those born between 2000 and 2019.
The Cigar Association of America opposed the bill, contending that 18-year-olds can serve in the military, vote and sign contracts and should thus enjoy the right to smoke, according to the Los Angeles Times.
David Sutton, a spokesman for Altria Group Inc, the parent of Philip Morris USA, said in an emailed statement that Altria believed states should defer to the federal government and “allow FDA and Congress the opportunity to think through this issue further before enacting different minimum age laws.”
Representatives for R.J. Reynolds Tobacco Company, a unit of Reynolds American Inc, did not return calls seeking comment.
Hawaii lawmakers approved a measure in April to raise the smoking age to 21, and that is awaiting the state governor’s signature. Democratic Governor David Ige has not indicated whether he will sign the measure, and has until June 29 to decide whether to veto it, a spokeswoman for his office said.
Since 2013, New York City has required tobacco purchasers to be 21 or older, according to the National Conference of State Legislatures. No state has a smoking age that high, but Alabama, Alaska, Utah and New Jersey set it at 19.
(Reporting by Alex Dobuzinskis and Cynthia Johnston; Editing by Sandra Maler)
http://www.reuters.com/article/2015/06/02/us-usa-smoking-california-idUSKBN0OI2EI20150602

Forum editorial: Minnesota tobacco use down

The anti-tobacco work of ClearWay Minnesota in conjunction with other tobacco cessation efforts has had remarkable results in reducing smoking rates among all age groups in Minnesota. It’s a record worthy of high praise. It’s unambiguous evidence that focused, science-based anti-tobacco campaigns can work.

Numbers released last week by ClearWay show only 14.4 percent of Minnesotans smoke cigarettes, down from 22.1 percent in 1999. The decline through the time period has been steady, and corresponds to increased education and imposition of legal restrictions on smoking in public places. Add new medical research about second-hand smoke, and graphic anti-smoking television advertising, and it appears the multi-faceted message is getting through.

But not to every age cohort.

In ClearWay statistics from 2010 to 2014, smoking hardly dipped at all (1 percent) in the 25-44 year-old group, from 19.7 percent to 18.7 percent. A similar slight improvement was measured in the 45-64 year-old cohort, compared with a huge drop (from 21.8 percent to 15.3 percent) in Minnesotans age 18-24. Which could lead to the conclusion that some Minnesotans don’t get smarter as they age. But whatever the reason, the overall percentages of all Minnesotans who smoke is down over the longer study period, and that’s good news for smokers who quit, non-smokers and reduced impacts on health costs associated with tobacco use. The trends are good.

ClearWay is not resting on its excellent record. In the eight years it has left in its mandate (funded by the national tobacco settlement of a few years back), the agency’s agenda includes raising cigarette taxes, which all studies show discourage young people from purchasing tobacco, and raising the age for tobacco purchases from 18 to 21. Again, research finds that raising the age to beyond high school age contributes to fewer high school students trying tobacco. New York City and Hawaii have already taken that step.

There is still much to be accomplished to achieve as smoke-free a society as possible. A lot has been done, often led by private sector companies that banned smoking from the workplace before cities and states enacted overall smoking bans in buildings and, in many instances, outdoor public spaces. Decades of research into smoking-related illness and death, and the proven health hazards of secondhand smoke, have been the underpinnings of changing public policy. ClearWay’s work and similar complementary efforts have been pivotal in changing the way enlightened Americans view tobacco use.

Forum editorials represent the opinion of Forum management and the newspaper’s Editorial Board.

http://www.inforum.com/opinion/editorials/3751883-forum-editorial-minnesota-tobacco-use-down

Fargo Forum: Anti-tobacco groups eye raising purchasing age to 21 in Minnesota

By Patrick Springer

MOORHEAD – Minnesota tobacco control advocates may propose raising the legal age for buying cigarettes to 21 years old.
Hawaii, New York City and more than 30 municipalities in Massachusetts have raised the legal age for buying tobacco, and the experiment will be closely watched, said Andrea Mowery, vice president of ClearWay Minnesota, a foundation that promotes prevention and cessation of smoking and tobacco use.
ClearWay Minnesota, funded by the state’s share of the 1998 tobacco settlement, will only move ahead with a proposal if a wide consensus of health groups and public health groups agree the approach has merit, Mowery told The Forum editorial board.
“We’re part of a broad coalition,” she said, and listed the American Cancer Society, American Lung Association and American Heart Association as frequent partners. “There’s a very collegial and collaborative process.”
More than 9 of every 10 smokers start before the age of 19 or 20, a reality that is behind the nascent movement to raise the legal age for buying tobacco, Mowery said.
Earlier efforts, which public health officials credit with reducing smoking rates, have centered on raising tobacco taxes and banning smoking in public places.
Teenagers are especially sensitive to price increases spurred by tax increases, which have been shown to be the most effective means to date of curbing youth smoking, Mowery said.
“Youth and young adults are much more sensitive to price,” she said.
Smoking prevalence continues to decline in Minnesota, where the smoking rate stood at 14.4 percent last year, down 35 percent since 1999 and the lowest rate ever recorded, according to the Minnesota Adult Tobacco Survey in 2014.
“So really significant progress,” Mowery said.
The national adult smoking rate is 19 percent. In North Dakota, the adult smoking rate was 21.9 percent in 2011, according to the Centers for Disease Control.
Persistent gaps remain in smoking rates, with those who have less than a high-school education the most likely to smoke, with a rate of 28.6 percent.
Young adult smoking decreased by 6.4 percentage points over the past four years, dropping to 15.3 percent from 21.8 percent, the only noteworthy decline for any age group.
“That is quite a stark departure,” Mowery said.
But that drop coincided with a sharp spike in the use of e-cigarettes, which jumped from a rate of 0.7 percent to 5.9 percent from 2010 to 2014.
The age group most likely to smoke is the 25- to 44-year-old bracket, with a rate of 19.7 percent for men and 18.7 percent for women.
American Indians smoke at a rate that far surpasses the overall population—a rate of 59 percent, quadruple the 14.4 percent overall rate.
“On the whole we’re making good progress,” Mowery said, adding that challenges remain.
http://www.inforum.com/news/3748538-anti-tobacco-groups-eye-raising-purchasing-age-21-minnesota

"Darth Vapor" Sending Students to the Hospital

Reported by Michigan 9 & 10 News

A new form of synthetic marijuana is sending teenagers to the hospital.

A Mason County student is in critical condition after inhaling something called “Darth Vapor”, a substance smoked with an E-cigarette.

School officials at Journey High School in Scottville called 911 yesterday afternoon after the 19-year-old had a seizure.

And it’s not the first problem with the drug in the area.

The sheriff says this is the fourth time since March that they’ve seen an overdose on the vapor. They had it tested, and confirmed it’s a form of synthetic marijuana.

It’s not regulated by the state, which he says, makes it hard to prevent more trips to the ER.

“Just because it’s not regulated by state law doesn’t stop you from being a parent. Your parental rights trump state law as far as I’m concerned,” says Mason County Sheriff Kim Cole.

The sheriff wants parents to help prevent more overdoses on “Darth Vapor”, which put a 19-year-old in critical condition

“The big thing is the parents need to know what these kids are getting into. If you see your child has a e-cig look into that, question why they have it and what they’re putting into it because you mark my words were going to be doing a story on somebody dying,” says Sheriff Cole.

Doctors say smoking vapors is the most dangerous way to ingest something, because the toxins have direct access to your blood.

“It’s almost like taking it in an IV. I mean you just absorb it and it doesn’t go through your liver. So you’re getting the drug directly into the vein, into the circulation,” says Dr. Robert Kowalski, and MD at Munson Healthcare Cadillac Hospital.

And because these vapors are so new and unregulated, treatment can be difficult.

“Most of the treatment for these overdoses is symptomatic. In other words we don’t have a specific antidote for these medications or drugs,” says Kowalski

A business in Ludington has agreed to take the vapor off the shelves, but teens can still manage to get their hands on it.

“I would, you know, tell young adults and children that sell it to you. They’re not pharmacists. They’re not physicians they just want to sell you the drug,” says Kowalski.

All of the overdoses involved students in mason county. The Ludington Schools Superintendent says they’re working with staff and students to prevent problems in the future.

————————-

A 19-year-old is in critical condition after inhaling a substance from an e-cigarette.

The call came in Monday afternoon from Journey High School in Scottville.

The man used an e-cigarette to inhale the substance that caused him to overdose.

The Mason County Sheriff says a 16-year-old was taken to juvenile court for giving the vapor to the 19-year-old.

During the investigation, deputies also found an unloaded rifle in the 16-year-old’s car.

The 19-year-old was airlifted to a Grand Rapids hospital for treatment.

Stay with Northern Michigan’s News Leader throughout the day on air and online for more information on this developing story.

http://www.9and10news.com/story/29102864/19-year-old-in-critical-condition-after-inhaling-e-cigarette-substance

Opinion: E-cigarettes: Doctors' View: E-cigarette, tobacco smoke enough alike to warrant regulation

By Terry Clark, Mary J. Boylan and Joseph Bianco

What are e-cigarettes? Have you ever seen one? Do you know how they work? Are they as bad for your health as traditional cigarettes?

It is fair to say that three or four years ago these were new questions and we did not know the answers. But now we do, and it is certainly time for you to know — and for our St. Louis County Board of Commissioners to know as they consider a vote to help protect citizens of our county from the “invisible” harm caused by these gadgets if being used indoors.

Details about e-cigarettes and their health effects are well-described in a recent report from the California Department of Health, and even more recent good information on e-cigarettes can be found in the News Tribune’s “Our View” editorial on Friday, headlined, “County up next in quest for clear air.”

E-cigarettes is a good news/bad news story. Are they less toxic than traditional cigarettes? Likely. Are they really safe to use? Not likely.

First, how do they work? With no tobacco or cigarette paper to burn, there’s no smoke. They really are electronic gadgets with several sections, one with a small battery, one with a small amount of fluid usually containing some nicotine as well as flavoring and other chemicals, and a high-temperature chamber that converts the liquid into an aerosol or fog to be inhaled by the user (an action called vaping) and then exhaled where it is readily inhaled by those around the user.

What is in this aerosol emitted by the e-cigarette? At least 10 chemicals known to cause cancer, birth defects or other reproductive harm, including nicotine, formaldehyde, heavy metals and volatile organic compounds, according to the report. It’s not what you or your favorite teenager should be exposed to.

Nicotine, a key ingredient in the aerosol, is highly addictive. Of course, that is why so many users of traditional cigarettes said for years that they could quit whenever they wanted but usually never could.

We should all wonder why the three major tobacco companies purchased start-up e-cigarette companies. What do they know that we do not? One thing is this: Kids who start using purportedly safer e-cigarettes often switch and become traditional smokers or, even worse, dual smokers who use both e-cigs and traditional tobacco cigarettes. They are then addicted to nicotine for decades. Is that what the big tobacco companies are banking on?

Our elected county leaders soon will vote on this simple question: Should e-cigarette use indoors be regulated as a public health hazard just like traditional tobacco smoke? That is, no smoking in indoor places such as worksites, bars, restaurants, stores, arenas, etc.

The city of Duluth and many other communities in Minnesota already have answered this question in the affirmative: Yes, e-cigarette aerosol and tobacco smoke have enough in common to warrant being regulated in the same way under the Minnesota Clean Air Act.

In short, keep them outside.

Terry Clark and Mary J. Boylan are doctors from Duluth. Joseph Bianco is a doctor from Ely.

http://www.duluthnewstribune.com/opinion/columns/3742094-e-cigarettes-doctors-view-e-cigarette-tobacco-smoke-enough-alike-warrant

Reuters Health: Youth who receive tobacco coupons may be more susceptible to smoking

BY KATHRYN DOYLE

(Reuters Health) – Middle and high school students exposed to tobacco coupons were more likely to find smoking “cool” and less likely to feel confident in quitting if they already smoked, according to recent U.S. survey data.

Some kids may encounter the coupons for free or discounted tobacco products passively, via direct mail campaigns aimed at their parents, but the coupons are also often sent by email and are readily available on the Internet.

“In previous studies, my collaborators and I found that exposure to cigarette coupons predicts smoking progression in youth and young adults and reduces likelihood of cessation among general adult smokers from the U.S. upper Midwest,” said the study’s author, Dr. Kelvin Choi of the National Institute on Minority Health and Health Disparities in Bethesda, Maryland.

This new national sample of middle and high school students who were included in the current analysis can be generalized to youth across the United States, Choi told Reuters Health in a statement.

Choi’s opinions do not necessarily reflect those of the National Institutes of Health, Department of Health and Human Services, or the United States Government, the statement added.

Using the National Youth Tobacco Survey 2012, Choi examined questionnaire responses from more than 24,000 middle and high school students, who reported if and where they had received coupons from a tobacco company over the past 30 days.

Almost 10 percent said they were current smokers, 16 percent were experimenters and almost 75 percent were non-smokers.

Thirteen percent of the students had received tobacco coupons over the previous month, most often digitally – by text message, Internet or social networks – and sometimes by paper mail or on tobacco packages themselves.

In the survey, kids who had been exposed to these coupons in any form were less likely to disagree with positive statements about cigarette smoking, such as that it helps young people fit in and have more friends. They were also less likely to agree with negative statements, such as that all tobacco products are dangerous.

The kids who were exposed to the coupons but had never smoked gave survey responses that suggested they were more susceptible to trying smoking, and those who were smokers gave responses suggesting they were less confident in their ability to quit.

Among those who experimented with cigarettes, kids who saw the coupons were more likely to purchase cigarettes over the next month, as reported in Tobacco Control.

“It is well-established that a wide variety of psychosocial factors are associated with smoking and are likely on the causal pathway to smoking,” said Dr. Jennifer O’Loughlin of the department of social and preventive medicine at the University of Montreal in Canada, who was not part of the new study.

“Note that one of the determinants of tobacco use is pricing,” O’Loughlin told Reuters Health by email. “Coupons directly reduce the price and may be a powerful incentive for tobacco use.”

But with a study of only one point in time, like this one, it is difficult to determine which came first, the coupons or the smoking, she said.

Without a long-term study randomizing kids to receive these coupons, it will be difficult to establish that the coupons cause kids to smoke, and therefore difficult to hold coupon distributors responsible, she said.

“In kids especially (who may be particularly vulnerable to advertising and promotion), it is vital to combat anything that contributes to the social norm that tobacco smoking is OK,” O’Loughlin said.

Since kids can download coupons from the Internet easily, they may easily do so without their parents’ knowledge, she said.

“We found that cigarette companies say on their websites that they do not target anyone under the age of 21 with direct mail materials, although their compliance with this self-regulation is unknown,” Choi said. “Interested youth could also potentially bypass the age-verification on cigarette company websites using someone else’s or inaccurate identification.”

On the Internet and in social network channels, it is much harder, if not impossible, to enforce stringent age-verification, he said. “Plus, as we found in a previous study, individuals give coupons to others if they don’t use them,” he said.

http://www.reuters.com/article/2015/05/06/us-adolescent-smoking-coupons-idUSKBN0NR25Q20150506