Hawaii’s tobacco report card is out – and the state got mixed grades.

Hawaii got an A for keeping public spaces free of smoke but earned an F for failing to prevent access to flavored tobacco products such as menthol cigarettes and fruity-flavored electronic cigarettes, according to a report by the American Lung Association.

While cigarette smoking has fallen to record lows in recent years due to a raft of tobacco control laws and gruesome yet effective public information campaigns, advocates and officials warn that Hawaii and the nation remain in the grips of a “vaping epidemic” among high school students and young adults.

“We saw our state being one of the best in tobacco use in youth – in 20 years, a lot of that has been eroded by vaping,” said Pedro Haro, executive director of the American Lung Association in Hawaii. “The new generation of adult tobacco users could be really astronomical in the cost of disease and death to the state.”

The 20th annual “State of Tobacco Control” report, published Wednesday, examines the tobacco use policies of all 50 states and the District of Columbia, giving letter grades in five categories: smoke-free air, program funding, tobacco taxes, quitting services and flavor restrictions.

Hawaii was early to ban smoking in most public areas, Haro said, including in restaurants and bars, government and private workplaces, state parks and within 20 feet of entrances, exits and air vents, and very much deserves its lone A grade, Haro said.

“The state really had a comprehensive law established back in 2006,” Haro said. “There’s very few people that are exposed to secondhand smoke through their work, which is really the foresight of legislators and advocates at the time bringing this forward.”

According to Hawaii law, vaping is considered the same as smoking a cigarette and is subject to the same location restrictions.

But despite its early success investing in smoke-free air and being the first state to raise the legal smoking age to 21, Hawaii has largely failed to prevent a new generation of teenagers from riding the wave of e-cigarettes, Haro said.

Driven by viral “vape” brands such as Juul, Vuse and NJOY, e-cigarettes have exploded in popularity since the 2010s. Lured by kid-friendly flavors with names like Frozen Lime Drop and Hawaiian POG — a take on island-favorite Passion Orange Guava — rates of vaping among Hawaii high school students tripled from 10% in 2013 to 33% in 2019, according to the Hawaii Youth Tobacco Survey.

Hawaii high school vaping rates of 10% were more than double the 4.5% national average in 2013, although mainland numbers have since caught up, according to the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System.

There are flavorless and tobacco-scented e-cigarettes available, but youth overwhelmingly choose the fun flavors. Of the 85% of young U.S. users who opted for flavored vapes in 2021, the CDC found 72% frequented the fruity flavors, while around 30% reported using the candy/dessert, mint and menthol flavors, respectively.

Yet despite this data, Hawaii currently has no law to target youth vaping by regulating the sale of flavored e-cigarettes, resulting in its failing grade in the ALA report card.

This is not for lack of trying – in the 2021 legislative session alone, lawmakers introduced at least six bills banning flavored tobacco from stores, in whole or in part. Five died in committee; the last, House Bill 826, made it through the House before the Senate amended it to exempt menthol-flavored tobacco products. House lawmakers disagreed, and the measure died.

“I know the conventional wisdom would say, ‘Let’s get rid of the pineapple and the juicy fruits or whatever, obviously, child targeting flavors,’” Haro said. “But the data shows that menthol is one of the most preferred flavors for youth, including Hawaii.”

While there are federal limits on certain flavored tobacco products, regulations are patchwork in nature and riddled with loopholes. For example, a Trump-era Food and Drug Administration policy banned most flavors of cartridge-based e-cigarettes but stopped short of curtailing flavors for disposable and other e-cigarette varieties.

Today, disposable e-cigarette line Puff Bar has become the favorite brand among youth, and flavored vapes and vape-refills remain readily available online and in-stores, a December 2021 Campaign for Tobacco Free Kids report found, leaving space for state-level intervention.

“States and cities cannot wait for the FDA and must act now to close the gaps left by the FDA in order to fully protect kids,” the report wrote.

While the e-cigarette industry and some public health experts maintain that vaping helps smokers quit the more-toxic cigarettes and, therefore, needs less regulation, opponents have pointed to signs of long-term lung illness and the potential for e-cigarettes to act as a “gateway” to nicotine addiction, especially among younger users.

In a 2016 survey of adult Hawaii e-cigarette users, 40% of respondents reported they had never smoked cigarettes before vaping. Another 21% continued to smoke regularly, while 12% said they started using cigarettes after they began vaping.

Besides its bookend-scores for limiting secondhand smoke and flavored tobacco, the ALA gave Hawaii a C for the taxes the state levees on various tobacco products and a C in its funding of tobacco control programs, with the state allocating just 62.6% of the $13.7 million recommended by the CDC, which calculates the amount according to the number of smokers in the state.

The state fared better in public access to tobacco cessation services, receiving a B for a well-funded tobacco quit line and treatment covered by the state’s Med-Quest Medicaid plan. The primary issue, Haro said, was the absence of a state mandate requiring private insurers to pay for these services.

“We just need that initial leadership to show again,” Haro said. “We need that initial spark to pass the legislation, allow the advocates to work with the communities to … finally see those tobacco numbers reduce.”

Civil Beat’s health care coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation and Papa Ola Lokahi.