Severe Respiratory Disease Associated with Vaping: A Case Report

Evan Denis Schmitz MD

La Jolla, CA USA

Abstract

A case of severe respiratory disease associated with vaping cannabinoid oil is reported in a 38-year-old woman. She presented with shortness of breath and nonproductive cough. Chest x-ray and CT scan showed diffuse ground glass opacities and consolidation. Bronchoscopy showed diffuse bronchial erythema and bronchoalveolar lavage contained an increased percentage of eosinophils (59%). She was treated with high dose corticosteroids and rapidly improved.

Case Report

History of Present Illness

A 38-year-old woman complained of worsening shortness of breath and nonproductive cough for four weeks. She used to be able to climb three flights of stairs but now can barely walk ten feet. She had been treated with various forms of antibiotics, inhalers and steroids and was taking 20 mg of prednisone a day on the day of hospitalization. She also received opiates to help control her cough. She denied any hemoptysis, fever, chills, or sputum production. Because of her progressive symptoms she was hospitalized for further evaluation and management.

Past Medical History, Social History and Family History

She has a history of obesity and fibromyalgia. She has a prior history of smoking one to two packs a day for five years quitting approximately 15 years ago. Because of a family crisis she tried vaping cannabidiol (CBD) oil approximately one month prior to admission. She also resumed smoking tobacco one half a pack per day. Her family history was unremarkable.

Medications

She was taking prednisone 20 mg/day and cyclobenzaprine (Flexeril®) for her fibromyalgia. She was also taking codeine cough syrup.

Review of Symptoms

She did have some chest pain associated with her shortness of breath as well as chronic muscle aches and intermittent lower extremity edema. Her review of systems was otherwise unremarkable.

Physical Examination

Vital Signs: BP 137/72 mm Hg, Pulse 84 beats/min, temperature 98.8 °F, respirations 22 breaths/min, height 5’0, weight 231 lbs, SpO2 96%

General: She was morbidly obese and only able to speak in short sentences.

Mouth: Moist. Mallampati 3.

Pulmonary: Faint expiratory crackles. No wheezing.

Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard.

Abdominal: Soft, bowel sounds normal. No distension, mass or tenderness. No rebound or guarding. Centripetal obesity.

Extremities: Normal range of motion. No edema or tenderness.

Lymphatics: No cervical or supraclavicular adenopathy.

Neurological: Alert and oriented to person, place and time.

Skin: Warm and dry. No rash, erythema or pallor. Not diaphoretic. Capillary refill within normal limits. No skin tenting.

Psychiatric: Depressed mood.

Laboratory

Pertinent findings are on her laboratory evaluation include an elevated white blood cell count of 16,850 cells/µL with an increased number of neutrophils. Her electrolytes, liver enzymes, creatinine, blood urea nitrogen and urinalysis were within normal limits.

Radiology

Her admission chest x-ray is shown in Figure 1.

Figure 1. The admission portable chest x-ray showed bilateral patchy pulmonary infiltrates.

To better define the areas of consolidation, a thoracic CT scan was performed (Figure 2).

Figure 2. Representative images in lung windows from contrast enhanced thoracic CT scan showing nonspecific patchy areas of ground glass and alveolar opacities with septal thickening involving both lungs.

Hospital Course

Echocardiography was unremarkable. Bronchoscopy with bronchoalveolar lavage was performed. She had diffuse upper and lower airway erythema and considerable coughing during the procedure. The cell differential revealed an increase in eosinophils (59%) and multiple foamy macrophages. Smears and cultures of the lavage fluid were negative for pathogens. She was treated with high dose corticosteroids (methylprednisolone 1000 mg/day). She rapidly improved over four days with her cough and shortness of breath resolving. A chest x-ray at discharge revealed improvement of the pulmonary infiltrates (Figure 3).

Figure 3. Chest x-ray on the morning of discharge showing near resolution of her pulmonary infiltrates.

Discussion

At the time of this writing (9/21/19) there have been 530 cases of lung injury associated with e-cigarette product use or vaping reported with seven deaths (1).  Nearly three fourths (72%) of cases have been male with two thirds (67%) 18 to 34 years old. Most patients have reported a history of using e-cigarette products containing tetrahydrocannabinol (THC). Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine.

At present no specific e-cigarette or vaping product (devices, liquids, refill pods, and/or cartridges) or substance has been linked to all cases. It seems likely that there may be different mechanisms of lung injury from different substances. In support of this concept, the present case had high numbers of eosinophils in the bronchoalveolar lavage while other cases have shown an increase in neutrophils (2). Our patient was treated with high dose corticosteroids and did improve while on the corticosteroids. However, the time course does not establish a definite relationship between corticosteroid treatment and her improvement.

At present the CDC recommends refraining from using e-cigarette or vaping products (1). Anyone who uses an e-cigarette or vaping product should not buy these products (e.g., e-cigarette or vaping products with THC or CBD oils) off the street, and should not modify or add any substances to these products that are not intended by the manufacturer.

References

1. CDC. Outbreak of lung injury associated with e-cigarette use, or vaping. September 19, 2019. Available at: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html (accessed 9/21/19).
2. Arizona Thoracic Society. September 2019 Arizona thoracic society notes. Southwest J Pulm Crit Care. 2019;19(3):99-100. [CrossRef]

Cite as: Schmitz ED. Severe respiratory disease associated with vaping: a case report. Southwest J Pulm Crit Care. 2019;19(3):105-9. doi: https://doi.org/10.13175/swjpcc062-19 PDF 

Tobacco Company Campaign Contributions and Congressional Support of Tobacco Legislation

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

Although it is widely held that campaign contributions influence Congressional support for legislation, the impact of these contributions is unclear. Three bills involving tobacco regulation were introduced into the 2017-8 Congress and were co-sponsored in both the House of Representatives and Senate. One was pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act). The association between tobacco political action committee (PAC) campaign contributions with sponsorship of these bills was examined. Tobacco PAC contributions to sponsors of pro-tobacco HR564/S294 were significantly larger [$18218, 95% confidence interval (CI) $15077-$21359, p<0.01] than to non-sponsors ($8730, 95% CI, $6959-$10501). Sponsors of the anti-tobacco HR4273/S2100 received significantly smaller contributions ($2114, 95% CI $0-$4833, p<0.01) than non-sponsors ($12048, 95% CI, $10289-$13707). Similarly, sponsors of the anti-tobacco HR2878/S1341 also received significantly smaller contributions ($2500, 95% CI $0-$5284, p<0.01) than non-sponsors ($12097, 95% CI $10429-$13765). These data demonstrate a significant correlation between campaign contributions and legislative support of pro- and anti-tobacco legislation.

Introduction

Previously, it has been shown tobacco contributions influence state legislators in terms of tobacco control policy-making and support by Southwest US Members of Congress of The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441, aka the "Cigar Bill") (1,2). Although it is widely held that campaign contributions influence elected legislators, Powell (3) notes "political scientists have had great difficulty determining whether and how much influence contributions have on the legislative process". Studies have been inconsistent, with some demonstrating a linkage between campaign contributions and influence while others do not, suggesting that there are other influences in addition to contributions. Powell (3) has pointed out that the influence of donations is likely to occur early in the legislative process, such as during sponsorship for legislation or by directing that funds should be spent on a specific project (earmarks).

During the current 115^th Congress, the pro-tobacco “The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” was reintroduced (HR564/S294) (4). In addition, two anti-tobacco bills were introduced (HR4273/S2100 and HR2878/S1341) (4). Tobacco PAC contributions were examined for their association with sponsorship of these bills.

Methods

Tobacco Bills

The website Congress.Gov (4) was searched with the key word tobacco. Three bills were identified that had reached sufficient maturity to be introduced into the House of Representatives and the Senate and had co-sponsors listed in both the House and Senate. One was the pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act) (Table 1).

Table 1. Tobacco related legislation introduced during the 115^th session of Congress.

Sponsors and cosponsors were identified as listed on Congress.Gov.

Campaign Contributions

Tobacco company political action committee (PAC) contributions to members of Congress were obtained from the Campaign for Tobacco-Free Kids website (5). Contributions from the years listed (2006-18) were summed and no effort was made to separate recent from more past contributions.

Statistics

The relationship between sponsorship of the tobacco-related bills and tobacco PAC campaign contributions was done by Fisher's exact test using a 2X2 contingency table. Amounts of campaign contributions were expressed as means with 95% confidence intervals. The Mann-Whitney U test was used to calculate comparisons of the amounts of campaign contributions.

Results

Tobacco PAC Contributions

Sixty-five percent of the members of Congress have received a tobacco PAC contribution since 2006 (Appendix 1). The average reported was $11,637. Ten members received over $80,000, of which the largest was to Sen. Richard Burr (R-NC)($124,022); all but three were from what is referred to as the deep South. Over $6 million was donated in total; 82% of the donations went to Republicans.

Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (HR564/S294)

Ninety-four percent of the members of Congress who cosponsored the pro-tobacco "Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (aka Cigar Bill)" had received tobacco PAC campaign contributions (Appendix 2). In contrast, 53% of who were not cosponsors had received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was larger for those who had cosponsored the bill larger ($18218, 95% CI $15077-$21359) than non-sponsors ($8730, 95% CI, $6959-$10501, p<0.01 by Mann-Whitney U test).

Tobacco to 21 Act (HR4273/S2100)

Eighty-two percent of the members of Congress who cosponsored the anti-tobacco " Tobacco to 21 Act" had not received tobacco PAC campaign contributions (Appendix 3). In contrast, 35% of who were not cosponsors had not received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2114, 95% CI $0-$4833) than non-sponsors ($12048, 95% CI, $10289-$13707, p<0.01 by Mann-Whitney U test).

Children Don't Belong on Tobacco Farms Act (HR2878/S1341) 

Data were similar with the anti-tobacco “Children Don't Belong on Tobacco Farms Act”. Seventy-eight percent of the members of Congress who sponsored the bill had not received tobacco PAC campaign contributions (Appendix 4). Thirty-five percent of the members of Congress who had not cosponsored the bill did not receive contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2500, 95% CI $0-$5284) than non-sponsors ($12097, 95% CI $10429-$13765), p<0.01 by Mann-Whitney U test).

Discussion

This manuscript shows an association between tobacco PAC campaign contributions and sponsorship of both pro- and anti-tobacco legislation. More members of Congress who supported the pro-tobacco “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017” had received tobacco PAC campaign contributions and the contributions were larger compared to those not sponsoring the legislation. The data was the opposite for the anti-tobacco “Tobacco to 21 Act” and “Children Don't Belong on Tobacco Farms Act”. The percentage of the members of Congress who had not received tobacco PAC contributions was higher for those who sponsored the legislation compared to those who did not. Taken together these data suggest an influence of campaign contributions on the sponsoring of tobacco legislation in the US Congress.

The data in this manuscript confirms and extends the previous observations that tobacco contributions to state legislators and Southwest Members of Congress influence support of tobacco legislation (1,2).  The Southwest US is not a major tobacco growing or manufacturing region (7). Furthermore, tobacco consumption tends to be low in Southwest US (7). The Southwest is a good area to study the influence of campaign contributions because of the lack of confounding influences from a constituency that makes a living by tobacco growing or manufacturing or has a high prevalence of smokers. Reexamination of the correlation between tobacco PAC contributions and Congressional sponsorship of the "Cigar Bill" shows similar results with the data in 2016 (1, Appendix 1). The present study shows that association occurred in Congress as a whole and extended to anti-smoking legislation.

The title of HR564/S294 is deceiving. The “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” is titled to conjure up images of small businesses hand-rolling premium cigars. However, many of the cigars affected by the legislation are not the large, thick, and expensive ones manufactured with fine tobacco but rather small, thin, cheap cigars that are often flavored (8).

There is no doubt that smoking tobacco is harmful including cigars where the risk can be as high as or exceed those of cigarette smoking (9). Cigarette consumption in the United States is decreasing, compelling US tobacco companies to search for new markets (10). The cigar market, especially the flavored cigar market, represents one strategy to increase tobacco consumption and profits. Flavored cigar use is increasing in US middle and high school students (11). Therefore, tobacco companies support of the "Cigar Bill" is not surprising. By removing regulation, the tobacco companies can increase advertising to children and grow the candy-flavored cigar market (8).

The amount of money donated by the tobacco PACs is quite large and would seem to exceed anything that anti-tobacco smoking organizations could muster. Sixty-five percent of the members of Congress have received contributions totaling over 6 million dollars since 2006. The influence of these contributions may make regulation of tobacco quite difficult.

This manuscript has several limitations. Receiving tobacco PAC contributions and sponsoring pro-tobacco legislation does not necessarily represent cause and effect. It seems likely that tobacco companies would be more likely to support legislators that they perceive as sympathetic. It also seems likely that the tobacco PACs would be less likely to donate to supporters of anti-tobacco legislation.

References

1. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legislative behavior? Am J Public Health. 1998 Jun;88(6):918-23. [CrossRef] [PubMed]
2. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
3. Powell LW. The influence of campaign contributions on legislative policy. The Forum: A Journal of Applied Research in Contemporary Politics 2013;11(3):339-55. [CrossRef]
4. Congress.gov. Available at: https://www.congress.gov/ (accessed 3/26/18).
5. Campaign for Tobacco-Free Kids. Tobacco company political action committee (PAC) contributions to Federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions  (accessed 3/26/18).
6. Statistica. Statistics and facts about the tobacco industry. Available at: http://www.statista.com/topics/1593/tobacco/ (accessed 3/26/18).
7. Campaign for tobacco-free kids. Key state-specific tobacco-related data & rankings. Available at: https://www.tobaccofreekids.org/assets/factsheets/0176.pdf (accessed 3/26/18).
8. American Thoracic Society. ATS Joins Letter Opposing Cigar Exemption. October, 2017. Available at: https://news.thoracic.org/washington-letter/2017/ats-joins-letter-opposing-cigar-exemption.php (accessed 3/26/18).
9. Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015 Apr 24;15:390. [CrossRef] [PubMed]
10. Centers for Disease Control. Current Cigarette Smoking Among Adults in the United States. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm (accessed 3/26/18).
11. King BA, Tynan MA, Dube SR, Arrazola R. Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. J Adolesc Health. 2014 Jan;54(1):40-6. [CrossRef] [PubMed]

Cite as: Robbins RA. Tobacco company campaign contributions and congressional support of tobacco legislation. Southwest J Pulm Crit Care. 2018;16(4):232-6. doi: https://doi.org/10.13175/swjpcc053-18 PDF 

January 2018 Pulmonary Case of the Month

Lewis J. Wesselius, MD

 Departments of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 67-year-old man from Idaho was seen in November 2017 for a second opinion. He has a history of slowly progressive dyspnea on exertion for 7 to 8 years. He has a significant smoking history of 50 pack-years, but is still smoking “a few cigarettes”.

He saw an outside pulmonologist in September 2017 and was noted to have abnormal pulmonary function testing with the primary abnormality being a low DLco. A thoracic CT Scan was reported to be abnormal with evidence of interstitial lung disease. He underwent video-assisted thorascopic surgery and the biopsies were reported to show usual interstitial pneumonitis (UIP). His pulmonologist questioned whether this was interstitial pulmonary fibrosis or UIP associated with rheumatoid arthritis.

PMH, SH and FH

He has a history of rheumatoid arthritis and had been treated with methotrexate for approximately 8 years. His methotrexate had been discontinued in September with no change in symptoms. FH is noncontributory.

Medications

Prednisone 5 mg/daily and tiotropium (these also did not change his dyspnea).

Physical Examination

• Chest:  bibasilar crackles.
• Cardiovascular:  regular rhythm without murmur.
• Ext:  no clubbing, no edema, no joint deformity noted

Which of the following are indicated at this time? (Click on the correct answer to proceed to the second of five pages)

1. Obtain a complete blood count and rheumatoid factor
2. Begin pirfenidone or nintedanib
3. Review his pulmonary function testing and radiographic studies
4. 1 and 3
5. All of the above

Cite as: Wesselius LJ. January 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(1):8-13. doi: https://doi.org/10.13175/swjpcc157-17 PDF

Tobacco Company Campaign Contributions and Congressional Support of the Cigar Bill

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

Although it is widely held that campaign contributions influence support for legislation, the impact of contributions is unclear. Despite lack of a tobacco growing or manufacturing constituency, many members of Congress (MOC) in the Southwest support the pro-tobacco Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441), aka the "Cigar Bill". The association between campaign contributions from tobacco companies (2006-16) with cosponsor for the Cigar Bill were examined. There was a highly significant correlation with 92% of Southwest MOC who cosponsored the Cigar Bill having received campaign contributions. In contrast, 31% of those who did not cosponsoring the bill had received tobacco company campaign contributions (p<0.001 by Fisher's Exact Test). These data demonstrates a highly significant correlation between campaign contributions and legislative support for the "Cigar Bill".

Introduction

It is generally accepted that campaign donations buy influence from elected legislators. However, a review by Powell (1) states that "political scientists have had great difficulty determining whether and how much influence contributions have on the legislative process". Studies have been inconsistent with some demonstrating a linkage between campaign contributions and influence while others do not, suggesting that there are other influences in addition to contributions. Powell (1) has pointed out that the influence of donations is likely to occur early in the legislative process such as during cosponsorship for legislation or earmarks.

The Traditional Cigars Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441, aka the "Cigar Bill"), would permanently exempt hand-rolled and certain machine-rolled cigars from any sort of FDA regulation. This legislation is opposed by at least 20 medial and public health organizations including the American Thoracic Society (ATS), the parent organization of the state thoracic societies including those in the Southwest US (2). The ATS states that  “HR 662 would undermine the science-based process created by the Tobacco Control Act for determining the appropriate level of oversight of tobacco products. The bill would prohibit FDA from promulgating any public health protections related to 'traditional large and premium cigars'. The bill would specifically exempt from FDA oversight some machine made cigars, including those which can cost as little as $1.00. It also could allow some flavored cigars to qualify for an exemption. Inexpensive and flavored cigars such as strawberry, grape, cherry, and chocolate, are exactly the type of cigars attractive to young people.” Furthermore, the bill would create a giant regulatory loophole for the cigar industry to exploit, including advertising to children, growing the candy-flavored cigar market and returning to false advertising tactics such as "light" or "low tar", and allowing certain machine rolled cigars to be widely distributed.

The Southwest US is not a major center for tobacco growing or manufacturing (3). Furthermore, tobacco consumption tends to be low in Southwest US (4). Therefore, the Southwest is a good area to study the influence of campaign contributions on legislative behavior because of the lack of the confounding influence of a constituency that makes a living by tobacco growing or manufacturing and even has a low prevalence of smokers. In this context, we examined the correlation between prior campaign contributions to MOC and their cosponsorship of the "Cigar Bill".

Methods

Campaign Contributions

Tobacco company political action committee (PAC) contributions to Congressional candidates was obtained from the Campaign for Tobacco-Free Kids website (5). Contributions from the years listed (2006-14) were summed and no effort was made to separate recent from more past contributions. The data was examined for Southwest US Congressmen from Arizona, New Mexico, Colorado, California, Nevada and Hawaii. Appendix A shows contributions to individual Congressmen.

Cosponsorship of the "Cigar Bill"

HR 662 and S 441 were introduced in the 2015 Congress by Rep. Bill Posey (R-FL-8) and Sen. Bill Nelson (D-FL) respectively. Cosponsorship was obtained from Congress.gov (6,7). The bill was cosponsored by 165 members of the US House and 20 members of the US Senate. MOC who did or did not the "Cigar Bill" from Arizona, New Mexico, Colorado, California, Nevada and Hawaii are identified in Appendix B.

Statistics

The relationship between cosponsorship for the "Cigar Bill" and tobacco campaign contributions was done by Fisher's exact test using a 2X2 contingency table. Amounts of campaign contributions were expressed as mean + SD. The Mann-Whitney U test was used to calculate comparisons of the amounts of campaign contributions.

Results

Eighty-four percent of Southwest MOC who cosponsored the "Cigar Bill" had received tobacco campaign contributions. In contrast, only 31% of Southwest MOC not cosponsoring the "Cigar Bill" had received tobacco company campaign contributions (p<0.001 by Fisher's Exact Test). Furthermore, the amount of contributions was larger for those cosponsoring the bill $14024 + $18384 compared to those who did not $4165 + $11240 (p<0.01 by Mann-Whitney U test).

Discussion

This manuscript shows a relationship between tobacco campaign contributions and cosponsorship of the pro-tobacco "Cigar Bill". Furthermore, the campaign amounts tended to be larger to those supporting the legislation compared to those who did no cosponsor the bill. Taken together these data suggest an influence of campaign contributions on legislation.

There is no doubt that cigarette smoking is harmful. Cigarette use among adults and high school students is decreasing compelling US tobacco companies to search for new markets (8). The cigar market, especially the flavored cigar market, represents one strategy to increase tobacco consumption and profits. Flavored cigar and cigarette use is increasing in US middle and high school students (9). Tobacco manufacturers have a history of modifying their products to avoid public health protections or attain lower tax rates (2). Therefore, tobacco companies supporting the "Cigar Bill" is not surprising. By removing regulation the tobacco companies can increase advertising to children and grow the candy-flavored cigar market. Furthermore, it seems likely that cigar manufacturers will modify their products or change their manufacturing processes to qualify for the exemptions provided by the "Cigar Bill" thus increasing the number of cigars on the market.

The title of the HR 662/S 441 is deceiving. The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act is titled to conjure up images of small businesses hand-rolling premium cigars. However, many of the cigars being manufactured would not appear to be the large, thick, and expensive cigars manufactured with fine tobacco but rather small, thin, cheap cigars that are often flavored. There is little tobacco growing or manufacturing in the Southwest US making it difficult for the Congressmen to claim that they are supporting local small business. The lack of a constituency raises the question of why Southwest Congressmen are supporting this bill.  

This manuscript has several limitations. First, it seems likely that more recent campaign contributions might have greater legislative influence. However, we do not have campaign contributions after 2014 and made no effort to separate more recent from past tobacco company campaign contributions. Second, receiving tobacco company campaign contributions and cosponsoring the "Cigar Bill" does not necessarily represent cause and effect. It seems likely that tobacco companies would be more likely to support legislators that they perceive are sympathetic. Third, as pointed out by Powell (1), the issue of buying influence is likely more complex. For example, at least 2 of the legislators in Arizona object to smoking on religious grounds but have taken tobacco company contributions.  

Political support for any candidate is a complex issue. However, during this election year voters might wish to examine the behavior of their elected representatives and factor in support of pro-tobacco legislation when casting their ballot.

References

1. Powell LW. The influence of campaign contributions on legislative policy. The Forum: A Journal of Applied Research in Contemporary Politics 2013;11(3):339-55. [CrossRef]
2. American Thoracic Society. ATS opposes cigar bill in Congress. ATS Perspectives. Available at: https://www.thoracic.org/about/ats-perspectives/ats-opposes-cigar-bill-in-congress.php (accessed 8/9/16).
3. Statistica. Statistics and facts about the tobacco industry. Available at: http://www.statista.com/topics/1593/tobacco/ (accessed 8/9/16).
4. Campaign for tobacco-free kids. Key state-specific tobacco-related data & rankings. Available at: https://www.tobaccofreekids.org/research/factsheets/pdf/0176.pdf (accessed 8/9/16).
5. Campaign for Tobacco-Free Kids. Tobacco company political action committee (pac) contributions to Federal candidates. Available at: https://www.tobaccofreekids.org/what_we_do/federal_issues/campaign_contributions/ (accessed 8/9/16).
6. Congress.gov. H.R.662 - Traditional cigar manufacturing and small business jobs preservation act of 2015. Available at: https://www.congress.gov/bill/114th-congress/house-bill/662/cosponsors (accessed 8/9/16).
7. Congress.gov. S.441 - Traditional cigar manufacturing and small business jobs preservation act of 2015. Available at: https://www.congress.gov/bill/114th-congress/senate-bill/441/cosponsors?q=%7B%22search%22%3A%5B%22S441%22%5D%7D&resultIndex=1 (accessed 8/9/16).
8. Centers for Disease Control. Trends in current cigarette smoking among high school students and adults, United States, 1965–2014. Available at: http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/ (accessed 8/9/16).
9. King BA, Tynan MA, Dube SR, Arrazola R. Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. J Adolesc Health. 2014 Jan;54(1):40-6. [CrossRef] [PubMed]

Cite as: Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. doi: http://dx.doi.org/10.13175/swjpcc076-16 PDF