Tobacco use is associated with over 400,000 annual U.S. deaths. and one third of all U.S. cancer deaths (Pesko et al., 2017). Although cigarette smoking has declined in the United States (US), smoking prevalence remains high in specific subpopulations and continues to be the country’s leading cause of preventable disease and death (Rogers, Forster, & Unger 2018). Most groups affected by tobacco include vulnerable populations. Policies have been put into place to stop people from starting the use of tobacco, but Big Tobacco companies have the political power and money to keep their products in reach of these vulnerable populations. A new policy plan is needed to help those that need it the most in this battle against Big Tobacco.
Health Issue Identification and Assessment
Smoking prevalence varies by demographic subgroups including; race, economic status, and stress (Rogers, Forster, & Unger 2018). People that live below the poverty level have twice the prevalence rates of smoking compared to those above the poverty line, and people with serious psychological distress report dramatically higher prevalence of smoking compared to persons experiencing lower levels of stress (Rogers, Forster, & Unger 2018). Discriminatory stress resulting from ethnic, sexual orientation, or gender discrimination predicts tobacco product use among women and minorities (Rogers, Forster, & Unger 2018).
Financial strain is also associated with smoking and is commonly defined as people who are in debt, unable to afford basic survival items, poor housing conditions, long-term unemployment, and low income (Rogers, Forster, & Unger 2018). People suffering from severe financial strain increases quitting difficulty and increases the likelihood of relapsing (Rogers, Forster, & Unger 2018). Discriminatory and financial stressors are not equally distributed across populations and tend to vary by ethnicity, with disparities in tobacco product use especially pronounced in populations dealing with ethnic discrimination, such as African Americans, Asians/Pacific Islanders, Hispanics, and multiethnic communities (Rogers, Forster, & Unger 2018). The most frequently reported age range was 29 years and younger (Rogers, Forster, & Unger 2018).
There is another vulnerable population that doesn’t discriminate based on sexual orientation, socioeconomic status, or race and that would be people suffering from mental illness. Life expectancy for people with severe mental disorders is up to 25 years less in comparison to the general population, due to the diseases brought on by smoking tobacco (Ballbè et al., 2016). The prevalence of smoking in people with mental disorders is higher than in the general population (Ballbè et al., 2016). Smoking is viewed as a normal habit in the culture of mental health settings (Ballbè et al., 2016). In my hospital in our psych ward there is a designated place for people to go smoke. Patients with mental illness are less likely to receive advice to quit smoking than patients without mental illness (Ballbè et al., 2016).
Big Tobacco is not just targeting age appropriate individuals in our society. When this author has talked to any patient who has smoked, they all have said they started in their teenage years. Preference for Hip Hop music has been associated with increased tobacco use risk among youth (Walker et al., 2018). Hip Hop is more than a genre of music; it is a powerful “peer crowd,” or culture, that influences millions of people, including many African American and Hispanic youth, given the culture’s roots in these communities (Walker et al., 2018). Peer crowds are defined as macro-level connections between peer groups with similar interests, lifestyles, and influencers that transcend race/ethnicity and geography (Walker et al., 2018). It is not only the youth that Big Tobacco is targeted it is our minority youth in America.
Current and Ongoing Research
Pei et al. (2019) did a study using neuroimaging, self-report, and automated linguistic measures to investigate the relationships between neural responses to tobacco prevention messages, sharing engagement, and smoking-relevant belief changes. Thirty-seven adolescent nonsmokers viewed 12 ads from the U.S. Food and Drug Administration’s “The Real Cost” campaign during a functional magnetic resonance imaging scan session (2015−2016) (Pei et al., 2019). Neural activity in self- and value-related subregions of the medial prefrontal cortex during exposure to “The Real Cost” campaign was associated with subsequent sharing engagement, which in turn was related to social belief change (Pei et al., 2019). Increased brain activation in self- and value-related subregions of the medial prefrontal cortex during message exposure was associated with subsequent sharing engagement when participants verbally talked about the ads (Pei et al., 2019).
Current Prevention Strategies
The California Tobacco Control Program is the longest standing, publicly funded tobacco control program in the U.S. California’s adult smoking rate declined from 23.7% (1989) to 11% (2016) but California still has more than 3 million smokers dispersed over 58 counties, requiring a coordinated approach to further tobacco control (Kaslow et al., 2018). California now has the second lowest smoking prevalence in the nation, higher only than Utah, early California Tobacco Control Program success is rooted in public health policy strategies and a statewide media campaign that shifted social norms (Kaslow et al., 2018). California’s smokers are disproportionately low-income, facing multiple health disparities and barriers to accessing health care (Kaslow et al., 2018).
In 2009, concepts for a coordinated approach were introduced by the California Tobacco Control Program in the state’s first tobacco quit plan (Kaslow et al., 2018). Much of this success was achieved by employing population-level strategies including restricting and regulating smoking, taxing tobacco products, and a statewide media campaign to change social norms the state quit plan called for public health’s tobacco control programs to engage healthcare systems and insurers to work more directly with the California Smoker’s Helpline (Kaslow et al., 2018). Now, as tobacco prevention is increasingly prioritized for quality improvement, California Tobacco Control Program is funding CA Quits, a statewide tobacco-cessation learning collaborative and technical assistance resource to promote integration of tobacco treatment services and quality improvement activities into safety-net health systems (Kaslow et al., 2018).
Current Screening and Early Prevention Strategies
Fresh Empire is FDA’s first public education campaign designed to prevent and reduce tobacco use among at-risk multicultural youth ages 12–17, specifically African American, Hispanic, Asian-Pacific Islander, and Multiracial youth (Walker et al., 2018). Launched in the Southeastern United States in May 2015 and expanded nationally in October 2015, Fresh Empire targets the Hip Hop peer crowd to reach its intended audience (Walker et al., 2018). Peer crowd-targeted campaigns such as Fresh Empire have the potential to reach at-risk youth by focusing on message characteristics relevant to high-risk groups (Walker et al., 2018).
Current Policies and Current Policy Landscape
Health insurance may help tobacco users access effective smoking cessation treatments and, in turn, quit tobacco use (Pesko et al., 2017). The Affordable Care Act (ACA) improved insurance access overall by establishing marketplaces, which simplify purchasing non-group insurance, and offering premium tax credits that can reduce insurance costs for lower income families (Pesko et al., 2017). Previously, insurers could use health status to set premiums; insurers could charge sicker people more than healthy people (Pesko et al., 2017).
Health rating was banned by the ACA, but tobacco rating of up to 50% remained a criterion that could be used to differentiate premiums (Pesko et al., 2017). While charging tobacco users more for health insurance may reduce the moral hazards of tobacco use and provide a financial incentive to quit, tobacco rating may also cause health insurance to be unaffordable to smokers and reduce their access to healthcare services and products that could help them to quit successfully (Pesko et al., 2017). Consequently, it is to be noted that while there was an increase of non-tobacco smoker’s underneath healthcare.gov, there isn’t a decline in smoking (Pesko et al., 2017). Leading cause of this could be falsified documents saying they are non-tobacco users but in reality, still consume tobacco.
Tobacco Tax Increase Initiative
In 2016, California voters passed Proposition 56, which increased the statewide tax on tobacco products by $2.00 per pack, bringing the total tax to $2.87 into alignment with the taxes imposed by most other states (Kaslow et al., 2018). With California’s Medicaid (Medi-Cal) program expansion and the implementation of electronic medical record systems, health care plans and providers received additional support for system changes (Kaslow et al., 2018). Simultaneous with these changes, coordinated tobacco control efforts began, including California’s Medi-Cal Incentives to Quit Smoking project (2012 −2015) (Kaslow et al., 2018).
In the Medi-Cal Incentives to Quit Smoking project, safety-net providers and Medi-Cal plans were outreached and engaged to promote incentives for Medi-Cal members to utilize Helpline services (Kaslow et al., 2018). With the growth in Medi-Cal enrollment following the implementation of the ACA, and Medi-Cal’s transition away from fee-for-service care, the 28 Medi-Cal managed care plans have assumed a greater role in population health (Kaslow et al., 2018). Tobacco assessment and counseling has become an important quality metric for California safety-net hospital clinics participating in pay for performance programs administered by DHCS (Kaslow et al., 2018).
On July 10, 2015, the Minneapolis City Council followed the example of other cities such as Providence, Rhode Island; Santa Clara, CA; Chicago, IL; and New York, NY; and unanimously passed new restrictions on the sale of flavored tobacco products and set a minimum sales price for cigars Counter Tobacco (2019). In June 2017, San Francisco became the first city to completely restrict the sale of any flavored tobacco product, including menthol, within the city limits, without exception Counter Tobacco (2019).
The 2009 Family Smoking Prevention and Tobacco Control Act gave the United States Food and Drug Administration (FDA) the authority to regulate the manufacture, distribution and marketing of tobacco products to protect public health. Products included under this regulatory authority included cigarettes, smokeless tobacco, roll-your-own tobacco, and any other product the FDA deemed subject to the law. The Tobacco Control Act has dramatically changed how tobacco products are sold and marketed in stores.
On May 5, 2016, the FDA finalized additional deeming regulations on tobacco products. This expands products under FDA regulatory authority to also include electronic nicotine delivery systems (e.g. e-cigarettes, vape pens, e-hookah, advanced refillable personal vaporizers, electronic pipes), all cigars (including little cigars, cigarillos, and premium cigars), hookah (water pipe) tobacco, pipe tobacco, nicotine gels, dissolvable, and any novel and future tobacco products.
Health Policy Design
Minimum smoking age 21. The large majority of smokers start smoking before age 21. According to the National Survey on Drug Use and Health, over 80% of adult smokers smoked their first cigarette before they turned 18, and nearly 95% started before age 21. In 2005, Needham, Massachusetts was the first town in the US to enact a law raising the MLSA to 21. As a result, smoking rates decreased by 47%.
As part of their “Sensible Tobacco Enforcement” legislation,” New York City implemented a minimum pack size that requires that cheap cigars and cigarillos be sold in packages of at least four, and little cigars be sold in packages of at least 20. Haverstraw, NY: In 2012, the Village of Haverstraw, NY enacted a ban on the display tobacco products, specifically at stores that are open to minors. Policies that restrict tobacco product placement and display can help to counteract the tobacco industry’s efforts to attract new, current, and recently quit smokers through power walls.
Tobacco product display bans have been implemented in many countries, such as Iceland, Canada, Thailand, Australia, New Zealand, Finland, and the United Kingdom, as part of the World Health Organization’s Framework Convention on Tobacco Control. Evidence has shown high retailer compliance, de-normalization of tobacco use, and preliminary support for declines in tobacco use in combination with other comprehensive restrictions on tobacco promotions. The New York City Board of Health passed a resolution in September 2009 requiring health warnings and cessation information to be placed near the cash register or near the tobacco product display everywhere tobacco is sold in New York City (read more about the original proposal).
Preliminary research with adult current smokers and recent quitters both before and after the signs were posted showed an 11% increase in respondents who were thinking about quitting smoking. Unfortunately, in June 2010, the regulation was challenged in court by Phillip Morris, R.J. Reynolds, Lorillard, and a convenience store trade group in 23-34 94th St. Grocery Corp. v. N.Y. City Board of Health. In December 2010, the court ruled that implementation of the warnings was preempted by the Federal Cigarette Labeling and Advertising Act (FCLAA). This ruling was upheld in the U.S. Court of Appeal for the Second Circuit in July 2012.
Jefferson County, Alabama pioneered an innovative program based on voluntary commitments of store owners to the health of their communities. The United Way of Central Alabama and the Jefferson County Department of Health have worked together to start a program in which retailers post health warning signs in their stores. Signs were created based partially on the new graphic warning labels required by the 2009 FDA Act. Encouragingly, 51 convenience store owners voluntarily agreed to post the warning signs in their place of business, demonstrating strong commitment to the health of their communities. Through these signs and other communication strategies, the number of callers to the quitline (1-800-QUIT-NOW) exposed to this service by the media has more than doubled.