Recommendations to advance equity in tobacco control.

Reducing racial and socioeconomic inequities in smoking has been declared a priority for tobacco control in the USA for several decades. Yet despite the rhetoric, these inequities persist and some have actually worsened over time. Although tobacco companies have targeted racially and ethnically diverse and lower-income tobacco users, which substantially contributes to these disparities, less attention has been given to the role of individuals and organisations within the tobacco control movement who have allowed progress in eliminating disparities to stagnate. We examine the failure of tobacco control professionals to ensure the widespread adoption of equity-focused tobacco control strategies. Review of major US tobacco control reports found that the focus on equity often stops after describing inequities in tobacco use. We suggest ways to advance equity in tobacco control in the USA. These recommendations fall across five categories: surveillance, interventions, funding, accountability and addressing root causes. Policy interventions that will have a pro-equity impact on smoking and related disease should be prioritised. Funding should be designated to tobacco control activities focused on eliminating racial and socioeconomic inequities in smoking, and tobacco control programmes should be held accountable for meeting equity-related goals.

A qualitative assessment of the perceptions and attitudes towards commercial tobacco policies and education among tribal communities in California.

Background: California has the largest American Indian and Alaska Native (AIAN) population in the United States and faces several commercial tobacco related disparities. This study assessed current interest, readiness, and knowledge regarding commercial tobacco control policies in California Tribal communities.Objectives: A community readiness assessment was conducted in California Tribal communities to understand commercial tobacco policies that included: Tobacco 21 (California State, and now federal, law restricting commercial tobacco sales to age 21 and over), tobacco tax, smoke-free worksites on Tribal lands, smoke-free households, and smoke-free indoor and outdoor areas in multi-unit housing.Methods: Twelve Tribal communities participated in focus groups and interviews between 2016-2019. Content analysis was utilized to code and data were analyzed using ATLAS.ti software.Results: A total of 165 community members participated (65% female), with most expressing support for unwritten, community-based "small p" policies, (e.g., placing signage to create a smoke-free perimeter). However, there was little to no support for "big P" policies (e.g., written ordinances on smoke-free casinos, smoke-free housing). Support for tobacco product taxation varied. The importance of Tribal sovereignty and the need for tobacco prevention and cessation programs for youth were two additional topics that emerged.Conclusions: Participants supported Tribal policies and wished for outsiders to respect Tribal sovereignty in this regard. Communities are currently working to raise awareness about the dangers associated with commercial tobacco use and would benefit from the responsiveness of future funders to these requests.

The African American Tobacco Control Leadership Council: Advocating for a menthol cigarette ban in San Francisco, California.

The African American Tobacco Control Leadership Council (AATCLC) is an advocacy group that works to inform the direction of tobacco control policy and priorities in the USA. This article narrates the AATCLC's work advocating for a comprehensive, flavoured tobacco product sales ban in San Francisco, California. Recommendations for tobacco control advocates and lessons learned from their work are provided. The article concludes by discussing conditions necessary to enact the policy. These include having a dedicated advocacy team, community support, a policy sponsor, and clear and repeated messaging that is responsive to community concerns.

Effects of Cigarette Prices on Intention to Quit, Quit Attempts, and Successful Cessation Among African American Smokers.

INTRODUCTION: This study examined the effects of cigarette price on intention to quit, quit attempts, and successful cessation among African American smokers in the United States and explored whether price effects differed by income level and menthol use status. Price effects were further compared to White counterparts. METHODS: We used pooled cross-sectional data from 2006 to 2007 and 2010 to 2011 Tobacco Use Supplements to the Current Population Survey to analyze 4213 African American recent active smokers. Three dependent variables were examined: any quit attempts in the past 12 months, successful cessation for at least 3 months, and intention to quit in the next 6 months. For each dependent variable, separate multiple logistic regression models were estimated to determine the impact of cigarette prices. RESULTS: There was no indication that price was associated with quit attempts or successful cessation, but price was positively associated with increased odds of intending to quit among African American smokers (p < .001). In contrast, prices were positively associated with intention to quit and quit attempts for White smokers. The association between price and intention to quit was significantly positive for African American low-income and menthol smokers but was not statistically significant for African American high-income and non-menthol smokers. There was no evidence of a price effect on quit attempts and successful cessation for each subgroup of African Americans. CONCLUSIONS: Tobacco tax policy alone may not be enough to increase quit attempts or successful cessation among African Americans. Community-based cessation programs tailored toward African American smokers, especially low-income menthol smokers, are needed. IMPLICATIONS: The results revealed that, among African American smokers, particularly among low-income and menthol smoking African American smokers, price appears to be positively associated with intention to quit; nevertheless, this deterrent effect does not appear to translate to actualized quit attempts or successful cessation. Increasing cigarette prices as a standalone policy may not be independently effective in increasing quit attempts and successful cessation within the African American community. Community-based cessation interventions tailored for African Americans are needed to help further translate desired cessation into actualized quit attempts.

Responsiveness to cigarette prices by different racial/ethnic groups of US adults.

OBJECTIVE: To evaluate the impact of cigarette prices on adult smoking for four US racial/ethnic groups: whites, African-Americans, Asians and Hispanics. METHODS: We analysed pooled cross-sectional data from the 2006/2007 and 2010/2011 Tobacco Use Supplement to the Current Population Survey (n=339 921 adults aged 18+) and cigarette price data from the Tax Burden on Tobacco. Using a two-part econometric model of cigarette demand that controlled for sociodemographic characteristics, state-level antismoking sentiment, local-level smoke-free air laws and monthly indicator, we estimated for each racial/ethnic group the price elasticities of smoking participation, smoking intensity and total demand for cigarettes. RESULTS: Smoking prevalence for whites, African-Americans, Asians and Hispanics during the study period was 18.3%, 16.1%, 8.2% and 11.3%, respectively. The price elasticity of smoking participation was statistically significant for whites, African-Americans, Asians and Hispanics at -0.26, -0.10, -0.42 and -0.11, respectively. The price elasticity of smoking intensity was statistically significant among whites (-0.22) and African-Americans (-0.17). Overall, the total price elasticity of cigarette demand was statistically significant for all racial/ethnic groups: 0.48 for whites, -0.27 for African-Americans, -0.22 for Asians and -0.15 for Hispanics. CONCLUSIONS: Our results suggest that raising cigarette prices, such as via tobacco tax increases, would result in reduced cigarette consumption for all racial/ethnic groups. The magnitude of the effect and the impact on cessation and reduced smoking intensity differ across these groups.

Tanning Capacity and Nicotine Dependence Among African Americans.

PURPOSE: Recent findings suggest a link between facultative melanin and nicotine dependence among African Americans. We hypothesized that tanning capacity is associated with the time to first cigarette (TTFC) of the day. METHODS: Using a criterion based sample of 150 adult African American current smokers, reflectometer measures of constitutive and facultative melanin, tanning capacity, smoking status and history, saliva cotinine, sociodemographic characteristics, and stress and discrimination scales were recorded. TTFC was categorized as: 1) within the first 5 min versus more than 5 min; and 2) within the first 30 min versus more than 30 min. Descriptive and multivariate analyses were conducted. RESULTS: Analysis revealed significantly higher tanning capacity among individuals who smoked their first cigarette of the day within the first 5 min of awakening (13.5) than among those who smoked after 5 min (10.3, p = 0.01) and among those who smoked within the first 30 min (12.8 vs. 9.6, p = 0.03) compared to those who initiated after this time point. Multivariate logistic regression indicated that tanning capacity was significantly and positively related (OR = 1.14, 95% CI = 1.05-1.22) to TTFC within the first 5 min and was also significantly related to TTFC within the first 30 min (OR = 1.13, CI = 1.03-1.23). CONCLUSION: Tanning capacity was positively associated with a behavioral measure of nicotine dependence among African American smokers. This association was consistent whether comparing smokers at higher or lower levels of dependence. Future research should examine tanning capacity and other indicators of melanin content with smoking cessation rates and tobacco-attributable health disparities.

The Association of Menthol Cigarette Use With Quit Attempts, Successful Cessation, and Intention to Quit Across Racial/Ethnic Groups in the United States.

INTRODUCTION: Few studies have examined the relationship between menthol use and smoking cessation across various racial/ethnic groups; the findings were mixed. This study explored the association of menthol cigarette use with quit attempts, smoking cessation, and intention-to-quit among US adults and by race/ethnicity. METHODS: Using the 2006/2007 and 2010/2011 Tobacco Use Supplements to the Current Population Survey data, this study analyzed 54 448 recent active smokers, defined as current smokers or former smokers who quit less than 12 months ago. Three behaviors were examined: any quit attempts in the past 12 months, successful cessation for ≥3 months, and intention-to-quit smoking in the next 6 months. For each cessation behavior, multiple logistic regression models were estimated separately for the full-sample and stratified racial/ethnic subsamples. RESULTS: While 72.3% of African American recent active smokers typically smoked menthol cigarettes, this proportion was 21.7%, 21.5%, and 28.0% for whites, Asians, and Hispanics, respectively. African American menthol smokers had higher odds of quit attempts compared to non-African American, non-menthol smokers (full-sample analysis), as well as African American non-menthol smokers (subsample analysis). Menthol use was not significantly associated with quit attempts in other racial/ethnic subsamples. There was no significant difference in either successful cessation or intention-to-quit between menthol and non-menthol smokers. CONCLUSIONS: African American menthol smokers were more likely to attempt to quit smoking than non-menthol smokers but these quit attempts did not translate into successful cessation. This study revealed no association of menthol use with quit attempts, successful cessation, and intention-to-quit among other racial/ethnic groups. IMPLICATIONS: The findings suggested that African American menthol smokers were more motivated to quit smoking; yet, the results also indicated no significant differences in successful cessation between African American menthol and non-menthol smokers. Interventions targeting menthol smokers within the African American community may help bridge this gap. While more local sales restrictions are beginning to occur (eg, Tobacco 21 efforts), additional policies restricting price discounting as well as the regulation of access to and the time, place, and/or manner of menthol tobacco advertising could also improve cessation rates. Further evaluation is needed to determine the viability of these policies.

"Tired of watching customers walk out the door because of the smoke": a content analysis of media coverage of voluntarily smokefree restaurants and bars.

BACKGROUND: News media are key sources of information regarding tobacco issues, and help set the tobacco control policy agenda. We examined US news coverage of voluntarily smokefree restaurants and bars in locales without mandatory policies to understand how such initiatives are perceived. METHODS: We searched three online media databases (Access World News, Lexis Nexis, and Proquest) for all news items, including opinion pieces, published from 1995 to 2011. We coded retrieved items quantitatively, analyzing the volume, type, provenance, prominence, and content of news coverage. RESULTS: We found 986 news items, most published in local newspapers. News items conveyed unambiguous support for voluntarily smokefree establishments, regardless of venue. Mandatory policies were also frequently mentioned, and portrayed positively or neutrally. Restaurant items were more likely to mention health-related benefits of going smokefree, with bar items more likely to mention business-related benefits. CONCLUSION: Voluntary smokefree rules in bars and restaurants are regarded by news media as reasonable responses to health and business-based concerns about worker and customer exposure to secondhand smoke. As efforts continue to enact comprehensive smokefree policies to protect all in such venues, the media are likely to be supportive partners in the advocacy process, helping to generate public and policymaker support.

Evaluating the implementation process of a citywide smoke-free multiunit housing ordinance: insights from community stakeholders.

We evaluated the implementation process of Richmond, California's citywide smoke-free multiunit housing ordinance. We conducted semistructured focus groups with multiunit housing tenants, owners, and managers. Residents understood the harms of secondhand smoke but lacked accurate information about the ordinance and questioned its enforceability. They shared concerns that the city lacked cessation resources for smokers wishing to quit because of the ordinance. To increase compliance with the ordinance, tenants, owners, and managers need accurate information.

"A breath of fresh air worth spreading": media coverage of retailer abandonment of tobacco sales.

OBJECTIVES: Media play an important role in the diffusion of innovations by spreading knowledge of their relative advantages. We examined media coverage of retailers abandoning tobacco sales to explore whether this innovation might be further diffused by media accounts. METHODS: We searched online media databases (Lexis Nexis, Proquest, and Access World News) for articles published from 1995 to 2011, coding retrieved items through a collaborative process. We analyzed the volume, type, provenance, prominence, and content of coverage. RESULTS: We found 429 local and national news items. Two retailers who were the first in their category to end tobacco sales received the most coverage and the majority of prominent coverage. News items cited positive potential impacts of the decision more often than negative potential impacts, and frequently referred to tobacco-caused disease, death, or addiction. Letters to the editor and editorials were overwhelmingly supportive. CONCLUSIONS: The content of media coverage about retailers ending tobacco sales could facilitate broader diffusion of this policy innovation, contributing to the denormalization of tobacco and moving society closer to ending the tobacco epidemic. Media advocacy could increase and enhance such coverage.

Being part of something: transformative outcomes of a community-based participatory study.

OBJECTIVES: Calls for public health practices, including research, to better integrate social theories of power, agency, and social change suggest that increased reflexivity about both the process and outcomes of community engagement is warranted. Yet few community-based participatory research (CBPR) projects specifically report nonresearch outcomes of such projects. The authors analyzed "secondary outcomes" of Protecting the 'Hood Against Tobacco (PHAT), a CBPR project conducted in San Francisco, California. METHODS: Interpretive analysis of quasi-ethnographic project documentation, including meeting minutes, field notes, retrospective observations, and interviews. RESULTS: PHAT participation created "ripple effects," encouraging healthier behaviors and public health promotion among community research partners, prompting academics to confront power asymmetries and recognize community knowledge, and widening social networks. CONCLUSIONS: CBPR benefits both communities and researchers beyond the findings of the research itself. More systematically capturing these effects, perhaps through wider use of ethnographic approaches, could help enhance understanding of CBPR's true contributions.

Quid pro quo: tobacco companies and the black press.

OBJECTIVES: We explored the relationship between tobacco companies and the Black press, which plays an important role in conveying information and opinions to Black communities. METHODS: In this archival case study, we analyzed data from internal tobacco industry documents and archives of the National Newspaper Publishers Association (NNPA), the trade association of the Black press. RESULTS: In exchange for advertising dollars and other support, the tobacco industry expected and received support from Black newspapers for tobacco industry policy positions. Beginning in the 1990s, resistance from within the Black community and reduced advertising budgets created counterpressures. The tobacco industry, however, continued to sustain NNPA support. CONCLUSIONS: The quid pro quo between tobacco companies and the Black press violated journalistic standards and represented an unequal trade. Although numerous factors explain today's tobacco-related health disparities, the Black press's service to tobacco companies is problematic because of the trust that the community placed in such media. Understanding the relationship between the tobacco industry and the NNPA provides insight into strategies that the tobacco industry may use in other communities and countries.

Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study.

PURPOSE: Describe racial/ethnic patterns of flavored tobacco use to illuminate equity implications of flavored tobacco policies. METHODS: Using data on US young adults (ages 18-34; n = 8,114) in the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019) and survey-weighted logistic regression, we estimated any flavors (regular brand) and mint/menthol (vs. other flavors) use by race/ethnicity among cigarette, e-cigarette, cigar, blunt, hookah, smokeless tobacco, and any tobacco product users. RESULTS: Any flavored tobacco use was common and was significantly higher for Black (75.1%; OR: 1.4; 95% CI: 1.2, 1.7) and Hispanic/Latinx (77.2%; OR: 1.4; 95% CI: 1.1, 1.7) users than White users (73.5%). The most pronounced difference across products was in menthol cigarette use between Black and White smokers (OR: 4.5; 95% CI: 3.5, 5.9). Among flavored product users, mint/menthol use was significantly higher for Latinx blunt and hookah users. DISCUSSION: Racial/ethnic disparities in flavored tobacco use include and extend beyond menthol cigarettes. Comprehensive flavored tobacco restrictions that include mint/menthol and non-cigarette products will likely have more equitable impact.

Menthol's potential effects on nicotine dependence: a tobacco industry perspective.

OBJECTIVE: To examine what the tobacco industry knows about the potential effects menthol may have on nicotine dependence. METHODS: A snowball strategy was used to systematically search the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu/) between 22 February and 29 April, 2010. Of the approximately 11 million documents available in the Legacy Tobacco Documents Library, the iterative searches returned tens of thousands of results. We qualitatively analysed a final collection of 309 documents relevant the effects of menthol on nicotine dependence. RESULTS: The tobacco industry knows that menthol overrides the harsh taste of tobacco and alleviates nicotine's irritating effects, synergistically interacts with nicotine, stimulates the trigeminal nerve to elicit a 'liking' response for a tobacco product, and makes low tar, low nicotine tobacco products more acceptable to smokers than non-mentholated low delivery products. CONCLUSION: Menthol is not only used in cigarettes as a flavour additive; tobacco companies know that menthol also has sensory effects and interacts with nicotine to produce tobacco products that are easier to smoke, thereby making it easier to expose smokers, especially those who are new and uninitiated, to the addictive power of nicotine.

Menthol sensory qualities and smoking topography: a review of tobacco industry documents.

OBJECTIVE: To determine what the tobacco industry knew about the potential effects of menthol on smoking topography-how a person smokes a cigarette. METHODS: A snowball strategy was used to systematically search the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) between 1 June 2010 and 9 August 2010. We qualitatively analysed a final collection of 252 documents related to menthol and smoking topography. RESULTS: The tobacco industry knew that menthol has cooling, anaesthetic and analgesic properties that moderate the harshness and irritation of tobacco. Owing to its physiological effects, menthol contributes to the sensory qualities of the smoke and affects smoking topography and cigarette preference. CONCLUSION: Our review of industry studies suggests that the amount of menthol in a cigarette is associated with how the cigarette is smoked and how satisfying it is to the smoker. If menthol in cigarettes was banned, as the US Food and Drug Administration (FDA) is currently considering, new/experimental smokers might choose not to smoke rather than experience the harshness of tobacco smoke and the irritating qualities of nicotine. Similarly, established menthol smokers might choose to quit if faced with an unpleasant smoking alternative.

Tobacco documents research methodology.

Tobacco documents research has developed into a thriving academic enterprise since its inception in 1995. The technology supporting tobacco documents archiving, searching and retrieval has improved greatly since that time, and consequently tobacco documents researchers have considerably more access to resources than was the case when researchers had to travel to physical archives and/or electronically search poorly and incompletely indexed documents. The authors of the papers presented in this supplement all followed the same basic research methodology. Rather than leave the reader of the supplement to read the same discussion of methods in each individual paper, presented here is an overview of the methods all authors followed. In the individual articles that follow in this supplement, the authors present the additional methodological information specific to their topics. This brief discussion also highlights technological capabilities in the Legacy Tobacco Documents Library and updates methods for organising internal tobacco documents data and findings.