Following a successful 2016 ballot initiative that raised the tobacco tax to provide additional funding for the California Tobacco Control Program , CTCP defined its goal as “end[ing] the tobacco epidemic for all population groups” by 2035. This was the first time CTCP had specified an “endgame” goal. There is no agreed-upon policy approach for the tobacco endgame, and internationally, countries have adopted different goals and metrics. CTCP, in setting a goal without a more concrete definition of how it will be achieved, is following this trend. Additionally, this has been CTCP’s approach generally, to support local policy innovation without imposing specific requirements. In previous research, conducted November 2016-April 2017, advocates and legislators active in California tobacco control, while supportive of the “endgame” idea and various policies proposed to achieve it, favored incremental policy measures over abrupt changes. Participants also raised concerns about equity and the potential unintended consequences of rapid policy change. Since that study a wave of new policy activity has swept California, with more than 27 cities and counties instituting bans on sales of some or all flavored tobacco products , or passing other new policies restricting the sale or use of tobacco, or both.Advocates help set the agenda for the public and policymakers,greenhouse rolling racks remove barriers to the adoption of policies, and counter interest group opposition. Local advocates have the most knowledge about their policy environments and may see opportunities for, or challenges to, endgame policy implementation and enforcement that others would miss.
To better understand how local advocates understand endgame oriented policies, we interviewed advocates from California communities that had recently adopted tobacco control policies and explored how they are thinking about their work in terms of tobacco endgame goals. This research can provide a model for investigating the ideas and concerns of the advocates best positioned to understand popular sentiment about local tobacco control policy. In the U.S., policy innovation often appears first at the local level, where advocates are most influential and the industry is weakest; these innovations are then gradually adopted by other localities, states, or nations. Drawing on personal knowledge and recommendations from members of tobacco control networks, we identified and interviewed a purposive sample of advocates in 5 California counties and 1 city that had recently adopted tobacco control policies . Six participants had been involved in these campaigns but worked for statewide or national organizations. These policies included several approaches only recently added to California’s tobacco control agenda, such as bans on the sale of some or all tobacco products, minimum pricing, raising the minimum age of tobacco purchase from 18 to 21 , and laws that prohibit smoking in multi-unit housing , such as apartments, to prevent smoke from drifting into other units, with enforcement mechanisms that vary by jurisdiction. Table 2 provides details on the population, median income, and smoking prevalence in each of the 6 jurisdictions. Between January 2018 and May 2019, we conducted by phone 30-60 minute recorded semi-structured interviews. We asked participants to discuss a tobacco policy recently adopted by their locality that they saw as consistent with California’s endgame goal. Participants most often discussed the policy of banning the sale of flavored tobacco products, followed by a variety of other restrictions on retail sellers of tobacco products .
Questions focused on participants’ understanding of the endgame and California’s goals, and their views of their recently adopted policy, including its perceived advantages and disadvantages, how understandable it was, how enforceable it was, and whether it had any unintended consequences. This paper focuses on issues that participants raised across all policies, including: arguments about “Prohibition”; policy exemptions; policy equity; and policy diffusion. Interviewers recorded interviews and then we arranged for recordings to be professionally transcribed. We used the software package NVivo10 for data management and analyzed data qualitatively by coding for recurrent themes and iteratively reviewing clusters of coded text. Numerous participants mentioned the “Prohibition didn’t work” argument frequently employed against U.S. proposals to ban tobacco sales. Some dismissed this argument as irrelevant, however, since a sales ban was “a purchase location law…not a prohibition on [tobacco] use” . Others seemed more apprehensive about the argument. One advocate, for example, expressed concern that although some localities might embrace “prohibition” language, doing so “makes us seem a little more extreme” when viewed among developments across the U.S. Another participant, asked about a ban on sales of flavored products, responded, “We tried to remove ourselves from the word ‘ban’ in particular, because when you think ‘ban’, you think like Prohibition…and nobody likes – history doesn’t even like Prohibition” .Several participants mentioned marijuana-related policy issues. An advocate for banning sales of flavored tobacco products noted that her local policy included flavors for “blunt” wrappers . An advocate working on smoke-free MUH aimed to include both cannabis and tobacco smoke . Other participants expressed concern about the added complexity of addressing marijuana or mixed products in tobacco policies.
One advocate reported “taking a deep dive into hemp [marijuana] policy” in order to determine how new marijuana/THC products fit into tobacco retail licensing. A participant who worked with youth and people of color suggested that equitable tobacco control policies could not just focus on cigarette smokers but had also to take marijuana into account, noting that, “I don’t know a lot of cigarette smokers, but I know a lot of flavored blunt wrap users…So that would be our endgame,vertical grow ridding our communities of flavored blunt wraps.” Some participants felt that the marijuana issue could be helpful to tobacco control efforts. A T21 policy advocate found pointing out links between tobacco and other drug use, “including smoking marijuana” was helpful in conveying the T21 message . A proponent of placing restrictions on retail sellers of marijuana noted that some cities tightly regulated the number and location of marijuana shops, causing advocates to think, “how can we align our… messaging…to say, ‘Well, tobacco is really harmful…and you don’t have any of these’” restrictions on tobacco retailers . Questions from the public about marijuana regulation also provided a point of engagement with people concerned about the health implications of marijuana’s increased use after legalization.Some participants expressed concern that liberalization of marijuana laws might mean that the public would not support stricter tobacco control measures. An advocate of setting minimum prices for tobacco warned that “we have to make sure that…progress in tobacco prevention isn’t undone in the name of” cannabis legalization . Other respondents, however, indicated that the public seemed capable of making distinctions between tobacco and cannabis. For example, one advocate noted that, despite marijuana legalization, his city strongly supported an initiative banning flavored tobacco products . Most participants agreed that “the fewer exemptions, the better” . The topic of exemptions came up primarily in discussion of bans on sales of some or all tobacco products. Beverly Hills in enacting its policy to prohibit all sales, made exceptions for hotels, which may continue to sell tobacco products to guests, and for three cigar lounges. Some advocates expressed disappointment, remarking that the policy “does not accomplish…our goal…[of] be[ing] a smoke-free city” . Referring to the hotels, another participant pointed out, “not one of them has smoking rooms anymore…So…why do they need to sell cigarettes?” . Nonetheless, he conceded that, regarding cigar lounges, “we have to be pragmatic politically” . Another advocate concurred, remarking that “to get a bold policy through, sometimes you have to make concessions” . Those who discussed bans on sales of flavored tobacco products criticized policies that, for example, eliminated sales only from areas around schools and parks. As one participant pointed out, “youth do move about the community,” so a buffer zone policy had “less of an impact” than comprehensive bans on sales.
Bans targeted to schools and parks were more complex to monitor and involved purchasing expensive Geographic Information System software to determine the location of retailers whose sales were to be banned . Flavored tobacco product sales bans that exempted adults-only stores had some of the same issues – for instance, “youth living in those neighborhoods still indirectly have access to tobacco products” . That is, adults could pass the products on to youth. In addition, some retailers tried to claim adults-only store status by “mov[ing] all their menthol and flavored tobacco products into [a] closet,” sectioned off from the rest of the store, which was “just nonsense.” . These products remained in the store. In contrast to those who acknowledged the need for concessions, others saw greater potential for “wholeheartedly comprehensive” policies without “any loopholes” . This was a change for some. One participant said that “two years ago I would’ve said, ‘Oh, I wouldn’t dare pass [a ban on sales of flavored products] without adults only [exemptions]. That’s suicide.’ Numerous participants stressed the significance of equity and social justice. They emphasized that they were focusing their efforts on “vulnerable populations that are using tobacco on a regular basis” . Banning sales of menthol products was most frequently mentioned in this context, as a way of “correcting a wrong…linked to targeting of highest need communities, particularly African American, LGBT [lesbian, gay, bisexual and transgender], Latino, lower-income working class folks, for many, many generations” . Participants expressed concern that if policies banning sales of flavored tobacco excluded menthol , “it might actually be more difficult to get rid of menthol cigarettes, because, unless we can lump them all together as candy-flavored tobacco…it makes the job campaign-wise, a little more challenging” . Policymakers at the federal level already made this mistake: “menthol is just a painful reminder of how things went just terribly wrong; [when] Congress could really step up and pass protections for most kids, but not African-American kids” . Neglecting menthol on the state or local level would mean “you only get the lowest hanging fruit, when…equity-wise, the greatest health impact is going to be menthol cigarettes” . That is, it was relatively easy to get policy-makers to act to prohibit new candy-flavored e-cigarette products, which were overtly appealing to kids, but eliminating the menthol products associated with African-Americans would affect far more people. Comprehensive policies including all products made use of the outrage candy-flavored products engendered to protect all users of flavored products. Equity could be affected by numerous policies, and it worked in a variety of ways. For example, one advocate pointed out that those vulnerable populations were “the populations that have the least resources to come up to hours-long city council meetings.” In achieving a smoke-free MUH policy, she continued, “my strongest supporters were owners of condominiums. And the people most helped, I would argue, were people in low income housing” . Similarly, a participant discussing tobacco-free pharmacies noted that his work had started with the LGBT community, but “every part of [the city] benefitted from the reduction in retail outlets” for tobacco products. The value of equity raised other complexities. One participant noted that adult-only stores were frequently located “in low-income communities of color,” leading to more tobacco availability in those areas. But another noted that “Big Tobacco has somehow rallied some of the current owners of tobacco retail stores…And they’re framing it up like it’s…a cultural/ethnic discrimination angle” . Because small stores were frequently owned or operated by members of a particular ethnic group , neighborhood residents could see them as both representatives of a community and a source of harm to it. The advocate continued that the discrimination framing was “manipulative” but also acknowledged that the store owners “are just trying to live” . For many participants, equity required considering the process of passage of a policy and the consequences of implementing it. One participant warned that “it behooves people to have a very local approach and…real buy-in” . Getting true community involvement was crucial for African-American communities, another participant noted, because without it, “It’s going to be the white man coming in and trying to regulate us again. That’s what the push-back is going to be” . Numerous participants voiced concern that public health advocates not forget communities once policies were passed and tobacco products were removed: “The other reasons [aside from addiction] they might be smoking [such as stress brought on by economic hardship or racial discrimination] are not going to be mitigated by the policies that we are pushing…And I think the more that we ignore that, the more people are going to push back and fight the policies” .