For too long, tobacco industry strategies to normalize and glamorize use of their product have perpetuated a preventable epidemic. Although US adult smoking rates declined to 15.1% in 2015, nearly half a million people die annually just from cigarette use in the United States. Projections are that 5.6 million US children alive today will die prematurely from tobacco-related disease. For every tobacco-related death, approximately 30 more individuals live with chronic tobacco-induced disease and disability.
A place-based strategy for tobacco control can promote progress toward ending the epidemic. A culture shift—that is, changing “the way we do things around here”—can create healthy change. For example, efforts to foster tobacco-free norms have resulted in healthier worksites, restaurants, bars, and other public places. Denormalizing and deglamorizing use in an even wider variety of high-risk settings—places where tobacco is sold or used—can further accelerate culture change to foster health.
In the United States, tobacco products are sold in about 375 000 retail outlets. Establishments such as gas stations, convenience stores, supermarkets, warehouse clubs, and pharmacies had annual tobacco sales exceeding $50 billion in 2007. Retail sites also serve as marketing venues for tobacco; the average store selling cigarettes has nearly 30 tobacco product advertisements, with about a third visible below 3 feet—eye level for some children.
These sites can change. When CVS, the nation’s second largest pharmacy chain, made a landmark decision in 2014 to stop selling tobacco products at its more than 9600 stores, this action made a bold statement about what should be considered normal practice for health-related businesses.
Also, raising the minimum legal age of sale from 18 years to 21 years could prevent high school students from buying tobacco for peers, preclude teen initiation, and reduce lifetime premature deaths by an estimated 10%. Most Americans and current smokers support this change, which (as of June 2016) has been enacted by at least 145 localities, including New York City, Chicago, Boston, and the states of Hawaii and California.
Military exchanges and commissaries have traditionally sold tobacco products at prices lower than in surrounding communities. A stipulation that military outlets charge no more than 95% to 100% of the lowest competitive price for tobacco products, coupled with exemptions from state and local taxes, have led to discounts that can be substantial. Lower prices contribute to higher smoking rates in the military compared with the general public—24% vs 19% in 2011—with the highest rates in the Marine Corps and Army (30.8% and 26.7%, respectively). Of note, up to 40% of current service members who smoke initiated use after joining the military.
In April 2016, US Defense Secretary Ashton Carter issued policy guidelines to raise prices on all tobacco products (including e-cigarettes) in military stores to “match the prevailing local price” in civilian stores when taxes are included. He also announced plans for increasing tobacco-free zones around areas frequented by children.
The rate of smoking among the nation’s 2 million public housing residents is double the national average, related to higher use in lower-income populations. Most residents live in multi-unit settings where secondhand smoke can spread (for example, through ventilation ducts); this increases exposure risk to fellow residents of whom approximately a third (750 000) are children. To date, about 10% of the 3200 public housing authorities are voluntarily smoke-free.
Julián Castro, secretary of the US Department of Housing and Urban Development (HUD), announced a proposed rule last November, supported by most residents, to prohibit indoor smoking on all HUD-supported public housing properties. As this policy moves forward, engaging residents in implementation will be critical, with special attention to facilitating access to smoking cessation services where needed.
Behavioral Health Facilities
Tobacco use represents the leading cause of death in persons with behavioral health issues, who consume approximately 40% of cigarettes in the United States. Among longtime misconceptions are beliefs that persons with mental illness have no interest in, or ability to, quit because they use tobacco for necessary self-medication. Such misconceptions, refuted by recent studies, have to date, fostered a culture where tobacco is tolerated in treatment settings.
This culture is changing. Between 2005 and 2011, the proportion of state psychiatric hospitals that are smoke-free has steadily increased, from 20% to 83%. Furthermore, the Substance Abuse and Mental Health Services Administration now recommends that all of its funded treatment sites be tobacco-free.
Between 2002 and 2014, the number of young adults aged 18 to 25 years who started smoking increased from nearly 650 000 to almost 1.2 million. In 2014, about 18% of full-time college students were smokers.
The Tobacco-Free College Campus Initiative began in 2012, launched by a collaboration featuring the American College Health Association, the University of Michigan, and the Department of Health and Human Services (which I represented at that time as assistant secretary for health). The goal has been to encourage voluntary adoption of smoke-free and tobacco-free campuses. Doing so can support the many on campuses who are trying to quit while dissuading others from starting. Among the more than 4000 campuses in the country, the number that are smoke-free more than tripled between 2010 and 2016, from 446 to 1483 (of which 1137 are completely free of all tobacco products).
Debating this policy option can catalyze constructive deliberations among all members of a college community about how to make campuses healthier. Engaging students and student government, faculty, administration, and staff—users and nonusers alike—is vital to success.
Major League Baseball Parks
Although minor league baseball has banned use of smokeless tobacco since the 1990s, major league baseball has instead long considered its use the norm. Young boys often emulate use by their sports heroes, which contributes, in part, to smokeless tobacco use rates of about 15% in male high school students.
Since 2015, San Francisco, Boston, Los Angeles, Chicago, and New York City have led the first wave of cities to prohibit smokeless tobacco within their major league baseball stadiums. This policy applies to players, staff, and fans alike. When California makes all its stadiums tobacco-free in 2017, nearly a third of all major league parks will be affected.
Place matters. Changing culture can restore healthy tobacco-free norms in many places. Recognizing and reinforcing successful approaches broadly can move the country toward a tobacco-free future.
About the author: Howard Koh, MD, MPH, is the Harvey V. Fineberg professor of the practice of public health leadership at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School. He is also the former Massachusetts commissioner of public health and the 14th assistant secretary for health for the US Department of Health and Human Services. A quadruple-boarded physician, Dr Koh has published more than 250 articles in medical and public health literature, earned more than 70 awards for interdisciplinary achievements in public health, and has received 5 honorary doctorate degrees.
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