It was important to “beef up cessation services in a comprehensive way so that it is relevant to the communities that are most affected” . The flip side of including menthol in policies banning sales of flavored tobacco products to address the health of African Americans and other targeted populations such as the LGBT community, was fear within those communities about criminalizing smoking and smokers. Numerous participants emphasized that flavor policies were “not about the behavior but about sales of the product. We’re not about policing people’s behavior. We don’t want to see any more negative police/community interaction” . Most participants believed flavor bans were unlikely to result in over-policing: “I…don’t think we’re going to see…this law be misused to justify inappropriately criminalizing residents” . Another participant remarked that the argument was raised because “the tobacco industry has…paid some African American leaders to come out and say [bans on sales of menthol products] were criminalizing the Black community” . However, she also pointed out that she wasn’t sure what would happen “if an officer sees somebody selling some [contraband menthol cigarettes] New ports out of their trunk…I would like us to get a handle on [that] before we have an Eric Garner case in California” . Many participants showed awareness that their policies were precedents for other jurisdictions to follow . An advocate reported that a jurisdiction implementing a novel ordinance helps “a lot of people [in other cities] to understand that this is the next big step that can be taken” in their own community .
Even if a policy change did not seem to have a short term impact, one participant said, “we really have to take the long view,plant grow table that we’re creating a flavor-free tobacco region and state…so that youth [eventually] wouldn’t be able to go across the street into the next town and buy these products” . Participants also exhibited awareness that policy innovation in California generally had cities and counties taking the lead, not state government. Asked whether the state’s new endgame focus had influenced his work, one participant replied, “I think our local work has shifted the conversation of the state, to be honest” . Another noted that his organization “always had that vision…even before the state wanted that endgame” . This local, then state adoption of policy change was normal, as another participant noted: “the idea [is] they grow from the local jurisdictions to make statewide implementation more likely” . That influence could spread not only through the state, but also to other states and from there, “ripple out into the rest of the world” . A couple of participants sounded a warning about this process. One commented that, once policy making started to move forward at the state level, “We need to be very vigilant of preemption,” . Another was concerned that state-level action would skip over the community work necessary to make policies acceptable and successful, particularly among communities of color: “You ban flavored tobacco and menthol, and…where’s the community engagement?…There can’t be one without the other or there’s going to be imbalance” between policymakers and those most affected by regulations . Several participants also noted a greater readiness that they had seen in even the recent past for new, innovative policies. One noted this conceptual transition, saying, “To think about the endgame at first was kind of jarring . . .[but after Beverly Hills] you start to think, wow, maybe this is possible!” . Another said of his local elected officials, “They wanted a bolder move…They wanted things like, ‘what is the way to end this?…How do we stop this?’” This was a big change, he noted. “There wasn’t a conversation even happening…And that was just the last couple of years” . An advocate from another area reported that, “I’ve heard elected officials say…‘We’re saying we won’t allow pharmacies to sell tobacco anymore. Well, can’t we just say that nobody sells tobacco anymore?’” . One participant saw her role as getting people to believe an “endgame” was possible, saying: “Let’s believe [in zero smoking prevalence], and then we can work towards how we’re going to get there” . Creating an endgame vision and overcoming skepticism seemed increasingly possible in California, as one advocate noted: “the entire United States is learning a lot from California, and I think putting those big goals in front of public health advocates is really making a huge difference, and believing it will happen is making a big difference.
The policies we now consider, and we would have considered impossible, even just two years ago, now people are taking as commonplace” .Previous research [5] in 2018 found that California legislators and advocates to be somewhat cautious about endgame-oriented policies, preferring more gradual approaches. This study found an overall sense from interviewees of momentum for policy innovation, with greater belief in the possibility of an endgame. Some of this may be a response to advocates’ having begun to receive funding from the state’s new tobacco tax, enacted in 2016, that enabled local tobacco control agencies and coalitions to hire staff and engage in more ambitious policy-oriented planning. Advocates likely understood the success of the tax as signaling public support for tobacco control efforts in the state. The influx of funding and resources from the tax increase may have also bolstered advocates’ enthusiasm. The greater caution about endgame policies found in previous research may also relate to the specific participants. The previous study included interviews with state legislators and leaders of statewide organizations; the current study prioritized local advocates . Statewide leaders – and particularly members of the state legislature — think in terms of what can be accomplished at the state level,hydroponic table taking into account that law must get support from legislators who represent communities on a wide spectrum of readiness for policy change. The local advocates knew that their localities could take bolder steps, and judged that they would be willing to do so again. Participants understood that there were challenges ahead, for example, framing the endgame in such a way as to avoid or undercut arguments made in the past by the tobacco industry and its allies. For example, participants did not feel that the history of alcohol prohibition in the US was an appropriate reference for the tobacco endgame, but understood that it would be important to make that distinction, notably by distinguishing sales bans from prohibitions on possession or use of tobacco products. Making that distinction was also important to establish that new tobacco control policies would not invite further over policing of marginalized communities, such as occurred in the Eric Garner case. Another challenge that participants foresaw was California’s recent legalization of marijuana for recreational use.
Although there was some concern that the liberalization of marijuana regulation suggested that public opinion would not favor stricter tobacco policy, most participants had a more nuanced perspective—that one could simultaneously favor restricting tobacco sales, especially to youth, while permitting sales of marijuana, especially to adults. The combined use of tobacco products and marijuana meant that policies had to encompass both. Further, some participants proposed that the stricter rules relating to marijuana retail sales could provide a model for tobacco. Participants demonstrated awareness that policy innovations carried risks. Although they identified policies containing exemptions as less than ideal, requiring more complex and expensive enforcement or a difficult amendment process, participants sometimes considered exemptions to be a pragmatic way of advancing a policy; this was true even in the case of a policy traditionally considered so far from being considered “pragmatic” as to be almost unthinkable, a tobacco sales ban. In some cases, participants considered exemptions to be harmful. For example, a flavor ban that exempted menthol “solved” the problem by removing the products most obviously marketed to children and youth. However, it left African Americans still vulnerable, and without the allies concerned about youth-oriented “candy” flavors. There appeared to be broad understanding that the goal of ending the epidemic “for all population groups,” meant increased engagement with communities with the highest levels of tobacco use. The trend of California tobacco control policy efforts, led by localities, then followed at state level, was well known to participants. Some suggested that the state’s new focus on a tobacco endgame was the result of local innovation. Participants also recognized that communities took their cues from others, so that policy innovations even in small communities would “ripple outward” and engender wider effects over time. Our study has limitations. We interviewed a small number of key informants selected because they worked in communities that had recently passed innovative tobacco control policies; thus, our sample cannot be considered representative of all California tobacco control advocates. Those working in more conservative communities may view the idea of an endgame more skeptically. However, other tobacco control policies , were once regarded as radical and became more normative with their adoption. Indeed, during the course of the study, Beverly Hills began discussing the first-ever prohibition on sales. Some participants interviewed before these deliberations found such an idea out of reach, while others, interviewed afterward, remarked that the conversation alone made such policies seem possible. Discussions of the tobacco endgame have frequently focused on complex and drawn-out plans, sometimes involving sizable state investment, such as the proposal that the state should buy out the tobacco industry. Recent events in California suggest a different, in many ways a simpler future, more in line with the history of tobacco control, in which localities have taken the lead. The first laws in California calling for non-smoking sections in restaurants were local and largely symbolic, but they demonstrated the possibility for clean indoor air, and more, and stronger laws followed. A tobacco sales ban in a small municipality such as Beverly Hills will not substantially reduce tobacco use in California, but it serves as proof of concept. Municipalities and counties in the U.S. may increasingly recognize and exercise their ability to pass such laws, as the 2014 U.S. Surgeon General’s report suggested. This study, and the recent, rapid spread of policies to ban sales of flavored tobacco products in the state, suggest that tobacco control advocates in California are attentive to such possibilities and willing to act. This study, and the history of California’s approach to tobacco control more generally, point to the importance of local policy advocacy. Local advocates understand the specific issues in their communities, and have a nuanced perspective on policy development, such as when exemptions or exceptions are and are not acceptable. Local advocates also may be able to implement policies that would not be possible at a state or national level; such policies may seem radical, but passage normalizes them. Not every community is ready, but this study suggests that we should encourage more attention to the local actors and new, small-scale policy changes happening around the world that have the potential to ultimately end the tobacco epidemic. Acknowledgement: Support for this paper was provided by the California Tobacco Related Disease Research Program, Grant 26IR-0003. Cigarette smoking causes and exacerbates chronic obstructive pulmonary disease and asthma,1 and is associated with wheezing and cough in populations without a respiratory diagnosis.While the relationship between cigarette smoking and respiratory symptoms is well-established, the relationship between use of other tobacco products besides cigarettes and respiratory symptoms in adults is less clear. Changes in the tobacco market, in part, reflect efforts to market products that may cause less harm than cigarettes. Electronic nicotine delivery devices may represent such a product. With respect to respiratory symptoms, findings have been mixed, however. Numerous animal and in vitro studies raise theoretical concerns about e-cigarette use and lung disease.Short term human experimental studies have linked adult e-cigarette use with wheezing and acute alterations in lung function,and lower forced expiratory flow.One longer term 12-week prospective study of cigarette smokers switching to e-cigarettes found no effects on lung function,and two 1-year randomized controlled clinical trials found reduced cough and improved lung function in persons who used e-cigarettes to reduce or quit cigarettes.