While my criticism of the FDA tobacco legislation and my support for alternative legislation that would approach the tobacco problem in a different way (from the demand side rather than the supply side) have been based largely on an analysis of the likely public health effects of each approach, it is also worth considering the implications of these proposals for the tobacco control movement itself. After all, over the long term it is community-based actions by tobacco control practitioners and community advocates that will have the greatest effect on tobacco use, as it has been for the past four decades.
If there is one lesson I have learned from 23 years of practice in tobacco control, it is that the greatest gains have been made by tireless grassroots activists and communities working day-to-day at the front lines, not by grand public policies. Without a doubt, the most successful stories in tobacco control have been those derived from comprehensive, statewide tobacco control programs, such as those in California and Massachusetts, which have not only utilized state-of-the-art media campaigns as air cover, but which have also made it a priority to fund local community groups and coalitions as the ground attack (sorry for the war analogy, but it seems to work).
The local programs are essential not only because grassroots, community activism is what most effectively creates change, but also because the focus on the local level allows programs to be targeted to particular populations, thus ensuring - for example - that communities of color are not left behind in generic tobacco control plans and that these programs serve not only to reduce tobacco use but to reduce disparities in tobacco use as well. (See my 2004 article from the American Journal of Public Health for an example of how tobacco control programs may increase health protection overall, but actually increase rather than decrease health disparities -- Skeer M, George S, Hamilton WL, Cheng DM, Siegel M. Town-level characteristics and smoking policy adoption in Massachusetts: Are local restaurant smoking regulations fostering disparities in health protection? Am J Public Health 2004; 94:286-292).
To me, the unsung heroes of tobacco control have been those who have worked at the front lines and never brought attention to themselves, but focused all of their efforts on the mobilization and empowerment of communities to take action for themselves: Makani Themba, Sharyn Sutton, the Reverend Michael Crosby, the Reverend Jesse Brown, and the Reverend Hessie Harris come immediately to mind.
And some of the greatest effects on tobacco use have come from the most basic social activism - communities rising up together to fight efforts to addict their members: arguably, the uprising against X cigarettes and later Uptown cigarettes had a lasting effect on reducing the appeal of smoking initiation among African American youths -- an effect which did not notably wane until the mid- to late-1990s.
The profound changes in social norms regarding smoking in the past decade are largely due to community-based efforts to protect nonsmokers from secondhand smoke through workplace, casino, bar and restuarant smoking bans. My research has shown that these local policies - resulting from local grassroots activism - have a substantial effect both on smoking-related social norms and on smoking initiation.
Thus, any national strategy to reduce tobacco use and protect the public's health must be viewed not only in terms of direct protection provided to the public, but also in terms of the capacity of communities to become engaged in and successfully practice tobacco control.
The Proposed FDA Tobacco Legislation Will Decimate Grassroots Tobacco Control
If the FDA legislation is enacted, especially in its current form, it will essentially destroy the grassroots tobacco control movement as we know it. I have already provided a detailed analysis of the reasons for this. Briefly, if the FDA asserts jurisdiction over cigarettes, there will be a perception on the state level that there is no more need for tobacco control action. In particular,I think it will become impossible to obtain state funding for tobacco control if the FDA legislation is enacted. Efforts to get state legislatures to allocate tobacco settlement monies for tobacco control are already quite dismal. If the federal government is charged with the major responsibility for addressing the tobacco problem, it will be impossible to convince state legislators that their states need to allocate a substantial amount of funding (that could be used for other purposes) to tobacco control. This is especially true now, when state budgets are already strapped.
It is unlikely that we will see again the successful program models such as in California and Massachusetts, where state cigarette excise tax increases are used to fund comprehensive statewide tobacco control programs. If cigarette taxes are increased, the revenues will almost certainly be used to fund unrelated programs, such as health care, building roads and bridges, etc. If the FDA tobacco legislation is enacted, there will be zero incentive for state governments to continue to take on the tobacco issue with any seriousness. The legislation will permanently displace tobacco control activity from the state to the federal level. In short, it will decimate community capacity in tobacco control.
On top of this, the FDA legislation would all but put an end to tobacco litigation. The legislation directly preempts state legislation and legal claims related to tobacco product standards, premarket approval, adulteration, misbranding, labeling, registration, good manufacturing standards, or modified risk tobacco products. But more importantly, by placing cigarette production and marketing under the FDA's jurisdiction, the legislation would all but preclude punitive damages in litigation, thus taking away any incentive for future tobacco litigation.
Enactment of the FDA legislation would also provide cigarette companies with a very strong argument to shield themselves from any significant punitive damages in existing litigation. They could argue, quite correctly, that they are now under the jurisdiction of the FDA. Thus, there is no need to impose substantial punitive damages upon them as an incentive for them to change their behavior. I believe that the unavailability of punitive damages would decimate most existing tobacco litigation.
The Alternative National Tobacco Control Legislation Would Allow Community Tobacco Control to Flourish
In contrast, the alternative national tobacco control legislation would specifically support a new (in many cases) infrastructure that would allow grassroots, community-based tobacco control activism to flourish. The proposal would use revenues from penalties to tobacco companies based on youth smoking to fund a national tobacco control campaign as well as campaigns in all 50 states. Much of the funding would be used for state-of-the-art media campaigns that would provide (sorry about this...) the air cover for the ground attack of community-based coalitions and groups. Funding would specifically be allocated towards communities of color, representatives of which would be requisite partners in all aspects of program planning and revenue allocation. Targeted initiatives to support community development would be a key part of the strategy. Elimination of disparities within population subgroups would stand side-by-side with overall population reductions in tobacco use as dual goals of the program. The potential role of harm reduction (no, I don't persume to have any answers) could be discussed in an informed, inclusive manner to determine the appropriate nature, scope, and targeting of particular harm reduction messages.
The presence of community coalitions would allow local and state-level tobacco legislation to continue on as well. Legislation related to tobacco product standards, premarket approval, adulteration, misbranding, labeling, registration, good manufacturing standards, or modified risk tobacco products would still be allowed. States, for example, could decide to eliminate menthol from cigarettes (New Jersey recently considered a bill that would have eliminated cigarette flavorings, but as expected, menthol was exempted in the legislation). Fire-safe cigarette standards could also continue to be enacted. And of course, the movement to promote smoke-free workplaces for all employees in the nation would receive a huge boost. This is especially important, because the safety of working conditions are becoming a huge source of disparity in health protection between people living in different regions of the country.
You can call this back to basics. You can call this old school if you want to. But the point is: it works. And frankly, it's the only intervention that has ever been demonstrated to work (other than increasing the federal cigarette tax, which has already been done in 2009 and is probably a no-go for the remainder of this Congressional session).
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