Thursday, April 18, 2013

The Mainstream Tobacco Control Movement and Smoking Among African Americans: Some Diversity But Little Inclusivity or Participation

No More than Token Support for Policy Change and Withholding of Evidence-Based Treatment

1. No More than Token Support for Policy Change

When the Campaign for Tobacco-Free Kids negotiated the Family Smoking Prevention and Tobacco Control Act with Philip Morris (with Congressional mediation), it had a perfect opportunity to advance a policy initiative that truly would have made a difference in reducing smoking among African Americans: banning flavored cigarettes. After all, approximately 80%-85% of African Americans smoke flavored cigarettes. This disproportionate preference for menthol cigarettes applies both to youth and adult African American smokers.

However, the Campaign agreed to exempt the one flavor that is preferred by the 80%-85% of African American smokers, and instead, to only ban flavors that are not actually used, such as banana, pineapple, coconut, cherry, lime, lemon, chocolate, vanilla, and raspberry. Moreover, when the Senate HELP Committee considered an amendment that would have eliminated the menthol exemption, the Campaign for Tobacco-Free Kids opposed this amendment.

Now, as essentially an after-thought, the Campaign has co-signed a petition to urge the FDA to ban menthol cigarettes. But I'm afraid that it is too little, too late. The FDA's decision has already been made, and it was made at the negotiating table when the Campaign agreed to the menthol exemption and in the Senate HELP Committee when the Campaign opposed the removal of the menthol exemption.

Thus, the Campaign's signing on to this petition represents no more than token support for policy change to reduce tobacco-related morbidity and mortality among African Americans.

2. Withholding of Evidence-Based Treatment

The state-of-the-art, evidence-based tool to promote smoking cessation among African American smokers is the Pathways to Freedom project. Unlike most other smoking cessation programs, Pathways to Freedom is truly culturally competent because it considers not only health issues, but also history, community culture and context, racial discrimination, literacy, and multigenerational appeal. In addition, unlike most other programs, Pathways to Freedom includes spirituality, community outreach, and community mobilization.

The evidence is clear. Use of Pathways to Freedom by an NCI telephone cessation hotline resulted in a one-year quit rate of 25% for the intervention group compared to 15.4% in the control group. The intent-to-treat analysis percentages were 15% and 8.8%, respectively.

Yet in spite of this evidence, Pathways to Freedom has not been adopted by the CDC as well as by most smoking cessation quitlines and services. Special populations, and in this case the African American community, continue to be ignored.

The Rest of the Story

What ties these two phenomena together? Why was a menthol ban considered but quickly dismissed? And why the failure in dissemination of Pathways to Freedom to African American smokers after clear evidence of its being the state-of-the-art intervention available?

In my view, these failures are a result of a tobacco control movement that has largely been co-opted by a few large national organizations. While these organizations recognize the importance of communities of color, the extent of this recognition has been diversity (including representatives of these minority groups), but has not been extended to inclusivity and participation (actually integrating members of these communities into the decision-making process). Here, of course, I am borrowing from Dr. Bob Robinson's innovative diversity model.

The most egregious violation of participation was the development of the Family Smoking Prevention and Tobacco Control Act, in which African American groups were denied a place at the table. The Campaign essentially negotiated this bill by itself, with input from the major voluntary health groups, but few others. This made it easy, come negotiating time, for the Campaign to throw African American smokers under the bus in order to make the political sacrifice necessary to appease Philip Morris. I doubt it would have been as much of a no-brainer compromise had African American groups been able to actually participate in the negotiating process.

In fact, after the menthol exemption was announced, several African American groups (including the Black Congressional Caucus) voiced their displeasure. The response was merely to call for a committee to consider the menthol issue, but we have seen how meaningless an exercise that was. 

There is precedent for what a community-participatory process might look like in tobacco control. California's tobacco control program has long included a focus on not only the inclusion but the equal participation of communities of color in all aspects of the tobacco control movement, including research, program and policy development and implementation, evaluation, planning, and training. (The SOL project is just one current example of many exemplary California programs).

If only our national organizations, including CDC and the Campaign for Tobacco-Free Kids, could take a lesson from California.

(See my 2005 discussion of the co-optation of the tobacco control movement by a few national organizations, turning what used to be a true grassroots movement into little more than a one-man propaganda machine.)

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