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  1. Ruth E Malone,
  2. Valerie B Yerger
  1. Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
  1. Correspondence to Professor Ruth E Malone, Social and Behavioral Sciences, University of California, San Francisco, CA 94118, USA; ruth.malone{at}

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Many people all over the world have recently been learning a great deal more than ever before about the depth and breadth of racism, the shameful histories we were never taught in school and more about what it means to be complicit in ongoing systems of White privilege. The videotaped murder of George Floyd in Minneapolis, Minnesota, at the hands of police brought a global outpouring of calls for addressing racist police violence, but it also catalysed a much larger conversation about how other racist practices and policies affect housing, transportation, education, employment, food systems, healthcare, community resources and safety, overall well-being and many other areas of life for Black people and other people of colour, both in the USA and elsewhere. Deeply racist practices and institutions have undercut the life chances of millions of people around the world, and as the carefully constructed curtains of normalcy are being pulled aside to make it visible, it becomes possible to see how tobacco is intertwined with racist practices that have shaped many if not most of these foreshortened lives in multiple ways and how these practices continue to this day.

In the USA, these racist practices perhaps began with the outright genocide and multiple betrayals of agreements with Native Americans, some of whom have used tobacco in rituals for hundreds of years. From being regarded by Native Americans as a sacred leaf used in special ceremonies of friendship or given in trade for ceremonial gifts, colonisers made tobacco a highly commodified product and later used appropriated Native American imagery to sell it.1

The enslavement of African people is often associated with cotton plantations, but millions of African people were kidnapped from their homes and tortured in slave ships to provide free labour for White tobacco growers in the southern USA, the Caribbean and South America. Tobacco was marketed with racist images of African Americans.2 Later, the descendants of those enslaved people were heavily targeted with menthol cigarette marketing, shaping today’s health disparities.3

Tobacco smoke wafts through the racist history of many wealthy institutions constructed on the foundations of White privilege, including now-revered universities, arts organisations and even health systems. Even today, tobacco industry exploitation of indigenous people continues as the industry deceptively attempts to paint itself as a friend to indigenous communities while pushing new forms of its addictive products.4 5 Given all this, the complicity reflected in tacitly accepting the tobacco industry’s continuing contributions to human suffering and inequity, demonstrated clearly by the generally higher tobacco use rates among people of colour and poorer populations compared with wealthier White populations, is inexcusable.

Recently, US civil rights icon and Congressman John Lewis died. Many of the elegiac tributes referenced the words ‘good trouble’, his brilliant pairing of two words that initially seemed antithetical. Lewis had for decades led non-violent civil rights protests against injustice. About this he said in 2016, speaking to a younger generation of graduating students: ‘You must find a way to get in the way and get in good trouble, necessary trouble. … Good trouble, necessary trouble … that is your calling. That is your mission. That is your moral obligation. That is your mandate. Get out there and do it. Get in the way’.6

Lewis understood that ‘getting in the way’ means confronting powerful actors like the tobacco industry. He was a cosponsor of HR 2339, the Protecting American Lungs and Reversing the Youth Tobacco Epidemic Act of 2020, which would remove flavoured tobacco products from the marketplace, including menthol and mint. Passed by the US House, it awaits Senate consideration. Menthol makes smoking easier to start and harder to quit, and Black smokers in the USA use menthol products almost exclusively.

What is Good Trouble in public health? It means calling out governments that fail to act to protect human well-being. It means disrupting the status quo in ways that are hard to ignore and doing it over and over again. This June, the African American Tobacco Control Leadership Council and Action on Smoking and Health filed a lawsuit against the US Food and Drug Administration over its shameful inaction on menthol in tobacco products.7 This action came only after two scientific reports, a Citizens Petition, and numerous efforts to push forward this issue of great importance to Black communities. While the agency has acted to protect children by regulating other characterising flavours, it has repeatedly and inexplicably failed to regulate menthol, the product flavour with which African Americans have been disproportionately targeted, despite the evidence that it contributes to harm. The agency’s Whiteness is showing. This lawsuit is about getting in the way. Good Trouble.

‘Getting in the way’ can also mean confronting our own assumptions, such as the idea that it would be impossible, infeasible, a distraction, shooting ourselves in the foot or otherwise counterproductive to start now to create serious plans to phase out the sale of the most deadly tobacco products. Yes, that will create trouble, including trouble for tobacco companies, and in the short term for the public health and other programmes that depend on tobacco taxes for funding. Clearly, not every place will be ready to do it at the same time, and no policy will work 100% of the time. Does that mean there is no way to do it or that we shouldn’t even try? No. So far, two cities in California have passed ordinances phasing out sales of tobacco products. We will learn a great deal from how that implementation goes. It may go badly, like many early civil rights actions did. We will learn from it and go on. That is getting in the way. Good Trouble.

Twenty years ago, in August 2000, BMJ published a special issue focused on tobacco, featuring a cover photograph of an Irian Jaya Indonesian tribal man wearing a Marlboro-branded shirt. That photograph had previously appeared on the cover of Tobacco Control, accompanied by an essay by the photographer who described the ‘mixed’ results of opening up a remote tribal region to the modern world. Now, he observed, western commercial cigarettes were widely sold even in small rural villages, and ‘adults, children, and even pregnant women all smoked, coughed, spit, and smoked some more’.8 The Marlboro man had arrived in one of the most isolated places on the planet and was making his mark among new groups of people, most of whom likely had no idea that these attractively marketed products would kill them. Some of them have probably died since then from smoking Marlboro, because even in wealthy countries these products are still sold everywhere as though they were candy.

Ten years ago, in these pages, Callard9 pointed out how billions of dollars flowed from smokers in poor countries to multinational corporations in rich countries, illustrating how inadequate was funding for tobacco control. Undoubtedly, today, the same inequitable flow of resources continues, as wealthier (and Whiter) countries enact stronger tobacco control policy measures, smoking rates go down, and advocates begin to talk about achieving an endgame, while poor countries have few resources with which to protect their people from multinational corporate power. However, rather than meaning that people in Whiter, wealthy communities or countries that already have strong tobacco control measures in place should sit on their hands until other communities and countries catch up, this means that they should use their privilege to force open the larger conversation about why governments have been unwilling to demand from tobacco companies what they expect from every other business: that their products that kill people when used as intended be removed from the marketplace. That would be making Good Trouble. That is the business of public health.

Finally, good trouble means getting in the way of and confronting the Whiteness of and racism within the tobacco control movement itself. As the scholar Eve Ewing wrote recently, ‘when we ignore the specificity and significance of Whiteness — the things that it is, the things that it does — we contribute to its seeming neutrality and thereby grant it power to maintain its invisibility’.10 Not granting the power of Whiteness means more than speaking up when all the suggested speakers on a panel are White. It means examining with humility how White the leadership of the movement is and why, and considering how unreflexively we overburden people of colour in the movement with expectations that they can or should represent the points of view of all Black people, all Native Americans or all Indigenous people, for example. It means considering (and compensating for and rewarding in all work settings) the heavy commitment of emotional labour, time and skill involved in proactively building relationships and nurturing leaders within communities of colour based on their priorities. In short, getting in the way for the tobacco control movement ought to mean learning to get out of the way by helping ensure that leaders of colour have what they say they need to do the work of public health: the essential, ceaseless, critical work of making more Good Trouble.



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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.