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The African American Tobacco Control Leadership Council: Advocating for a menthol cigarette ban in San Francisco, California
  1. Sarah D Mills1,2,
  2. Carol O McGruder3,
  3. Valerie B Yerger3,4
  1. 1 Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2 Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3 African American Tobacco Control Leadership Council, San Francisco, California, USA
  4. 4 Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
  1. Correspondence to Dr. Sarah D Mills, Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; sarahmills{at}unc.edu

Abstract

The African American Tobacco Control Leadership Council (AATCLC) is an advocacy group that works to inform the direction of tobacco control policy and priorities in the USA. This article narrates the AATCLC’s work advocating for a comprehensive, flavoured tobacco product sales ban in San Francisco, California. Recommendations for tobacco control advocates and lessons learned from their work are provided. The article concludes by discussing conditions necessary to enact the policy. These include having a dedicated advocacy team, community support, a policy sponsor, and clear and repeated messaging that is responsive to community concerns.

  • public policy
  • tobacco industry
  • advocacy

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The African American Tobacco Control Leadership Council (AATCLC) is an advocacy group that partners with community stakeholders, elected officials and public health agencies to inform the direction of tobacco control policy and priorities in the USA, with a focus on Black American and African immigrant populations (henceforth referred to as African Americans). The AATCLC educates the public about the predatory and discriminatory marketing practices of the tobacco industry, the effects of tobacco on African-American communities and the need to regulate flavoured tobacco products.

This article narrates the AATCLC’s work advocating for a comprehensive, flavoured tobacco product sales ban in San Francisco, California. Recommendations for tobacco control advocates and lessons learned are provided that are generalisable.

Recommendation 1: Build an advocacy team

In 2017, the AATCLC convened an ancillary event to the statewide Project Directors Meeting of the California Tobacco Control Program. The ‘Town Hall’ soiree showcased their work over the past decade advocating for bans on menthol cigarettes at the federal level and in cities across the USA. Menthol cigarettes, used by 85% of African Americans as a result of targeted marketing by the tobacco industry, are easier to start smoking and more difficult to quit than non-menthol cigarettes.1–3 After hearing about AATCLC’s success while at the Town Hall, Dr. Stanton Glantz, Professor at the University of California, San Francisco (UCSF), asked his UCSF colleague and founding member of the AATCLC, Dr. Valerie Yerger, to join the San Francisco Cancer Initiative (SF CAN) by leading an effort focused on getting a flavour sales ban ordinance passed in San Francisco. SF CAN was a newly established collaborative among healthcare systems, community groups, government and residents to reduce cancer disparities.

Dr. Yerger agreed, immediately forming the ‘SF Menthol Task Force’ and inviting the participation of AATCLC co-chairs Ms. Carol McGruder, a seasoned veteran of California’s tobacco control experience, and Dr. Phillip Gardiner, Programme Officer in the Tobacco-Related Disease Research Program of the University of California. The six other members of the task force included a doctoral student in public health and an advisory board composed of representatives from the San Francisco Department of Public Health, the San Francisco Tobacco Free Coalition, Breathe California and other community-based organisations. The Task Force proposed a 3-year plan to implement a flavour sales ban policy in San Francisco.

Recommendation 2: Engage the community

In the first year, the SF Menthol Task Force engaged a broad spectrum of San Franciscans including lesbian, gay, bisexual, transgender, and queer (LGBTQ), African American, Latino, Chinese and Native Hawaiian/Pacific Islander (NH/PI) community groups to educate them and garner support for a flavour ban that included menthol cigarettes. Although the AATCLC’s advocacy work focuses on African Americans, to meet their goal they recognised the importance of engaging other groups that make a substantive share of the population in San Francisco and are harmed by menthol cigarettes. Menthol cigarettes are the only remaining flavoured cigarette on the US market and are used by more than one-third (39%) of smokers.2 As a result of targeted marketing, menthol cigarettes are used disproportionately among African Americans and among other racial/ethnic minorities, lower-income, LGBT and youth smokers, and those with serious psychological distress.2–5

AATCLC members lived and worked in the greater San Francisco Bay Area and used their personal and professional contacts to engage communities. For example, Ms. McGruder and Dr. Yerger hosted lunches with members of the LGBTQ, Asian American and NH/PI communities where they discussed the harms of menthol cigarettes. They spoke at churches in the Samoan community. Ms. McGruder and Dr. Yerger had an agenda focused on a menthol ban policy but meetings sometimes centred around different subject matter (e.g., gun violence). The AATCLC did not force discussions about the policy when it seemed inappropriate. They prioritised the development of genuine relationships that increased community trust. Community members would take information presented about menthol cigarettes and share it with others in their networks, increasing the reach of the AATCLC’s work.

Dr. Yerger also engaged community members by offering grant funding. Using funds provided by SF CAN, Dr. Yerger provided grants to individuals and organisations who came up with ways to spread information about the flavour policy. For example, individuals from the Tongan community in San Francisco were given funds to have radio segments about the harms of smoking and menthol cigarettes. The SF Menthol Task Force completed paperwork required to disperse funds to make it easier for community members without administrative staff to receive funding.

Representatives of Breathe California, a partner in the SF Menthol Task Force, used their existing community relationships to coordinate a meeting where the AATCLC presented on the social justice implications of the flavour policy to youth in San Francisco. Youth were encouraged to share what they learned with their networks. Presenting tobacco industry documents that expose the industry’s targeted marketing to marginalised groups was especially effective for garnering interest among youth.

A member of the Task Force coordinated interviews with media and identified opportunities for the AATCLC to write opinion editorials. Dr. Yerger and Ms. McGruder were interviewed on live radio. They discussed the industry’s marketing of tobacco products to African American and other communities. Two editorials were written by the AATCLC media coordinator and published in the San Francisco Bayview National Black Newspaper.6 7 One editorial was written by Ms. McGruder and published in the San Francisco Chronicle.8 Editorials discussed the AATCLC’s advocacy work and the importance of the flavour policy for public health.

Recommendation 3: Find a policy sponsor

Identifying a strong policy sponsor is critical and often takes multiple meetings with different government office holders. Searching for a policy sponsor, Dr. Yerger and her team contacted Malia Cohen, who at the time was the Supervisor for San Francisco’s 10th district. One of Cohen’s staff members, Brittni Chicuata, had previously worked in tobacco control advocacy and was an acquaintance of the AATCLC. Brittni quickly set up a meeting. Cohen was perfect. In 2011, Cohen, with engagement from Ms. McGruder, led a resolution unanimously passed by the San Francisco Board of Supervisors asking the Food and Drug Adminstration to take mentholated tobacco products off the market.9 Cohen also had experience fighting big corporate interests. She spearheaded the 2016 San Francisco soda tax ordinance.10

On 7 March 2017, Drs. Yerger and Gardiner met with Supervisor Cohen to explain from public health and social justice perspectives the importance of enacting a flavoured tobacco product sales ban. Cohen recognised the significance of the policy for those she represented. She agreed to sponsor a bill. Prior to the meeting, the AATCLC discussed what type of policy they should recommend. There were concerns within the AATCLC that a jurisdiction-wide policy was most likely to be legally contested. The AATCLC had prior success advocating for policies that restrict the sales of flavoured products to tobacco shops or create a buffer zone around schools. The buffer zone policy had already been successfully litigated in Chicago, Illinois, and had been adopted in Berkeley, California. Since 2017, the policy landscape has shifted. Weaker policies that exempt certain types of retailers (e.g., tobacco shops) or create buffer zones are now discouraged. Drs. Yerger and Gardiner discussed policy options with Cohen. She preferred the most comprehensive policy, acknowledging that the San Francisco Board of Supervisors had been ‘inoculated against big industry.’ The ordinance was drafted by a city attorney who previously worked in tobacco control.

On 18 April 2017, Supervisor Cohen held a press conference with the SF Menthol Task Force on the steps of San Francisco City Hall to announce the ordinance.11 AATCLC members made comments to the press. Ms. McGruder taped a five-minute interview about the ordinance that aired on cable television and the media company’s website. The comprehensive legislation would prohibit retailers from selling any tobacco product (cigarettes, e-cigarettes, cigarillos and smokeless products) with a characterising flavour, including menthol, in San Francisco.12 The legislation noted there would be no penalties for use or possession of these products.13 On 27 June 2017, the San Francisco Board of Supervisors unanimously approved the ordinance.14 Mayor Ed Lee signed the bill into law on 7 July 2017. The implementation date was scheduled for 1 April 2018.

Recommendation 4: Partner with other organisations to counter industry

Reynolds American, Inc. (RAI) filed notice of a referendum (vote by the electorate) petition on behalf of Let’s Be Real San Francisco.15 RAI is the parent company of RJ Reynolds, which manufactured Newport menthol cigarettes, the most popular menthol brand.16 The campaign website stated that Let’s Be Real was a coalition of adult consumers, neighbourhood retailers, and advocates for free choice.17 Reports, however, indicate RAI was the major funder of Let’s Be Real.18 See figure 1 for the Let’s Be Real campaign logo. RAI spent over $685,000 to collect the required 19,000 signatures for the referendum.19 Because this industry-backed group submitted enough signatures, the San Francisco Board of Supervisors was required to vote on whether they would uphold the ban. On 5 September 2017, the Board voted unanimously to uphold the ban. In accordance with San Francisco law, the measure was then placed on the June 2018 ballot.18

Figure 1

Let’s Be Real San Francisco campaign logo.

RAI committed a total of nearly $12 million to the ‘No on Prop E - Stop the Prohibition Proposition’ campaign.20 The campaign blitzed San Francisco with flyers, billboards and television advertisements.21 The campaign argued that more restrictions on tobacco were not needed because California raised the smoking age to 21 years in 2016 and increased taxes on cigarettes by $2 in 2017.22 A rally was held where an attendee discussed the economic loss her family’s corner store would endure if a ban was implemented.23 Another speaker stated that young men of colour would be harassed by police.23 Such arguments had often been made by front groups for the tobacco industry.24

To combat the industry’s efforts, the AATCLC welcomed partnerships with other organisations. The tobacco industry’s referendum against the ordinance led to the creation of the San Francisco Kids vs Big Tobacco campaign. This collaborative partnership included the AATCLC, San Francisco Tobacco Free Coalition, Breathe California and national advocacy groups such as the Campaign for Tobacco-Free Kids, American Lung Association, American Heart Association and American Cancer Society-Cancer Action Network. San Francisco Kids vs Big Tobacco received funding from philanthropist Michael Bloomberg, who donated $1.8 million to the ‘Yes on E’ campaign.25 Funding was used to hire a political strategist. The San Francisco Kids vs Big Tobacco campaign coordinated media interviews for the AATCLC.

Dr. Yerger and Dr. Gardiner lobbied on behalf of AATCLC in the evenings and weekends outside of their primary employment. Ms. McGruder had limited time to lobby as part of her primary employment; lobbying on behalf of AATCLC occurred in the evenings and on weekends. Members of the SF Menthol Task Force were not permitted to lobby as part of their employment with the Task Force. Mr. Bob Gordon, the co-chair of the San Francisco Tobacco Free Coalition and member of the Task Force, and Ms. McGruder presented about the harms of menthol cigarettes and the potential benefits of the flavour policy to Democratic clubs in San Francisco, such as the African American Democratic Club, to seek their endorsement. Voters look to clubs for policy endorsements. The political strategist hired as part of the San Francisco Kids vs Big Tobacco campaign connected Ms. McGruder and Mr. Gordon with the Democratic clubs.

Recommendation 5: Be responsive to community concerns

Dr. Yerger, Ms. McGruder, and Dr. Gardiner held community forums to educate voters on Proposition E. They clarified what a ‘yes’ or ‘no’ vote meant for the proposition. The AATCLC and SF CAN also hosted five workshops and two spoken-word contests titled ‘What’s Menthol Got to Do With It? Everything!’ Youth and young adults were invited to give poetic performances using facts about the tobacco industry and from a social justice perspective. Contests had live DJs and were catered.26 Cash prizes of $750, $500 and $250 were provided. The AATCLC found that incorporating ‘artivism,’ such as spoken-word poetry, in their work was an effective way to increase engagement.

A survey conducted by partners in the San Francisco Kids vs Big Tobacco campaign found that residents of San Francisco were most responsive to messaging about flavoured tobacco product use among youth. The AATCLC’s messaging had focused on targeted marketing by the tobacco industry and the importance of the policy for social justice. AATCLC had mixed feelings about changing their messaging. Implications for social justice were a principal motivator for their work. In effort to pass the policy, they pivoted their messaging in meetings with the general public.

To increase the visibility of their efforts as being youth focused, the SF Menthol Task Force distributed educational materials to middle and high schools in San Francisco. Schools were selected in racial/ethnic minority communities to target education to this population. The Task Force also met with a San Francisco YMCA programme focused on empowering youth to promote health initiatives.

Despite Reynolds’ efforts, Proposition E was passed on 5 June 2018, with 68% of voters favouring the policy.27 The comprehensive flavour ban in San Francisco serves as exemplary legislation.

Lessons

Several conditions necessary for policy enactment can be replicated in other localities. First, a team of advocates is needed. AATCLC member Dr. Yerger and co-chairs Ms. McGruder and Dr. Gardiner worked as a team. They attended meetings individually or in pairs, or to be more compelling, as a trio. They became synonymous with advocacy work for the ban.

A second condition necessary was community support. The AATCLC reached out to community groups harmed by menthol cigarettes. The AATCLC had a comprehensive agenda that included other pressing community issues. AATCLC hosted events targeting youth and young adults, empowering them with evidence-based information. Existing relationships between tobacco retailers and the San Francisco Department of Public Health, a partner in the Task Force, were leveraged to garner policy support from businesses. The industry-funded campaign argued that the policy would hurt local business.

The third condition necessary was a policy sponsor. This may require reaching out to several government office holders. Highlighting concerns for social justice and the health of children were important for garnering sponsor support. A policy sponsor who has experience fighting corporate interests is ideal. If existing relationships with elected officials cannot be leveraged, demonstrating strong community support for the policy is critical for securing a sponsor. Connecting with advocates in other localities that have implemented flavour sales restrictions and have relationships with elected officials is useful for learning how to grow one’s network of potential sponsors.

The fourth condition necessary was a cohesive working group comprised of national and local foundations, voluntary organisations, and a professional campaign manager. This ‘all hands-on deck’ team supported this community-driven initiative with organisational support, funding, and power. A group with political, legal, and administrative support is important for countering the tobacco industry.

A final condition was having clear and repeated messages that were responsive to community concerns. In response to growing concerns about e-cigarettes, AATCLC pivoted their messaging from a focus on menthol and the African American community to concerns about flavoured tobacco product use among youth generally.

Conclusion

Local communities in the USA are leading policy change on flavoured tobacco products. More than 100 US localities and two states have passed restrictions on menthol cigarettes.28 Outside the USA, several countries restrict the sale of menthol cigarettes including Brazil, Canada, Ethiopia and Turkey, as well as the European Union.29 30 Advocates may learn from the process leading to the passing of the San Francisco policy to continue this work in their own communities.

Data availability statement

There are no data in this work.

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References

Footnotes

  • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

  • Contributors All authors made substantial contributions to the conception and design of the work. All authors drafted the work and revised it critically for important intellectual content. All authors provided final approval of the version published and are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of the work are appropriately investigated and resolved.

  • 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 SM receives funding from the National Cancer Institute and the Food and Drug Adminstration. VY and COM have no competing interests.

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