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In a rapidly evolving tobacco marketplace, research and evidence-based advocacy in action can help avert public health crises and achieve landmark progress in tobacco control.1 Research in action here relates to timely scientific investigations of emerging or ongoing tobacco control milestones; evidence-based advocacy in action is focused on using emerging scientific evidence to inform urgent tobacco control efforts.
Strategic partnerships, combining tobacco control research and advocacy in action, referred to as partnership in action from hereon, involve experts aligning on tobacco control priorities while considering or generating evidence related to the unintended, intended and potential implications of tobacco control efforts. These experts pursue a common goal but typically come from diverse backgrounds and expertise, employ domain-specific language and may use different metrics to evaluate the impact of their contributions. While partnership in action is not a novel phenomenon in tobacco control, a blueprint of such collaboration can help (1) unify efforts and forge productive and sustainable partnerships at an organisational level, and (2) advance conversations about structures and processes of thriving collaborations in a dynamic tobacco control landscape.
We conceptualised a partnership in action framework including six stages guiding collaborations between the tobacco control researchers at the American Cancer Society (ACS) and advocates at the American Cancer Society Cancer Action Network (ACS CAN). ACS houses an intramural Surveillance and Health Equity Science research department comprised of 39 research scholars with expertise in epidemiology, public health, regulatory science, economics, statistics, tobacco control and data science; 10 of them are specialised in tobacco control research. As the ACS’s non-profit, non-partisan advocacy affiliate founded in 2001, ACS CAN has successfully advocated for billions of dollars in cancer research funding, expanded access to quality affordable healthcare and advanced proven tobacco control measures.
Below is a description of the partnership framework followed by one case study of how we have applied this framework in the recent past.
Our model of partnership involves a closed group of in-house experts at ACS and ACS CAN who define and address research and advocacy priorities (also known as the ‘Elite Circle’ model of collaboration).2
Scope: Tobacco control efforts in the USA.
Objectives: To build and strengthen ties between tobacco control research and advocacy practitioners; inform tobacco control policies at the local, state and federal levels.
Values: Integrity (driven by truth, ethics and fact of science), compassion (caring for and supporting those touched by cancer), courage (undeterred by challenges and bold in action), determination (relentlessly pursuing a world without tobacco), diversity (intentionally striving for equity through inclusion and respect).
Conceptual framework: The partnership is conceptualised as loops—collaboration on one project typically creates opportunities, organically or otherwise—for new or spin-off follow-up projects. The first five stages typically occur sequentially and may contribute to or benefit from other stages of the project during and beyond the project implementation life cycle (see figure 1):
Stages of collaboration
Exchange: The ACS tobacco control team researchers and ACS CAN advocacy practitioners exchange weekly updates and answer questions related to ongoing efforts (internally and externally) to advance tobacco control efforts at the local, state and federal levels in the USA. This platform serves as the (1) official conduit of information in the field (eg, emerging research findings, proposed policies), interpretation of events and news (eg, potential regulatory implications of synthetic nicotine products in the market) and opportunities (eg, introduction of very low nicotine products), and (2) a sounding board for all members to discuss potential partnership possibilities (eg, integration of evidence-based tailored email messages devised by ACS researchers to help people who smoke quit with ACS patient support pillar helping patients with cancer with smoking cessation) and challenges (eg, tobacco industry lawsuits that delay passage of laws, and our collective position in the context of debated topics.)
Align: The partners converge as needed on priorities in need of evidence-based advocacy (eg, proposed tobacco control policies, gaps in current regulations and newly enforced policies). Next, we form priority-specific task groups that include at least one researcher and one advocacy practitioner to determine the deliverable, timeline and the best course of action. Typically, researchers translate broader priorities (eg, Was the public less inclined to quit smoking during the COVID-19 pandemic?) into specific research questions (eg, What were the trends in the point-of-purchase sales of Nicotine Replacement Therapy products before and after the COVID-19 pandemic?) to explore pertinent data and publish in peer-reviewed journals or other outlets; advocates also translate broader priorities into specific advocacy goals (eg, How much of a tax increase is needed to achieve a desired reduction in tobacco use?). Researchers support this effort by operationalising variables or measures of interest, and advocates help refine the strategic scope of the priorities to maximise their practical relevance (eg, advocate for tax increase for all tobacco products or just cigarettes). Collectively, the task group finalises deliverables involved in addressing the priority (eg, advocacy letter, position statement, amicus briefs, public fact sheet, peer-reviewed manuscript publication).
‘Partner’ source: Task group members co-create a pool of resources that can potentially address the priority—identify qualitative or quantitative datasets that can potentially answer research questions, conduct literature search of published findings on the topic, analyse tobacco policy documents (eg, proposed rules, passed legislation, draft ordinances) and reach out to internal and external partners for collaboration or information, if needed.
Generate: At this stage, the members generate deliverables while working in close consultation with each other. The task group members first draft and discuss an outline of the deliverable (eg, a table of contents with sections and subsections in a public comment to a proposed rule) with other task group members. Reflexive questions and constructive feedback become an important part of this process. The final version of the deliverable is reviewed and approved by all task group members and external members (if any).
Outreach: Outreach activities typically begin after an expected gestation period, which typically depends on the nature of deliverable (eg, duration for manuscript to undergo peer-review until final acceptance, time taken for co-signers to review an advocacy letter) in the generate stage. The objective is to maximise the reach of the deliverable with policymakers, media, community and public health organisations, and members of regulatory agencies and scientists.
Impact: Project impact varies by the duration, nature, strength, type and size:
Duration: Short-term (up to 1 year since project implementation), medium-term (one to 1–2 years since project implementation) and long-term (beyond 2 years since project implementation) project impact is tracked by the project lead and the task group. Cross-sectional impact, defined as impact at a point in time, is also differentiated from cumulative impact, sum of incremental instances of impact in the past and present regardless of the project’s intended impact. For instance, when a project informs a state-level policy, which then informs a federal level policy of a similar nature, the impact on federal policy is viewed as cumulative impact.
Nature: Direct impact is measured in terms of outcomes, efforts or developments occurring as a result of a project’s contribution and goal (eg, measuring health disparities post implementation of the Tobacco 21 law), indirect impact is defined as instances, not defined a priori as intended impact and occurring incidentally (eg, increase in the point-of-sales volume of non-flavoured cigarettes post implementation of prohibiting menthol cigarette sales).
Strength: Enduring impact of a project refers to contributions that persist or grow organically even after project completion (eg, contributions of health behaviour theories conceptualised several years ago). At the same time, temporary impact may also be powerful when it is timely (eg, advocacy letter alerting regulatory authorities of non-compliant tobacco retailers).
Type: Public health impact is measured in terms of lives saved as result of the project; economic impact is reflected in tax dollars saved as a result of a project; health equity impact is defined in terms of the extent to which a project reduced the gap in health disparities; policy impact is the extent to which a project informs a draft policy, proposed policy or an enacted policy.
Size: A project may claim attributive impact only if it is able to effect direct, causal, and intended change, and contributive impact if it contributed to or helped to cause the intended change.
Case study: informing Food and Drug Administration (FDA)’s decision to regulate menthol-flavoured cigarettes
Exchange: In light of robust evidence, ACS CAN has advocated for a federal ban on mentholflavored tobacco products to advance health equity and protect public health in the past. ACS Tobacco Control team and ACS CAN members were collectively exchanging notes on the enforcement of a state-level policy— Massachusetts’ statewide law to restrict the sale of flavoured tobacco products implemented in June 2020. In the meantime, the team was also aware of the FDA’s intention and impending announcement of its proposed rule banning menthol flavoured cigarettes and flavoured cigars in 2021–2022.
Align: We determined that evaluating the impact of the Massachusetts menthol law would be timely evidence to the other states considering similar laws at that time and potentially a federal ban in the pipeline. We determined that examining changes in menthol and non-flavoured cigarette sales in Massachusetts may inform flavoured tobacco restriction advocacy efforts across the nation.
‘Partner’ source: Identification of evidence gap: post a literature review, an evidence gap with regard to the effectiveness of restricting the sale of menthol cigarettes emerged; finding appropriate data source(s): to answer the research questions in the absence of data on individual-level trajectories pre-statewide and post-statewide prohibitions, the Nielsen point-of-purchase sales data in Massachusetts was determined to be a feasible alternative; analytic approach: a quasi-experimental approach using difference-in-differences strategy was deemed to be the most appropriate given the dataset and the research question; manuscript format: we determined that a brief research letter (600–700 words) would offer pointed and timely evidence needed for advocacy.
Generate: We compared 4-week cigarette sales per capita in Massachusetts to sales in 27 other states available in Nielsen point-of-purchase sales data that did not implement state-level or local-level menthol flavour ban using before (from January 2017 to May 2020) and after (from June 2020 to July 2021). The findings were reported and discussed in a research letter submitted to JAMA Internal Medicine.
Outreach: On publishing the manuscript,3 the study findings were shared at the following avenues:
On 19 April 2022, the lead author, Dr Samuel Asare, presented study findings with the White House’s Office of Information and Regulatory Affairs (OIRA) to inform the FDA’s proposed rule (pending at that time) to implement ban on menthol in cigarettes and flavours in cigars nationwide.4
The lead author also presented this work at an ACS fund-raising event showcasing to demonstrate the role of ACS research in advancing tobacco control and cancer prevention, particularly among the black population disproportionately affected by menthol cigarette smoking.
Impact: This project has made an enduring, long-term, policy impact within 6 months of project conceptualisation.
This work was cited multiple times in the FDA’s proposed rule on prohibiting the sales of menthol cigarettes.4 Findings from the study were used to strengthen the case for a nationwide comprehensive menthol flavour prohibition after the lawsuit requiring the FDA to act on a Citizen’s Petition prompted the FDA’s proposed rule.5
In a testimony submitted on 11 January 2022 in opposition to an ordinance to end the sale of flavoured tobacco products coming up in Portland, Maine, the tobacco industry denounced the study findings as unsubstantiated.6 The Tobacco Control Research team helped in crafting a response for an ACS CAN volunteer to testify in the hearing and counter this tobacco industry interference.
JAMA Internal Medicine also published an editorial ‘Association of policy interventions with tobacco use behaviours’ that described how laws restricting the sale of menthol cigarettes were effective in reducing menthol and overall cigarette smoking and ensuring health equity.7
Currently, based on the public and expert feedback on the publication, the task group has explored a follow-up research question on how the Massachusetts menthol law was associated with changes in sales in the bordering states of Massachusetts, currently under review at a high-impact publication outlet.
This partnership framework has been applied only in a US Tobacco Control context, by a team of advocates and researchers, in a non-profit organisational setting. The scope of this collaboration model is currently restricted to research and advocacy efforts internal to ACS and ACS CAN, which represents a defined scope of research-advocacy collaborations addressing tobacco control priorities. We seek collaboration from researchers and advocates in universities and public health organisations to supplement our efforts when need for external capacity arises. Evidence-based tobacco control advocacy in other organisational settings may consider tailoring the framework based on their needs and priorities. Taken together, this collaborative model offers agency to partners involved in the process and sustain long-term research advocacy partnerships in an evolving tobacco control context.
Data availability statement
There are no data in this work.
Patient consent for publication
Twitter @AnujaMajmundar, @samasares2
Contributors Planning: AM. Conduct: AM. Concept: AM. First draft: AM. Critical review of manuscript review: AM, ZX, SA, CM, CC, LL, AJ, NN. Supervision: NN. Guarantors: AM, NN.
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.
Provenance and peer review Not commissioned; externally peer reviewed.