This year marks the 60th anniversary of the groundbreaking surgeon general’s report on the dangers of smoking, and 20 years since the last comprehensive review of the health effects of involuntary exposure to smoke. Both catalyzed the field of tobacco and nicotine prevention to advance policy, systems, and environmental (PSE) change approaches that counter egregious industry tactics and mitigate harm to the public. Advocates have achieved wins from eliminating smoking on airplanes to dramatically reducing smoking rates among youth, implementing smoke-free workplace restrictions to improve indoor air quality, and disrupting industry marketing tactics.
“The tobacco and nicotine prevention field were – and continue to be – pioneers in using PSE approaches to change social norms and fight against powerful industry interests,” said Kathleen McCabe, Managing Director of Policy and Practice and longtime tobacco prevention advocate. “HRiA’s work in this space demonstrates how our deep relationship in community, commitment to youth leadership, and knowledge about PSE can result in positive and lasting community impact.” Below are three examples from HRiA that illustrate how we advance PSE to address tobacco-related inequities.
Developing an anti-racist tobacco prevention movement among youth
Challenge: It is well established that the tobacco and vaping industries target young people in their marketing campaigns, with the intent to initiate young smokers. Despite the evidence of the health impacts of tobacco and nicotine, these companies continue to release new products that appeal to young people, such as flavored cigars and vapes, employing the same playbook to recruit their next generation of customers.
Approach: In 2006, a group of young people partnered with HRiA and the Massachusetts Tobacco Cessation and Prevention Program at the Massachusetts Department of Public Health to establish The 84 Movement (The 84). This statewide tobacco prevention program builds the capacity of youth to reverse the influence of the tobacco industry, shift social norms, and reduce the presence and impact of nicotine in their communities. The 84 takes an approach that youth care about by focusing on anti-racism, especially on educating youth about the racist tactics used by the tobacco industry for centuries. By heightening awareness among youth about their own identities, The 84 helps personalize the connection for youth to fight back against the industry. “The 84 empowers youth to step out of their comfort zone and challenge themselves to take up leadership roles and develop a culture of activism that encourages them to be lifelong advocates,” said Neha Ninan, a youth from the Hopkinton Organizing for Prevention 84 Chapter who serves on The 84’s Statewide Leadership Team. “Youth share knowledge with their coalition, which shares this knowledge within their town and so forth, creating collective awareness and action across Massachusetts. Especially by informing leaders in government about tobacco issues, the movement helps to enact laws that protect future generations from the tobacco industry, creating a healthier environment,” she said. Today, over 60 community-based organizations and schools comprise The 84, made up of “Chapters” representing over 1,500 youth statewide. Program staff and partners offer training (such as media advocacy), grant opportunities, and youth-led events to unite young advocates and connect their work to a broader statewide movement.
Results: The 84 moniker was adopted to represent the 84% of MA high school youth who did not smoke cigarettes when the movement began. As of 2023, that number has increased to 97%, and 84% do NOT vape. Since 2015, The 84 has achieved several meaningful policy victories in Massachusetts, including:
- Creating age restrictions for e-cigarettes.
- Restricting the sale of flavored tobacco products to adult-only establishments in 134 municipalities before this became a statewide law in 2019 (see below).
- Banning the sale of tobacco in pharmacies.
- Raising the price of single cigars.
- Raising the legal age of tobacco sales to 21.
These wins are built upon years of collaboration, capacity-building, and multi-pronged efforts among many young people, adult champions, and organizational partners. Beyond the policy wins, states are looking to hold tobacco and nicotine companies accountable. In early 2020, former MA Attorney General Maura Healey announced an investigation into JUUL for their role in contributing to the youth vaping epidemic, which resulted in a 2023 multistate settlement of $462M. Some of this funding was then passed through to The 84 to expand their impact.
Eliminating secondhand smoke exposure in Boston public housing
Challenge: There is no safe level of exposure to secondhand smoke. Those most exposed often live in communities that are explicitly targeted by the tobacco industry, including but not limited to people of color, LGBTQIA+ community members, people with a low-income, and people who live in multi-unit residential buildings.
Approach: Smoke-free building policies are among the most effective strategies to eliminate the impact of secondhand smoke and other smoking-related hazards. Since 2008, HRiA has been a Massachusetts Department of Public Health-funded statewide technical assistance provider for smoke-free housing. HRiA engages with community residents and housing providers to build a shared understanding of their challenges. From 2010-2012, HRiA partnered with the Boston Housing Authority (BHA) to support a resident-centered approach to adopting smoke-free housing policies. Throughout the process, HRiA collaborated with BHA residents and property managers to (1) deliver education and training, (2) co-create an implementation plan that would reduce secondhand smoke exposure, and (3) minimize resident displacement.
Results: In 2012, BHA became the first large city housing authority in the country to successfully adopt a smoke-free housing policy. After capturing this process in a toolkit, HRiA and our Public Health Advocacy Institute partners supported dozens more Massachusetts landlords, including public housing authorities, as they adopted smoke-free housing policies. To date, well over 50,000 units in 200+ municipalities across the state have adopted smoke-free housing policies, and the U.S. Department of Housing and Urban Development implemented a rule for all federally funded public housing to become smoke-free in 2018. [Read our 2016 statement or check out the toolkit adapted from HRiA’s original.]
Mobilizing community to ban flavored tobacco products
Challenge: Menthol, mint, and wintergreen-flavored cigarettes cause greater harm to people of color due to racist tactics employed by the tobacco and vaping industries, such as more advertisements and lower pricing in communities of color. In 2019, as a vaping crisis swept across the country, states began implementing sale restrictions of flavored products; however, these restrictions often exempted menthol, mint, and wintergreen flavors due to hard lobbying from the industry to not have them count as “flavors.” Tobacco prevention advocates in Massachusetts wanted to ensure that these flavors were included in local and state sale restrictions.
Approach: In July 2019, HRiA received funding from the Campaign for Tobacco Free Kids (CTFK) to mobilize community members—including young people—with the goal of banning all flavored tobacco and nicotine products without exception. The campaign explicitly named the tobacco industry’s racist marketing tactics, centering the stories of people across Massachusetts whose lives were impacted by them. HRiA leveraged the youth power of The 84 Movement, which educated local lawmakers about racist marketing for more than five years and activated cross-sector partnerships to mobilize Massachusetts residents to advocate for a complete flavor ban—the Fight All Flavors campaign. Efforts included (1) facilitating trainings and community conversations, (2) awarding capacity building grants to community- and faith-based organizations, (3) developing communication materials to support local mobilization efforts, (4) organizing multi-sector rallies, and (5) supporting people to provide testimony to the state legislature.
Results: In November 2019, Massachusetts became the first state in the nation to pass a law to stop the sale of ALL flavored tobacco, including menthol, mint, and wintergreen products and flavored e-cigarettes. [Read reflections from the team.] Following this victory, HRiA ran a campaign (No Menthol. Know Why.) to generate awareness about this landmark legislation to ensure a more effective implementation after the law was enacted in June 2020. Today, four additional states have enacted permanent bans. Several other states, as well as 380 localities, have since passed some level of restriction.
In an interview with WGBH’s Callie Crossley on Under the Radar, The 84 Movement’s director Carly Caminiti emphasized how the young people of The 84 Movement were essential to the success of the menthol ban. “Massachusetts is definitely a leader in [restricting the sale of flavored products],” she said, “and a lot of that is thanks to the young people that led the movement.” (Hear the full interview.)
Looking ahead
PSE approaches are compelling because they go beyond programming to create fundamental changes to underlying structures and conditions, perpetuating and amplifying positive outcomes over time. Tobacco and nicotine prevention advocates continue to push the field of public health and expand thinking about the types of PSE approaches that can ultimately eliminate tobacco as the number one cause of preventable death in this country. For example, in Massachusetts, a growing number of cities and towns, starting with the town of Brookline, have passed a Nicotine-Free Generation (NFG) law, which prohibits the sale of tobacco and nicotine products to anyone born in 2004 or later. In other places, policies like those limiting the number of permits available to sell tobacco are reducing industry influence by scaling back point of sale exposure to the products; studies show youth who shop at stores with tobacco two or more times a week are 64% more likely to start smoking than their peers who don’t.
Building from our past successes and looking towards a healthy future, HRiA will continue to advance policy approaches that center youth and community voice and push back against corporations more interested in profit than health.
