Here at the Public Health Law Center, we have long advocated for accelerating the so-called “end game” to phase out the sale of cigarettes and other combustible commercial tobacco products.  But today, like so many others, we find ourselves re-examining our agenda, wondering where yesterday’s priorities fit in today’s crazy times, when we are not only consumed by the coronavirus, but also awakening more fully to the underlying crisis of racism that infects every institution of our society.  

These dual crises are so overwhelming that, in the heat of the moment, yesterday’s agendas can feel slightly disconnected from reality, almost tone deaf. The crises of the hour are so monumental that we feel called to respond to the urgency of now.  Should we set aside our long-standing priorities and commitments, to focus more directly on the immediate pandemic and the overarching crisis of racism?

As we struggle to find the right path forward, to set appropriate priorities in this new time, we are struck increasingly by a belief that it’s not an either-or proposition, and that the alternate paths may actually point in the same direction:  We’ve been saying for years that all public health problems are inter-related, and the more we pull back our lens today, the more we come to understand just how deeply interrelated they are.  From that new vantage point, the case for phasing out combustible tobacco becomes even more compelling.  The tobacco epidemic falls most heavily on Black and Indigenous people and people of color, as well as those with lower incomes and the LGBTQ+ community.  Perhaps more than any other underlying condition, tobacco dependence weakens the health of those communities, ensuring a built-in vulnerability and guaranteeing an inequitable impact not only from COVID-19, but from every future assault on America’s health, whether from climate change, unhealthy food, inequitable access to health care, or the catastrophe we have yet to imagine. From this perspective, the case for the tobacco end game becomes more urgent, not less.

From its earliest days, public health has defined itself as the prevention side of the health equation: the upstream counterpart to the health care system’s treatment model. Whether the focus was sanitation and clean water, vaccinations, or highway safety, public health secretly prided itself, in fact, on being the smarter and more impactful side of the equation, well aware that no amount of treatment can equal the power of effective prevention.  For many years, prevention was understood in terms of an idealized model (usually unstated) of “personal responsibility,” that viewed individuals as fully autonomous, rational actors, with complete agency to control their destinies, uninfluenced by external factors or the surrounding environment. In infectious disease control, this paradigm pointed toward individualized interventions like encouraging parents to support childhood vaccinations. In chronic disease prevention, practitioners focused on influencing individual behavioral choices and lifestyles. Poster campaigns. Pamphlets. It was a mindset that strikes us today as outdated and ineffective, if not dangerously naïve.

In time we came to understand that moving upstream meant much more than individual choices.  Farther upstream were the social and environmental structures that shape and even dictate the supposed choices of the individuals downstream. We called them the Social Determinants of Health. Today they are familiar: economic inequality, inadequate housing, lack of transportation, inadequate education, unequal access to care, an unjust system of justice.  As self-evident as these social factors feel to us today, it is easy to forget what a revelation they seemed only a decade or two ago. We forget that it was only twelve years ago that a prophetic WHO report helped introduce the world to the fundamental role of Social Determinants in achieving ─ or preventing ─ equity. And how that understanding transformed our approach to health and to health disparities!  For public health attorneys, it changed everything, by helping us see the legal structures underpinning every determinant of health, both positive and negative.  And it set the course for organizations like ours, committed to addressing inequities.

Now we are pulling back the lens even farther, moving even farther upstream, toward the headwaters of injustice.  If the Social Determinants of Health are the root of disparities, we are awakening to the fact that there are even deeper, underlying drivers of injustice, and for many Americans, the root of the root is racism.  Its cascading effects cut across everything. The entrenched inequities of 400 years, 8 minutes and 46 seconds of racial oppression run so deep that, whatever our immediate response to the crisis of the hour, whether a virus today or climate change tomorrow, every problem falls harder on Black and Indigenous people and people of color.  Like a patient with a compromised immune system or diminished lung capacity, communities of color are left in a weakened state, condemned in advance to suffer the most from the next calamity, whatever it may be.

And so, if we are called to attack the root of the root of injustice, and if we hope to maximize our impact, what better place to focus than on cross-cutting measures that restore the collective health of all disadvantaged communities, and in doing so, help create the elusive Culture of Health that the Robert Wood Johnson Foundation has urged as our guiding star for the decades ahead?  And how better to begin that work than with tobacco? How much stronger, how much more resilient, will the Black and Indigenous communities, and all communities of color, be, not only in the age of COVID-19, but in every crisis ahead, if we can phase out the scourge of commercial tobacco?  If it’s not enough that tobacco, in and of itself, remains the leading preventable cause of death, then consider its role as a principal cause of virtually every known risk factor for the most severe forms of COVID-19, from hypertension and heart disease to asthma, COPD and other lung disease, to diabetes and impaired immune systems.

And what about the next health crisis?  Whether it’s a warmer planet, another novel disease, or a failing health care system, we can predict with confidence that the next crisis, too, will fall hardest on those addicted to tobacco, and that they will still be disproportionately Black, Indigenous, and people of color, people with limited incomes, LGBTQ+ communities, those without homes, those who are incarcerated, those with substance use disorders, those with mental health issues – in short, those who always find themselves at the back of the line. Oh, and as we consider economic injustice, let’s not forget that smoking two packs a day costs nearly fifteen percent of the entire annual income of a median Black household.  And for what?  Despite the thousands of studies that have made commercial tobacco the most-studied product in all of history, even the most advanced research has yet to uncover a single redeeming social benefit of tobacco dependence.

And so, if we go far enough upstream, in search of a master key, a single intervention that can begin to topple the structures of injustice, and strengthen health and resilience across the entire spectrum of health problems, we may actually find ourselves back where we started, with tobacco as a perfect place to begin.

Posted by Doug Blanke, Executive Director, Public Health Law Center
June 30, 2020