Image: Five Fundamental Drivers of Health Inequity. A Blueprint for Changemakers: Achieving Health Equity Through Law & Policy (ChangeLab Solutions, 2019).

The Geographic Health Equity Alliance invited Derek Carr, J.D., and Jessica Breslin, J.D., from ChangeLab Solutions to present at CADCA’s 2021 National Leadership Forum. Their presentation, “Equitable Policymaking in Commercial Tobacco Control,” addresses the importance and need for applying a health equity framework in every step of the policymaking and implementation process. It requires not only working to reduce tobacco-related health disparities, but also moving further upstream to address the social and structural determinants—the root causes—of tobacco use and poor health. We are delighted to share the recording from this informative session with you, along with Derek and Jessica’s introduction to the video below:

Equitable Policymaking in Commercial Tobacco Control

No person, regardless of their race, ethnicity, who they are or where they live, should be exposed to experiences that are known to be harmful. Yet, factors such as targeted marketing and variations in policy protections increase many underserved communities’ exposure to tobacco. People who live in underserved communities may be more likely to use tobacco due to inequitable policies and social, structural and environmental factors such as income inequality and poverty, structural discrimination and racism, intergenerational trauma, toxic stress, housing instability and lack of access to quality education.

Individuals and communities facing these conditions experience significant structural barriers and high levels of pressure related to finding good jobs, taking care of their families and securing a roof over their head and food on the table. The combination of chronic stress and higher rates of tobacco exposure contribute to greater commercial tobacco use and subsequent health harms among many structurally marginalized communities.

To address these inequities, stakeholders must prioritize the integration and advancement of health equity in all aspects of commercial tobacco control policymaking. Considering equity at each step in the process—from policy selection and design to implementation and enforcement—can help ensure that any policy change is grounded in a deep understanding of the health priorities, goals and lived experiences of communities. Placing equity at the center of the policy process can also draw attention to broader structural solutions aimed at fixing the unjust environments that push people to use tobacco in the first place.

Enforcement is a particularly important consideration in advancing tobacco-related health equity. How a law or policy is enforced has a major effect on who it will impact and whether that impact will be fair and proportionate. Enforcement actions taken in the name of public health can sometimes harm, discriminate against or otherwise undermine the health of the very people the laws are meant to protect. In fact, when enforcement is carried out inequitably, it can often create, maintain or exacerbate existing health inequities. Equitable enforcement, which is the process of ensuring compliance with laws and policies in a way that considers and minimizes harm to underserved communities, can hold wrongdoers accountable while simultaneously protecting the health and well-being of individuals and the community.

A health equity approach to commercial tobacco control also means ensuring that how we talk about tobacco, tobacco-related health disparities and policy solutions takes into consideration the unique context and lived experiences of individuals and communities. This is because how we talk about and define an issue directly affects how people perceive the topic and the types of solutions that get proposed and implemented. Successful, equity-oriented policymaking requires changing the conversation in a way that not only builds support for action, but does so in a way that emphasizes systems-level drivers of tobacco use, rather than ineffective and stigmatizing narratives of personal responsibility and moral failing.

This presentation outlines the fundamental drivers of health inequities, including health inequities related to commercial tobacco, explains how to apply a health equity framework to commercial tobacco control policymaking, from policy selection and design to implementation and enforcement and identifies opportunities to change the frame from individualistic thinking of tobacco use as a personal choice towards systems-level thinking of commercial tobacco use as being driven by social, structural and environmental factors.