Mobilizing for Policy: Using Community-Based Participatory Research to Impose Minimum Packaging Requirements on Small Cigars

Abstract

The Problem

Cigarette sales have declined in the United States over the past decade; however, small cigar sales have been rapidly increasing. In most urban areas, small cigars are inexpensive and are sold as singles without health warnings.

Purpose of Article

This paper describes a community–academic–practice partnership’s (CAPP) efforts to decrease small cigar use in young adults living in Baltimore, Maryland, through legislative strategies.

Key Points

Survey data among young adults not in school indicated that 20% of individuals reported current small cigar use, often in combination with cigarettes. The community–academic partnership engaged the community in discussion about small cigar use in the fall of 2007. In collaboration with partners, bills were submitted to the legislative bodies for the city and state to impose minimum packaging requirements on small cigars.

Conclusion

Collaborative partnerships between community-based organizations, public health agencies, and academic institutions can lead to policy initiatives with the potential to improve public health.

Through evidence-based tobacco control policy, public health researchers and policymakers have been effective in reducing the prevalence of cigarette use; cigarette sales decreased by 18% from 2000 to 2007. However, an opposite trend is apparent in small cigar sales. During the same time period, small cigar sales increased by 115%, from 112.7 million cigarette-equivalent packs (a package of 20 small cigars similar in size, shape, and weight to a package of cigarettes) in 2000 to 242.5 million cigarette-equivalent packs in 2007.¹ Small cigars, also known as little cigars, cigarillos, or miniatures, are defined by the United States Department of Agriculture as cigars weighing less than 3 lb per thousand.^1–3 There are many products included in this definition. Products marketed as little cigars are also commonly called brown cigarettes, because they are the same size and shape as cigarettes and are generally offered in a package of 20, although the package may be lawfully broken so that the cigars may be sold singly. Winchester is a popular product of this nature. Other cigars smaller than the traditional premium cigar are included in this definition; these so-called small cigars are generally sold singly and offered in packages of five. The popular Black and Mild cigar falls in this category. Little cigars, cigarillos, and miniatures will be herein referred to as small cigars.

The product substitution from cigarettes to other combustible tobacco is alarming, because small cigars often contain roughly two to five times the amount of nicotine found in traditional paper cigarettes.^4,5 Also, small cigars are often inhaled like a traditional cigarette, rather than smoked like a cigar with minimal inhalation, thus increasing exposure to harmful chemicals.⁵

The popularity of these small cigars arises from a wide range in their size, flavor, packaging, price, marketing, and advertising. Small cigars are available in various flavors including apple, cherry, cream, and wine; federal law prohibits the sale of flavored cigarettes on the basis that such flavors entice youth to smoke (Family Smoking Prevention and Tobacco Control Act, P.L. 111-31 (2009).⁶ Counter advertisements and prominent placement by retailers may also account for the rising popularity of small cigar use. Further, cigars are generally taxed at rates much lower than cigarettes and may be lawfully sold “loose” or singly without health warnings, unlike cigarettes, which may be sold only in minimum packages of 20.⁷

The low-cost brand Black & Mild by Altria Group (parent company of Philip Morris) is the most popular brand of cigar among smokers 12 and over.⁸ National data on small cigar use reveal that 23.1% of high school seniors reported that they smoked small cigars in the past month.⁹ A barrier to assessing the prevalence of small cigar use is that many young adults do not recognize Black & Mild and other popular brands as a cigar.^4,10,11 This flawed perception of Black & Mild can also lead to increased product switching among former smokers who view small cigars as a safe alternative to cigarettes. The environment of heavily taxed cigarettes also proves conducive to product substitution, especially among those with low spending capital. Specifically, small cigars have become quite popular among African-American youth in urban settings.⁴ Jolly⁴ conducted focus groups with students at a historically Black university and found that the Black & Mild brand was sometimes synonymous with small cigar. This evidence suggests that brand-specific examples be included in national surveys (e.g., National Survey on Drug Use and Health) to avoid underestimation of small cigar use.^4,7

Tobacco policies have been effective at curbing tobacco use, specifically cigarettes, among youth and young adults. Because youth are particularly price sensitive, policy designed to increase the price of access—the price that must be paid to get the product—is effective at reducing youth tobacco use. Imposing a minimum pack size increases price of access and has been adopted to reduce youth cigarette smoking. Similarly, increasing taxes has been among the most effective strategies to reduce youth cigarette use and should have the same impact on youth cigar use.^12–16

This paper explores the use of community based participatory research (CBPR) in an urban community as a means to create regulations and policies to reduce the use of small cigars among young adults. The benefits of academic–community partnerships, resulting policies, and lessons learned are discussed. This example is presented in chronological order to show how effective the partnerships and timing were in introducing policies designed to reduce small cigar smoking.

CBPR

CBPR is a community-driven and action-oriented approach focused on social change and policy. Although this method is becoming increasingly popular, CBPR’s utility to drive policy changes has been understudied.^17,18 This paper describes a community–academic–practice partnership (CAPP) that utilizes principles of CBPR and was oriented toward public health practice and translation of practice to research and to policy. The CAPP involved the Baltimore City Mayor’s Office of Employment Development (Baltimore Youth Opportunity [YO!] Baltimore and Civic Works program directors, staff, and program members), the community partner; the Baltimore City Health Department (BCHD), the practice partner; and the Legal Resource Center for Tobacco Regulation, Litigation and Advocacy and The Johns Hopkins Bloomberg School of Public Health Center for Global Tobacco Control, the academic partners. These entities worked to study small cigar use among young adults in an urban setting and to inform policy designed to decrease small cigar use. The partnership grew from mutual interests in tobacco use and cessation. In 2003, the academic partner worked with another community of young adults in Baltimore City with similar demographics and partnered with the community to conduct a health needs assessment. Several health issues were identified; the top priorities were mental health, substance use, and stress. Tobacco use emerged as a primary coping strategy for stress. As a result of these findings, the academic partner and the community partner worked together to learn more about tobacco use and tobacco acquisition through focus groups with YO! center staff and members. Out of the focus groups, the issue of small cigar use emerged and was investigated.

Methods

The YO! centers and civic works provide education, life skills, and employment training and internships to young adults (18–24 years old) not in school or college. These programs were initially created through financial support from the Department of Labor and the Mayor’s Office of Employment Development. Focus groups with program directors and center participants were conducted to inform the partnership about how to address tobacco use in urban young adults. Major themes and issues from the focus groups, in addition to questions from national tobacco surveys, were used to develop a tobacco survey.¹⁹ The former raised our awareness of the sale of loose cigarettes and use of small cigars. This survey was administered in group sessions to consenting YO! Center members. The survey included questions on sociodemographics, tobacco acquisition and use, advertising, community attitudes, and norms.²⁰ The tobacco survey and focus groups were approved by the Institutional Review Board at The Johns Hopkins Bloomberg School of Public Health.

Survey data were collected on a sample of 333 young adults: 57% (n = 191) were female, 63% (n = 196) of the young adults had less than a high school education, and 56.7% (n = 189) were younger than 20 years of age. The entire sample responded to questions about the prevalence of tobacco use and a subsample of 142 (42.6%) responded to additional questions related to attitudes and beliefs about small cigars including perceived harm. The survey data analysis was completed in Stata 11.2.²¹ Chi-square tests were performed to examine differences in small cigar use by demographics (e.g., age, gender, education). Frequencies were also computed to examine knowledge, attitudes, and beliefs about small cigars.

Key Findings From the Tobacco Survey

The findings from the tobacco survey indicated that 20.1% (n = 67) of participants used small cigars in the past 30 days; small cigar use in past month was associated with gender and education. Males and those with a high school diploma were more likely to smoke small cigars (λ²; p < .001 and p < .05, respectively). Age was not related to small cigar use.

In general, respondents were uninformed and unsure about the content of small cigars and the harms associated with small cigar consumption. Among the subsample (n = 142) responding to questions regarding perceived harm, 58% (n = 82) of survey respondents disagreed or did not know if small cigars contain nicotine. In addition, 43% of respondents did not know whether small cigars or cigarettes were safer, meaning which product might cause fewer negative health consequences like cancer, respiratory ailment and cardiovascular disease. Nearly half of the respondents (47%) did not know whether cigarettes or small cigars were more addictive. Addiction alone does not cause harm; belief about the addictive quality of a tobacco product may, however, contribute to product selection. For example, if one believes that cigarettes are highly addictive but assumes that small cigars are not, one may choose to smoke small cigars—and then come to the quick realization that the assumption was wrong.

Disseminating the Results From the Tobacco Survey to Partners

Community Forum

Preliminary data on the prevalence of tobacco use were presented to the Baltimore City Commissioner of Health and relevant deputies and staff. To gather additional information and to confirm the preliminary findings, the commissioner recommended that his staff conduct a literature review on the use of small cigars and work with the existing community–academic partnership to conduct a stakeholder’s forum to solicit input and information from young adults and other stakeholders such as City and state legislators and the media about use of small cigars. Before the forum, the BCHD released a report on their website concerning the health effects and popularity of small cigars, citing the research gathered from the research partners.

Partners including the YO! center directors, staff, and BCHD members held several planning meetings to decide on the logistics of the forum including the location, time, invitees, and who from the YO! center membership would be speakers at the forum. The forum was held on a weekday afternoon in the community at the site of one of the centers. Transportation was arranged to assure that all YO! center members would be able to attend to the forum discussion. The BCHD invited multiple stakeholders including researchers, legal experts, media (Baltimore Sun and The New York Times) and legislators who serve on committees that focus on public health issues.

More than 60 young adults, invited stakeholders, and the media attended the forum where young people candidly discussed the use, availability and acceptability of small cigars. Public health researchers presented the data revealing increasing prevalence of small cigar use, and legal experts described possible policies that may deter the use of small cigars.

Reporting

The research and partnership experience was featured on the front page of The New York Times. In addition, the Baltimore Sun and the Washington Post also printed feature articles related to this public health problem. These articles highlighted the increase in small cigar use, especially among young African Americans. The articles in The New York Times and Baltimore Sun allowed broad dissemination of the research findings, assisting in the push for policies to regulate small cigars.

Results

The community–academic partnership was able to move into action quickly, in part due to the strong support of the health commissioner and the coverage of the forum by The New York Times and Baltimore Sun. The partners also had access to local research data and feedback from the community and relevant stakeholders including political leadership and institutions focused on the health and well-being of young adults.

Attendees of the forum included a Maryland State delegate representing Baltimore City, who serves on the Health and Government Operations Committee, along with a faculty member in the Center for Tobacco Regulation at the University of Maryland School of Law. During this same time period and 1 month after the community forum, Maryland faced a budget deficit and the governor called for a Special Legislative Session to balance the budget. During the 2007 Special Session, this same delegate, with the help of the faculty member from University of Maryland, introduced a bill that sought to tax certain small cigars (weighing less than 3 lb per thousand) at the same level as cigarettes and mandate that they be sold only in minimum packages of five.²² By increasing the tax and imposing a five-pack minimum, this bill would have resulted in an increase in the price to access small cigars. Although this bill was not passed, it introduced the policy community to this emerging public health problem. Similar bills were introduced unsuccessfully in the 2008 and 2009 Maryland legislative sessions.^23,24 Although the reason for the failure of any proposed legislation is not easily determined, the cigar packaging bills faced fierce opposition from the cigar industry, including the Maryland Retailers Association. The business community has powerful influence in the legislative committee that heard the bill and they employ highly effective lobbyists who are aggressive in opposing business regulations like the cigar packaging law. That no other state had passed a packaging law was also persuasive with the committee, because they had no other state’s experience on which to rely for proof of efficacy of the proposal. These factors and a general sentiment against business and tobacco regulation resulted in the failure of the bill.

After the introduction of the statewide bill to regulate small cigars (Table 1), similar bills were introduced in Baltimore City and in Prince George’s County, another predominately African-American jurisdiction. Relying on his power to abate public nuisances, the Baltimore City Health Commissioner also issued a health department regulation imposing a minimum packaging requirement on small cigars. Although the Baltimore City Council failed to take action on its pending bill, the Prince George’s County Council adopted legislation prohibiting the sale of small cigars in packages of fewer than five. The Prince Georges County ordinance and the Baltimore City Health regulation were both challenged in court on a variety of state law bases. At the trial level, the Prince Georges County ban was upheld, whereas the Baltimore City Health regulation was overturned on the ground that the health commissioner had exceeded his authority in issuing the regulation. The cigar industry appealed the ruling in Prince George’s County and the city appealed the trial court’s ruling in the city’s case. The Court of Appeals of Maryland, the state’s highest court, agreed to hear the appeal in the Prince George’s case and the Baltimore City case was suspended pending the outcome of that appeal. The court of appeals heard arguments on March 4, 2011, but has not yet issued a decision.

Table 1.

Small Cigar Legislation in Maryland

May 22, 2007	BCHD: Data Presentation.
August 15, 2007	Meeting with BCHD Commissioner Dr. Sharfstein is held. Discussed findings from tobacco survey. Dr. Sharfstein decided to focus on small cigars.
August 31, 2007	BCHD meeting: Little Cigars
October 9, 2007	BCHD seeks input on small cigars (Baltimore Sun). Immediate Press Release is produced. BCHD releases background paper on small cigars.
October 15, 2007	BCHD, the YO! Center, and The Johns Hopkins Center for Global Tobacco Control hold a forum at the Westside YO! Center to seek input on small cigars.
November 24, 2007	Maryland Special Legislative Session: New cigarette tax extension to low price cigars is proposed. This legislation would have prohibited sales in packages of <5 and would have imposed the cigarette tax on certain small cigars. The small cigar legislation failed.
January 31, 2008	Legislation is introduced in Maryland General Assembly to impose minimum packaging requirements on small cigars. Legislation unsuccessful.
May 28, 2008	Mayor and Health Commissioner propose regulation to impose minimum packaging for small cigars in Baltimore City. City requested comments on the regulation.
July 9, 2008	Maryland’s Attorney General submits memorandum saying Baltimore City is not preempted from imposing minimum packaging requirements on small cigars.
October 21, 2008	Prince George’s County, MD, introduces a bill to impose minimum packaging requirements on small cigars.
November 18, 2008	Small cigar bill is passed in Prince George’s County and the county is sued by the tobacco industry.
January 14, 2009	Baltimore City finalizes the regulation to impose minimum packaging requirements on small cigars and introduces legislation similar to the regulation. Baltimore City is sued by the tobacco industry.
June 25, 2010	City Circuit Court rules that the Baltimore City Health Commissioner does not have the authority to impose packaging requirements on small cigars. The city case is stayed pending the outcome of the county appeal.
July 12, 2010	Prince George’s County cigar packaging ordinance is upheld in County Circuit Court. Tobacco industry appealed the court ruling.
March 4, 2011	The Court of Appeals of Maryland heard the county case. The court has not yet issued an opinion.

That a tobacco control effort in Maryland would fail at the state level but prevail at the county level is not unique. From at least 1997 to 2006, tobacco control advocates unsuccessfully sought statewide legislation to prohibit smoking in all indoor workplaces and public places, closing the existing gap for bars and restaurants. During that time, several local jurisdictions in Maryland—from the large DC suburb of Montgomery County to the rural Talbot County—adopted comprehensive clean indoor air laws, mirroring the proposed statewide legislation. Shortly after Baltimore City adopted a similar law in February 2007, the statewide bill passed. Many of those who worked to secure the Prince George’s County ordinance and the Baltimore City regulation are poised to assist those jurisdictions with implementation and enforcement should the county prevail on appeal.

Discussion

This paper described how a CAPP rallied together to increase awareness, obtain community feedback, and create legislation to decrease the use of small cigars among young adults. Preliminary survey data from a sample of young, African-American adults indicated that small cigar use was prevalent. However, most of the young adults were unaware of the harm associated with small cigar use. Using these and other national data, the CAPP worked together to disseminate the findings and accelerate the “action” goal of this project to develop policy and intervention strategies to reduce tobacco use. The CAPP worked with policymakers to craft legislation to impose minimum packaging requirements on small single cigars. Legislation has been introduced at the state level several times and local jurisdictions have adopted provisions imposing packaging requirements. The partnership continues to work with the Maryland General Assembly and the Baltimore City Council and other policymakers in the state interested in evidence-based tobacco control policy; the researchers continue to provide relevant data on young adult tobacco use to the CAPP.

There were several challenges encountered and lessons learned during this process. In moving ahead, we realized the need to plan for continuing involvement of the health department, given the fact that leadership and priorities change. It may have been prudent to gain full support of all members of the city council; however, this can be difficult and time consuming. An alternate strategy is to assume that one can leverage leadership endorsement to win over the balance of city council members.

Another challenge was the need to collect additional local data and the inherent time lag data collection requires. Although national data and other research demonstrated that small cigar use was an emerging problem in urban areas and on the rise nationally, city and state legislators and other policymakers sought data specific to their constituencies. Deepening our relationship with the community may have evoked additional anecdotal information and support, such as that from the YO! forum, otherwise, we still would have lacked additional raw numbers that the policymakers sought. Timing is a major issue in translating research into policy and practice. With public health practitioners and policymakers, data are needed sooner rather than later, particularly if the public health problem is not well understood, is emerging but significant, and poses a health risk to vulnerable populations. Yet, traditionally researchers spend significant time collecting and analyzing data before disseminating their findings. This makes addressing an emerging issue a challenge when data and research lags prevent us from providing sufficient data to policymakers as a problem dawns in a community. Sometimes a legislator who was very interested in an issue has left office or moved on to other priorities by the time peer-reviewed findings are available. In most instances, however, those seeking to impact public health must be engaged in the process of establishing research priorities to ensure emerging issues are addressed and disseminated quickly. The emergence of the Public Health Law Research Program (PHLR), which issues small research grants with quick turnaround times for projects designed to impact public health policy, should help to address this particular dynamic. The PHLR is funded by the Robert Wood Johnson Foundation to support research that evaluates the effectiveness of public health policy to provide an evidence base for modeling or modifying that policy. For example, the PHLR has funded research into whether water fluoridation laws have a positive impact on oral health. More funding of that nature is required, however.

Another issue related to timing is determining at what stage to disseminate research findings. Our approach was to alert stakeholders of this project with interim reports rather than waiting until the conclusion of the project. This is conceptually important in the context of community-engaged research. Once the researchers learned of the relatively high prevalence of small cigar use in this population they contacted the BCHD and anticipated that mobilizing the stakeholders would lead to action. As a result, the former health commissioner discussed this issue in an editorial,

The end goal is not a publication. If the evaluations of pilot programs are … too long in coming to be relevant, then we will lose critical opportunities to make progress. In some cases, this failure has its roots in poor communication between researchers and the policymakers who could provide sustainable support. Engaging the interest of policymakers early and often is an often-overlooked part of a sustainability strategy.²⁵

We must also be cautious in such circumstances; preliminary research may not be fully consistent with final conclusions. Preliminary or interim research should be shared for the purposes of engaging the community and public stakeholders and compelling further research and policy. This will result in a better final product upon which policy action can be based.

In summary, this research was conducted utilizing community-based participatory research approaches. The partnership for this research included action-oriented, academic, community, practice partners and program participants, who rapidly moved from initial research to policy within a 2-year time period. As with most research, the work continues, particularly as the packaging restriction is being discussed now across the country while we have only secured one local ordinance and one local regulation in Maryland. The community–academic partnership remains intact; we are now exploring the translation of best practices for reducing tobacco use among YO! center staff and members.

Future efforts should include monitoring tobacco legislation, sustaining the partnership, and evaluating the effectiveness of tobacco regulation and excise taxes and implementation of tobacco cessation programs on young adult tobacco use. Public health officials at the state and local levels depend on the research generated through community partnerships to design sound policy appropriate for the particular jurisdiction. At the same time, much research on the impact of tobacco use and evaluation of tobacco policy is occurring at the national level. Effective future efforts will bridge this disconnect, using national data and resources to guide community-based research and policy development, giving policymakers both the national and local frameworks within which they can develop effective tobacco control policies. At the same time, the community should be continually engaged on the issue so that the community is aware of the health consequences and addictiveness of small cigar use and so that the community is involved in inspiring and designing policy to address the issues. When policymakers rely on science and value input from the community, policy is more effectively drafted, implemented, and enforced, and the community is more likely to support and enhance the goals of the policy.