The report concludes that implementing Tobacco 21 and a statewide tobacco retail permitting system is essential for preventing youth tobacco use and advancing health equity in North Carolina. Tobacco disproportionately affects marginalized communities, where aggressive marketing and retailer density contribute to higher tobacco use rates and worse health outcomes. Raising the minimum legal sales age to 21 has already been shown to decrease youth initiation rates in many places across the country, preventing lifelong addiction and tobacco-related diseases. A strong tobacco retail licensing system will provide essential oversight, ensuring retailers comply with regulations and reduce the prevalence of illegal sales. North Carolina can take a proactive approach to reducing health disparities, ensuring all residents, regardless of income, race, or background, have a fair chance at a healthier future.

Kim Bayha, Tobacco Prevention & Control Supervisor of the Office of Chronic Disease Policy & Prevention, spearheads Mecklenburg County Public Health’s tobacco point-of-sale policy work:

“Mecklenburg County Public Health collaborated with Counter Tools to assess our local retail tobacco environment and collect qualitative data to examine equity-centered impacts of Tobacco-21 and Tobacco Retail Permitting policies. Having access to digital tools and technical assistance from Counter Tools staff was invaluable. They provided training, developed a framework for the Health Equity Impact Assessment and led creation of a comprehensive Tobacco Retail Policy Impact Report and interactive dashboard. We can now use these online products to increase awareness about tobacco industry tactics in our local community and advocate for actions to reduce youth access to tobacco and address tobacco disparities. We could not have done this robust work without them.”

To learn more about this issue, view the executive summary and full report.

Nearly two years ago, the FDA announced a proposed rule to prohibit menthol as a characterizing flavor in cigarettes, as well as prohibit menthol and all other characterizing flavors in cigars. The FDA has studied prohibiting menthol through policy change for more than 12 years. The policy is supported by overwhelming scientific evidence, and it will save hundreds of thousands of lives.

Menthol makes tobacco products easier to start and harder to quit. Tobacco companies have targeted its marketing to African Americans and other marginalized groups across the country for decades, contributing to disparities in tobacco product use and subsequent harm. Recent research has found that between 1980 and 2018, menthol cigarettes were responsible for 10.1 million extra smokers, 3 million life years lost, and 378,000 premature deaths. With the tobacco industry’s relentless targeted marketing of menthol cigarettes to the African American community, a disproportionate amount of the harm from menthol has fallen on African Americans. While 12% of the US population is African American, African Americans account for 41% of the premature deaths and 50% of the life-years lost during this same time period.

The latest delay in action is unacceptable and prolongs the 45,000 Black lives lost to tobacco-related illness each year. Counter Tools urges the Office of Information and Management Affairs (OIRA) to complete its review of the Tobacco Product Standard for Menthol in Cigarettes (menthol cigarette rule) and to allow it to be finalized without delay. Prohibiting menthol as a characterizing flavor in cigarettes will reduce youth smoking, save lives, and advance health equity.

Unfortunately, access can differ drastically depending on where someone lives. Because of this, the health behaviors that reduce cancer risk are much harder to implement for some than others. In many cases, rural communities and neighborhoods with low-income individuals or racial and ethnic minorities face added barriers to health. For example, rural residents often live miles from the nearest source of fresh, healthy food. This lack of access is one of several reasons why rural households face food insecurity at a higher rate than urban households. According to Feeding America, 9 out of 10 high food insecure counties are rural, and 8 out of 10 counties are located in the South. In comparison to neighborhoods with higher household income residents, neighborhoods with lower income residents feature fewer sports areas, parks, greenways, well-maintained sidewalks or bike paths. Rural communities lack the availability of public transit or close proximity of residential areas to everyday destinations, such as retail stores and schools, that help promote more daily physical activity in urban areas. The places people live can also impact their tobacco and alcohol use. Research shows that neighborhoods featuring an overabundance of convenience or liquor stores, and thus more advertising for alcohol and tobacco products, contribute to disparities in use rates. These retailers tend to cluster in neighborhoods with a high percentage of low-income residents or residents of color.  

While there is no one-size-fits all solution, there are a number of ways state and local governments, along with community partners, can work to reduce these disparities so everyone has the opportunity to be healthy, regardless of where they live. A few examples include: 

1. Providing support and resources for existing food retailers by assisting with food distribution challenges and establishing healthy retail programs 
2. Developing affordable and efficient transportation services for neighborhoods without convenient access to healthy food retail venues and adopting Complete Street policies to ensure streets are designed to be safely used by all
3. Supporting shared use agreements so that existing facilities, such as schools, can be used for physical activity by the broader community 
4. Decreasing the density of alcohol and tobacco outlets through licensing or zoning restrictions

By building healthier communities for all, we have the potential to make a profound impact on the health behaviors that are proven to reduce cancer risks.

The survey results will both help us improve our current offerings and guide us in developing new materials and services related to topics such as health equity and disparities in the retail environment.

If you are a current or past client-partner of Counter Tools, please share your feedback on this survey by Friday, December 9th.  We thank you in advance for your candid feedback!

See more information about this survey here.

Healthy Active Communities sets out to explore and expand conversations around the impacts of policy and systems change to reduce chronic conditions in communities through health equity, nutrition security with weight-inclusive approaches.

The 2022 conference will be a great place for students and professionals in national, tribal, state and local public health; community organizations and nonprofits; and, health care and nutrition professionals to contribute and learn. We hope insight from across the United States will foster innovation, enthusiasm, and progress in communities around Oregon and beyond.

Counter Tools staff member Mollie Mayfield will be presenting on healthy retail and the retail environment as a social determinant of health. Other conference topics include Strategies for De-Emphasizing BMI for More Equitable Health Promotion, Racist Origins of Anti-Fat Bias, Food Justice, Marketing Unhealthy Foods to Children (especially children of color), Building an Equity Foundation for Sugary Drinks Policy, and more.

Learn more about the conference, speakers, and agenda at HealthyActiveCommunities.com.

Register for the virtual conference here.

Health equity means that everyone has a fair and just opportunity to be as healthy as they can be, and this requires reducing and removing structural barriers and obstacles that impact health. Structural elements that disadvantage certain racial groups through institutional racism, along with industry targeting, can impact exposure, availability, and access to both healthy and harmful products.

We know that the Black community has been targeted by the tobacco industry for decades with marketing tactics and point-of-sale strategies such as advertising, product availability and pricing at retail stores. This targeting has resulted in disparities in tobacco product use, such as the prevalence of the use of menthol cigarettes among Black Americans, and caused disproportionate harm.

There has historically been a lack of urgency surrounding policies that would benefit Black communities, and policies that restrict menthol do not seem to have the same publicity and support as other types of policies. Policies to protect youth from e-cigarette flavors have received considerable support and attention, and while the youth vaping epidemic is critical, these policies disproportionately benefit white youth as they are more likely to use electronic products.

Using an equity viewpoint, we can start to understand how even the best intentioned tobacco product regulation policies may reinforce racism and the inequitable impact on marginalized communities. For example, targeted marketing of Black communities is an ongoing strategy of the tobacco industry, menthol was exempted from the 2009 Family Smoking Prevention and Tobacco Control Act flavored cigarette ban, and there is a lack of flavor tobacco product restrictions on cigars. While 274 localities across the United States have placed restrictions on flavored tobacco products since 2019, the majority of these flavor restrictions have excluded menthol. In April this year a long overdue announcement was made by the FDA that they are proposing product standards to prohibit menthol as a characterizing flavor in cigarettes and prohibit all characterizing flavors in cigars.

When creating policies, it is critical to consider equity issues to achieve equitable outcomes. Policies that focus on equality instead of equity, such as reducing all available tobacco retailer licenses by half, do not address the existing disparity of higher retailer density in certain neighborhoods. Other policies like banning the sale of tobacco products at pharmacies may disproportionately reduce retailers in wealthier neighborhoods, as there are fewer pharmacies in neighborhoods with more Black residents. Mapping tobacco retailers and other locations like schools and parks can be a useful tool to visualize the impact of policies before they are enacted and raise awareness about disparities. (Check out some examples from the six states that participated in the Geographic Surveillance Learning Collaborative for Comprehensive Cancer Control and National Tobacco Control Programs)

In a recent paper on centering equity in flavored tobacco ban policies, the authors recommend examining the entire policy process through an equity lens, including policy formulation, adoption, enforcement, and evaluation. They advocate for partnering and agenda-setting with communities, examining policy language for exemptions, determining the reach of policy on different populations, and assessing the equitable nature of policy implementation and enforcement. The guidelines shared in Tobacco Control Enforcement for Racial Equity: Decriminalizing Commercial Tobacco – Addressing Systemic Racism in the Enforcement of Commercial Tobacco Control may be a starting point for helping advance equitable enforcement practices related to purchase, possession, sale and distribution of tobacco products.

Equity needs to be at the forefront of public health in order to address systemic issues that have gone on for too long. We need to continue to address racism at its roots and understand the history and consequences. With a health equity lens, we can create more effective policies at both the federal and local level that address ongoing disparities, reduce the burden on Black communities, and strive for health equity for all.

We empower communities to become healthier places for all.

Our mission for the past ten years has guided us to support our partners as they work to improve the health of their communities. We know that the places where people live, work, learn, and play greatly impact our health. Our work has always focused on addressing place-based public health issues that disproportionately affect marginalized communities.

Equity for all has become even more critical in how we define ourselves and our work. We recognize that not every individual or community has equal access to healthy spaces and opportunities. Structural elements – including both governmental and organizational policies and practices – historically have and continue to disadvantage certain racial groups through institutional racism. These structural elements, along with industry targeting, impact exposure, availability, and access to both healthy and harmful products.

For example, we know that historical and ongoing policies and practices like redlining have created neighborhood segregation, which has in turn allowed the tobacco industry to easily target already underserved communities with marketing for harmful products.

We define health equity to mean that everyone has a fair and just opportunity to be as healthy as they can be, which means reducing and removing structural barriers and obstacles that apply to and extend beyond the retail environment.

To guide our efforts in making changes both internally and externally, we released a stance that defines how we approach equity, diversity, and inclusion. Internally, we have made operational changes to continue to learn, hold ourselves accountable, and actively work to address the implicit biases and structural racism that make up our world. We continually work to empower and equip our partners with the resources, knowledge and understanding necessary to combat racism, health disparities, and inequality in their communities.

Adding the words “for all” to our mission reflects our ongoing commitment to health equity and inclusion. It also signifies how important it is to us to be an active participant in the larger conversation about racism, other systems of inequality, and their intersectionalities. We thank our partners for continually inspiring us with innovative examples of how to create more equitable communities and working with us towards this goal.

In community-based prevention, researchers and professionals have realized that the best solution for one community may not be the same for another. The best solution to address problems in a community often comes from the folks most heavily impacted. Laws and policies adopted at the local level are key to improving health outcomes and reducing inequities because they are community specific solutions.

An important feature of local laws is the ability to enhance the enforcement and regulatory structure for state or federal policies. When it comes to tobacco point-of-sale policies, FDA inspections and visits through the Synar program are required. However, FDA inspections and Synar program visits only cover a small sample of retailers each year. Local-level policies like local tobacco retailer licensing can require visits to all retailers in a community each year. This may assist in identifying retailers with frequent violations and enforcing stronger penalties on retailers that violate these policies.

In addition, local level policies can be adapted and tailored to be more effective at reducing disparities. For example, restricting tobacco sales in pharmacies may reduce the overall number of tobacco retailers statewide, but in some communities this type of policy may only exacerbate inequities in retailer density. This is the case when there are more pharmacies located in already advantaged neighborhoods where tobacco retailer density is lower. Another benefit to local innovations is that their success can spur statewide change. The Tobacco 21 movement is a great example of this, with many localities successfully raising the minimum legal sales age before statewide policy was enacted. The eventual passage of a federal Tobacco 21 policy can be in part attributed to momentum that began at the local level. A similar process is currently unfolding as localities across the country gain traction with comprehensive flavor bans.

Unfortunately, thanks to industry lobbying, some states use their authority to block local policy innovations. This strategy relies on the legal doctrine of preemption, which allows a higher level of government to limit or even eliminate the power of a lower level of government. Examples of preemption exist in a variety of realms that impact public health, including environmental protections, affordable housing, and regulation of alcohol or sugar-sweetened beverages. The common areas impacted by preemption in tobacco prevention and control policy work are related to youth access, smokefree indoor air and licensure. See the CDC’s STATE System Preemption Fact Sheet for a summary of the preemption status for each state in these three categories.

Starting this summer, Counter Tools and GHEA will be launching a three-part local control webinar series. The series will include guest speakers, resources, and stories of local control efforts from the fields of tobacco and alcohol control. Stay tuned for registration details coming soon!

Additional Resources

Local control and preemption within the field of tobacco prevention and control:

1. Tobacco Point of Sale Preemption Playbook (Counter Tools & ChangeLab Solutions)
2. Untangling The Preemption Doctrine in Tobacco Control (Public Health Law Center)
3. Preemption: The Biggest Challenge to Tobacco Control (Public Health Law Center)
4. Checked at the Check-Out Counter: Preemption at the Tobacco Point of Sale (Public Health Law Center)
5. State Legislated Actions on Tobacco Issues (SLATI) (American Lung Association)
6. Protect Local Control (Americans for Nonsmokers’ Rights)

This post was originally published as a feature article for The Geographic Health Equity Alliance (GHEA), a CADCA initiative. GHEA is a CDC funded National Network dedicated to reducing geographic health disparities related to tobacco and cancer. 

There were some grand ideas touted by the tech world at the start of the pandemic, such as the promise of a Google-powered site where anyone in the U.S. could find a place to get a test. A testing system was piloted by Verily, but was eventually phased out over concerns about patient data and accessibility to low-income groups. Tech companies built some helpful tools like Google’s Community Mobility Reports, apps that monitored social distancing, and large-scale data crunching websites, but these were not incorporated into existing public health systems. It became clear that new tech needed to be partnered with guidance on how communities should interpret and use the data, and how communities would be supported by social systems when risk levels are high and daily life is affected.

With the endemic spread of COVID-19, data dashboards became popular as a way to share data about cases, tests, hospitalizations, deaths, and eventually vaccinations. The democratized data was used to support community organizations, health advocates, hospitals, physicians, public health officials and policymakers as they responded to the pandemic. The Johns Hopkins Coronavirus Resource Center (CRC) quickly became a leading resource used by public health policymakers and major news outlets around the world and continues to be two years later.

State public health departments built dedicated COVID-19 websites and data dashboards to educate the public and share data on local trends. Some ventures were in partnership with private companies or universities to supplement outdated data systems and lack of resources. Michigan’s online dashboard, MI Safe Start Map, was a partnership between the Michigan Departments of Health and Human Services (MDHHS) and the University of Michigan School of Public Health. Washington State Department of Health partnered with Microsoft’s AI for Health team to build a COVID-19 Data Dashboard that shares daily data updates for the state where many Microsoft employees live and work.

In California, Blue Shield built the Neighborhood Health Dashboard to increase transparency around community health and help address health disparities that were further highlighted by the pandemic. Dashboards use demographic data for race & ethnicity, income, and other factors to help public health departments and communities identify and address inequities. California’s data hub was used to produce a new vulnerability index, which focused on social and economic vulnerability of communities to assist in prioritizing the resources for COVID-19 recovery efforts.

Mapping of local areas is key to understanding how different neighborhoods are impacted by COVID-19. NYC’s neighborhood-level COVID-19 maps in April 2020 from New York City Department of Health and Mental Hygiene helped communities address risk and showed how ongoing technology investments minimize the time needed to build something when it is urgently needed.

New mobile apps were available to report symptoms, help with contract tracing or warn of potential exposure areas. The North Carolina Department of Health and Human Services SlowCOVIDNC app uses location data and notifies a user if they have been in close contact with someone who has shared a positive COVID-19 test result.

These technology innovations helped our understanding of the pandemic’s spread and risk levels, as well as the disparate effect on some communities. Public health departments have an opportunity to use these successes as evidence for increasing investment in digital public health tools. This will help ensure that we are building a systems-level approach that invests in the infrastructure needed to ensure that the pieces are integrated, data is standardized and accessible, and public health agencies are ready for the next crisis.

Data gives a strong evidence-base when developing and implementing policy. Mapping data is often a strategic element that helps educate and raise awareness around issues that impact communities. For examples of our work with mapping data, check out our relevant success stories: in Minnesota’s Golden Valley our mapping technology software was used to understand tobacco retailer density and proximity to schools, and in Florida’s Alachua County, we created local area maps to show potential effects of proposed policy changes. To learn more about how we can help reach your policy goals, reach out to us at hello@countertools.org.

Colleges and universities across the country have had significant success in using policy to protect their students and employees from exposure to secondhand smoke on campus. In fact, as of February 2022, there are close to 2,600 100% smokefree campuses, with a large majority of these sites being 100% tobacco-free. However, these policies do not address the tobacco retail environment immediately off-campus. Research shows that tobacco availability and marketing can have a significant impact on smoking behavior. This is an especially important consideration in areas full of young adults. Young adults are one of Big Tobacco’s favorite target audiences since 9 out of 10 daily smokers start before age 18.

The tobacco industry channels billions of dollars into the retail environment, which is the primary place where college students are exposed to tobacco marketing. In the United States, close to 40% of colleges are located within 3 miles of a hookah lounge and almost 70% are located within 3 miles of a vape shop. In a study of California colleges and universities, analysis showed that retailers cluster near campuses, even when accounting for population size, and nearly all community colleges and 4-year colleges in the state are located within 3 miles of at least one licensed tobacco retailer. This data points to convenient access to tobacco products for college students.

We know the retail availability of tobacco is important for a number of reasons, including:

1. Perpetuation of social norms about tobacco use. The ubiquitous presence of tobacco retailers gives the impression that tobacco is available and socially acceptable.
2. Contributions to higher smoking rates. Tobacco retail outlet density is associated with higher rates of tobacco use, as well as higher rates of tobacco use initiation among youth and young adults.
3. Increased exposure to industry point-of-sale advertising, marketing and promotions. The tobacco industry channels most of its marketing dollars into the retail environment because they are well aware of how successful this marketing can be. In addition, this exposure leads to increased brand recognition, which increases odds of smoking.
4. Reduced search costs for tobacco products. By requiring less effort to attain tobacco products, it is easier for young adults to start or continue smoking. Proximity to tobacco retailers can also encourage impulse purchases and reduce the success of quit attempts for people looking to curb their tobacco use.
5. Contribution to social and environmental inequities. Tobacco retail outlet density is higher in low income and minority neighborhoods, fueling disparities in tobacco use and its associated health effects.

There are several different strategies for reducing retailer density, including using strong licensing or zoning policies to cap the number of retailers or limiting their proximity to locations such as schools. Mapping the point locations of tobacco retailers in the vicinity of college campuses offers powerful insight into the potential of these policies to reduce access to tobacco products.

Because most local and state smokefree laws do not cover college or university campuses, colleges and universities have had to work hard to create smokefree environments on campus for their students and staff. The hard work doesn’t have to end there. Considering the off-campus retail environment in tobacco control efforts can be the perfect next step to further protecting the health of college students and their communities.

Additional Resources

• Licensing, Zoning, and Retailer Density, Counter Tools
• Tobacco Retailer Density- Place Based Strategies to Advance Health and Equity, ChangeLab Solutions
• Using Licensing and Zoning to Regulate Tobacco Retailers, the Public Health Law Center

This post was originally published as a feature article for The Geographic Health Equity Alliance (GHEA), a CADCA initiative. GHEA is a CDC funded National Network dedicated to reducing geographic health disparities related to tobacco and cancer. 

Photo by Cole Parsons on Unsplash.