Naphtali Offen

Is tobacco a gay issue? Interviews with leaders of the lesbian, gay, bisexual and transgender community

This study examined the extent of tobacco industry funding of lesbian, gay, bisexual and transgender (LGBT) organisations and whether leaders of these organisations thought tobacco was a priority health issue for their community. We interviewed leaders of 74 LGBT organisations and publications in the USA, reflecting a wide variety of groups. Twenty‐two percent said they had accepted tobacco industry funding and few (24%) identified tobacco as a priority issue. Most leaders did not perceive tobacco as an issue relevant to LGBT identity. They saw smoking as a personal choice and individual right rather than as a health crisis fuelled by industry activities. As such, they were reluctant to judge a legal industry, fearing it might lead to having to evaluate other potential funders. They saw tobacco control as divisive, potentially alienating their peers who smoke. The minority who embraced tobacco control saw the industry as culpable and viewed their own roles as protecting the community from all harms, not just those specific to the gay community. Lesbian, gay, bisexual and transgender tobacco‐control advocates should reframe smoking as an unhealthy response to the stresses of homophobia to persuade leaders that tobacco control is central to LGBT health.

Pictures worth a thousand words: noncommercial tobacco content in the lesbian, gay, and bisexual press.

Smoking prevalence in the lesbian, gay, and bisexual (LGB) community is higher than in the mainstream population. The reason is undetermined; however, normalization of tobacco use in the media has been shown to affect smoking rates. To explore whether this might be a factor in the LGB community, we examined noncommercial imagery and text relating to tobacco and smoking in LGB magazines and newspapers. Tobacco-related images were frequent and overwhelmingly positive or neutral about tobacco use. Images frequently associated smoking with celebrities. Text items unrelated to tobacco were often illustrated with smoking imagery. Text items about tobacco were likely to be critical of tobacco use; however, there were three times as many images as text items. The number of image items was not accounted for by the number of text items: nearly three quarters of all tobacco-related images (73.8%) were unassociated with relevant text. Tobacco imagery is pervasive in LGB publications. The predominant message about tobacco use in the LGB press is positive or neutral; tobacco is often glamorized. Noncommercial print images of smoking may normalize it, as movie product placement does. Media advocacy approaches could counter normalization of smoking in LGB-specific media.

A breath of fresh air worth spreading: media coverage of retailer abandonment of tobacco sales.

OBJECTIVES Media play an important role in the diffusion of innovations by spreading knowledge of their relative advantages. We examined media coverage of retailers abandoning tobacco sales to explore whether this innovation might be further diffused by media accounts. METHODS We searched online media databases (Lexis Nexis, Proquest, and Access World News) for articles published from 1995 to 2011, coding retrieved items through a collaborative process. We analyzed the volume, type, provenance, prominence, and content of coverage. RESULTS We found 429 local and national news items. Two retailers who were the first in their category to end tobacco sales received the most coverage and the majority of prominent coverage. News items cited positive potential impacts of the decision more often than negative potential impacts, and frequently referred to tobacco-caused disease, death, or addiction. Letters to the editor and editorials were overwhelmingly supportive. CONCLUSIONS The content of media coverage about retailers ending tobacco sales could facilitate broader diffusion of this policy innovation, contributing to the denormalization of tobacco and moving society closer to ending the tobacco epidemic. Media advocacy could increase and enhance such coverage.

The perimetric boycott: a tool for tobacco control advocacy

Objectives: To propose criteria to help advocates: (1) determine when tobacco related boycotts may be useful; (2) select appropriate targets; and (3) predict and measure boycott success. Methods: Analysis of tobacco focused boycotts retrieved from internal tobacco industry documents websites and other scholarship on boycotts. Results: Tobacco related boycotts may be characterised by boycott target and reason undertaken. Most boycotts targeted the industry itself and were called for political or economic reasons unrelated to tobacco disease, often resulting in settlements that gave the industry marketing and public relations advantages. Even a lengthy health focused boycott of tobacco industry food subsidiaries accomplished little, making demands the industry was unlikely to meet. In contrast, a perimetric boycott (targeting institutions at the perimeter of the core target) of an organisation that was taking tobacco money mobilised its constituency and convinced the organisation to end the practice. Conclusions: Direct boycotts of the industry have rarely advanced tobacco control. Perimetric boycotts of industry allies offer advocates a promising tool for further marginalising the industry. Successful boycotts include a focus on the public health consequences of tobacco use; an accessible point of pressure; a mutual interest between the target and the boycotters; realistic goals; and clear and measurable demands.

Sexual Identity Disparities in Smoking and Secondhand Smoke Exposure in California: 2003–2013

OBJECTIVES To determine smoking prevalence, smoking behavior, and secondhand smoke (SHS) exposure of lesbian, gay, and bisexual (LGB)-identified Californians; compare these with that of heterosexuals; and analyze changes over time. METHODS We analyzed self-reported variables from 111 965 heterosexual, 1667 lesbian, and 1706 bisexual women, and 79 881 heterosexual, 2505 gay, and 911 bisexual men, aged 18 to 70 years, in the 2003-2013 California Health Interview Surveys. RESULTS Sexual minority women had higher smoking prevalence, and female bisexual smokers were less likely to be light smokers, than heterosexuals. Smoking prevalence was higher among sexual minority men, and gay smokers were more likely to be daily smokers than were heterosexuals; and male bisexual smokers were more likely to be light smokers than were gay or heterosexual smokers. Sexual minority adults were more likely to have SHS exposure at home than were heterosexuals. Current smoking prevalence decreased annually 4% and 7% for lesbian and bisexual women, and 5% and 6% for gay and bisexual men, respectively. Exposure to SHS fell an average of 11% annually for sexual minority men and women. CONCLUSIONS Sexual identity disparities in smoking and SHS exposure exist in California, with bisexuals particularly at risk.

“Tired of watching customers walk out the door because of the smoke”: a content analysis of media coverage of voluntarily smokefree restaurants and bars

BackgroundNews media are key sources of information regarding tobacco issues, and help set the tobacco control policy agenda. We examined US news coverage of voluntarily smokefree restaurants and bars in locales without mandatory policies to understand how such initiatives are perceived.MethodsWe searched three online media databases (Access World News, Lexis Nexis, and Proquest) for all news items, including opinion pieces, published from 1995 to 2011. We coded retrieved items quantitatively, analyzing the volume, type, provenance, prominence, and content of news coverage.ResultsWe found 986 news items, most published in local newspapers. News items conveyed unambiguous support for voluntarily smokefree establishments, regardless of venue. Mandatory policies were also frequently mentioned, and portrayed positively or neutrally. Restaurant items were more likely to mention health-related benefits of going smokefree, with bar items more likely to mention business-related benefits.ConclusionVoluntary smokefree rules in bars and restaurants are regarded by news media as reasonable responses to health and business-based concerns about worker and customer exposure to secondhand smoke. As efforts continue to enact comprehensive smokefree policies to protect all in such venues, the media are likely to be supportive partners in the advocacy process, helping to generate public and policymaker support.

Early history of LGBT tobacco control: CLASH at 25

In the spring of 2016, the Food and Drug Administration (FDA) launched a national campaign, This Free Life , to discourage lesbian, gay, bisexual and transgender (LGBT) people from smoking (see front cover). This Free Life would have been only a fantasy 25 years ago, when a few LGBT advocates met during the campaign that made San Francisco restaurants smoke-free. They suspected that LGBT smoking rates were high and founded the first organisation dedicated to LGBT tobacco control, the Coalition of Lavender-Americans on Smoking or Health (CLASH). Its mission was three-pronged: to work within the LGBT community to raise awareness of tobaccos deadliness, to lobby mainstream tobacco control for the resources to do so and to contribute to the larger tobacco control movement. At the time, HIV/AIDS, with few effective treatments available, commanded the communitys attention. Other priorities included sodomy law repeal; legalising LGBT military service; and fighting antigay discrimination and violence. Marriage equality was not even a dream. The community was also grappling with high alcohol and drug use. With this burden, tobacco control was far from a priority. In this context, industry framing of smoking as a personal freedom had great salience for the LGBT community. Hampered by a lack of data, CLASH instigated one of the …

Max et al. Respond

We thank Cochran et al. for their thoughtful comments regarding the needed research to eliminate health disparities, in this case, related to tobacco use and secondhand smoke (SHS) exposure in the lesbian, gay, and bisexual (LGB) community. As we reported in our study, both tobacco use and SHS exposure have fallen over time for sexual minority as well as heterosexual adults in California, although both prevalence rates remain higher for the former. A number of explanations have been suggested to explain the greater rates of tobacco use and SHS exposure in the LGB community, including a bar-focused subculture, targeted tobacco industry efforts, stress, and structural stigma and discrimination commonly perceived by LGB adults. Cochran et al. suggest that another factor that might be considered as moderating SHS exposure is household composition, which they define as living alone or with others.1 Other measures of household composition could include living with a spouse and the presence of absence of children in the home.

Smoking or My Job? US Media Coverage of Nonsmoker-Only Hiring Policies.

Objectives Media advocacy plays a critical role in tobacco control, shaping the content of news in ways that generate public support for tobacco control. We examined US media coverage of nonsmoker-only hiring policies, which have little US public support, exploring the extent to which tobacco control advocates and experts have engaged the media on this controversial issue. Methods We searched online media databases (Lexis Nexis, Access World News, and Proquest) for articles published from 1995–2013, coding retrieved items through a collaborative, iterative process. We analyzed the volume, type, provenance, prominence, content and slant of coverage. Results We found 1,159 media items on nonsmoker-only hiring policies, most published in local newspapers in regions where such policies were enacted. The most common reason given for implementing such policies was to reduce healthcare costs. Most news items offered reasons both to support and oppose such policies; thus, the slant of the majority of news items was neutral or mixed. Tobacco control advocates or experts were infrequently cited or quoted in news items, and rarely authored opinion pieces. Those who expressed opinions were more likely to support than oppose nonsmoker-only hiring policies, for economic and health reasons. Ethical concerns about the policies were seldom raised. Conclusions As presented in the media, nonsmoker-only hiring policies were primarily framed in terms of business cost savings and had little connection to health initiatives. Tobacco control advocates were rarely quoted and their positions were not consistent. Given their intrusiveness and the lack of strong evidence that such business policies actually do improve worker health, tobacco control advocates may feel that the status quo is preferable to engaging on a policy that the majority of Americans dislike.

Offen et al. Respond

LETTERS SMOKING AND TOBACCO USE WITHIN THE DEPARTMENT OF VETERANS AFFAIRS Offen et al. provide an insightful review of the complexity of enacting tobacco control policy at the federal level, as seen in their case study of the efforts by the US Department of Veterans Affairs (VA) to adopt a smoking ban in VA medical facilities in the early 1990s. 1 As the authors indicated, tobacco use among the US military has traditionally been higher than among the civilian population. 1 In recent years, however, the VA has made great strides in reducing the rate of smoking among veterans served. For veterans enrolled in the VA health care system in 2011, the proportion of smokers was 19.7%, 2 comparable to the 19.0% reported for the United States as a whole in 2011. 3 Although federal law still requires that VA health care facilities provide areas where pa- tients can smoke, 1 progress has been made in reducing exposure to secondhand smoke for both veterans and VA employees. In citing a 2005 VA survey on smoking and tobacco use cessation within the VA, the authors incorrectly stated that one quarter of 783 smoking sites reported by VA facilities were indoors. 1 In fact, Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the articles appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Mary E. Northridge, PhD, MPH, at men6@nyu.edu. all 783 smoking sites were outdoor smoking areas or shelters. 4 The 2005 survey actually reported that 36 out of 158 VA facilities (23%) still had an indoor smoking area somewhere at the facility, mainly in nursing homes and in- patient psychiatric units. 4 Although still far from ideal, by 2009 this number had dropped to 19 facilities; 88% had complete indoor smoke-free policies in place. 5 In referring to military and veteran facilities, it is important to note that the Department of Defense (DoD) and the VA are distinct federal executive branch agencies. Their vari- ous policies and initiatives are independent of each other, reflecting the differences in their populations and missions. Thus, in de- scribing the VA tobacco control efforts as a pattern of “advance and retreat,” the authors incorrectly attribute DoD policies and initia- tives to the VA. 1,6 The article they cited discusses DoD initiatives only, not the VA or VA policies. 6 This misperception that the two departments operate as a single unit is not uncommon, but it is one that must be avoided in future studies. j Kim Hamlett-Berry, PhD Dana E. Christofferson, PhD Richard A. Martinello, MD About the Authors The authors are with the Veterans Health Administration, US Department of Veterans Affairs, Washington, DC. Correspondence should be sent to Kim Hamlett-Berry, PhD, Department of Veterans Affairs, 810 Vermont Avenue (10P3B), Washington, DC 20640 (e-mail: kim.hamlett@va. gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted April 3, 2013. doi:10.2105/AJPH.2013.301375 Note. The authors certify that there is no financial conflict of interest with any financial organization with interest in the subject matter discussed in the letter. The views expressed here represent those of the authors and not necessarily those of the US Department of Veterans Affairs. Contributors K. Hamlett-Berry and D. E. Christofferson drafted the letter. R. A. Martinello supervised the overall writing and edited the final version. July 2013, Vol 103, No. 7 | American Journal of Public Health Acknowledgments The authors thank Richard Kaslow, MD, for his insightful comments. References 1. Offen N, Smith EA, Malone RE. “They’re going to die anyway”: smoking shelters at veterans’ facilities. Am J Public Health. 2013;103(4):604---612. 2. Department of Veterans Affairs. 2011 survey of veteran enrollees’ health and reliance upon VA. Available at: http//www.va.gov/healthpolicyplanning/soe2011/ soe2011_report.pdf. Accessed March 22, 2013. 3. Centers for Disease Control and Prevention. Current cigarette smoking among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(44):889---894. 4. US Department of Veterans Affairs. Smoking and Tobacco Use Cessation Report—2005. Washington, DC: Veterans Health Administration, Office of the Assistant Deputy Under Secretary for Health for Policy and Planning; 2006. 5. US Department of Veterans Affairs. Smoking and Tobacco Use Cessation Report—2010. Washington, DC: Veterans Health Administration, Office of the Assistant Deputy Under Secretary for Health for Policy and Planning; 2010. 6. Arvey SR, Malone RE. Advance and retreat: tobacco control policy in the US military. Mil Med. 2008;173 OFFEN ET AL. RESPOND We appreciate the comments by Hamlett-Berry et al. We apparently created confusion based on a misreading of the following paragraph from the Institute of Medicine report, 1 which discusses both smoking shelters and smoking areas: According to the 2005 Smoking and Tobacco Use Cessation Report on tobacco-use practices at 158 VA hospital facilities (VA, 2006b), 51 VA facilities provide 134 smoking shelters for pa- tients only, 41 facilities provide 76 shelters for employees only, and 137 facilities provide 573 shelters for use by both patients and employees, with some facilities providing up to 32 shelters for combined use by patients and employees. Almost all (91%) of the VHA facilities indicated that patients and employees smoke in the same des- ignated smoking areas. Of the 158 facilities surveyed, 77% are smoke-free indoors; 23% (36) permit some indoor smoking in areas such as long-term-care inpatient, locked psychiatry wards, resident rooms, and nursing-home units; and 94% have separate ventilation systems. Almost half of the facilities allow smoking only in desig- nated areas; the rest allow smoking outside Letters | e3