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Race, Ethnicity, and Equity

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Globally, health inequities associated with tobacco use do not receive sufficient attention. Racial and ethnic groups marginalized by social, political, and economic systems are less likely to be protected by policies that meet their basic needs, support their health, and provide access to systems of care when they become ill. This lack of protections makes these marginalized communities more vulnerable to the tobacco industry. Even when the tobacco industry is not targeting these groups purposefully—which it often does—tobacco use alone contributes to factors that drive and reinforce inequities, including exacerbating poverty and diverting resources from education and health care, which in turn can disproportionately worsen health outcomes in marginalized groups. Tobacco control programs should include a focus on health inequities by race and ethnicity and work both to mitigate the inequitable impacts on these groups due to socioeconomic drivers, as well as to identify and counter tobacco industry efforts to weaponize identity and racism in targeting specific groups.

Targeting Black communities with deadlier, more addictive menthol cigarettes.

An industry rooted in racism, slavery, and white supremacy

The global tobacco industry’s roots in racism, slavery, and white supremacy continue to affect industry practices to this day, driving disproportionate and unjust death and disease among Black, Brown, and Indigenous peoples around the world. The legacy of the industry’s racist origins include: colonialist and extractive production models, sophisticated race-based tactics to target communities of color, cultural exploitation of marginalized groups, interference with public health initiatives in marginalized communities, and strategic co-optation of community leadership under the guise of so-called “corporate social responsibility” or support for these communities. The targeting of Black communities in the United States with more addictive and deadlier mentholated cigarettes exemplifies how racist tactics and targeting can drive disproportionate harm among racial groups. Further exacerbating these inequities is the fact that measures to counter tobacco’s impacts on racial groups and the industry’s targeted efforts in these communities have been consistently under-resourced.

We don’t smoke that sh*t. We just sell it. We reserve the right to smoke for the young, the poor, the black and stupid.

R.J. Reynolds Tobacco Company Executive
Percentage of deaths attributable to smoking at ages above 50 by sex among blacks and whites, United States 1980–2005. Source: Calculations by the authors

In the United States, although Black people smoke at similar rates to white people, they have higher associated death rates, including from cancer. This is both because systemic racism leaves Black communities more vulnerable to tobacco use and because of decades of the tobacco industry’s targeted marketing of menthol cigarettes to Black communities in the US. Menthol cigarettes have a minty chemical flavoring designed to make them easier to start and harder to quit—and, therefore, deadlier. Internal documents show that tobacco companies exploited the use of Black models and actors in their ads, aggressively flooded Black communities with menthol cigarette marketing, and handed out free samples in Black communities with the goal of creating a false “cultural affinity” for their deadly products. Unfortunately, these predatory marketing tactics worked to a great degree: of Black smokers aged 12 or older, 88.5% use menthol cigarettes, compared to 29% for white Americans. As a result, tobacco use fueled by menthol cigarettes has become a major vector for death and disease in Black communities in the United States, taking 45,000 lives a year.

Industry interference in policies for health equity

The tobacco industry strategically opposes tobacco control measures that would help alleviate the disproportionate harms of tobacco using various tactics, including the guise of social activism. For instance, for the past decade momentum has built in the US for banning menthol tobacco products. Although this is one of the most significant interventions that could be made to improve the health of Black Americans, industry proponents (and groups and policy makers who have accepted industry money) argued that such a ban is paternalistic and would regressively target Black people—including cynically raising the prospect of unequal police enforcement of bans. A recent simulation study, however, asserts that a ban on menthol products from 2021 to 2060 could reduce cumulative smoking- and vaping-attributable deaths “by 5% (650,000 in total) and reduce life-years lost by 8.8% (11.3 million).” In 2020, tobacco companies even unashamedly appropriated #BlackLivesMatter, Juneteenth, and Martin Luther King Jr. quotes to sell their products, while simultaneously opposing policies that would actually protect Black lives.

Cultural exploitation beyond the Black community

The tobacco industry strategically promotes perceived affinity of tobacco and identity among non-majority groups to drive sales, normalize tobacco use, and oppose public health interventions. Industry promotion of waterpipes as “ancient” and “cultural tradition” in Middle Eastern and South Asian cultures misrepresents the fact that tobacco was introduced into these regions by Europeans only 400 years ago. This “cultural tradition” rhetoric has been used to directly challenge policy interventions, such as 100% smoke-free laws. In the United States, cultural exploitation by the tobacco industry has also included the misappropriation of Native American and Indigenous culture, values, and beliefs through, for example, the sale of American Spirit brand tobacco products. Marketed with Native American imagery, American Spirit “implicitly communicates naturalness” to falsely suggest its products are less harmful and to drive profit.

Incorporating an equity lens into global tobacco control

The role of the social construct of race and/or ethnicity as a driver of health inequities is a global issue. Understanding how race and ethnicity have been and can be exploited to perpetuate harm is necessary to support populations targeted by the tobacco industry in preventing and healing from the disproportionate impacts of inequitable adoption and implementation of public health policies. One essential step is monitoring prevalence and other aspects of tobacco use behaviors among racial and ethnic subgroups to help policy makers understand trends, determinants, and disparities in tobacco use by race or ethnicity. Moreover, communities, advocates, and governments must work together to address racial inequities through specific and targeted interventions that counteract decades of tobacco industry exploitation.

This work must be in partnership with or—even better—led by groups most affected by the issue. One successful example is the lawsuit filed in 2020 by the African American Tobacco Control Leadership Council and co-plaintiffs Action on Smoking and Health, the American Medical Association, and the National Medical Association that successfully compelled the US FDA in 2021 to announce their intention to ban menthol cigarettes and flavored cigars. Engaging the relevant communities to identify, design, and evaluate interventions to protect their communities is critical if these interventions are to be effective and sustained. An excellent model for sustainable and equitable tobacco control in partnership with the most affected populations is the process in New Zealand to build a specific commitment to Maori leadership within the Smokefree Aotearoa 2025 action plan.

References

Overview of racism and the tobacco industry:

Chamberlain P, Karreman N, Laurence L. Racism and the Tobacco Industry. Bath UK: Tobacco Tactics. https://tobaccotactics.org/wiki/racism-and-the-tobacco-industry/

Agaku I, Caixeta R, Carvalho de Souza M, Blanco A, Hennis A. Race and Tobacco Use: A Global Perspective, Nicotine & Tobacco Research 18, (supp 1) 2016, Pages S88–S90, https://doi.org/10.1093/ntr/ntv225

Exacerbating poverty and undermining education:

Chaloupka FJ and Blecher E. Tobacco & Poverty: Tobacco Use Makes the Poor Poorer; Tobacco Tax Increases Can Change That. A Tobacconomics Policy Brief. Chicago, IL: Tobacconomics, Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, 2018.  https://tobacconomics.org/uploads/misc/2018/03/UIC_Tobacco-and-Poverty_Policy-Brief.pdf

Co-opting leaders:

Levin M. The Troubling History of Big Tobacco’s Cozy Ties With Black Leaders. Mother Jones. 2015. https://www.motherjones.com/politics/2015/11/tobacco-industry-lorillard-newport-menthol-black-smokers/

Yerger VB, Malone REAfrican American leadership groups: smoking with the enemyTobacco Control 2002;11:336-345. https://tobaccocontrol.bmj.com/content/11/4/336

Targeted marketing:

Heley K, Popova L, Moran MB, et alTargeted tobacco marketing in 2020: the case of #BlackLivesMatterTobacco Control Published Online First: 14 December 2021. doi: 10.1136/tobaccocontrol-2021-056838.

RJ Reynolds Executive Quote:

Giovanni, J. “Come to Cancer Country, USA, Focus,” The Times of London, August 2, 1992 [quoting Dave Goerlitz, RJ Reynolds’ lead Winston model for seven years, regarding what an R.J. Reynolds executive replied to him when Goerlitz asked why the executive did not smoke].

Mortality rates by race in the US

Office US. Smoking Cessation: A Report of the Surgeon General [Internet]. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf.

Menthol in the US:

The African American Tobacco Control Leadership Council. AATCLC Statement on FDA Decision to Ban Menthol. 2021. https://files.constantcontact.com/199ccd27001/bab51938-c4a0-4f9b-a458-a958d06739a1.pdf.

Campaign for Tobacco Free Kids (and partners). Stopping Menthol, Saving Lives: Ending Big Tobacco’s Predatory Marketing to Black Communities. https://www.tobaccofreekids.org/assets/content/what_we_do/industry_watch/menthol-report/2021_02_tfk-menthol-report.pdf.

Campaign for Tobacco Free Kids.  Menthol Marketing to African Americans. https://www.tobaccofreekids.org/assets/factsheets/0208.pdf.

Truth Initiative. Tobacco Use in the African American Community. https://truthinitiative.org/research-resources/targeted-communities/tobacco-use-african-american-community.

Mullin S, Bassett M. To tobacco companies, Black lives don’t matter. The Hill. https://web.archive.org/web/20210127142921/https:/thehill.com/changing-america/opinion/516531-to-tobacco-companies-black-lives-dont-matter.

Levy DT, Meza R, Yuan Z, et alPublic health impact of a US ban on menthol in cigarettes and cigars: a simulation studyTobacco Control Published Online First: 02 September 2021. doi: 10.1136/tobaccocontrol-2021-056604.

Hookah:

Alpert Reyes E. L.A. is taking aim at flavored tobacco. Hookah businesses are upset. LA Times 2021. https://www.latimes.com/california/story/2021-06-16/flavored-tobacco-hookah-los-angeles.

Save LA Hookah. https://savelahookah.com/  [organizational website for organization opposing hookah restrictions].

Misappropriating indigenous cultures for tobacco:

D’Silva J, O’Gara E, Villaluz NT. Tobacco industry misappropriation of American Indian culture and traditional tobacco. Tob Control. 2018 Jul;27(e1):e57-e64. doi: 10.1136/tobaccocontrol-2017-053950. Epub 2018 Feb 19. PMID: 29459389; PMCID: PMC6073916.

Truth Initiative. Why Natural American Spirit cigarettes could be especially dangerous. July 29, 2019. https://truthinitiative.org/research-resources/traditional-tobacco-products/why-natural-american-spirit-cigarettes-could-be.

New Zealand Tobacco Control Plan

Government of New Zealand (Ministry of Health). Smokefree Aotearoa 2025 Action Plan https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/smokefree-aotearoa-2025-action-plan.