• FPs in Advocacy Don’t Need to Reinvent the Wheel

    Most of the time, I am a regular clinic doc. My biggest passion in medicine, however, is public health, and of late I’ve been asked to give talks for my state chapter and state medical association about how clinicians can get involved in public health work. Today, I am going to share the secrets of my public health infiltration with you, by way of talking about some very cool tobacco policies.

    person crushing cigarette with shoe

    It’s much easier to get into public health work if you are friends with the people already doing public health work. Therefore, you should either live in a small community where everyone knows each other or create your own small community where the people doing the work know each other. Make yourself and your interests known to the people doing the work you want to help with. If you want to be extremely active, say so and work together to create a project you want to invest your time in. If you only have a little time for this, say so and they likely will tag you in when they need you to write a letter, sign onto a grant as a sponsor, do a radio interview, etc.

    There are, of course, other avenues for more formalized involvement, like getting a job as the medical director of the public health department, or starting a suboxone program, or becoming a public health advisor to a politician. Or becoming a politician yourself.

    But if you want to get your feet wet, there is no better way than cold calling the people doing what you are interested in and asking to meet with them so you can talk about how you and your training and expertise can help. Jennifer Little, M.P.H., my county’s director of public health, is fond of saying, “I will use you as much as you would like to be used, and there is nothing I like more than getting coffee with a new partner in public health.”

    To sum up: Tell the people who are already working on issues that are important to you that you want to help them.

    OK. On to tobacco. In Klamath Falls, Ore., we are working on a lot of public health issues, from HPV vaccination rates to climate change (have you seen our fires?) to tobacco legislation.

    The reason I suggest starting with your local public health and community-based organizations is that regulation is complicated. For instance, e-cigarettes were not federally regulated until 2016, so all regulation was up to the states. In 2016, the FDA finally flexed successfully (the agency had tried previously but got stymied by a few well-placed tobacco lobby lawsuits) and implemented regulation, which included making it illegal to sell e-cigarettes to those younger than 18. Prior to that, it was not illegal for a 12-year-old to buy an e-cigarette unless a city, county or state law prohibited it. In December 2019, the federal minimum age for tobacco sales (including cigarettes, cigars and e-cigarettes) was raised from 18 to 21 years of age, but enforcement is still a nightmare, given that there is no actual infrastructure supporting it.

    Additionally, federal regulations make it illegal to sell e-cigarettes in vending machines and prohibit business from offering free samples. Since 2018, the FDA has been imposing fines on vendors who sell e-cigarettes without checking IDs, though enforcement infrastructure is also lacking. This year, the FDA banned flavored e-cigarette cartridges, but non-cartridge products remain unrestricted.

    If you want bans on all flavored e-cigarettes, legislation regarding advertising near schools, or regulation on packaging of vape liquid so it doesn’t look like candy or a toy, you have to rely on local laws. Importantly, I did not know about some of the most recent federal regulations until the first draft of this blog was reviewed and updated by the AAFP’s Health of the Public and Science staff. It’s a clear example of how easy it is to miss regulatory changes when you’re knee-deep in clinical work.

    All this is to say, your local public health officials should know what regulations are in place in your city/county/state, and they know what additional regulations are being pursued. In Oregon, the 2020 ballot included a measure to both increase tobacco taxes and expand them to include e-cigarettes. In Klamath Falls, our Healthy Klamath Tobacco Coalition is advocating for the creation of smoke-free areas, including parks, downtown and near the hospital. For both of these initiatives, I wrote letters to the editor at my local paper, recorded radio interviews and worked with the state level campaign (Yes for a Healthy Future) to pass the e-cigarette tax.

    I started doing these things because my public health director knew I was interested and emailed me to ask if I had the time to help when the PR campaigns ramp up for our state and local initiatives. I did.

    It seems so simple, but I want to remind you that public health is complicated because it is at once hyper local and wildly broad. Yes, you can start your own campaign, but for those of us looking to participate without the responsibility of creating something from scratch, your first step is to talk to someone who knows what is already happening.

    From a national perspective, The AAFP has a Tobacco & Nicotine Prevention and Control online community, which is a forum to share developments with other interested clinicians. The Academy also helps coordinate Tar Wars, a “community-based education program designed to teach kids to live tobacco-free.”

    For state and local perspectives, there is no one better than your state chapter (specifically its advocacy arm) or, perhaps best of all, your public health department.

    I can almost guarantee that people where you live are already working on some sort of tobacco legislation, be it smoke-free parks, smoke-free public places or advertising regulations for e-cigarettes. I can also guarantee you that the people running those campaigns would love to have another clinician to work with, be it for public relations, letters, grants, TV or radio. If you want to change tobacco regulations in your area, start with the stuff that is already in the works.

    This approach, by the way, is true for every public health issue, from the built environment to infectious disease to systemic racism (including, but not limited to, voter suppression, equitable housing and policing). As a health care professional, you have an unusual amount of trust capital, and there are countless public health officials and community-based organizations that know just how to make use of that invaluable resource.

    I’ll end with my favorite pie-in-the-sky tobacco legislative efforts that I would love to see implemented.

    • Tobacco taxes reliably reduce smoking rates, but they are not the most impactful way of doing so. Such taxes are regressive (they affect those with less money more, but to be honest, so does lung cancer). Here are the numbers: a 10% increase in price leads to a 4% reduction in consumption by adults and a 6.5% reduction among youth. Pretty good and worth doing, but we can do better.
    • Smoke-free workplaces reduce cigarette consumption by 29%. For reference, to get this same result through tobacco taxes you would have to increase the price of cigarettes by 73%. 
    • Strong graphic warning labels would reduce smoking by 16%. The FDA tried this nationally a few years ago and was stopped by a First Amendment suit. Thankfully, the FDA is trying again with implementation starting in October 2021. Perhaps this will again end up contested, but maybe that would be a good target for physician-led advocacy.
    • An automatic R rating for movies that show smoking would decrease youth smoking by 18%. 
    • Media campaigns, like the Legacy Foundation’s “Truth” campaign, reduced youth smoking by 22%. This is work you can get into today, and it is global. Maybe send them an email to see what you can do?

    Stewart Decker, M.D., is a family physician practicing in southern Oregon. He focuses on the intersection of public health and primary care.

    Read other posts by this blogger.


    RSS     About RSS

    Our Other AAFP News Blogs

    Leader Voices Blog - An AAFP Leaders Forum
    In the Trenches - AAFP Advocacy Updates
    FPs on the Front Lines - Meeting the Challenge


    The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.