New Surgeon General Report highlights how tobacco industry promotes health disparities, supports menthol and flavor bans and highlights cannabis crossover

Surgeon General Vivek Murthy just released a new Surgeon Genera Report, “Eliminating Tobacco-Related Disease and Death: Addressing Disparities—A Report of the Surgeon General” (Press release).

Surgeon General Reports, which, like this one, often take years to complete, represent the broad (if cautious) consensus on a scientific topic. Hundreds of people are involved in drafting, reviewing, and combining information and the whole report undergoes multiple levels of review, all the way up to the Secretary of Health and Human Services.

While there are many detailed conclusions in the individual chapters, here are the major overall conclusions from the whole report. I have highlighted several key points that seem particularly relevant today.

While the overall conclusion that tobacco takes a higher toll on less advantaged people is not new, the level of detail is, including very specific statements about the role of the tobacco companies in promoting these disparities. (Al Sharpton and the other African American shills for Big Tobacco that successfully convinced President Biden to torpedo the FDA’s well-crafted rule ending menthol in cigarettes and other tobacco products should read the report to understand how they have been serving Big Tobacco at the expense of the African American Community they claim to represent.)

While the primary focus of the report is on tobacco, it also notes the important and growing role of cannabis in promoting health disparities and undermining tobacco control. These findings, discussed at the end of this blog post, are particularly relevant for the debate on whether to exclude cannabis from Oakland’s pending smokefree multiunit housing ordinance.

Major conclusions

1. Despite strong progress in reducing tobacco use at the population level, disparities in use persist by race and ethnicity, level of income, level of education,
   sexual orientation, gender identity, type of occupation, geography, and behavioral health status. Exposure to secondhand tobacco smoke remains disproportionately higher among Black people than among people in other racial and ethnic groups,
   youth than among adults, and people from lower socioeconomic backgrounds than among those from higher socioeconomic backgrounds.
2. Tobacco-related health disparities are a social injustice, in addition to an economic and health burden. Addressing disparities requires reflection on the complex history of the commercialization of tobacco and both past and present-day experiences of racism, discrimination, and targeted marketing by the tobacco industry.
3. Social, structural, and commercial determinants of health—such as persistent poverty and inequitable economic and social conditions—lead to inequitable opportunities for living a life free from tobacco related death and disease. Racism, discrimination, and targeted marketing by the tobacco industry; geographic disparities in evidence-based policy protections; preemptive laws that thwart communities from protecting their residents’ health and safety; and financial and other structural barriers to accessing cessation treatments also drive tobacco related health disparities.
4. The tobacco industry has designed, engineered, and marketed menthol cigarettes and other tobacco products that deliver multisensory flavor experiences which increase the likelihood of tobacco initiation, addiction, and sustained use. Policies that restrict the availability of menthol cigarettes can reduce smoking initiation and prevalence among adolescents, young adults, Black people, and other population groups that have disproportionately higher use of menthol cigarettes.
5. For decades, the tobacco industry has targeted its products and marketing to specific groups, including through concentrated marketing in neighborhoods with greater percentages of Black people, Hispanic people, and residents with lower incomes. Tobacco companies employ multiple tactics to undermine tobacco prevention and control efforts and enhance their corporate image.
6. Cigarette smoking remains a major cause of death and disease—including cancer, cardiovascular disease, and chronic obstructive pulmonary disease—among all racial and ethnic groups. More than 490,000 deaths attributable to cigarette smoking and exposure to secondhand tobacco smoke are estimated to occur in the United States each year—about one in five of all deaths in the United States. This includes more than 473,000 deaths attributable to cigarette smoking and more than 19,000 deaths attributable to exposure to secondhand tobacco smoke.
7. Each year, more than 50,000 Black adults, 15,000 Hispanic adults, and 400,000 White adults are estimated to die from causes attributable to cigarette smoking. Despite large absolute differences in the numbers of smoking-attributable deaths by race and ethnicity, smoking accounts for a similar proportion of deaths among non-Hispanic Black (18%) and non-Hispanic White (20%) people and for approximately 10% of deaths among Hispanic people.
8. Data from surveillance and intervention research are limited for many groups known to be at high risk for tobacco use, exposure to secondhand tobacco smoke, and targeted marketing by the tobacco industry. While protecting recent gains in measurement, further efforts are warranted to assess structural and social determinants of health across the lifespan, disaggregate data, oversample disparate populations, and increase understanding of the impact of interventions on tobacco-related health disparities.
9. Endgame efforts to eliminate tobacco-related disease, disability, and death should create opportunities and conditions for all people to live healthy lives that are free from commercial tobacco. Interventions designed to reduce the use of tobacco products and the influences of the tobacco industry on society should accompany efforts to remove the underlying social, structural, commercial, and political drivers of health inequities.
10. In addition to social and structural interventions, a comprehensive and multilevel effort toward health equity must include a combination of complementary approaches to reduce the affordability, accessibility, appeal, and addictiveness of tobacco products; eliminate exposure to secondhand tobacco smoke; conduct high-impact media campaigns; and promote barrier-free access to cessation support with broad reach to disparate populations. Strategies should be implemented equitably and with fidelity in all jurisdictions. [emphasis added]

Cannabis is important, too

As noted above the report the important and growing role of cannabis in promoting health disparities and undermining tobacco control. Two sections, quoted in full below, are particularly relevant for the debate on whether to exclude cannabis from Oakland’s pending smokefree multiunit housing ordinance because they show how the exemption will worsen health disparities, something that the Councilmembers seemed concerned about at the hearing I attended.

As states have legalized adult cannabis use, use in public places has generally been prohibited, including outdoors. Some states have begun to make certain exceptions for indoor cannabis use within their otherwise comprehensive smokefree laws. For example, Colorado allows for the use of cannabis in certain restaurants and Michigan allows for use in certain restaurants and bars, despite otherwise having comprehensive laws that prohibit tobacco use indoors (American Nonsmokers’ Rights Foundation 2022c). Allowing cannabis use indoors and making exceptions to otherwise comprehensive smokefree laws will undermine the progress that has been made over decades to protect people who do not smoke, particularly those who are employed in jobs in the hospitality sector, from exposure to secondhand tobacco smoke and could lead to health disparities. As states and communities consider whether use of cannabis in public places should be permitted as a part of legalization, protecting all populations from exposure to secondhand tobacco smoke, including exposure to cannabis smoke, in all indoor settings should remain a priority. [page 559; emphasis added]

And

Common Threats Between Commercial Tobacco and Cannabis
Cannabis use represents an important public health concern, especially given the high prevalence of tobacco and cannabis co-use in youth and young adults; social, economic, and health disparities associated with chronic cannabis use; and disparities in exposure to secondhand cannabis smoke by age and race and ethnicity (University of California–Davis Health System 2016; Terry-McElrath et al. 2017; Substance Abuse and Mental Health Services Administration 2021). Although efforts to decriminalize cannabis possession and reschedule cannabis under federal law are important to redress racial and ethnic disparities in the criminal justice system (The White House 2022), the issue of decriminalization is distinct from health related concerns about exposure to cannabis smoke. The increased legalization of recreational cannabis at state and local levels represents a threat to smokefree norms and protections and has implications for health disparities (Jacobus and Tapert 2014; D’Souza et al. 2016; Substance Abuse and Mental Health Services Administration 2020, 2021). As of July 2022, two states (Colorado and Nevada) with statewide smokefree laws contain an exemption for cannabis smoking in 100% smokefree restaurants and one state (Michigan) contains an exemption for cannabis smoking in 100% smokefree restaurants and bars (American Nonsmokers’ Rights Foundation 2022). Although the short- and long-term health effects of exposure to cannabis smoke are unknown (National Academies of Sciences, Engineering, and Medicine 2017), a World Health Organization (2016) review concluded that evidence suggests that cannabis smoke is carcinogenic, and California added cannabis smoke to its list of carcinogens, as required under California Proposition 65 (California Office of Environmental Health Hazard Assessment n.d.). Studies suggest that many of the same constituents of tobacco smoke are present in cannabis smoke; some constituents (e.g., ammonia and hydrogen cyanide) are higher in concentration in cannabis smoke than in tobacco smoke (Moir et al. 2008; Tomar et al. 2009). Furthermore, the commercial tobacco industry is investing heavily in commercial cannabis and seeking to shape regulations for and policies about cannabis (Dewhirst 2021), which may undermine efforts to address health disparities and specifically jeopardize efforts to promote equitable smokefree protections. [page 778; emphasis added]

This effort started when Donald Trump was President

In the current political environment following Donald Trump’s reelection, there may be a tendency for some to dismiss this report of one more example of out-of-control Democratic wokeness. In fact, the idea for this report originated around 2018 from Jerome Adams when he was Trump’s Surgeon General. (Surgeon General reports often take years to complete.) Indeed, I was asked to contribute material on secondhand smoke protections to the report and did so in 2018 or 2019. Knowing how long these reports take, Amy Hafez (who worked with me to prepare the requested materials) and I used the same work to prepare the peer reviewed paper Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019. which we published in American Journal of Public Health in 2019. That paper is cited in the new Surgeon General report.

The full citation is: U.S. Department of Health and Human Services. Eliminating Tobacco-Related Disease and Death: Addressing Disparities—A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2024. It is available for free here.

Related materials (fact sheets, summaries, etc) to the new report as well as links to the other reports on tobacco and health are here.