1. A Focus on Health Equity in POS Tobacco Control

The United States has steadily expanded tobacco protections since 1964, resulting in less smoke in the air and fewer advertisements of tobacco products. However, these protections, which most Americans now take for granted, are not evenly distributed across the country or even across neighborhoods.

The availability and marketing of tobacco products on a neighborhood level impact these disparities. Recent data from the 500 largest cities in the United States shows that census tracts with the highest smoking rates are also the ones with a greater density of tobacco retailers. These census tracts, which generally face multiple disadvantages, are also the ones with lower median household incomes and a greater proportion of people of color. ^[1] 

The tobacco industry also targets specific groups through tailored marketing tactics;  bright candy-

like packaging and an array of flavors appeal to youth while ads depicting rugged cowboys and hunters appeal to rural populations. As well, the industry, on countless occasions, has exploited Native American images on commercial tobacco products, a tactic used to encourage Native American use while also portraying tobacco products as more ‘natural’ to other communities.

A critical assessment of these manipulative tactics helps explain why, despite the overall US smoking rate decreasing to 14%, rates are much higher among people with lower levels of income and education, people who identify as American Indian/Alaska Native, men, people who identify as LGBTQ, people facing mental illness and disabilities,  people who are uninsured or on Medicaid, and people living in the South and Midwest.

Fortunately, we have some promising pro-equity solutions at the point of sale:

• Raising tobacco prices, through imposing taxes, banning the redemption of coupons and other discounts, or setting minimum floor prices, is one of the most effective strategies for reducing initiation, decreasing consumption, and increasing cessation of tobacco products.^[13] Additionally, this strategy can help reduce tobacco use among low-income groups and reduce socioeconomic disparities in smoking; in fact, one study found that increasing tobacco prices was the only policy option of those assessed to show a significant pro-equity effect.^[14]
• Research conducted in New York and Missouri has shown that restricting tobacco retailers from locating near schools could nearly eliminate disparities in density between neighborhoods.^[2] This restriction can be accomplished through licensing. Licensing strategies in San Francisco and Philadelphia that have capped the number of retailers within a geographic area are also working to reduce disparities in density.
• Restricting the sale of menthol cigarettes and all other flavored tobacco products also has significant potential to improve health equity. A report from the Tobacco Products Scientific Advisory Committee shows that if menthol cigarettes were banned, 39% of all people who smoke menthol cigarettes and 47% of African Americans who smoke menthol cigarettes would quit.^[8] A menthol ban could also curb both initiation and progression to regular smoking among youth, as 80% of youth who have ever tried tobacco started with a flavored product,^[9] and youth who initiate smoking with menthol cigarettes are 80% more likely to later smoke every day.^[10] Recently, the U.S Food and Drug Administration (FDA) released a guidance document prohibiting retailers from selling flavors other than menthol or tobacco of cartridge-based electronic nicotine delivery systems (ENDS). While we discuss this in more detail below, we would like to point out that this scaled-back policy does little in protecting youth and vulnerable populations or advancing health equity.

Health equity can and should be considered as part of any tobacco control policy. Localities can consider conducting a health equity impact assessment to determine what the results of any given policy may be on the ground. An approach considering social determinants of health can help practitioners ensure that a policy’s benefits reach all populations and that resources and services are distributed consistently and equally across these populations so as not to exacerbate existing disparities.^[3] 

2. Comprehensive Bans on the Sale of Flavored Tobacco Products

We know that youth are more likely to initiate tobacco use with a flavored or menthol tobacco product. We also know that menthol products are easier to start and harder to quit. Scientific reviews and publications have time and again concluded that their removal from the market would benefit public health. In 2020, keep an eye out for increasingly comprehensive action on the sale of flavored tobacco products at the federal, state, and local level.

More than three months after the Trump administration announced plans for a ban on the sale of flavored e-cigarettes, the FDA finally released a guidance document on January 2, 2020, detailing enforcement priorities of a new federal ban on flavored tobacco products. According to the document, retailers will be prohibited from selling all flavors, other than menthol and tobacco, of cartridge-based electronic nicotine delivery systems. Exempt from this rule are self-contained disposable vaping devices and e-liquids used in customizable, refillable e-cigarette pods. With such a fine-tuned focus, the ban ultimately protects the tobacco industry rather than kids. In addition, the FDA has not yet moved to follow-up on their November 2018 proposals to ban menthol in cigarettes and other combustible tobacco products or to ban flavors in all cigars. Even if (hopefully when) enforceable rules and regulations are released for these policies, we expect that some of them may face legal challenges from the tobacco industry – a move that will further delay their implementation, meaning they could take years to become a reality.

Meanwhile, localities and states have not been waiting around for FDA action. In 2019, we saw Massachusetts become the first state to pass a nearly complete ban on the sale of all flavored tobacco products, including menthol cigarettes and flavored e-cigarettes. The only exception is that flavored tobacco products can still be sold at licensed smoking bars such as cigar bars and hookah lounges, though consumption must occur on-site.

This builds on the legislative movement we saw in 2018 on menthol and other flavored tobacco products across the country, from cities and counties in California to those in Minnesota and Massachusetts. While some policies, like the one in San Francisco, prohibit the sale of menthol and other flavored tobacco products entirely, other regulations restrict them to adult-only stores or restrict the sale of these products within a certain distance of youth-serving venues like schools and parks. However, more and more places are seeing the value in a comprehensive flavor ban that addresses all tobacco products in all places for the health equity reasons stated above, as well as for fair implementation and enforcement, and a more thorough means of addressing the youth vaping epidemic. See specifics from the Public Health Law Center about the different types of flavor policies now in place all around the country.

Learn more about flavored tobacco products and menthol tobacco products in our evidence summaries.

3. Tobacco 21

Now that the federal government has passed a policy raising the minimum legal sales age to 21, states and localities will likely update their laws to reflect this change as well. The federal policy, signed into law on December 20, 2019, gives the FDA up to 180 days to update its regulations to carry out the rule. The FDA has stated on their website that “It is now illegal for a retailer to sell any product – including cigarettes, cigars, and e-cigarettes – to anyone under 21. FDA will provide additional details on this issue as they become available.” Prior to the rule’s passage at the federal level, 19 states and over 500 cities had passed their own “Tobacco 21” policies. However, not all of these policies are strong policies. Learn more about Tobacco 21 best practices here. The new federal minimum age presents an opportunity for states and localities to pass or strengthen their own existing age of sale laws to include stringent and well-funded enforcement that will help ensure that retailers follow the new law. In addition, while a higher minimum legal sales age is a positive step forward for tobacco control across the US, localities considering Tobacco 21 may find it helpful to their overall tobacco control work to consider framing it as part of a broader comprehensive plan to limit youth’s access to tobacco products and exposure to the effects of tobacco marketing. Localities may also consider including their own Tobacco 21 policy as part of a licensing program; doing so would allow for both enforcement of this policy as well as any additional point of sale tobacco control interventions to be put into effect. See more about this in our next trend to watch: tobacco retailer licensing.

4. Tobacco Retailer Licensing

Tobacco retailer licensing (TRL) is a regulatory tool that can be used to implement a range of policies. In its simplest form, a TRL policy requires stores that want to sell tobacco products to obtain a license from the city, county, and/or state. Strong TRL ordinances also require retailers to pay an annual fee to obtain or renew their license; this fee is ideally set at a price point that covers the cost of administration and enforcement of the license. A study published in the journal Pediatrics showed that strong TRL policies may lower youth initiation of both cigarettes and e-cigarettes.^[14] In California localities that had a strong TRL, youth were 33% less likely to initiate cigarette use and 26% less likely to initiate e-cigarette use over the course of 1.5 years compared to localities that had no licensing or did not have a licensing fee high enough to cover the costs of enforcement.^[14]

In addition, licensing allows for more accurate tracking of all tobacco retailers in a given geography and can serve as a platform on which to build other regulations that can have a large impact on the community environment, such as restricting the density, type, and location of tobacco retail outlets. Despite the major benefits of licensing for tracking retailers, nearly a dozen states still lack any licensing requirement for tobacco retailers at the state level. With an increasing focus on sales to underage youth with the passage of a federal Tobacco 21 policy, we may see a push for states to update their laws to include licensing or to strengthen their current licensing laws.

Licensing is also an optimal way for localities and states concerned about the youth vaping epidemic to track where e-cigarettes are being sold in their communities. The Surgeon General’s advisory on the e-cigarette epidemic among youth recommended licensing retailers as one evidence-based population-level strategy to reduce e-cigarette use among young people.

In addition to keeping track of retailers and ensuring they are complying with the law, licensing can also be a foundation to further limit access and exposure to tobacco products and marketing at the point of sale. San Francisco currently has the most comprehensive tobacco retailer licensing policy, capping the number of licenses permitted in each of the city’s 11 districts at 45 and prohibiting any new retailer from locating within 500 feet of a school or other tobacco retailer. Promisingly, more cities are moving towards a similar model. In December 2016, Philadelphia passed a law limiting the number of tobacco retailers to 1 per 1,000 people in each planning district and prohibiting new tobacco retailers within 500 feet of a school. In addition, at least 125 cities and towns in Massachusetts have instituted some sort of cap on the total number of tobacco retail outlets, and many of them also have restrictions on how close tobacco retailers can be located to schools. Several cities in California, Colorado, Illinois, New York, and Wisconsin also limit retailers within 500 or 1,000 feet of schools. 

Mapping can help communities determine the impact of any given TRL policy on the ground, for example, by helping to provide visual evidence displaying the number of tobacco retailers currently located near schools in their town or disparities in tobacco retailer density rates in their community. Mapping can also help determine what TRL “plug-ins” might have the most impact on the tobacco retail environment in their community.

5. A Changing Tobacco Product Landscape

In 2020, we will see changes, both large and small, to the tobacco product landscape. Some changes, like any resulting from federal action on flavored tobacco products, have yet to take shape. However, here are a few things we do expect to see emerge or expand on the market in the coming year:

1. 1. Heated Tobacco Products like iQOS. In November 2019, Philip Morris International introduced its heated tobacco product, iQOS, to the Richmond, Virginia area after rolling out the product the previous month in Atlanta, Georgia. Classified and regulated by the FDA as cigarettes, the iQOS products are heated tobacco products comprised of a rechargeable heating device that Marlboro-branded tobacco “HeatSticks” are inserted into; the HeatSticks are sold in packs of 20 and also come in a mentholated flavor. While the FDA states that these devices “may help reduce the risk of tobacco-related harms for adult smokers who switch completely from combusted cigarettes“, they have yet to come to a decision on whether the device can be marketed as a modified risk tobacco product. In addition, an FDA Tobacco Product Scientific Advisory Committee found that the iQOS did not substantially reduce risks of tobacco-related death and disease. As of now, iQOS devices can only be found at a handful of flagship stores and pop-up shops in the Atlanta and Richmond areas; HeatSticks, on the other hand, are being sold at various tobacco retailers across these two cities. Based on the industry marketing efforts, concerns remain about the product’s appeal to youth. Find out more information and access additional resources about this emerging product here. 
   2. Nicotine Pouches like Zyn and Velo. These pouches claim that they are “tobacco-leaf free,” distinguishing them from smokeless products like snus. They’re being offered in various flavors and for cheap, but only time will tell whether they’ll gain popularity with youth or with those looking for alternative nicotine products.
   3. Very Low Nicotine Cigarettes. The FDA announced in December 2019 that two new, reduced nicotine cigarette products – Moonlight and Moonlight Menthol, manufactured by 22nd Century Group Inc. – can be marketed and sold in stores in the US. Through a review of their premarket tobacco product application, the FDA determined that these low nicotine cigarettes (0.2-0.7 mg of nicotine per cigarette, compared to an average 10-14 mg per cigarette in standard combustible cigarettes) are “appropriate for the protection of the public health” due to the potential for these products to reduce adult smokers’ nicotine dependence. Additionally, the FDA determined that these new products are unlikely to attract non-smokers and youth, and that those who do choose to experiment with these products are less likely to become addicted than if they had experimented with conventional cigarettes. While Moonlight and Moonlight Menthol have far less nicotine content than traditional cigarettes, the new products are otherwise identical to cigarettes in composition with numerous toxic ingredients known to cause adverse health consequences. While these two products are now legal to market and sell and offer a lower nicotine content option, they, like any tobacco product, are not considered “FDA-approved” or deemed “safe” by the FDA. The FDA will continue to monitor these two new products to confirm they are effectively protecting the health of the public.
   4. Cigarette packs with graphic health warnings. Cigarette packs will also hopefully contain graphic warning labels starting sometime in 2020. The FDA proposed a set of new images and warnings in August 2019 and is set to issue a final rule by March 15, 2020.

6. Debate around the “Public Health Standard” and Balancing Harm Reduction with Youth Prevention

Under the pre-market review process, in order for the FDA to approve a tobacco product to be marketed in the US, that product must be “appropriate for the protection of public health,” taking into consideration, among other things:

• “Risks and benefits to the population as a whole, including people who would use the proposed new tobacco products as well as nonusers
• Whether people who currently use any tobacco product would be more or less likely to stop using such products if the proposed new tobacco product were available
• Whether people who currently do not use any tobacco products would be more or less likely to begin using tobacco products if the new product were available; and
• The methods, facilities, and controls used to manufacture, process, and pack the new tobacco product.”

How this standard is interpreted, and in particularly whether it includes the impacts of the product on health equity, will likely be hotly debated in 2020.

So far, we have seen the agency authorize the marketing and sale of both the heated tobacco product “iQOS” and two new, reduced nicotine cigarette products – Moonlight and Moonlight Menthol, manufactured by 22nd Century Group Inc.

Tobacco companies must submit their pre-market applications for all products by May 12, 2020, and the FDA will have up to a year to review those applications, during which time the products can stay on the market.

Debate about whether any e-cigarettes should be approved as appropriate for the protection of public health will likely center around balancing the products’ potential for harm reduction with youth prevention. A 2018 congressionally mandated report on the Public Health Consequences of E -Cigarettes from the National Academies of Science, Engineering, and Medicine found that e-cigarettes are likely less harmful than conventional cigarettes and may help adults quit smoking, though more research needs to be done on the specific conditions under which this can occur. While they found conclusive evidence that completely switching to e-cigarettes reduces exposure to toxicants and carcinogens found in conventional cigarettes, the report also finds that there is substantial evidence that, among youth, e-cigarette use increases the risk of smoking conventional cigarettes later on. The report states that the overall impact of e-cigarettes on public health is still unknown, with more research needed on both the short and long-term effects of use, as well as their relationship to conventional cigarette use. In addition, recent research shows that people who continue to use both regular cigarettes and e-cigarettes (as 60% of adult e-cigarette users do) are exposed to more toxicants than using either product alone.^[16]

Meanwhile, youth use of e-cigarettes has reached ‘epidemic’ levels, as described by the Surgeon General in a rare advisory on the topic. Between 2017 and 2018, youth use of e-cigarettes skyrocketed, with the largest one-year increase in any kind of substance use by adolescents in the past 44 years. Use continued to rise in 2019, with 27.5% of high school students reporting current use.

As well, in 2019, for the first time, the FDA authorized a tobacco product to be marketed with a ‘modified risk’ claim. Granted to Swedish Match USA, Inc., eight snus smokeless tobacco products, sold under their ‘General’ brand name, can be marketed with the claim that “using General Snus instead of cigarettes puts you at a lower risk of mouth cancer, heart disease, lung cancer, stroke, emphysema, and chronic bronchitis.” The FDA has made it clear that, while these products can now be sold with a ‘modified risk’ claim, this designation does not indicate that the products are safe or “FDA approved”; moreover, packaging and advertising for these products must continue to include the warning statements required for all smokeless tobacco products. Though this authorization has been the first of its kind, the modified risk tobacco product pathway is “outlined in the 2009 Family Smoking prevention and Tobacco Control Act [and] allows companies to submit applications for the FDA to evaluate whether a tobacco product may be sold or distributed for use to reduce harm or the risk of tobacco-related disease associated with commercially marketed tobacco products.”

In 2020, as we wait on any additional moves forward from the FDA on very low nicotine e-cigarettes, products they’ll approve through the pre-market review system, and products they’ll approve to be marketed as “modified risk,”, we will likely see shifts from Big Tobacco as they try to stay in (the addiction) business.^[17]  While Big Tobacco talks about a “smoke-free world,” they continue to market the most deadly of their products aggressively both in the U.S. and in low- and middle-income countries, where they see untapped markets. Don’t expect voluntary action from Big Tobacco or retailers to result in the end of cigarettes.

We’ll be keeping an eye on these trends in 2020. While the long-term effects of e-cigarette use are still unknown, we do know that combustible tobacco products are the leading cause of preventable death and disease in the U.S., contributing to 480,000 premature deaths each year. With the tobacco industry spending over $7.3 billion yearly to market these deadly products at the point of sale, we’ve got plenty of work to do fighting the “War in the Store.” 

7. Battles over Preemption

In 2019, we saw wide ranging preemption on local laws governing the sale of tobacco products that were enacted in Arkansas as part of a “Tobacco 21” bill. This follows a trend, though not a new one, of the tobacco industry pushing for preemption at the state level where their influence is most concentrated. This mirrors a trend in pushes for preemption happening on many public health fronts, including higher minimum wages, paid sick leave, anti-discrimination laws, gun control laws, sugar-sweetened beverage taxes, and plastic bag or straw bans. Preemption is one of the tobacco industry’s favorite tools to limit local innovation and prevent the implementation of life-saving policies at the local level. We know that local-level policy work often precedes state-level adoption of a policy, so tobacco companies have a vested interest to keep local power limited; the industry also often has more influence at the state level.

Despite this, some states with preemption currently in place are beginning to push back on those limits to local authority. For example, in early 2019, advocates in Colorado successfully passed a law that reversed a previously existing de-facto preemption on local cigarette regulation. Previously, if a Colorado jurisdiction passed a retail licensing law for cigarettes or a cigarette tax law, that jurisdiction would forfeit eligibility to receive their portion of cigarette sales tax money from the state. The new law removed that restriction and gave counties the express authority to regulate the sale of cigarettes and other tobacco or nicotine products, as is further discussed in our case study. Since then, Colorado localities have been on the move with proposals to restrict the sale of flavored tobacco products in Boulder, Aspen, and Glenwood Springs; proposals for Tobacco 21 and tobacco retailer licensing in Boulder, Breckenridge, Dillon, Glenwood Springs, and Denver; and tobacco tax proposals in Eagle County, Summit County, Pitkin County, Glenwood Springs, New Castle, Boulder, and Crested Butte, according to this article from Colorado Public Radio. 

8. Minimum Price Policies

Continuing with the focus on health equity, point-of-sale pricing policies are innovative tobacco control solutions that can reduce health disparities, counteract industry targeting, and encourage smokers to quit. Prices can be increased through excise taxes and through other policies such as establishing minimum “floor” prices and prohibiting coupon redemption and discounts on tobacco, which can help prevent the tobacco industry from circumventing the effects of tax increases.^[6]  In 2013, New York City was the first city to set a minimum floor price for all cigarettes (then $10.50/pack); New York City has since raised their minimum floor price for cigarettes to $13/pack and has also set minimum prices for all tobacco products. As well, Sonoma County in California passed a policy that went into effect last year that set a minimum price of $7/pack. Other localities in California, Massachusetts, and Minnesota have set minimum prices for cigars. Minimum price policies that also prohibit the use of price promotions (e.g. coupons, multi-pack discounts) could help reduce socioeconomic disparities in smoking by raising the price of discount brands, which may encourage more lower-income smokers to quit. ^[8]Strong minimum price laws can also prevent price manipulation by geographic area or by brand, thereby reducing targeting of products to certain populations. Models estimate that prohibiting price promotions across the US could reduce smoking rates by 13%, ^[9] and establishing a national minimum price of $10 per pack of cigarettes could reduce cigarette sales by 5.7 billion packs per year and result in 10 million people quitting.^[10] Learn more about raising the  price of tobacco through non-tax approaches.

9. Tobacco-Free Pharmacies

In 2018, Massachusetts became the first state to prohibit the sale of tobacco products in pharmacies (and all healthcare institutions). This was preceded by a groundswell of local action; following Boston’s action in 2008 to become the second city in the nation to ban tobacco sales in pharmacies, more than 160 cities and towns across the state of Massachusetts did the same over the next 10 years. Also in 2018, Albany County and Erie County in New York joined Rockland County and New York City, NY in passing tobacco-free pharmacy policies. In January 2019, Governor Cuomo of New York announced a proposal to prohibit the sale of tobacco in pharmacies statewide as part of comprehensive legislation to curb tobacco use, and in April 2019, Suffolk County, NY joined the list of communities with tobacco-free pharmacies. San Francisco and at least 14 places in California also prohibit tobacco sales in pharmacies.

Localities can create tobacco-free pharmacies as part of a tobacco retailer licensing program by restricting the type of stores such as pharmacies that may be issued a license or through passing a law that directly prohibits tobacco sales in pharmacies. Prohibiting tobacco sales in pharmacies is one strategy for reducing tobacco retailer density. New York City’s policy is projected to decrease tobacco retailer density by 6.8% across the city and by up to 15% in some neighborhoods.^[15] The steeper decreases in density in NYC will be seen in largely higher-income, white neighborhoods, while neighborhoods with more Hispanic residents and residents with lower levels of education will see less substantial reductions. ^[15]  However, tobacco-free pharmacy policies can be paired with other retailer restrictions, such as neighborhood-based retailer caps, as NYC is also implementing, or restricting stores near schools, which can help reduce income- and race-based disparities in retailer density.

Ending tobacco sales in pharmacies is a policy with broad support from pharmacists and the overall public, and retailers are starting to take notice. CVS, the nation’s largest pharmacy chain ended tobacco sales in 2014, but Walgreens, the second largest, has resisted pushes for them to follow suit. Truth Initiative and the Campaign for Tobacco Free Kids have both led efforts calling on Walgreens to end tobacco sales, and a recent survey says Walgreens customers would be on board with the change. This past year, Walgreens dipped a toe in the water by piloting an end to tobacco sales in their stores in Gainesville, FL. It remains to be seen if they’ll scale that pilot up or make the policy official nationwide, but 2019 put them in the hot seat even more with data showing that at a violation rate of 22%, Walgreens had the highest rate of sales to minors of any other pharmacy chain between 2012-2017; as a result, former FDA Commissioner Scott Gottlieb wrote to the corporation, putting them “on notice” until they address these violations.

Taking tobacco sales out of pharmacies just makes sense. These retailers sell products to help treat tobacco-related illnesses – why then would they also sell the very products that cause these diseases? Learn more about tobacco-free pharmacies here.

10. Partnerships to Create Healthier Places: Tobacco, Food, Alcohol, Marijuana, and Physical Activity

Interventions in the retail setting present the opportunity to address multiple factors that influence health. The evidence behind how exposure to tobacco advertising and promotions at the point of sale contributes to tobacco use behaviors continues to grow. Across multiple studies, research has shown that youth more frequently exposed to tobacco promotion are 60% more likely to have tried smoking and 30% more likely to be susceptible to future smoking.^[18] As such, community interest in creating healthy retail environments has heightened, not only around tobacco but also around alcohol, food, marijuana, and the ways in which the community retail environment can support physical activity. The retail environment includes both the community environment (e.g. number, type, and location of stores) and the consumer environment (e.g. what products are sold, how they are advertised, prices, etc.). A study of food retailers that also sold tobacco in three North Carolina counties found that the community and consumer environments for nutrition, physical activity, and tobacco were interrelated, indicating that measures solely assessing the community environment can miss characteristics of the consumer environment.^[19]

Policies can address the retail environment holistically by tackling multiple issues at the point of sale in coordination instead of addressing each in isolation. The authors of the study in North Carolina suggested that food ordinances requiring licensed grocery stores to sell a minimum standard of healthy food, like Minneapolis’s staple food ordinance, can be expanded to place a cap on the amount of tobacco marketing allowed outside the store to reduce youth exposure.^[19]  Given that areas with a higher number of tobacco retail outlets are also more urban and more walkable, restricting exterior advertisements to reduce youth exposure may be of heightened importance. ^[19]  Further improvements to the aesthetics of the store exterior, such as better lighting, removing graffiti, providing adequate trash receptacles, and preventing loitering could also be incorporated as requirements for participation in healthy store programs in order to encourage walkability and active transport around the store. ^[19]  

Monitoring and tracking of the sale of tobacco, e-cigarettes, alcohol, marijuana, food and beverages can be done with the Counter Tools’ Store Audit Center. For more information on other food environment measurements, look to the National Collaborative on Childhood Obesity Research’s Measures Registry. 

For more strategies on interdisciplinary collaboration to create healthy retail environments, review:

• ChangeLab Solution’sHealthy Retail: A Set of Tools for Policy and Partnership, which includes a healthy retail Playbook, Conversation Starters, and a Collaboration Workbook.
• Our Case Study: Healthy Retail San Francisco
• Integrating Tobacco Control and Obesity Prevention Initiatives at Retail Outlets, published in the journal Preventing Chronic Disease.
• California Department of Public Health’s Healthy Stores for a Healthy Community
• SmokeFree Philly’s Healthy Retailer pilot project

BONUS: Endgame Strategies

The ‘Tobacco Endgame’ is a set of initiatives that seeks to eradicate tobacco use by establishing strategies that “eliminate the social, political, and structural constructs that allow the tobacco epidemic to continue.” ^[20] In 2019, we saw some movement towards creating a tobacco-free future through more stringent restrictions of tobacco products. In June, Beverly Hills, California unanimously passed a ban on almost all sales of tobacco products, becoming the first locality in the United States to do so. The ordinance banned the sale of cigarettes, cigars, and e-cigarettes at gas stations, pharmacies, convenience stores, and grocery stores; exempt from the ban are only hotels and three cigar lounges in the township. On a state-wide level, Hawaii similarly attempted to phase out tobacco sales through a bill that called for raising the age to buy cigarettes and ultimately banning the sale of cigarettes over a five year period. While the bill died in the House Health Committee, the proposal foreshadowed movement towards tobacco endgame initiatives at a statewide level.

At the beginning of this year, the American Heart Association was awarded a $5.6 million grant by the California Department of Public Health, California Tobacco Control Program to establish the California Tobacco Endgame Center for Organizing and Engagement. With a goal of totally eliminating tobacco use in California by 2035, the Center plans to provide training and technical assistance to support and grow the capacity of state and local organizations and agencies to pass comprehensive policies focused on heavily restricting tobacco products, which, in turn, would lead to a phasing out of public use of tobacco products. While movement from tobacco control to tobacco product elimination is a lofty goal, we expect to see great progress in California this year and hope to see other state and local-level initiatives utilizing endgame strategies.