Equity in Tobacco and Vapor Product Prevention and Control

State Preemption of Commercial Tobacco Regulations: Impact in Washington State (PDF)


Tobacco remains the leading cause of death and disease in Washington state. For some communities, that burden is much higher than others despite a decrease in overall smoking rates.

One of the most persistent and historic disparities in the United States, the use of tobacco is linked to many diseases. Nicotine, the addictive component of cigarettes and most tobacco or vapor products, is an addiction that is incredibly difficult to quit, as nicotine is one of the most addictive substances. Nicotine is especially harmful to adolescent brains. Effects on brain chemistry can include those related to reward pathways (which affect addiction potential in a person), attention deficits, and increased risk of developing psychiatric disorders and cognitive impairment in later life. This means that youth who use nicotine-containing products are more likely to develop addictions to other substances, perform poorly in academics, and experience other behavioral disorders.

For some communities, traditional tobacco use may be used for ceremonial or traditional purposes. For other communities, the use of tobacco in a different form may be a cultural practice. An example of this is hookah, which is also known as waterpipe tobacco, argeelah, or shisha. Research conducted mostly within the past decade clearly shows that smoking hookah is an extremely harmful manner of consuming tobacco. Despite popular claims propagated by the tobacco industry, hookah does contain large amounts of nicotine, tar, and many other harmful components of the burning tobacco, as well as the coal that is used.

Despite these varied forms of tobacco use, cigarette smoking is the most popular commercial form. Chewing tobacco, cigars, and cigarillos are also popular forms of tobacco.

These products are often used by the same people. This is because people with an addiction to nicotine rarely discriminate, and the use of one product often normalizes another. The same can be said for the use of cannabis or alcohol. In these cases, social culture is as important as the sharing of addiction pathways in increasing the risk of tobacco use and nicotine addiction.

Industry Marketing

Tobacco companies spend millions of dollars targeting specific communities and making sure that people in these communities always have access to their products. The fact that tobacco companies target African Americans/Blacks, American Indians/Alaska Natives, Hispanics and Latinos, Asians and Pacific Islanders, veterans, people who identify as LGBTQ, as well as people with behavioral health concerns, has led to higher rates of tobacco use and related diseases for people in these demographics.

Consumers of mentholated tobacco products are more likely to sustain a habit of smoking and suffer from a more severe addiction to nicotine, and are less likely to successfully quit. Menthol makes it easier for the body to absorb nicotine, and has been shown to affect nicotine metabolism and dependence. These users are more dependent on nicotine, and engage in behaviors such as smoking sooner after waking compared to users of non-mentholated tobacco products. Essentially, menthol makes tobacco use easier to start and harder to quit.

Use of menthol is higher among youth, females who smoke, sexual minorities, those with mental illness, and racial and ethnic minorities. African Americans who smoke cigarettes report the highest prevalence of menthol cigarette smoking of any racial/ethnic group, with levels of menthol smoking over 88 percent. Despite starting smoking later and smoking fewer packs per day, African Americans who smoke menthols successfully quit at a lower rate than non-menthol smoking African Americans. This could be linked to the more severe addiction to nicotine that users of mentholated tobacco products experience.

African Americans have been targeted by the tobacco industry since the 1970s, where advertisements and promotions were “concentrated in predominately African-American neighborhoods and with campaigns that exploit cultural hallmarks and stereotypes.” Kool, a brand of menthol cigarette, used pop culture to appeal to African American communities, hosting free concerts, using cultural themes in brand marketing, and featuring popular Black musicians and athletes in radio, television and print advertisements.

Tobacco industry marketing tactics have misappropriated American Indian culture and traditional use of tobacco since at least the 1930s, with products such as Natural American Spirit cigarettes and the portrayal of harmful stereotypes of Native people in advertisements. Using American Indian imagery such as traditional headdresses and other cultural symbols in product branding, the historical and cultural significance of traditional tobacco was used to validate and promote the use of commercially available tobacco.


Due to the nature of inequities in the United States, those who are at risk for tobacco use and nicotine addiction are also at higher risk for chronic diseases and other illnesses. Disparities in health, and specifically tobacco, are the result of broader and more fundamental inequities. Health disparities are not the result of a single factor. Rather, they come from an inequitable system in which many factors affect the health status of individuals and/or communities.

The disparities found in tobacco use are the result of broader systemic inequities exacerbated by factors such as dense and predatory targeted marketing of tobacco and menthol in low-income and diverse communities, many of which have been historically marginalized and bear a higher burden of tobacco use and related diseases, and a lack of equity in the allocation of resources to those communities to aid prevention and cessation efforts. Access to healthcare, discrimination or perceived discrimination, education, adverse childhood experiences (ACEs) and other social determinants of health (SDOH) also affect the risk of tobacco use and nicotine addiction.

Characteristics that affect one's risk of tobacco use include, but are not limited to: race/ethnicity, gender, sexual orientation, gender identity, age, disability/limitation, education, income, geographic location, substance abuse status, veteran status, and occupation.

Consequences / Link to Chronic Disease

Because smoking affects nearly every organ and system in the body in a harmful manner, people who smoke and suffer from an addiction to nicotine are more likely to suffer from other illness. This can include chronic diseases such as hypertension or chronic obstructive pulmonary disorder (COPD), or acute issues such as asthma attacks or even a stroke.

Smoking also affects fertility in both males and females, which further contributes to the health disparities in some communities where tobacco use is more common.

What DOH is doing

According to CDC, equity in tobacco prevention and control is best achieved by:

  • Reducing disparities among groups most affected by tobacco use and secondhand smoke exposure.
  • Addressing the factors that influence tobacco-related disparities.
  • Building support for tobacco control among diverse parts of the community.
  • Creating a return on investment.

DOH contracts with regional and priority population partners to implement interventions to reduce the burden of tobacco in Washington state. Priority population partners, in particular, provide key community expertise in our joint efforts to eliminate tobacco-related disparities through culturally appropriate interventions.

Interventions include educating community members, leaders, youth, and other stakeholders; promoting the Washington State Quitline, and other innovative, promising, and evidence-based practices to reduce disparities; and promoting equity in tobacco and vapor product prevention and control.

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