"What about menthol?"

That’s what Delmonte Jefferson wanted to know in 2011 when he became the executive director of The Center for Black Health & Equity (formerly NAATPN), which promotes tobacco cessation, cancer prevention, and HIV prevention programs that benefit African-American communities. Because 82% of African-American smokers use menthol-flavored cigarettes, it was a huge priority for The Center for Black Health & Equity. The Tobacco Control Act had banned most flavors in cigarettes just two years earlier, but hadn’t banned menthol.

“Why had they excluded menthol tobacco products?” Jefferson asked. “Menthol tobacco products need to be banned just like the other flavored products. We were saying that but there was no one listening.”

Tobacco manufacturers have used menthol cigarettes to target young and vulnerable populations for years. The menthol “mint” flavor reduces the harshness and irritation of tobacco smoke, and is a popular choice for those first starting to smoke. Menthol cigarettes are also used at far higher rates by African Americans and other racial and ethnic minorities relative to white smokers.

“We couldn’t get any of the other national partners to take up that menthol mantra, but finally we noticed that the Public Health Law Center and Truth Initiative started saying menthol tobacco products should be banned as well,” Jefferson said. “All of a sudden, we had allies.”

The Public Health Law Center and The Center for Black Health & Equity began to partner, and create connections for each other with new partners. “They did not back down,” Jefferson said. “In fact, they would ask people in states considering legal options for flavor bans to consider banning menthol as well. If they hadn’t considered it, then their attorneys would say, you should talk to The Center for Black Health & Equity.”

Jefferson helped the attorneys at the Center understand the horrendous impact of menthol on minority communities, and soon they began making joint presentations around the country. “We do tag-team presentations very well,” he said. In 2013, both organizations were heavily involved in creating the Citizen Petition Asking the U.S. Food and Drug Administration to Prohibit Menthol as a Characterizing Flavor in Cigarettes, and continue to work together on this issue today.

“Having national partners like the Public Health Law Center actually saying that menthol should be banned, that helped as we started gaining traction, and now I don’t think it’s a question.” he said. “They’ve shown, clearly, that our interests were their interests. They stuck their necks out when no one else would on menthol. That is invaluable.”

The Center for Black Health and Equity: The Menthol Issue

“There is no substitute for having people sitting together in a room, face to face.” said Ellen Vargyas, General Counsel and Corporate Secretary at Truth Initiative, as she discussed recent strategic meetings with the leading minds on tobacco control from around the country. These meetings were hosted by the Tobacco Control Legal Consortium, a program of the Public Health Law Center.

“I have personally attended two meetings, which have been extremely valuable in bringing people together who might not normally be in touch with each other,” she said. “Having those honest and tough discussions about what can work, what won’t work, the pitfalls, and the opportunities, is of enormous value.”

The Public Health Law Center has been bringing together researchers, advocates, attorneys, and public health departments with local, state, and national perspectives on a number of tobacco control issues, such as menthol sales restrictions and other retail policies.

“There are some complex legal issues involved,” Vargyas said. “There are questions about which provisions are effective, how to ensure compliance; there are a whole basket of important issues. The Consortium attorneys are always a pleasure to work with, and always open to feedback.”

Truth Initiative is pioneering anti-tobacco public education with its truth® campaign, and its youth engagement programs supporting populations at high risk of using tobacco. Truth Initiative also conducts very sophisticated scientific research and policy studies as part of its mission, and is an important contributor to these national meetings with its ability to examine problems and the efficacy of potential solutions.

“The Public Health Law Center has structured its meetings in a very effective way, with presentations and case studies, and people have given some real thought about these complicated issues,” Vargyas said. “You could not ask for better collaborators.”

“We salute the Consortium for taking this leadership role of bringing people together, and then following up. It’s of huge value to the tobacco control community.”

Truth Initiative

Missty Lechner has been spending all her time with the American Heart Association in Kansas advocating for policies that increase access to healthy food. But she knows the health advocates can’t do it by themselves.

“People take food very seriously in Kansas,” Lechner said. “We can’t effectively impact healthy food access unless we engage more people. The American Heart Association can provide tools to help, but there are consumers, community groups, farmers, retailers, nonprofits and health departments in those counties that can and should lead this work.”

To engage those stakeholders, Lechner has focused on food policy councils, which are groups that can examine how the local food systems operate, and provide policy recommendations to improve those systems. In Kansas, they call them “food and farm councils.”

Many of the councils have to be established by a public resolution or proclamation, which is where the Public Health Law Center comes in. Bylaws that determine the purpose and structure of the council need to be written by stakeholders, and when resolutions are used, they need to be drafted so counties can officially form the councils.

“I am not a lawyer,” Lechner said. “The Public Health Law Center has developed a starting point and a language that communities across the state can use.”

Center attorneys have created resources on local government options to increase access to healthy food, and specifically, on creating food policy councils. “Those are the two documents I come prepared with, and have been particularly helpful,” said Lechner. “They have a credibility with stakeholders and elected officials because they are developed by legal professionals.”

Center attorneys have also attended local and statewide meetings to help build awareness and develop this knowledge in Kansas. “The Center presentations have helped elevate this policy option. I don’t have to go out and approach communities, now they are approaching me,” Lechner said.

In 2012, one council had been established in Kansas, and two more were just getting started. In 2016, ten counties had appointed councils, with efforts underway in 20 more counties. One third of the state either has a council or is working toward one.

“It’s pretty incredible,” Lechner said. “I would not be as far as I am with food and farm councils today if it wasn’t for these resources. I feel like I’m in debt to the Public Health Law Center.”

Kansas Alliance for Wellness (American Heart Association/Kansas Health Foundation)

When the South Dakota legislature expanded its public smoke-free policy to include bars, restaurants and casinos in 2009, Rae O’Leary was an excited supporter. She works as a nurse and respiratory therapist at Missouri Breaks, a private, Native-owned research firm located on the Cheyenne River Reservation in rural Eagle Butte, SD.

“I care a lot about lung health,” she said.

However, the law’s passage wouldn’t affect the Cheyenne River Reservation because of tribal sovereignty. O’Leary’s husband and children are Cheyenne River Sioux Tribe members, and she is a member of the Turtle Mountain Band of Chippewa in North Dakota. “I knew that the state law couldn’t be enforced with tribal members or tribal businesses on reservation property.” As a health professional, O’Leary wanted the benefits of a smoke-free ordinance for the reservation because she knows how profoundly commercial tobacco affects her tribal community.

“Our smoking rate is 51%, which is higher than the U.S. rate in 1964 when the surgeon general first declared that smoking was harmful,” she said. “That was the motivation for developing the Canli Coalition.” Canli [pronounced CHUN-lee] is the Lakota word for commercial tobacco, distinctly different than the traditional plants that are used in tribal ceremonies.

After O’Leary made a few calls to others who wanted smoke-free air for the tribe, the Coalition first met in 2009. They all cared about the issue, but none had any experience with community public health policy.

“Very early in the process, I contacted the Public Health Law Center,” she said. “I was set up with Mike Freiberg. At that time, I don’t think he had a lot of experience with tribal law, but he had extensive experience with smoke-free policies.”

Freiberg recommended they start by reviewing the South Dakota smoke-free law together. After many phone calls and emails, the Coalition created a draft of a tribal commercial smoke-free law that was similar but stronger than the South Dakota law, with an exemption protecting the use of traditional tobacco.

“Mike helped us understand the importance of definitions in a law, and the integration of local, relevant research about the health impact of tobacco on our community,” O’Leary said. But despite its legal work with the Center, and its efforts to educate the community about second-hand smoke, the tribal council remained hesitant to move forward for several years.

“Mike helped us review the ordinance every time the council had concerns,” she said. “We changed the definition of commercial tobacco to include e-cigarettes, because e-cigarettes weren’t even a thing when we started! We always knew we had Mike there as a resource.”

Finally, the Coalition’s efforts were rewarded. At an emotional meeting in April 2015, the Cheyenne River Sioux Tribal Council passed the smoke-free ordinance after dozens of tribal supporters, many of them children, spoke to the council about how commercial tobacco had affected their lives. There wasn’t a single ‘no’ vote that day.

"The Public Health Law Center helped us use tribal sovereignty as it is intended – to protect the health, safety and welfare of tribal citizens within tribal territory,” O’Leary said.

“Every time we share our experiences with other tribes, we recommend the Public Health Law Center, because I absolutely believe that we would not have been successful without their support."

The Canli Coalition Facebook page

The Canli Coalition Timeline & Resource Guide for Tobacco Policy Change

Building a coalition to promote healthy food access is complex. Just ask Vayong Moua. “You can imagine all the various stakeholders at the table, anti-poverty, anti-hunger, public health, economic development, farmers,” he said. “It’s a very diverse set of perspectives.”

Moua and stakeholders in Minnesota came together to create the Good Food Access Fund, a financing initiative meant to bring healthy food to retail settings in low-food-access and low-income areas. The coalition approached the Minnesota Legislature in 2016 to try to pass a bill to create the Fund, and sought $10 million in the form of grants, loans, and technical assistance to make healthy food more available throughout the state.

“We’re not trying to bring unhealthy food into low food access areas,” said Moua, Health Equity Advocacy Director at the Center for Prevention at Blue Cross Blue Shield of Minnesota. “We believe strongly in health equity. We’re trying to make sure the food is healthy, culturally appropriate, and affordable.”

As a longtime partner of the Center for Prevention, the Public Health Law Center answered the call to support the coalition as it reviewed policy options and shaped the initiative. It provided value in other ways as well.

“[Staff attorney] Susan Weisman helped us first think about the core elements, values, and principles we wanted in a policy. She didn’t lead with technicalities or minutiae, but helped us identify what was important to us before the translation into policy legalese.”

Weisman helped to facilitate a series of listening sessions and followed up with stakeholders to make sure their interests were clear as the coalition developed policy language. “We were managing very different and very strong personalities and organizational cultures,” Moua said. “This relationship management can be tough, but it’s a role that the Public Health Law Center plays very thoughtfully and respectfully, even if it isn’t always visible.”

“The Center is like the Switzerland of public health,” Moua continued. “It is a neutral authority with the both the street cred and the skillset to create high impact public health policy.”

By the end of the 2016 Minnesota Legislative Session, the Good Food Access Fund bill was adopted with nearly all the coalition language intact. The initiative was not fully funded, so the coalition plans to return next session to press the Legislature to close access gaps in Minnesota food systems.

“We were fortunate to get that much traction. It was originally intended to be a two, maybe even three year campaign,” Moua said. “Having the Center involved with the Good Food Access Fund was critical, helping us shape our approach as well as our policy.”

Blue Cross Blue Shield of Minnesota, Center for Prevention

Good Food Access Fund Fact Sheet (Hunger Solutions Minnesota)