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Title: Health Program Manager, Impact Sonoma Tobacco-Nicotine Prevention, County of Sonoma, California, Department of Health Services, Public Health Division
- MPA, California State University, Sonoma
- BS, Social Work, California State University, Long Beach
Public Health Law News (PHLN): Please describe your career path.
Voge: I started my career as a social worker in rehabilitation hospitals/skilled nursing facilities. From there, after graduate school, I was hired to work on children’s advocacy in a small non-profit where we were afforded the opportunity to think boldly and advance some very forward-thinking policies to address deeply entrenched problems—like uninsured children and a lack of services for children’s mental health and dental health. I worked with and learned from some amazing women in that job. Next, I worked for an organization called the Center for Applied Research Solutions, which held several statewide contracts to facilitate technical assistance and trainings to the substance use disorder prevention field. I was responsible for the development of curricula and publications. For the past six years, I’ve held my current position. Initially, I managed a team and programs related to preventing alcohol, tobacco, other drug, and violence in Sonoma County. With the passage of Proposition 56 tobacco tax in California, we were able to expand our tobacco team, and that is now my sole focus.
PHLN: What drew you to public policy and education and, more specifically, substance abuse and tobacco use prevention?
Voge: Early on, social work fed my need to make sense of my childhood, as well as societal problems, while providing a path to take action. Further along, I found that my interests lied in the study of public policy and government systems, as this cultivated my desire to address injustice and inequity. I think prevention is a natural leaning for those of us who have worked with people in crisis; it’s about self-preservation and guards against burnout. The substance use prevention field is attractive because it’s a source of passion and it’s a robust field. Tobacco prevention allows me to work in the arena of policy, systems, and environmental change every day, and I’m grateful for the opportunity.
PHLN: What are tobacco retail license (TRL) programs and what are they supposed to achieve?
Voge: TRLs are policies passed by state and local governments that can greatly affect how and where tobacco is sold, as well as the types of tobacco products. Many governments have used TRLs to expand their ability to check up on retailers, to stipulate additional conditions with the intention of decreasing access to tobacco products by underage youth/young adults, and to mitigate health inequities.
Unlike regulating tobacco sales through land use policy, for example, TRLs have the advantage of charging a fee to retailers. This provides the revenue to support the associated program. At the heart of a TRL program is compliance, which is achieved by conducting regular visits and establishing a rapport with the retailers. These compliance visits are critical because they’re used to educate the retailer and help them adhere to all tobacco laws, while also monitoring for violations. Our goal in Sonoma County is to always avoid penalties and fees that come with persistent or egregious violations by ensuring the retailer really understands the rules.
As I mentioned, TRLs also provide a pathway to address local issues by adding conditions and restrictions to the policy. These components can mean the difference between a strong and very effective policy versus a weak one. Strong TRL policies have been proven to decrease sales to minors. Ultimately, the goal is to lower youth tobacco use rates. If a TRL can, for example, ban flavored tobacco products, which are popular among youth, then fewer youth will have access to them.
PHLN: In broad strokes, can you please describe some TRL strategy options?
Voge: There are a number of TRL components that are options for policymakers. Some of the most effective, according to research, are increasing the price (essentially, setting a price floor—meaning, no product can be sold for less than the determined minimum price). There’s also setting pack size limits. This was done in 2009 by the FDA with cigarettes, but other products, such as cigars and little cigars, don’t have such limits. We know that youth are particularly sensitive to price. Other measures include restrictions on density, meaning how many retailer outlets are allowed in a jurisdiction, or certain area, for example, within a school perimeter. Also, the type of retailer can be prohibited, for example, retailers that sell primarily tobacco products, or pharmacies. With the epidemic use of e-cigarettes by youth, and the role that flavors play in their popularity, flavor bans have become increasingly more common.
PHLN: How are TRL programs related to public health equity? How can implementing innovative tobacco retail licensing programs work to help achieve health equity?
Voge: TRLs are an important policy vehicle to help mitigate health impacts wrought by the tobacco industry’s targeting of certain populations. Data tells us that people of low socioeconomic status (SES) and certain populations (e.g., LGBTQ) are more likely to use tobacco. These rates are the result of industry tactics; it’s well established that tobacco prices are lower in low-income areas and that tobacco retailers are more concentrated in low SES neighborhoods. We can help undo this targeting by setting density limits and price floors. Another example has to do with menthol. In 2009, the FDA banned all flavored cigarettes, but they made an exception for menthol. Menthol is more than a flavor, it provides a medicinal-type effect, soothing the harshness of burned tobacco, which makes it easier for those initiating use to keep on using. It’s also a product heavily marked to African Americans and LGBTQ populations. Many jurisdictions have recognized the exemption as a wrong, and that allowing menthol to stay on the market will perpetuate health inequities. As a result, we are now seeing flavor bans that include menthol.
PHLN: How did your office determine that TRL might be a viable a tobacco control intervention for Sonoma County?
Voge: Locally, the interest in the policy was raised by the Board of Supervisors, with two members, Shirlee Zane and Susan Gorin being the main proponents. They requested staff to research options for a TRL and return to the Board.
The fact that tobacco policies, such as TRLs, have gained such traction in California is in large part due to the vast structure in place to assist local public health departments, and community-based and statewide-organizations in their efforts to protect the public against tobacco. California voters have made this possible by passing tobacco taxes that now generate funding for prevention work throughout the state. The state program that makes this all possible is the California Tobacco Control Program (CTCP). CTCP works closely with each county’s designated tobacco control Local Lead Agency (LLA) and other grantees to guide, monitor, and coordinate their work. They provide technical assistance and engage in the critical thinking necessary to move the research into practice. As a result, LLAs are kept up to date on the most effective policies to prevent and address tobacco use and exposure to secondhand smoke, are trained on the intricacies of those policies, and are funded to assist jurisdictions in adopting these policies. I really think that without this coordinated and well-funded program, we’d be no match for the tobacco companies. Fortunately, because CTCP equips LLAs with the resources and support to establish expertise, when local policymakers are interested in curbing youth tobacco use, they can find the guidance they need. This complex system of support has led to the passage of over 156 strong tobacco retailer licensespdf icon[PDF – 670KB]external icon in California.
PHLN: What kind of TRL legal provisions have been implemented in Sonoma County jurisdictions?
Voge: There are currently four jurisdictions within Sonoma County with TRLs: 3 cities and the county unincorporated. Each TRL consists of different provisions. Two cities have variations of flavor bans, while the county unincorporated and one city have instituted one of the more unique provisions: minimum price. Two cities have pack size restrictions, and pharmacies were banned from selling tobacco products in the jurisdictions that had pharmacies actively selling tobacco products.
County of Sonoma unincorporated also established a ban on new retailers, setting a density limit to a ratio of 1 retailer per 2,500 county residents. They are restricting new retailers that sell primarily tobacco products. They also added a provision that requires ID to be checked at the door of these retailers so no one under 21 may enter.
PHLN: What are the challenges to implementing innovative TRL programs? What are some ways to overcome these obstacles?
What we think of as “innovative” may not initially be embraced by the general public, and that can influence elected officials’ opinions and actions. For any particular policy, the reality is there may be one or two elected officials who are proponents, a few on the fence, and some opposed. It’s important to understand their reasons and address their concerns and questions, and a good way to communicate with public officials and the community is through a study session with an elected body. The public policy vetting process is intended to consider the concerns of all involved. However, it’s necessary to get ahead of the process before you’ve done a first read of a policy in order to understand all the positions and community concerns. Often, it’s community members or organizations who bring the issue and potential policy solutions to the elected body in the first place.
As public health professionals, we have the advantage of being on the forefront of research, and we contemplate solutions, often for years, before they become mainstream; we’re essentially early thought-adopters. One of the things we do best is to educate the public, and we do this by appealing to the head and the heart—by sharing data and telling stories and using real-life scenarios. Think about how social norms have shifted about smoking in public places, but this did not happen overnight, and there’s still a long way to go. We don’t let people smoke on planes anymore, but there are still restaurants in the US that allow smoking.
Innovative policies also call for more legal scrutiny to ensure the jurisdiction will not open itself up to a lawsuit. Often small jurisdictions just don’t have the resources to enter into a costly legal battle. For this reason, larger jurisdictions, who are better resourced, go first, then smaller cities and counties can follow.
The City of Healdsburg adopted a TRL policy that placed them first among California cities to raise the legal age of tobacco purchase to 21. While they were ultimately sued by the industry, which delayed implementation of the policy, the threat did not stop them from adopting the policy. Healdsburg’s mayor at the time, Dr. Jim Wood, went on to become a State Assembly member. No surprise, Dr. Wood was instrumental in the passage of the Tobacco 21 policy in California, which passed just a few years after Healdsburg’s. Also, a noteworthy caveat in Healdsburg was the strong community support for the policy. In particular, two medical doctors, Dr. Dave Anderson and Dr. Drexler, both members of Sonoma County’s Tobacco-Free Community Coalition, played essential roles in the passage of the policy.
PHLN: What are some productive ways to engage retailers in the process, whether they are in support of or opposed to strict TRL programs?
Voge: In Sonoma County, the Board of Supervisors directed health department staff to hold a series of public meetings to hear and develop options to mitigate retailer concerns and hear from the community. This was a productive way to ensure concerns were fully understood, and to then share the information with our Board in order for them to contemplate changes to the ordinance. One of the retailer’s biggest concerns was regarding the license transfer. As a result, the policy was amended to remove the provision that prohibited transfer for most retailers, and where transfer prohibition remained, within 1,000 ft of schools, and an exception was made to allow a transfer of license to a relative.
PHLN: Why was parity such a big issue for Sonoma County’s TRL implementation and how was it addressed?
Voge: In Sonoma County, retailers were also concerned about the minimum price provision—proposed at $7 a pack.
They were concerned about fairness, that the pricing mandate would cause them to lose business to retailers in neighboring city jurisdictions, who could charge less. Interestingly, a number of retailers said they were fine with the provision itself, that they would even support a higher minimum price, as long as the retailer down the street had the same price floor.
The Board of Supervisors heard this concern and decided to delay the implementation of the minimum price provision by a year and a half. To help, the Board also directed health services staff to work with cities to present the option of adopting a TRL with the same minimum price provisions in order to create a more even playing field among retailers. Between the time that the TRL was adopted and the time that the minimum price went into effect, California passed an additional $2/pack tax on tobacco products, which greatly neutralized the minimum price impact. The provision went into effect with little opposition from retailers.
PHLN: What other community partners, if any, assisted in the development of Sonoma County’s TRL program? Why is it important to include these stakeholders?
Voge: I think in examples like this, those directly impacted by new restrictions and fees—in this case the retailers—tend to get most of the attention, compared to those who suffer at the hands of the tobacco industry. The reason these policies are being suggested in the first place, which is to address existing problems and inequities, should be afforded equal attention and voice. In Sonoma County, one of the main reasons the TRL was even considered was due to the high levels of sales to minors, 18% at the time, in our local retail environment. In our case, we educated partners and supported the local tobacco coalition to ensure a broad swath of the community was heard from, including health- and wellness-related organizations, parents, youth, schools, medical professionals, etc. Their personal and professional accounts informed the policy debate immensely. For example, many of the retailers blamed the problem of youth use on poor parenting, and the community response was really effective at showing how complex the problem was, and that parents can’t be the scapegoat.
PHLN: What results have you seen since the implementation of the tobacco retailer licensing program?
Voge: Within two years of passage, we saw a significant reduction in our undercover youth purchase rates within the County of Sonoma Unincorporated, from 18% to 2%. Our approach was to emphasize the education and support aspects of compliance, and this has resulted in having good rapport with the retailers. We have not had to issue any citations for violations. The number of retailers has decreased from about 140 prior to passage of the TRL, to about 86. This is in part due to attrition as retailers who sold few tobacco products to begin with decided not to sell any longer. The license fee has remained at $350 a year, with the Board of Supervisors choosing to subsidize the cost of the fee the first two years of implementation in order for staff to provide two visits per year to each retailer. Currently, retailers receive one visit per year, more if there are issues identified and re-inspection is warranted.
PHLN: What advice would you give others who are considering implementing or changing their TRL laws?
Voge: My advice would be to think about TRLs as part of an overall strategy necessary for a community to tackle an immense and complex problem. Having a strong local tobacco coalition that can lead advocacy efforts and bring many people and interests to the table to address a common goal is essential. This is important because when it comes to policy making, voices of opposition are sure to show up. Also, I can’t emphasize enough the importance of the youth/young adult voice as they provide authenticity to the problem. If you can involve youth in tobacco prevention work, they become experts in their own right, and are usually wanting to have a voice.
PHLN: Where can jurisdictions interested in implementing innovative local tobacco retailer license programs learn more?
Voge: Having access to technical assistance support from think-tank and expert organizations makes all the difference for localities. We are fortunate in California that these types of agencies are funded by the State to support tobacco prevention work. I’m naming a few stand-outs who we work with: ChangeLab Solutions, the Center for Tobacco Policy & Organizing (American Lung Association), the Public Health Law Center (Mitchell Hamline School of Law), and the Center for Tobacco Control Research and Education at the University of California San Francisco.
PHLN: Have you read any good books lately?
Voge: One of my recent reads was The Sympathizerby Viet Thank Nguyen, which was made even more interesting by the post-discussion I had with my book group. The book is a great reminder about how history is made and understood, and that there’s always another perfectly valid perspective, which can be suppressed or overlooked if we’re not open to hearing it.
PHLN: Do you have any hobbies?
Voge: For the past year or so, I’ve been learning flamenco dance and culture, and it’s been a wonderful way to challenge the brain and body to be in sync. It’s a niche interest, so meeting new friends with such passion for flamenco has also been fun. I’m an avid reader and podcaster. I just returned from my fourth backpacking trip with a group of girlfriends, a great way for me to connect, unplug, and enjoy the beauty of the mountains and lakes.
PHLN: Is there anything else you would like to add?
Voge: I would like to acknowledge that this work is successful only with the talents and hard work of the tobacco prevention team here at the county: Jay Macedo (recently left the county), Ariel Thomas-Urlik, Greg Damron, Ana Quintana, Carley Moore, and my supervisor Kelly Elder.
Source of original article: Centers for Disease Control and Prevention (CDC) / Public Health Professionals Gateway (tools.cdc.gov).
The content of this article does not necessarily reflect the views or opinion of Global Diaspora News (www.GlobalDiasporaNews.com).
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