I am thrilled and honored to join the Smoking Cessation Leadership Center as its new Director. I started my medical and public health career over 2 decades ago as a street outreach worker for people experiencing homelessness in Boston, MA. This community included migrant laborers, those who transitioned in and out of homelessness, and those who were chronically homeless. Many used tobacco to cope with stressors of homelessness, and for some, their use was linked with co-occurring mental health and substance use disorders.
The lack of access to tobacco and substance use treatment was apparent but neglected, as these problems did not measure up to the major competing priority of obtaining housing. This experience and many others in the field has inspired my career in community-engaged, tobacco control research.
My work in the last decade has helped quantify tobacco use among marginalized communities and has led to interventions to improve access to smoke-free policies and cessation services in these populations. I am a generalist at heart and fortunate to enjoy all aspects of my work: first, as a primary care physician, then, as a community-engaged researcher and educator. These experiences have set the foundation for the next stage of my career at the SCLC.
Now in its 20th year, the SCLC has singularly focused on reducing the burden of commercial tobacco—the leading preventable cause of death in the U.S. With its national presence and reputation for collaboration, the SCLC achieved this goal through collective partnerships with over 150 clinicians, pharmacists, dentists, and other healthcare organizations to elevate the issue of tobacco use and its population-level burden.1
Recognizing that tobacco use is concentrated among our nations’ most vulnerable, the SCLC, with dogged persistence, started to address the staggering rates of tobacco use among populations with mental health and substance use disorders, when many thought it was an impossible task. 2 The SCLC has achieved striking results. Through unique partnerships with agencies like the Substance Abuse Mental Health Services Administration, the National Alliance on Mental Illness and others, the SCLC has been instrumental in fostering a culture change in behavioral health facilities including substance use treatment facilities on screening for and treating tobacco use. 2,3
But our work is far from over as tobacco use is still the leading preventable cause of death in the U.S., contributing to an increased burden among the very marginalized populations that have benefited the least from federal and state tobacco control policies. These tobacco related disparities will continue to be the focus of SCLC’s work moving forward.
I see four overarching opportunities that will direct SCLC’s work in the future:
- Promoting equity
A recent report from the Centers for Disease Control and Prevention (CDC) showed that the prevalence of tobacco use remained high among adults with mental health conditions. 4 Subpopulations with mental health conditions and high smoking rates include adults aged 26 to 64 years, those who identify as sexual and gender minority, those living below the federal poverty line, those with low educational attainment, people living in rural areas, and those who have had criminal system involvement in the past 12 months. These populations—with or without mental health conditions—have large disparities in tobacco cessation. Further, race/ethnicity and geographic locale (urban versus rural) may intersect and magnify tobacco-related disparities in these priority populations.5
The SCLC will continue to work with state and national partners to promote policies that combine tobacco-free grounds with coordinated access to tobacco treatment in multi-unit housing, behavioral health clinics, and substance use treatment facilities. The SCLC will expand focus on populations with very high rates of tobacco use – people experiencing homelessness and justice-involved populations – to reach and engage these populations and their service providers to integrate tobacco treatment as part of housing and re-entry services. We will develop cessation toolkits that address the intersectional nature of tobacco risk in priority populations using collaborative community-based approaches with impacted populations and their service providers.
- Evidence generation and synthesis
Our work will contribute evidence to support legislation that promotes tobacco-free grounds and tobacco treatment where, historically, there have been none. In correctional systems where there is a national smoke-free policy, the policy is not accompanied by tobacco treatment. The lack of access to tobacco treatment in jails and prisons contributes to periods of forced quitting, with high rates of relapse after release, which negates the potential positive effects of a smoke-free policy. On the other hand, policies in California where tobacco treatment is mandated without the presence of tobacco-free grounds, 6 may also lead to periods of quitting that are not sustained.
The SCLC will continue to use a collective partnership model3 to work with state and national partners to use qualitative and quantitative data-driven approaches to evaluate whether existing policies are reaching disproportionately impacted populations and identify ways in which policies may need to be modified to increase efficacy of quitting. In this work, we will contribute to evidence generation and synthesis of best practices to support tobacco cessation in these populations.
- Tobacco cessation as tobacco control policy
Tobacco cessation has generally been viewed from the health services lens but is seldom discussed as tobacco control policy, essential to ending the commercial use of tobacco. Many states are putting forward tobacco endgame plans that include policies to reduce the prevalence of tobacco use to <5% in the general population.7 Notable is the absence of tobacco cessation in the implementation plan for these endgame policies. We cannot reach these ambitious endgame policy targets without increasing cessation.
The SCLC will continue to highlight ways in which tobacco treatment can be included in states’ tobacco endgame plans and prioritized with federal tobacco control policy. Other policies like the flavor ban on tobacco products also have implications for tobacco cessation, and SCLC’s work will help provide a framework for integrating tobacco treatment with this and similar tobacco control policies.
- Training the next generation of public health practitioners
The SCLC’s activities of capacity building, training, and service delivery naturally lend themselves to training the next generation of public health practitioners.
The SCLC will use its situation being embedded within an academic health center, to identify opportunities for trainees in different disciplines (e.g., medical, dental, nursing, pharmacy) at the graduate and post-doctoral levels. These opportunities might include field work with our team through engaging with state and national partners at summits or at service sites like substance use treatment facilities, and/or data analysis opportunities with national data sets of tobacco prevalence, cessation or services, or tobacco policy-level data among impacted populations. We will partner internally with the Center for Tobacco Control Research and Education and others at UCSF, and externally through our state and national partners to increase training opportunities in cessation research and practice.
I want to extend my deep gratitude to Dr. Steven Schroeder and Dr. Pamela Ling for their mentorship and for being maximally supportive in helping me transition to this new role. I cannot imagine a better team to guide and support me, including the SCLC’s Deputy Director, Ms. Catherine Bonniot, and each member of the SCLC team. Lastly, I am looking forward to working with all of you—SCLC’s partners and network—in support of our shared goal of a tobacco-free future.
1. Schroeder SA, Clark B, Cheng C, Saucedo CB. Helping Smokers Quit: New Partners and New Strategies from the University of California, San Francisco Smoking Cessation Leadership Center. J Psychoactive Drugs. Jan-Mar 2018;50(1):3-11. doi:10.1080/02791072.2017.1412546
2. Schroeder SA, Clark B, Cheng C, Saucedo CB. Helping Smokers Quit: The Smoking Cessation Leadership Center Engages Behavioral Health by Challenging Old Myths and Traditions. J Psychoactive Drugs. Apr-Jun 2018;50(2):151-158. doi:10.1080/02791072.2017.1412547
3. Santhosh L, Meriwether M, Saucedo C, et al. From the sidelines to the frontline: how the Substance Abuse and Mental Health Services Administration embraced smoking cessation. Am J Public Health. May 2014;104(5):796-802. doi:10.2105/AJPH.2013.301852
4. Loretan CG, Wang TW, Watson CV, Jamal A. Disparities in Current Cigarette Smoking Among US Adults With Mental Health Conditions. Prev Chronic Dis. Dec 22 2022;19:E87. doi:10.5888/pcd19.220184
5. Tan ASL, Hinds JT, Smith PH, et al. Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift. Nicotine Tob Res. Jan 1 2023;25(1):73-76. doi:10.1093/ntr/ntac110
6. California department of health care services. Understanding Assembly Bill (AB) 541: Assessment of Tobacco Use Disorder in Substance Use Disorder Recovery or Treatment Facilities. Available at: https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CTCB/CDPH%20Document%20Li…. Accessed on January 21, 2023.
7. Puljevic C, Morphett K, Hefler M, et al. Closing the gaps in tobacco endgame evidence: a scoping review. Tob Control. Mar 2022;31(2):365-375. doi:10.1136/tobaccocontrol-2021-056579