When Big Tobacco companies reached a landmark legal settlement with states in 1998, they agreed to pay at least $206 billion for health damages related to smoking. They also agreed to release years of secret documents detailing the ways they obscured health science and sought to attract new smokers.
Among those papers were decades of marketing plans targeting inner city African-American communities. An R.J. Reynolds meeting summary from 1989 identified young African-American males as trend-setters who could promote smoking across society. Other papers described the potential for menthol to hook new smokers by masking some harsh effects of tobacco.
Bastyr University graduate Valerie B. Yerger, ND ('92), has spent the past decade bringing these tactics to light. Together with colleagues at the University of California, San Francisco, she detailed how tobacco companies sponsored community events and club nights, paid black leaders for political support, and positioned menthol-flavored brands like Kool and Newport as "friends" of black communities.
"If you have a product that is killing a community, but they see your brand as a friend, that ensures your brand has vitality," says Dr. Yerger. "That was — and still is —a very important tactic for the tobacco industry."
Dr. Yerger has published extensively on her research, which is funded in part by the National Institutes of Health. But she has not stopped there. She also took her findings to black communities across the country. In the Bay Area, she gathered smokers, former smokers and young people in focus groups (using "community-based participatory research”) to find out how to eradicate a leading killer of African Americans.
"We were one of the first teams to take these documents to the communities discussed in them," Dr. Yerger says. "It's very humbling to see someone who has been smoking for 20 years suddenly start yelling and screaming: 'Screw these cigarettes. Screw these companies. I'm not picking up another cigarette.'"
Public health research is not the career Dr. Yerger imagined when she graduated from Bastyr's Doctor of Naturopathic Medicine program 21 years ago. But she says a naturopathic philosophy has informed her work ever since. The naturopathic doctor-patient relationship taught her to listen before prescribing solutions, she says. For example, listening to smokers in poor neighborhoods taught her that people must feel safe from violence before they grow interested in quitting tobacco.
Naturopathic philosophy also helps her see connections among all parts of a person's health and their community.
"African American smokers want to quit smoking as much as anyone else," she says. "They make more quit attempts. But when you have social pressures and inequities that make it difficult for people to live thriving, high-quality lives, smoking is part of what they do to cope."
"When people have a lot of stress and financial hardship and can't get jobs, and they don't have other ways to release feel-good hormones because there's no place to exercise in their neighborhoods, or they can't get nutritious food in the neighborhood corner store, that's all connected. You have to look at the whole situation."
From there, she worked to learn why African American smokers struggled with quitting. As she learned about health care disparities in the U.S., she found that inequality was about more than "access" to health centers. Poverty, violence, imprisonment, discrimination — and the stress they cause — all contribute to health problems.
She asked smokers why nicotine replacement therapies (such as patches or gum) often failed. She found that many of them did not have a consistent relationship with a primary care doctor, a key indicator in whether cessation programs succeed. She also found that black smokers tended to smoke fewer cigarettes per day than other races, but were getting the same dosages for nicotine replacement.
"So a lot of black smokers were being over-prescribed," she says.
Her archival research of tobacco documents found evidence that nicotine accumulates in tissues containing melanin, the substance that gives skin and hair their color but is also distributed throughout the body and brain. Dr. Yerger suggests that this accumulation of nicotine may help explain why, despite smoking fewer cigarettes per day and becoming regular smokers later in life than the general population, African Americans are disproportionately affected by tobacco’s health effects.
Crucially, she found that "blame the smoker" guilt messages are ineffective. Instead, she advocates for framing tobacco as a social justice issue, using peer pressure within communities to help reduce smoking.
"As communities, we need to look at how the tobacco industry is coming here to do harm to us," she says. "We need to find the strategies to help folks see that."
Industry records (UCSF's Legacy Tobacco Documents Library hosts more than 14 million of them) provide ample evidence. A summary [PDF] of a Salem cigarette "Black Initiative Program" meeting in 1989 reads: "The Program should be endearing to the target, which as a result, will make Salem endearing to them as well. Salem should be seen as a friend."
Dr. Yerger has lost several family members to smoking-related diseases, including her mother and grandmother. She says it has been "very, very difficult to read" about tobacco companies collaborating with her college sorority and organizations her grandparents helped build.
Yet she has seen cultural norms about smoking change, slowly, with her work contributing.
A Food and Drug Administration science committee repeatedly cited her work in finding that menthol cigarettes lure new smokers and reduce cessation rates. Dr. Yerger is working with a national effort to present a citizens petition to ban menthol cigarettes.
In August 2012, the Legacy Foundation honored Dr. Yerger for her research. Bastyr honored her as one of its distinguished alumni when the award was first presented in 2004.
Naturopathic doctors follow seven core principles, including doctor as teacher, which recognizes the importance of educating patients and teaching them to take responsibility for their own health. Dr. Yerger has found the same to be true working with communities.
"We've watched people in our focus groups say, 'I want to do more. How can I help?'" she says. "We watched people say, 'I want to make copies of these documents and take them to all of my neighbors. I want to talk about this, and I can't talk about it if I'm a smoker, so I'm going to quit.’ We saw that over and over and over again."