I initially entered the tobacco world when I was 16. Part of the work was ATOD (alcohol, tobacco and other drugs). My very first job allowed me to understand tobacco and spread prevention messages to youth. The issue I had was that it was all fear based. It focused on the number of deaths or on uncommon, ridiculous health issues people may get from smoking tobacco. Yet, promotion of these tobacco-related illnesses as equal and likely pushes what we know about the "dangers" of tobacco.
As I began to enter college and got wrapped up in HIV/safe-sex work, I increasingly learned about risk reduction and the need to be client-focused in figuring out risk. This spoke to me, as it made most sense to work with people and allow them to figure out the options that best fit their lifestyles. When HIV changed from being a terminal to a manageable disease, HIV funding changed and began to filter in from various other state health departments. Substance abuse and tobacco funding began to funnel money into HIV prevention. Many rehabs began to work with HIV testing agencies to make sure their clients were being tested and educated about HIV and other sexually transmitted infections (STIs). This allowed for sustainable, diverse funding for AIDS serving organizations (ASOs). But, no real discussions took place on how to go about prevention and intervention.
For HIV workers, risk reduction is essential to meeting client needs and lifestyles. But tobacco and substance abuse work do not focus on risk reduction. There are more applications of risk reduction in substance abuse than in anti-tobacco efforts, and this causes some hiccups in care. I remember being trained by the Mayo Clinic in LGBTQ and tobacco use. Its biggest focus was not risk reduction but pushing the gum, lozenge or patch for nicotine replacement. Mostly Michigan ASOs attended that Mayo Clinic training, and there were big debates on preventative measures. We were instructed to not work on risk-reduction techniques, but to push abstinence with assistance from nicotine replacement. This caused a huge uproar among the agencies that attended the trainings.
Many of those agencies did not change their prevention messaging. They just amalgamated their messaging into tobacco prevention but still focused on risk reduction. In my opinion, HIV programs are consequently doing better tobacco work than tobacco-focused programs. Those tobacco programs seem so out of step from everyday people. HIV programming began to treat tobacco as a health focus for those living with HIV. It is true that those living with HIV have a higher rate of cancer and other smoking-related diseases. And HIV workers knew that, so they began to work on preventing tobacco use in the same way they work on STI prevention. Agencies began to make it work the best they knew how.
But what happens when those techniques begin to work, but they are neither recognized nor promoted by the tobacco prevention world? This dynamic affects the ability to obtain more funding because the techniques used are not validated.
In HIV programs, tobacco reduction focuses on the community environment and stress. Many of these programs teach the "5 As" to their case managers, and those case managers work with patients and their special immunologist to track their tobacco use. The 5 As are:
- Ask: Ask each and every session or appointment about tobacco use. Do this in a way that allows clients to be open and honest.
- Advise: Continue to encourage clients to quit or to think often about quitting. Let them know the dangers and how they can increase the use of meds and live longer and healthier.
- Assess: Are they ready to quit? Are they likely to quit? Do they really want to quit? And what are the issues keeping them from quitting. Most people have tried to quit; what prevented their success?
- Assist: Work with clients who wish to or are thinking of quitting by giving them options that allow them to see a change or reduction in their tobacco use. At this step, offering encouragement and congratulations for any small step toward success is important.
- Arrange: Follow up with them at a scheduled time and arrange for more resources and support.
Through such methods, which seem less invasive in practice, case managers began to treat tobacco as a larger intersection of people's identities. Since tobacco is so intertwined with people's, and especially marginalized population's, ability to cope, case managers focused on coping and self-health and awareness. Case managers reached out to other organizations to provide tobacco cessation classes to their clients.
Having taught many tobacco cessation courses, I was initially given a presentation that focused not on risk reduction, but on those nicotine replacement therapies and state-wide quit lines. These presentations not only didn't work, they also didn't relate to what HIV clients were used to working with. Clients had the ability to see the reduction in their risk and how that reduction created healthier choices. But, when choices are reduced to mere gum, lozenge, patch and a random phone call with a random person to discuss personal tobacco use, it creates a difficult-to-navigate system of prevention and intervention.
I changed and encouraged other organizations to change their focus. In the newer presentations, I began to talk about changing habits that can trick your mind, which can change addiction. Many people use tobacco at the same time each day or after the same daily routine. This means smokers smoke in the morning, usually with their coffee, after a meal and of course when stressed. We should focus on those not-stressful times of smoking, such the morning smoke or after-meal smoke. Many people put their tobacco in a particular place where they know it will be available for their routine smokes. For example, they leave their tobacco product on the kitchen table close to their coffee maker, so they know they are complimentary each morning. It can help to change this placement and move the tobacco product or delay its use for an hour or more after the morning coffee. It doesn't immediately deter risk, but it changes habits and makes people think more about smoking or not versus just doing it because it something that is always done.
In those cessation sessions, we also talked about reducing the number of tobacco products used daily. This creates the ability to see the reduction and celebrate those changes. In these classes, I began to see more changes toward quitting tobacco. There was more of an ability to change because there were options and plans for quitting smoking. Working with clients to change their habits and environment is essential to helping them become tobacco free. Risk reduction works; abstinence, as seen with sex education, never works.
Lilianna Angel Reyes, a trans Latina woman and graduate of the University of Michigan Rackham Graduate School, has extensive history working with marginalized populations including people of color, women, LGBTQ communities and HIV-positive communities. She has worked with many state and national civil rights organizations including Affirmations, Planned Parenthood, National Organization of Women, Transgender Michigan and the NAACP. She is currently a Founding Mother and sitting Board Member for a transformative Detroit-metro non-profit, The Trans Sistas of Color Project (TSCOP). Her work includes health care sensitivity trainings, diversity and equity trainings, policy initiatives, program creation and community awareness and organizing. Empowering marginalized people through education and advocacy is her life's purpose.