Research and Action in Urban Tobacco Control Joshua M. Sharfstein, MD Tobacco use in Baltimore and other urban areas remains a major public health challenge. Rates of use are high, with 28% of adults in our city reporting smoking in the 2007 behavioral risk factor survey conducted by the Centers for Disease Control and Prevention, compared to a statewide rate of 17%. Other studies have found very high rates of tobacco use among young adults in urban areas, as high as 60% in some subpopulations.1 Tobacco use, of course, also is associated with substantial morbidity and mortality. In Baltimore, over the last seven years, our age-adjusted heart disease mortality has been 30% greater than the rate among Maryland residents, with substantially higher rates among African-Americans.2 Complicating this bleak picture is the fact that some common tobacco control measures may have less than optimal effectiveness in large cities. For example, cessation services may be inaccessible to many without regular sources of health care. Public education campaigns designed for the country or state as a whole may fail to resonate. The myriad corner stores in an urban environment further complicate the task of enforcement. As a result, new research and new ideas are needed to address urban tobacco use. The paper by Katherine Clegg Smith and her colleagues starts with this critical and understudied challenge.3 It is based on in-depth interviews with 14 senior city officials in government, education, and job training. According to the study, the city leaders believe that young adults in training programs are seeking major change in their lives, but that to date, changing their tobacco use has not been not part of the package. Those interviewed felt that mentorship could be an avenue to help youth quit smoking. They also believe that tobacco control programs aimed at young adults should address the role tobacco has in helping them deal with many stressors in their lives. These findings should be viewed as preliminary. The number of people interviewed is small, and the researchers do not present data from any interviews with the young adults themselves. Yet the results suggest an opportunity for intervention that is worth pursuing – building cessation and tobacco prevention education into job training and education programs. If we can reach young people at a time and place where they are already making changes in their lives, then we may have a chance to have a much greater impact than with more diffuse, citywide efforts alone. To succeed, such efforts must overcome several obstacles. First, the efforts must integrate tobacco control into the overall approach and message of the training programs. This may require opening up the curricula to add points of discussion and teaching on tobacco. Second, the efforts must overcome any resistance among the teachers and trainers. If addressing tobacco is seen as a hindrance or distraction, it is unlikely that the young people will hear the right message. One of the roadblocks to tobacco control may be that the staff model tobacco use themselves. Third, the efforts must have a message that resonates with young people. I am not persuaded by the fear that tobacco control is impossible until we solve all other urban ills, including poverty, joblessness, and violence. But helping young people see that tobacco use only complicates their own efforts at self-advancement in the face of these challenges could prove to be very important. It is also critical for researchers to evaluate these efforts. The approach of community-based participatory research embodied by this paper and others by the same research group exemplifies what can be accomplished through creative and inclusive partnerships. [End Page 1] But as these researchers make clear, the end goal is not a publication. If the evaluations of pilot programs are too small to be useful or too long in coming to be relevant, then we will lose critical opportunities to make progress. Unfortunately, there are far too many examples of successful research projects that have never led to substantial health improvements in cities, including Baltimore. In some cases, this failure has its roots in poor communication between researchers and the policymakers who could provide sustainable support. Engaging the...