No More Flavors: A Case Study Addressing Flavored Tobacco in San Francisco

Bright Research Group
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"At the time of its passage, San Francisco’s Flavored Tobacco Sale policy was the most
comprehensive flavored tobacco regulation of any municipality in the United States. A key prerequisite
for the success of this policy campaign was a dedicated network of community
organizations that had trusting relationships with local policymakers."
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Introduction:

In 2017, the San Francisco Board of Supervisors unanimously passed a policy that prohibits the
sale and distribution of flavored tobacco products, including mentholated cigarettes. San
Francisco’s Flavored Tobacco Sale policy (hereafter, referred to as the Flavored Tobacco Sale
policy) aims to eliminate youth access to flavored tobacco products and reduce the
disproportionate impact of flavored tobacco on communities of color. At the time of the
policy’s adoption, San Francisco was the only municipality to have adopted a comprehensive
policy that limits flavored tobacco sales at a citywide level.

The San Francisco Tobacco Free Project (TFP)—a project of the San Francisco Department of
Public Health—and its partner community coalition—the Tobacco-Free Coalition—were
actively engaged in the development of and support for the policy campaign in San Francisco.
This case study describes this policy in San Francisco, examines the key strategies and lessons
learned from the campaign that led to the policy adoption, and discusses the intended impact of
the policy.

Flavored Tobacco as a Social Justice Issue:

What is flavored tobacco?
The Flavored Tobacco Sale policy defines flavored tobacco as any tobacco product (cigarettes, hookah tobacco, cigars, blunts, vaping liquid, etc.) with a characterizing flavor (fruit, chocolate, mint/menthol, candy, etc.).

Who uses flavored tobacco?
Flavored-tobacco products have the same negative health effects as unflavored tobacco. Flavored tobacco is marketed and sold in a way that is attractive and highly accessible to youth (Figure 1). Through a combination of visually appealing packaging, cheap prices (e.g., little cigars for 50 cents), and plentiful flavor options, flavored tobacco products appear—and can even taste—very similar to candy (see below). Furthermore, the characterizing flavors in flavored tobacco products mask the harsh flavor of tobacco, making it much easier for youth to start using tobacco and become addicted. Tobacco companies are particularly keen on establishing smoking habits in adolescents, which could cause them to become regular smokers as they get older. Of the 5.6 million Americans under 18 who smoke today (1) 80 percent started smoking using a flavored tobacco product.(2)

Similarly, there is clear evidence of flavored tobacco’s disproportionate impact on minority populations. African Americans, specifically, have been targeted by mentholated cigarette brands Kool, Newport, and Salem through the use of culturally tailored advertising images and messages for decades (3). This has resulted in elevated mentholated-cigarette smoking rates in the African American community. An estimated 70 percent of African American adult smokers smoke mentholated cigarettes, compared to fewer than 30 percent in other ethnic groups (4). Studies have shown that people who smoke mentholated cigarettes are much less successful at quitting smoking than non mentholated-cigarette smokers, regardless of race (5). As a result, African Americans bear inequitable and long-term negative health impacts due to targeted advertising from menthol-flavored tobacco producers (4).

How is flavored tobacco regulated?
The federal government currently regulates flavored cigarettes but not non-cigarette flavored tobacco products (i.e., blunts, wraps, cigarillos, snuff, etc.). In 2009, Congress banned the production and sale of flavored cigarettes (6).  However, this legislation did not ban mentholated cigarettes, despite strong efforts by the Congressional Black Caucus to include mentholated cigarettes on the list of restricted products (7). Furthermore, this regulation did not establish any limitations on the sale or production of flavored non-cigarette tobacco products. As a result, tobacco producers have continued to sell mentholated cigarettes, and an increasing variety of flavored e-cigarettes, blunts, and cigarillos have been marketed to entice first-time smokers.

Several municipal jurisdictions have passed additional policies to regulate flavored tobacco at the local level. The implementation of these ordinances varies by region, ranging from solely allowing adults-only tobacco stores to sell flavored tobacco products (8) to banning the sale of flavored tobacco products near specific sites, such as schools (9,10). Some of these policies explicitly ban mentholated tobacco products (including cigarettes), while others do not, allowing mentholated tobacco products to continue being sold legally under current FDA regulations. Within California, several counties and cities have recently passed legislation regulating the sale or distribution of flavored cigarettes and flavored tobacco products, including Berkeley, whose legislation predated the San Francisco policy. San Francisco’s Flavored Tobacco Sale policy passed in July 2017, with Contra Costa County, Oakland, and San Leandro passing their own flavored tobacco regulation soon after.

Please see Appendix A for a timeline of flavored-tobacco regulation in the Bay Area.

Successful Strategies for Passing Flavored-Tobacco Regulation:

At the time of its passage, San Francisco’s Flavored Tobacco Sale policy was the most comprehensive flavored tobacco regulation of any municipality in the United States. A key prerequisite for the success of this policy campaign was a dedicated network of community organizations that had trusting relationships with local policymakers. This section describes how the San Francisco Tobacco-Free Coalition secured unanimous support for the policy from the Board of Supervisors and highlights lessons learned that other communities might apply in their efforts to regulate flavored tobacco products (Figure 2).

Engage and empower youth and community members

The San Francisco Tobacco Free Coalition mobilized and coordinated a high volume of community stakeholders to participate in the policy process. These organizations include the African American Tobacco Control Leadership Council, Breathe California Golden Gate Public Health Partnership (hereafter referred to as “Breathe California”), the Youth Leadership Institute, the American Cancer Society Cancer Action Network, and researchers from UCSF, among others.
One specific tool for empowering community based organizations to activate youth and other community members is the Community Action Model (CAM). The CAM is a five-step, community-driven process designed to support emerging community leaders in identifying policy solutions to eliminate health disparities. The San Francisco Department of Public Health’s Tobacco-Free Project oversees the funding and training of community-based organizations that participate in CAM.

Breathe California, a lung health organization, received a CAM grant in 2015. Their CAM project, known as Project E-NUFF, engaged a dozen young-adult community members to conduct research, analyze data, develop strategic communications materials, and educate policymakers and key stakeholders on the topic of flavored and mentholated tobacco products. The E-NUFF team conducted research in fall 2015 and analyzed the results through summer 2016. Between that time and the adoption of the San Francisco Flavored Tobacco Sale policy, they did the following:
• Published a letter to the editor calling for an end to the sale of flavored tobacco
products in two newspapers before the policy was being considered by the Board of
Supervisors
• Developed an educational packet to present to public officials, their community, and the
Board of Education
• Wrote a messaging guide for the issue
• Developed an infographic highlighting the impact of flavored tobacco on youth in various
languages
• Spoke at public hearings to provide testimony on how menthol-flavored and other
flavored-tobacco products were impacting their schools and neighborhoods

The sustained work of Breathe California on this issue and investment in emerging community leaders allowed them to capitalize on the opportunity to work with a supportive policymaker in the spring of 2017.

Identify a policy champion:

Supervisor Malia Cohen represents San Francisco’s District 10, which
includes Bayview-Hunters Point. As a primarily working-class and
historically African American community, Bayview-Hunters Point has
acutely felt the negative public-health effects of flavored-tobacco products.
Prior to the Flavored Tobacco Sale policy, Supervisor Cohen had
demonstrated a commitment to protecting her constituents’ health and a
willingness to challenge large industry manufacturers. For example, she had
previously supported public-health legislation, including the 2016 Sugar-
Sweetened Beverage Tax, and cosponsored a previous nonbinding
resolution to remove mentholated tobacco products from San Francisco.
The San Francisco Tobacco-Free Coalition has developed and maintained ongoing relationships
with several supervisors by consistently sharing data pertaining to the impact of tobacco on
their communities and, where possible, policy solutions to protect the health of their
constituents. In this instance, the coalition was able to support Supervisor Cohen’s efforts on
this issue by providing her with meaningful data and research on the topic and organizing
community members to attend press conferences and provide testimony at hearings.