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- Aim and Outcome:
Given the pervasive and intentional targeting of minority populations [including youth, African
American, and the LGBQT communities] to promote use of flavored tobacco products, the San
Francisco Tobacco Free Project (TFP) and Tobacco Free Coalition set out to find solutions that
promoted health equity regarding sales of flavored tobacco in the city of San Francisco.
Objective: By June 30, 2019, the City and County of San Francisco will implement the existing Tobacco Retailer License (TRL) policy to prohibit the sale and distribution of mentholated and/or other flavored tobacco products.
Indicator 3.2.9: The number of jurisdictions with a policy restricting or prohibiting the sale and/or distribution of any mentholated cigarettes and other flavored tobacco products, and paraphernalia.
Through active engagement in the development, awareness raising and support of a campaign to
prohibit the sale of flavored tobacco products in San Francisco, the Tobacco Free Coalition was
successful in achieving this objective. On June 20, 2017 the policy to prohibit the sale and
distribution of flavored tobacco products, including mentholated cigarettes, was introduced to San
Francisco’s full Board of Supervisors, passed upon its second reading on June 27, 2017, and
signed by the Mayor on July 7, 2017. This document is an interim brief evaluation report
documenting the early findings from the adoption of this policy.
For over two decades, the Tobacco Free Project has provided support to organizations and community members doing work that aligns with the three priorities of California’s tobacco control plan: (1) reduce exposure to environmental tobacco smoke; (2) reduce youth access to tobacco; and (3) counter pro-tobacco influences. Work of the TFP and its collaboration with youth, community members, and community coalitions has led to a number of successful tobacco prevention measures such as reducing the density of tobacco retailers in a given area and prohibiting the use of e-cigarettes wherever smoking of any other tobacco product is banned. While previous policies have made strides in reducing tobacco uptake and usage as well as access to tobacco among youth, there is still more work to be done.
Over 80% of teen smokers began with a flavored tobacco product1. Flavored tobacco products in many cases have the same negative and deadly consequences as non-flavored tobacco products. Yet, products, including e-cigarettes and blunt wraps/little cigars, are especially attractive to youth because of their candy-like flavors such as bubblegum, mint, and strawberry. The packaging of these products also imitates that of popular candy such as chocolate cigars wrapped in foil packages and alternative tobacco products in circular cans similar to mint containers. Even the price point of flavored tobacco targets and entices youth with discounts such as two for one dollar.
In 2015, Project E-NUFF, a program of Breathe California (a member of the San Francisco Tobacco Free Coalition) surveyed a sample of 150 high school students in San Francisco and found that of students who indicated that they had tried and/or currently use blunt cigars or e-cigarettes, over half preferred flavored tobacco products. Research has shown that smoking during adolescence is both harmful to brain development and also increases their risk of nicotine addiction2. Supporting a restriction on the sale of flavored and mentholated tobacco products was a natural progression from the previous advocacy and prevention work of the Tobacco Free Project, its coalition, and other supporters of tobacco prevention.
- Evaluation Methods and Design:
Table 1: Summary of Key Evaluation Activities
Evaluation Activity Purpose Sample Instrument Source Analysis Method Timing Key informant Interviews To explore successes, challenges, and lessons learned throughout the policy adoption campaign Purposive sample of 6 Evaluation Consultant Content Analysis Year 1, 1 Wave Media Activity Record To assess media coverage and reaction to the proposed legislation Scan of print, online, and social media Evaluation Consultant Content Analysis Year 1, 1 Wave Key Informant Interviews To explore awareness, attitudes and future behavioral intentions of Black menthol cigarette smokers in San Francisco following the passage of a menthol and flavor ban. Convenient sample of 11 Evaluation Consultant Content Analysis Year 1, 1 Key Informant Interviews To explore changes in awareness, attitudes, and behavior or behavioral intention among Black San Franciscan residents after the implementation of a menthol and flavor tobacco ban. Convenient sample of 11 Evaluation Consultant Content Analysis Year 2, Wave 2
The evaluation design was non-experimental and for “policy adoption only.” Process data were collected and analyzed to document the strategies utilized that either supported or opposed the adoption of the updated TRL ordinance to include the prohibition of flavored and mentholated tobacco products.
Six key informant interviews were conducted in the fall of 2017 with policymakers, TFP staff and Coalition members to explore successful strategies implemented to support policy adoption, the opposition’s response, and lessons learned from the policy adoption process. Media coverage, both print and online media, was also monitored and analyzed to produce a media activity record which highlighted major supporters, opponents, their reach (i.e. followers), and the messages they used to either support or oppose the menthol and flavored tobacco ban. Eleven residents in San Francisco that identified as Black and current menthol smokers were interviewed in the fall of 2018, several months after the Proposition E (menthol and flavor tobacco ban) was upheld via local elections, about their awareness and opinions of the new tobacco legislation as well as their projected behavioral changes as a result of the policy. A year later, from November 2019 – February 2020, three of the original interviewees and eight new informants were interviewed regarding changes in their awareness, opinions and behavior following implementation of the menthol and flavored tobacco ban.
- Implementation and Results:
The San Francisco Tobacco-Free Project achieved the policy objective regarding menthol and flavored tobacco products. Prior to the implementation of the new policy, opponents were able to gather enough signatures to add a referendum to dismiss the ordinance on the June 2018 elections ballot. Following implementation, interviews with African American/Black residents yielded mixed perceptions on the impact of the menthol ban regarding reduction and cessation of menthol products in the Black communities of San Francisco.
Identification and partnership with a policy champion kept the issue relevant among policymakers. Supervisor Malia Cohen represents San Francisco’s 10th District and has expressed passion about improving the health of her constituents. The Tobacco Free Coalition engaged with Supervisor Cohen, provided her with pertinent data about the impact of tobacco on community health, and gave educational testimonies at district hearings. Many key informants noted that Supervisor Cohen’s history of supporting the 2016 Sugar Sweetened Beverage Tax made her a public health leader in the community and that the successful partnership between the Tobacco Free Coalition and Supervisor Cohen led to increased support from other policymakers on the Board of Supervisors.
“Supervisor Cohen is a champion and educator to her colleagues on the board for how industries target vulnerable populations with harmful products and their intention and precision.”
Local data and evidence-based research enabled advocates to gather support early from key stakeholders. TFP funded Breathe California with a Community Action Model (CAM) grant to convene Project E-NUFF, a youth group housed under Breathe California. CAM grants are intended to build the capacity of youth to become change agents in their communities. CAM grantees are provided with training and support to improve the health equity of their communities by engaging in activities (i.e. community based participatory research, organizing media campaigns, and health education) that lead to policy, systems, and environmental changes. Throughout 2015-2016, Project E-NUFF youth collected data about how the tobacco industry targets minority groups as well as information regarding adult and youth knowledge, attitudes, and practices pertaining to flavored tobacco products. They then used their findings to develop an infographic and key messages to convey when talking to city Supervisors. Key informant interviews found that the data provided by both the youth and the Tobacco Free Coalition, in addition to personal testimonies from the youth, resonated strongly among the Board of Supervisors. As a result, six supervisors indicated that they would support the ordinance prior to a press conference informing the public of the proposed legislation.
“The most effective messaging was around how these were starter products for youth.”
“There was a lot of focus on the role played by flavored tobacco in getting youth to start smoking.”
Use of a social justice lens when forming key messages resonated well with the elected officials. Tobacco Free Coalition, Project E-NUFF, as well as other proponents of the proposed ordinance framed their key messages and talking points as a social justice issue in which youth and African Americans are disproportionately impacted by mentholated and other flavored tobacco products (Figure 1). Organizations communicated to policy makers and the public that the majority of current youth smokers began by using flavored products while underage. Several young people gave testimonials at public comment describing peers who had become addicted to smoking by starting with flavored products that mask the harsh taste and addictive nature of tobacco products. Respondents attributed this messaging to facilitating unanimous approval of the ordinance. Advocates centralized racial health inequities in their messaging, communicating to public officials the targeted, predatory relationships between flavored tobacco products (specifically menthol) and African-American communities. Respondents mentioned a particularly impactful testimonial using this framing delivered by the African-American Tobacco Control Leadership Council during public comment.
Figure 1. Examples of flavored tobacco products and paraphernalia that attract youth populations
Use of media as an avenue for disseminating information. Media records analyses found that while the opposition’s social media accounts had more followers (n=70,000) compared to the proponent accounts (N=40,000) over 60% of social media posts were in support of the policy adoption. This depicts a strong social media presence of proponents of tobacco legislation as well as the importance of using a variety of media platforms to reach the public.
Table 2: Social Media Scan
Frequent Social Media Users on Proponent Side Total Number of Followers Frequent Social Media Users on Opposing Side Total Number of Followers Supervisor Cohen 19,710 Not Blowing Smoke 57,286 African American Tobacco Control Leadership Council 724 Let’s Be Real SF 344 Breathe California 2,222 Stefan Didak 6,499 Truth Initiative 16,013 Still Blowing Smoke 3,137 A.J. Brave 2,221 Total Followers (Pro) 38,669 Total Followers
Opposition primarily consisted of small business owners concerned about the policy’s impact on their revenue and vaping interest groups who claimed the policy infringed upon adult’s rights. Small business owners attested that they already experienced reduced revenue because of other recently passed tobacco regulation policies (i.e. tobacco retailer density policy and increased state tobacco taxes). Local organizations representing small businesses, most notably the Arab American Grocer’s Association (AAGA), state the policy as anti-immigrant. Other arguments of the opposition included statements that flavored tobacco products are “anchor products” that brought business to their stores and without them they would lose that business.
“I really hope business owners understand that they don’t have to profit by harming the public. With the Health Department, the city, all the agencies, we really get together and ask how our small businesses can thrive.”
After the policy was voted on and passed through the Board of Supervisors, vaping interest groups began campaigning to repeal the policy. One novel approach the opposition used was by advertising the policy as breaching citizen freedom of choice. The speedy response and novel approach to protesting the new tobacco policy has led to a delay in its implementation until confirmation via public ballot.
“The Tobacco Industry figured out a strategy. Not many people foresaw that, most just assumed a lawsuit. We thought we heard someone say that they had lawyers and this would be fine. No one was prepared for the possibility of a referendum.”
After the vote to uphold the menthol and flavor ban, many Black menthol smokers did not have intentions to quit smoking; however, follow up interviews revealed that some Black smokers had quit, reduced their usage, or were contemplating quitting. Many informants were adamant that their smoking habits were not going to change and that they could, would, travel to neighboring jurisdictions to obtain their preferred tobacco product.
“I have no intentions to quit unless my doctor tells me something drastic is going on with my health and I will die if I don’t stop.” – KII, year 1
When Black residents were interviewed a year later, some (i.e. typically older residents with one or more health issues) interviewees had either quit or were contemplating quitting as they did not feel that the additional costs and travel associated with obtaining menthol cigarettes was worth it and/or they were more cognizant about their health and more motivated to change their behavior.
“[The ban] has caused me to think about quitting starting January 1st because the lengths I’m going through to get them [menthol cigarettes] are ridiculous and it’s [smoking] not even good for me.” – KII, year 2
“If I can’t get them at the corner store, I’m not going out of my way to get them.” – KII, year 2
“Black markets” have emerged as an unintended consequence of the menthol and flavored tobacco ban. During the first phase of interviews, several informants predicted that the sale of menthol products would just go “underground” as long as there was demand for menthol cigarettes in the city. During the second phase of interviews, informants confirmed that the sale of menthol cigarettes had gone “underground,” noting that if you knew the right code word or had an established relationship with merchants, they usually had a secret stash that they would sale to consumers. Informants also noted that some people traveled outside of the city limits, bought in menthol cigarettes in bulk and resold them for a profit.
“You pay $10-$15 and they [retailers] may get you a pack of Newports from the back. It’s creating a black market, a lucrative black market.” – KII, year 2
2021 Update: Since the policy implementation in June 2018, the San Francisco Tobacco-Free Project continued to support flavored product users with tobacco cessation services. Between 2018 and 2021, SFTFP developed and funded two local media campaigns, “SF Quits!” and “Connect to Quit” to encourage flavored product users to change their tobacco use. For Connect to Quit, in 2019, SF TFP contracted with 510 Media, an advertising firm, to develop a local stop-smoking ad campaign designed to reach flavored tobacco users in San Francisco. 510 Media conducted focus groups with populations most affected by flavored tobacco products (African American, Asian/Pacific Islander, LGBTQ, Hispanic/Latino), which led to the development of online, print, and television smoking cessation ads directing traffic to the ConnectToQuit.org website and hotline. Visitors to the website were connected with SF TFP’s cessation services.
Additionally, eight grantees were funded across multiple years, reaching an estimated 150 San Francisco residents. During the Covid-19 pandemic in 2020 and 2021, TFP cessation staff were activated to respond to the pandemic. In response to this change in staffing and safety, we shifted funding completely to CBOs, who were able to provide virtual smoking cessation services during this time period.
The San Francisco Tobacco-Free Project achieved the policy objective of getting legislation passed by the San Francisco Board of Supervisors that updates existing TRL policies to prohibit the sale of menthol and flavored tobacco products. 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. Educating elected officials on the targeting of specific groups through tobacco advertising and providing data on the status of tobacco use in San Francisco played a big role in securing a “policy champion” and garnering early support for the ordinance. However, post policy adoption there was a huge response and pushback from opponents of the ordinance. The pushback resulted in a referendum, Proposition E, added to the June 2018 primary elections in which San Francisco residents voted whether to repeal or uphold the policy. On June 5, 2018, the California primary elections took place and the ordinance prohibiting the sale of menthol and flavored tobacco products was upheld with 68.41% (n=103,624) votes in favor of upholding the City ordinance and 31.59% (n=47,857) votes in opposition of upholding the ordinance. As San Francisco County and City departments as well as tobacco advocates continue work towards improving population health, there is room for targeted interventions to better raise awareness and knowledge about the implications of tobacco use among minority populations.
With each policy success, such as a flavor ban, jurisdictions should be prepared to offer support to smokers who are motivated to quit as a result. San Francisco TFP focused our cessation services funding towards community based organizations that were already experienced in serving the populations most likely to be using flavored tobacco. Even during the Covid-19 pandemic, these organizations were able to continue to provide cessation services virtually. We recommend other jurisdictions working on similar policy initiatives should be prepared to support culturally appropriate cessation services alongside policies that limit tobacco access.