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Gender and tobacco control in San Francisco: A policy brief
2
Contents

Summary of Recommendations 3

Executive Summary 3

More males than females smoke, however women are quitting at a slower rate 4

Tobacco advertisements exploit gender norms 4

Tobaccos consequences are sex-specific 5

San Franciscos current tobacco policies are not enough 5

Developing gender-responsive tobacco control for San Francisco 6

Conclusion 7

References 8






















Gender and tobacco control in San Francisco: A policy brief
3
Summary of Recommendations

1. Implement a new regulatory fee of $0.20 per pack
Make tobacco products less affordable while raising revenue for gender-specific
tobacco control activities.

2. Ban advertising and promotions that target specific genders or gender stereotypes
Tobacco manufacturers and marketers rely on values and lifestyle preferences that
appeal to all genders. San Francisco should ban all forms of advertisements that
employ this technique within county limits.

3. Introduce counter advertising that warns of gender-targeting in tobacco
advertisements
Expose the needs satisfaction and lifestyle preference messages employed by
tobacco advertisers. Promote the idea that independence, individuality, and life-
balance are attainable through San Francisco-specific activities rather than
tobacco use.

4. Implement visible warnings that reflect sex-specific effects of tobacco use
Large, visible warnings should be placed in all point of sale locations. Warnings
should not be general, but should instead relate to the sex-specific consequences
of tobacco use.


Executive Summary

For the better part of the last century, tobacco manufacturers and marketers have
successfully exploited gender norms to increase sales. Therefore, it is essential that tobacco
control policies account for these tactics and respond appropriately to reduce tobacco use. New
studies have shown that generic tobacco control policies may not be equally effective for all
genders and that gendered perspectives should be included to adequately address the needs of all
individuals
1
.
In the last five years, the San Francisco Board of Supervisors has passed ten ordinances
and five resolutions concerning tobacco use, yet none take gender into account
2
. Despite the
great number of tobacco restrictions in San Francisco, the county still has a smoking problem.
Currently, San Francisco has the highest urban area smoking rate in California at 13.5%.
Additionally, the number of female smokers is declining at a slower rate than that of males
3
.
Despite significant decreases in the last decade, these statistics suggests that new approaches are
needed to reduce the countys number of smokers equally among genders.
Historically, the most effective way of reducing substance consumption has been price
increases. However, advertising practices and warning labels are also effective. In order to
better combat San Franciscos high smoking rate, the Board of Supervisors should adopt new
tobacco control policies that respond to gender differences. A new regulatory fee should fund
gender-specific tobacco control activities throughout the county, advertising targeting specific
genders should be banned, counter advertising that exposes gendered needs satisfaction
Gender and tobacco control in San Francisco: A policy brief
4
techniques used by tobacco advertisers should be implemented, and large, visible warnings that
reflect sex-specific effects of tobacco use should be placed in point of sale locations. Adopting
these policies will provide new, effective ways to address tobacco use and improve the health of
men and women throughout the county.


More males than females smoke, however women are
quitting at a slower rate

In California, the number of male
smokers is significantly higher than that of
women, yet the cessation rate is also
higher among males. In 2010, 14.4% of
California males smoked, while 9.4% of
females did so. From 2008 to 2010,
smoking prevalence among males
decreased by 2.1% and smoking
prevalence among women decreased by
1.9%
3
. While these statistics may not
seem significant upon first glance, if the
cessation rates among genders had been
equal, California could have had 57,000
fewer female smokers in the year 2010.
Assuming equal cessation rates in San Francisco, the county could have seen 1,200 more females
quit smoking in these two years, which would have further reduced the current rate of 13.5%.


Tobacco advertisements exploit gender norms

Advertisements have the ability to manipulate people, turning them into unconscious
consumers. Tobacco advertisers have taken advantage of this idea and appealed to typical
gender constructs since the their introduction. Values and lifestyle preferences associated with
glamour, physical build, and social status have permeated tobacco advertisements for most of the
last century and suggest mass pleasure in these areas if consumed.
Virginia Slims was the first brand to target females specifically by promoting a slim body
type and independence with the phrase Youve Come a Long Way, Baby! Just six years after
the brands introduction in 1968, the smoking rate of 12-year-old girls skyrocketed by 110%
4
.
Today, brands such as Marlboro continue to manipulate consumers with gender norms.
While the iconic Marlboro Man ads have disappeared from television, the brand maintains its
rugged, masculine image by advertising all expense paid trips to a Montana ranch in its Rock
the Ranch campaign. Winning consumers are given a Stetson hat, boots, and five packs of their
preferred Marlboro cigarettes
5
.


Gender and tobacco control in San Francisco: A policy brief
5
Tobaccos consequences are sex-specific

Smoking is associated with heart disease, stroke, lung diseases and cancers. While both
sexes fall victim to these diseases, there is increasing evidence that there are sex-specific
differences in their effects. Additionally, more women than men now die from lung cancer
worldwide, despite the higher smoking prevalence among men
6
.
Studies have found that women actually get lung cancers at lower exposures than men
and that estrogen may play a role in the development of the disease. Chronic obstructive
pulmonary disease (COPD) has also been shown to develop faster in women than in men
7,8
.
In regards to reproductive health, the sex-specific effects of smoking are also
distinguished. Vascular damage from smoking has been linked to erectile dysfunction and low
sperm quality has also been linked to smoking. In women, smoking has been associated with
difficulty breastfeeding and low birth weight
8
.
The sex-specific effects of tobacco are not exclusive to smokers. Secondhand smoke
contributes to increased breast cancer risk in women and lung cancer in both men and women
9,6
.


San Franciscos current tobacco policies are not enough

Despite the 15 ordinances and
resolutions passed by San
Franciscos Board of Supervisors in
the last five years, the county
continues to lag behind Californias
overall average and urban area
average smoking rates. California
recently became one of two states to
meet Healthy People 2020s goal of
a 12.0% smoking rate, coming in at 11.9%. The states current urban area smoking rate is
10.9%, a rate considerably lower than San Franciscos 13.5%
10
. So why is the smoking rate in
San Francisco, an area with some of the most stringent tobacco restrictions in the nation, still so
high? It may have to do with the fact that recently passed policies only place restrictions on
point of sale and usage areas. In San Francisco, consumers cannot buy cigarettes at any
pharmacy or county-owned property and retailers cannot devote more than 10% of their space to
tobacco. The county is a national leader in policies that restrict where cigarettes can be bought
and smoked, but has, so far, failed in addressing how people think about cigarettes.
Although studies have shown that addressing psychosocial aspects of tobacco use,
including gender norms, is an effective control method, the Board of Supervisors has not
introduced any policy measures that seek to address the smoking rate through the incorporation
of gender
11
. Gender issues have an impact on all measures of tobacco use and in order to
effectively reduce San Franciscos smoking rate, tobacco control measures should take gender
and its psychosocial constructs into account.

Gender and tobacco control in San Francisco: A policy brief
6
Developing gender-responsive tobacco control for San
Francisco

A comprehensive approach that includes a number of measures is best when targeting
tobacco control. Therefore, the following recommendations utilize gender-responsive techniques
in a number of policy areas. The following recommendations reflect a set of policy measures
that the San Francisco Board of Supervisors should consider introducing:

Implement a new regulatory fee of $0.20 per pack

Implementing a regulatory fee for each pack of cigarettes purchased within county limits
will make products less affordable and raise revenue that can be used to benefit gender-specific
tobacco control activities such as cessation information sessions, support groups, and advertising.
Taxation has long been accepted as one of the most effective substance control policies
available, yet California state law prohibits local governments from adopting new tobacco taxes.
Historically, San Francisco has gotten around this restriction by implementing regulatory fees,
not taxes, which provide a service. In 2009, the Board of Supervisors passed an ordinance that
added a $0.20 abatement fee to each pack of cigarette sold
2
. In order to fund gender-specific
control activities throughout the county, the Board should consider adding an additional fee of
$0.20 per pack. Revenue should fund services led
by the San Francisco Department of Public Health
and local health clinics. Additionally, revenue
will fund counter advertising and visible warnings
as described below.

Ban advertising and promotions that
target specific genders or gender
stereotypes

Tobacco manufacturers and advertisers
have clearly relied on gender roles to sell products
over the last century and, in turn, have created
male and female brands. In order to remove
big tobaccos continuing influence on lifestyle
preferences, the Board of Supervisors should
consider banning all advertising and promotions
that target specific genders or gender stereotypes
within county limits.

Introduce counter advertising that warns of gender-targeting in tobacco
advertisements
Banning gender-focused advertisements is not enough to protect male and female
residents of San Francisco. UCSF researchers have found that anti-tobacco policies may be
more effective if counter advertising is utilized
12
. This should expose the gendered needs
Gender and tobacco control in San Francisco: A policy brief
7
satisfaction and lifestyle preference tactics used by advertisers and promote the psychosocial
elements often seen in tobacco advertisements in place-specific ways. For example,
independence, individuality, and life-balance should be promoted as attainable through San
Francisco-specific activities rather than cigarette use. To effectively show consumers how the
tobacco industry manipulates lifestyle preferences of all genders, San Francisco should introduce
a series of counter advertisements to replace all banned advertisements.

Implement visible warnings that reflect sex-specific effects of tobacco use

Multiple studies have shown that large, visible warnings, which are typically pictoral, are
more effective in reducing smoking prevalence than our current FDA standards. Such warnings
have been shown to significantly influence future smoking uptake and reduce cessation rates
13
.
While the Board of Supervisors does not have the power to place warnings directly on cigarette
packaging, they can implement warnings that display the sex-specific effects of tobacco use in
point of sale locations. San Francisco should introduce a variety of large, pictoral warnings in all
point of sale locations throughout the county. These will effectively incorporate gender into
tobacco warning techniques and inform both genders about the sex-specific effects of individual
tobacco use and secondhand smoke.









Conclusion

Statistics indicate that San Franciscos current tobacco control policies are not as
effective as they could be. In an area with some of the most stringent tobacco regulations, a
smoking rate this high above the state and urban area averages suggests the need for a new
approach. Because gender and its psychosocial aspects have been proven as effective tobacco
control topics, San Francisco should implement a comprehensive policy approach that accounts
for all aspects of gender through fees, advertising practices, and warnings. San Francisco enjoys
being a trendsetter and with the adoption of such policies could become one of the first counties
in the nation to implement gender-responsive tobacco control techniques. The future of tobacco
control depends on successful passage of gender-responsive tobacco control policies. Now is the
time to equalize gender cessation and make San Francisco a leader in urban area smoking rates.


Gender and tobacco control in San Francisco: A policy brief
8
References

1
Canadian Womens Health Network. Why bring a gender and inequity lens to tobacco? The
Canadian Womens Health Network. Winnipeg, Manitoba, Canada.

2
City and County of San Francisco Board of Supervisors. Legislation Records. Available at
http://sfgov.legistar.com/Legislation.aspx. Accessed on July 27, 2013.

3
California Department of Public Health (2010). California Tobacco Survey. Available at
http://www.cdph.ca.gov/programs/tobacco/Documents/Media/2010%20adult%20and%20
youth%20prevalence%20memo_figures%20(7)v2.pdf. Accessed on July 26, 2013.



4
Pierce J, Lee L, Gilpin E. Smoking initiation by adolescent girls, 1944 through 1988: An
association with targeted advertising. Journal of American Medical Association,
271(8):629-30.

5
Yager S (2013). Welcome to Marlboro Country: Philip Morris Stakes a Last Claim in the West.
The Atlantic. Available at
http://www.theatlantic.com/national/archive/2013/03/welcome-to-marlboro-country-
philip-morris-stakes-a-last-claim-in-the-west/274056/. Accessed on August 1, 2013.

6
Payne S (2001). Smoke like a man, die like a man?: a review of the relationship between
gender, sex and lung cancer. Social Science & Medicine, 53:1067-80.

7
Samet JM, Yoon SY et al. (2001). Women and the tobacco epidemic: challenges for the 21st
century. Geneva, World Health Organization.

8
Perkins KA, Donny E, Caggiula A (1991). Sex differences in nicotine effects and self-
administration: human and animal evidence. Nicotine & Tobacco Research, 1:301-315.

9
Band PR et al. (2002).Carcinogenic and endocrine disrupting effects of cigarette smoke and risk
of breast cancer. Lancet, 360(9339):1044-49.

10
California Department of Public Health (2011). California Adult Smoking Rate Reaches
Historic Low. Available at http://www.cdph.ca.gov/Pages/NR11-031.aspx. Accessed on
July 27, 2013.

11
Poland B et al. (2006). The social context of smoking: the next frontier in tobacco control? Tob
Control, 15(1):59-63.

12
Anderson S J, Glantz S A, Ling P M (2005). Emotions for sale: cigarette advertising and
womens psychosocial needs. Tobacco Control, 14:127-135.

13
Myers M (2007). New Studies Show Effectiveness of Large Cigarette Health Warnings Like
Those Required by Legislation Granting FDA Authority Over Tobacco. Available at
http://www.tobaccofreekids.org/press_releases/post/id_0976. Accessed on July 27, 2013.