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Smoking and Women:Understanding Social Marketing

and Office StrategiesPamela Ling, MD MPH

University of California San FranciscoControversies in Women’s Health

December 6, 2007

Smoking and Women

Tobacco Marketing to WomenCounter strategies for tailored smoking cessationNew product developmentSecondhand smoke and breast cancer risk

Tobacco Industry Documents

Contain industry research on womenOver 40 million pageshttp://legacy.library.ucsf.edu/

1983 Brown & Williamson report Bates # 670513219/3259

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Women’s psychosocial needs

Philip Morris, 1994, 2060127742/7919

PsychographicsDetermine types of smokers based on attitudes, lifestyle, social groups, self descriptorsUsed in addition to demographicsTailored campaigns

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Qualitative research on women

Often very richSometimes translates directly into advertising campaigns

Virginia Slims Research, 1997

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Example questions What one item in your purse would tell the most about who you really are?What can people learn about you by looking at your friends?Is there something you’ve dreamed of doing for a long time?Do you think others expect too much of you?What are the biggest stressors in women’s lives?

Philip Morris, 1997, Bates # 2080960510/0519

“If our best friend seems to know everything about us, it’s because she does.”

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Key learning:

Tobacco companies invest in learning about different types of womenCessation messages can and should be similarly tailoredHealth not always the prime motivator

Economics

Secondhand Smoke

Tobacco Industry Manipulation

Light/Mild Fallacy

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Potential Counter-strategies

Secondhand smokeLight and mild not saferSkepticism about “new” cigarettes & productsActivism against tobacco industry

2000:

“Superslim Capri means less smoke for those around you”

1926:

“Blow some my way”

Many smokers are interested in Socially Acceptable Products

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Appeal to Women

RJR, 1985. Bates #506084952/4956

“With the recent attrition rate of smokers, attaining “new” smokers is no longer synonymous with capturing young smokers.

We already have Marlboro as the brand of choice for young smokers entering the market.

We do not have a product that meets the needs of the growing population of ex-smokers.”

J. Jones for Philip Morris, 1988, #2050801835/1853

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Appeal to Quitters

Socially Acceptable Products

1980s – Attractive concept, poor taste– Favor, Passport– Premier

Pollay collection, Trinkets & Trash.org

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Late 1980s-1990sLine extensions– Vantage Excel, – Virginia Slims

Superslims

• Pleasant Aroma–Chelsea, Horizon

Pollay collection


Late 1990s –Market to nonsmokersgrouping benefits– Eclipse, Accord

Pollay collection

Project CC – less sidestream

50% reduction in smoke did not provide meaningful benefit80% reduction did not provide meaningful benefit

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BAT, 1984 study on Passport Bates 400169500-9539

Pollay collection

Why These Products Failed

Attractive concept, but impossible reality100% sidestream reduction necessaryThe products taste badUnwilling to sacrifice much for nonsmokersLow smoke doesn’t motivate purchaseExhaled smoke still a problem

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Ongoing efforts

“Eclipse works much like a coffeemaker, which passes hot water through coffee grounds to release the flavor.”

Low smoke product fails in USA but succeeds in Japan

“hygiene fanatics”– Antibacterial pens– Pills erase smell in

stool– Wash hair twice daily

Especially young professional femalesFemale to male 4:1

1997 News articlehttp://www.trinketsandtrash.org/tearsheet.asp?ItemNum=300020

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CalEPA report and Breast Cancer

http://www.arb.ca.gov/regact/ets2006/ets2006.htm

Mammary Carcinogens in Tobacco Smoke

Aromatic hydrocarbonsBenzeneBenzo[a]pyreneDibenz[a,h]anthraceneDibenzo[a,e]pyreneDibenzo[a,h]pyreneDibenzo[a,I]pyreneDibenzo[a,l]pyrene

NitrosaminesN-nitrosodiethylamineN-Nitrosodi-n-butyl-amine

Aliphatic compoundsAcrylamideAcrylonitrile1,3-ButadieneIsopreneNitromethanePropylene oxideUrethaneVinyl chloride

Arylamines andnitrarenes4-AminobiphenylNitrobenzeneOrtho-Toluidine

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Biology

Tobacco smoke contains multiple fat-soluble compounds known to induce mammary tumors in rodents. These carcinogens can be activated into electrophilic intermediates by enzymes active in the human breast epithelial cell.Bind to DNA and form DNA adducts in human breast epithelium.p53 damage in some breast tumors of smokers, but not nonsmokers

SHS Breast Cancer Risk

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100

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Premenopausal Postmenopausal

Solid symbols designate studies OEHHA considered most informative

CalEPA Report, 2006 Fig 7.4.4

CalEPA and Surgeon General found similar passive risks

1.85 (1.19-2.87)62.20 (1.69-2.87)5Premenopausalwith lifetime exposure assessment

1.64 (1.25-2.14)111.68 (1.31-2.15)14Premenopausal/ Women < 50

1.20 (1.08-1.35)211.25 (1.08-1.44)19All studies

Relative Risk (95% CI)

NRelative Risk (95% CI)

nExposure

Surgeon GeneralCalifornia EPA

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Surgeon General’s Basic Premise

“There is substantial evidence that active smoking is not associated with an increased risk of breast cancer in studies that compare active smokers with persons who have never smoked.”

Surgeon General’s Report 2006 (p 446)

Effect of Exposure Misclassification on Estimates of Relative Risk

0123456789

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# Cases/1000 People Exposed

Not Exposed

Relative Risk:1000

21000

10

= 5

Effect of Exposure Misclassification on Estimates of Relative Risk

0123456789

10

# Cases/1000 People

True Mis-

Classification

ExposedNot Exposed

Relative Risk:

10002

100010

= 58

1 0 0 04

1 0 0 0

= 2

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Comparison of breast cancer risk from active and passive smoke exposure in studies CalEPA

considered most informative

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1

10

Smith

Mor

abia

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Han

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Smith

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OR

(95%

CI)

Active Passive

Studies of breast cancer must …

Separate women based on age (menopause?)Make sure the control group is not “contaminated” with passive smokers

The bottom lineIncreases in risks for smoking and passive smoking among younger womenExposure between puberty and lactation probably most dangerousSusceptible women probably get the cancers youngLittle evidence for an effect in older women

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What to tell womenAvoid exposure to SHSWaitresses have the highest occupational exposures–At the riskiest time–Much less of a problem in CaliforniaEspecially before having childrenDon’t smoke around your female children, especially after pubertyTeens and young women should not date smokers

What to do in 3 minutes

Raise tobacco on the agenda Ask, advise…refer–1-800-NO-BUTTS

Caution against Secondhand smoke exposure–Message for nonsmokers and smokers