Smoking and Women: Understanding Social Marketing and Office Strategies Pamela Ling, MD MPH University of California San Francisco Controversies in Women s Health December 6, 2007 Smoking and Women Tobacco Marketing to Women Counter strategies for tailored smoking cessation New product development Secondhand smoke and breast cancer risk Tobacco Industry Documents Contain industry research on women Over 40 million pages http://legacy.library.ucsf. edu/ 1983 Brown & Williamson report Bates # 670513219/3259 1
Women s psychosocial needs Philip Morris, 1994, 2060127742/7919 Psychographics Determine types of smokers based on attitudes, lifestyle, social groups, self descriptors Used in addition to demographics Tailored campaigns 2
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Qualitative research on women Often very rich Sometimes translates directly into advertising campaigns Virginia Slims Research, 1997 7
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. 8
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Key learning: Tobacco companies invest in learning about different types of women Cessation messages can and should be similarly tailored Health not always the prime motivator Light/Mild Fallacy Economics Tobacco Industry Manipulation Secondhand Smoke 10
Potential Counter-strategies Secondhand smoke Light and mild not safer Skepticism about new cigarettes & products Activism against tobacco industry 1926: Blow some my way 2000: Superslim Capri means less smoke for those around you Many smokers are interested in Socially Acceptable Products 11
Appeal to Women RJR, 1985. Bates #506084952/4956 Appeal to Quitters 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 Socially Acceptable Products 1980s Attractive concept, poor taste Favor, Passport Premier Pollay collection, Trinkets & Trash.org 12
Socially Acceptable Products Late 1980s-1990s Line extensions Vantage Excel, Virginia Slims Superslims Pleasant Aroma Chelsea, Horizon Pollay collection Socially Acceptable Products Late 1990s Market to nonsmokers grouping benefits Eclipse, Accord Pollay collection Project CC less sidestream 50% reduction in smoke did not provide meaningful benefit 80% reduction did not provide meaningful benefit 13
BAT, 1984 study on Passport Bates 400169500-9539 Pollay collection Why These Products Failed Attractive concept, but impossible reality 100% sidestream reduction necessary The products taste bad Unwilling to sacrifice much for nonsmokers Low smoke doesn t motivate purchase Exhaled smoke still a problem 14
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 females Female to male 4:1 1997 News article http://www.trinketsandtrash.org/tearsheet.asp?itemnum=300020 15
CalEPA report and Breast Cancer http://www.arb.ca.gov/regact/ets2006/ets2006.htm Mammary Carcinogens in Tobacco Smoke Aromatic hydrocarbons Benzene Benzo[a]pyrene Dibenz[a,h]anthracene Dibenzo[a,e]pyrene Dibenzo[a,h]pyrene Dibenzo[a,I]pyrene Dibenzo[a,l]pyrene Nitrosamines N-nitrosodiethylamine N-Nitrosodi-n-butyl-amine Aliphatic compounds Acrylamide Acrylonitrile 1,3-Butadiene Isoprene Nitromethane Propylene oxide Urethane Vinyl chloride Arylamines and nitrarenes 4-Aminobiphenyl Nitrobenzene Ortho-Toluidine 16
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 100 Relative Risk (95% 10 1 Solid symbols designate studies OEHHA considered most informative 0.1 Premenopausal Postmenopausal Hirayama 84 Sandler 85 Smith 94 Morabia 96 Millikan 98 Zhao 99 Delfino 00 Johnson 00 Wartenburg 00 Kropp 02 Shrubsole 04 Gammon 04 Reynolds 04a Hanaoka 05 Hirayama 84 Sandler 85 Millikan 98 Zhao 99 Delfino 00 Johnson 00 Gammon 02 Reynolds 04a Hanaoka 05 CalEPA Report, 2006 Fig 7.4.4 CalEPA and Surgeon General found similar passive risks California EPA Surgeon General Exposure n Relative Risk (95% CI) N Relative Risk (95% CI) All studies 19 1.25 (1.08-1.44) 21 1.20 (1.08-1.35) Premenopausal/ Women < 50 14 1.68 (1.31-2.15) 11 1.64 (1.25-2.14) Premenopausal with lifetime exposure assessment 5 2.20 (1.69-2.87) 6 1.85 (1.19-2.87) 17
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 10 9 8 7 # Cases/1000 6 People 5 4 3 2 1 0 Exposed Not Exposed Relative Risk: 10 1000 2 1000 = 5 Effect of Exposure Misclassification on Estimates of Relative Risk 10 9 8 7 # Cases/1000 6 People 5 4 3 2 1 0 Relative Risk: 10 1000 True Mis- Classification 2 1000 = 5 8 1000 4 1000 Exposed Not Exposed = 2 18
Comparison of breast cancer risk from active and passive smoke exposure in studies CalEPA considered most informative 10 OR (95% CI) 1 Active Passive 0.1 Smith Morabia Zhao Johnson Kropp Hanaoka Smith Morabia Zhao Johnson Kropp Hanaoka Studies of breast cancer must Separate women based on age (menopause?) Make sure the control group is not contaminated with passive smokers The bottom line Increases in risks for smoking and passive smoking among younger women Exposure between puberty and lactation probably most dangerous Susceptible women probably get the cancers young Little evidence for an effect in older women 19
What to tell women Avoid exposure to SHS Waitresses have the highest occupational exposures At the riskiest time Much less of a problem in California Especially before having children Don t smoke around your female children, especially after puberty Teens 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 20