More direct evidence that SF flavor ban worked

Last year we published a paper on implementation of San Francisco’s ban on the sale of flavored tobacco products (including menthol) that reported that health department inspectors found high compliance with the flavor ban when they visited retailers. Now, Doris Gammon and colleagues have shown that the law virtually eliminated sales of flavored tobacco products in San Francisco (see figure above).

Their paper, “Implementation of a comprehensive flavoured tobacco product sales restriction and retail tobacco sales,” reports an analysis of actual sales of tobacco products in San Francisco and two comparison cities (San Jose and San Diego) that did not have laws using checkout bar code scanner data from a wide range of retailers. They found that in the year after January 1, 2019 when the Heath Department told retailers enforcement would begin, sales of flavored tobacco products dropped by 96%. For comparison, during the same time sales of flavored tobacco products did not change in San Jose and dropped 17% in San Diego.

They also found that sales of unflavored products did not increase, “suggesting that there was not a one-to-one substitution of unflavored products for flavored products.” Indeed, total tobacco sales dropped by 25% in San Francisco, compared to just 8% and 17% in San Jose and San Diego during the same time.

This is a bigger health benefit than we used our analysis of the fiscal impacts of California’s state ban on flavored tobacco sales, which suggests that the health and economic benefits of the state law would be even bigger than we estimated. No wonder Big Tobacco spent millions to delay implementation by forcing a referendum on the law.

As Gammon and her colleagues note, a limitation of this paper is that The Neilsen Company collects does not include small stores that do not use scanner technology or internet sales. Given the high compliance in small stores that the SF Health Department found, however, it is unlikely that this is a problem. The SF law also makes it illegal to deliver flavored products ordered on the internet.

Gammon’s paper shows that in terms of its stated goal of reducing access to flavored products San Francisco’s law was a strong success.

They attribute San Francisco’s success to the Health Department’s implementation program as well as how the law was written:

The reduction in flavoured tobacco sales, including among concept-named flavours, could be attributed to efforts by the SFDPH and affiliated volunteers to educate themselves about ambiguously named products and conduct rigorous retailer education prior to enforcement, and an ordinance provision that states, ‘There shall be a rebuttable presumption that a Tobacco Product […] is a Flavoured Tobacco Product if a Manufacturer or any of the Manufacturer’s agents or employees […] has made a statement or claim directed to consumers or to the public that the Tobacco Product has or produces a Characterizing Flavour, including, but not limited to, text, color, and/or images on the product’s Labeling or Packaging that are used to explicitly or implicitly communicate that the Tobacco Product has a Characterizing Flavour’.

The SF experience provides strong evidence to the FDA that such laws work if properly implemented as it considers what to do about menthol. (The online supplement to our paper on implementation contains details of what the SF Department of Public Health did that can guide the FDA and other communities on implementation.) Even more important, these findings support other communities and states enacting and implementing SF-style flavored tobacco sales bans.

Here is the abstract:

Objective: San Francisco’s comprehensive restriction on flavoured tobacco sales applies to all flavours (including menthol), all products and all retailers (without exemptions). This study evaluates associations of policy implementation with changes in tobacco sales in San Francisco and in two California cities without any sales restriction.

Methods: Using weekly retail sales data (July 2015 through December 2019), we computed sales volume in equivalent units within product categories and the proportion of flavoured tobacco. An interrupted time series analysis estimated within-city changes associated with the policy’s effective and enforcement dates, separately by product category for San Francisco and comparison cities, San Jose and San Diego.

Results: Predicted average weekly flavoured tobacco sales decreased by 96% from before the policy to after enforcement (p<0.05), and to very low levels across all products, including cigars with concept-flavour names (eg, Jazz). Average weekly flavoured tobacco sales did not change in San Jose and decreased by 10% in San Diego (p<0.05). Total tobacco sales decreased by 25% in San Francisco, 8% in San Jose and 17% in San Diego (each, p<0.05).

Conclusions: San Francisco’s comprehensive restriction virtually eliminated flavoured tobacco sales and decreased total tobacco sales in mainstream retailers. Unlike other US flavoured tobacco policy evaluations, there was no evidence of substitution to concept-flavour named products. Results may be attributed to San Francisco Department of Health’s self-education and rigorous retailer education, as well as the law’s rebuttable presumption of a product as flavoured based on manufacturer communication.

The full citation is: Gammon DG, Rogers T, Gaber J, Nonnemaker JM, Feld AL, Henriksen L, Johnson TO, Kelley T, Andersen-Rodgers E. Implementation of a comprehensive flavoured tobacco product sales restriction and retail tobacco sales. Tob Control. 2021 Jun 4:tobaccocontrol-2021-056494. doi: 10.1136/tobaccocontrol-2021-056494. Epub ahead of print. PMID: 34088881. It is available here.