Density and proximity of tobacco outlets to homes and schools: relations with youth cigarette smoking

Impact of regulatory tightening of the Hungarian tobacco retail market on availability, access and cigarette smoking prevalence of adolescents

INTRODUCTION

Policies that reduce tobacco retail density to decrease tobacco use among the youth are critical for the tobacco endgame. This paper reviews a Hungarian tobacco regulatory measure, which, since 2013, has confined the sale of tobacco products exclusively to so-called National Tobacco Shops, summarises the changes in the national tobacco retail marketplace and reports on analyses of the impact of this intervention on illegal sales to minors and adolescent smoking behaviour.

METHODS

We reviewed the available national statistical data on the structure and dynamics of the tobacco retail market. Changes in lifetime and current (past 30 days) use of cigarettes among Hungarian adolescents aged 13-17 years were assessed using data from international youth surveys on health behaviours collected in 2010-2020.

RESULTS

Since the start of policy implementation, the density of tobacco shops in Hungary decreased by 85%, from 4.1 to 0.6 per 1000 persons. The prevalence of lifetime and current cigarette smoking among adolescents declined by 13-24 percentage points (pp) and by 4.8-15 pp, respectively. The rate of illegal sales of tobacco products to minors decreased by 27.6 pp, although the prevalence of compensatory access strategies, especially asking others to buy cigarettes for minors, increased.

CONCLUSIONS

After a significant decrease in the nationwide availability of licensed tobacco retailers, Hungary experienced short-term reductions in youth smoking prevalence. However, the sporadic implementation of complementary, evidence-based tobacco control strategies might limit further declines in youth smoking initiation and tobacco product use.

A longitudinal analysis of the impact of the local tobacco retail availability and neighbourhood deprivation on male smoking behaviours in Shanghai, China

Some evidence from Western high-income countries suggests local tobacco retail availability and neighbourhood deprivation may influence smoking behaviours. However, this assertion has not been considered in China, where 44% of males continue to smoke. Data were analysed from Chinese males (n = 2054) who participated in Waves 3-5 (2009-2015) of the International Tobacco Control (ITC) China Survey by linking information on tobacco retail availability (estimated through population weighted Kernel Density of tobacco retailers in 2019) and neighbourhood deprivation (calculated as a composite score derived from the 2010 Chinese census) across Shanghai. Generalised Estimating Equation models were fitted to examine the impacts of local tobacco availability and neighbourhood deprivation on smoking behaviours (current smoking versus current non-smoking, quitting versus current smoking, longer durations of smoking abstinence versus current smoking) using the longitudinal data. Examining the impacts separately, participants living in neighbourhoods with greater availability and higher levels of deprivation were less likely to maintain longer durations of smoking abstinence in both unadjusted and adjusted models. Neighbourhood deprivation, but not availability, was found to be associated with higher odds of being a current smoker. Examining the impacts jointly, neighbourhood deprivation was still positively associated with current smoking and negatively associated with longer durations of smoking abstinence, but the negative association between availability and longer durations of smoking abstinence disappeared. The findings offer some evidence that greater tobacco retail availability and deprivation are obstacles on prolonged smoking cessation among males in Shanghai, China. Policymakers should consider small-area level place-based restrictions in China, such as reducing the availability of tobacco, as part of a comprehensive tobacco control strategy aimed at addressing the high prevalence of smoking.

Proximity to Legal Cannabis Stores in Canada and Use of Cannabis Sources in the First Three Years of Legalization, 2019-2021

OBJECTIVE

The accessibility of legal cannabis in Canada may influence how consumers source their cannabis. The aims of this study were to examine (a) the distance between respondents' homes and legal retail stores, (b) the cannabis sources used in the past 12 months, and (c) the association between cannabis sources used and distance to legal retail stores.

METHOD

Data were analyzed from Canadian respondents participating in the International Cannabis Policy Study from 2019 to 2021. Respondents were 15,311 past-12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models examined cannabis sources used and their association with the Euclidean distance to the nearest legal store, province of residence, and year (n = 12,928).

RESULTS

Respondents lived closer to a legal retail store in 2021 (1.5 km) versus 2019 (6.8 km) as the number of retail stores increased. Respondents in 2020 and 2021 had higher odds of obtaining cannabis from legal sources (e.g., legal stores: 47.9% and 60.0% vs. 38.6%, respectively, adjusted odds ratio [AOR] range: 1.41-2.42) and lower odds of obtaining cannabis from illegal sources versus 2019 (e.g., dealers: 22.6% and 19.9% vs. 29.1%, respectively, AOR range: 0.65-0.54). Respondents who lived closest to legal stores had higher odds of sourcing from legal stores and lower odds of sourcing from legal websites or growing their own cannabis.

CONCLUSIONS

Legal cannabis stores are increasingly accessible to people living in Canada 3 years after legalization. Household proximity to a legal cannabis store was associated with sourcing cannabis from legal retail stores, but only among those who live very close (<3 km). Findings suggest that proximity to legal cannabis stores may aid uptake of the legal market, yet there may be diminishing returns after a certain point.

A statewide study of disparities in local policies and tobacco, vape, and cannabis retail environments

The current study: (1) assesses sociodemographic disparities in local policies related to tobacco and cannabis retail, and (2) examines the cross-sectional association between policy strength and retailer densities of tobacco, e-cigarette (vape), and cannabis retailers within California cities and county unincorporated areas (N = 539). We combined (a) American Community Survey data (2019 5-year estimates), (b) 2018 tobacco, vape, and cannabis retailer locations from a commercial data provider, (c) 2017 tobacco and vape retail environment policy data from American Lung Association, and (d) 2018 cannabis policy data from California Cannabis Local Laws Database. Conditional autoregressive models examined policy strength associations with sociodemographic composition and retailer density in California jurisdictions. Jurisdictions with larger percentages of Black and foreign-born residents had stronger tobacco and vape policies. For cannabis policy, only income had a small, significant positive association with policy strength. Contrary to hypothesis, tobacco/vape policies were not significantly associated with retailer density, but cannabis policy strength was associated with lower cannabis retailer density (relative rate = 0.58, 95% Uncertainty Interval 0.47-0.70)-this effect was completely driven by storefront bans. Thus, storefront cannabis bans were the only policy studied that was associated with lower cannabis retailer density. Further research is needed to understand policies and disparities in retail environments for tobacco, vape, and cannabis, including data on the prospective association between policy implementation and subsequent retailer density, and the role of enforcement.

Changes in Retail Tobacco Product Availability Following a Chicago City Ordinance Restricting Sales of Menthol and Other Flavored Tobacco Products Near Schools

BACKGROUND

In April 2016, the City of Chicago implemented an ordinance restricting the sale of all flavored (including menthol) tobacco products (FTPs), including electronic cigarettes, at retailers located within 500 feet of any public, private, or alternative elementary, middle ("primary"), or high ("secondary") school. We examined changes in retail availability of FTPs from before to after policy implementation among policy-affected retailers compared with retailers not subject to the policy.

METHOD

Observational data were collected in June to September 2015 (Wave 1; pre-policy) and November to December 2016 (Wave 2; post-policy) from a panel of 194 randomly selected policy-area stores (located within 500 feet of a school), and a panel of 199 randomly selected comparison-area stores (located more than 500 feet from a school). Using generalized estimation equation regression, we assessed differences in FTP availability changes across study areas.

RESULTS

We observed a statistically significant policy effect on FTP availability (Area × Wave interaction, p < .05); however, more than half of policy-area retailers continued to display at least one FTP after policy implementation (87.11% at Wave 1, 57.73% at Wave 2, p < .05). Similar reductions were seen for the availability of flavored cigarillos/little cigars and menthol cigarettes, while policy effects varied across store types.

DISCUSSION

FTP availability reductions appear to be associated with policy implementation, but FTPs remained readily available at retailers subject to the policy. This study contributes to the evidence base indicating that policies with exclusions or exemptions for certain flavors, products, store types, or retailer locations have a limited effect on retail availability of FTPs.

Recreational Cannabis Legalization and Proximity to Cannabis Retailers as Risk Factors for Adolescents' Cannabis Use

Within-person studies are lacking regarding how recreational cannabis legalization (RCL) and the numbers of neighborhood cannabis retailers relate to adolescents' cannabis use. Study participants were 146 offspring (55% girls; 77% White non-Latinx) of men recruited in childhood from neighborhoods with high delinquency rates. Youth were assessed for past-year cannabis and alcohol use one or more times from ages 13 to 20 years (age M[SD] = 16.4 [2.1] years across 422 observations), while they were living in Oregon or Washington from 2005 to 2019 (where cannabis retail stores opened to adults ages 21 years and older in 2014 and 2015, respectively). We calculated distances between addresses of licensed cannabis retailers and participants' homes. Multilevel models that accounted for effects of age on cannabis use did not support that the number of retail stores within 2-, 5-, 10-, or 20-mile radii of adolescents' homes increased likelihood of past-year cannabis use at the within- or between-subjects levels. Likewise, primary models did not support a greater likelihood of cannabis use among youth whose adolescence coincided more fully with the post-RCL period. A secondary model suggested that after adjusting for adolescents' concurrent alcohol use as a marker of general substance use risk, RCL was associated with cannabis use (between-subjects B [95% CI] = .35 [.05-.66], p = .024). Further research is needed with larger prospective samples, at-risk subgroups, and as cannabis markets mature.

Tobacco retail availability and cigarette and e-cigarette use among youth and adults: a scoping review

OBJECTIVE

States and localities are formulating strategies to reduce the widespread retail availability of tobacco products. Evidence of associations between retailer density/proximity and tobacco use outcomes can help inform those strategies. We conducted a scoping review on tobacco retail availability and cigarette/e-cigarette use in adults and youth, and considered variations in spatial units, measures of retailer exposure and outcomes across studies.

METHODS

A systematic search for studies examining the association between retailer density/proximity and youth and adult cigarette/e-cigarette use was conducted across MEDLINE (PubMed), Web of Science and Google Scholar through 27 August 2020 with no restrictions.

RESULTS

Thirty-five studies were included in our qualitative synthesis. While there were differences in neighbourhood definitions (eg, egocentric vs administrative), there is evidence for a positive association between higher retailer density in egocentric neighbourhoods around homes and current smoking in adults and adolescents. Administrative unit measures in some studies showed associations with adult current smoking, and adolescent lifetime and current smoking. Studies on tobacco outlet proximity to homes obtained mixed results. Density/proximity of tobacco outlets around schools showed no or inverse association with adolescent smoking, but suggests higher susceptibility to smoking. Evidence of an association between e-cigarette retail availability and e-cigarette use is limited due to a small number of studies.

CONCLUSION

The current literature provides limited empirical evidence of the association between tobacco retailer availability and smoking or e-cigarette use. More research with uniform measures of environmental exposure to tobacco retailers is needed to allow for greater comparability between studies.

Variations in Tobacco Retailer Type Across Community Characteristics: Place Matters

Introduction

The density of tobacco retailers varies by community characteristics such as poverty levels or racial and ethnic composition. However, few studies have investigated how specific types of tobacco retailers vary by community characteristics. Our objective was to assess how the types of tobacco retailers in Ohio varied by the characteristics of the communities in which they were located.

Results

For all US Census tracts, convenience stores were the most common type of retailer selling tobacco. Yet, the prevalence of convenience stores was higher in high-poverty urban tracts than in low-poverty urban tracts. Discount stores were the second-most common type of tobacco retailer and were most prevalent in rural tracts and high-racial and ethnic minority urban tracts. Grocery stores, pharmacies, and vape or hookah shops typically had the highest prevalence in more advantaged tracts.

Conclusion

Our findings demonstrate that the distribution of specific retailer types varies by community characteristics. The distribution of these retailer types has implications for product availability and price, which may subsequently affect tobacco use and cessation. To create equitable outcomes, policies should focus on retailers such as convenience and discount stores, which are heavily located in communities experiencing tobacco-related health disparities.

Spatial Disparities: The Role of Nativity in Neighborhood Exposure to Alcohol and Tobacco Retailers

Studies of retail environment, one of the social determinants of health, document racial/ethnic disparities in exposure to alcohol and tobacco (A and T) retailers, but have largely overlooked nativity. We examined associations between A and T retailer density and rates of foreign-born Latinx and foreign-born Asian residents in California census tracts (N = 7888), using spatial regressions and controlling for population and ecological confounders (e.g., population density, zoning, residential instability, urbanicity). Socio-demographic data came from the American Community Survey (2012-2016); census tract density of A and T retailers came from geocoded addresses from state license data for off-sale alcohol distributors and purchased data on tobacco retailers from a commercial provider. Models predicting A and T tract retailer density showed that the rate of foreign-born Latinx residents was associated with higher tobacco retailer density but lower alcohol retailer density, and demonstrate no significant associations between rate of foreign-born Asian residents tobacco and alcohol retail density. Retail environment could contribute to observed declines in immigrant health over time in the US and across generations.

Retail cannabis environment and adolescent use: The role of advertising and retailers near home and school

Youth cannabis use is influenced by overlapping environmental contexts. We examined the associations between proximity to cannabis retailers and seeing cannabis advertisements and cannabis use behaviors in Oregon, a state with adult cannabis legalization. We used 2017 anonymous survey data from 24,154 Oregon 8th and 11th grade students. After adjustments for student and school district characteristics, advertising for 8th graders and presence of a retailer within a mile from school for 11th graders were associated with cannabis use and perceived harm. Additional policy efforts may further reduce youth exposure to cannabis.

Density of Cigarette Retailers Near Facilities for Children and Adolescents in Urban and Rural Areas in Indonesia: A Geospatial Analysis

The lack of regulation banning cigarette retailers near facilities for children and adolescents has made cigarettes easily accessible to youth in Indonesia. This study aimed to investigate the density of cigarette retailer near children and adolescent facilities in urban and rural areas in the country. We mapped all cigarette retailers and facilities for children and adolescents in Surabaya city (urban) and Banyuwangi district (rural) in East Java province. All types of facilities for children and adolescents and retailers visible from the streets in the study areas were mapped. We conducted geospatial analysis of the density of retailers to the facilities for children and adolescents in QGIS 2.8 and STATA 14. We found that the density of cigarette retailers was 81% higher in the areas within 100 m from the facilities for children and adolescents, compared with the areas within 100 to 250 m from facilities. We also found that the density of cigarette retailers within 100 m from facilities was 2.35 times higher in the rural setting, compared with the urban setting. Controlling cigarette retailers through zoning and licensing is urgently needed in Indonesia.

Associations of cannabis retail outlet availability and neighborhood disadvantage with cannabis use and related risk factors among young adults in Washington State

BACKGROUND

This study examined associations of local cannabis retail outlet availability and neighborhood disadvantage with cannabis use and related risk factors among young adults.

METHODS

Data were from annual cross-sectional surveys administered from 2015 to 2019 to individuals ages 18-25 residing in Washington State (N = 10,009). As outcomes, this study assessed self-reported cannabis use at different margins/frequencies (any past year, at least monthly, at least weekly, at least daily) and perceived ease of access to cannabis and acceptability of cannabis use in the community. Cannabis retail outlet availability was defined as the presence of at least one retail outlet within a 1-kilometer road network buffer of one's residence. Sensitivity analyses explored four other spatial metrics to define outlet availability (any outlet within 0.5-km, 2-km, and the census tract; and census tract density per 1000 residents). Census tract level disadvantage was a composite of five US census variables.

RESULTS

Adjusting for individual- and area-level covariates, living within 1-kilometer of at least one cannabis retail outlet was statistically significantly associated with any past year and at least monthly cannabis use as well as high perceived access to cannabis. Results using a 2-km buffer and census tract-level metrics for retail outlet availability showed similar findings. Neighborhood disadvantage was statistically significantly associated with at least weekly and at least daily cannabis use and with greater perceived acceptability of cannabis use.

CONCLUSIONS

Results may have implications for regulatory and prevention strategies to reduce the population burden of cannabis use and related harms.

Effect of tobacco outlet density on quit attempts in Korea: a multi-level analysis of the 2015 Korean Community Health Survey

OBJECTIVES

This study aimed to examine whether the regional density of tobacco outlets in Korea was associated with the likelihood of attempting to quit among smokers

METHODS

This study was designed as a secondary data analysis of a cross-sectional study. Data from the 2015 Korean Community Health Survey and tobacco outlet registrations in 17 metropolitan cities and provinces with 254 communities in Korea were used for the analysis. In total, 41,013 current smokers (≥19 years of age) were included. Multi-level logistic regression analysis was conducted to investigate regional differences associated with smokers’ attempts to quit and to evaluate the effects of individual and regional characteristics on quit attempts.

RESULTS

Higher tobacco outlet density was associated with lower odds of attempting to quit. Smokers who resided in districts with the highest tobacco outlet density were 18% less likely to attempt quitting (odds ratio, 0.82; 95% confidence interval, 0.70 to 0.98) than smokers who resided in the regions with the lowest tobacco outlet density (intraclass correlation coefficient, 0.030).

CONCLUSIONS

This study showed that quit attempts were related to community-level factors, such as tobacco outlet density, as well as other individual factors. These findings support the implementation of national policies restricting the number of tobacco outlets within communities or zones and limiting tobacco marketing in tobacco outlets.

Tobacco Retail Environment and Smoking: A Systematic Review of Geographic Exposure Measures and Implications for Future Studies

INTRODUCTION

To review the geographic exposure measures used to characterize the tobacco environment in terms of density of tobacco outlets and proximity to tobacco outlets, and its association with smoking-related outcomes.

METHODS

We used PubMed and Google Scholar to find articles published until December 2019. The search was restricted to studies that (1) measured the density of and/or proximity to tobacco outlets and (2) included associations with smoking outcomes. The extraction was coordinated by several observers. We gathered data on the place of exposure, methodological approaches, and smoking outcomes.

RESULTS

Forty articles were eligible out of 3002 screened papers. Different density and proximity measures were described. 47.4% density calculations were based on simple counts (number of outlets within an area). Kernel density estimations and other measures weighted by the size of the area (outlets per square kilometer), population, and road length were identified. 81.3% of the articles which assessed proximity to tobacco outlets used length distances estimated through the street network. Higher density values were mostly associated with higher smoking prevalence (76.2%), greater tobacco use and smoking initiation (64.3%), and lower cessation outcomes (84.6%). Proximity measures were not associated with any smoking outcome except with cessation (62.5%).

CONCLUSION

Associations between the density of tobacco outlets and smoking outcomes were found regardless of the exposure measure applied. Further research is warranted to better understand how proximity to tobacco outlets may influence the smoking outcomes. This systematic review discusses methodological gaps in the literature and provides insights for future studies exploring the tobacco environment.

IMPLICATIONS

Our findings pose some methodological lessons to improve the exposure measures on the tobacco outlet environment. Solving these methodological gaps is crucial to understand the influence of the tobacco environment on the smoking outcomes. Activity spaces should be considered in further analyses because individuals are exposed to tobacco beyond their residence or school neighborhood. Further studies in this research area demand density estimations weighted by the size of the area, population, or road length, or measured using Kernel density estimations. Proximity calculations should be measured through the street network and should consider travel times apart from the length distance.

Tobacco retailer density and smoking behavior in a rural Australian jurisdiction without a tobacco retailer licensing system

INTRODUCTION

An emerging body of research has developed around tobacco retailer density and its contribution to smoking behavior. This cross-sectional study aimed to determine the association between tobacco retailer density and smoking behavior in a rural Australian jurisdiction without a tobacco retailer licensing system in place.

METHODS

A local government database (updated 2018) of listed tobacco retailers (n=93) was accessed and potential unlisted tobacco retailers (n=230) were added using online searches. All retailers (n=323) were visited in 2019 and GPS coordinates of retailers that sold tobacco (n=125) were assigned to suburbs in ArcMap. A community survey conducted in the Local Government Area provided smoking and sociodemographic data amongst adult respondents (n=8981). Associations between tobacco retailer density (calculated as the number of retailers per km² based on respondents’ suburb of residence) and daily, occasional and experimental smoking were assessed using multilevel logistic regression analysis. Separate models with and without covariates were undertaken.

RESULTS

Without adjusting for possible confounders, living in suburbs with greater retailer density did not increase the odds of daily smoking (OR=1.01; 95% CI: 0.92–1.12), occasional smoking (OR=1.05; 95% CI: 0.94–1.18), or experimental smoking (OR=0.98; 95% 0.92– 1.05). However, after adjustment, living in suburbs with greater retailer density increased the odds of occasional smoking behavior (AOR=1.37; 95% CI: 1.10–1.71) but not daily or experimental smoking.

CONCLUSIONS

This study found a significant positive association between tobacco retailer density and the likelihood of occasional smoking in a rural Australian jurisdiction without a tobacco retailer licensing system in place. The findings strengthen calls for the introduction of a comprehensive, positive tobacco retailer licensing system to provide a framework for improving compliance with legislation and to reduce the overall availability of tobacco products in the community.

A geospatial analysis of age disparities in resolute localities of tobacco and vaping-specific storefronts in California

INTRODUCTION

Concomitant with the popularization of vaping, vape shops have dramatically proliferated over the past years. This study assesses whether vape storefronts in California are significantly associated with density of different age groups, and whether this differs between tobacco storefronts or non-specific tobacco retailers.

METHODS

Addresses for licensed tobacco retailers were obtained from the California Department of Tax and Fee Administration. Business names and addresses were used to obtain store categories cross-referenced from Yelp. Using a cross-sectional ecological design, stores categorized as ‘Vape Shop’ or ‘Tobacco Shop’ were geolocated and compared with age-related variables from the American Community Survey. Regression was conducted in R to determine relationships between age group concentration, in ventiles, and proportion of tracts with tobacco-specific or vape-specific stores. Geospatial visualization was conducted using ArcGIS.

RESULTS

We found 848 vape shops, 820 tobacco shops, 419 categorized as both, and 20320 retailers with neither category. Overall, 1800 tobacco and/or vape shops were categorized in 1557 of California’s 23194 census tracts. A positive linear association was found between ventiles of two age categories, 20–24 and 25–34 years, and proportion of tracts with vape-specific or tobacco-specific shops separately.

CONCLUSIONS

Positive associations were found for ages 20–34 years but not for other ages, suggesting vape shops are strategically located in areas populated by young adults. Location-based targeting increases access, thereby increasing proportion of tobacco users, and could be a critical factor in e-cigarette uptake and use. Further study to identify additional age-related demographic characteristics among clientele of tobacco storefronts is warranted.

The relationship between density of drug outlets, crime hot spots and family factors on the consumption of drugs and delinquent behaviour of male adolescent Mexican students

This study examined the relationship between community risk factors (drug outlets density and crime hot spots) and family factors on the risk behaviours (drugs consumption and delinquent behaviour) of male adolescent Mexican students. Results were obtained based on data bank analysis and direct collection of information regarding family factors and risk behaviours of adolescents attending school. Spatial and statistical analysis was performed. The final sample was composed of 1450 male adolescents, from 11 secondary and high schools located in marginal and violent areas of Mexico. Spatial analysis revealed that when considering only the prevalence of the risk behaviours of the adolescents, the area of highest risk was the northwestern area of the city. However, after performing conjunct analysis of all evaluated variables using density point risk (aside from confirming that the northwestern area is still the one with the greatest risk), results indicated that the southern area has a high-density point risk. All densities of the variables showed a statistically significant positive association (p < 0.05). However, the results of the structural equation model indicated than only the family factors influenced the risk behaviours of adolescents (p < 0.05). The spatial distribution of the risk behaviours in male adolescent students and community risk variables surrounding the area where schools are located allows for the description of patterns and hotspot detection that facilitate the prioritization of where interventions must be directed. Besides, the interventions should target family factors.

The Association Between Tobacco Outlet Density and Smoking Among Young People: A Systematic Methodological Review

Aim

Evidence on the association between tobacco outlet density and proximity and smoking behavior among youth is inconsistent, which may be due to methodological problems in some studies. We assessed the association of outlet density or proximity with smoking behavior among young people while taking into account the methodological quality of studies.

Methods

MEDLINE, EMBASE, and Google Scholar were systematically searched for studies on the relationship between outlet density or proximity and smoking behavior among 12- to 25-year-olds, published between 1997 and 2017. Methodological quality of the included studies was evaluated independently by two reviewers.

Results

Twenty studies were included in the review. The quality assessment identified five primary sources of potential bias: overadjustment for mediators (problems identified in 14 studies), underadjustment for confounders (six studies), poor statistical model fit (four studies), selection bias (three studies), and misclassification of exposure measurements (eight studies). Four studies were of high methodological quality. In studies with relatively high quality, 10 associations were reported, of which seven were nonsignificant, two positive, and one negative. Similarly, the complete body of evidence demonstrated mostly nonsignificant associations, but a larger proportion of positive associations than negative.

Conclusion

Although there is some support for a positive direction, current literature does not provide consistent evidence for a positive association between outlet density and smoking among youth. This is not necessarily due to bias in specific studies, but more to fundamental challenges in study design and exposure measurements. These issues need to be addressed in future studies using more rigorous methods.

Implications

Our findings suggest that, although there is some evidence for a positive association, current scientific literature does not provide consistent support to claim an effect of tobacco outlet density or proximity on youth smoking. This underlines the need for more research with improved methodology. There is a need for quasiexperimental studies, in which the outlet density changes substantially, studies measuring the actual exposure of youth to tobacco outlets, and qualitative research on the mechanisms underlying any association.

[The Effect of Neighborhood Characteristics and Friends' Smoking Status on the Habitual Smoking Onset in Adolescents]

PURPOSE

The aim of this study was threefold, to longitudinally examine the risk of habitual smoking onset in adolescents, to delineate the effects of neighborhood characteristics and friends' smoking status on the habitual smoking onset, and to investigate whether the association between friends' smoking status and habitual smoking onset was moderated by neighborhood characteristics.

METHODS

This study conducted multilevel discrete-time survival analysis, using cohort data from the 3rd to 6th waves of the Korean Child and Youth Panel Survey, which excluded habitual smokers, matched with 2010 census data on respondents' residence.

RESULTS

Habitual smoking onset risk increased from the 8th to the 11th grade, and then slightly decreased from the 11th to the 12th grade. Friends' smoking status (B = 0.60, p < .001), smoking rate (B = 0.06, p = .038), and the number of tobacco outlets in the respondents' neighborhood (B = 0.51, p = .003) were positively associated with habitual smoking onset risk. Furthermore, the association between friends' smoking status and habitual smoking onset risk was moderated by the number of tobacco outlets in the neighborhood. Specifically, the association was stronger in neighborhoods with more tobacco outlets (B = 0.58, p = .048).

CONCLUSION

Friends' smoking status and living in neighborhoods that are more susceptible to smoking increase the risk of habitual smoking. The number of tobacco outlets in the neighborhood enhances the peer effect of adolescent's smoking behavior. Therefore, policies or interventions designed to reduce youth's tobacco use should focus on not only on reducing peer smoking, but also restricting smoking by adults and the number of neighborhood tobacco outlets.

The legacy of redlining: Associations between historical neighborhood mapping and contemporary tobacco retailer density in Ohio

In the 1930s United States, urban neighborhoods were graded on their desirability for investment (often based on race), a process known as "redlining." This study examined how historical redlining relates to current disparities in an important health determinant: tobacco retailer density. Analyses were conducted for thirteen Ohio cities using negative binomial models that accounted for retailer spatial dependence and controlled for present-day sociodemographic characteristics. Findings indicated that as grades increased from "Best" to "Still Desirable" to "Definitely Declining" and "Hazardous," retailer density increased monotonically. These results highlight the persisting impacts of redlining and how disparities, once intentionally created, can be perpetuated over time.

Association between density and proximity of tobacco retail outlets with smoking: A systematic review of youth studies

BACKGROUND

Reducing the retail availability of tobacco has been proposed as a component of tobacco endgame, yet it is not known whether retail availability has a direct impact on smoking behaviours. A narrative review and a meta-analysis have been undertaken to examine the density and proximity of tobacco retail outlets, but were limited in scope, exposure and outcome variables. The aim of this current study was to undertake a systematic review of the international literature on the density and proximity of tobacco retail outlets to homes, schools and communities and their association with smoking behaviours among youth.

METHODS

We reviewed and critically appraised the evidence documenting the association between density or proximity of tobacco retail outlets and smoking behaviours among school-age youth (18 and under), between 1 January 1990 and 21 October 2019. We reviewed original quantitative research that examined the associations of tobacco retail outlet density and proximity with individual smoking status or population-level smoking prevalence; initiation of smoking; frequency of tobacco use; sales to minors; purchasing by minors; susceptibility to smoking among non-smokers; perceived prevalence of smoking, and quitting behaviours.

FINDINGS

Thirty-five peer-reviewed papers met the inclusion criteria. This review provided evidence of a relationship between density of tobacco retail outlets and smoking behaviours, particularly for the density near youths' home. A study using activity spaces also found a significant positive association between exposure to tobacco retail outlets and daily tobacco use. The review did not provide evidence of an association between the proximity of tobacco retail outlets to homes or schools and smoking behaviours among youth.

CONCLUSIONS

The existing evidence supports a positive association between tobacco retail outlet density and smoking behaviours among youth, particularly for the density near youths' home. This review provides evidence for the development and implementation of policies to reduce the density of tobacco retail outlets to reduce smoking prevalence among youth.

Youth daily exposure to tobacco outlets and cigarette smoking behaviors: does exposure within activity space matter?

AIMS

To examine whether daily exposure to tobacco outlets within activity spaces is associated with cigarette smoking and with the number of cigarettes smoked by youth that day.

DESIGN

The study used geographic ecological momentary assessment (GEMA) data that combined daily surveys with ecological momentary assessment of global positioning systems (GPS) using geographic information systems (GIS) to allow for real-time data collection of participants' environments and behaviors.

SETTING

Eight mid-sized California (USA) city areas.

PARTICIPANTS

The analytical sample included 1065 days, which were clustered within 100 smoker and non-smoker participants (aged 16-20 years, 60% female).

MEASUREMENTS

Any cigarette smoking and number of cigarettes smoked on a given day, the number of tobacco outlets within 100 m of activity space polylines each day, the number of minutes participants spent within 100 m of tobacco outlets each day and demographic characteristics (age, sex, race/ethnicity and perceived socio-economic status).

FINDINGS

Controlling for demographic characteristics, the findings of multi-level mixed effects logistic models were inconclusive, whether or not the number of tobacco outlets within 100 m of youths' activity space polylines or the number of minutes spent within 100 m of tobacco outlets were associated with whether the participant smoked cigarettes on a given day [odds ratio (OR) = 1.05, P = 0.24; OR = 0.99, P = 0.81, respectively]. However, in multi-level zero-inflated negative binomial models, the risk of smoking an additional cigarette on a given day increased with each additional tobacco outlet [incidence rate ratio (IRR) = 1.04, P < 0.05] and each additional minute spent within 100 m of tobacco outlets (IRR = 1.01, P < 0.001) each day.

CONCLUSIONS

Among young people in urban California, differences in day-to-day exposure to tobacco outlets within activity spaces does not seem to be significantly associated with whether a person smokes a cigarette on a given day, but higher exposure to tobacco outlets appears to be positively associated with the number of cigarettes smoked on that day.

Sociodemographic Disparities in the Tobacco Retail Environment in Washington, DC: A Spatial Perspective

Objective

Studies assessing sociodemographic disparities in the tobacco retail environment have relied heavily on non-spatial analytical techniques, resulting in potentially misleading conclusions. We utilized a spatial analytical framework to evaluate neighborhood sociodemographic disparities in the tobacco retail environment in Washington, DC (DC) and the DC metropolitan statistical area (DC MSA).

Methods

Retail tobacco availability for DC (n=177) and DC MSA (n=1,428) census tract was assessed using adaptive-bandwidth kernel density estimation. Density surfaces were constructed from DC (n=743) and DC MSA (n=4,539) geocoded tobacco retailers. Sociodemographics were obtained from the 2011-2015 American Community Survey. Spearman's correlations between sociodemographics and retail density were computed to account for spatial autocorrelation. Bivariate and multivariate spatial lag models were fit to predict retail density.

Results

DC and DC MSA neighborhoods with a higher percentage of Hispanics were positively correlated with retail density (rho = .3392, P = .0001 and rho = .1191, P = .0000, respectively). DC neighborhoods with a higher percentage of African Americans were negatively correlated with retail density (rho = -.3774, P = .0000). This pattern was not significant in DC MSA neighborhoods. Bivariate and multivariate spatial lag models found a significant inverse relationship between the percentage of African Americans and retail density (Beta = -.0133, P = .0181 and Beta = -.0165, P = .0307, respectively).

Conclusions

Associations between neighborhood sociodemographics and retail density were significant, although findings regarding African Americans are inconsistent with previous findings. Future studies should analyze other geographic areas, and account for spatial autocorrelation within their analytic framework.

Effects of a Youth-Engaging Intervention on Illegal Sales by Tobacco Retailers Near Schools in Thailand

This study assessed the effects of youth-engaging interventions on illegal sales by tobacco retailers near schools in Thailand. The youth were educated and engaged in the planning and implementation of a program to reduce tobacco retailers' illegal sales in the Uttaradit Municipality, Thailand. Intervention components included community education, retailer education, and direct approaches to tobacco retailers. A study included a pretest-posttest control group. The 6-month intervention focused on 114 tobacco retailers. The posttest showed that the percentage of tobacco retailers violating the retail law decreased: tobacco product displays at points of sales decreased from 67.5% to 23.7%, single cigarette sales declined from 71.1% to 36.0%, and tobacco sales to minors decreased from 74.6% to 5.3%. Asking for identification or the buyer's age before selling tobacco increased from 33.3% to 78.1%. The intervention led to a significant reduction in the violation of tobacco retail laws near schools.

How Is Exposure to Tobacco Outlets Within Activity Spaces Associated With Daily Tobacco Use Among Youth? A Mediation Analysis

INTRODUCTION

We investigated associations between exposure to tobacco outlets within activity spaces and daily tobacco use, and whether exposure to adults or peers using tobacco mediate these relationships.

METHODS

We used Geographic Ecological Momentary Assessment data over 14 days from 85 youth aged 16-20 years in eight mid-sized California city areas. Tobacco outlet addresses and global positioning systems locations were geocoded and activity spaces were constructed by joining sequential points. We assessed daily number of tobacco outlets within 50 or 100 m of activity space polylines and number of minutes participants were within 50 or 100 m of tobacco outlets each day; daily use of tobacco; and whether participants saw (1) adults and (2) people their age (peers) using tobacco each day.

RESULTS

Controlling for demographics, results of multilevel structural equation models showed no association between number of tobacco outlets within 50 m of polylines and tobacco use (probit regression coefficient: 0.01, p = .82). However, we found evidence of an indirect effect (p = .001) through daily exposure to peers using tobacco. Specifically, greater number of tobacco outlets within 50 m of polylines was positively associated with seeing peers use tobacco (probit regression coefficient: 0.10, p < .001). In turn, seeing peers use tobacco was positively associated with tobacco use on that day (probit regression coefficient: 2.23, p < .001). Similar results were found for number of tobacco outlets within 100 m of polylines.

CONCLUSIONS

Exposure to tobacco outlets within activity spaces affects youth tobacco use through daily exposure to peers who use tobacco.

IMPLICATIONS

Using real-time-ordered data, this article examines whether exposure to adults and peers using tobacco mediate associations between exposure to tobacco outlets within activity spaces and daily tobacco use among youth. Results suggest that exposure to tobacco outlets within activity spaces affects daily tobacco use through exposure to peers who use tobacco. These findings provide additional significant support for policy makers who are considering regulating the number and density of tobacco retailers and point to the importance of interventions focused on peer tobacco use and youths' daily environments to reduce tobacco use.

School proximity and census tract correlates of e-cigarette specialty retail outlets (vape shops) in central Texas

E-cigarettes are the most widely used tobacco product among middle and high school students in the United States. This study investigates the proximity of e-cigarette retail outlets (vape shops) to middle and high schools in Austin, Texas, as well as the sociodemographic determinants of outlet presence, at the census tract level. A proximity analysis was conducted using school geo-data derived from the Texas Education Agency and vape shop geo-data derived from a validated online search. Logistic regressions using 5-year estimates of the 2014 American Community Survey were performed to determine the correlates of vape shop presence in census tracts. Overall, 20% of the census tracts in Austin, Texas, had at least one vape shop. The proportion of vape shop-containing census tracts that met the criteria for classification as a “poverty area” (36.5%) was greater than that of vape shop-free census tracts (26.3%). Vape shops were more likely to be present in census tracts classified as poverty areas; however, the odds of vape shop presence declined as the percentage of the non-Hispanic Black population and the percentage of persons aged 10–14 years in census tracts increased. About 40% of the vape shops were located within 0.5 miles of a middle or high school. Sociodemographic disparities exist in the e-cigarette retail environment. In addition to the need to address the disparities identified in this study, our results showing the presence of vape shops within walkable distances of schools calls for tighter regulations and continued surveillance around the marketing practices of e-cigarette retailers.

Tobacco Retail Density and Initiation of Alternative Tobacco Product Use Among Teens

PURPOSE

The rise of noncigarette, alternative tobacco product (ATP) use among adolescents may be due in part to an increase in retail availability of ATPs. We examined whether proximity and density of tobacco retailers near students' homes are associated with a higher likelihood of initiating ATP use over time.

METHODS

Using data from 728 adolescents (aged 13-19 years at baseline) residing in 191 different neighborhoods and attending 10 different California high schools, longitudinal multilevel and cross-classified random effect models evaluated individual-level, neighborhood-level, and school-level risk factors for ATP initiation after 1 year. Covariates were obtained from the American Community Survey and the California Department of Education.

RESULTS

The sample was predominantly female (63.5%) and was racially and ethnically diverse. Approximately one third of participants (32.5%) reported ever ATP use at baseline, with 106 (14.5%) initiating ATP use within 1 year. The mean number of tobacco retailers per square mile within a tract was 5.66 (standard deviation = 6.3), and the average distance from each participant's residence to the nearest tobacco retailer was .61 miles (standard deviation = .4). Living in neighborhoods with greater tobacco retailer density at baseline was associated with higher odds of ATP initiation (odds ratio = 1.22, 95% confidence interval = 1.07-2.12), controlling for individual and school factors.

CONCLUSIONS

Tobacco retailers clustered in students' home neighborhood may be an environmental influence on adolescents' ATP use. Policy efforts to reduce adolescent ATP use should aim to reduce the density of tobacco retailers and limit the proximity of tobacco retailers near adolescents' homes and schools.

Similarities Between Alcohol and Tobacco Advertising Exposure and Adolescent Use of Each of These Substances

OBJECTIVE

Underage alcohol use is a major public health problem and substantial corporate money supports alcohol advertising across multiple venues. A diverse research literature demonstrates that adolescent exposure to such advertising is associated with drinking attitudes and behavior, but no scientific body has determined these associations to be causal. The objective of this study was to assess the association between alcohol advertising and teen drinking in the context of the "Analogy" criterion of the Bradford Hill criteria and consider a determination that the association between exposure to alcohol advertising and alcohol use is causal.

METHOD

This study was a narrative review on the association between adolescent exposure to alcohol advertising and subsequent alcohol use in the context of domains utilized in the Surgeon General's 2012 Report, Preventing Tobacco Use Among Youth and Young Adults, which concluded, "Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults."

RESULTS

In every aspect compared (i.e., adolescent knowledge; attitudes toward; initiation of use; continuation of use; mediums of advertisement; the use of mascots, celebrities, and themes; and frequency and density of advertisements and retailers), the findings for both tobacco and alcohol and their association with exposure to advertising are analogous.

CONCLUSIONS

Application of the Analogy criterion of the Bradford Hill criteria comparing alcohol and tobacco supports a judgment that the association between exposure to alcohol advertising and increased adolescent knowledge, attitudes toward, initiation, and continuation of alcohol use are causal in nature.

Density of cigarette retailers near schools and sales to minors in Banyuwangi, Indonesia: A GIS mapping

INTRODUCTION

There are weak regulations and controls on tobacco sales to adolescents in Indonesia, and these may have contributed to the increase in smoking prevalence among adolescents in the country. Our study aims to calculate the density of cigarette retailers near schools and ascertain the factors associated with sales to minors.

METHODS

We conducted geographical mapping by recording the GPS position of cigarette retailers in 15 locations in Banyuwangi District, Indonesia, to assess the density and proximity of cigarette retailers to schools. We interviewed randomly selected retailers, from the geographical mapping, for information on sales to minors, the cheapest price cigarettes are sold and the most popular cigarette brand purchased by adolescents, as well as owners/keepers knowledge of the regulation regarding sales to minors.

RESULTS

We identified 770 retailers of consumer goods in the study location; 28.1% (216) sold cigarettes, with mean density of 1.1 cigarette retailers per 100 m. Of the cigarette retailers, 6.9% were located <25 m from schools and all schools had at least one retailer within a 250 m radius. Owners/keepers of 107 cigarette retailers agreed to be interviewed for information on sales to minors. Brands from Gudang Garam were the most popular among adolescents and the brand from Bentoel, part of British American Tobacco, was the cheapest. The median of the cheapest price sold was US$0.7 per pack. Only 43.6% of retailers ever refused to sell cigarettes to adolescents. Within a school complex, retailers’ refusal to sell cigarettes to adolescents was higher than in other locations.

CONCLUSIONS

Schools in Banyuwangi are surrounded by cigarette retailers. Half of the retailers sell cigarettes at a price affordable by adolescents, attracting adolescents to initiate smoking. There needs to be strict regulation to control cigarette sales to minors, through zoning and licensing in Indonesia.

Cigarette retailer density around schools and neighbourhoods in Bali, Indonesia: A GIS mapping

INTRODUCTION

The presence and density of tobacco retailers is associated with the perception of high availability of cigarettes and ease of purchase. Indonesia is the second largest cigarette market in the world with an increasing smoking rate among young people aged 10-18 years. Our study aims to assess density of cigarette outlets in neighbourhoods and around schools, and to evaluate correlation between retailer proximity to schools and retailer selling practices.

METHODS

We conducted a geographical mapping and then an audit survey of 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia. We measured neighbourhood retailer density, and retailer proximity to schools. We linked the coordinate data to the audit data to assess the association between retailer distance from schools with likelihood of selling tobacco to young people and selling single cigarette sticks.

RESULTS

We mapped 4114 cigarette retailers in Denpasar, the most common type was a kiosk, 3199 (77.8%), followed by mini market/convenience stores, 606 (14.7%). Retailer density was 32.2/km² and 4.6/1000 population. We found that 37 (9.7 %) of the 379 schools in Denpasar have at least one cigarette retailer within a 25 m radius and 367 (96.8%) within a 250 m radius. Of the 485 audited retailers within a 250 m radius of a school, 281 (57.9%) admitted selling cigarettes to young people and 325 (67.0%) sold cigarettes as single sticks. Cigarette retailers were less likely to sell cigarettes to young people based on distance from schools, but this was only significant at the furthest distance of more than 500 m from schools.

CONCLUSIONS

In an unregulated retailer setting such as Indonesia, cigarette retailers are ubiquitous and selling to young people is commonplace. The Indonesian government should enforce the prohibition on selling to young people and should regulate cigarette retailers to reduce youth access to cigarettes.

Policies that limit youth access and exposure to tobacco: a scientific neglect of the first stages of the policy process

BACKGROUND

Policymakers can adopt and implement various supply-side policies to limit youth access and exposure to tobacco, such as increasing the minimum age of sale, limiting the number or type of tobacco outlets, or banning the display of tobacco products. Many studies have assessed the impact of these policies, while less is known about the preceding policy process. The aim of our review was to assess the available evidence on the preceding process of agenda setting, policy formulation, and policy legitimation.

METHODS

A systematic literature search was conducted using the PubMed and the Social Sciences Citation Index databases. After selection, 200 international peer-reviewed articles were identified and analyzed. Through a process of close reading, evidence based on scientific enquiry and anecdotal evidence on agenda setting, policy formulation and policy legitimation was abstracted from each article.

RESULTS

Scientific evidence on the policy process is scarce for these policies, as most of the evidence found was anecdotal. Only one study provided evidence based on a scientific analysis of data on the agenda setting and legitimation phases of policy processes that led to the adoption of display bans in two Australian jurisdictions.

CONCLUSION

The processes influencing the adoption of youth access and exposure policies have been grossly understudied. A better understanding of the policy process is essential to understand country variations in tobacco control policy.

The Relationship between Tobacco Retailer Density and Neighborhood Demographics in Ohio

INTRODUCTION

Studies from various parts of the country suggest that tobacco-related health disparities are exacerbated by disparities in the distribution of tobacco retailers (convenience stores, tobacco shops, etc.). The purpose of the present study was to use advanced spatial modeling techniques for count data to estimate current disparities in tobacco retailer density in Ohio.

METHODS

We identified and geocoded 11,392 tobacco retailers in Ohio. Next, we obtained census tract-level information on race/ethnicity, poverty, and age and obtained county-level information on whether an area was Urban, Suburban, or Rural. Finally, we used negative binomial generalized linear models, adapted for residual spatial dependence, to determine the association between per capita tobacco retailer density and demographic characteristics-summarized by adjusted rate ratios.

RESULTS

There were more (from 1.4-1.9 times as many) retailers per capita in high-poverty, vs. low-poverty tracts. Poverty also interacted with age: the association between high poverty and high retailer density was stronger for tracts with a low youth population. Density was also greater in tracts with a high (vs. low) prevalence of African Americans (1.1 times as many) and Hispanics (1.2 times as many). Finally, density was generally greater in rural (vs. suburban or urban) tracts, although the effect was modified by a three-way interaction: density was particularly high for rural tracts that also had both a high prevalence of poverty and a low youth population.

DISCUSSION

Overall, our findings indicate that Ohio's vulnerable populations are exposed to a greater per capita density of tobacco retailers.

PUBLIC HEALTH IMPLICATIONS

There is a need for state and local-level tobacco control policies that will improve equity and reduce health disparities.

Toward an Intergenerational Model for Tobacco-Focused CBPR: Integrating Youth Perspectives via Photovoice

The growing prominence of community-based participatory research (CBPR) presents as an opportunity to improve tobacco-related intervention efforts. CBPR collaborations for tobacco/health, however, typically engage only adults, thus affording only a partial understanding of community context as related to tobacco. This is problematic given evidence around age of tobacco use initiation and the influence of local tobacco environments on youth. The CEASE and Resist youth photovoice project was developed as part of the Communities Engaged and Advocating for a Smoke-free Environment (CEASE) CBPR collaboration in Southwest Baltimore. With the broader CEASE initiative focused on adult smoking cessation, CEASE and Resist had three aims: (1) elucidate how youth from a high-tobacco-burden community perceive/interact with their local tobacco environment, (2) train youth as active change agents for tobacco-related community health, and (3) improve intergenerational understandings of tobacco use/impacts within the community. Fourteen youth were recruited from three schools and trained in participatory research and photography ethics/guiding principles. Youth met at regular intervals to discuss and narrate their photos. This article provides an overview of what their work revealed/achieved and discusses how including participatory youth research within traditionally adult-focused work can facilitate intergenerational CBPR for sustainable local action on tobacco and community health.

Tobacco outlet density and adolescents' cigarette smoking: a meta-analysis

OBJECTIVE

We conducted meta-analyses of studies that investigated the associations between tobacco outlet density around homes and schools and adolescents' past-month cigarette smoking.

DATA SOURCES

Systematic literature searches of eight databases were carried out in February 2017. Searches were not limited by date, language, country or peer-reviewed status.

STUDY SELECTION

After screening for quality, studies that examined the relationship between tobacco outlet density and adolescents' past-month smoking were selected for inclusion.

DATA EXTRACTION

Two investigators screened study abstracts and full texts and independently extracted data. Consensus was reached at each stage.

DATA SYNTHESIS

Random-effects meta-analyses were conducted on 11 studies that provided 13 effect sizes. Results showed that there was a significant association between tobacco outlet density around homes and adolescents' past-month smoking behaviour, with an overall effect size of OR=1.08 (95% CI 1.04 to 1.13; P<0.001; I2=0%). For density around schools, the association was not statistically significant (OR=1.01, 95% CI 0.98 to 1.03; P=0.53; I2=39%).

CONCLUSIONS

These findings suggest that exposure to tobacco outlets near home environments may be important for understanding adolescents' past-month smoking. Restricting access to tobacco outlets and controlling the number of outlets in residential areas may be an effective preventive strategy to help reduce adolescents' smoking.

Medical Marijuana Availability, Price, and Product Variety, and Adolescents' Marijuana Use

PURPOSE

We aimed to examine the availability of medical marijuana dispensaries, price of medical marijuana products, and variety of medical marijuana products in school neighborhoods and their associations with adolescents' use of marijuana and susceptibility to use marijuana in the future.

METHODS

A representative sample of 8th, 10th, and 12th graders (N = 46,646) from 117 randomly selected schools in California participated in the cross-sectional 2015-2016 California Student Tobacco Survey (CSTS). Characteristics of medical marijuana dispensaries in California were collected and combined with school locations to compute availability, price, and product variety of medical marijuana in school neighborhoods. Multilevel logistic regressions with random intercepts at school level were conducted to test the associations, accounting for individual and school socioeconomic characteristics.

RESULTS

The distance from school to the nearest medical marijuana dispensary (within 0- to 1-mi and 1- to 3-mi bands) was not associated with adolescents' use of marijuana in the past month or susceptibility to use marijuana in the future, nor was the weighted count of medical marijuana dispensaries within the 3-mi band of school. Neither the product price nor the product variety in the dispensary nearest to school was associated with marijuana use or susceptibility to use. The results were robust to different specifications of medical marijuana measures.

CONCLUSIONS

There was no evidence supporting the associations of medical marijuana availability, price, or product variety around school with adolescents' marijuana use and susceptibility to use.

Tobacco outlet density and tobacco knowledge, beliefs, purchasing behaviours and price among adolescents in Scotland

Despite long-term falls in global adult smoking prevalence and over 50 years of tobacco control policies, adolescent smoking persists. Research suggests greater densities of tobacco retail outlets in residential neighbourhoods are associated with higher adolescent smoking rates. Policies to reduce retail outlets have therefore been identified by public health researchers as a potential 'new frontier' in tobacco control. Better understanding of the pathways linking density of tobacco retailers and smoking behaviour could support these policies. In this study we use path analysis to assess how outlet density in the home environment is related to adolescent tobacco knowledge, beliefs, retail purchases and price in Scotland. We assessed 22,049 13 and 15 year old respondents to the nationally representative cross-sectional 2010 Scottish School Adolescent Lifestyle and Substance Use Survey. Outlet density was based on Scottish Tobacco Retailers Register, 2012, data. A spatially-weighted Kernel Density Estimation measure of outlet density within 400 m of respondents' home postcode was grouped into tertiles. The analysis considered whether outlet density was associated with the number of cigarette brands adolescents could name, positive beliefs about smoking, whether smokers purchased cigarettes from shops themselves or through adult proxies and perceived cost of cigarettes. Models were stratified by adolescent smoking status. The path analyses indicated that outlet density was not associated with most outcomes, but small, significant direct effects on knowledge of cigarette brands among those who had never smoked were observed. With each increase in outlet density tertile the mean number of brands adolescents could name rose by 0.07 (mean = 1.60; SD = 1.18; range = 4). This suggests greater outlet densities may have affected adolescents' knowledge of cigarette brands but did not encourage positive attitudes to smoking, purchases from shops or lower cigarette prices. Exposure to tobacco outlets may influence adolescents' awareness of tobacco products, a potential pathway to smoking behaviour.

The impact of military service and traumatic brain injury on the substance use norms of Army Reserve and National Guard Soldiers and their spouses

INTRODUCTION

Traumatic brain injury (TBI) and substance use are highly prevalent conditions among military populations. There is a significant body of evidence that suggests greater approval of substance use (i.e., norms) is related to increased substance use. The objective of this work is to understand the impact of TBI and military service on substance use norms of soldiers and their partners. Data are from the baseline assessment of Operation: SAFETY, an ongoing, longitudinal study of US Army Reserve/National Guard (USAR/NG) soldiers and their partners.

METHODS

Multiple regression models examined associations between alcohol, tobacco, illicit drug use, and non-medical use of prescription drug (NMUPD) norms within and across partners based on current military status (CMS) and TBI.

RESULTS

Male USAR/NG soldiers disapproved of NMUPD, illicit drug use and tobacco use. There was no relation between military status and alcohol use. Among females, there was no relation between CMS and norms. The NMUPD norms of wives were more likely to be approving if their husbands reported TBI symptoms and had separated from the military. Husbands of soldiers who separated from the military with TBI had greater approval of the use of tobacco, NMUPD, and illicit drugs.

CONCLUSION

Overall, there is evidence to suggest that, while generally disapproving of substance use, soldiers and partners become more accepting of use if they also experience TBI and separate from the military. Future research should examine the longitudinal influence of TBI on substance use norms and subsequent changes in substance use over time.

Residential Proximity to Electronic Dance Music Nightclubs and Associations with Substance Use, Sexual Behaviors, and Related Problems

This study examines the association between proximity of place of residence to preferred nightclub and substance use, sexual risk behaviors, and related problems, among a sample of 498 young adult substance users in Miami who report regular nightclub participation. Hierarchal linear models and logistic regressions were constructed to examine the impact of residential proximity to preferred nightclub on risk behaviors. Compared with participants residing in closer proximity to their preferred nightclub, participants residing further away reported higher intensities of alcohol and cocaine use (p < .01), greater condomless vaginal sex frequencies (p < .001), and more substance dependence symptoms (p < .05). Conversely, participants residing in closer proximity to their preferred nightclub had higher likelihood of arrest history (p < .05) than participants residing further away. Results suggest that participants residing further from their preferred nightclubs may be more invested in the nightclub outing and, therefore, engage in more risk behaviors.

Smoking and binge-drinking among adolescents, Ontario, Canada: Does the school neighbourhood matter?

This study examines whether access to alcohol and tobacco around the school relates to higher or lower odds of cigarette smoking and binge-drinking among Ontario high school students. The 2013 Ontario Student Drug Use and Health Survey provides data on self-reported smoking and drinking, individual covariates and subjective socio-economic status for 6142 students (grades 9-12) in Ontario, Canada. Locations of schools were geocoded and 1.6km network buffers defined the school neighbourhoods. Multi-level logistic regression examines individual and school neighbourhood factors with smoking and binge drinking as the dependent variable. Higher density of retail outlets increased the odds of smoking, but not the odds of binge-drinking. Older age, lower SES and being male increased the odds of smoking; while older age and being male also increased the odds of binge-drinking. Lower SES and higher population density decreased the odds of binge-drinking. Proximity to tobacco and alcohol outlets was not significant. Findings showed that a greater number of outlets in the school neighbourhood is significantly associated with higher odds of smoking, but not binge-drinking. School neighbourhood access to tobacco outlets should be considered when formulating policy interventions to reduce smoking for adolescents.

The Moderating Role of Gender in the Relationship Between Tobacco Outlet Exposure and Tobacco Use Among African American Young Adults

Tobacco outlet exposure is a correlate of tobacco use with potential differences by gender that warrant attention. The aim of this study is to explore the moderating role of gender in the relationship between tobacco outlet exposure and past month tobacco use among African American young adults 21 to 24 years old. This cross-sectional study (n = 283) used geospatial methods to determine the number of tobacco outlets within walking distance (i.e., a quarter mile) of participants' homes and distance to the nearest outlet. Logistic regression models were used to test interactions between gender and tobacco outlet exposure (i.e., density and proximity). Tobacco outlets were classified based on whether or not they were licensed to sell tobacco only (TO outlets) or tobacco and alcohol (TA outlets). Neither density nor proximity was associated with past month tobacco use in the pooled models. However, gender modified the relationship between TO outlet density and tobacco use, and this relationship was significant only among women (OR = 1.02; p < 0.01; adjusted OR = 1.01; p < 0.05). This study underscores the importance of reducing tobacco outlet density in residential neighborhoods, especially TO outlets, as well as highlights potential gender differences in the relationship between tobacco outlet density and tobacco use.

Association Between Electronic Cigarette Marketing Near Schools and E-cigarette Use Among Youth

PURPOSE

Electronic cigarettes (e-cigarettes) are now the most popular tobacco product among youth. Little is known about the relationship between exposure to e-cigarette marketing at the point-of-sale and youth e-cigarette use.

METHODS

Research staff collected data on e-cigarette availability and promotion in tobacco retailers within a half-mile of 41 schools participating in the 2014 New Jersey Youth Tobacco Survey. These data were linked with participant responses from the New Jersey Youth Tobacco Survey (n = 3,909) and log-Poisson regression models estimated adjusted prevalence ratios for ever and past-month e-cigarette use.

RESULTS

Nearly a quarter of high school students in New Jersey have tried e-cigarettes (24.1%) and 12.1% were past-month users. Prevalence was highest among males, non-Hispanic whites, and students who have used other tobacco products. After controlling for covariates and the clustered nature of the data, e-cigarette retailer density around schools was positively associated with ever and past-month use of e-cigarettes (p < .05). E-cigarette advertising volume significantly increased the probability of being a past-month e-cigarette user (adjusted prevalence ratio: 1.03, p = .031).

CONCLUSIONS

This study suggests that the point-of-sale environment around schools may contribute to e-cigarette use among youth. Policy efforts to restrict tobacco promotion at the point-of-sale may play a role in reducing the use of e-cigarettes.

E-cigarette use among students and e-cigarette specialty retailer presence near schools

OBJECTIVE

This study examined the association between presence of e-cigarette specialty retailers near schools and e-cigarette use among middle and high school students in Orange County (OC), CA.

METHODS

The OC subsample of the 2013-2014 California Healthy Kids Survey (N=67,701) was combined with geocoded e-cigarette retailers to determine whether a retailer was present within one-quarter mile of each public school in OC. Multilevel logistic regression models evaluated individual-level and school-level e-cigarette use correlates among middle and high school students.

RESULTS

Among middle school students, the presence of an e-cigarette retailer within one-quarter mile of their school predicted lifetime e-cigarette use (OR=1.70, 95% CI=1.02, 2.83), controlling for confounders but no effect for current use. No significant effect was found for high school students.

CONCLUSIONS

E-cigarette specialty retailers clustered around schools may be an environmental influence on student e-cigarette experimentation.

Tobacco outlet density near home and school: Associations with smoking and norms among US teens

This study examined whether living or going to school in neighborhoods with higher tobacco outlet density is associated with higher odds of cigarette smoking among teens, and with perceptions of greater smoking prevalence and peer approval. Using an Internet panel that is representative of US households, we matched data from teen-parent pairs (n=2771, surveyed June 2011-December 2012) with environmental data about home and school neighborhoods. Density was measured as the number of tobacco outlets per square mile for a ½-mile roadway service area around each participant's home and school. Logistic regressions tested relationships between tobacco outlet density near home and schools with ever smoking. Linear regressions tested relationships between density, perceived prevalence and peer approval. Models were adjusted for teen, parent/household and neighborhood characteristics. In total, 41.0% of US teens (ages 13-16) lived within ½ mile of a tobacco outlet, and 44.4% attended school within 1000ft of a tobacco outlet. Higher tobacco outlet density near home was associated with higher odds of ever smoking, although the relationship was small, OR=1.01, 95% CI (1.00, 1.02). Higher tobacco outlet density near home was also associated with perceptions that more adults smoked, coef.=0.09, 95% CI (0.01, 0.17). Higher tobacco outlet density near schools was not associated with any outcomes. Living in neighborhoods with higher tobacco outlet density may contribute to teen smoking by increasing access to tobacco products and by cultivating perceptions that smoking is more prevalent. Policy interventions to restrict tobacco outlet density should not be limited to school environments.

The availability of medical marijuana dispensary and adolescent marijuana use

PURPOSE

To examine the association between medical marijuana dispensary (MMD) availability and adolescent marijuana use.

METHODS

The study sample was comprised of 8th, 10th, and 12th graders (N=14,953) from 141 schools in the 2014 Monitoring the Future study, who resided in the 18 states that had legalized medical marijuana as of January 1, 2014. Multilevel logistic regressions with random effects were conducted to quantify the cross-sectional associations of the availability of MMD within 5- and 25-mile buffers from the centroid of school zip codes with self-reported recent use (past-year) and current use (past-month) of marijuana, controlling for individual characteristics and school, zip code, and state contextual factors.

RESULTS

In the combined sample, the availability of MMD was not associated with recent or current use of marijuana. Subsample analyses suggested that the availability within a 5-mile buffer was associated with a higher likelihood of recent use in 8th graders (OR=1.93, 95% CI=1.11-3.33) and the availability within a 5- to 25-mile buffer was associated with a higher likelihood of recent use in 10th graders (OR=1.33, 95% CI=1.00-1.77). The availability of MMD was not associated with recent use in 12th graders or current use in any grades.

CONCLUSIONS

The availability of MMD was not associated with current use of marijuana among adolescents. There was some evidence suggesting that the availability of MMD within short to medium traveling distance may be associated with a higher level of recent use in middle schoolers who are also at a high risk of experimenting with marijuana.

Reducing Disparities in Tobacco Retailer Density by Banning Tobacco Product Sales Near Schools

INTRODUCTION

This study examined whether a policy of banning tobacco product retailers from operating within 1000 feet of schools could reduce existing socioeconomic and racial/ethnic disparities in tobacco retailer density.

METHODS

We geocoded all tobacco retailers in Missouri (n = 4730) and New York (n = 17 672) and linked them with Census tract characteristics. We then tested the potential impact of a proximity policy that would ban retailers from selling tobacco products within 1000 feet of schools.

RESULTS

Our results confirmed socioeconomic and racial/ethnic disparities in tobacco retailer density, with more retailers found in areas with lower income and greater proportions of African American residents. A high proportion of retailers located in these areas were in urban areas, which also have stores located in closer proximity to schools. If a ban on tobacco product sales within 1000 feet of schools were implemented in New York, the number of tobacco retailers per 1000 people would go from 1.28 to 0.36 in the lowest income quintile, and from 0.84 to 0.45 in the highest income quintile. In New York and Missouri, a ban on tobacco product sales near schools would either reduce or eliminate existing disparities in tobacco retailer density by income level and by proportion of African American.

CONCLUSIONS

Proximity-based point of sale (POS) policies banning tobacco product sales near schools appear to be more effective in reducing retailer density in lower income and racially diverse neighborhoods than in higher income and white neighborhoods, and hold great promise for reducing tobacco-related disparities at the POS.

IMPLICATIONS

Given the disparities-reducing potential of policies banning tobacco product sales near schools, jurisdictions with tobacco retailer licensing should consider adding this provision to their licensing requirements. Since relatively few jurisdictions currently ban tobacco sales near schools, future research should examine ways to increase and monitor the uptake of this policy, and assess whether it has an impact upon reducing exposure to tobacco marketing and on tobacco product availability and use.

Availability of Medical and Recreational Marijuana Stores and Neighborhood Characteristics in Colorado

Objective. To examine the availability of marijuana stores in Colorado and associations with neighborhood characteristics. Methods. The addresses for 650 medical and recreational marijuana stores were geocoded and linked to the characteristics of 1249 census tracts in Colorado. Accounting for spatial autocorrelations, autologistic regressions were used to quantify the associations of census tract socioeconomic characteristics with the availability of marijuana stores. Results. Regardless of store types, marijuana stores were more likely to locate in neighborhoods that had a lower proportion of young people, had a higher proportion of racial and ethnic minority population, had a lower household income, had a higher crime rate, or had a greater density of on-premise alcohol outlets. The availability of medical and recreational marijuana stores was differentially correlated with household income and racial and ethnic composition. Conclusions. Neighborhood disparities existed in the availability of marijuana stores, and associations between availability of stores and neighborhood characteristics varied by store types. This study highlighted the need for regulatory measures to prevent marijuana related outcomes in high risk neighborhoods.

The role of tobacco outlet density in a smoking cessation intervention for urban youth

This study investigates the role of tobacco outlet density in a randomized controlled trial of a text messaging-based smoking cessation intervention conducted among a sample of 187 primarily African American youth in a midsize U.S. city. A moderated mediation model was used to test whether the indirect effect of residential tobacco outlet density on future smoking was mediated by the intention to smoke, and whether this indirect effect differed between adolescents who received the intervention and those who did not. Results indicated that tobacco outlet density is associated with intention to smoke, which predicts future smoking, and that the indirect effect of tobacco outlet density on future smoking is moderated by the intervention. Tobacco outlet density and the intervention can be viewed as competing forces on future smoking behavior, where higher tobacco outlet density acts to mitigate the sensitivity of an adolescent to the intervention's intended effect. Smoking cessation interventions applied to youth should consider tobacco outlet density as a contextual condition that can influence treatment outcomes.

Youth activity spaces and daily exposure to tobacco outlets

We explored whether exposure to tobacco outlets in youths' broader activity spaces differs from that obtained using traditional geographic measures of exposure to tobacco outlet within buffers around homes and schools. Youths completed an initial survey, daily text-prompted surveys, and carried GPS-enabled phones for one week. GPS locations were geocoded and activity spaces were constructed by joining sequential points. We calculated the number of tobacco outlets around these polylines and around homes and schools. Results suggest that activity spaces provide a more accurate measure of tobacco outlet exposures than traditional measures. Assessing tobacco outlet exposure within activity spaces may yield significant information to advance the field.