The Outdoor MEDIA DOT: The development and inter-rater reliability of a tool designed to measure food and beverage outlets and outdoor advertising

Comparing the number of outdoor sugar-sweetened beverage and caffeinated beverage advertisements near schools by school type and school-level economic advantage

INTRODUCTION

Sugar-sweetened beverage and caffeinated beverage consumption are associated with a variety of health issues among youth. Food and beverage marketing has been shown to affect youth's preferences, purchases, and consumption of marketed products. Previous research suggests that outdoor food and beverage marketing differs by community demographics, with more advertisements in lower-income communities and near schools. The purpose of this study is to examine the density of sugar-sweetened and caffeinated beverage advertisements near schools by school type (middle vs. high school) and by school-level SES.

METHODS

Data are from the Outdoor Measuring and Evaluating the Determinants and Influence of Advertising (MEDIA)study, which documented and described all outdoor food and beverage advertisements near 47 middle and high schools in 2012. Beverage advertisements were categorized as: sugar-sweetened/caffeinated, sugar-sweetened/non-caffeinated, non-sugar-sweetened/caffeinated, or non-sugar-sweetened/non-caffeinated. Schools were categorized by type (middle vs high) and by SES as determined by the percentage of students qualifying for free or reduced-price lunch. Bootstrapped non-parametric Mann-Whitney U tests compared the number of advertisements in each category by school type and school-level SES (higher vs lower).

RESULTS

Compared to schools with higher SES, schools with lower SES had significantly more advertisements for sugar-sweetened/non-caffeinated beverages (Medianlow = 28.5 (IQR 17-69), vs Medianhigh = 10.5 (IQR 4-17) (p = 0.002)., sugar-sweetened non-caffeinated (Medianlow = 46 (IQR 16-99) vs Medianhigh = 13.5 (IQR 6-25), p = 0.002), -sugar-sweetened caffeinated (Medianlow = 12 (IQR 8-19) vs Medianhigh = 6 (IQR 2-8), p = 0.000), and non-sugar-sweetened non-caffeinated (Medianlow = 30 (IQR 13-65) vs Medianhigh = 14 (IQR 4-29), p = 0.045).There were no significant differences by school type.

CONCLUSION

This study adds to the literature demonstrating pervasive marketing of unhealthy products in lower-income communities. Disproportionate exposure to sugar-sweetened and caffeinated beverage advertisements in lower-income communities may contribute to the disparities in associated health outcomes by economic status.

School-Level Socioeconomic Status and Nutrient Content of Outdoor Food/Beverage Advertisements

We examined if areas around schools with more students of lower socioeconomic status (SES) have more total food/beverage advertisements and/or more advertisements with poorer nutritional content as compared to areas around schools with fewer students with lower SES. All outdoor food/beverage advertisements within a half-mile radius of 47 middle and high schools in the United States were objectively documented in 2012 and coded for nutritional content. The total number of advertisements and the macronutrient and micronutrient contents (total calories, fat (g), protein (g), carbohydrate (g), sugar (g), and sodium (mg)) of food and beverage items depicted in the advertisements were calculated. In total, 9132 unique advertisements were recorded, with 3153 ads displaying food and beverages that could be coded for nutrient content. Schools located in areas of lower SES (≥60% students receiving free/reduced-price lunch) had significantly more advertisements displaying food and beverages that could be coded for nutrient content (z = 2.01, p = 0.04), as well as advertisements that contained more sodium (z = 2.20, p = 0.03), as compared to schools located in areas of higher SES. There were no differences in calorie, fat, protein, carbohydrate, or sugar content. Policies to reduce the prevalence of outdoor food and beverage advertising are warranted.

Exposure to tobacco retail outlet tobacco marketing and initiation of cigarette and e-cigarette use: Depressive symptoms as a moderator

INTRODUCTION

While tobacco retail outlet (TRO) marketing exposure has been associated with tobacco use, little research has explored how this relationship may vary by the experience of depressive symptoms. The purpose of this study was to examine if the relationship between TRO tobacco marketing exposure and tobacco use initiation is moderated by depressive symptoms among young adults.

METHODS

Participants were drawn from 24 colleges in Texas who were participating in a multi-wave cohort study (2014-2019). The present study included 2020 cigarette or ENDS naïve participants at wave 2 (69.2% female; 32.1% white; m age=20.6 [SD=2.0] at wave 1). Generalized mixed-effects logistic regression analyses were used to examine the association between cigarette and ENDS TRO marketing exposure and subsequent initiation for both products with depressive symptoms as a moderator.

RESULTS

The interaction between cigarette marketing and depressive symptoms was significant (OR=1.38 95% CI=[1.04,1.83]). Cigarette marketing did not impact cigarette initiation among participants with low depressive symptoms (OR=0.96 95% CI= [0.64,1.45]), but did impact cigarette initiation among participants with high depressive symptoms (OR=1.83 95% CI=[1.23,2.74]). There was no interaction effect for ENDS initiation. Main effects showed that ENDS marketing exposure predicted ENDS initiation (OR=1.43 95% CI=[1.10,1.87]).

CONCLUSIONS

Exposure to tobacco marketing at TROs is an important risk factor for initiation of cigarette and ENDS use, particularly for cigarette initiation among those who experience greater levels of depressive symptoms. Future work is needed to better understand why this type of marketing is influential for this group.

Restricting Tobacco Retail Outlets Around Middle and High Schools as a Way to Reduce Tobacco Marketing Disparities: A Simulation Study

INTRODUCTION

Communities with more people of color and economically disadvantaged residents are disproportionately exposed to tobacco marketing from tobacco companies. This study examined if banning tobacco retail outlets (TROs) within 1000 ft of schools would reduce these marketing disparities through a greater reduction in the amount of tobacco advertising around schools in these communities.

METHODS

Data from objectively audited advertisement data from 106 convenience stores and gas stations around 42 middle and high schools located in the four major metropolitan areas of Texas were linked with schools' enrollment data. ArcGIS (Aeronautical Reconnaissance Coverage Geographic Information System) was used to simulate a 1000-ft ban of tobacco sales around the schools. Independent sample T-tests and Mann-Whitney U tests were used to test mean differences where appropriate.

RESULTS

Schools with a higher enrollment of Hispanic/Latino (mean = 171.6, SD = 96.9) and economically disadvantaged students (mean = 168.9, SD = 102.3) were surrounded with significantly greater advertising at TROs than schools with lower enrollment of these groups (mean = 82.8, SD = 49.1 and mean = 89.2, SD = 50.6, respectively). A simulated 1000 ft ban of TROs around schools led to greater advertising reduction around schools with a higher enrollment of Hispanic/Latino students (13.3%-29.4% reductions) in comparison to schools with lower Hispanic/Latino student enrollment. However, the more economically disadvantaged schools had a smaller reduction in the number of advertisements (5.9%-21.9% reductions) in comparison to schools with less economically disadvantaged students.

CONCLUSION

The implementation of a ban of tobacco sales at TROs within 1000 ft of schools is one policy approach to reduce youth exposure to tobacco marketing, particularly among students of color.

STUDY IMPLICATION

Tobacco retail outlets (TROs) around schools with a higher enrollment of Hispanic/Latino and economically disadvantaged students had significantly more tobacco advertisements in comparison to schools with lower enrollment of these student groups. A simulated ban of TROs within 1000 ft of schools led to greater advertising reduction around schools with a higher enrollment of Hispanic/Latino students. For schools with more economically disadvantaged students, the ban led to a smaller reduction in advertisements in comparison to schools with less economically disadvantaged students. This proposed place-based strategy could be a successful means to reduce tobacco advertising and marketing disparity among communities of color.

A scoping review of outdoor food marketing: exposure, power and impacts on eating behaviour and health

BACKGROUND

There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research.

METHODS

A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria.

RESULTS

Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes.

CONCLUSIONS

This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

Qualities of the Restaurant Food Environment: A Direct Observation Pilot Study of Restaurants Located Near High Schools

Objective: This study aimed to identify and describe healthful and youth-oriented qualities of the restaurant food environment around high schools. Methods: Using direct observation data from 58 restaurants located within a half-mile (804.5 meters) of all high schools in a single district, two index measures of the restaurant food environment were created: healthfulness index and youth-oriented index. Wilcoxon signed-rank order was used to examine differences in restaurant features according to index scores. Results: Mean healthfulness score was 8.9 (range = 2-14, max = 19) and mean youth-oriented score was 5.5 (range = 0-11, max = 12). Differences were found in signed-rank order of healthfulness and youth-oriented index restaurant scores (p = 0.02). Conclusion: Results suggest that restaurants have room for improvement in offering customers a healthful environment, some restaurants are more likely to appeal to youth, and that youth-oriented restaurants were different than restaurants with high healthfulness scores. Further qualitative exploration of food environment features will help contextualize the influence of restaurants on youth eating behaviors.

A Simulation of the potential impact of restricting tobacco retail outlets around middle and high schools on tobacco advertisements

OBJECTIVE

To examine (1) if tobacco retail outlets (TROs) closer to middle and high schools have more tobacco advertisements than TROs farther away and (2) the potential impact of two place-based tobacco control strategies on tobacco advertisements: a simulated ban of TROs (1) within 1000ft of schools and (2) within 500 ft of other TROs.

METHODS

TROs within half-mile of 53 middle and high schools in the four largest Metropolitan areas in Texas were audited for all tobacco marketing. ArcGIS was used for mapping and grouping TROs by distance from the schools and simulating the ban. Mean differences in the number of tobacco advertisements were examined with t-tests. Percentage reductions in tobacco advertisements were calculated after simulation of both bans, reported by school type and by location, product and flavour.

RESULTS

TROs within 1000 ft of schools had significantly more tobacco advertisements as compared with TROs located within 1000-2000 ft (p=0.03) for all schools combined and middle schools. Simulation of the 1000 ft ban of TROs led to a slightly greater reduction in advertisements (19.4%) as compared with the 500 ft ban of TROs from other TROs (17.9%). The reduction in all advertisement types was greater around middle schools and greatest for e-cigarettes (23.6%).

CONCLUSION

Students can be exposed to a great deal of tobacco advertising in TROs around their schools. The implementation of a 1000 ft ban of TROs, or at minimum a ban on tobacco advertising outside and within these outlets, is one way to prevent or reduce the use of tobacco among adolescents.

Exposure to cigar Point-of-Sale marketing and use of cigars and cigarettes among young adults

INTRODUCTION

Few studies examine the impact of objective exposure to point-of-sale (POS) marketing for cigars including little cigars and cigarillos (LCCs) on tobacco use. The present study aimed to examine the relationship between exposure to LCC marketing at the POS and current and future use of LCCs and cigarettes among young adult college students.

METHOD

Data on LCC and cigarette use from 4201 young adult students (mean age = 22.8 [SD = 2.3]; 35.9% non-Hispanic whites) attending 24 Texas colleges was linked to objective assessments of POS marketing at 220 tobacco retail outlets within one mile of the colleges. Multilevel logistic regression analyses examined the impact of LCC marketing at the POS on use of LCCs and cigarettes currently and 6-months later.

RESULTS

Participants were, on average, exposed to 43 LCC marketing materials per week. Results from cross-sectional analyses indicated that exposure to LCC POS marketing was associated with higher odds of current use of LCCs (AOR = 1.003, 95% CI = 1.0002, 1.0053) and cigarettes (AOR = 1.006, 95% CI = 1.0050, 1.0075). The relationship between LCC POS marketing exposure and LCC use was not significant in longitudinal models; however, exposure to LCC POS marketing at baseline did predict current cigarette use at 6-month follow-up (AOR = 1.004, 95% CI = 1.0021, 1.0052).

CONCLUSION

Findings suggest a substantial influence of LCC marketing exposure at the POS. Regulations on LCC marketing at the POS, especially around college campuses, should be considered.

Defining and Developing Measures of Checklist for Measuring Food Store Environment: A Systematic Review

Background:

Food store measurement is important for planners and policy makers to improve unhealthy stores towards healthy stores. This review aimed to outline the concepts and measures development of checklists that assess food store environment in urban communities.

Methods:

The search was carried out in PubMed, Embase, Web of Science and Scopus as well as reference lists of included studies for obtaining published articles between 1990 up to the date of search (30 June 2017). Eligibility criteria attempted to capture peer-reviewed articles aimed at development and validation of checklists for assessing food stores.

Results:

From 3,862 records, 24 studies were included in this review. Findings showed constructs included in the instruments were availability (n=22); price (n=22); quality of fresh foods (n=13); promotion (n=6); product placement (n=6); advertisement (n=5); shelf space (n=3); display (n=3); store features or characteristics (n=2); marketing (n=2); accessibility; nutrition information; visibility; food variety; signage. There are differences on the conceptual definition of each constructs across the checklists. Only half of studies pursued fully systematic steps for the measures development.

Conclusion:

Consensus for definition of constructs of food store measurement is necessary. Besides, the development of the measures of checklists needs to be done by high-quality methods.

Describing Food and Beverage Restaurants: Creating A Reliable Coding Tool

Objective

To develop an informed, reliable data collection tool to code restaurants found within the youth food environment.

Methods

Registered Dietitians were surveyed and academic literature review was reviewed to determine health centric food environment features. Features were incorporated into an electronic data collection tool. Inter-rater reliability was tested across coders of varying nutrition training on all restaurants located within a half-mile of three high schools.

Results

Sixteen restaurant food environment codes were generated. Data collection had a mean inter-rater reliability of 90.7% agreement (range=81.3-100%), suggesting that regardless of nutrition training, the restaurant food environment can be reliability coded.

Conclusions

Academic and public health professionals can use this tool to collect reliable, informed local restaurant food environment data.

Targeting Hispanic adolescents with outdoor food & beverage advertising around schools

OBJECTIVES

Although some research has focused on the food environment and food marketing, little has examined outdoor food and beverage (FB) advertising, particularly its relationship to the Hispanic composition in schools. Therefore, the purpose of this study was to determine if the prevalence of outdoor FB advertising was greater around middle and high schools with a majority Hispanic population as compared to schools with a lower Hispanic population.

DESIGN

All FB advertisements located within a half-mile of 47 schools in Central Texas were documented. Advertisements were coded as free standing or on establishments. Advertisements were coded for theme including price (emphasizing price) and deals/value meals (promoting discounted price/meal deals). These two themes were combined to create an overall price promotion variable. In order to determine if the prevalence of FB advertising varied by the Hispanic composition of the students in the school, data from the Texas Education Agency was used to create a variable which dichotomized the schools into two groups: schools that reported ≥60% Hispanic students or 'Hispanic schools' (n = 21) and schools that reported <60% Hispanic students or 'non-Hispanic schools' (n = 26). Linear regression analyses were conducted to determine if the prevalence of outdoor FB advertising was greater around Hispanic schools as compared to non-Hispanic schools.

RESULTS

Hispanic schools had more overall outdoor FB advertisements as compared to non-Hispanic schools (p = 0.02). Similarly, we found significantly more outdoor FB establishment (p = 0.02) and price promotion (p = 0.05) around Hispanic schools as compared to non-Hispanic schools. Differences in freestanding advertisements by school type approached significance (p = 0.07) with Hispanic schools having more freestanding FB advertisements on average.

CONCLUSION

Further research is needed that documents the content of these advertisements and determines the extent to which these advertisements affect Hispanic and other racial/ethnic minority youth's attitudes and behaviors toward the consumption of these products.