Rural-urban disparities in tobacco retail access in the southeastern United States: CVS vs. the dollar stores

Exploring associations of population characteristics and tobacco and vape retailer density and proximity in Australia: a scoping review

OBJECTIVE

This scoping review synthesises Australian evidence on associations between tobacco and vape retailer density/proximity and various population measures and smoking behaviour to identify research gaps and inform future policy and strategies.

DATA SOURCES

Following Joanna Briggs Institute methodology, relevant studies published in English since 2003 were identified via searches of eight databases in March and August 2023.

STUDY SELECTION

Two reviewers independently completed screening procedures. Eligible studies were from Australia and described associations between tobacco or vape retailer density/proximity and adult or youth smoking/vaping prevalence or behaviours, neighbourhood socioeconomic status, geographic location, school locations and/or Indigenous status.

DATA EXTRACTION

Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SYNTHESIS

Of 794 publications screened, 12 studies from 6 Australian states were included. Six studies from five states reported statistically significant associations between neighbourhood-level socioeconomic disadvantage and tobacco retailer density, yet only two studies from two states found a significant relationship between retailer density and adult smoking prevalence. Increasing retailer density was consistently significantly associated with increasing geographical remoteness in three states. No studies explored associations with tobacco retailer proximity or vape retailer density/proximity.

CONCLUSIONS

Despite a moderate number of studies overall, state-level evidence is limited, and unknown for Australian territories. Evidence from five Australian states reflects the international evidence that increasing retailer density is significantly associated with increasing socioeconomic disadvantage and remoteness, supporting the need for tobacco supply-based policies. Further research is required to understand the impact of retailer density and adult and youth smoking prevalence in Australia.

A smoking cessation intervention for rural veterans tailored to individual risk factors: A multicenter randomized clinical trial

INTRODUCTION

Rates of cigarette use remain elevated among those living in rural areas. Depressive symptoms, risky alcohol use, and weight concerns frequently accompany cigarette smoking and may adversely affect quitting. Whether treatment for tobacco use that simultaneously addresses these issues affects cessation outcomes is uncertain.

METHODS

The study was a multicenter, two-group, randomized controlled trial involving mostly rural veterans who smoke (N = 358) receiving treatment at one of five Veterans Affairs Medical Centers. The study randomly assigned participants to a tailored telephone counseling intervention or referral to their state tobacco quitline. Both groups received guideline-recommended smoking cessation pharmacotherapy, selected using a shared decision-making approach. The primary outcome was self-reported seven-day point prevalence abstinence (PPA) at three and six months. The study used salivary cotinine to verify self-reported quitting at six months.

RESULTS

Self-reported PPA was significantly greater in participants assigned to Tailored Counseling at three (OR = 1.66; 95 % CI: 1.07-2.58) but not six (OR = 1.35; 95 % CI: 0.85-2.15) months. Post hoc subgroup analyses examining treatment group differences based on whether participants had a positive screen for elevated depressive symptoms, risky alcohol use, and/or concerns about weight gain indicated that the cessation benefit of Tailored Counseling at three months was limited to those with ≥1 accompanying concern (OR = 2.02, 95 % CI: 1.20-3.42). Biochemical verification suggested low rates of misreporting.

CONCLUSIONS

A tailored smoking cessation intervention addressing concomitant risk factors enhanced short-term abstinence but did not significantly improve long-term quitting. Extending the duration of treatment may be necessary to sustain treatment effects.

Changes in retail tobacco product sales and market share among retail payroll establishments in the U.S. Economic Census between 1997 and 2017

The tobacco industry spends the vast majority of their marketing and promotional budget at retail outlets. However, few studies have used publicly available data to examine trends in the number and types of retail establishments where tobacco products are sold. Using the U.S. Economic Census for 1997, 2002, 2007, 2012 and 2017 (the latest year), we examined the number, type, and sales of payroll establishments selling tobacco products. Nine store types accounted for 94% - 99% of tobacco product sales between 1997 and 2017. Gas/convenience stores had the greatest market share (33% - 49% of tobacco sales). The number of warehouse clubs selling tobacco quadrupled; however, market share only increased from 9.6% to 10.3%. Supermarkets experienced the largest decrease in percent of stores selling tobacco. Pharmacy tobacco sales increased in 2012 then decreased in 2017; per store sales volume more than doubled between 1997 and 2012. Online shopping accounted for less than 1% of the market share between 1997 and 2012, but rose to 6.3% in 2017. Between 1997 and 2017, consumers shifted where they purchased tobacco products. Declining tobacco sales in supermarkets is a promising trend for consumers seeking healthy food without exposure to tobacco product marketing; however, the consistently large number of tobacco retailers, and thus widespread tobacco availability, is concerning. Consumer tobacco purchase changes over time support the case for point-of-sale policies that affect different retail types, including pharmacy bans, to reduce tobacco retailer density. Additionally, the rapid shift to online tobacco purchasing in 2017 identifies a new target for enhanced regulation and enforcement.

Urban-rural differences in tobacco product availability in food retailers, United States, 2017

PURPOSE

Tobacco use prevalence is higher in rural compared to urban settings, possibly due to differences in tobacco availability, including the option to purchase food and other essential items in stores that do not sell tobacco (tobacco-free food retailers). The goal of this research is to determine whether tobacco-free food retailer availability varies by urbanicity/rurality.

METHODS

Using the 2017 National Establishment Time-Series database, we identified food retailers across all census tracts containing food retailers in the United States (n = 66,053). We used multivariable logistic and linear regression models to test whether tobacco-free food retailer availability varied across 4-levels of census tract urbanicity/rurality (urban, suburban, large town, and small town/rural) for 2 outcomes: (1) the presence of at least 1 tobacco-free food retailer and (2) the percent of all food retailers that were tobacco-free.

FINDINGS

Compared to urban core census tracts, suburban census tracts had a lower odds (aOR = 0.77, 95% CI = 0.73, 0.81) of having at least 1 tobacco-free food retailer, while small town/rural census tracts had greater odds (aOR = 1.23, 95% CI = 1.15, 1.32). Suburban census tracts (B = -2.29, P < .001) and large town census tracts (B = -1.90, P < .001) also had a lower percentage of tobacco-free food retailers compared to urban census tracts.

CONCLUSIONS

Compared to urban cores, tobacco-free food retailers were less prevalent in suburban and large town areas, though similarly or slightly more available in rural areas. Future research should assess whether these differences depend on varying store types.

Cancer disparities related to poverty and rurality for 22 top cancers in Florida

We aimed to examine poverty and rurality as potential predictors of cancer health disparities. This cross-sectional study used data from the Florida Cancer Data System on all cancer diagnoses in the years 2014–2018 to determine age-adjusted incidence and mortality (per 100,000 population) for the 22 most common cancer sites within rural and urban counties, and high poverty and low poverty communities. Rural/urban and high/low poverty related cancer disparities were tested for statistical significance using the Rate Ratio statistical test. Overall cancer incidence was significantly lower in rural areas than in urban, but significantly higher in high poverty communities. Rurality and poverty were both associated with disparity in cancer incidence risk for tobacco-related cancers. The overall mortality was 22% higher in high poverty areas compared to low poverty areas. Ten cancer sites had mortality disparity from 83% to 17% higher in high poverty areas. Only three cancer sites, all tobacco-related, had higher mortality in rural areas than urban areas, demonstrating the intersectional nature of inhaled and smokeless tobacco use in rural low-income communities. Cancer and mortality rates in rural and urban areas may be largely driven by poverty. The high disparities related to high poverty areas reflects poor access to preventative care and treatment. Low income communities, rural or urban, will require focused efforts to address challenges specific to each population.

Smoking and the widening inequality in life expectancy between metropolitan and nonmetropolitan areas of the United States

Background

Geographic inequality in US mortality has increased rapidly over the last 25 years, particularly between metropolitan and nonmetropolitan areas. These gaps are sizeable and rival life expectancy differences between the US and other high-income countries. This study determines the contribution of smoking, a key contributor to premature mortality in the US, to geographic inequality in mortality over the past quarter century.

Methods

We used death certificate and census data covering the entire US population aged 50+ between Jan 1, 1990 and Dec 31, 2019. We categorized counties into 40 geographic areas cross-classified by region and metropolitan category. We estimated life expectancy at age 50 and the index of dissimilarity for mortality, a measure of inequality in mortality, with and without smoking for these areas in 1990-1992 and 2017-2019. We estimated the changes in life expectancy levels and percent change in inequality in mortality due to smoking between these periods.

Results

We find that the gap in life expectany between metros and nonmetros increased by 2.17 years for men and 2.77 years for women. Changes in smoking-related deaths are responsible for 19% and 22% of those increases, respectively. Among the 40 geographic areas, increases in life expectancy driven by changes in smoking ranged from 0.91 to 2.34 years for men while, for women, smoking-related changes ranged from a 0.61-year decline to a 0.45-year improvement. The most favorable trends in years of life lost to smoking tended to be concentrated in large central metros in the South and Midwest, while the least favorable trends occurred in nonmetros in these same regions. Smoking contributed to increases in mortality inequality for men aged 70+, with the contribution ranging from 8 to 24%, and for women aged 50-84, ranging from 14 to 44%.

Conclusions

Mortality attributable to smoking is declining fastest in large cities and coastal areas and more slowly in nonmetropolitan areas of the US. Increasing geographic inequalities in mortality are partly due to these geographic divergences in smoking patterns over the past several decades. Policies addressing smoking in non-metropolitan areas may reduce geographic inequality in mortality and contribute to future gains in life expectancy.

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.

Neighborhood Inequities in Tobacco Retailer Density and the Presence of Tobacco-Selling Pharmacies and Tobacco Shops

Studies document inequitable tobacco retailer density by neighborhood sociodemographics, but these findings may not be robust to different density measures. Policies to reduce density may be less equitable depending on how the presence of store types differs by neighborhood characteristics. We built a 2018 list of probable tobacco retailers in the United States and calculated four measures of density for all census tracts (N = 71,495), including total count, and number of retailers per 1,000 people, square mile, and kilometers of roadway. We fit multivariable regression models testing associations between each density measure and tract-level sociodemographics. We fit logistic regression models testing associations between sociodemographics and the presence of a tobacco-selling pharmacy or tobacco shop. Across all measures, tracts with a greater percentage of residents living below 150% of the federal poverty level (FPL) had higher density. A higher percentage of Black residents, Hispanic or Latino residents, and vacant housing was inconsistently associated with density across measures. Neighborhoods with a greater percentage of Black residents had a lower odds of having a pharmacy (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI; 0.95, 0.97]) and tobacco shop (aOR = 0.87, CI [0.86, 0.89]), while those with a greater percentage of residents living below 150% FPL had greater odds of having a tobacco shop (aOR = 1.18, CI [1.16, 1.20]). Researchers and policymakers should consider how various measures of retailer density may capture different aspects of the environment. Furthermore, there may be an inequitable impact of retailer-specific policies on tobacco availability.

Cigarettes smoked among daily and non-daily smokers following CVS Health's tobacco-free pharmacy policy

INTRODUCTION

In September 2014, CVS Health ceased tobacco sales in all of its 7700 pharmacies nationwide. We investigate the impact of the CVS policy on the number of cigarettes smoked per day among metropolitan daily and non-daily smokers, who may respond to the availability of smoking cues in different manners.

METHODS

Data are from the US Census Bureau Tobacco Use Supplement to the Current Population Survey 2014-2015 and the Blue Cross and Blue Shield Institute Community Health Management Hub. Adjusted difference-in-difference (DID) regressions assess changes in the number of cigarettes smoked per day among daily smokers (n=10 759) and non-daily smokers (n=3055), modelling core-based statistical area (CBSA) level CVS pharmacy market share continuously. To assess whether the policy had non-linear effects across the distribution of CVS market share, we also examine market share using tertiles.

RESULTS

CVS's tobacco-free pharmacy policy was associated with a significant reduction in the number of cigarettes smoked by non-daily smokers in the continuous DID (rate ratio=0.985, p=0.022), with a larger reduction observed among non-daily smokers in CBSAs in the highest third of CVS market share compared with those living in CBSAs with no CVS presence (rate ratio=0.706, p=0.027). The policy, however, was not significantly associated with differential changes in the number of cigarettes by daily smokers.

CONCLUSION

The removal of tobacco products from CVS pharmacies was associated with a reduction in the number of cigarettes smoked per day among non-daily smokers in metropolitan CBSAs, particularly those in which CVS had a large pharmacy market share.

Cumulative disadvantage as a framework for understanding rural tobacco use disparities

Traditional tobacco product (cigarettes and smokeless tobacco) and polytobacco use rates are significantly higher among rural adolescents and adults compared to their nonrural counterparts. Such disparities are due to several factors that promote tobacco use initiation and continuation, including individual-level psychopharmacological factors and structural-level factors such as fewer tobacco control efforts (e.g., fewer smoke-free policies and lower tobacco excise taxes), targeted tobacco marketing, less access to health-relevant resources, and more positive cultural norms surrounding tobacco use in rural communities. In this review, we use cumulative disadvantage theory as a framework for understanding how psychopharmacological and structural-level factors serve as drivers of tobacco use in rural areas. We start by describing how structural-level differences between rural-nonrural communities impact psychopharmacological influences and, when available, how these factors influence tobacco use. We conclude by discussing the interplay between factors, providing suggestions for ways to assess our application of cumulative disadvantage theory empirically and making recommendations for research and policy implementation in rural areas. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Trends in the Number and Type of Tobacco Product Retailers, United States, 2000-2017

INTRODUCTION

Tobacco product retailers provide access to tobacco products and exposure to tobacco marketing. Without a national tobacco retailer licensing system in the United States (U.S.), there are no estimates of national trends in tobacco retailer numbers and store type over time.

METHODS

We developed a protocol to identify likely tobacco retailers across the U.S. between 2000-2017 using industry codes and retailer names in the annual National Establishment Time Series (NETS) database. We calculated annual counts of tobacco retailers in seven store type categories, and annual numbers of tobacco retailers that opened and closed.

RESULTS

We estimate that there were 317,492 tobacco product retailers in 2000; the number grew to 412,536 in 2009 before falling to 356,074 in 2017, for a net 12% increase overall. Gas/convenience stores and grocery stores accounted for more than two thirds of all retailers. On average, new openings accounted for 8.0% of the total retailers, while 7.3% of retailers closed or stopped selling tobacco each year, with stronger market volatility following the Great Recession. Since 2011, there was a disproportionate reduction in tobacco-selling pharmacies, and an increase in both tobacco-specialty shops and tobacco-selling discount stores.

CONCLUSIONS

During two decades when smoking declined, tobacco retailer availability increased in the U.S. The economic climate, corporate and public policies, and new tobacco products may all contribute to trends in tobacco retailer availability. State and local jurisdictions considering tobacco retailer policies may find retailer trend information useful for forecasting or evaluating potential policy impacts.

IMPLICATIONS

This study provides historic data tracking tobacco retailers in the U.S. between 2000-2017, documenting trends that unfolded as the general economic market contracted and grew, with greater regulation of the tobacco retailer environment. These data provide a context for better understanding future changes in the tobacco retailer market. In addition, the protocol established in this study could be applied in any U.S.-based location without tobacco retailer licensing to allow identification of stores and tracking of trends.