Association of availability of tobacco products with socio-economic and racial/ethnic characteristics of neighbourhoods

Neighbourhood inequities in the availability of retailers selling tobacco products: a systematic review

OBJECTIVE

To examine inequities in tobacco retailer availability by neighbourhood-level socioeconomic, racial/ethnic and same-sex couple composition.

DATA SOURCES

We conducted a 10 November 2022 search of PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus.

STUDY SELECTION

We included records from Organisation for Economic Co-operation and Development member countries that tested associations of area-level measures of tobacco retailer availability and neighbourhood-level sociodemographic characteristics. Two coders reviewed the full text of eligible records (n=58), including 41 records and 205 effect sizes for synthesis.

DATA EXTRACTION

We used dual independent screening of titles, abstracts and full texts. One author abstracted and a second author confirmed the study design, location, unit of analysis, sample size, retailer data source, availability measure, statistical approach, sociodemographic characteristic and unadjusted effect sizes.

DATA SYNTHESIS

Of the 124 effect sizes related to socioeconomic inequities (60.5% of all effect sizes), 101 (81.5%) indicated evidence of inequities. Of 205 effect sizes, 69 (33.7%) tested associations between retailer availability and neighbourhood composition of racially and ethnically minoritised people, and 57/69 (82.6%) documented inequities. Tobacco availability was greater in neighbourhoods with more Black, Hispanic/Latine and Asian residents (82.8%, 90.3% and 40.0% of effect sizes, respectively). Two effect sizes found greater availability with more same-sex households.

CONCLUSIONS

There are stark inequities in tobacco retailer availability. Moving beyond documenting inequities to partnering with communities to design, implement, and evaluate interventions that reduce and eliminate inequities in retail availability is needed to promote an equitable retail environment.

PROSPERO REGISTRATION NUMBER

CRD42019124984.

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.

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) and co-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remain unclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis. We combined 2018 statewide California (US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders. Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis. Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

Is the neighbourhood context important for a tobacco retailer proximity policy?

A spatial modelling approach was used to explore how a proximity limit (150 m, 300 m, and 450 m) between tobacco retailers may impact different neighbourhoods in New Zealand. Neighbourhoods were categorised into three density groups (0, 1-2, 3+ retailers). As the proximity limit increases, there is a progressive redistribution of neighbourhoods in the three density groups with, the 3+ density group incorporating fewer neighbourhoods and the 0 and 1-2 density groups conversely each consisting of more. The differing measures available at the neighbourhood level enabled our study to discern potential inequities. More directed policies targeting these inequities are needed.

Area-level sociodemographic differences in tobacco availability examined with nationwide tobacco product retail licence data in Finland

BACKGROUND

Differences in tobacco retailer density between areas by sociodemographic composition have been observed. However, little research comes from European jurisdictions and from countries with a tobacco retail licensing system. In Finland, the system consists of criteria for retailers and supervision fees.

METHODS

The tobacco product retail licence data and sociodemographic data were retrieved from corresponding Finnish authorities. Area-level tobacco availability was measured as the presence of a retailer and as the number of retailers per 1000 inhabitants by postcode area. Sociodemographic indicators included median income, percentage of inhabitants in the lowest income tertile, percentage of adults with higher education and unemployment rate. Analyses were based on logistic regression and Ordinary Least Squares regression with log-transformed density.

RESULTS

Lower area-level sociodemographic composition was mainly associated with higher tobacco availability. Income was the strongest correlate of the tobacco retailer availability: areas with higher median income had lower odds of having a tobacco retailer (OR 0.54, 95% CI 0.48 to 0.61 per €1000) and lower retailer density (-4.4% per €1000, Cohen's f=0.51). Areas with a greater proportion of people in the lowest income category had higher densities of tobacco retailers (+2.8% per percentage point, Cohen's f=0.07). Other sociodemographic indicators showed inconsistent associations with retailer presence and density.

CONCLUSION

Tobacco availability can be higher in areas with lower sociodemographic composition also in a country with a comprehensive tobacco retail licensing system and small income inequalities. Retailing policies should be further developed to reduce tobacco availability and narrow inequalities in tobacco use.

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.

The effect of race/ethnicity and adversities on smoking cessation among U.S. adult smokers

INTRODUCTION

Black and Hispanic individuals in the US experience more socioeconomic adversities that are associated with disparities in tobacco use and cessation than White individuals. This study examined if racial/ethnic differences in smoking abstinence were mediated by socioeconomic (SES) adversities.

METHODS

Data from 7,101 established smokers were identified in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) and followed to Wave 4 (2016-2018). The study outcome was cigarette abstinence at Wave 4. The main independent variable was race/ethnicity (Non-Hispanic White [White], Non-Hispanic Black [Black] and Hispanic). The mediators were five measures of SES adversities (unemployment, poverty, difficulty with money, lower education level, lack of health insurance). A weighted Generalized Structural Equation Model (GSEM) was used to estimate the total, direct, and indirect effect of race/ethnicity on the odds of quitting mediated by the five SES adversities. This model was adjusted by study covariates, including health and smoking characteristics.

RESULTS

The indirect effect of race/ethnicity on cessation showed that differences in quitting between Black and White individuals as well as Hispanic and White individuals were mediated by SES adversities. However, the differences in quitting between Hispanic and Black individuals were not mediated by SES adversities. Black and Hispanic individuals were less likely to quit than White individuals, but Hispanic individuals were more likely to quit than Black individuals. There were no direct effects between Black or Hispanic individuals compared to White individuals. Those with higher SES were more likely to quit compared to those with lower SES.

DISCUSSION

Smoking abstinence is higher in White individuals compared to Black and Hispanic individuals and is mediated by SES adversities. However, smoking abstinence is higher among Hispanic individuals compared to Black individuals and it is not mediated by SES adversities. Future studies should consider the role of other factors, such as psychosocial support, racism, discrimination, and stress over the life course in explaining differences in smoking abstinence between Black and Hispanic individuals.

Point-of-sale cigarette pricing strategies and young adult smokers' intention to purchase cigarettes: an online experiment

BACKGROUND

Point-of-sale tobacco marketing has been shown to be related to tobacco use behaviours; however, specific influences of cigarette price discounts, price tiers and pack/carton availability on cigarette purchasing intention are less understood by the tobacco control community.

METHODS

We conducted discrete choice experiments among an online sample of US young adult smokers (aged 18-30 years; n=1823). Participants were presented scenarios depicting their presence at a tobacco retail outlet with varying availability of cigarette price discounts, price tiers and pack/carton. At each scenario, participants were asked whether they would purchase cigarettes. Generalised linear regression models were used to examine the associations between of cigarette price discounts, price tiers and pack/carton with intention to purchase cigarettes overall and stratified by educational attainment.

RESULTS

Participants chose to purchase cigarettes in 70.9% of the scenarios. Offering price discounts were associated with higher odds of choosing to purchase cigarettes. Reducing the number of cigarette price tiers available in the store was associated with lower odds of choosing to purchase cigarettes. Stratified analysis showed that offering discounts on high-tier cigarette packs increased odds of choosing to purchase cigarettes among young adult smokers with at least some college education, while offering discounts on medium-tier cigarette packs increased odds of choosing to purchase cigarettes among those with some college education or less (eg, with a 10% discount, adjusted odds ratio [AOR]some college=1.62, 95% confidence interval [CI] 1.21 to 2.16; AOR≤high school=1.44, 95% CI 1.08 to 1.93).

CONCLUSIONS

Availability of cigarette price discounts, price tiers and pack/carton could potentially influence cigarette purchasing behaviours among young adult smokers. Regulating these marketing strategies may, therefore, reduce education-related smoking disparities.

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.

Disentangling individual and neighborhood differences in the intention to quit smoking in Asian American male smokers

Numerous studies have assessed individual-level factors associated with intention to quit smoking. However, fewer studies have assessed how neighborhood and built environment also contribute towards individual-level behavior. We used baseline data of 340 Chinese and Vietnamese male daily smokers from August 2015 to November 2017 living in the San Francisco Bay Area, who enrolled in a lifestyle intervention trial. The outcome variable was intention to quit in 30 days. To understand the role of contextual factors participants' residential addresses were geocoded, and neighborhood median income, ethnic composition, and tobacco retail density were computed. Individual level analysis suggested that Vietnamese American men had greater intention to quit smoking (OR = 2.90 CI = 1.59, 5.26) in comparison to Chinese Americans. However, after adding neighborhood level factors to the model, no ethnic group difference was observed. Neighborhood household median income (OR = 0.74, CI = 0.64, 0.86) and tobacco retail counts (OR = 0.79, CI = 0.67, 0.94) were negatively associated with intention to quit. Years lived in the U.S. was the only individual level factor associated with intention to quit. By comparing two Asian American groups that live in heterogeneous neighborhoods, we identify key environmental and policy drivers that are associated with quit intention. Future studies aimed at influencing individual-level behavior should take into consideration the neighborhood context and built environment characteristics.

Neighborhood Disadvantage and Tobacco Retail Outlet and Vape Shop Outlet Rates

Neighborhood-level socioeconomic variables, such as the proportion of minority and low-income residents, have been associated with a greater density of tobacco retail outlets (TROs), though less is known about the degree to which these neighborhood indicators are related to vape shop outlet (VSO) density. Many studies of TROs and neighborhood characteristics include only a small set of variables and also fail to take into account the correlation among these variables. Using a carefully curated database of all TROs and VSOs in Virginia (2016–2018), we developed a Bayesian model to estimate a neighborhood disadvantage index and examine its association with rates of outlets across census tracts while also accounting for correlations among variables. Models included 12 census tract variables from the American Community Survey. Results showed that increasing neighborhood disadvantage was associated with a 63% and 64% increase in TRO and VSO risk, respectively. Important variables associated with TRO rates included % renter occupied housing, inverse median gross rent, inverse median monthly housing costs, inverse median monthly housing costs, and % vacant housing units. Important variables associated with VSO rates were % renter occupied housing and % Hispanic population. There were several spatial clusters of significantly elevated risk for TROs and VSOs in western and eastern Virginia.

PhenX: Environment measures for Tobacco Regulatory Research

OBJECTIVE

A Working Group (WG) of tobacco regulatory science experts identified measures for the tobacco environment domain.

METHODS

This article describes the methods by which measures were identified, selected, approved and placed in the PhenX Toolkit.

FINDINGS

The WG identified 20 initial elements relevant to tobacco regulatory science and determined whether they were already in the PhenX Toolkit or whether novel or improved measures existed. In addition to the 10 complementary measures already in the Toolkit, the WG recommended 13 additional measures: aided and confirmed awareness of televised antitobacco advertising, interpersonal communication about tobacco advertising, media use, perceived effectiveness of antitobacco advertising, exposure to smoking on television and in the movies, social norms about tobacco (for adults and for youth), worksite policies, youth cigarette purchase behaviours and experiences, compliance with cigarette packaging and labelling policies, local and state tobacco control public policies, and neighbourhood-level racial/ethnic composition. Supplemental measures included youth social capital and compliance with smoke-free air laws and with point of sale and internet tobacco marketing restrictions. Gaps were identified in the areas of policy environment (public and private), communications environment, community environment and social environment (ie, the norms/acceptability of tobacco use).

CONCLUSIONS

Consistent use of these tobacco environment measures will enhance rigor and reproducability of tobacco research.

Examining the role of a retail density ordinance in reducing concentration of tobacco retailers

Neighborhood characteristics and the built environment are important determinants in shaping health inequalities. We evaluate the role of a retail density ordinance in reducing concentration of tobacco stores based on neighborhood characteristics and land use pattern in San Francisco. The study evaluated the spatial distribution of tobacco retailers before and after the ordinance to identify geographic pockets where the most significant reduction had occurred. A generalized additive model was applied to assess the association between the location of the closure of tobacco retailer and socio-demographic characteristics and land use pattern. We did not find a meaningful change in the overall concentration of retailers based on neighborhood income and ethnicity but found a significant association based on patterns of land use. Our findings suggest that future polices must account for the differential distribution of retailers based on land use mix to lower concentration in areas where it is needed the most.

Residential environments and smoking behaviour patterns among young adults: A prospective study using data from the Interdisciplinary Study of Inequalities in Smoking cohort

Young adults have the highest prevalence of smoking among all age groups. Studies have shown associations between presence/density of tobacco retail and presence of smoker accommodation and smoking prevalence. However, little is known about their potential to influence different smoking patterns including initiation, maintenance, or cessation. This is important because smoking behaviour patterns in young adults may be subject to ongoing changes. Moreover, smoking pattern determinants may be different to those of smoking prevalence, and feature-pattern associations may be scale-dependent, requiring the consideration of different analytical spatial units. We examined associations between prospectively-measured smoking behaviour patterns and presence/density of tobacco retail, and presence of smoker accommodation facilities across 2 nested spatial units in Montreal, Canada. Data were from 18 to 25 year-old Montreal residents who had participated in the Interdisciplinary Study of Inequalities in Smoking cohort both at baseline in 2011-2012 and follow-up in 2014 and resided in the same area at follow-up. 2-year smoking behaviour patterns were assessed for 2 cohorts based on participants' smoking status at baseline. Associations were examined using multilevel logistic models. Young adults who were smokers at baseline residing in areas with higher local-level presence of tobacco retail were less likely to quit smoking (i.e.: to be non-smokers for fewer than 2 years). Higher presence of smoker accommodation was not associated with smoking patterns at any scale. Findings provide evidence of scale-specific associations between residential environment features and smoking behaviour patterns in young adults, which may point to specific exposure-outcome processes underlying these associations.

Regulating the local availability of tobacco retailing in Madrid, Spain: a GIS study to evaluate compliance

Background

In Spain, tobacco sales are limited to tobacco-exclusive stores and associated vending machines. A minimum of 150 m between stores is required, unless they exceed a legal sales threshold. Minimum distances to schools are recommended but not defined. We evaluated compliance with these regulations in Madrid, Spain.

Methods

Information about tobacco-exclusive stores and their sales volume was obtained in 2014. We used geographic information system to identify stores closer than 150 m between them and examine whether they exceeded the sales threshold. We estimated distances between stores and schools, considering different distance intervals (<150 m, 150–300 m and >300 m) and calculations (crow flies and street network). We assessed the association of area-level demographic and socioeconomic characteristics with the distribution of tobacco stores.

Results

5.3% (34/638) of tobacco stores were within 150 m of each other. Among those, 76% (26/34) did not meet the regulation sales threshold. These stores were in areas with lower proportion of young population (<15 years) and higher proportion of people with university-level education. 75% (476/638) of stores were situated closer than 300 m to schools. No differences were identified in sociodemographic and economic characteristics by the store distance to schools.

Conclusion

Most tobacco stores are compliant with the regulations in Spain. However, these regulations are insufficient to reduce tobacco availability. More restrictive regulations are needed to limit the geographic distribution of tobacco retailers, and health criteria should also be considered in the current legislation. The evaluation of the Spanish regulatory model may provide useful insights for other jurisdictions looking to decrease the tobacco retail availability.

Change in Neighborhood Disadvantage and Change in Smoking Behaviors in Adults: A Longitudinal, Within-individual Study

BACKGROUND

Evidence for an association between neighborhood disadvantage and smoking is mixed and mainly based on cross-sectional studies. To shed light on the causality of this association, we examined whether change in neighborhood socioeconomic disadvantage is associated with within-individual change in smoking behaviors.

METHODS

The study population comprised participants of the Finnish Public Sector study who reported a change in their smoking behavior between surveys in 2008/2009 and 2012/2013. We linked participants' residential addresses to a total population database on neighborhood disadvantage with 250 × 250-m resolution. The outcome variables were changes in smoking status (being a smoker vs. not) as well as the intensity (heavy/moderate vs. light smoker). We used longitudinal case-crossover design, a method that accounts for time-invariant confounders by design. We adjusted models for time-varying covariates.

RESULTS

Of the 3,443 participants, 1,714 quit, while 967 began to smoke between surveys. Smoking intensity increased among 398 and decreased among 364 participants. The level of neighborhood disadvantage changed for 1,078 participants because they moved residence. Increased disadvantage was associated with increased odds of being a smoker (odds ratio of taking up smoking 1.23 [95% confidence interval: 1.2, 1.5] per 1 SD increase in standardized national disadvantage score). Odds ratio for being a heavy/moderate (vs. light) smoker was 1.14 (95% confidence interval: 0.85, 1.52) when disadvantage increased by 1 SD.

CONCLUSIONS

These within-individual results link an increase in neighborhood socioeconomic disadvantage, due to move in residence, with subsequent smoking behaviors.

Associations Between Neighborhood Environment, Health Behaviors, and Mortality

INTRODUCTION

Considering the joint association of neighborhood socioeconomic environment and individual-level health behaviors with health outcomes may help officials design effective disease prevention strategies. This study evaluates the joint influences of neighborhood socioeconomic environment and individual health behaviors on mortality in a cohort primarily comprising people with low individual-level SES.

METHODS

The prospective Southern Community Cohort Study includes 77,896 white and African American participants recruited in the years 2002-2009; 55% of participants had a household income <$15,000 at baseline interview. Mortality from cancer (n=2,471), cardiovascular diseases (n=3,005), and all-causes (n=10,099) was identified from the National Death Index through December 31, 2013 (median follow-up, 8 years). Data were analyzed in 2016 and 2017. Associations were assessed between mortality, a neighborhood deprivation index composed of 11 census tract-level variables, five health behaviors, and a composite healthy lifestyle score.

RESULTS

Living in a neighborhood with the greatest socioeconomic disadvantage was associated with higher all-cause mortality in both men (hazard ratio=1.41, 95% CI=1.27, 1.57) and women (hazard ratio=1.77, 95% CI=1.57, 2.00). Associations were attenuated after adjustment for individual-level SES and major risk factors (hazard ratio for men=1.09, 95% CI=0.98, 1.22, and hazard ratio for women=1.26, 95% CI=1.12, 1.42). The dose-response association between neighborhood disadvantage and mortality was less apparent among smokers. Nevertheless, individuals who lived in disadvantaged neighborhoods and had the unhealthiest lifestyle scores experienced the highest mortality.

CONCLUSIONS

Disadvantaged neighborhood socioeconomic environments are associated with increased mortality in a cohort of individuals of low SES. Positive individual-level health behaviors may help negate the adverse effect of disadvantage on mortality.

Retailer licensing and tobacco display compliance: are some retailers more likely to flout regulations?

Objectives

To assess retailer compliance with a licensing scheme requiring tobacco retailers to list their business details with the government, to examine whether listed retailers are more likely to comply with a point-of-sale (POS) display ban and other in-store retailing laws and to explore variations in compliance between different retailer types and locations.

Method

An audit of 1739 retailers in New South Wales, Australia, was used to assess compliance with tobacco retailing legislation. Auditors actively searched for and audited unlisted retailers and all listed retailers in 122 metropolitan and regional postcodes. Multivariate generalised linear regression models were used to examine associations between compliance and retailer type, remoteness and demographic characteristics (socioeconomic level, proportion of population under 18 years and proportion born in Australia).

Results

One unlisted tobacco retailer was identified for every 12.6 listed tobacco retailers. Unlisted retailers were significantly more likely than listed retailers to breach in-store retailing laws (p<0.001). Compliance with the POS display ban was observed in 91.3% of tobacco retailers, but compliance with all retailing laws was only 73.4%. Retailers in socioeconomically disadvantaged areas had lower compliance than those in high socioeconomic areas.

Conclusions

Some tobacco retailers did not list their business details with the government as required, even though there was no financial cost to do so. Unlisted retailers were more likely to violate in-store regulations. The results suggest licensing schemes can be useful for providing a list of retailers, thus facilitating enforcement, but require a system to search for, and respond to, unlisted/unlicensed retailers.

Science for Reducing Health Inequalities Emerges From Social Justice Movements

Although the health sciences have investigated economic and social inequalities in morbidity and mortality for hundreds of years, health inequalities persist and are, by some measures, increasing. This is not simply a situation in which the knowledge exists but is not implemented. Rather, science in general and epidemiology in particular have focused on quantifying the effects of specific agents considered in isolation. This approach is powerful, but, in the absence of ecological concepts that connect parts and wholes, contributes to maintaining health inequalities. By joining movements for human rights and social justice, health scientists can identify research questions that are relevant to public health, develop methods that are appropriate to answering those questions, and contribute to efforts to reduce health inequalities.

Do Socioeconomic Risk Factors for Cigarette Smoking Extend to Smokeless Tobacco Use?

INTRODUCTION

Individuals with lower socioeconomic status (SES) are at increased risk for cigarette smoking. Less research has been conducted characterizing the relationship between SES and risk of using of other tobacco products. The present study examined SES as a risk factor for smokeless tobacco (ST) use in a US nationally representative sample, utilizing data from the 2012 National Survey on Drug Use and Health.

METHODS

Odds were generated for current cigarette smoking and ST use among adults (≥18 years) based on SES markers (educational attainment, income, blue-collar employment, and unemployment) after controlling for the influence of demographics and other substance dependence.

RESULTS

Odds of current cigarette smoking increased as a graded, inverse function of educational attainment as well as lower income and being unemployed. Odds of current ST use also increased as a function of lower educational attainment, although not in the linear manner seen with cigarette smoking. Odds of ST use but not cigarette smoking also increased with blue-collar employment. In contrast to patterns seen with cigarette smoking, ST use did not change in relation to income or unemployment.

CONCLUSIONS

Markers of SES are significantly associated with odds of cigarette smoking and ST use, but which indicators are predictive and the shape of their relationship to use differs across the two tobacco products.

Density of tobacco retail outlets near schools and smoking behaviour among secondary school students

OBJECTIVE

To investigate whether the density of tobacco retail outlets near schools in Victoria, Australia, is associated with adolescent smoking behaviour.

METHODS

Cross-sectional survey data of 2,044 secondary school students aged 12-17 years was combined with tobacco outlet audit data. Associations between students' self-reported tobacco use and the density of tobacco outlets near schools was examined using multilevel logistic and negative binomial regression models, with cigarette price at local milk bars and key socio-demographic and school-related variables included as covariates.

RESULTS

Increased tobacco retail outlet density was associated with a significant increase in the number of cigarettes smoked in the previous seven days among students who smoked in the past month (IRR=1.13; 95% CI 1.02-1.26), but not the odds of smoking in the past month in the larger sample (OR=1.06; 95% CI 0.90-1.24), after controlling for local mean price of cigarettes and socio-demographic and school-related variables.

CONCLUSIONS AND IMPLICATIONS

This study suggests there is a positive association between tobacco retail outlet density and cigarette consumption among adolescent smokers, but not smoking prevalence, in the Australian context. There is value in considering policy measures that restrict the supply of tobacco retail outlets in school neighbourhoods as a means of reducing youth cigarette consumption.

Is There a Relationship Between the Concentration of Same-Sex Couples and Tobacco Retailer Density?

BACKGROUND

Tobacco use is markedly higher among lesbian, gay, and bisexual populations than heterosexuals. Higher density of tobacco retailers is found in neighborhoods with lower income and more racial/ethnic minorities. Same-sex couples tend to live in similar neighborhoods, but the association of this demographic with tobacco retailer density has not been examined.

METHODS

For a national sample of 97 US counties, we calculated the number of tobacco retailers per 1000 persons and rates of same-sex couples per 1000 households in each census tract (n = 17 941). Using spatial regression, we examined the association of these variables in sex-stratified models, including neighborhood demographics and other environmental characteristics to examine confounding.

RESULTS

Results from spatial regression show that higher rates of both female and male same-sex couples were associated with a higher density of tobacco retailers. However the magnitude of this association was small. For female couples, the association was not significant after controlling for area-level characteristics, such as percent black, percent Hispanic, median household income, the presence of interstate highways, and urbanicity, which are neighborhood correlates of higher tobacco retailer density. For male couples, the association persisted after control for these characteristics.

CONCLUSION

Same-sex couples reside in areas with higher tobacco retailer density, and for men, this association was not explained by neighborhood confounders, such as racial/ethnic composition and income. While lesbian, gay, and bisexual disparities in tobacco use may be influenced by neighborhood environment, the magnitude of the association suggests other explanations of these disparities remain important areas of research.

Concentration of tobacco advertisements at SNAP and WIC stores, Philadelphia, Pennsylvania, 2012

Introduction

Tobacco advertising is widespread in urban areas with racial/ethnic minority and low-income households that participate in nutrition assistance programs. Tobacco sales and advertising are linked to smoking behavior, which may complicate matters for low-income families struggling with disparate health risks relating to nutrition and chronic disease. We investigated the relationship between the amount and type of tobacco advertisements on tobacco outlets and the outlet type and location.

Methods

By using field visits and online images, we inspected all licensed tobacco retail outlets in Philadelphia (N = 4,639). Point pattern analyses were used to identify significant clustering of tobacco outlets and outlets with exterior tobacco advertisements. Logistic regression was used to analyze the relationship between the outlet’s acceptance of Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and the presence of tobacco advertisements.

Results

Tobacco outlets with exterior tobacco advertisements were significantly clustered in several high-poverty areas. Controlling for racial/ethnic and income composition and land use, SNAP and WIC vendors were significantly more likely to have exterior (SNAP odds ratio [OR], 2.11; WIC OR, 1.59) and interior (SNAP OR, 3.43; WIC OR, 1.69) tobacco advertisements than other types of tobacco outlets.

Conclusion

Tobacco advertising is widespread at retail outlets, particularly in low-income and racial/ethnic minority neighborhoods. Policy makers may be able to mitigate the effects of this disparate exposure through tobacco retail licensing, local sign control rules, and SNAP and WIC authorization.

Neighbourhood availability of alcohol outlets and hazardous alcohol consumption in New Zealand

The socio-spatial arrangement of alcohol retailers is potentially important in understanding the relationship between neighbourhood context and 'excessive' alcohol consumption. This New Zealand study examines whether the availability of alcohol products is associated with individual-level alcohol consumption. Measures capturing the availability of alcohol retailers were calculated for neighbourhoods across the country and then appended to a national health survey. At the national level there was no evidence for an association between hazardous consumption and alcohol outlet access. However, there was evidence of associations with neighbourhood retailing for younger Māori and Pacific peoples males; younger European females; middle-aged European men; and older men. The findings provide evidence that 'alcogenic' environments are associated with excessive drinking in New Zealand, albeit that the associations are restricted to particular vulnerable groups.

Out of view but in plain sight: the illegal sale of single cigarettes

The practice of selling single cigarettes (loosies) through an informal economy is prevalent in urban, low socioeconomic (low SES) communities. Although US state and federal laws make this practice illegal, it may be occurring more frequently with the recent increase in taxes on cigarettes. This investigation provides information concerning the illegal practice of selling single cigarettes to better understand this behavior and to inform intervention programs and policymakers. A total of 488 African American young adults were recruited and surveyed at two education and employment training programs in Baltimore City from 2005 to 2008. Fifty-one percent of the sample reported smoking cigarettes in the past month; only 3.7% of the sample were former smokers. Approximately 65% of respondents reported seeing single cigarettes sold daily on the street. Multivariate logistic regression modeling found that respondents who reported seeing single cigarettes sold on the street several times a week were more than two times as likely to be current smokers compared to participants who reported that they never or infrequently saw single cigarettes being sold, after controlling for demographics (OR = 2.16; p = 0.034). Tax increases have led to an overall reduction in cigarette smoking. However, smoking rates in urban, low SES communities and among young adults remain high. Attention and resources are needed to address the environmental, normative, and behavioral conditions influencing tobacco use and the disparities it causes. Addressing these factors would help reduce future health care costs and save lives.

Tobacco retail availability and smoking behaviours among patients seeking treatment at a nicotine dependence treatment clinic

Background

Availability of tobacco may be associated with increased smoking. Little is known about how proximity to a retail outlet is associated with smoking behaviours among smokers seeking treatment.

Methods

A cross sectional study was conducted using chart data was extracted for 734 new clients of a nicotine dependence clinic in Toronto, Canada who visited during the period April 2008 to June 2010. Using a tobacco retail licensing list, clients were coded as to whether there were 0, 1, or more than 1 retail outlet located 250 m from their postal code address. Conditional fixed effects regression analyses were used to assess the association between proximity and quit status, number of previous quit attempts, number of cigarettes per day, and time to first cigarette, controlling for demographic characteristics and neighbourhood.

Results

72% of patients lived within 250 m of a retail outlet. Those who had more than one outlet with 250 m of their address were less likely to be abstinent at the initial assessment (OR = 0.45; 95% CI: 0.23, 0.87; p = 0.014) and less likely to have a longer time to first cigarette (OR = 0.60; 95% CI: 0.45, 0.79), both before and after adjustment for covariates. Smokers who had at least one outlet within 250 m of their address smoked 3.4 cigarettes more per day than smokers without an outlet after controlling for neighbourhood and covariates. There was no significant association between proximity and lifetime number of quit attempts.

Conclusions

Proximity to a tobacco retail outlet was associated with smoking behaviours among a heavily addicted, treatment seeking population. Environmental factors may have a substantial impact on the ability of smokers to quit smoking.

Tobacco retail outlets and vulnerable populations in Ontario, Canada

Interest has been increasing in regulating the location and number of tobacco vendors as part of a comprehensive tobacco control program. The objective of this paper is to examine the distribution of tobacco outlets in a large jurisdiction, to assess: (1) whether tobacco outlets are more likely to be located in vulnerable areas; and (2) what proportion of tobacco outlets are located close to schools. Retail locations across the Province of Ontario from Ministry of Health Promotion data were linked to 2006 Census data at the neighbourhood level. There was one tobacco retail outlet for every 1,000 people over age 15 in Ontario. Density of outlets varied by public health unit, and was associated with the number of smokers. Tobacco outlets were more likely to be located in areas that had high neighbourhood deprivation, in both rural and urban areas. Outlets were less likely to be located in areas with high immigrant populations in urban areas, with the reverse being true for rural areas. Overall, 65% of tobacco retailers were located within 500 m of a school. The sale of tobacco products is ubiquitous, however, neighbourhoods with lower socio-economic status are more likely to have easier availability of tobacco products and most retailers are located within walking distance of a school. The results suggest the importance of policies to regulate the location of tobacco retail outlets.

Retail tobacco exposure: using geographic analysis to identify areas with excessively high retail density

INTRODUCTION

There is great disparity in tobacco outlet density (TOD), with density highest in low-income areas and areas with greater proportions of minority residents, and this disparity may affect cancer incidence. We sought to better understand the nature of this disparity by assessing how these socio-demographic factors relate to TOD at the national level.

METHODS

Using mixture regression analysis and all of the nearly 65,000 census tracts in the contiguous United States, we aimed to determine the number of latent disparity classes by modeling the relations of proportions of Blacks, Hispanics, and families living in poverty with TOD, controlling for urban/rural status.

RESULTS

We identified six disparity classes. There was considerable heterogeneity in relation to TOD for Hispanics in rural settings. For Blacks, there was no relation to TOD in an urban moderate disparity class, and for rural census tracts, the relation was highest in a moderate disparity class.

CONCLUSIONS

We demonstrated the utility of classifying census tracts on heterogeneity of tobacco risk exposure. This approach provides a better understanding of the complexity of socio-demographic influences of tobacco retailing and creates opportunities for policy makers to more efficiently target areas in greatest need.

Predictors of tobacco outlet density nationwide: a geographic analysis

OBJECTIVE

To elucidate how demographics of US Census tracts are related to tobacco outlet density (TOD).

METHOD

The authors conducted a nationwide assessment of the association between socio-demographic US Census indicators and the density of tobacco outlets across all 64,909 census tracts in the continental USA. Retail tobacco outlet addresses were determined through North American Industry Classification System codes, and density per 1000 population was estimated for each census tract. Independent variables included urban/rural; proportion of the population that was black, Hispanic and women with low levels of education; proportion of families living in poverty and median household size.

RESULTS

In a multivariate analysis, there was a higher TOD per 1000 population in urban than in rural locations. Furthermore, higher TOD was associated with larger proportions of blacks, Hispanics, women with low levels of education and with smaller household size. Urban-rural differences in the relation between demographics and TOD were found in all socio-demographic categories, with the exception of poverty, but were particularly striking for Hispanics, for whom the relation with TOD was 10 times larger in urban compared with rural census tracts.

CONCLUSIONS

The findings suggest that tobacco outlets are more concentrated in areas where people with higher risk for negative health outcomes reside. Future studies should examine the relation between TOD and smoking, smoking cessation, as well as disease rates.

Tobacco environment for Southeast Asian American youth: results from a participatory research project

Despite reports of high rates of smoking among Southeast Asian refugees in the United States, few studies have described the environmental aspects of tobacco use among this population, particularly for the second-generation youths. This absence is notable because the social environment within which second-generation youths are exposed to tobacco products differs radically from the natal environment of their parents. We describe results of a youth-led community participatory research project for Southeast Asians in Northern California. Using multiple data sources, second-generation youths documented the salience of tobacco products in their social environment, notably products such as blunts and mentholated cigarettes.

Proximity to a tobacco store and smoking cessation: a cohort study

BACKGROUND

It is not clear whether the availability of tobacco affects the likelihood of smoking cessation. We examined whether the proximity to a tobacco store and the number of stores were associated with smoking cessation, and compared results for proximity variables based on walking and straight-line (as the crow flies) distance.

METHODS

The study population consisted of 8751 baseline smokers from the Finnish Public Sector study in 1997-2005. Smoking intensity (cigarettes/day) was determined at baseline and smoking cessation was determined from a follow-up survey in 2008-2009. Proximity was measured using straight-line and walking distance from home to the nearest tobacco store, and another exposure variable was the number of stores within 0.50 km from home. We calculated associations with log-binomial regression models, adjusting for individual-level and area-level confounders.

RESULTS

Of the participants, 3482 (39.8%) quit smoking during the follow-up (mean follow-up 5.5 years, SD 2.3 years). Among men who were moderate/heavy smokers at baseline and lived <0.50 km walking distance from the nearest tobacco store, the likelihood of smoking cessation was 27% (95% CI 12% to 40%) lower compared with those living ≥0.50 km from a store. Having even one store within 0.50 km walking distance from home decreased cessation in men who were moderate/heavy smokers by 37% (95% CI 19% to 51%). No decrease was found for men who were light smokers at baseline or for women.

CONCLUSIONS

Living within walking distance of a tobacco store reduced the likelihood of smoking cessation among men who were moderate/heavy smokers.

Tobacco outlet density and demographics: a geographically weighted regression analysis

Previous studies have indicated that tobacco outlets seem to be clustered in low-income minority neighborhoods. This study utilized a cross-sectional design to examine the relationships among minority status, median household income, population density, commercial land use, and location of tobacco outlets at the census tract level in Polk County, Iowa. Using geographically weighted regression, this study re-examines one previously carried out in the same location by Schneider et al. (Prevention Science 6: 319-325, 2005). Contrary to that and some other previous studies, this research found no relationship between tobacco outlet density and percent Hispanic, and found a negative relationship with regard to two variables-that of being African American and median household income. Positive significant relationships were found with population density and land use.

The relationship of neighborhood demographic characteristics to point-of-sale tobacco advertising and marketing

OBJECTIVES

Exposure to tobacco marketing has been associated with an increased likelihood that youth start smoking and may interfere with tobacco cessation. We aimed to describe the prevalence, placement, and features of tobacco advertising at the point of sale by race, ethnicity, and other neighborhood demographics, as well as by store type.

DESIGN

A cross-sectional assessment of the advertising environment in establishments that held tobacco licenses in our study region (a metropolitan area in the Midwest USA) was conducted in 2007. Stores were geocoded and linked with block group demographic data taken from the Year 2000 US census. We calculated associations between our hypothesized predictors, race, ethnicity, and other neighborhood demographics, and two types of outcomes (1) amount and (2) characteristics of the advertising.

RESULTS

Tobacco advertising at the point of sale was most common in gas stations/convenience stores, liquor stores, and tobacco stores. A 10% difference in a block group's African-American/Black population was associated with 9% (95% confidence interval [CI]=3%, 16%) more ads as well as a greater likelihood that ads would be close to the ground (prevalence ratio [PR]=1.15 [95% CI=1.04, 1.28]). Block groups with greater African-American/Black, Asian, people on public assistance or below 150% of the poverty threshold, or people under the age of 18 years had more ads for menthol brands. Block groups with greater proportions of Whites were more likely to have ads that used health words, such as 'light' or 'natural' (PR for 10% difference in White population=1.41 [95% CI=1.17-1.70]). Chain stores were more likely to have greater amounts of advertising, ads close to the ground, ads for price deals, or ads that use words that imply health.

CONCLUSION

Tobacco advertising targets communities with various racial and ethnic profiles in different ways. Now that US Food and Drug Administration has the authority to regulate the marketing and sale of tobacco products, there is new opportunity to reduce the harmful impact of tobacco advertising.

Neighbourhood deprivation and outlet density for tobacco, alcohol and fast food: first hints of obesogenic and addictive environments in Germany

OBJECTIVE

The current discussion regarding ‘place effects on health’ is increasingly focusing on the characteristics of a specific physical environment. Our study investigated whether socially deprived residential areas are more likely than affluent neighbourhoods to provide access to addictive substances and fast food.

DESIGN

In this ecological study the total number of tobacco, alcohol and fastfood outlets was recorded and visualized using a geographic information system. Area affluence was measured through the percentage of parents with children of kindergarten or school age with joint annual taxable income ,h12 272.

SETTING

Eighteen social areas in Cologne, Germany.

SUBJECTS

All social areas in four districts in Cologne, Germany, with a total of 92 000 inhabitants, were analysed.

RESULTS

In the investigation area, 339 tobacco, 353 alcohol and sixty-seven fastfood outlets were identified. As area affluence declined the availability of the following potentially health damaging sources increased: cigarettes (Kendall’s tau50?433; P50?012), alcohol (Kendall’s tau50?341, P50?049) and fast food (Kendall’s tau50?473; P50?009).

CONCLUSIONS

The availability of addictive substances and fast food can be seen to have a contextual influence on an individual’s lifestyle and can, in the form of physical exposure to obesogenic and addictive environments, contribute to a culmination of health risks.

Menthol smoking in relation to time to first cigarette and cotinine: results from a community-based study

Smokers who have their first cigarette shortly after waking, an indicator of nicotine dependence, have substantially higher cotinine levels. There is controversy regarding the role of menthol in nicotine dependence. We hypothesized that menthol smokers have a shorter time to first cigarette (TTFC), and tested whether any statistical association actually reflects increased dependence by measuring nicotine uptake (e.g. cotinine) in the same group of smokers. A cross-sectional community-based study was conducted that included 495 black and white daily cigarette smokers. Results showed a trend between menthol smoking and a shorter TTFC (P < 0.04 in blacks). Menthol was not an independent predictor of cotinine or an effect modifier with TTFC on cotinine levels in blacks and whites. These results show that while menthol in tobacco is associated with an indicator of nicotine dependence in blacks, menthol was not associated with biological uptake of nicotine in black and white smokers.

Comprehensive tobacco marketing restrictions: promotion, packaging, price and place

Evidence of the causal role of marketing in the tobacco epidemic and the advent of the WHO Framework Convention on Tobacco Control have inspired more than half the countries in the world to ban some forms of tobacco marketing. This paper briefly describes the ways in which cigarette marketing is restricted and the tobacco industry's efforts to subvert restrictions. It reviews what is known about the impact of marketing regulations on smoking by adults and adolescents. It also addresses what little is known about the impact of marketing bans in relation to concurrent population-level interventions, such as price controls, anti-tobacco media campaigns and smoke-free laws. Point of sale is the least regulated channel and research is needed to address the immediate and long-term consequences of policies to ban retail advertising and pack displays. Comprehensive marketing restrictions require a global ban on all forms of promotion, elimination of packaging and price as marketing tools, and limitations on the quantity, type and location of tobacco retailers.

Individual- and area-level unemployment influence smoking cessation among African Americans participating in a randomized clinical trial

African Americans suffer disproportionately from the adverse health consequences of smoking, and also report substantially lower socioeconomic status than Whites and other racial/ethnic groups in the U.S. Although socioeconomic disadvantage is known to have a negative influence on smoking cessation rates and overall health, little is known about the influence of socioeconomic status on smoking cessation specifically among African Americans. Thus, the purpose of the current study was to characterize the impact of several individual- and area-level indicators of socioeconomic status on smoking cessation among African Americans. Data were collected as part of a smoking cessation intervention study for African American smokers (N = 379) recruited from the Houston, Texas, metropolitan area, who participated in the study between 2005 and 2007. The separate and combined influences of individual-level (insurance status, unemployment, education, and income) and area-level (neighborhood unemployment, education, income, and poverty) indicators of socioeconomic status on continuous smoking abstinence were examined across time intervals using continuation ratio logit modeling. Individual-level analyses indicated that unemployment was significantly associated with reduced odds of smoking abstinence, while higher income was associated with greater odds of abstinence. However, only unemployment remained a significant predictor of abstinence when unemployment and income were included in the model together. Area-level analyses indicated that greater neighborhood unemployment and poverty were associated with reduced odds of smoking abstinence, while greater neighborhood education was associated with higher odds of abstinence. However, only neighborhood unemployment remained significantly associated with abstinence status when individual-level income and unemployment were included in the model. Overall, findings suggest that individual- and area-level unemployment have a negative impact on smoking cessation among African Americans. Addressing unemployment through public policy and within smoking cessation interventions, and providing smoking cessation treatment for the unemployed may have a beneficial impact on tobacco-related health disparities.

Socioeconomic, Rural-Urban, and Racial Inequalities in US Cancer Mortality: Part I-All Cancers and Lung Cancer and Part II-Colorectal, Prostate, Breast, and Cervical Cancers

We analyzed socioeconomic, rural-urban, and racial inequalities in US mortality from all cancers, lung, colorectal, prostate, breast, and cervical cancers. A deprivation index and rural-urban continuum were linked to the 2003-2007 county-level mortality data. Mortality rates and risk ratios were calculated for each socioeconomic, rural-urban, and racial group. Weighted linear regression yielded relative impacts of deprivation and rural-urban residence. Those in more deprived groups and rural areas had higher cancer mortality than more affluent and urban residents, with excess risk being marked for lung, colorectal, prostate, and cervical cancers. Deprivation and rural-urban continuum were independently related to cancer mortality, with deprivation showing stronger impacts. Socioeconomic inequalities existed for both whites and blacks, with blacks experiencing higher mortality from each cancer than whites within each deprivation group. Socioeconomic gradients in mortality were steeper in nonmetropolitan than in metropolitan areas. Mortality disparities may reflect inequalities in smoking and other cancer-risk factors, screening, and treatment.

Neighborhood perceptions are associated with tobacco dependence among African American smokers

INTRODUCTION

The animal and human research literatures suggest that deprived environmental conditions may be associated with drug dependence, but the relation of neighborhood perceptions with a multidimensional measure of tobacco dependence has not been previously studied. The purpose of this study was to examine the associations between neighborhood perceptions (neighborhood problems and neighborhood vigilance) and tobacco dependence among smokers as measured by the Wisconsin Inventory of Smoking Dependence Motives-68 (WISDM).

METHODS

Participants were 384 African American smokers (49% men, 80% < $30,000 annual household income) enrolled in a randomized clinical trial of a smoking cessation intervention. A series of regression models were conducted to examine the associations between neighborhood perceptions and tobacco dependence using a generalized estimating equation approach, which accounted for potential correlation in tobacco dependence between participants from the same neighborhood.

RESULTS

Results indicated that more self-reported neighborhood problems and greater neighborhood vigilance were significantly associated with tobacco dependence as measured by the WISDM total score in analyses adjusted for age, gender, income, education, employment status, and partner status (p ≤ .002). Neighborhood perceptions were related to both primary and secondary dependence motives (p ≤ .005).

CONCLUSIONS

Results suggest that the neighborhood context is associated with dependence on tobacco among African American smokers but longitudinal studies are needed to assess causation. Future research should also explore the mechanisms that account for the associations between neighborhood perceptions and tobacco dependence to better inform intervention development.

What happens after the implementation of electronic locking devices for adolescents at cigarette vending machines? A natural longitudinal experiment from 2005 to 2009 in Germany

INTRODUCTION

As of January 01, 2007, electronic locking devices based on proof of age (electronic cash cards or European driving licenses) were installed on 500,000 cigarette vending machines across Germany to restrict the purchase of cigarettes to those over the age of 16 years. In 2009, the age limit was raised to 18 years. The aim of this study was to compare the number of cigarette vending machines and other commercial sources before and after the enactment of the new law and to examine the association between commercial cigarette sources and area socioeconomic status (SES).

METHODS

We recorded and mapped using Geographical Information System software the total number of commercial cigarette sources in 4 selected districts in the major German city of Cologne. The city was the ideal setting for this study as we were able to use existing sociogeographical data from this area. We compiled a complete inventory of commercial cigarette sources in autumn 2005 and 2009. An interim inventory was also completed in 2007.

RESULTS

Between 2005 and 2009, the total number of cigarette sources decreased from 369 to 325 within the study area. Although the most obvious reduction was detected in the number of outdoor vending machines (-44%), the number of indoor vending machines also decreased by 5%. In 2005 as well as in 2009, we found significantly fewer commercial cigarette sources in districts with above-average SES than in districts with below-average SES.

CONCLUSIONS

Although the number of overall cigarette vending machines decreased, the disparity in distribution of cigarette sources between socially advantaged and disadvantaged areas increased.