The effect of retail cigarette pack displays on impulse purchase

IQOS point-of-sale marketing: a comparison between Arab and Jewish neighborhoods in Israel

Background

Philip Morris International's (PMI) IQOS, with its heatsticks (HEETS), is the heated tobacco product with the largest global market share. IQOS and/or electronic cigarettes use rate is higher among Arabs vs. Jews in Israel. This paper aims to compare IQOS point-of-sale (POS) marketing strategies, and regulatory compliance in Arab vs. Jewish neighborhoods in Israel.

Methods

We integrated data from two separate studies including a cross-sectional survey with IQOS retailers (December 2020-April 2021) and audits of POS that sold IQOS/HEETS (April 2021-July 2021) in 5 large cities in Israel, after marketing restrictions including a POS display ban and plain packaging became effective in Israel (January 2020). The survey included 69 POS (21 Arab, 48 Jewish neighborhoods) and the audits included 129 POS (48 Arab, 81 Jewish neighborhoods). Comparisons of IQOS marketing strategies between POS in Arab and Jewish neighborhoods were conducted using Chi-Square test, Fisher's exact test or Mann-Whitney test, as appropriate. Thematic analysis was used to analyze open-ended questions.

Results

Most marketing strategies, such as promotions to customers, were uniform across POS in Arab and Jewish neighborhoods. The most noteworthy differences were that a higher proportion of retailers from Arab neighborhoods were invited to IQOS parties (47.6% vs. 21.7%, p<0.05) and reported personal communication with a PMI representative (80.0% vs. 51.2%, p<0.05). Additionally, PMI representatives assisted POS in both Arab and Jewish neighborhoods in implementing the display ban by providing free compliant cabinets and product placement instructions, and directly interacted with customers. POS in Arab neighborhoods were more compliant with the display ban (25.5% vs. 8.8%, p<0.05), but less compliant with plain packaging (62.5% vs. 79.3%, p<0.05).

Conclusions

There were not many notable differences in IQOS marketing across POS in Arab vs. Jewish neighborhoods, but PMI utilized marketing elements of cultural significance, especially for POS in Arab neighborhoods, such as more personal communication and invitation to social events. Continuous surveillance of tobacco POS marketing and legislation compliance is needed, with a special focus on demographic/location-based differences.

Doing more with less: A proposal to advance cigarette packaging regulations in the United States

Cigarette packages are potent marketing tools. Following guidance from the WHO Framework Convention on Tobacco Control, many countries have sought to diminish this marketing power by mandating that (1) large graphic health warnings be affixed to the packages (i.e., text warnings combined with graphic images of the health consequences of smoking) and (2) all packages be fully "plain" in their design (i.e., all packages use the same drab/bland color and font type; no brand logos, other colors, or designs are permitted). Yet, the United States lags other countries in implementing regulations designed to blunt the marketing power of cigarette packages. This is not because of a lack of effort on the part of the Food and Drug Administration, the main governmental body charged with regulating tobacco products in the United States. Rather, it is because the regulatory options that that have been advanced in the country (e.g., graphic health warnings) have not been found - yet - to be legally feasible by its courts. This commentary works through some of the conceptual, practical, and legal issues regarding packaging regulations in the United States. It considers the political and bureaucratic risks involved with issuing new regulations. The overall intent is to prompt our field to think creatively about what is realistic in this regulatory space and to offer a novel perspective that may help move the United States tobacco control community forward in its efforts to reduce the promotional power of cigarette packages.

Causal effects of point-of-sale cigarette promotions and subjective social status on cigarette craving: a randomised within-person experiment

BACKGROUND

Cigarette smoking continues to be a leading cause of preventable deaths in the USA, in part because the USA has not adopted the WHO Framework Convention on Tobacco Control. One way the tobacco industry counteracts tobacco control policies is by heavily advertising cigarettes at the point of sale in retailers (eg, at the cash register) and by offering discounts on cigarettes.

DESIGN

A within-subject experimental design with adults who smoke cigarettes daily (n=281) investigated whether: (1) exposure to images of cigarette promotions in an online experiment is associated with greater cigarette craving relative to viewing images of non-smoking cues, and (2) if exposure to images of point-of-sale cigarette promotions with a discount (vs without) increases cigarette craving. The study also examined how participants' subjective social status (compared with others in the USA) relates to cigarette craving after exposure to images of cigarette promotions with and without a discount.

RESULTS

In an online experiment, exposure to images of smoking cues, including point-of-sale cigarette promotions, elicited greater craving relative to non-smoking cues (all p<0.001). In addition, images of promotions with a discount elicited higher levels of craving compared with those without a discount (b=0.09, p=0.001). Although participants with a higher (vs lower) subjective social status craved cigarettes less overall (b=-0.12, p=0.012), there was no difference in their craving between images of promotions with and without a discount, while craving was higher for images of promotions with a discount than without for participants with higher subjective social status (b=0.06, p=0.021).

CONCLUSION

Viewing images of point-of-sale cigarette promotions can causally increase cravings to smoke, which may also apply to real-world retail settings that display cigarette promotions. Restricting point-of-sale promotions generally, and discounts specifically, could help reduce cigarette smoking and address tobacco use disparities in the USA.

IQOS marketing strategies at point-of-sales: a cross-sectional survey with retailers

BACKGROUND

The point-of-sale (POS) is adapting to marketing restrictions, societal changes and the inclusion of new products, such as heated tobacco products (eg, Philip Morris International's (PMI) IQOS device and HEETS sticks). We aimed to assess (1) PMI's influences on IQOS/HEETS POS marketing and (2) the implications of the new legislation (POS display ban and plain packaging) for retailers.

METHODS

A cross-sectional survey of 43 IQOS/HEETS POS owners/managers in five Israeli cities assessed POS and participant characteristics, marketing strategies, attitudes towards IQOS, and POS implications of the legislation and COVID-19, including industry reactions. Bivariate analysis explored differences between POS selling of the IQOS device versus POS selling of HEETS only.

RESULTS

A higher proportion of those carrying IQOS (n=15) (vs HEETS only) had special displays (100% vs 17.9%, p<0.001) and interacted with specific IQOS salespersons (73.3% vs 28.6%, p=0.013). Common promotions were financial incentives based on HEETS sales for retailers (37.5%) and price discounts on HEETS for customers (48.7%). Most indicated positive attitudes towards IQOS (72.1%; eg, 'less harmful'), opposition to the legislation (62.7%), limited government assistance to implement the legislation (62.8%), and industry provision of display cases and/or signage to comply with the legislation (67.4%).

CONCLUSION

PMI uses similar tactics to promote IQOS at POS as they previously used for combustible products, including direct promotional activities with retailers, and circumvented legislation by using special displays and signage. Governments need to ban these measures and support retailers with clear practical guidance regarding the implementation of marketing restrictions at POS.

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.

Retailer experiences with tobacco sales bans: lessons from two early adopter jurisdictions

BACKGROUND

Beverly Hills and Manhattan Beach, California, are the first two US cities to prohibit the sale of tobacco products, passing ordinances that went into effect on 1 January 2021. We sought to learn about retailers' experiences with these laws 22 months after implementation.

METHODS

Brief in-person interviews with owners or managers of businesses that formerly sold tobacco (n=22).

RESULTS

Participant experiences varied by type of retailer. Managers at large chain stores reported no problems adapting to the law and little effect on overall sales. Many were largely indifferent to the sales bans. By contrast, most managers or owners of small, independent retailers reported losses of both revenue and customers, and expressed dissatisfaction with the laws. Small retailers in Beverly Hills objected particularly to exemptions that city made allowing hotels and cigar lounges to continue their sales, which they saw as undermining the health rationale for the law. The small geographical area covered by the policies was also a source of frustration, and retailers reported that they had lost business to retailers in nearby cities. The most common advice small retailers had for other retailers was to organise to oppose any similar attempts in their cities. A few retailers were pleased with the law or its perceived effects, including a reduction in litter.

CONCLUSION

Planning for tobacco sales ban or retailer reduction policies should include considering impacts on small retailers. Adopting such policies in as wide a geographical area as possible, as well as allowing no exemptions, may help reduce opposition.

Influence of cigarillo packaging characteristics on young adults' perceptions and intentions: findings from three online experiments

OBJECTIVES

Packaging is an important component of tobacco marketing that influences product perceptions and use intentions. However, little research exists on cigar packaging. We leveraged variability in existing Swisher Sweets cigarillo packaging to extend the evidence base.

METHODS

Between 2017 and 2019, we conducted three online experiments with 774 young adult past-year cigar smokers recruited via Amazon Mechanical Turk. After viewing Swisher package images that differed by flavour descriptor and/or colour, participants rated them on perceptions and purchase intentions. In study 1, participants viewed one of four cigarillos ('Wild Rush Encore', 'Wild Rush Limited', 'Twisted Berry' and 'Strawberry'). In study 2, participants viewed two different watermelon rum-flavoured cigarillos ('Boozy Watermelon' and 'Island Madness'). In study 3, participants viewed two of three 'Wild Rush' cigarillo versions ('Encore' with or without an explicit flavour descriptor or 'Limited').

RESULTS

In study 1, more participants perceived 'Twisted Berry' and 'Wild Rush Limited' as tasting good and less harsh tasting compared with 'Wild Rush Encore'. In study 2, compared with 'Island Madness', more participants perceived 'Boozy Watermelon' as tasting good, less harsh tasting and used by younger users but less by masculine users; female participants were more likely to purchase 'Boozy Watermelon'. In study 3, participants perceived 'Wild Rush Encore' with the explicit flavour descriptor as tasting better than packages without and being used by younger users but less by masculine users.

CONCLUSIONS

Variations in cigarillo packaging, even among cigarillos with the same flavour, may have differential consumer appeal, suggesting packaging features should be considered in cigar product regulation.

Policies regulating retail environment to reduce tobacco availability: A scoping review

Background

In 2005, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) entered into force. This treaty was developed in response to the global tobacco epidemic, and it includes measures to reduce both demand for and supply of tobacco. The measures related to demand reduction include raising tax, providing cessation services, promoting smoke free public places, banning advertising, and raising awareness. However, there are a limited number of measures for supply reduction, and these mainly include fighting illicit trade, banning sales to minors and providing alternatives to tobacco workers and growers. Unlike regulation of many other goods and services that have been subjected to retail restrictions, there is a lack of resources about restricting tobacco availability through regulation of tobacco retail environment. Considering the potential of retail environment regulations in reducing tobacco supply and consequently reducing tobacco use, this scoping review aims to identify relevant measures.

Methods

This review examines interventions, policies, and legislations to regulate tobacco retail environment to reduce tobacco availability. This was done by searching the WHO FCTC and its Conference of Parties decisions, a gray literature search including tobacco control databases, a scoping communication with the Focal Points of the 182 WHO FCTC Parties, and a databases search in PubMed, EMBASE, Cochrane Library, Global Health, and Web of Science.

Results

Themes of policies were identified to reduce tobacco availability by regulating retail environment: four WHO FCTC and twelve non-WHO FCTC policies. The WHO FCTC policies included requiring a license to sell tobacco, banning tobacco sale via vending machines, promoting economically alternative activities to individual sellers, and banning ways of sale that constitute a way of advertising, promotion, and sponsorships. The Non-WHO FCTC policies included banning tobacco home delivery, tray sale, tobacco retail outlets in or within a minimum distance from specific facilities, sale in specific retail outlets, and sale of tobacco or one or more of its products, in addition to restricting tobacco retail outlets per density of population and per geographic area, capping the tobacco amount allowed per purchase, limiting the number of hours or days in which tobacco can be sold, requiring a minimum distance between tobacco retailers, reducing tobacco products availability and proximity within a retail outlet, and restricting sale to government controlled outlets.

Discussion and conclusion

Studies show the effects of regulation of the retail environment in influencing overall tobacco purchases, and there is evidence that having fewer retails reduces the level of impulse purchasing of cigarettes and tobacco goods. The measures covered by WHO FCTC are much more implemented than ones not covered by it. Although not all widely implemented, many themes of limiting tobacco availability by regulating tobacco retail environment are available. Further studies to explore such measures and the adoption of the effective ones under the WHO FCTC decisions, could possibly increase their implementation globally to reduce tobacco availability.

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.

Prohibition no, abolition yes! Rethinking how we talk about ending the cigarette epidemic

As public health advocates struggle over how best to end the cigarette epidemic, one persistent obstacle to developing appropriate policies has been the lingering spectre of 'prohibition'. A misunderstanding of the USA's experience with the national ban on sales of alcohol more than a century ago has led even public health advocates to claim that we cannot end the sale of cigarettes because 'prohibition does not work': a ban on sales, we hear, would lead to crime and to black markets, among many other negatives. In this Special Communication, we show how the tobacco industry has carefully constructed and reinforced this imagined impossibility, creating a false analogy between cigarettes and alcohol. This improper analogy, with its multiple negative associations, continues to block intelligent thinking about how to end cigarette sales. Instead of prohibition, we propose abolition as a term that better captures what ending sales of the single most deadly consumer product in history will actually do: enhance human health and freedom.

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.

Boosting the Tobacco Control Vaccine: recognizing the role of the retail environment in addressing tobacco use and disparities

Much of the progress in reducing cigarette smoking and tobacco-related morbidity and mortality among youth and adults is attributable to population-level strategies previously described in the context of the Tobacco Control Vaccine. The retail environment is used heavily by the tobacco industry to promote and advertise its products, and variations in exposure to and characteristics of the retail environment exist across demographic groups. It is therefore also an essential environment for further reducing smoking, as well as ameliorating racial, ethnic and socioeconomic tobacco-related disparities. This commentary provides an overview of the importance of incorporating strategies focused on the tobacco retailer environment (availability; pricing and promotion; advertising and display; age of sale; and retail licensure) as part of a comprehensive approach to tobacco prevention and control. To reach tobacco endgame targets, such innovative strategies are a complement to, but not a replacement for, long-standing evidence-based components of the Tobacco Control Vaccine.

Image Processing for Public Health Surveillance of Tobacco Point-of-Sale Advertising: Machine Learning-Based Methodology

BACKGROUND

With a rapidly evolving tobacco retail environment, it is increasingly necessary to understand the point-of-sale (POS) advertising environment as part of tobacco surveillance and control. Advances in machine learning and image processing suggest the ability for more efficient and nuanced data capture than previously available.

OBJECTIVE

The study aims to use machine learning algorithms to discover the presence of tobacco advertising in photographs of tobacco POS advertising and their location in the photograph.

METHODS

We first collected images of the interiors of tobacco retailers in West Virginia and the District of Columbia during 2016 and 2018. The clearest photographs were selected and used to create a training and test data set. We then used a pretrained image classification network model, Inception V3, to discover the presence of tobacco logos and a unified object detection system, You Only Look Once V3, to identify logo locations.

RESULTS

Our model was successful in identifying the presence of advertising within images, with a classification accuracy of over 75% for 8 of the 42 brands. Discovering the location of logos within a given photograph was more challenging because of the relatively small training data set, resulting in a mean average precision score of 0.72 and an intersection over union score of 0.62.

CONCLUSIONS

Our research provides preliminary evidence for a novel methodological approach that tobacco researchers and other public health practitioners can apply in the collection and processing of data for tobacco or other POS surveillance efforts. The resulting surveillance information can inform policy adoption, implementation, and enforcement. Limitations notwithstanding, our analysis shows the promise of using machine learning as part of a suite of tools to understand the tobacco retail environment, make policy recommendations, and design public health interventions at the municipal or other jurisdictional scale.

Smokeless Tobacco Point of Sale Advertising, Placement and Promotion: Associations With Store and Neighborhood Characteristics

Introduction: Objectives of this study were to determine retail and neighborhood characteristics associated with smokeless tobacco (ST) product promotion, price promotion, and storefront advertising among retailers in Oklahoma.

Methods: In this statewide point-of-sale study, we collected data from 1,354 ST retailers. Using store characteristics and census tract information, we estimated summary statistics and adjusted prevalence ratios during 2019–2020.

Results: Of ST retailers audited, 11.0% demonstrated ST youth promotion, 43.0% ST price promotions, and 19.6% ST storefront advertising. The adjusted prevalence ratio (aPR) for convenience stores was higher for all three ST strategies: youth promotion (aPR = 3.4, 95% CI 1.9, 6.2), price promotion (aPR = 3.8, 95% CI 2.9, 5.0), and storefront advertising (aPR=16.4, 95% CI 6.7, 40.3) compared to other store types. Metropolitan tobacco retailers had higher aPRs for youth promotion (aPR = 1.7, 95% CI 1.12 2.6) and storefront advertising (aPR = 1.5, 95% CI 1.2, 1.9).

Conclusions: Findings of this study suggest there are currently ample opportunities for youth and adults at risk for tobacco initiation to be exposed to ST products in the retail environment. Convenience stores, more likely to be found and utilized in rural areas compared to metropolitan areas, are disproportionately more likely to engage in marketing strategies that could lure youth into trying smokeless tobacco.

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.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Implications

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

Tobacco and E-Cigarettes Point of Sale Advertising-Assessing Compliance with Tobacco Advertising, Promotion and Sponsorship Bans in Poland

The objective of this study was to evaluate compliance with the ban on tobacco and e-cigarette products advertising at point of sale (POS) before and after amendment of the Polish Tobacco Control Act. Data were collected, using an observation checklist, between March and October 2014 (n = 1450 POS) and between March and October 2019 (n = 1320 POS). Ban on tobacco and e-cigarette advertising at POS is commonly violated in Poland. In all POS, at least one form (including tobacco products display) of tobacco advertising was found in 2014 and in 2019. The most common types of tobacco advertising in 2014 were change and counter mats (61%, 42%), posters (38%) and illuminated banners (37%). In 2019, a decrease in promoting tobacco products in the form of mats (p ≤ 0.001), posters and boards (p < 0.001) but an increase in video screens were observed (from 8% in 2014 to 30% in 2019; p < 0.001). A significant increase in the presence of any e-cigarette ads, including e-cigarette displays, illuminated banners and video screens, was observed in 2019 as compared to 2014 (90% vs. 30%; 89% vs. 20%; 31% vs. 2%; 31% vs. 0.5%; p < 0.001). The minimum age or a no-sale-to-minors signs for tobacco and e-cigarettes were not sufficiently placed in POS to comply with the Act. Poor enforcement of the ban on tobacco and e-cigarette ads at POS provides the tobacco industry with an opportunity to promote their products using unlawful ways. There is a need to educate the public, retailers and civil society with respect to their legal responsibilities and roles.

Associations of tobacco retailer availability with chronic obstructive pulmonary disease related hospital outcomes, United States, 2014

There are associations between tobacco retailer density and smoking behaviors, but little is known about whether places with more tobacco retailers have more smoking-related health problems. Using cross-sectional data from 2014, we investigated the relationships between tobacco retailer density and chronic obstructive pulmonary disease (COPD) related outcomes in a sample of 1510 counties across the United States. Higher retailer density was associated with a 19% (IRR, 1.19; 95% CI, 1.12-1.27) higher COPD-related hospital discharge rate and 30% (IRR, 1.30; 95% CI 1.21-1.39) higher total COPD-related hospital costs per population. The tobacco retailer environment may be an important target for reducing smoking-related health burdens and costs.

Changes in Tobacco Product Advertising at Point of Sale: 2015-2018

OBJECTIVES

Tobacco point-of-sale advertising, particularly in retailers surrounding schools, is associated with youth tobacco use and must be monitored. This study examines how the point-of-sale environment surrounding youth changed over time with regard to diverse tobacco products.

METHODS

Each spring from 2015 to 2018, research staff visited the same tobacco retailers (n = 141) within a half-mile of New Jersey high schools. For cigarettes, cigars, electronic cigarettes, and smokeless tobacco, advertisement presence, volume, and share of advertising voice (SAV) were measured for both the exterior and interior of the store. Analyses examined changes over time by product, controlling for store type and poverty.

RESULTS

Over time, exterior cigarette advertisements declined in presence (61% to 49%) and SAV (50% to 40%), whereas interior advertisements maintained stable presence, volume, and SAV. In contrast, cigar advertisements increased in presence (exterior 11% to 23%; interior 19% to 30%) and volume (exterior mean 0.2 to 0.5; interior 0.3 to 0.8). For electronic cigarettes, exterior and interior advertising presence, volume, and SAV decreased from 2015 to 2017 but increased in 2018. Smokeless tobacco advertising was infrequent and stayed consistent except in volume in the interior of stores (mean 0.2 to 0.3). When there were any differences by store type, chain convenience stores had the most exterior and interior advertising for all products.

CONCLUSIONS

The longitudinal changes observed for each product's advertising reflect national youth use rates of the corresponding products. The point-of-sale environment around schools may be influencing youth tobacco use and must be monitored and regulated.

Tobacco industry and public health responses to state and local efforts to end tobacco sales from 1969-2020

BACKGROUND

In June 2019, Beverly Hills, California, became the first American city in the 21st century to pass an ordinance ending the sale of most tobacco products, including cigarettes, and it is unlikely to be the last. Knowledge of previous efforts to ban tobacco sales in the US, both successful and unsuccessful, may help inform tobacco control advocates' approach to future efforts.

METHODS

We retrieved and analyzed archival tobacco industry documents. We confirmed and supplemented information from the documents with news media coverage and publicly available state and local government materials, such as meeting minutes and staff reports, related to proposed bans.

RESULTS

We found 22 proposals to end the sale of cigarettes or tobacco products from 1969-2020 in the US. Proposals came from five states, twelve cities or towns, and one county. Most came from elected officials or boards of health, and were justified on public health grounds. In opposing tobacco sales bans, the tobacco industry employed no tactics or arguments that it did not also employ in campaigns against other tobacco control measures. Public health groups typically opposed sales ban proposals on the grounds that they were not evidence-based. This changed with Beverly Hills' 2019 proposal, with public health organizations supporting this and other California city proposals because of their likely positive health impacts. This support did not always translate into passage of local ordinances, as some city council members expressed reservations about the impact on small businesses.

CONCLUSION

Tobacco control advocates are likely to encounter familiar tobacco industry tactics and arguments against tobacco sales ban proposals, and can rely on past experience and the results of a growing body of retail-related research to counter them. Considering how to overcome concerns about harming retailers will likely be vital if other jurisdictions are to succeed in ending tobacco sales.

Peer crowd-based targeting in E-cigarette advertisements: a qualitative study to inform counter-marketing

Background

Cigarette lifestyle marketing with psychographic targeting has been well documented, but few studies address non-cigarette tobacco products. This study examined how young adults respond to e-cigarette advertisements featuring diverse peer crowds – peer groups with shared identities and lifestyles – to inform tobacco counter-marketing design.

Methods

Fifty-nine young adult tobacco users in California participated in interviews and viewed four to five e-cigarette advertisements that featured characters from various peer crowd groups. For each participant, half of the advertisements they viewed showed characters from the same peer crowd as their own, and the other half of the advertisements featured characters from a different peer crowd. Advertisements were presented in random order. Questions probed what types of cues are noticed in the advertisements, and whether and how much participants liked or disliked the advertisements.

Results

Results suggest that participants liked and provided richer descriptions of characters and social situations in the advertisements featuring their own peer crowd more than the advertisements featuring a different peer crowd. Mismatching age or device type was also noted: participants reported advertisements showing older adults were not intended for them. Participants who used larger vaporizers tended to dislike cigalike advertisements even if they featured a matching peer crowd.

Conclusion

Peer crowd and lifestyle cues, age and device type are all salient features of e-cigarette advertising for young adults. Similarly, educational campaigns about e-cigarettes should employ peer crowd-based targeting to engage young adults, though messages should be carefully tested to ensure authentic and realistic portrayals.

Exposure to Point-of-Sale Marketing of Cigarettes and E-Cigarettes as Predictors of Smoking Cessation Behaviors

Introduction

Cue-reactivity theory suggests that smoking-related visual cues such as point-of-sale (POS) marketing (eg, advertising, product displays) may undermine cessation attempts by causing an increase in nicotine cravings among users. This study examined the relationship between recall of exposure to POS marketing and subsequent cessation behaviors among young adult cigarette smokers.

Methods

Participants included 813, 18-29 year old (m = 21.1, SD = 2.70), current cigarette smokers attending 24 Texas colleges. Multivariable logistic regression models examined the impact of baseline self-reported exposure to cigarette and e-cigarette advertising and product displays, on using e-cigarettes for cessation and successful cigarette cessation at 6-month follow-up. Two-way interactions between product-specific advertising and between product-specific displays were examined to determine if the marketing of one product strengthened the cue reactivity of the other. Baseline covariates included sociodemographic factors, past quit attempts, intentions to quit smoking, and nicotine dependence.

Results

Exposure to e-cigarette displays was associated with lower odds of cigarette smoking cessation, controlling for covariates and conventional cigarette display exposure. E-cigarette advertising was positively associated with the use of e-cigarettes for cigarette cessation among participants exposed to low (ie, at least 1 SD below the mean) levels of cigarette advertising. Cigarette advertising was associated with the use of e-cigarettes for cigarette cessation only among those exposed to low levels of e-cigarette advertising. Exposure to cigarette displays was not associated with either outcome.

Conclusion

Smoking-related cues at POS may undermine successful cigarette cessation. Exposure to product displays decrease odds of cessation. Advertising exposure increased odds for using e-cigarettes for cessation attempts, but may have guided smokers towards an unproven cessation aid.

Implications

By examining the interaction of conventional cigarette and e-cigarette marketing exposure, this study adds a unique insight into the impact of retail tobacco marketing on cigarette smoking cessation behavior among young adults. These findings suggest that policies that balance encouraging cigarette smoking cessation while limiting marketing strategies should be considered, such as POS product displays, that may undermine successful cessation attempts.

The impact of the point-of-sale tobacco display ban on young people in Scotland: before-and-after study

Background

Tobacco displays at point of sale have been shown to increase young people’s pro-smoking attitudes, susceptibility to smoking and smoking initiation. In Scotland, legislation that prohibited tobacco point-of-sale displays was implemented in large stores (i.e. those > 280 m2) in April 2013 and in small retailers in April 2015.

Objective

To assess the impact of the point-of-sale tobacco display ban on young people’s exposure to tobacco advertising, their attitudes to smoking and smoking susceptibility, and their risk of smoking initiation.

Design

Multimodal before-and-after study design using mixed methods to collect data at baseline (2013) and then longitudinally for 4 years.

Setting

Four main study communities in the central belt of mainland Scotland, UK, purposively selected to reflect two levels of urbanity (urban vs. small town) and two levels of deprivation (high vs. medium/low). Four matched communities.

Participants

In the main study communities, 94 tobacco retail outlets. All Secondary 2 (aged 13 years) and Secondary 4 (aged 15 years) pupils in 2013 and 2014 together with all Secondary 1 to Secondary 6 (aged 12–17 years) pupils in 2015–17. This included 6612 pupils who completed 14,344 questionnaires over 5 years. Three hundred and eighty-two participants in 80 focus groups who were recruited from Secondary 2 and Secondary 4 in 2013–17. In matched communities, 24 retail panel members in 2013–17.

Main outcome measures

Tobacco product and tobacco storage visibility, density of retail outlets (the number of retailers in a pre-defined area such as a residential neighbourhood), tobacco product exposure, brand awareness, perceived accessibility of tobacco, pro-smoking attitudes, pro-smoking norms, smoking susceptibility and smoking initiation.

Data platform and methods

The study had four components – a mapping and spatial analysis of retail outlets; a tobacco marketing audit, including retail panel interviews in matched communities; school surveys; and focus group discussions with secondary school pupils.

Limitations

The study was based on a small number of communities and did not include communities in remote areas.

Results

Compliance with the point-of-sale legislation in Scotland was high. This led to a large reduction in the visibility of tobacco products in retail outlets. However, when the results were stratified by socioeconomic status, declines in retailer density, weighted by total product visibility, were restricted to the least disadvantaged tertile of participants. Nevertheless, the implementation of the legislation was associated with a reduction in risk of both smoking susceptibility and smoking initiation in young people, as well as a reduction in the perceived accessibility of tobacco and in pro-smoking attitudes after both the partial and the comprehensive bans were introduced.

Conclusions

The Scottish point-of-sale legislation has been successful in reducing the overall visibility of tobacco products and is associated with improvements in attitudinal and behavioural outcomes in young people. However, cues that tobacco is for sale are still highly visible, particularly in retail outlets in areas of deprivation. In addition, the increase in retailer density that was observed after 2015 increased inequalities in product visibility. There was also evidence that the emergence of e-cigarettes may have disrupted the full impact of the legislation.

Future work

Our research indicates that further research is needed to examine the longitudinal relationships between tobacco outlet availability and product visibility inequalities; and the impact of e-cigarettes and standardised packaging on smoking initiation and prevalence.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

Convenience store visitors recall cigarette advertisements even if they do not purchase cigarettes

Background

This study examined the extent to which visitors to convenience stores remember the cigarette advertisements they encounter in these stores and investigated the relationships between how advertisements are recalled and attitudes toward them.

Methods

Exit surveys of 1007 visitors to three convenience stores located in Seoul, Korea, were conducted between 25 November 2015 and 7 December 2015.

Results

Of the respondents, 23.4% (n = 236) freely recalled the cigarette advertisement in the store just visited. However, the percentage of participants who correctly recalled the advertisement increased to 55.2% (n = 556) after we presented them with a card showing options for the advertisement (i.e. a cued recall task). Regardless of sex or purchasing cigarettes, free recall performance was significantly associated with age, number of weekly visits to the convenience store and current smoking status. In addition, free recall increased with having a positive attitude toward cigarette advertisements.

Conclusions

Repeated visits to convenience stores may continue to expose individuals to cigarettes and their advertisements; such exposure may subconsciously affect recall of the advertisements and maintenance of a positive attitude toward cigarette advertisements. Therefore, to denormalize smoking in society, cigarette advertising and displays at points of sale including convenience stores, should be banned.

Antismoking Advertisements and Price Promotions and Their Association With the Urge to Smoke and Purchases in a Virtual Convenience Store: Randomized Experiment

Background

Point of sale (POS) advertising is associated with smoking initiation, current smoking, and relapse among former smokers. Price promotion bans and antismoking advertisements (ads) are 2 possible interventions for combating POS advertising.

Objective

The purpose of this analysis was to determine the influence of antismoking ads and promotions on urges to smoke and tobacco purchases.

Methods

This analysis examined exposure to graphic (graphic images depicting physical consequences of tobacco use) and supportive (pictures of and supportive messages from former smokers) antismoking ads and promotions in a virtual convenience store as predictors of urge to smoke and buying tobacco products among 1200 current cigarette smokers and 800 recent quitters recruited via a Web-based panel (analytical n=1970). We constructed linear regression models for urge to smoke and logistic regression models for the odds of purchasing tobacco products, stratified by smoking status.

Results

The only significant finding was a significant negative relationship between exposure to supportive antismoking ads and urge to smoke among current smokers (beta coefficient=−5.04, 95% CI −9.85 to −0.22; P=.04). There was no significant relationship between graphic antismoking ads and urge to smoke among current smokers (coefficient=−3.77, 95% CI −8.56 to 1.02; P=.12). Neither relationship was significant for recent quitters (graphic: coefficient=−3.42, 95% CI −8.65 to 1.81; P=.15 or supportive: coefficient=−3.82, 95% CI −8.99 to 1.36; P=.20). There were no significant differences in urge to smoke by exposure to promotions for current smokers (coefficient=−1.06, 95% CI −4.53 to 2.41; P=.55) or recent quitters (coefficient=1.76, 95% CI −2.07 to 5.59; P=.37). There were also no differences in tobacco purchases by exposure to graphic (current smokers: coefficient=0.93, 95% CI 0.67 to 1.29; P=.66 and recent quitters: coefficient=0.73, 95% CI 0.44 to 1.19; P=.20) or supportive (current smokers: coefficient=1.05, 95% CI 0.75 to 1.46; P=.78 and recent quitters: coefficient=0.73, 95% CI 0.45 to 1.18; P=.20) antismoking ads or price promotions (current smokers: coefficient=1.09, 95% CI 0.86 to 1.38; P=.49 and recent quitters: coefficient=0.90, 95% CI 0.62 to 1.31; P=.60).

Conclusions

The results of this analysis support future research on the ability of supportive antismoking ads to reduce urges to smoke among current cigarette smokers. Research on urges to smoke has important tobacco control implications, given the relationship between urge to smoke and smoking cigarettes, time to next smoke, and amount smoked.

Assessing the Relationship between Retail Store Tobacco Advertising and Local Tobacco Control Policies: A Massachusetts Case Study

Objective

This study documents the extent of tobacco ads in retail stores and evaluates its association with the comprehensiveness of local tobacco control policies in the state of Massachusetts, US.

Methods

Using a two-stage cluster sampling method, we sampled 419 retail stores across 42 municipalities to assess the presence and count of nine mutually exclusive tobacco ad categories. Tobacco ads by store type and municipality were analyzed using summary statistics and contingency tables. Regression models tested the association between the extent of tobacco ads and local tobacco control policy comprehensiveness.

Results

Overall, 86.6% (n = 363) of all the retail stores had tobacco ads. On average, there were 6.7 ads per retail store (SD = 6.61) and 2804 ads across all the retail stores (range = 0 : 32). Retail stores had an average of three different categories of tobacco ads (mean = 2.98, SD = 1.84). Across all retail stores, the most frequent ad categories were power walls (80.0%) and e-cigarette ads (55.8%). Retail stores in municipalities with more comprehensive local tobacco control policies were more likely to have fewer tobacco ads (IRR = 0.92, p < 0.01) and a lower number of tobacco ad categories (OR = 0.88, p < 0.05).

Conclusion

Municipalities can adopt more comprehensive tobacco control policies to help limit the extent of tobacco retail advertising. This can ultimately reduce smoking in their jurisdiction.

Tobacco company strategies for maintaining cigarette advertisements and displays in retail chain stores: In-depth interviews with Korean convenience store owners

INTRODUCTION

This study gathered data from store owners regarding the advertising and display of, and the contractual arrangements and promotional activities related to, the sale of tobacco products in convenience stores.

METHODS

In-depth interviews were conducted with three owners of convenience stores in South Korea: to examine the procedures for managing the sale of tobacco products; for allocating the advertising allowance for such products; and for coordinating the promotional activities of tobacco companies.

RESULTS

All tobacco advertisements and displays in convenience stores are installed and managed in accordance with the contract between the tobacco companies and the convenience store headquarters. The headquarters receives an allowance from the tobacco company in return for maintaining and displaying their product and promotional materials. The headquarters then pays a monthly advertising allowance to each franchisee as an operating subsidy. However, the owners also stated that tobacco companies provide financial incentives directly to them to engage in illegal promotional activities.

CONCLUSIONS

Because tobacco advertisements and displays at convenience stores are related to the profitability of these products, the participants in these relationships have become increasingly entangled. Illegal promotional activities must be monitored to limit tobacco sales and advertising. Furthermore, efforts to ban the advertising and display of tobacco products at the point of sale must be based on the development of policies emerging from an understanding of the roles of the major stakeholders.

Do graphic health warning labels on cigarette packages deter purchases at point-of-sale? An experiment with adult smokers

This experiment tested whether the presence of graphic health warning labels on cigarette packages deterred adult smokers from purchasing cigarettes at retail point-of-sale (POS), and whether individual difference variables moderated this relationship. The study was conducted in the RAND StoreLab (RSL), a life-sized replica of a convenience store that was developed to evaluate how changing POS tobacco advertising influences tobacco use outcomes during simulated shopping experiences. Adult smokers (n = 294; 65% female; 59% African-American; 35% White) were assigned randomly to shop in the RSL under one of two experimental conditions: graphic health warning labels present on cigarette packages versus absent on cigarette packages. Cigarette packages in both conditions were displayed on a tobacco power wall, which was located behind the RSL cashier counter. Results revealed that the presence of graphic health warning labels did not influence participants' purchase of cigarettes as a main effect. However, nicotine dependence acted as a significant moderator of experimental condition. Graphic health warning labels reduced the chances of cigarette purchases for smokers lower in nicotine dependence but had no effect on smokers higher in dependence.

From glass boxes to social media engagement: an audit of tobacco retail marketing in Indonesia

OBJECTIVE

To assess tobacco promotion intensity, retailer behaviours and tobacco company efforts to link retailer marketing to online channels.

METHODS

We completed an audit of tobacco advertisements and promotions at 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia that included an observation checklist, digital photos and structured interviews with retailers. We then calculated the tobacco promotion index for each retailer and made comparisons based on store types. Next, we conducted a photo analysis from 100 randomly selected retailers to explore links to online channels and other promotional cues to engage young people.

RESULTS

Mini-markets have both the highest total number of promotions and the highest indoor promotion index with a mean score of 5.1 and 3.7, respectively. Kiosks have the highest outdoor promotion index with a mean score of 1.6. Most of the retailers (98.9%) displayed cigarettes, more than half of kiosk retailers (54.8%) and mini-market retailers (56.3%) admitted selling cigarettes to young people, and 74% of kiosk retailers sell single stick cigarettes. We found links to online marketing, including two hashtags and a company website. Promotional materials also included youth-focused content such as English taglines, new products and small packs.

CONCLUSION

Tobacco companies in Indonesia have strategically differentiated their advertisements based on retailer type and have bridged conventional retailer marketing to online channels. Reforming Indonesian tobacco laws to include bans on single sticks and small pack sales, point-of-sale advertising, including displays, and enforcement of laws on sales to minors is urgently required.

Availability, price and promotions for cigarettes and non-cigarette tobacco products: an observational comparison of US Air Force bases with nearby tobacco retailers, 2016

INTRODUCTION

Active duty military personnel have higher cigarette and smokeless tobacco use rates than civilian populations. Although US Airmen (called Airmen regardless of gender or rank) are required to be tobacco-free during initial training, many resume use once this period ends, perhaps as a result of easy access to cheap tobacco products.

METHODS

Between July and September 2016, we collected tobacco product, price and promotion information by visiting on-base (n=28) and off-base (n=80) tobacco retailers near the eight technical training bases where approximately 99% of Airmen attend training. We conducted mixed linear effects models to examine on-base versus off-base differences.

RESULTS

Cigarette packs were 11%-12% cheaper at on-base retailers compared with off-base retailers. Newport Menthol and Marlboro Red cigarette packs were $0.87 and $0.80 lower on-base (p<0.001) while the cheapest pack available was $0.54 lower on-base (p<0.01). Copenhagen smokeless tobacco was also significantly cheaper on-base (B=-0.65, p<0.01). Interior price promotions were more common on-base.

CONCLUSIONS

Retail stores located on Air Force bases sell cigarettes and smokeless tobacco products at prices well below those in nearby off-base retailers: the vast majority of these retailers feature interior price promotions for these products. Federal policies regulating prices of on-base tobacco sales, if implemented more effectively, have the potential to protect the health of Airmen by helping them remain tobacco-free after technical training.

Tackling the tobacco epidemic in the Nordic countries and lower cancer incidence by 1/5 in a 30-year period-The effect of envisaged scenarios changing smoking prevalence

BACKGROUND

Tobacco smoking is a leading cause of cancer and the most preventable cause of cancer worldwide. The aim of this study was to quantify the proportion of the cancer burden in the Nordic countries linked to tobacco smoking and estimate the potential for cancer prevention by changes in smoking prevalence.

METHODS

The Prevent macro-simulation model was used, estimating the future number of cancer cases in the Nordic countries over a 30-year period (2016-2045), for 13 cancer sites, under different scenarios of changing smoking prevalence, and compared to the projected number of cases if constant prevalence prevailed.

RESULTS

A total of 430,000 cancer cases, of the 2.2 million expected for the 13 studied cancer sites, could be avoided in the Nordic countries over the 30-year period if smoking was eliminated from 2016 onwards. If prevalence of smoking is reduced to 5% by year 2030 and to 2% by 2040, 230,000 cancer cases could be avoided. The largest proportion of cancers can be avoided in Denmark, where smoking prevalence is the highest, and similar to the prevalence in many European countries.

CONCLUSION

A large amount of cancers could be avoided in the Nordic countries if smoking prevalence was reduced. The results from this study can be used to understand the potential impact and significance of primary prevention programmes targeted towards reducing the prevalence of tobacco smoking in the Nordic countries.

Point-of-Sale E-cigarette Advertising Among Tobacco Stores

The marketing expenditure and sale of e-cigarettes increased sharply in the United States in recent years. However, little is known about neighborhood characteristics of point-of-sale (POS) e-cigarette advertising among tobacco stores. The purpose of this study was to examine socio-demographic characteristics of POS e-cigarette advertising among tobacco stores in the Omaha metropolitan area of Nebraska, USA. Between April and June 2014, trained fieldworkers completed marketing audits of all stores that sell tobacco (n = 463) in the Omaha metropolitan area and collected comprehensive e-cigarette advertising data of these stores. Based on the auditing information, we categorized tobacco stores based on e-cigarette advertising status. Logistic regression was used to examine the association between neighborhood socio-demographic factors and e-cigarette advertising among tobacco stores. 251 (54.2%) of the 463 tobacco stores had e-cigarette advertisements. We found that neighborhoods of stores with POS e-cigarette advertising had higher per capita income (p < 0.05), higher percentage of non-hispanic whites (p < 0.005), and higher percentage of individuals with high school education (p < 0.005) than neighborhoods of stores without POS e-cigarette advertising. There were negative associations between e-cigarette advertising and number of adolescents or number of middle/high school students. After adjusting for covariates, only percentage of non-Hispanic Whites remained a significant factor for e-cigarette advertising. POS e-cigarette advertising among tobacco stores is related with neighborhood socioeconomic and demographic characteristics. Future studies are needed to understand how these characteristics are related with e-cigarette purchasing and e-cigarette prevalence among social groups.

Disparities in retail marketing for menthol cigarettes in the United States, 2015

This study describes retail marketing for menthol cigarettes and its relationship with neighborhood demographics in a national sample of tobacco retailers in the United States. Mixed-effects models were used to examine three outcomes: menthol cigarette exterior advertising, menthol cigarette price promotions, and the pack price of menthol and non-menthol cigarettes. Thirty-eight percent of retailers displayed at least one menthol advertisement on the store exterior and 69% advertised price promotions. Retail advertising was more common in neighborhoods in the second (OR = 1.5 [1.1, 2.0]) and fourth (OR = 1.9 [1.3, 2.7]) quartiles of Black residents as compared to the lowest quartile. Menthol advertising was more prevalent in the third (OR = 1.4 [1.0, 1.9]) and lowest (OR = 1.6 [1.2, 2.2]) income quartiles as compared to the highest quartile. Price promotions for Newport were more common in neighborhoods with the highest quartile of Black residents (OR = 1.8 [1.2, 2.7]). Prices of Newport were cheaper in neighborhoods with the highest quartiles of youth, Black residents, and lower-income households. Policies that restrict the sales and marketing of menthol cigarettes are needed to address disparities.

Pro-tobacco advertisement exposure among African American smokers: An ecological momentary assessment study

INTRODUCTION

Many African Americans live in communities with a disproportionately high density of tobacco advertisements compared to Whites. Some research indicates that point-of-sale advertising is associated with impulse purchases of cigarettes and smoking. Ecological Momentary Assessment (EMA) can be used to examine associations between tobacco advertisement exposure and smoking variables in the natural environment.

METHODS

Non-treatment seeking African American smokers were given a mobile device for 2weeks (N=56). They were prompted four times per day and responded to questions about recent exposure to tobacco advertisements. Participants were also asked to indicate the number of cigarettes smoked, and if they made any purchase, or an impulse purchase, since the last assessment. Linear mixed models (LMMs) analyzed between- and within-subject associations between exposure and outcomes.

RESULTS

Participants reported seeing at least one advertisement on 33% of assessments. Of those assessments, they reported seeing menthol advertisements on 87% of assessments. Between-subject analyses revealed that participants who on average saw more advertisements were generally more likely to report purchasing cigarettes and to purchase cigarettes on impulse. Within-subject analyses revealed that when an individual participant reported seeing more advertisements than usual they were more likely to have reported purchasing cigarettes, making an impulse purchase and smoking more cigarettes during the same period, but not the subsequent time period.

CONCLUSIONS

Many African American smokers are frequently exposed to pro-tobacco marketing. Advertisement exposure is cross-sectionally associated with impulse purchases and smoking. Future research should assess prospective associations in more detail.

Impact of removing point-of-sale tobacco displays on smoking behaviour among adolescents in Europe: a quasi-experimental study

BACKGROUND

An increasing number of European countries implemented a point-of-sale (PoS) display ban on tobacco products. This study assessed the association between PoS display bans in Europe and adolescent smoking and perceived accessibility of tobacco, 2-6 years after PoS display ban implementation.

METHODS

In a quasi-experimental design, we compared individuals in countries that did and countries that did not implement a PoS display ban, before and after implementation. We used repeated cross-sectional data of 174 878 15-year-old and 16-year-old adolescents from 25 countries from the 2007, 2011 and 2015 European Survey Project on Alcohol and Other Drugs surveys. Multilevel logistic regression models examined smoking behaviour (regular smoking vs other) and perceived access (easy vs difficult) as a function of display ban implementation and controlled for survey year, gender, parental education and implementation of other tobacco control policies. Interaction with gender was tested.

RESULTS

The implementation of a PoS display ban was associated with a 15% larger drop in the odds of regular smoking (OR 0.85, 95% CI 0.79 to 0.91), but was not significantly associated with perceived accessibility of tobacco (OR 0.97, 95% CI 0.892 to 1.03). Associations were similar in males and females (cross-level interactions of gender with display ban were not statistically significant for either outcome).

CONCLUSION

The implementation of PoS display bans in Europe was associated with a stronger decrease in regular smoking among adolescents. This decrease does not appear to be driven by a decreasing accessibility of tobacco, but might be caused by further de-normalisation of tobacco as a result of PoS display bans.

Pro-smoking responses and attitudes due to point-of-sale tobacco displays in never smokers: A cross-sectional study in Hong Kong

INTRODUCTION

Never smokers' responses to tobacco control policy are often overshadowed by the opposition from smokers and tobacco industry during policy advocacy and legislation. Very few studies have examined never smokers' exposure to point-of-sale (POS) tobacco displays and their effects. Therefore, we investigated the exposure, pro-smoking responses due to and attitudes towards such displays in never smokers in Hong Kong.

METHODS

We conducted two-stage, randomized cross-sectional telephone-based surveys in 2015 and 2016 of 1833 never-smoking adults. They were asked how often they noticed POS displays in the past 30 days (often, sometimes, never), whether they found POS displays attractive, felt encouraged to smoke, perceived POS displays as advertisements, and if they supported banning them. The distributions of the outcomes were analyzed by descriptive statistics with weighting to the general population. Risk ratios (RR) from Poisson regression models adjusted for sociodemographic characteristics were used to analyze the associations.

RESULTS

Our results showed that, in never smokers, the younger were more likely to often notice POS displays (RR=0.80, 95% CI: 0.72-0.89, p<0.01). Finding POS displays attractive was associated with primary (RR=2.52, 95% CI: 1.51-4.22, p<0.01) and secondary education (RR=1.68, 95% CI: 1.16- 2.44, p=0.01) versus tertiary education. Often noticing displays was associated with perceived attractiveness (RR=1.90, 95% CI: 1.32-2.75, p<0.01). The positive association between often noticing displays and being encouraged to smoke was marginally significant (RR=4.05, 95% CI: 0.98-16.85, p=0.054). Respondents who often noticed POS displays (RR=0.87, 95% CI: 0.77-0.98, p=0.02) and did not perceive them as advertisements (RR=0.70, 95% CI: 0.61-0.98, p<0.01) showed less support on banning them than those who did not notice them.

CONCLUSIONS

Frequent exposure to POS displays was associated with greater perceived attractiveness and lower support for banning them. A total ban on POS displays is needed to eliminate the advertising and normalization effect of POS displays.

Support for a point-of-sale cigarette display ban among smokers: findings from the international tobacco control (ITC) Netherlands survey

Background

Displaying tobacco products at point-of-sale (PoS) has become an important marketing strategy for the tobacco industry. This study was designed to (1) examine how support for a PoS cigarette display ban changed among Dutch smokers between 2010 and 2015 and (2) identify the variables that predict support among smokers for a PoS cigarette display ban.

Methods

Longitudinal data from six annual survey waves (2010-2015) from the International Tobacco Control (ITC) Netherlands Survey were analyzed. The sample consisted of between 1279 and 1800 smokers per year. Smokers were asked whether they supported a complete ban on displays of cigarettes inside shops and stores.

Results

Support for a PoS cigarette display ban increased from 28.9% in 2010 to 42.5% in 2015 (OR = 1.40, p < 0.001). A multiple logistic regression analysis revealed that support for a PoS display ban of cigarettes was more likely among smokers who had more knowledge about the health risks of smoking (OR = 3.97, p < 0.001), believed smoking-related health risks to be severe (OR = 1.39, p < 0.001), had a more positive attitude towards quitting smoking (OR = 1.44, p = 0.006), reported stronger social norms to quit smoking (OR = 1.29, p = 0.035), had a higher self-efficacy for quitting smoking (OR = 1.31, p = 0.001), and had stronger intentions to quit smoking (OR = 1.23, p = 0.006).

Conclusions

This paper showed that support for a PoS display ban of cigarettes increased among smokers in the Netherlands over the years. To further increase support, educational campaigns about the dangers of smoking, and campaigns that encourage quitting may be needed.

Public versus internal conceptions of addiction: An analysis of internal Philip Morris documents

BACKGROUND

Tobacco addiction is a complex, multicomponent phenomenon stemming from nicotine's pharmacology and the user's biology, psychology, sociology, and environment. After decades of public denial, the tobacco industry now agrees with public health authorities that nicotine is addictive. In 2000, Philip Morris became the first major tobacco company to admit nicotine's addictiveness. Evolving definitions of addiction have historically affected subsequent policymaking. This article examines how Philip Morris internally conceptualized addiction immediately before and after this announcement.

METHODS AND FINDINGS

We analyzed previously secret, internal Philip Morris documents made available as a result of litigation against the tobacco industry. We compared these documents to public company statements and found that Philip Morris's move from public denial to public affirmation of nicotine's addictiveness coincided with pressure on the industry from poor public approval ratings, the Master Settlement Agreement (MSA), the United States government's filing of the Racketeer Influenced and Corrupt Organizations (RICO) suit, and the Institute of Medicine's (IoM's) endorsement of potentially reduced risk products. Philip Morris continued to research the causes of addiction through the 2000s in order to create successful potentially reduced exposure products (PREPs). While Philip Morris's public statements reinforce the idea that nicotine's pharmacology principally drives smoking addiction, company scientists framed addiction as the result of interconnected biological, social, psychological, and environmental determinants, with nicotine as but one component. Due to the fragmentary nature of the industry document database, we may have missed relevant information that could have affected our analysis.

CONCLUSIONS

Philip Morris's research suggests that tobacco industry activity influences addiction treatment outcomes. Beyond nicotine's pharmacology, the industry's continued aggressive advertising, lobbying, and litigation against effective tobacco control policies promotes various nonpharmacological determinants of addiction. To help tobacco users quit, policy makers should increase attention on the social and environmental dimensions of addiction alongside traditional cessation efforts.

Disentangling the roles of point-of-sale ban, tobacco retailer density and proximity on cessation and relapse among a cohort of smokers: findings from ITC Canada Survey

OBJECTIVE

To examine how point-of-sale (POS) display bans, tobacco retailer density and tobacco retailer proximity were associated with smoking cessation and relapse in a cohort of smokers in Canada, where provincial POS bans were implemented differentially over time from 2004 to 2010.

METHODS

Data from the 2005 to 2011 administrations of the International Tobacco Control (ITC) Canada Survey, a nationally representative cohort of adult smokers, were linked via residential geocoding with tobacco retailer data to derive for each smoker a measure of retailer density and proximity. An indicator variable identified whether the smoker's province banned POS displays at the time of the interview. Outcomes included cessation for at least 1 month at follow-up among smokers from the previous wave and relapse at follow-up among smokers who had quit at the previous wave. Logistic generalised estimating equation models were used to determine the relationship between living in a province with a POS display ban, tobacco retailer density and tobacco retailer proximity with cessation (n=4388) and relapse (n=866).

RESULTS

Provincial POS display bans were not associated with cessation. In adjusted models, POS display bans were associated with lower odds of relapse which strengthened after adjusting for retailer density and proximity, although results were not statistically significant (OR 0.66, 95% CI 0.41 to 1.07, p=0.089). Neither tobacco retailer density nor proximity was associated with cessation or relapse.

CONCLUSIONS

Banning POS retail displays shows promise as an additional tool to prevent relapse, although these results need to be confirmed in larger longitudinal studies.

Does the uptake of wagering inducements predict impulse betting on sport?

Background and aims Marketing inducements for addictive products, such as wagering, can prompt impulse purchasing by triggering consumption reminders, urges, and cravings. Wagering inducements incentivize betting by providing bonus bets, money-back guarantees, deposits into betting accounts, and discounts. Their promotion during sporting events, push marketing efforts directed at consumers, and ease of uptake at the point-of-sale, may trigger betting on impulse. This study examined whether the uptake of wagering inducements predicted impulse betting on sport. Methods Australian sports bettors (N = 1,813) completed an online survey measuring their proportion of planned bets, impulse bets before match commencement, and impulse bets during play; frequency of using wagering inducements; and several psychological, behavioral, and demographic variables. Results More frequent users of wagering inducements had a greater tendency to place impulse in-play bets, which were also predicted by problem gambling, higher buying impulsiveness, higher frequency of watching sports, younger age, and higher educational status. Sports bettors with a greater tendency to place impulse bets before match commencement also tended to have higher buying impulsiveness and to be younger, but they used inducements less frequently, and tended to be female, less-educated and non-problem, moderate risk, or problem gamblers. Discussion and conclusions Uptake of wagering inducements appeared to be particularly effective in stimulating impulse in-play betting among problem gamblers and frequent sports viewers. These results suggest that a more cautious approach to the regulation of both in-play bets and wagering inducements may be required to better protect young adults from gambling problems and harm.

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

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

Global evidence on the effect of point-of-sale display bans on smoking prevalence

BACKGROUND

Since Iceland became the first country to impose a ban on point-of-sale (POS) tobacco product displays in 2001, 20 countries have implemented POS display bans as of 2016. This study examined the effect that POS display bans have on smoking prevalence.

METHODS

Data were sourced from Euromonitor International and the WHO MPOWER package for 2007-2014 from 77 countries worldwide. generalised linear models with country and year fixed effects were estimated to analyse the effect of POS display bans on smoking prevalence.

RESULTS

Having a POS display ban reduced overall adult daily smoking, male smoking and female smoking by about 7%, 6% and 9%, respectively.

CONCLUSIONS

Having a POS display ban is likely to reduce smoking prevalence and generate public health benefits.

Tobacco Smoke Exposure in Indoor and Outdoor Locations in Airports Across Europe and the United States: A Cross-Sectional Study

Objective

Conduct a systematic evaluation of indoor and outdoor areas of selected airports, assess compliance and identify areas of improvement with smoke-free policies in airports.

Methods

Cross-sectional observational study conducted at 21 airports in Europe (11) and the United States (10). Using a standardized protocol, we assessed compliance (smoking, cigarette butts, smoke smell), and the physical environment (signage, ashtrays, designated smoking rooms [DSRs], tobacco sales).

Results

Cigarette butts (45% vs. 0%), smoke smell (67% vs. 0%), ashtrays (18% vs. 10%), and DSRs (63% vs. 30%) were observed more commonly indoors in Europe than in the United States. Poor compliance indoors was related to the presence of DSRs (OR 4.8, 95% CI 0.69, 33.8) and to cigarettes sales in pre-security areas (OR 6.0, 95% CI 0.57, 64.7), although not significantly different. Smoking was common in outdoor areas of airports in Europe and the United States (mean (SD) number of smokers 27.7 (23.6) and 6.3 (7.7), respectively, p value < .001). Around half (55%) of airports in Europe and all airports in the United States had some/partial outdoor smoking restrictions.

Conclusions

Exposure to secondhand smoke (SHS) remains a public health problem in major airports across Europe and in some airports in the United States, specifically related to the presence of DSRs and SHS exposure in outdoor areas. Airports must remove DSRs. Research is needed in low- and middle-income countries and on the effectiveness of outdoor smoking-restricted areas around entryways. Eliminating smoking at airports will protect millions of people from SHS exposure and promote social norms that discourage smoking.

Implications

Airports are known to allow exceptions to smoke-free policy by providing DSRs. We found that smoking still occurs in indoor areas in airports, particularly in the context of DSRs. Smoking, moreover, is widespread in outdoor areas and compliance with smoking restrictions is limited. Advancing smoke-free policy requires improvements to the physical environment of airports, including removal of DSRs and implementation of stricter outdoor smoking restrictions.

Neighbourhood exposure to point-of-sale price promotions for cigarettes is associated with financial stress among smokers: results from a population-based study

AIM

To examine the association between neighbourhood exposure to point-of-sale (POS) cigarette price promotions and financial stress among smokers in a Midwestern metropolitan area in the USA.

METHODS

Survey data from 888 smokers provided information on sociodemographic and smoking related variables. Financial stress was measured with the question: 'In the last six months, because of lack of money, was there a time when you were unable to buy food or pay any important bills on time, such as electricity, telephone, credit card, rent or your mortgage? (Yes/No).' Using audit data from 504 tobacco retailers, we estimated a score of POS price promotions for each respondent by summing the different types of promotion in each store in their neighbourhood, as defined by a 1-km roadway buffer.

RESULTS

Adjusted results provided strong support for an association between higher scores of neighbourhood POS cigarette price promotions and a higher probability of financial stress (p=0.007).

CONCLUSION

Exposure to POS cigarette price promotions is associated with financial stress. This finding, coupled with previous reports that smokers with financial stress are less likely to attempt to quit or succeed in quitting smoking, suggests that POS cigarette price promotions may act as an impediment to smoking cessation.

The prevalence and marketing of electronic cigarettes in proximity to at-risk youths: An investigation of point-of-sale practices near alternative high schools

This study examines the point-of-sale marketing practices used to promote electronic cigarettes at stores near schools that serve at-risk youth. One hundred stores selling tobacco products within a half mile of alternative high schools in Southern California were assessed for this study. Seventy percent of stores in the sample sold electronic cigarettes. Convenience stores heavily frequented by youth had the highest number of interior ads for e-cigarettes and were the most likely to employ in-store product placement strategies. Increased exposure to the promotion of these products at the point-of-sale poses a challenge for anti-smoking efforts directed toward vulnerable populations.