Tobacco retail policy landscape: a longitudinal survey of US states

Exposure to school-based tobacco prevention interventions in low-income and middle-income countries and its association with psychosocial predictors of smoking among adolescents: a pooled cross-sectional analysis of Global Youth Tobacco Survey data from 38 countries

OBJECTIVES

To describe the prevalence of school-based tobacco prevention programme exposure among adolescents in low-income and middle-income countries (LMICs) and its association with psychosocial predictors of smoking.

DESIGN

Analysis of pooled cross-sectional data.

SETTING

Global Youth Tobacco Survey (GYTS), conducted in 38 LMICs.

PARTICIPANTS

This was a pooled analysis of data involving a total of 132 755 adolescent respondents to GYTS in 38 LMICs across Africa, Europe and Central/South America between 2014 and 2017.

EXPOSURE AND OUTCOME MEASURES

The primary independent variable for this study was self-reported exposure to school-based tobacco prevention programmes in the past year. Five psychosocial determinants of smoking were explored as outcomes: perceived addictiveness of nicotine, perceived harm of secondhand smoke exposure, support for restricting cigarette smoking at public indoor locations, support for restricting cigarette smoking at public outdoor areas and self-reported prediction of enjoying cigarette smoking. Multivariable logistic regression models were used to examine the relationship between exposure to school-based tobacco prevention programmes and study outcomes, controlling for sociodemographic and smoking-related characteristics of respondents.

RESULTS

Overall, 59.1% of adolescents in LMICs self-reported exposure to school-based tobacco prevention programmes. The country-specific prevalence of adolescent exposure to school-based tobacco interventions ranged from 24.9% in the Comoros to 99.3% in Turkmenistan. Exposure to school-based tobacco interventions was significantly associated with greater secondhand smoke harm perceptions (adjusted OR (AOR): 1.69; 95% CI: 1.69 to 1.70), perceptions of addictiveness (AOR: 1.37; 95% CI: 1.36 to 1.37) and supporting tobacco use restrictions indoors (AOR: 1.70; 95% CI: 1.69 to 1.70) and outdoors (AOR: 1.59; 95% CI: 1.59 to 1.60). Exposure to school-based tobacco interventions was associated with lower odds of anticipating enjoying cigarette smoking (AOR: 0.76; 95% CI: 0.76 to 0.76).

CONCLUSION

Exposure to tobacco prevention programmes in schools is suboptimal in LMICs. Given the protective associations described in this study from school-based tobacco prevention programme exposure, it is imperative that national governments implement school-based programmes into ongoing tobacco control measures.

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.

Relapse to problem drinking or trading up to spirits? Using U.S. national cross-sectional survey data to highlight possible negative impacts of potential tobacco retail changes

BACKGROUND

According to the National Alcohol Beverage Control Association, twelve states in the United States (U.S.) have government retail monopolies on spirits/liquor sales. With a new federal minimum legal sales age for tobacco (raised from 18 to 21, the minimum legal sales age for alcohol), we examine possible unintended consequences of a hypothetical policy change restricting retail tobacco sales to state-run spirits/liquor stores in alcohol control states, which has been proposed as a tobacco endgame strategy.

METHODS

We used cross-sectional survey data from 14,821 randomly-selected adults ages 21 and older who responded to the 2015 or 2020 U.S. National Alcohol Survey (51.8% female; 65.8% identified as non-Hispanic White, 12.4% as Black or African American, 14.2% as Hispanic or Latinx; 34.0% had a low level of education), including 2,274 respondents (18.9%) residing in one of the alcohol control states (representing 42.2 million (M) adults ages 21+). We estimated associations between tobacco measures (lifetime smoking status, lifetime daily smoking, past-year daily smoking) and alcohol measures (drinking status, beverage choices, lifetime alcohol use disorder (AUD) status, recovery status) overall and for specific subgroups.

RESULTS

In control states, 55.1% of people who smoked daily in the past year also reported lifetime AUD, including an estimated 3.56 M adults ages 21 + who reported prior (but not current) AUD. The association of daily smoking with lifetime AUD was stronger among those with low education compared to those with higher education. Further, 58.8% of people in recovery from an alcohol and/or drug problem (1.49 M adults ages 21+) smoked daily, and this was more marked among women than men in control states.

CONCLUSION

There could be negative consequences of an endgame strategy to restructure tobacco retail sales, including increased risk for relapse to drinking among people who smoke daily, especially among women and people with low levels of education. Strategies to mitigate unintended harms would be needed if such a policy were implemented.

U.S. State approaches to cannabis licensing

U.S. states have taken varied approaches to licensing cannabis businesses under federal prohibition, but up to now there is limited research on cross-state licensing approaches. This paper provides a systematic analysis of the current licensing strategies taken by all states that have passed medical cannabis laws (MCLs)/recreational cannabis laws (RCLs). We construct comprehensive data on cannabis business licenses offered in each state, as well as metrics for license categories, cost, and issuance volume. We then analyze patterns between these metrics, also considering how long ago states implemented MCLs/RCLs, qualitative licensing aspects, state ideology and voting preference, and state cannabis taxation data. We observe that states tend to license medical cannabis more restrictively than adult-use cannabis: i.e., by offering licenses in fewer categories, at higher cost, in lower issuance volume, and more often mandating vertical integration. Additionally, states that implemented MCLs/RCLs earlier tend to offer licenses in more categories, at lower cost, and in greater volumes. Further, though states that implemented MCLs recently lean conservative and Republican, we do not observe clear relationships between ideology or voting preference and licensing policy. In our supporting results, we observe that a greater share of states with complex licensing structures impose non-retail price cannabis taxes than states overall, and we discuss how states have changed their licensing policies over time.

Association of tobacco retailer count with smoking population versus vaping population in California (2019)

BACKGROUND

Access to tobacco products, including vape products, from local brick-and-mortar stores influences the exposure, uptake, and use of these products in local communities.

METHODS

Licensed tobacco retailers in California were classified as specialized tobacco/vape stores or non-specialized stores by obtaining categories published on Yelp. California smoking and vaping prevalence data were obtained from the 500 cities project and ESRI community analyst tool respectively. A series of simple linear regression tests were performed, at the zip code level, between the retailer count in each store category and smoking/vaping population. The Getis-Ord Gi* and Anselin Local Moran's I statistics were used for characterization of tobacco retail density hotspots and cold spots.

RESULTS

The association between CA smoking/vaping population and number of tobacco retailers was statistically significant for all store categories. Variability in smoking population was best explained by variability in non-specialized storefronts(R2=0.84). Spatial variability in tobacco-only storefronts explained the least proportion of variability in the overall smoking population. Similar results were obtained specific to vaping population, although the proportion of population explained by variability in the number of non-specialized storefronts was comparatively lower(R2=0.80).

CONCLUSIONS

Localities with greater numbers of non-specialized tobacco retailers had higher rates of smoking/vaping populations, and this association was much stronger for localities with greater numbers of specialized retailers. Non-specialized storefronts may represent convenient access points for nicotine products, while specialized storefronts may represent critical access points for initiation. Hence, regulations that address the entirety of the tobacco/vaping retail environment by limiting widespread access from non-specialized stores and reducing appeal generated by specialized retailers should be incorporated in future tobacco regulatory science and policymaking.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Regulating tobacco retail outlets in Bangladesh: retailers' views and implications for tobacco control advocacy

BACKGROUND

Tobacco products are ubiquitously available in Bangladesh. There are currently no restrictions on who can sell tobacco products and where they are allowed to be sold. The objective of this study was to explore tobacco retailers' views regarding tobacco retail licensing (TRL) in Bangladesh.

METHODS

A two-stage cluster sampling procedure was used to collect data from a representative sample of 472 tobacco retailers (97% response rate) in Dhaka city in 2018 through face-to-face interviews using a semistructured questionnaire. Data were analysed using descriptive statistics, X2 tests and logistic regression.

RESULTS

The majority (79%) of the retailers reported that they would support TRL, and 68% were interested in applying for TRL if adopted. Support for TRL was higher among those with a university degree (OR 2.1, 95% CI 0.8 to 5.3) and among those with knowledge about existing tobacco control regulations (OR 1.8, 95% CI 1.1 to 2.8). Furthermore, support for TRL was significantly higher among those who believed that it would restrict tobacco retailing locations (AOR 1.9, 95% CI 1.3 to 3.0) and prevent tobacco sales to minors (AOR 3.5, 95% CI 2.2 to 5.5).

CONCLUSION

This sample of tobacco retailers in Bangladesh supported TRL. TRL advocacy efforts could draw on this support.

Vape Shop Proliferation and Noncompliance in Pennsylvania: A Pre- and Post-tax Analysis

Background:

The growing use of electronic nicotine delivery systems (ENDS) among adolescents is a public health concern. Taxation of these products is a viable approach to reduce ENDS use, particularly among adolescents. Opponents of taxation posit that it puts specialty retailers (ie, vape shops) out of business, thereby reducing availability of ENDS for adult smokers seeking harm reduction. Pennsylvania enacted substantial ENDS taxes in October 2016. This study sought to examine (1) the prevalence of Pennsylvania vape shops before and after ENDS taxes were enacted and (2) ENDS retail licensing compliance among vape shops.

Methods:

We employed standardized searches for vape shops in Pennsylvania on the Yelp business-listing platform a month prior to and for 18 consecutive months following the imposition of ENDS taxes. We then compared listings to a public database of ENDS-related retail licenses to determine compliance status.

Results:

The number of listed vape shops increased in a linear fashion by a magnitude of 23%. In addition, when we compared a final listing of retailers to data from the state tax authority, we found roughly a quarter (22%-29%) of vape shops to be noncompliant with maintaining a valid ENDS retail license.

Conclusions:

Overall, ENDS taxation in Pennsylvania has not appeared to reduce prevalence of vape shops as anticipated. However, stricter enforcement of the tax law is necessary to ensure compliance among retailers. These findings have implications for implementation and enforcement of ENDS tax policy nationwide, including states that currently lack such policies.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Retailer density reduction approaches to tobacco control: A review

Tobacco retailer density is consistently associated with poor tobacco-use outcomes. The aim of this review was to synthesize the international evidence on density reduction policies. Searches in multiple databases resulted in 31 studies covering various policy approaches evaluated for their impact on retailer density. Findings indicate that bans on tobacco sales in pharmacies reduced retailer density, but perhaps not equitably. Prohibiting sale of tobacco near schools produced greater density reductions in higher-risk neighborhoods. Policies in combination were most effective. Future studies should measure the impact of these policies on tobacco use. Density-reduction policies offer a promising approach to tobacco control.

E-cigarette Tobacco Retail Licensing Laws: Variance Across US States as of January 1, 2020

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws.Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length).Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws.Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

Agent-based Modeling in Tobacco Regulatory Science: Exploring 'What if' in Waterpipe Smoking

Objectives

Waterpipe tobacco smoking (WTS) is an emerging public health crisis, particularly among youth and young adults. Different from the use of other tobacco products and e-cigarettes, WTS tends to be a social activity occurring among friends or persons associated with social networks. In this paper, we review a potential strategy for WTS-related research.

Methods

As a bottom-up computational model, agent-based modeling (ABM) can simulate the actions and interactions of agents, as well as the dynamic interactions between agents and their environments, to gain an understanding of the functioning of a system. ABM is particularly useful for incorporating the influence of social networks in WTS, and capturing people's space-time activity and the spatial distribution of WTS venues.

Results

Comprehensive knowledge of WTS-related behaviors at the individual level is needed to take advantage of ABM and use it to examine policies such as the interaction between WTS and cigarette smoking and the effect of flavors used in waterpipe tobacco. Longitudinal and WTS-specific surveys and laboratory experiments are particularly helpful to understand WTS basic mechanisms and elicit individual preferences, respectively.

Conclusions

We argue that the uniqueness of WTS makes ABM a promising tool to be used in WTS-related research, as well as understanding use of other tobacco products.

Development of a computational modeling laboratory for examining tobacco control policies: Tobacco Town

A key focus of recent policy efforts to curb tobacco product usage has been the role of place-specifically the density of retail and advertising and the resulting spatial pattern of access and exposure for consumers. Policies can alter the environment by reducing density or shifting distribution of tobacco retail and thus limiting access and exposure. Since little empirical evidence exists for the potential impact of these policies across potentially heterogeneous places, we develop and apply an original spatial computational model to simulate place-based retail tobacco control policies. The model is well-grounded in theory and available empirical evidence. We apply the model in four representative settings to demonstrate the utility of this approach as a policy laboratory, to develop general insights on the relationship between retailer density, retail interventions, and tobacco costs incurred by consumers, and to provide a framework to guide future modeling and empirical studies. Our results suggest that the potential impact on costs of reducing tobacco retailer density are highly dependent on context. Projected impacts are also influenced by assumptions made about agent (smoker) purchasing decision-making processes. In the absence of evidence in this area, we tested and compared three alternative decision rules; these interact with environmental properties to produce different results. Agent properties, namely income and cigarettes per day, also shape purchasing patterns before and after policy interventions. We conclude that agent-based modeling in general, and Tobacco Town specifically, hold much potential as a platform for testing and comparing the impact of various retail-based tobacco policies across different communities. Initial modeling efforts uncover important gaps in both data and theory and can provide guidance for new empirical studies in tobacco control.

E-Cigarette Use and Subsequent Cigarette Initiation and Sustained Use Among Youth, U.S., 2015-2017

PURPOSE

Using cross-sectional data, we measured the association between electronic cigarette (e-cigarette) use and subsequent initiation and sustained use of cigarettes among U.S. youth.

METHODS

Data were pooled from the 2015-2017 National Youth Tobacco Survey, a school-based survey of U.S. students in grades 6-12. Questions on current age and age of first use of different tobacco products (cigarettes, e-cigarettes, cigars, and smokeless tobacco) were used to ascertain the temporal sequence of tobacco product use. The pooled study population was 52,579 youth who 5 years before the survey had never smoked cigarettes. E-cigarette users were defined as those who used e-cigarettes before or without ever smoking cigarettes. Cigarette smoking was assessed with the following measures: ever smoking a cigarette at any time within the past 5 years and sustained smoking (smoked ≥1 year ago and within past 30 days). Adjusted odds ratios (AORs) were calculated, controlling for other tobacco product use and sociodemographics.

RESULTS

Among never cigarette smokers as of 5 years before the survey, 17.4% used e-cigarettes, and 15.6% first smoked within the past 5 years. Compared with those who did not use e-cigarettes, those who used e-cigarettes had higher odds of ever smoking cigarettes within the past 5 years (AOR = 2.73) and had higher odds of sustained smoking (AOR = 1.55; all p < .05).

CONCLUSIONS

E-cigarette use is associated with subsequent initiation and sustained use of cigarettes among youth. Efforts are warranted to reduce youth use of all tobacco products, including e-cigarettes.

An effectiveness hierarchy of preventive interventions: neglected paradigm or self-evident truth?

Non-communicable disease prevention strategies usually target the four major risk factors of poor diet, tobacco, alcohol and physical inactivity. Yet, the most effective approaches remain disputed. However, increasing evidence supports the concept of an effectiveness hierarchy. Thus, 'downstream' preventive activities targeting individuals (such as 1:1 personal advice, health education, 'nudge' or primary prevention medications) consistently achieve a smaller population health impact than interventions aimed further 'upstream' (for instance, smoke-free legislation, alcohol minimum pricing or regulations eliminating dietary transfats). These comprehensive, policy-based interventions reach all parts of the population and do not depend on a sustained 'agentic' individual response. They thus tend to be more effective, more rapid, more equitable and also cost-saving. This effectiveness hierarchy is self-evident to many professionals working in public health. Previously neglected in the wider world, this effectiveness hierarchy now needs to be acknowledged by policy makers.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Modelling the impact of menthol sales restrictions and retailer density reduction policies: insights from tobacco town Minnesota

Introduction

Tobacco control policies focused on the retail environment have the potential to reduce tobacco use and tobacco-related health disparities through increasing direct and indirect costs. Recently, national and subnational governments have begun to restrict the sale of menthol products and reduce tobacco retailer density.

Methods

We developed an agent-based model to project the impact of menthol cigarette sales restrictions and retailer density reduction policies for six types of communities and three priority populations. During each simulated day, agents smoke cigarettes, travel in the community and make purchase decisions—whether, where and which product type to purchase—based on a combination of their own properties and the current retail environment.

Results

Of the policies tested, restricting all cigarette sales or menthol cigarette sales to tobacco specialty shops may have the largest effect on the total (direct and indirect) costs of purchasing cigarettes. Coupling one of these policies with one that establishes a minimum distance between tobacco retailers may enhance the impact. Combining these policies could also make the costs of acquiring cigarettes more equal across communities and populations.

Discussion

Our simulations revealed the importance of context, for example, lower income communities in urban areas begin with higher retailer density and may need stronger policies to show impact, as well as the need to focus on differential effects for priority populations, for example, combinations of policies may equalise the average distance travelled to purchase. Adapting and combining policies could enhance the sustainability of policy effects and reduce tobacco use.

Tapping Into Multiple Data "Springs" to Strengthen Policy Streams: A Guide to the Types of Data Needed to Formulate Local Retail Tobacco Control Policy

In 2015, the tobacco industry spent $8.24 billion to market tobacco products in convenience stores, supermarkets, pharmacies, and other retail or point-of-sale settings. Community tobacco control partnerships have numerous evidence-based policies (eg, tobacco retailer licensing and compliance, tobacco-free–school buffer zones, eliminating price discounts) to counter point-of-sale tobacco marketing. However, deciding which point-of-sale policies to implement — and when and in what order to implement them — is challenging. The objective of this article was to describe tools and other resources that local-level tobacco use prevention and control leaders can use to assemble the data they need to formulate point-of-sale tobacco policies that fit the needs of their communities, have potential for public health impact, and are feasible in the local policy environment. We were guided by Kingdon’s theory of policy change, which contends that windows of policy opportunity open when 3 streams align: a clear problem, a solution to the problem, and the political will to work for change. Community partnerships can draw on 7 data “springs” to activate Kingdon’s streams: 1) epidemiologic and surveillance data, 2) macro retail environment data, 3) micro retail environment data, 4) the current policy context, 5) local legal feasibility of policy options, 6) the potential for public health impact, and 7) political will.

E-Cigarettes in Baltimore Alcohol Outlets: Geographic and Demographic Correlates of Availability

There is limited research on e-cigarette availability despite increased use. E-cigarette availability within Baltimore alcohol outlets was analyzed for disparities among residential neighborhoods. Data were obtained via field surveys of alcohol outlets, and then spatially merged with sociodemographic data; 18.8% of alcohol outlets had any e-cigarette availability. Regression models showed greater odds ratios for e-cigarette availability when cigarettes, cigars, or hookah paraphernalia were sold, and lower odds ratios when alcohol outlets had an on-site consumption license. Outlets with e-cigarette availability were in predominantly lower-income, nonwhite neighborhoods. It is important to assess exposure of another potentially damaging substance among perpetually disadvantaged populations.

Local Retail Tobacco Environment Regulation: Early Adoption in the United States

Objectives

To identify sociodemographic and policy environment characteristics of early adopters of retail tobacco control policies in U.S. localities.

Methods

We interviewed a sample of local tobacco control programs on policy progress for 33 specific policies, along with other program characteristics. We combine these results with secondary data in logistic regression analysis.

Results

Eighty (82% of 97) county tobacco control programs from 24 states were interviewed. Localities with lower smoking rates (OR: 0.7; 95%: 0.6-0.9) or higher excise taxes (OR: 6.0; 95%: 1.4-26.0) were more likely to have adopted a retail policy by late 2015. Early adopters were less likely to have voted majority Republican in the 2012 election (OR: 0.03; 95%: 0.00-0.34) or to have higher percentages of African American population (OR: 0.9; 95%: 0.8-0.99).

Conclusions

While localities with more resources, eg, program capacity, political will or policy options, were more likely to adopt policies by 2015, those with higher smoking rates and proportions of priority populations were less likely to do so. As local retail policy work becomes more commonplace, only time will tell if this "rich-get-richer" trend continues, or if the contexts in which retail policies are adopted diversify.

State-Level Point-of-Sale Tobacco News Coverage and Policy Progression Over a 2-Year Period

BACKGROUND

Mass media content may play an important role in policy change. However, the empirical relationship between media advocacy efforts and tobacco control policy success has rarely been studied. We examined the extent to which newspaper content characteristics (volume, slant, frame, source, use of evidence, and degree of localization) that have been identified as important in past descriptive studies were associated with policy progression over a 2-year period in the context of point-of-sale (POS) tobacco control.

METHOD

We used regression analyses to test the relationships between newspaper content and policy progression from 2012 to 2014. The dependent variable was the level of implementation of state-level POS tobacco control policies at Time 2. Independent variables were newspaper article characteristics (volume, slant, frame, source, use of evidence, and degree of localization) and were collected via content analysis of the articles. State-level policy environment contextual variables were examined as confounders.

RESULTS

Positive, significant bivariate relationships exist between characteristics of news content (e.g., high overall volume, public health source present, local quote and local angle present, and pro-tobacco control slant present) and Time 2 POS score. However, in a multivariate model controlling for other factors, significant relationships did not hold.

DISCUSSION

Newspaper coverage can be a marker of POS policy progression. Whether media can influence policy implementation remains an important question. Future work should continue to tease out and confirm the unique characteristics of media content that are most associated with subsequent policy progression, in order to inform media advocacy efforts.

Concordance of Advertised Cigarette Prices with Purchase Receipts in the United States

OBJECTIVES

Researchers and regulators study the advertised price of tobacco products to evaluate compliance with minimum price policies, tax increases, and geodemographic marketing. However, few studies report reliability of advertised price and none address its concordance with receipt price.

METHODS

In a sample of US tobacco retailers (N=1972), data collectors purchased the leading brand of non-menthol or menthol cigarettes, recorded advertised prices, whether sales tax was included and price was discounted. Intraclass correlation coefficients (ICCs) were computed for the same measures by different observers (reliability), and for receipt and advertised pack price (validity). Discrepancy between receipt and advertised price was modeled as a function of store type and presence of a discount.

RESULTS

Advertised price was assessed reliably (ICCs = 0.74 to 0.87) and concordance with receipt price was near perfect (ICCs = 0.96 to 1.00). Prices were identical in 77.7% of stores for Marlboro and 78.1% for Newport. Differences between receipt and advertised price were related to store type and presence of a discount for Marlboro, but not for Newport.

CONCLUSIONS

Findings validate a common measure of cigarette price in research on minimum price compliance, effects of tax increase and industry marketing.

Do 'environmental bads' such as alcohol, fast food, tobacco, and gambling outlets cluster and co-locate in more deprived areas in Glasgow City, Scotland?

This study utilised an innovative application of spatial cluster analysis to examine the socio-spatial patterning of outlets selling potentially health-damaging goods/services, such as alcohol, fast food, tobacco and gambling, within Glasgow City, Scotland. For all categories of outlets combined, numbers of clusters increased linearly from the least to the most income deprived areas (i.e. one cluster within the least deprived quintile to ten within the most deprived quintile). Co-location of individual types of outlets (alcohol, fast food, tobacco and gambling) within similar geographical areas was also evident. This type of research could influence interventions to tackle the co-occurrence of unhealthy behaviours and contribute to policies tackling higher numbers of 'environmental bads' within deprived areas.

Standardized Tobacco Assessment for Retail Settings (STARS): dissemination and implementation research

Objective

The Standardized Tobacco Assessment for Retail Settings (STARS) was designed to characterise the availability, placement, promotion and price of tobacco products, with items chosen for relevance to regulating the retail tobacco environment. This study describes the process to develop the STARS instrument and protocol employed by a collaboration of US government agencies, US state tobacco control programmes (TCPs), advocacy organisations, public health attorneys and researchers from the National Cancer Institute's State and Community Tobacco Control (SCTC) Research Initiative.

Methods

To evaluate dissemination and early implementation experiences, we conducted telephone surveys with state TCP leaders (n=50, response rate=100%), and with individuals recruited via a STARS download registry on the SCTC website. Website registrants were surveyed within 6 months of the STARS release (n=105, response rate=66%) and again after ∼5 months (retention rate=62%).

Results

Among the state TCPs, 42 reported conducting any retail marketing surveillance, with actual or planned STARS use in 34 of these states and in 12 of the 17 states where marketing surveillance was not previously reported. Within 6 months of the STARS release, 21% of surveyed registrants reported using STARS and 35% were likely/very likely to use it in the next 6 months. To investigate implementation fidelity, we compared data collected by self-trained volunteers and by trained professionals, the latter method being more typically in retail marketing surveillance studies. Results suggest high or moderate reliability for most STARS measures.

Conclusion

The study concludes with examples of states that used STARS to inform policy change.

Tobacco Town: Computational Modeling of Policy Options to Reduce Tobacco Retailer Density

OBJECTIVES

To identify the behavioral mechanisms and effects of tobacco control policies designed to reduce tobacco retailer density.

METHODS

We developed the Tobacco Town agent-based simulation model to examine 4 types of retailer reduction policies: (1) random retailer reduction, (2) restriction by type of retailer, (3) limiting proximity of retailers to schools, and (4) limiting proximity of retailers to each other. The model examined the effects of these policies alone and in combination across 4 different types of towns, defined by 2 levels of population density (urban vs suburban) and 2 levels of income (higher vs lower).

RESULTS

Model results indicated that reduction of retailer density has the potential to decrease accessibility of tobacco products by driving up search and purchase costs. Policy effects varied by town type: proximity policies worked better in dense, urban towns whereas retailer type and random retailer reduction worked better in less-dense, suburban settings.

CONCLUSIONS

Comprehensive retailer density reduction policies have excellent potential to reduce the public health burden of tobacco use in communities.

Implementation strategies to promote community-engaged efforts to counter tobacco marketing at the point of sale

The US tobacco industry spends $8.2 billion annually on marketing at the point of sale (POS), a practice known to increase tobacco use. Evidence-based policy interventions (EBPIs) are available to reduce exposure to POS marketing, and nationwide, states are funding community-based tobacco control partnerships to promote local enactment of these EBPIs. Little is known, however, about what implementation strategies best support community partnerships' success enacting EBPI. Guided by Kingdon's theory of policy change, Counter Tools provides tools, training, and other implementation strategies to support community partnerships' performance of five core policy change processes: document local problem, formulate policy solutions, engage partners, raise awareness of problems and solutions, and persuade decision makers to enact new policy. We assessed Counter Tools' impact at 1 year on (1) partnership coordinators' self-efficacy, (2) partnerships' performance of core policy change processes, (3) community progress toward EBPI enactment, and (4) salient contextual factors. Counter Tools provided implementation strategies to 30 partnerships. Data on self-efficacy were collected using a pre-post survey. Structured interviews assessed performance of core policy change processes. Data also were collected on progress toward EBPI enactment and contextual factors. Analysis included descriptive and bivariate statistics and content analysis. Following 1-year exposure to implementation strategies, coordinators' self-efficacy increased significantly. Partnerships completed the greatest proportion of activities within the "engage partners" and "document local problem" core processes. Communities made only limited progress toward policy enactment. Findings can inform delivery of implementation strategies and tests of their effects on community-level efforts to enact EBPIs.