Receipt of tobacco direct mail/email discount coupons and trajectories of cigarette smoking behaviours in a nationally representative longitudinal cohort of US adults

Young Adults' Experiences with Cannabis Retailer Marketing and Related Practices: Differences Among Sociodemographic Groups and Associations with Cannabis Use-related Outcomes

OBJECTIVES

Limited cannabis retail surveillance has been conducted, particularly assessing retailer practices in relation to consumer sociodemographic factors or use-related outcomes. This study examined young adults': exposure to promotions, health claims, warnings, and age restrictions at cannabis retailers; demographic correlates of retail exposures; and retail exposures in relation to use-related outcomes.

STUDY DESIGN

This study used the cross-sectional quantitative analysis.

METHODS

We analyzed 2023 survey data among 876 young adults in states with legal non-medical cannabis, reporting past-month cannabis use and past-year retailer visits.

RESULTS

In this sample (Mage = 27.1, 44.1% male, 31.7% sexual minority, 17.7% Black, 11.2% Asian, 25.1% Hispanic), 46.7% "at least sometimes" noticed free samples, 76.5% price promotions, 37.4% subpopulation-targeted promotions; 72.5% health claims on products/ads, 63.1% signage, and 70.5% from budtenders; 72.5% warnings on labels, 65.5% signage, and 38.9% from budtenders; and > 80% age verifications. Multivariable analyses identified sociodemographic correlates of exposure outcomes: greater promotion exposure was associated with Black race; greater health claim exposure with being heterosexual, Black, and less educated; less warning exposure with less education; and less age restriction exposure with being younger, male, and Black. Retail exposures were associated with use-related outcomes: more frequent cannabis use was associated with less health claim exposure; greater perceived social acceptability with greater promotion and age restriction exposure; greater perceived risk with greater warning and less age restriction exposure; more problematic use and driving after use with greater promotion and less age restriction exposure.

CONCLUSIONS

Cannabis retail exposure disparities and their associations with use-related outcomes highlight the importance of regulatory and prevention efforts.

Young adults' visual attention to features of social media marketing for disposable e-cigarettes and associated perceptions

BACKGROUND AND AIMS

E-cigarette marketing exposure on social media influences perceptions; however, limited knowledge exists regarding marketing features attracting the most visual attention. This study examined visual attention to features of social media marketing for disposable e-cigarettes and related product perceptions.

DESIGN, SETTING AND PARTICIPANTS

Participants viewed 32 disposable marketing post images from social media (Instagram) using computer-based eye-tracking technology to assess standardized attention metrics of marketing features. They then completed a survey assessing positive product perceptions. The study took place in New Jersey, USA, June-September 2022, comprising young adults (aged 18-29) who do not use tobacco (n = 72) or who smoke cigarettes (n = 42).

MEASUREMENTS

We examined associations between 14 marketing features (e.g. product package, personal item, fruit/candy descriptor, social media account) and standardized attention metrics of dwell time (fixation duration) and entry time (time to first fixation). Then, we assessed attention metrics for each feature in relation to positive product perceptions (appeal and positive use expectancy).

FINDINGS

Among all participants, dwell time was the longest for the product descriptor [marginal means (MM) = 1.77; 95% confidence interval (CI) = 1.69, 1.86], social media account (MM = 1.76; 95% CI = 1.67, 1.85) and fruit/candy descriptor features (MM = 1.56; 95% CI = 1.41, 1.70); entry time was the shortest for the social media account (MM = 0.35; 95% CI = 0.26, 0.46), personal item (MM = 0.36; 95% CI = 0.17, 0.56) and human model features (MM = 0.40; 95% CI = 0.08, 0.72). Two use status groups had comparable dwell and entry times, except for the product descriptor feature. Longer dwell time for the product package feature increased positive product perceptions among both use status groups [regression coefficient (β) = 0.44 and 2.61]. Longer dwell time for fruit/candy descriptor (β = 1.80) and price promotion features (β = 4.04) increased positive product perceptions among those who smoke.

CONCLUSIONS

US young adults appear to be particularly visually engaged by disposable e-cigarette marketing that uses social media account features (account profile pictures, information about the products marketed and relevant hashtags) and features enhancing the products' personal relatability. Disposable product packages, fruit/candy descriptors and price promotions may increase the influence of social media marketing among various use status groups.

Changes in online marketing and sales practices among non-medical cannabis retailers in 5 US cities, 2022 to 2023

Objectives

Given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time.

Methods

In 2022 and 2023, researchers assessed website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies) among 175 randomly-selected cannabis retailers' websites across 5 US cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles [LA], California, n=∼35/city). Analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities.

Results

Similar to 2022, in 2023, 76.6 % required age verification for site entry, 85.1 % used social media promotion, and 90.9 % offered online sales (82.4 % of which required age verification and 34.6 % offered delivery). There were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4 % to 15.4 %), purchase limits (59.4 % to 47.4 %), health warnings (38.9 % to 29.7 %), health benefits (60 % to 47.4 %), and discounts/price promotions (92.6 % to 86.3 %). In 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90 % in Denver, Las Vegas, LA), allowed discounts/price promotions (100 % in Denver and Las Vegas), or required health warnings (48-60 % in Seattle and LA vs. < 20 % elsewhere). Despite all sites prohibiting youth-oriented content and all but Denver and Las Vegas prohibiting health claims, 30.3 % posted content targeting youth/young adults (LA = 8.1 % to Denver = 74.2 %) and 47.4 % health claims (Seattle = 27.0 % to Denver = 71.0 %).

Conclusions

Online cannabis retail presents risks for access and appeal to minors, emphasizes health benefits, and uses price promotions, regardless of restrictions, indicating need for greater regulatory efforts.

Content analysis of IQOS direct mail and email marketing in the US

Objective

Novel nicotine and tobacco products, including heated tobacco products (HTPs) like IQOS, are growing in global popularity. IQOS was the first HTP authorized for sale by the US Food and Drug Administration, entering the US market in 2019 and being removed in 2021 due to patent-related legal challenges, with the possibility of returning in 2024. Direct marketing is one method tobacco companies use to reach consumers of these products. The purpose of this study was to investigate the content of US IQOS direct mail and email marketing.

Methods

Direct marketing items were collected between September 2019 and July 2021 by seven team members in the first US IQOS test market, Atlanta, Georgia.

Results

Overall, 101 marketing items were collected, 59 of which were unique. Among the unique items that showed images of persons ("models"), 70 % showed models appearing to be from racial/ethnic minoritized groups, 86.8 % showed at least one female-presenting model, and 37.5 % showed models appearing to be young adults (18-29 years). Items often had an embedded link/URL (91.5 %) and mentioned topics such as online services (54.2 %; for example, online ordering and tutorials), user experience (49.2 %), social media (44.1 %), and purchasing locations (37.3 %). When examined for their main purpose, items focused on subjects such as store experience (37.7 %), product introduction (18.6 %), and product use (15.3 %).

Conclusions

Our study highlights the importance of better understanding how novel tobacco products are marketed, which can inform policymakers' regulatory efforts and product authorization decisions.

Exposure to E-Cigarette Advertisements or Reviews and E-Cigarette Use Progression: A Longitudinal Examination of Short-Term and Long-Term Associations among US Young Adults

Limited research has investigated the impact of e-cigarette advertising and reviews on the progression of e-cigarette use among young adults in the US. This study utilized five-wave longitudinal data (2018-2020) with 3006 young adults aged 18-34, reporting exposure to e-cigarette advertisements or reviews at Wave 1 (W1) and W3. Generalized estimating equations (GEE) were used to examine the prospective associations between frequent exposure to e-cigarette advertisements or reviews and e-cigarette use progression in four groups: never users (n = 1271 at W1), former users (previously used but quit ≥ 6 months ago, n = 422 at W1), recent former users (used in the past 6 months but not in the past month, n = 186 at W1), and current users (used in the past month, n = 1127 at W1). Among baseline former users, frequent exposure to e-cigarette reviews was associated with current use at 6-month follow-up (aOR = 4.40, 95%CI = 1.46-13.29). Among baseline current users, frequent exposure to e-cigarette reviews was associated with increased days of use at 6-month follow-up (IRR = 1.20, 95%CI = 1.07-1.34) and 12-month follow-up (IRR = 1.18, 95%CI = 1.03-1.35). E-cigarette reviews may contribute to relapse among recent former users and increased usage frequency among current users, highlighting the need for enhanced e-cigarette promotional activity regulation.

Cumulative Exposure to E-Cigarette Coupons and Changes in E-Cigarette Use Among U.S. Adults

INTRODUCTION

Coupons are an effective, frequently used tobacco marketing strategy. This study examined prospective associations between cumulative exposure to e-cigarette coupons and changes in e-cigarette use among U.S. adults.

METHODS

Data were from a representative U.S. adult cohort (n=19,824) in the Population Assessment of Tobacco and Health Study (waves [W] 2, 3, 4, and 5), collected from October 2014 to November 2019. Analysis was conducted in 2022. Four logistic regression models examined associations of a number of waves for which participants received e-cigarette coupons during W2-W4 with changes in e-cigarette use: W2 never use to W5 current use (initiation); W2 current nondaily use to W5 daily use (progression); W2 current use to W5 former use (cessation), and W2 former use to W5 current use (return-to-use).

RESULTS

Overall, 66.1% of U.S. adults never used e-cigarettes, 10.6% currently used e-cigarettes, and 23.4% formerly used e-cigarettes at W2. The average number of waves for which participants received e-cigarette coupons during W2-W4 was 0.13: 0.10 among W2 individuals who never used e-cigarettes, 0.30 among individuals who currently used e-cigarettes on a nondaily basis, 0.50 among individuals who currently used e-cigarettes, and 0.17 among individuals who formerly used e-cigarettes. Receiving coupons at increased waves was associated with (1) greater odds of initiation (AOR=1.58, 95% CI=1.26-1.97); (2) lower odds of cessation (AOR=0.78, 95% CI=0.67-0.91); and (3) increased odds of return-to-use (AOR=1.39, 95% CI=1.14-1.69). Findings did not differ by W2 cigarette smoking status.

CONCLUSIONS

E-cigarette coupons may encourage and sustain e-cigarette use. Policies restricting e-cigarette coupons may curb e-cigarette use.

Cigarette Coupon Receipt and Smoking Relapse by Duration of Smoking Abstinence

INTRODUCTION

It is unknown whether and to what extent the duration of smoking abstinence may modify the association between receiving cigarette coupons and smoking relapse in the U.S. This study aims to fill this gap.

METHODS

Data were from the Population Assessment of Tobacco and Health study Wave 4 (December 2016-January 2018, baseline) and Wave 5 (December 2018-November 2019, follow-up) surveys. Analysis was conducted in May 2022. The study sample was participants who formerly smoked cigarettes at baseline (N=5,186). The exposure was past 12-month receipt of cigarette coupons (yes/no) at baseline, and the outcome was cigarette smoking relapse (yes/no) at follow-up. A potential modifier was the duration of smoking abstinence (within/>1 year) at baseline. Baseline single-wave weights were applied, and a multivariable logistic regression model was used to estimate the adjusted association. Interaction between cigarette coupon receipt and duration of smoking abstinence was examined to explore potential modification effects.

RESULTS

Participants who received cigarette coupons at baseline were more likely to relapse at follow-up (AOR=1.63, 95% CI=1.15, 2.32). This association was significantly stronger among participants who quit within 1 year than among participants who quit >1 year at baseline (AOR for the interaction term=2.77, 95% CI=1.22, 6.25). Subgroup analysis shows that receipt of cigarette coupons was significantly associated with smoking relapse among participants who quit within 1 year (AOR=2.10, 95% CI=1.39, 3.17), and this association was not statistically significant among participants who quit >1 year (AOR=0.76, 95% CI=0.36, 1.63).

CONCLUSIONS

Policies restricting cigarette coupons may help adults who recently quit sustain abstinence.

Cannabis retailer marketing strategies and regulatory compliance: A surveillance study of retailers in 5 US cities

As cannabis retail expands in the US, its surveillance is crucial to inform regulations and protect consumers. This study addresses this need by conducting point-of-sale audits examining regulatory compliance (e.g., age verification, signage), advertising/promotional strategies, products, and pricing among 150 randomly-selected cannabis retailers in 5 US cities (30/city: Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California) in Summer 2022. Descriptive and bivariate analyses characterized the retailers overall and across cities. Age verification rates were high (>90%). The majority of retailers had signage indicating restricted access (e.g., no minors; 87.3%), onsite consumption (73.3%), and distribution to minors (53.3%). Retailers were likely to post warnings regarding use during pregnancy/breastfeeding (72.0%), followed by health risks (38.0%), impacts on children/youth (18.7%), and DUI (14.0%). Overall, 28.7% posted health claims, 20.7% posted youth-oriented signage, and 18.0% had youth-oriented packaging. Price promotions were prevalent, particularly price specials (75.3%), daily/weekly/monthly specials (66.7%), and membership programs (39.3%). One-fourth had signs/promotions indicating curbside delivery/pick-up (28.0%) and/or online ordering (25.3%); 64.7% promoted their website or social media page. The most potent cannabis products were most often e-liquids (38.0%) or oils (24.7%); the least potent were often edibles (53.0%). The most expensive product was often bud/flower (58.0%); the least was joints (54.0%). The vast majority (≥81%) sold vaporizers, wrapping papers, and hookah/waterpipes/bongs, and 22.6% sold CBD products. Marketing strategies differed across cities, reflecting differences in state-specific regulations and/or gaps in compliance/enforcement. Findings underscore the need for ongoing cannabis retail surveillance to inform future regulatory and enforcement efforts.

The longitudinal association between coupon receipt and established cigarette smoking initiation among young adults in USA

INTRODUCTION

Tobacco companies frequently distribute coupons for their products. This marketing tactic may be particularly effective among young adults, who tend to be especially price-sensitive. Young adulthood is also a stage during which many individuals initiate established cigarette smoking and are especially vulnerable to the effects of tobacco marketing.

METHODS

We used five waves of data from the US Population Assessment on Tobacco and Health Study (2013-2019) to assess the longitudinal relationship between cigarette coupon receipt and initiation of established cigarette smoking among young adults (18-24 years) who did not report current smoking and had smoked <100 cigarettes in their lifetime at baseline. Initiation of established cigarette smoking was defined as reporting current cigarette use and having smoked ≥100 cigarettes at follow-up. To test this relationship, we fit four discrete time survival models to an unbalanced person-period data set. The first model included our time-varying coupon receipt variable, which was lagged one wave. Subsequent models added sociodemographic, cigarette smoking exposure and other tobacco use variables.

RESULTS

Adopting the model adjusting for sociodemographic variables, respondents who received a coupon were found to be more likely to initiate established cigarette smoking at follow-up (adjusted HR (aHR): 2.31, 95% CI 1.41 to 3.80). This relationship remained significant when controlling for all covariates in the fully adjusted model (aHR: 1.96, 95% CI 1.18 to 3.26).

CONCLUSIONS

These findings show that receiving tobacco coupons may increase the likelihood that young adults will initiate established cigarette smoking, underscoring the need to address the effects of this tobacco marketing tactic.

Presence of flavoured electronic nicotine delivery system (ENDS) products in US ENDS advertisements, 2015-2020: a content analysis

OBJECTIVES

Electronic nicotine delivery systems (ENDS) products come in a variety of flavours (eg, fruit, dessert, menthol). Tobacco advertising has historically used flavours as an advertising tactic, but little is known about flavour type and prevalence in ENDS advertisements. We assess the presence of flavoured ENDS in ads over time, by media outlet (eg, magazines, online) and brand.

METHODS

We acquired ENDS ads (N=4546) that first ran between 2015-2017 (n=1685; study 1) and 2018-2020 (n=2861; study 2) in outlets including opt-in emails, direct-to-consumer mail (study 1 only), video (TV and online), radio (study 2 only), static online/mobile (ie, ads without video or moving graphics), social media, outdoor (eg, billboards; study 2 only) and consumer magazines. We coded for presence of flavoured ENDS products and flavour type (eg, fruit, tobacco, menthol) and merged this information with metadata on ad year, outlet and manufacturer/retailer brand.

RESULTS

Overall, nearly half (45.5%; n=2067) of ads in our sample featured a flavoured product. Tobacco (59.1%; n=1221), menthol (42.9%; n=887) and fruit (38.6%; n=797) were the most advertised flavours. Over time, the proportion of ads containing tobacco-flavoured and menthol-flavoured ENDS generally decreased before menthol rebounded in 2020. The proportion of ads containing fruit, mint and dessert flavours generally increased over time, with a substantive drop in 2020. We found notable differences in flavoured ENDS advertising by outlet and brand.

CONCLUSIONS

The overall presence of flavoured ENDS in our sample of ads remained relatively consistent, with tobacco flavour decreasing over time and some non-tobacco flavours increasing over time until 2020 when the presence decreased.

Financial hardship during the COVID-19 pandemic and increased receipt of commercial tobacco discount coupons among US adults who use commercial tobacco

INTRODUCTION

Many individuals experienced financial hardship during the COVID-19 pandemic; yet commercial tobacco (CT) sales increased in the USA. We examined how experiencing financial hardships relates to increased CT discount coupon reception during the pandemic.

METHODS

A nationally representative sample of 1700 US adults who used CT during the 12 months prior to the survey were surveyed online during January to February 2021. Participants reported if they had received more discount coupons for various CT products during (compared with before) the pandemic. They also reported whether they experienced six different types of financial hardships since the pandemic, and the total number of hardships experienced was counted. Weighted multivariable logistic regressions were used to examine the associations between financial hardships and increased coupon reception, adjusting for demographics and CT product use.

RESULTS

During the first 10-11 months of the pandemic, 21.3% of US adults who used CT during the 12 months prior to the survey reported receiving more CT discount coupons. Experiencing financial hardship during the pandemic was associated with higher odds of receiving more coupons for all types of CT products: every additional count of financial hardship was associated with higher odds of increased reception of discount coupons for all CT products (adjusted odds ratios ranging from 1.13 to 1.23 across products).

CONCLUSIONS

Over one-fifth of US adults who used CT received more discount coupons during the pandemic. Those facing financial hardships had higher discount coupon reception, suggesting potential targeted marketing to financially vulnerable individuals by the tobacco industry.

Cumulative cigarette discount coupon exposure and trajectories of cigarette smoking: a longitudinal analysis in US adults

INTRODUCTION

Exposure to cigarette discount coupons is associated with short-term increase in cigarette smoking; however, long-term impact is unclear. This study examined associations of cumulative exposure to cigarette coupons with trajectories of cigarette smoking in US adults.

METHODS

Data were from the US Population Assessment of Tobacco and Health Study Adult Surveys (n=19 824; waves 2-5). We examined the number of waves participants received cigarette discount coupons/promotions during waves 2-4 and smoking behaviours at wave 5. Weighted logistic multivariable regression models were used, adjusting for wave 2 demographics and stratified by wave 2 smoking status.

RESULTS

Among wave 2 adults who never smoked, each increment wave of exposure to cigarette discount coupons was associated with greater odds of wave 5 current smoking (adjusted OR (aOR)=2.09, 95% CI 1.24-3.52). Among wave 2 adults who smoked daily, each wave of coupon exposure was associated with lower odds of quitting smoking at wave 5 (aOR=0.67, 95% CI 0.62-0.73). Among wave 2 adults who had quit smoking, each increment wave of exposure was associated with greater odds of wave 5 current smoking (aOR=1.61, 95% CI 1.41-1.85). Additionally, women (vs men) and adults with lower socioeconomic status (SES) (vs higher SES) were more frequently exposed to cigarette coupons for a higher number of waves (p<0.05).

DISCUSSION

Exposure to cigarette coupons exhibited a dose-response relationship with changes in cigarette smoking behaviours over time, promoting smoking progression and hindering smoking cessation especially among women and people with lower SES. Prohibiting these coupons can be an important tobacco control strategy.

The Short-Term and Long-Term Associations Between Receiving Tobacco Discounts or Coupons and Smoking Cessation Among U.S. Adult Cigarette Smokers With Intention to Quit

INTRODUCTION

To examine the associations between baseline receipt of cigarette and non-cigarette tobacco discounts or coupons and smoking cessation at follow-up among US adult cigarette smokers with the intention to quit at baseline.

AIMS AND METHODS

Data were from the Population Assessment of Tobacco and Health (PATH) study wave 3 (October 2015-October 2016), wave 4 (December 2016-January 2018), and wave 5 (December 2018-November 2019) surveys. Two separate sets of analyses were conducted using wave 3-4 data (N = 3707) and wave 4-5 data (N = 6251). Specifically, wave 4 was used as the 1-year follow-up of wave 3 to examine the short-term association, and wave 5 was used as the 2-year follow-up of wave 4 to examine the longer-term association. Study population were current established cigarette smokers with the intention to quit (within 1 year for wave 3-4 data) at baseline. Exposure was self-reported past 12-month receipt of discounts or coupons for cigarettes and non-cigarette tobacco products at baseline, and outcome was self-reported completely quitting cigarette smoking at follow-up. Baseline single-wave weights were applied, and multivariate logistic regressions were used to estimate the adjusted associations.

RESULTS

Participants who received cigarette discounts or coupons at baseline were less likely to quit completely for both 1-year follow-up (aOR = 0.66, 95% CI: 0.48 to 0.90) and 2-year follow-up (aOR = 0.74, 95% CI: 0.61 to 0.90). Baseline receipt of discounts or coupons for non-cigarette tobacco products were not consistently associated with cigarette smoking cessation at follow-up.

CONCLUSIONS

Receipt of cigarette discounts or coupons was associated with a reduced likelihood of successful quitting among cigarette smokers with intention to quit. Policies restricting cigarette coupons may help them quit completely.

IMPLICATIONS

This study found that among baseline current established cigarette smokers with intention to quit in the United States, baseline receipt of cigarette discounts or coupons was negatively associated with cigarette smoking cessation for both 1-year follow-up and 2-year follow-up. Baseline receipt of discounts or coupons for e-cigarettes, cigars, and other tobacco products were not consistently significantly associated with cigarette smoking cessation at follow-up. Our study results indicated that policies restricting cigarette coupons may help increase the likelihood of successful smoking cessation for smokers with intention to quit.

Longitudinal associations between receiving E-cigarette price promotions and subsequent E-cigarette use among U.S. Young adult cigarette smokers

INTRODUCTION

E-cigarette price promotions (EPPs; i.e., marketed reductions in cost) may influence young adult cigarette smokers to try, dual use with, or completely transition to e-cigarettes. We assessed whether receiving EPPs was associated with subsequent e-cigarette use among this group.

METHODS

Data were from Waves 4 (2016-2018) and 5 (2018-2019) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study survey. Analysis was restricted to participants who were young adult (18-34 years) established, current cigarette smokers who did not use e-cigarettes at Wave 4 (baseline; n = 2,664; Sample 1), and a subsample of those who tried to quit smoking completely in the past year at Wave 5 (follow-up; n = 948; Sample 2). Multivariable logistic regressions were used to examine associations between receiving EPPs at baseline and past year use of e-cigarettes in general (Sample 1) and to help quit smoking (Sample 2) at follow-up, controlling for covariates.

RESULTS

Overall, 4.1% and 4.9% of Sample 1 and 2 participants received EPPs, respectively; At follow-up, 33.4% of Sample 1 participants used e-cigarettes, and 12.0% of Sample 2 participants used e-cigarettes to quit smoking. Receiving EPPs was associated with subsequent past-year e-cigarette use in general (AOR = 2.07; 95% CI = 1.31 to 3.27), and past-year e-cigarette use to help with quitting smoking (AOR = 3.20; 95% CI = 1.48 to 6.90).

DISCUSSION

EPPs may increase e-cigarette use among established, current smokers and may be used to quit smoking. Research is needed to understand how EPPs may be differentially associated with complete product transition versus dual/poly use among young adult smokers.

Price promotion receipt and use progression of any tobacco, cigarettes, e-cigarettes and cigars among US youth between 2016 and 2018

BACKGROUND

Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression.

METHODS

The analysis included a nationally representative sample of youth never tobacco users (aged 12-16; n=9405) from wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017-2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates.

RESULTS

At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation.

DISCUSSION

Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics.

Financial challenges and hardship during the COVID-19 pandemic and tobacco expenditure minimizing strategies among U.S. adult commercial tobacco users

INTRODUCTION

Commercial tobacco (CT) users employ tobacco expenditure minimizing strategies (TEMS) to manage their CT expenditures. We examined how financial challenges and hardships during the COVID-19 pandemic relate to increases in TEMS use.

METHODS

Data from a nationally representative sample of 1,700 U.S. adult recent former and current CT users were collected from an online panel during January-February 2021. Participants reported if they had increased use of eight TEMS to save money on CT since the pandemic, and experienced financial challenges (e.g., losing a job) and hardships (e.g., not having enough money to pay for food). The number of financial hardships experienced was counted (range: 0-6). Weighted multivariable logistic regression models were used to examine the associations between financial challenges and hardships and increased TEMS use, adjusting for demographics.

RESULTS

Since the COVID-19 pandemic, three TEMS showed the largest increase in use by U.S. adult current and recent former CT users: cutting back (22.4%), finding less expensive places to purchase (15.6%), and buying by bulk (15.5%). Many financial challenges and hardships were consistently associated with increased uses of TEMS. Furthermore, every additional count of financial hardships was associated with higher odds of increasing use of each TEMS (AORs ranging between 1.12 and 1.23).

CONCLUSIONS

Many CT users increased TEMS use to manage their CT expenditures when facing financial challenges and hardships during the pandemic. This could hinder CT cessation and promote relapse. Prohibiting certain TEMS (e.g., discount coupon and price promotions) may promote CT cessation among this financially vulnerable group.

Tobacco Couponing: A Systematic Review of Exposures and Effects on Tobacco Initiation and Cessation

INTRODUCTION

Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation.

AIMS AND METHODS

We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies' potential risk of bias.

RESULTS

Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies.

CONCLUSIONS

Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point.

IMPLICATIONS

A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco's harms and address health inequities.

Price Promotions of E-Liquid Products Sold in Online Stores

Background: Retailer price promotions are an important marketing strategy to attract consumers. However, there is scarce evidence on how retail price promotions are being implemented by e-cigarette online stores, particularly for e-liquid products that are not often found in brick-and-mortar stores and sold in lower prices compared to other types of e-cigarettes. Objectives: We collect data on e-liquid price-promotion activities from online stores using web scraping. From February to May 2021, we scraped the price promotion data of over 14,000 e-liquid products, from five popular online vape shops that sell nationwide in the US. We present descriptive analyses of price promotion on those products, assess price promotion practices in online stores, and discuss components of the final purchase price paid by online customers. Findings: Of the 14,000 e-liquid products and over, 13,326 (92.36%) were on sale, and each online store on average offered discounts from 9.20% to 47.53% for these products. The distribution of the after-discount price was largely similar across the five stores, and there is evidence that each store had adopted different price-promotion strategies. Conclusion: Despite low prices, price promotions are common for e-liquid products, which may undermine the effect of e-cigarette pricing policies such as excise tax that are designed to raise e-cigarette prices.

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.

A content analysis of promotional features in US direct-mail from ads across tobacco products from 2018-2020

INTRODUCTION

Direct-mail advertising is a crucial channel through which tobacco companies deliver price incentives that lower the barrier to tobacco use while promoting tobacco products via thematic appeals not legally permitted on other marketing channels. We examine the prevalence of price incentives and ad characteristics used in tobacco product ads mailed directly to US consumers.

METHODS

We analyzed the content of direct-mail tobacco advertisements (N= 1047) in circulation between January 2018 and December 2020 as captured by Mintel Comperemedia Direct. These ads were coded for product type, manufacturer/brand type, model characteristics, price incentives, and themes known to appeal to vulnerable subgroups.

RESULTS

Ads across all tobacco products included price incentives (96%) and contained themes that appealed to rural white (40%) and black audiences (15%). Themes known to appeal to youth and young adults were present in 40% of ads across all products, including 78% of ads promoting electronic nicotine delivery systems (ENDS). Moreover, among the ENDS ads featuring youth appealing themes (51%), also featured young models.

DISCUSSION

Expanding on previous research which focused on combustible and smokeless tobacco products, this analysis examines direct-mail ads across the full range of tobacco products. Our findings highlight the need for regulations to address 1) the high prevalence of price incentives which undermine the effectiveness of excise taxes on tobacco use, and 2) ad themes and characteristics that appeal to groups vulnerable to tobacco use, both of which have the potential to further exacerbate tobacco related health disparities.

IMPLICATIONS

This study reinforces the importance of examining direct-mail as the dominant medium for tobacco advertising, particularly by including coupons and discount codes that reduce product price and thus circumventing the effect of tobacco-related tax legislation.Direct-mail encourages continued product loyalty and use and engages new consumers using price incentives and advertising strategies likely to appeal to price-sensitive consumers and other vulnerable populations.Substantial use of youth-appealing elements in ENDS ads contradict the tobacco industry's mandate to not appeal to youth, warranting highlighting the gaps in current regulations that allows them to continue appealing to this population.

Current state of unhealthy living characteristics in Black/African American and Latino populations: Tobacco use

Over the past six decades, the United States has significantly improved tobacco-related health outcomes through mass efforts in policies, research, and behavioral and clinical interventions. Disparities persist, however, among communities of color who continue to suffer disproportionate rates of cardiovascular disease and other tobacco-related morbidity and mortality. In this review, we synthesize and discuss the tobacco use lifecycle across the lifespan, with special attention paid to socioecological determinants of tobacco-use behavior among Blacks and Latinos. This review summarizes the permeability of tobacco use and tobacco-related determinants across multiple levels of influence, from the individual to the societal, and highlights gaps in the tobacco control and prevention landscape. Given its continued evolution and impact on socially disadvantaged communities, we conclude with recommendations for improving current tobacco research and treatment and prevention efforts.

Discretionary spending priorities of unemployed, job-seeking adults who smoke cigarettes

Objective

Tobacco use is detrimental to physical and financial wellbeing. Smoking is associated with unemployment and a harder time finding re-employment. The current study examined job-seekers' prioritization of smoking over other discretionary items.

Methods

Adult, unemployed job-seekers smoking daily ranked items from 1 (highest) to 13 (lowest) for prioritization of their discretionary spending. The online survey randomly ordered the presentation of items. The Heaviness of Smoking Index (HSI, time to first cigarette and cigarettes per day) assessed severity of nicotine addiction.

Results

The sample (N = 290) was 70% men, 42% African American and 30% non-Hispanic Caucasian, with mean age of 43 (SD = 11), smoking an average of 12 cigarettes per day (SD = 6), and 67% smoking within 30 min of waking. Overall, cigarettes (M = 4.7, SD = 3.1) ranked second in importance behind only food (M = 2.5, SD = 2.7); 45% of the sample ranked tobacco in their top 3 spending priorities, and 26% ranked cigarettes as a higher priority than food. Cellular charges, transportation, grooming, and clothing ranked third through sixth, respectively. Higher HSI scores significantly correlated with greater prioritization of cigarettes (r = -0.25), and lower prioritization of food (r = 0.16) and transportation (r = 0.13), p's < 0.05.

Conclusions

Findings indicate cigarettes were highly prioritized, second only to food among job-seekers who smoke. Cigarettes were prioritized over job-seeking resources and health care, particularly among those who were more heavily addicted. Tobacco addiction can preempt basic life needs and reduce resources for finding re-employment.

Tobacco Industry Marketing Exposure and Commercial Tobacco Product Use Disparities among American Indians and Alaska Natives

Background: Non-Hispanic American Indians and Alaska Natives (NH AI/AN) have the highest commercial tobacco use (CTU) among U.S. racial/ethnic groups. Tobacco marketing is a risk factor, however few studies examine it among NH AI/AN. Objective: We identified prevalence of tobacco industry marketing exposure and correlates of CTU among NH AI/AN compared to other racial/ethnic groups. Methods: Data were from wave 1 (2013-2014; N = 32,320) of the Population Assessment of Tobacco and Health Study, analyzing self-reported exposure to tobacco ads from stores, tobacco package displays, direct mail and email marketing. Correlates of CTU were identified and interactions between racial/ethnic groups and tobacco marketing were assessed. Results: NH AI/AN (n = 955) had a higher prevalence of exposure to retail tobacco ads (64.5% vs 59.3%; p < 0.05), mail (20.2% vs.14.3%; p < 0.001) and email (17.0% vs.10.6%; p < 0.001) marketing than NH Whites (n = 19,297). Adjusting for tobacco use and related risk factors, exposure to email marketing remained higher among NH AI/AN than NH Whites. Interactions between racial/ethnic groups and marketing exposures on CTU were nonsignificant. CTU was higher among NH AI/AN than NH Whites and among adults who reported exposure to tobacco ads, mail, and email marketing. Conclusions/importance: There is higher tobacco marketing exposure in stores and via mail for NH AI/AN. Email marketing exposure was higher, even after controlling for tobacco-related risk factors. The tobacco industry may be targeting NH AI/AN through emails, which include coupons and other marketing promotions. Culturally relevant strategies that counter-act tobacco industry direct marketing tactics are needed to reduce disparities in this population.

Receipt of direct tobacco mail/email coupons and coupon redemption: Demographic and socioeconomic disparities among adult smokers in the United States

A key marketing strategy used by tobacco companies to lower tobacco product prices is the distribution of tobacco coupons via direct marketing channels such as mail or email. We analyzed data on adult smokers from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (n = 10,994) to examine the prevalence and correlates of coupon receipt via both channels, and associations with cigarette coupon redemption. Overall, 22% and 32% of smokers received tobacco coupons via email and mail, respectively, and 22% redeemed cigarette coupons. White, 25-44 year old, female, sexual minority, and more nicotine dependent smokers were more likely to receive coupons via both channels and to redeem coupons, as were smokers with mid-levels education (GED to associate degree) and those unable to pay important bills (OR _{email receipt} = 1.37, 95% CI 1.22-1.54; OR _{mail receipt} = 1.38, 95% CI 1.24-1.55; and OR _{coupon redemption} = 1.44, 95% CI 1.26-1.64). Smokers who received coupons via mail only or via both channels, had three times (OR = 2.97, 95% CI 2.31-3.83) and five times (OR = 4.56, 95% CI 3.61-5.76) higher odds to redeem cigarette coupons compared to those who received them via email only. Major demographic and socioeconomic disparities exist in receipt and redemption of direct email\mail tobacco coupons among US smokers. Cigarette coupons received via direct mail are more likely to be redeemed than coupons received via email. Restrictions on tobacco coupon redemption, implemented jointly with increasing access to affordable cessation resources, may incentivize smokers vulnerable to tobacco marketing tactics to quit.

Selling tobacco: A comprehensive analysis of the U.S. tobacco advertising landscape

OBJECTIVES

To describe advertising tactics of cigarette, e-cigarette, little cigar/cigarillo and smokeless tobacco manufacturers.

METHODS

We conducted a content analysis of tobacco 827 ads run in the US in 2016. Ads were double coded by trained coders across ten domains: promotions, web/social media presence, use cues, warnings and disclaimers, descriptors, claims, activities, setting, imagery, and themes.

RESULTS

Cigarette ads relied on promotional tactics like discounts and sweepstakes and featured links to websites and mobile apps, all of which can increase brand loyalty and customer engagement. E-cigarette ads used tactics that appear to target new consumers, such as highlighting the product's qualities and modeling product use. Little cigar/cigarillo ads often positioned the product as social and featured music, urban and nightlife settings. Smokeless tobacco ads frequently featured themes, activities and settings stereotypically thought of as masculine.

CONCLUSIONS

The tactics used to advertise tobacco products can help generate new consumers, encourage product/brand switching, and escalate use among current users. Understanding how different products are advertised can inform the Food and Drug Administration's regulatory efforts, and tobacco counter-marketing campaigns.

Exploiting the "video game craze": A case study of the tobacco industry's use of video games as a marketing tool

BACKGROUND

Video games have grown in popularity since the 1970s, and tobacco imagery is present in a substantial subset of games, including those oriented to youth. Much like exposure to tobacco content in films, exposure to tobacco content in video games may influence smoking uptake and use; however, the tobacco industry's role in facilitating or promoting the use of tobacco imagery in video games is unclear. We explored the industry's interest in and use of video games to market their products to youth and young adults.

METHODS

We retrieved and analyzed archival tobacco industry documents. We supplemented information from the documents with current and archived versions of several brand and corporate websites and one website containing user-supplied information on video games.

RESULTS

Tobacco companies recognized the youth appeal and marketing potential of video games as early as 1980. Initial marketing ideas included incorporating video game themes into product packaging and design. More fully realized plans focused on incorporating video games into product promotions in bars, as a high visibility way to attract younger patrons and increase long-term marketing opportunities by generating names for tobacco company direct-marketing databases. Tobacco companies also incorporated video games into in-home product promotions, primarily as components of brand websites, in order to enhance brand image and generate repeat website traffic. A similar desire to attract and keep visitors led to discussions about the inclusion of video games on corporate youth smoking prevention websites, although only one company, Lorillard, followed through.

CONCLUSIONS

Video game players are an attractive target market for tobacco companies. Video games, as used by these companies, facilitate consumer engagement with particular tobacco brands or particular corporate messages. Eliminating the use of video games as a promotional vehicle may require limiting tobacco marketing in both physical and online environments.

Cross-country comparison of cigarette and vaping product marketing exposure and use: findings from 2016 ITC Four Country Smoking and Vaping Survey

OBJECTIVE

To compare exposure to and use of certain cigarette and vaping product marketing among adult smokers and vapers in four countries with contrasting regulations-Australia (AU), Canada, England and the USA.

DATA SOURCES

Adult smokers and vapers (n=12 294) from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Survey (4CV1).

ANALYSIS

Self-reported exposure to cigarette and vaping product advertising through point-of-sale, websites/social media, emails/texts, as well as exposure to and use of price offers were assessed for country differences using logistic regression models adjusted for multiple covariates.

RESULTS

Reported exposure to cigarette advertising exposure at point-of-sale was higher in the USA (52.1%) than in AU, Canada and England (10.5%-18.5%). Exposure to cigarette advertising on websites/social media and emails/texts was low overall (1.5%-10.4%). Reported exposure to vaping ads at point-of-sale was higher in England (49.3%) and USA (45.9%) than in Canada (32.5%), but vaping ad exposure on websites/social media in Canada (15.1%) was similar with England (18.4%) and the USA (12.1%). Exposure to vaping ads via emails/texts was low overall (3.1%-9.9%). Exposure to, and use of, cigarette price offers was highest in the USA (34.0 % and 17.8 %, respectively), but the use rate among those exposed was highest in AU (64.9%). Exposure to, and use of, price offers for vaping products was higher in the USA (42.3 % and 21.7 %) than in AU, Canada and England (25.9%-31.5 % and 7.4%-10.3 %).

CONCLUSIONS

Patterns of cigarette and vaping product marketing exposure generally reflected country-specific policies, except for online vaping ads. Implications for research and policy are discussed.