Associations of tobacco retailer density and proximity with adult tobacco use behaviours and health outcomes: a meta-analysis

Tobacco retail availability and smoking-A systematic review and meta-analysis

ISSUES

Health policy makers worldwide have adopted evidence-based legislation, largely directed at consumers, to reduce tobacco-related harm. It is suggested that limiting supply by decreasing retail availability can also reduce cigarette smoking. To inform policy makers this systematic literature review assesses whether reducing availability is associated with smoking behaviours.

APPROACH

Systematic literature searches of five databases were carried out up to January 2023. Included studies had at least one exposure (tobacco retail density, proximity or mixed measures thereof) and outcomes of smoking behaviour. Meta-analysis of effect estimates were undertaken if there were at least three studies with similar population, exposure and outcome measures.

KEY FINDINGS

Sixty-two studies were included, and positive associations were found between tobacco outlet density and cigarette smoking in pregnancy, youth, adults and cessation. Meta-analyses were undertaken for retail density and ever smoking (odds ratio [OR] 1.20; 95% confidence interval [CI] 1.04, 1.37; I2 = 87.3%), and current youth smoking (OR 1.23; 95% CI 1.08, 1.40; I2 = 0.0%), adult smoking (OR 1.11; 95% CI 1.01, 1.22; I2 = 74.8%); and mixed measures of retail availability near schools and current youth smoking (OR 1.03; 95% CI 1.01, 1.05; I2 = 0.0%).

IMPLICATIONS AND CONCLUSION

There is evidence higher tobacco retail density is consistently associated with cigarette smoking in pregnant women, young people and adults when ecological studies are included in meta-analysis. Meanwhile, evidence synthesis reveals restrictive tobacco retail laws based on proximity or mixed measures near home or very near school may not reduce smoking except in men who smoke heavily. Mechanisms to reduce retailer density should be thus considered part of tobacco control strategies.

Tobacco retailer density and its association with birth outcomes in the USA: 2000-2016

INTRODUCTION

Significant progress has been made in reducing maternal exposure to tobacco smoke and subsequent adverse birth outcomes, however, reductions may require strategies that reduce the availability of tobacco retailers. In this study, we investigated the relationship between tobacco retailer density and birth outcomes across the USA and predicted the potential impact of a tobacco retailer density cap on these outcomes.

METHODS

Annual US county (n=3105), rates of preterm birth, low birth weight, small-for-gestational age, all-cause infant mortality and sudden infant death syndrome (SIDS) were calculated using National Vital Statistics System data. Tobacco retailers were identified from the National Establishment Time-Series Database. We used Poisson regression to estimate the effect of capping retailer density at 1.4 retailers per 1000 population, controlling for county demographics and air pollution, using propensity score weighting.

RESULTS

Tobacco retailer density was positively associated with most adverse birth outcomes. We estimate that a nationwide cap on tobacco retailer density, implemented in 2016, would have resulted in a reduction of 4275 (95% CI 2210 to 6392) preterm births, 6096 (95% CI 4421 to 7806) small-for-gestational-age births, 3483 (95% CI 2615 to 4378) low birthweight births, 538 (95% CI 345 to 733) all-cause infant deaths and 107 (95% CI 55 to 158) SIDS deaths in that year.

CONCLUSION

Higher rates of adverse birth outcomes were seen in counties with high tobacco retailer density compared with those with low density. These results provide further support for regulating tobacco retail density to reduce adverse health outcomes associated with tobacco use.

Supply and demand effects between tobacco retailer density and smoking prevalence

OBJECTIVE

Places with more tobacco retailers have higher smoking prevalence levels, but whether this is because retailers locate where people who smoke live or whether tobacco availability prompts tobacco use is unknown. In this study, we compare the role of consumer demand with that of tobacco supply in longitudinal, area-based associations of tobacco retailer density with smoking prevalence.

METHODS

We merged annual adult smoking prevalence estimates derived from the USA Behavioural Risk Factor Surveillance System data with annual county estimates of tobacco retailer density calculated from the National Establishment Time Series data for 3080 counties between 2000 and 2010. We analysed relationships between retailer density and smoking in 3080 counties, using random intercept cross-lagged panel models and employing two measures of tobacco retailer density capturing the number of likely tobacco retailers in a county divided by either the population or land area.

RESULTS

Both density models provided evidence of significant demand and supply effects; in the population-based model, the association of smoking prevalence in 1 year with tobacco retailer density in the next year (standardised coefficient=0.038, p<0.01) was about double the association between tobacco retailer density with subsequent smoking prevalence (0.017, p<0.01). The reverse was true in the land area-based model, where the supply effect (0.042, p<0.01) was more than 10 times stronger than the demand effect (0.003, p<0.01).

CONCLUSIONS

Policies that restrict access to retail tobacco have the potential to reduce smoking prevalence, but pairing such policies with interventions to reduce consumer demand remains important.

Global policy scan of commercial combustible tobacco product retailing regulations by WHO region

BACKGROUND/AIMS

Regulatory schemes for tobacco retailing help restrict the supply and availability of smoked tobacco products. Tobacco retailer density and the proximity of tobacco outlets to youth spaces, such as schools, are greater in more disadvantaged areas. Exposure to tobacco retailing normalises smoking and increases ease of access, thus increasing smoking uptake and undermining quitting. To inform future policy, we conducted a global scan of combustible tobacco retail regulatory schemes (We use the term schemes to refer to any kind of relevant initiative, policy, regulations or legislation that we found).

METHODS

All types of English language records concerning the regulation of commercial tobacco product availability were considered, including peer-reviewed journal articles, key reports and policy documents. The key features of regulatory schemes were documented. In addition, we contacted key informants in different countries and regions for advice on additional sources and undertook targeted searching in regions where we initially found little data.

RESULTS/FINDINGS

Although many countries have well-established and comprehensive tobacco control programmes, tobacco retail policy that actively addresses the availability of tobacco is underutilised. Many jurisdictions have implemented a minimum purchase age and restricted point-of-sale advertising and marketing. Other tobacco retailing regulations also included licensing systems with licence fees, caps on licences and restrictions on store location, type and retailer density/proximity. A very small number of jurisdictions have ended tobacco retailing altogether.

CONCLUSIONS

At a minimum, policy-makers should implement licensing schemes, licence caps and proximity limits and invest in robust monitoring systems and compliance enforcement. Tobacco products' ubiquity is incompatible with its status as a dangerous addictive substance and does not align with tobacco endgame goals.

Modeling the Effects of Policies that Restrict Tobacco Retail Outlets on Prenatal Smoke Exposure and Perinatal Health Care Utilization

Tobacco retail outlet (TRO) density has been associated with increased cotinine levels in pregnant persons and their children. As such, the higher densities of TROs may represent higher levels of active smoking during pregnancy. The purpose of this study is to simulate the reduction in cotinine (a biomarker of smoke exposure) and health care utilization that could occur in pregnant persons under enactment of several candidate TRO reduction policy recommendations. Using existing retail outlet data from the state of North Carolina and from the Newborn Epigenetic Study (NEST), the present study created hypothetical policy-informed datasets of TROs that a) limited the number of TROs to the same density as the 2014 San Francisco (SF) policy (Policy 1), b) set the minimum distance to 500 feet between TROs from a school and from other TROs (Policy 2), c) restricted the types of TROs to exclude pharmacies (Policy 3), and d) a combination of Policies 1-3 (Policy 4). We estimated the effects of each policy individually and in a separate model with their combined effects in terms of the reduction on cotinine levels and health care utilization, as measured by number of visits to the emergency department (ED). We found that the hypothetical policies were likely to be effective in reducing maternal cotinine and ED visits, with the majority of the mothers in the dataset demonstrating reductions in these outcomes after implementation of the policies. We found that Policy 1 led to moderate reductions in TRO exposure for the majority of the sample as well as stratified by race/ethnicity. Additionally, Policy 4 had slightly larger estimated effects than Policy 1, but could be more onerous to implement in practice. Overall, we identified evidence supporting the efficacy of TRO reduction strategies that could impact smoke exposure during pregnancy in our diverse sample in North Carolina.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42019124984.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Potential impacts of spatial restrictions on tobacco retail availability in China: a simulation study in Shanghai

OBJECTIVES

Regulating tobacco retail availability provides promising new opportunities for effective tobacco control. This study simulates the potential impacts of introducing spatial restrictions on the availability of tobacco in Shanghai, the largest city in China.

METHODS

Twelve stakeholder-informed simulation scenarios under four types of spatial restrictions were considered: (1) capping, (2) ban of sales, (3) minimum spacing and (4) school-buffer exclusion zone. Tobacco retailer data for Shanghai (n=19 413) were used. The main outcome was per cent reduction in retail availability measured by population-weighted kernel density estimation across neighbourhoods, and impacts on social inequality in availability were estimated using the Kruskal-Wallis test and effect size estimation. All analyses were further stratified by three levels of urbanity to examine geographical disparities in overall effectiveness and equity of the simulation scenarios.

RESULTS

All simulation scenarios have the potential to reduce availability, with overall reductions ranging from 8.60% to 85.45%. Compared with the baseline, the effect size regarding the association between availability and neighbourhood deprivation quintiles suggests that the most effective scenario, '500 m minimum spacing' between retailers, increased the social inequality in availability (p<0.001). Conversely, school-buffer scenarios were both effective and equitable. Additionally, the effectiveness and the equity impact of scenarios varied by urbanity level.

CONCLUSION

Spatial restrictions offer potential new policy opportunities to reduce retail availability, but some may increase social inequality in accessing tobacco. For effective tobacco control, policymakers should consider the overall and equity impacts of spatial restrictions when developing comprehensive tobacco retail regulations.

Birthdate-based commercial tobacco sales restrictions: will 'tobacco-free generation' policies advance or delay the endgame?

Endgame thinking means transitioning from merely trying to 'control' the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as 'endgame' policies are so-called 'tobacco-free generation' or 'smoke-free generation' policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis

BACKGROUND

Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Māori. However, we lack in-depth analyses of how this measure could affect people who smoke.

METHODS

We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data.

RESULTS

Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses.

CONCLUSIONS

Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Māori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

What impact would tobacco retailer proximity limit have on tobacco availability in New Zealand?

INTRODUCTION

One policy option to reduce the density of tobacco retailers is to restrict the distance retailers can be located to each other. This study examined the impacts of proximity limits of 150 m, 300 m and 450 m between tobacco retailers in New Zealand and if critical threshold reduction in tobacco retailers of 90%-95% would be achieved.

METHODS

Using a spatial modelling approach, tobacco retailers were randomly removed based on a minimum distance between retailers until there were zero retailers within each scenario's minimum distance. This was repeated for all three proximity limit scenarios and descriptive statistics are provided for each.

RESULTS

Implementation of 150 m, 300 m or 450 m distance restrictions between tobacco retailers would result in an average reduction in availability of 35%, 49% and 58%, respectively. On average, the current median distance to the closest retailer increases from 110 m to 377 m, to 568 m or to 718 m, respectively. The average median distance from a retailer to the closest school also increases across the three proximity limits, from 1017 m to 1087 m, to 1149 m or to 1231 m, respectively. Reduced clustering in deprived areas would be most apparent if a 450 m restriction policy was implemented.

CONCLUSIONS

A proximity limit of 450 m would reduce retailers by 58%, but would not reach proposed critical behaviour-change threshold of 90%-95% required to reduce smoking prevalence independently. There is a need for a combination of policies, which focus on promoting equity, to achieve this bold endgame goal.

Impact of regulatory tightening of the Hungarian tobacco retail market on availability, access and cigarette smoking prevalence of adolescents

INTRODUCTION

Policies that reduce tobacco retail density to decrease tobacco use among the youth are critical for the tobacco endgame. This paper reviews a Hungarian tobacco regulatory measure, which, since 2013, has confined the sale of tobacco products exclusively to so-called National Tobacco Shops, summarises the changes in the national tobacco retail marketplace and reports on analyses of the impact of this intervention on illegal sales to minors and adolescent smoking behaviour.

METHODS

We reviewed the available national statistical data on the structure and dynamics of the tobacco retail market. Changes in lifetime and current (past 30 days) use of cigarettes among Hungarian adolescents aged 13-17 years were assessed using data from international youth surveys on health behaviours collected in 2010-2020.

RESULTS

Since the start of policy implementation, the density of tobacco shops in Hungary decreased by 85%, from 4.1 to 0.6 per 1000 persons. The prevalence of lifetime and current cigarette smoking among adolescents declined by 13-24 percentage points (pp) and by 4.8-15 pp, respectively. The rate of illegal sales of tobacco products to minors decreased by 27.6 pp, although the prevalence of compensatory access strategies, especially asking others to buy cigarettes for minors, increased.

CONCLUSIONS

After a significant decrease in the nationwide availability of licensed tobacco retailers, Hungary experienced short-term reductions in youth smoking prevalence. However, the sporadic implementation of complementary, evidence-based tobacco control strategies might limit further declines in youth smoking initiation and tobacco product use.

Impact and Equity of New York City's Tobacco Retail Reduction Initiative

INTRODUCTION

High levels of tobacco retailer density in communities is associated with a range of tobacco use behaviors and is a key structural driver of tobacco-related disparities. This study evaluates the impacts of New York City's (NYC) novel policy intervention to cap tobacco retail licenses on tobacco retailer density levels and neighborhood inequities in tobacco access.

METHODS

Using geocoded tobacco retail licensing data from 2010 to 2022, Bayesian conditional autoregressive Poisson panel models estimated the association between policy implementation in 2018 and retailer density per 1,000 population, controlling for neighborhood-level sociodemographic factors. Data were analyzed in 2023.

RESULTS

The number of tobacco retail licenses decreased from 9,304 in 2010 to 5,107 in 2022, with the rate of decline significantly accelerating post-policy (-14·2% versus -34·2%). Policy effects were stronger in districts with lower income and greater proportions of non-Hispanic Black residents.

CONCLUSIONS

NYC's policy substantially reduced tobacco retailer density and appeared to close longstanding patterns of inequity in tobacco access, serving as a rare example of a tobacco control policy that may effectively reduce tobacco-related disparities. This emergent approach to restructure tobacco retail in communities may reach populations that have not benefitted from traditional tobacco control policies and should be considered by other localities.

New Zealand community pharmacists' perspectives on supplying smoked tobacco as an endgame initiative: a qualitative analysis

INTRODUCTION

Tobacco endgame strategies often include measures to reduce tobacco availability by decreasing retailer numbers. Recently, some US pharmacies have delisted tobacco, though overall retailer numbers have not reduced markedly. Paradoxically, others have suggested limiting tobacco sales to pharmacies, to reduce supply and support cessation. We explored how pharmacists from Aotearoa New Zealand, a country planning to reduce tobacco supply, perceived supplying tobacco.

METHODS

We undertook in-depth interviews with 16 pharmacists from Ōtepoti Dunedin; most served more deprived communities with higher smoking prevalence. We probed participants' views on supplying tobacco, explored factors that could limit implementation of this policy, and analysed their ethical positions. We used qualitative description to analyse data on limiting factors and reflexive thematic analysis to interpret the ethical arguments adduced.

RESULTS

Most participants noted time, space and safety concerns, and some had strong moral objections to supplying tobacco. These included concerns that supplying tobacco would contradict their duty not to harm patients, reduce them to sales assistants, undermine their role as health experts, and tarnish their profession. A minority focused on the potential benefits of a pharmacy supply measure, which they thought would use and extend their skills, and improve community well-being.

CONCLUSIONS

Policy-makers will likely encounter strongly expressed opposition if they attempt to introduce a pharmacy supply measure as an initial component of a retail reduction strategy. However, as smoking prevalence falls, adopting a health-promoting supply model, using pharmacies that chose to participate, would become more feasible and potentially enhance community outreach and cessation support.

Tobacco retailer density and smoking behaviour: how are exposure and outcome measures classified? A systematic review

INTRODUCTION

To date only a limited number of reviews have focused on how exposure and outcome measures are defined in the existing literature on associations between tobacco retailer density ('density') and smoking behaviour ('smoking'). Therefore this systematic review classified and summarised how both density and smoking variables are operationalised in the existing literature, and provides several methodological recommendations for future density and smoking research.

METHODS

Two literature searches between March and April 2018 and April 2022 were conducted across 10 databases. Inclusion and exclusion criteria were developed and keyword database searches were undertaken. Studies were imported into Covidence. Cross-sectional studies that met the inclusion criteria were extracted and a quality assessment was undertaken. Studies were categorised according to the density measure used, and smoking was re-categorised using a modified classification tool.

RESULTS

Large heterogeneity was found in the operationalisation of both measures in the 47 studies included for analysis. Density was most commonly measured directly from geocoded locations using circular buffers at various distances (n = 14). After smoking was reclassified using a smoking classification tool, past-month smoking was the most common smoking type reported (n = 26).

CONCLUSIONS

It is recommended that density is measured through length-distance and travel time using the street network and weighted (e.g. by the size of an area), or by using Kernel Density Estimates as these methods provide a more accurate measure of geographical to tobacco and e-cigarette retailer density. The consistent application of a smoking measures classification tool, such as the one developed for this systematic review, would enable better comparisons between studies. Future research should measure exposure and outcome measures in a way that makes them comparable with other studies.

IMPLICATIONS

This systematic review provides a strong case for improving data collection and analysis methodologies in studies assessing tobacco retailer density and smoking behaviour to ensure that both exposure and outcome measures are clearly defined and captured. As large heterogeneity was found in the operationalisation of both density and smoking behaviour measures in the studies included for analysis, there is a need for future studies to capture, measure and classify exposure measures accurately, and to define outcome measures in a manner that makes them comparable with other studies.

Perspectives on limiting tobacco access and supporting access to nicotine vaping products among clients of residential drug and alcohol treatment services in Australia

INTRODUCTION

Tobacco endgame strategies aim to drive down population smoking rates, the success of which can be improved with public buy-in, including from populations with high smoking rates such as alcohol and other drug (AOD) service clients. This study aimed to explore acceptability of tobacco retail and nicotine reduction, and subsidised nicotine vaping to support AOD service clients following a smoking cessation attempt.

METHODS

We interviewed 31 Australian AOD service clients who currently or previously smoked, following a 12-week randomised trial comparing nicotine replacement therapy with nicotine vaping product (NVP) for smoking cessation. Participants were asked how effectively three scenarios would support tobacco cessation: tobacco retailer reduction, very low-nicotine cigarette standard and subsidised NVP access. We thematically analysed participant views on how each approach would support tobacco abstinence.

RESULTS

Tobacco retailer reduction raised concerns about increasing travel and accessing cigarettes from alternate sources, with generally lower acceptability, though a range of perspectives were provided. Reducing nicotine in tobacco products was described as reducing appeal of smoking and potentially increasing illicit purchases of non-reduced nicotine products. Clients of AOD services were highly accepting of subsidised NVP access for tobacco cessation, as this would partly address financial and socioeconomic barriers.

CONCLUSIONS

Australian tobacco control policy should consider how these approaches impact ease and likelihood of tobacco access by AOD service clients in relation to the general population. Understanding clients' acceptability of tobacco control and endgame measures can inform how to avoid potential unintended consequences for these clients.

Use of geographically weighted regression models to inform retail endgame strategies in South Korea: application to cigarette and ENDS prevalence

BACKGROUND

Reducing tobacco retailer availability is a key tobacco endgame policy. The development and evaluation of retail-based policies require spatial methodologies. We modelled the prevalence of adult cigarette and electronic nicotine delivery system (ENDS) use according to tobacco retailer density, considering geographical variations.

METHODS

Registration data for tobacco retail businesses, a population-representative survey of South Koreans aged ≥19 years, and population and land area data were used. We merged the datasets according to geographical units. Ordinary least squares (OLS) and geographically weighted regression (GWR) analyses were conducted to model cigarette and ENDS use prevalence, respectively.

FINDINGS

Tobacco retailer density was associated with increased cigarette use prevalence in the OLS model (β=2.19, p=0.02). A 1.9-fold difference by region was identified for the coefficient, indicating an association with tobacco retailer density (minimum 1.39, maximum 2.65), in the GWR analysis. No significant association was present between tobacco retailer density and ENDS prevalence in either the OLS (β=0.24, p=0.37) or the GWR model (minimum 0.20, maximum 0.28).

CONCLUSION

Our results suggest the importance of using spatial methods to develop and evaluate retail-based endgame policies. The establishment of tobacco retailer databases by the introduction of licensing is necessary to develop and evaluate the effectiveness of tobacco retailer regulations.

A statewide study of disparities in local policies and tobacco, vape, and cannabis retail environments

The current study: (1) assesses sociodemographic disparities in local policies related to tobacco and cannabis retail, and (2) examines the cross-sectional association between policy strength and retailer densities of tobacco, e-cigarette (vape), and cannabis retailers within California cities and county unincorporated areas (N = 539). We combined (a) American Community Survey data (2019 5-year estimates), (b) 2018 tobacco, vape, and cannabis retailer locations from a commercial data provider, (c) 2017 tobacco and vape retail environment policy data from American Lung Association, and (d) 2018 cannabis policy data from California Cannabis Local Laws Database. Conditional autoregressive models examined policy strength associations with sociodemographic composition and retailer density in California jurisdictions. Jurisdictions with larger percentages of Black and foreign-born residents had stronger tobacco and vape policies. For cannabis policy, only income had a small, significant positive association with policy strength. Contrary to hypothesis, tobacco/vape policies were not significantly associated with retailer density, but cannabis policy strength was associated with lower cannabis retailer density (relative rate = 0.58, 95% Uncertainty Interval 0.47-0.70)-this effect was completely driven by storefront bans. Thus, storefront cannabis bans were the only policy studied that was associated with lower cannabis retailer density. Further research is needed to understand policies and disparities in retail environments for tobacco, vape, and cannabis, including data on the prospective association between policy implementation and subsequent retailer density, and the role of enforcement.

Is it time to increase the cost of tobacco licences after 10 years of stagnation?

OBJECTIVE

Reducing tobacco licences is one potential lever to reduce tobacco-related harms. A 15-fold increase in annual tobacco retailer licence fees in 2007 led to a 24% decline in the number of licences in 2009. This study investigates the changes in tobacco licences over a subsequent decade in the absence of real fee increases.

METHODS

The South Australian (SA) government tobacco licencing system databases for 2009 and 2020 were audited, measuring changes in the number and distribution of tobacco and vending machine licences by outlet type, disadvantage, and remoteness.

RESULTS

The number of tobacco licences declined by 33.1% overall. Large reductions were observed in food service venues (65.2%) and hotel/motels (37.2%). In 2020, most licences were in service stations (25.1%), hotel/motels (22.9%), and supermarkets (22.2%). Despite proportional reductions across all disadvantage quintiles, the most disadvantaged areas continued to have the largest number of tobacco licensees. Vending machines declined by 63.6% and remained concentrated in hotels/motels (91.4%).

CONCLUSIONS

Since a 15-fold licence fee increase in 2007 effectively reduced tobacco retailers from 2007-2009, the decline since has been incremental.

IMPLICATIONS FOR PUBLIC HEALTH

Increasing tobacco licence fees is a straightforward and effective measure to reduce tobacco availability and should be re-prioritised.

Socioeconomic differences in tobacco outlet presence, density, and proximity in four cities in the Netherlands

BACKGROUND

Previous studies found that tobacco outlets were unevenly distributed by area socioeconomic status (SES). However, evidence from continental Europe is limited. This study aims to assess differences in tobacco outlet presence, density and proximity by area SES in the Netherlands.

METHODS

All tobacco outlets in four Dutch cities (Amsterdam, and medium-sized cities Eindhoven, Haarlem, and Zwolle) were mapped between September 2019 and June 2020. We estimated associations between average property value of neighbourhoods (as an indicator of SES, grouped into quintiles) and (1) tobacco outlet presence in the neighbourhood (yes/no), (2) density (per km2), and (3) proximity to the closest outlet (in meters), using logistic and linear regression models.

RESULTS

46% of neighbourhoods contained at least one tobacco outlet. Tobacco outlets were mostly situated in city centres, but the distribution of tobacco outlets varied per city due to differences in urban structures and functions. In the medium-sized cities, each quintile higher neighbourhood-SES was associated with lower tobacco outlet presence (OR:0.71, 95%CI:0.59;0.85), lower density (B:-1.20 outlets/km2, 95%CI:-2.20;-0.20) and less proximity (B:40.2 m, 95%CI 36.58;43.83). Associations were the other way around for Amsterdam (OR:1.22, 95%CI:1.05;1.40, B:3.50, 95%CI:0.81;6.20, and B:-18.45, 95%CI:-20.41;-16.49, respectively). Results were similar for most types of tobacco outlets.

CONCLUSION

In medium-sized cities in the Netherlands, tobacco outlets were more often located in low-SES neighbourhoods than high-SES. Amsterdam presented a reverse pattern, possibly due to its unique urban structure. We discuss how licensing might contribute to reducing tobacco outlets in low-SES neighbourhoods.

Exploring the Presence and Type of Premium Cigar Retailers With Neighborhood Sociodemographic Correlates in the United States, 2019-2021

INTRODUCTION

Little is known about the location and store type of premium cigar retailers in the United States. Different store types may expose people to secondhand smoke (eg, cigar bar or lounge) and may also have age restrictions (eg, tobacco shops) that could reduce youth exposure to products and marketing.

AIMS AND METHODS

We obtained a national retailer dataset from the Premium Cigar Association (PCA) from 2019 to 2021. We coded store type using nine categories and used generalized estimating equations to examine associations between census tract sociodemographic characteristics and PCA store type.

RESULTS

Of the 1279 PCA retailers, the majority were cigar stores (39%), followed by tobacco shops (26%), cigar bars or lounges (20%), and beer, wine, or liquor stores (15%). Overall, there were no statistically significant associations between tract-level sociodemographic characteristics and the odds that a retailer was a specific store type versus another store type. However, PCA retailers located in tracts with a higher percentage of non-Hispanic Black residents were associated with 1.12 times the odds of being a cigar bar or lounge versus another type (95% CI, 1.02 to 1.22).

CONCLUSIONS

The majority of PCA retailers are specialty cigar stores or cigar bars or lounges, and few are more traditional tobacco retailers, such as convenience stores. We document a higher odds of a store being a cigar bar or lounge for retailers located in neighborhoods with a higher proportion of Black residents, which may contribute to inequities in tobacco-related disease and disability because of potentially greater secondhand smoke exposure.

IMPLICATIONS

Specialized retailers account for most premium cigar stores. One in five PCA retailers was a cigar bar or lounge, which raises public health concerns around exposure to secondhand smoke for patrons and employees. Local jurisdictions should examine zoning ordinances in tandem with sociodemographic characteristics to ensure inequities in the location of cigar bars or lounges are not produced or sustained given the potential harms associated with secondhand smoke exposure.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Reducing the number and types of tobacco retail outlets in the Netherlands: Study protocol for a comprehensive mixedmethods policy evaluation

The Netherlands plans to ban tobacco sales in supermarkets in 2024. In a comprehensive policy evaluation, we aim to examine: 1) the impact of the policy on the number and types of tobacco outlets, 2) the impact on attitudes and behaviors of smoking adults and non-smoking youth, and 3) the influence of the tobacco industry on the policy process and the retail environment. In addition, our study focusses on differential effects in disadvantaged neighborhoods, where both smoking rates and tobacco outlet density are typically highest. This study brings together economic, psychological, and journalistic research methods. We investigate the impact of the new legislation on the number and type of tobacco outlets, and on the number of smokers by using routinely collected population monitoring data. We examine the impact of the legislation on smoking susceptibility of non-smoking youth and on impulse tobacco purchases by smoking adults with yearly quantitative surveys and with qualitative interviews and discussion sessions. We describe whether these impacts differ for disadvantaged versus non-disadvantaged neighborhoods. We investigate what strategies the tobacco industry uses to influence the new legislation, policy processes, and the tobacco retail environment by performing a journalistic investigation, by means of documents obtained by Freedom of Information Act (FOIA) requests, (possibly) leaked documents from insider meetings, and interviews with insiders. The methods of our evaluation can be used as a model for other comprehensive public policy evaluations.

Trends in Education-Related Smoking Disparities Among U.S. Black or African American and White Adults: Intersections of Race, Sex, and Region

INTRODUCTION

Despite its overall decline in the United States, trends in cigarette smoking could vary by intersection with demographic characteristics. We explored trends in education-related disparities in current smoking among U.S. adults by race (Black or African American and White), sex, and U.S. census region.

AIMS AND METHODS

Data were from U.S. civilian non-institutionalized adults (aged ≥18 years) who self-identified as Black or African American and White and participated in the 1995-2019 Tobacco Use Supplement to the Current Population Survey. We estimated average annual percent changes in current cigarette smoking by the intersections of race, sex, census region, and educational attainment. We calculated educated-related prevalence differences in current cigarette smoking by subtracting the prevalence of bachelor's degrees from that of

RESULTS

Education-related disparities in current cigarette smoking increased over time, especially among Black or African American male (PD1995-1996 = 22.8%; PD2018-2019 = 27.2%) and female adults (PD1995-1996 = 12.1%; PD2018-2019 = 16.5%). By region, Black or African American male adults in the Midwest showed the largest increase in education-related current cigarette smoking disparities, followed by Black or African American male and female adults in the South, and White male and female adults in the Midwest. These findings were because of small to no declines in the prevalence of current cigarette smoking among those with

CONCLUSION AND RELEVANCE

The gap in the prevalence of current cigarette smoking by education widened over time, especially among Black or African American adults in certain regions.

IMPLICATIONS

Despite the decline in the prevalence of current cigarette smoking in the U.S. population overall, such public health gain may not benefit all individuals equally. Using the data from a U.S. representative serial cross-sectional survey study during 1995-2019, we found that disparities in current cigarette smoking prevalence between those with Collapse

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MESH Headings

• Adult
• Female
• Humans
• Male
• Black or African American
• Cigarette Smoking/epidemiology
• Cross-Sectional Studies
• Educational Status
• Prevalence
• Surveys and Questionnaires
• United States/epidemiology
• White
• Health Status Disparities

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Grants

• FDA HHS
• NIMHD NIH HHS
• National Institute on Minority Health and Health Disparities
• U.S. Food and Drug Administration

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Affiliation(s)

Kelvin Choi Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
Jamal T Jones Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Beltsville, Maryland, USA
Andrea L Ruybal Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Beltsville, Maryland, USA
Timothy S McNeel Information Management Services, Inc., Calverton, Maryland, USA
Danielle A Duarte Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
Monica Webb Hooper Office of the Director, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA

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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.

The Association Between Tobacco Retailer Outlet Density and Prevalence of Cigarette Smoking in Virginia

OBJECTIVE

We examine the association between tobacco retail outlet density and adult smoking prevalence at the county level in Virginia, controlling for spatial autocorrelations.

AIMS AND METHODS

Pooling data from 2020 County Health Rankings (compiled data from various sources including, but not limited to, the National Center for Health Statistics-Mortality Files, the Behavioral Risk Factor Surveillance System (BRFSS), and the American Community Survey) and Counter Tools, we conducted regression analyses that accounted for spatial autocorrelation (spatial lag models, LMlag) and adjusted for county-level access to healthcare, demographics, SES, environmental factors, risk conditions or behaviors, and population health measures.

RESULTS

Our estimates provide evidence that every increase of one tobacco retail outlet per 1000 persons was associated with 1.16 percentage points (95% CI: 0.80-1.52) higher smoking prevalence at the county level in Virginia after controlling for spatial autocorrelation. The effect of outlet density was largely explained by social determinants of health such as SES, risky conditions or behaviors, and environmental factors. We further noticed that the impact of social determinants of health were closely related and can be explained by indicators of population health (rates of mental distress (β = 1.49, 95% CI: 1.31-1.67) and physical inactivity (β = 0.07, 95% CI: 0.04-0.10).

CONCLUSIONS

Although higher tobacco outlet density was associated with an increase in county-level smoking prevalence, the impact of outlet density was largely explained by social determinants of health and mental illness. Improving well-being at the community level could be a promising strategy in future tobacco control policies.

IMPLICATION

The influence of tobacco outlet density seems to be explained by other social determinants of health and population level of mental or physical health. Thus, efforts to reduce tobacco use and consequent negative health effects should explore the impact of improving regional living standards. However, a sole focus on economic growth may not be sufficient, whereas a focus on such things as promoting work-life balance and improving overall well-being at the community level may be more.

Recommendations to advance equity in tobacco control

Reducing racial and socioeconomic inequities in smoking has been declared a priority for tobacco control in the USA for several decades. Yet despite the rhetoric, these inequities persist and some have actually worsened over time. Although tobacco companies have targeted racially and ethnically diverse and lower-income tobacco users, which substantially contributes to these disparities, less attention has been given to the role of individuals and organisations within the tobacco control movement who have allowed progress in eliminating disparities to stagnate. We examine the failure of tobacco control professionals to ensure the widespread adoption of equity-focused tobacco control strategies. Review of major US tobacco control reports found that the focus on equity often stops after describing inequities in tobacco use. We suggest ways to advance equity in tobacco control in the USA. These recommendations fall across five categories: surveillance, interventions, funding, accountability and addressing root causes. Policy interventions that will have a pro-equity impact on smoking and related disease should be prioritised. Funding should be designated to tobacco control activities focused on eliminating racial and socioeconomic inequities in smoking, and tobacco control programmes should be held accountable for meeting equity-related goals.

Variations in Tobacco Retailer Type Across Community Characteristics: Place Matters

Introduction

The density of tobacco retailers varies by community characteristics such as poverty levels or racial and ethnic composition. However, few studies have investigated how specific types of tobacco retailers vary by community characteristics. Our objective was to assess how the types of tobacco retailers in Ohio varied by the characteristics of the communities in which they were located.

Results

For all US Census tracts, convenience stores were the most common type of retailer selling tobacco. Yet, the prevalence of convenience stores was higher in high-poverty urban tracts than in low-poverty urban tracts. Discount stores were the second-most common type of tobacco retailer and were most prevalent in rural tracts and high-racial and ethnic minority urban tracts. Grocery stores, pharmacies, and vape or hookah shops typically had the highest prevalence in more advantaged tracts.

Conclusion

Our findings demonstrate that the distribution of specific retailer types varies by community characteristics. The distribution of these retailer types has implications for product availability and price, which may subsequently affect tobacco use and cessation. To create equitable outcomes, policies should focus on retailers such as convenience and discount stores, which are heavily located in communities experiencing tobacco-related health disparities.

Sociodemographic Disparities in Tobacco Retailer Density in the United States, 2000-2017

INTRODUCTION

Studies find differences in tobacco retailer density according to neighborhood sociodemographic characteristics, raising issues of social justice, but not all research is consistent.

AIMS AND METHODS

This study examined associations between tobacco retailer density and neighborhood sociodemographic characteristics in the United States at four timepoints (2000, 2007, 2012, and 2017) and investigated if associations remained stable over time. Data on tobacco retailers came from the National Establishment Time-Series Database. Adjusted log-linear models examined the relationship between retailer density and census tract sociodemographic characteristics (% non-Hispanic Black [Black], % Hispanic, % vacant housing units, median household income), controlling for percentage of youth, urbanicity, and US region. To examine whether the relationship between density and sociodemographic characteristics changed over time, additional models were estimated with interaction terms between each sociodemographic characteristic and year.

RESULTS

Tobacco retailer density ranged from 1.22 to 1.44 retailers/1000 persons from 2000 to 2017. There were significant, positive relationships between tobacco retailer density and the percentage of Black (standardized exp(b) = 1.05 [95% CI: 1.04% to 1.07%]) and Hispanic (standardized exp(b) = 1.06 [95% CI: 1.05% to 1.08%]) residents and the percentage of vacant housing units (standardized exp(b) =1.08 [95% CI: 1.07% to 1.10%]) in a census tract. Retailer density was negatively associated with income (standardized exp(b) = 0.84 [95% CI: 0.82% to 0.86%]). From 2000 to 2017, the relationship between retailer density and income and vacant housing units became weaker.

CONCLUSIONS

Despite the weakening of some associations, there are sociodemographic disparities in tobacco retailer density from 2000 to 2017, which research has shown may contribute to inequities in smoking.

IMPLICATIONS

This study examines associations between tobacco retailer density and neighborhood sociodemographic characteristics in the United States at four timepoints from 2000 to 2017. Although some associations weakened, there are sociodemographic disparities in tobacco retailer density over the study period. Research suggests that sociodemographic disparities in retailer density may contribute to inequities in smoking. Findings from this study may help identify which communities should be prioritized for policy intervention and regulation.

Draining the tobacco swamps: Shaping the built environment to reduce tobacco retailer proximity to residents in 30 big US cities

Combining geospatial data on residential and tobacco retailer density in 30 big US cities, we find that a large majority of urban residents live in tobacco swamps - neighborhoods where there is a glut of tobacco retailers. In this study, we simulate the effects of tobacco retail reduction policies and compare probable changes in resident-to-retailer proximity and retailer density for each city. While measures of proximity and density at baseline are highly correlated, the results differ both between effects on proximity and density and across the 30 cities. Context, particularly baseline proximity of residents to retailers, is important to consider when designing policies to reduce retailer concentration.

Retail endgame strategies: reduce tobacco availability and visibility and promote health equity

An increasing number of countries have set tobacco endgame goals that target dramatic reductions in smoking prevalence. To achieve those targets and promote health equity, policies are needed to reduce the retail supply and visibility of tobacco products. Focusing on retailer reduction strategies and tobacco display bans, this special communication reviews solution-oriented research about the retail environment. It highlights examples of policy implementation and identifies data needs and research gaps for designing and evaluating retail policies to promote population health equitably.

Sociodemographic inequities in tobacco retailer density: Do neighboring places matter?

We apply a spatial perspective to measure the extent to which the 2018 U.S. racial, ethnic, and socioeconomic composition of census tracts were each associated with tobacco retailer density within a tract and in its neighboring tracts (n = 71,409). A 10-percentage point increase in the Black population was associated with 0.07 (p < 0.05) more retailers per square mile within a focal tract and 0.35 (p < 0.001) more retailers per square mile in its neighbors on average. A greater percent of Hispanic/Latino residents was associated with more retailers per square mile, both within a focal tract (b = 0.95, p < 0.001) and in its neighbors 0.39 (p < 0.001). Inverse associations were observed for percent white. We also observed inequities by socioeconomic status. The overall magnitude of inequities may be underestimated if the spatial dependence between focal tracts and their neighbors are not taken into consideration. Policymakers should prioritize interconnected geographic areas experiencing high racialized and socioeconomic segregation when designing and implementing policies to reduce retail tobacco product availability.