Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest

The effect of tobacco tax increase on price-minimizing tobacco purchasing behaviours: A systematic review and meta-analysis

BACKGROUND AND AIMS

Tobacco product excise taxes are a cost-effective method for reducing tobacco consumption, but industry pricing and marketing strategies encourage consumers to engage in price-minimizing behaviours (PMBs). We investigated the relationship between tobacco tax increases and PMBs, measuring whether PMBs intensify following tax increases, whether low-income consumers with higher nicotine dependence are more likely to engage in PMBs and whether PMBs are negatively related to smoking cessation.

METHOD

This was a systematic review with meta-analysis of cross-sectional and longitudinal studies from seven databases up to March 2023, using studies that reported any product- and purchasing-related smoking behaviours post-tobacco tax increase in a general representative population. Sixty-eight studies were quality-assessed using the Newcastle-Ottawa scale. All studies were narratively synthesized, with five studies involving 13 068-26 575 participants providing data for pooled analyses on PMBs [purchasing lower-priced brands, roll-your-own (RYO) tobacco and cartons] pre- and post-tax increases using a random effects meta-analytical model.

RESULTS

Fifty-seven studies reported on legal PMBs, and 17 studies reported illicit cigarette purchasing. Meta-analysis showed that consecutive tax increases were positively associated with purchasing RYO [odds ratio (OR) = 1.60, 95% confidence interval (CI) = 1.04-2.46], especially in higher tobacco taxing environments, with substantial heterogeneity (I2 = 96%). Lower income and higher nicotine dependence were associated with purchasing lower-priced brands and RYO, whereas higher income and nicotine dependence were associated with purchasing cartons, large-sized packs and cross-border sales. Less evidence associated illicit tobacco purchases with tax increases or PMBs with smoking cessation.

CONCLUSIONS

Tobacco purchasers' PMBs vary widely by state, country and time-period within countries. Both legal and illegal PMBs, potentially influenced by industry pricing tactics, may exacerbate health inequalities and dilute the public health benefits of tobacco tax increases.

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.

Impacts of Tax and Flavor Tobacco Policies on San Francisco Bay Area Tobacco Prices

California Proposition 56 increased the state tobacco tax by $2 per cigarette pack effective April 1, 2017. Between 2015-2020 San Francisco (SF) and some cities in Alameda County enacted local flavored tobacco sales restrictions. SF also increased its Cigarette Litter Abatement Fee, from $0.20/pack in 2015 to $1.00 in 2020. Compare the change in tobacco prices before (2015) and after (2019/20) the implementation of a $2 increase in tobacco excise tax and local flavored tobacco policies in SF and Alameda Counties. Descriptive study of the pre-to-post policy analysis design. We drew a proportional random sample of retailers (N=463) in SF and Alameda Counties, by city. Using multivariable, single- and multiple-level linear regressions, we compared inflation-adjusted average tobacco prices in 2015 vs. 2019/20 by county and by flavor policy, accounting for socio-demographics. Change in inflation-adjusted average tobacco prices in 2015 vs. 2019/20 by county and flavor policy, accounting for socio-demographics. Between 2015-2019/20, the increase in cigarette prices was higher than the $2 tax increase, and higher in SF than Alameda County (+$4.6 vs +$2.5). SF retailers stopped selling Newport menthol cigarettes and Blu brand menthol e-cigarettes in 2019/20. Adjusted average cigarette prices increased significantly more in SF and Alameda County cities with comprehensive or partial flavor policies versus cities without flavor policies (by $3.23 and $2.11). Local flavor policies affected menthol product availability and may have had positive spillover effects and indirectly increased pack prices.

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.

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.

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.

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.

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.

Disparities in self-reported exposure to tobacco marketing among youth and young adults from low-socioeconomic status neighbourhoods in Mexico City

Exposure to tobacco marketing is positively associated with smoking initiation and behaviours. There is limited literature examining disparities among reported exposure in low- and middle-income countries. This study sought to fill this gap with a survey among 1427 adolescents and 889 adult smokers in Mexico City in 2020. Data were analysed using chi-square and hierarchical regression models. Two-thirds of adolescents noticed cigarette pack displays in stores. Participants from low- and mid-socioeconomic status (SES) neighbourhoods were more exposed to tobacco marketing than their counterparts through several channels. After addressing the shared variance among participants from the same household nested in neighbourhood SES level and controlling for gender, adolescent non-smokers and adult smokers who noticed pack displays were more likely to be susceptible to smoking (OR = 1.8, 95% CI 1.4-2.4) and to smoke more (OR = 1.7, 95% CI 1.21-2.47); adult smokers who noticed tobacco marketing at more places were less likely to be certain about smoking risks (OR = 0.9, 95% CI 0.8-0.9). The results suggest that the tobacco industry targets youth and individuals from low-SES neighbourhoods through several channels. Greater exposure to tobacco marketing was associated with increased susceptibility to smoking and decreased risk perception. These findings support a comprehensive ban on tobacco marketing in Mexico.

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.

Predictors of Cigarette Smoking Cessation in Adolescents: A Systematic Review

PURPOSE

To update a systematic review published in 2012 that identified predictors of cigarette smoking cessation among adolescents.

METHODS

The PubMed and Web of Science databases were searched for relevant articles published between September 2010 and January 2018, using the following keywords: smoking OR tobacco OR cessation; quit OR stop; longitudinal OR prospective OR cohort. Our search identified 3,399 articles. Inclusion criteria included longitudinal studies (intervention and cohort studies) evaluating cigarette smoking cessation in young people (aged 10-24 years). After screening, in total, 34 articles were included in the review.

RESULTS

In total, 63 predictors of smoking cessation among adolescents were identified, with 36 new predictors that were not identified in the previous review: nine sociodemographic factors, 13 psychosocial factors, five behavioral factors, 19 social influences factors, eight smoking related variables, six environmental factors, 2 health related variables, and one genetic factor.

CONCLUSIONS

To increase the probability of successful smoking cessation, strategies targeting young smokers should consider both individual and environmental predictors of cessation.

Cigarette Packs With URLs Leading to Tobacco Company Websites: Content Analysis

BACKGROUND

Tobacco companies include on the packaging of their products URLs directing consumers to websites that contain protobacco messages. Online media tend to be underregulated and provide the industry with an opportunity to present users with protobacco communication.

OBJECTIVE

The objective of our study was to document the content of websites that were advertised on tobacco packs in 14 low- and middle-income countries.

METHODS

We purchased tobacco packs from 14 low- and middle-income countries in 2013 and examined them for the presence of URLs. We visited unique URLs on multiple occasions between October 1, 2016 and August 9, 2017. We developed a coding checklist and used it to conduct a content analysis of active corporate websites to identify types of protobacco communication. The coding checklist included the presence of regulatory controls and warnings, engagement strategies, marketing appeals (eg, description of product popularity, luxury/quality, taste), corporate social responsibility programs, and image management. We coded brand websites separately and also described social media and other website types.

RESULTS

We identified 89 unique URLs, of which 54 were active during the search period. We assessed 26 corporate websites, 21 brand websites, 2 nontobacco websites, and 5 social media pages. We excluded 2 corporate websites and 14 brand websites due to limited accessible content or incomplete content. Corporate social responsibility was discussed on all corporate websites, and marketing appeals were also common. Corporate websites were also more likely to include more nonspecific (12/24, 50%) than specific (7/24, 29%) health warnings. Promotions (6/7, 86%) and sociability appeals (3/7, 43%) were common on brand websites. The small number of social media webpages in our sample used gendered marketing.

CONCLUSIONS

URLs appearing on tobacco packs direct consumers to websites where users are exposed to marketing that highlights the "positive" contributions of tobacco companies on corporate websites, and extensive promotions and marketing appeals on brand websites and social media pages. It is essential that marketing regulations become more comprehensive and ban all protobacco communication, a policy that is in line with articles 5.3 and 13 of the World Health Organization Framework Convention on Tobacco Control. For countries that already ban internet tobacco advertising, enforcement efforts should be strengthened. Tobacco companies' use of URLs on packs may also be compelling for plain packaging advocacy, where all branding is removed from the pack and large graphic health warning labels are the only communication on the tobacco packaging. Future research should consider including tobacco websites in marketing surveillance.

Exposure to Multimedia Tobacco Marketing and Product Use Among Youth: A Longitudinal Analysis

INTRODUCTION

Tobacco companies continue to reach youth through direct-to-consumer marketing, which has been associated with overall tobacco use. We examine how exposure to these marketing activities influences product-specific use behaviors.

METHODS

We analyzed data from 10 081 youth (aged 12-18 years) who participated in Waves 1 and 2 (2013-2015) of the Population Assessment of Tobacco and Health (PATH) Study. Participants reported past 6-month tobacco coupon receipt and online tobacco marketing engagement, and susceptibility to ever and current use of cigarette, e-cigarettes, cigars, smokeless tobacco, and hookah. Weighted multivariable logistic regression examined Wave 1 predictors of coupon receipt at Wave 2, and associations between coupon receipt, online engagement, and past 30-day use of different tobacco products.

RESULTS

Youth received tobacco coupons at one (9.7%) or both waves (1.2%) and 11.1% engaged with online tobacco marketing. Coupon receipt and online marketing engagement at Wave 1 predicted Wave 2 coupon receipt among susceptible-never, ever-but-not-current, and current tobacco users (p < .05). Coupon receipt and online engagement at Wave 1 was positively associated with past 30-day use of cigarettes, e-cigarettes, cigars, smokeless tobacco, and hookah at Wave 2 (p < .05). The relationships were stronger for those who received coupons at both waves or engaged with more sources of online marketing.

CONCLUSIONS

Tobacco direct-to-consumer marketing is reaching youth. Repeated exposure to these marketing activities within and across media is associated with use of different tobacco products. New policies and strong enforcement of existing regulations prohibiting these illegal marketing tactics are critical to protect youth from future tobacco use.

IMPLICATIONS

Tobacco companies utilize coupons and online engagement activities to increase brand awareness, knowledge, and sales of their products. These kinds of marketing activities can be influential among youth at a time when they may develop tobacco use behaviors. Our findings suggest that tobacco companies may be targeting at-risk youth through cross-media marketing activities. The findings also indicate that exposure to these marketing activities predicts subsequent use of different tobacco products, with suggestive dose-response relationships. Increased regulations are needed to protect youth from these marketing activities.

Association between free tobacco product sample receipt and tobacco use in youth and adults in the PATH Study, 2014-2016

Tobacco companies have distributed free samples of tobacco products in the past. While prior studies have found a relationship between various marketing strategies and tobacco use, no study has assessed the prevalence of free sample receipt or the relationship between receipt and subsequent tobacco use. We analyze three waves of Population Assessment of Tobacco and Health (PATH) Study data to provide the first nationally representative prevalence estimates of free tobacco product receipt among US youth and adults in 2014 to 2016. This analysis also examines the relationship between free tobacco product receipt and ever, past 30-day, and new tobacco use one year later. The prevalence of free sample receipt in the US population in 2014-2016 was 0.8% for any tobacco product but 1.6% for ENDS/e-liquid in adults, and 0.5% for any tobacco product but 1.05% for ENDS/e-liquid in youth. Free sample receipt was higher among vulnerable subgroups. Receipt of free tobacco product samples was associated with tobacco use status using cross-sectional data in youth and adults, as well as one year later in youth. Receipt of a free ENDS or e-liquid sample was associated with any tobacco and ENDS use status using cross-sectional data in youth and adults. After these data were collected, the US Food and Drug Administration broadened the ban on distributing free samples to include all tobacco products except smokeless tobacco in adult-only facilities. Our findings support limiting free samples to further prevent youth access to tobacco products.

Association of Educational Attainment and Race/Ethnicity With Exposure to Tobacco Advertisement Among US Young Adults

Importance

Associations of educational attainment with improved health outcomes have been found to be weaker among racial/ethnic minority groups compared with those among the racial/ethnic majority group. Recent research has also documented higher than expected prevalence of smoking in highly educated African American and Hispanic adults.

Objective

To compare the association of educational attainment with exposure to tobacco advertisements among racial/ethnic groups of US young adults.

Design, Setting, and Participants

This cross-sectional study included data from 6700 young adults who participated in wave 1 of the Population Assessment of Tobacco and Health Study, a nationally representative survey of US adults in 2013. Educational attainment was classified as less than high school diploma, high school graduate, or college graduate. Analysis was conducted between September 20 and October 4, 2019.

Main Outcomes and Measures

The independent variable was educational attainment (less than high school diploma, high school graduate, and college graduate). The dependent variable was any exposure to tobacco advertisements in the past 12 months. Race/ethnicity, age, sex, poverty status, unemployment, and region were the covariates. Binary logistic and Poisson regression were used to analyze the data.

Results

The study included 6700 participants (3366 [50.2%] men) between ages 18 and 24 years. Most participants were non-Hispanic (5257 participants [78.9%]) and white (5394 participants [80.5%]), while 1443 participants (21.5%) were Hispanic. Educational levels included 1167 participants (17.4%) with less than a high school diploma, 4812 participants (71.8%) who were high school graduates, and 4812 participants (10.8%) who were college graduates. A total of 4728 participants (70.6%) reported exposure to tobacco advertisements in the past 12 months. Exposure to tobacco advertising was reported by 383 participants (53.1%) who were college graduates, 3453 participants (71.8%) who were high school graduates, and 892 participants (76.4%) with less than high school educational attainment. In regression analysis, high school graduation (odds ratio, 0.79; 95% CI, 0.68-0.92) and college graduation (odds ratio, 0.46; 95% CI, 0.39-0.54) were associated with lower odds of exposure to tobacco advertisements compared with young adults with lower educational attainment. Compared with non-Hispanic participants, high school education had a weaker protective association for tobacco advertisement exposure among Hispanic participants (odds ratio, 1.44; 95% CI, 1.03-2.01; P = .03), suggesting that the association of high school graduation with lower exposure to tobacco advertisement is weaker among Hispanic young adults than non-Hispanic young adults.

Conclusions and Relevance

This study found that high school graduation had a weaker inverse association with tobacco advertisement exposure among Hispanic than non-Hispanic young adults. Future research should explore the role of targeted marketing strategies of the tobacco industry that largely advertise tobacco in areas with high concentrations of racial/ethnic minority groups. Future research should also evaluate the efficacy of more restrictive marketing policies on racial/ethnic disparities in tobacco use.

Marketing of e-cigarettes to vulnerable populations: An emerging social justice issue

PURPOSE

To describe the practice of e-cigarette marketing to vulnerable populations and to suggest strategies to help reduce e-cigarette use.

CONCLUSIONS

E-cigarette companies target vulnerable populations through civil rights, freedom marketing, and advertising strategies, which may perpetuate continued tobacco disparities in these populations.

PRACTICE IMPLICATIONS

Health care providers have the responsibility as social justice advocates to engage in efforts to reduce e-cigarette use among vulnerable populations. We must increase knowledge, education, and training specific to e-cigarettes. Awareness of marketing strategies related to vulnerable populations is necessary to develop and implement counter strategies.

Sales Trends in Price-Discounted Cigarettes, Large Cigars, Little Cigars, and Cigarillos-United States, 2011-2016

Introduction

Tobacco manufacturers continue to implement a range of pricing strategies to increase the affordability and consumption of tobacco products. To demonstrate the extent of retail- and brand-level price discounts at the point of sale, this study assessed national sales trends in price-discounted cigarettes, large cigars, little cigars, and cigarillos.

Methods

Retail scanner data for tobacco product sales were obtained for convenience stores (C-store) and all-other-outlets-combined (AOC) from September 25, 2011, to January 9, 2016. The proportion of price-discounted sales, average nondiscounted unit price, and average discounted unit price were examined by product category and brand. JoinPoint regression was used to assess average monthly percentage change.

Results

Overall, price-discounted sales accounted for 11.3% of cigarette, 3.4% of large cigar, 4.1% of little cigar, and 3.9% of cigarillo sales. The average difference between nondiscounted and discounted prices was 25.5% (C-store) and 36.7% (AOC) for cigarettes; 11.0% (C-store) and 11.2% (AOC) for large cigars; 19.2% (C-store) and 9.6% (AOC) for little cigars; and 5.3% (C-store) and 14.7% (AOC) for cigarillos. Furthermore, price-discounted sales of top-selling tobacco brands comprised up to 36% of cigarette, 7.4% of large cigar, 7.7% of little cigar, and 4.2% of cigarillo unit sales.

Conclusions

These findings highlight the use of price discounts by tobacco manufacturers to reduce the cost of cigarettes, large cigars, little cigars, and cigarillos to consumers. These sales patterns underscore the importance of sustained efforts to implement evidence-based strategies to increase prices and reduce availability and consumption of combustible tobacco in the United States.

Implications

This study highlights the prevalence and provides a baseline of price-discounted cigarettes, large cigars, little cigars, and cigarillos. Surveillance of tobacco sales data, including state-level trends and additional product types, is critical for informing approaches to reduce tobacco consumption. These approaches include countering tobacco product price-discounting practices and raising and maintaining a high sales price for all tobacco products. The implementation of evidence-based population-level interventions, together with local, state, and federal regulation of tobacco products, could prevent tobacco initiation, increase tobacco cessation, and reduce overall tobacco use among US youth and adults.

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.

Ethnic and Socioeconomic Disparities in Recalled Exposure to and Self-Reported Impact of Tobacco Marketing and Promotions

The role of tobacco marketing in tobacco use, particularly among the vulnerable ethnic and socioeconomic sub-populations is a regulatory priority of the U.S. Food and Drug Administration. There currently exist both ethnic and socioeconomic disparities in the use of tobacco products. Monitoring such inequalities in exposure to tobacco marketing is essential to inform tobacco regulatory policy that may reduce known tobacco-related health disparities. We use data from the Population Assessment of Tobacco and Health (PATH) Wave 1 youth survey to examine (1) recalled exposure to and liking of tobacco marketing for cigarettes, non-large cigars, and e-cigarettes, (2) self-reported exposure to specific tobacco marketing tactics, namely coupons, sweepstakes, and free samples, and (3) self-reported impact of tobacco marketing and promotions on product use. Findings indicate that African Americans and those of lower SES were more likely to recall having seen cigarette and non-large cigar ads. Reported exposure to coupons, sweepstakes and free samples also varied ethnically and socioeconomically. African Americans and those of lower SES were more likely than other respondents to report that marketing and promotions as played a role in their tobacco product use. Better understanding of communication inequalities and their influence on product use is needed to inform tobacco regulatory action that may reduce tobacco company efforts to target vulnerable groups. Tobacco education communication campaigns focusing on disproportionately affected groups could help counter the effects of targeted industry marketing.

Receipt of Tobacco Direct Mail Coupons and Changes in Smoking Status in a Nationally Representative Sample of US Adults

Introduction

Direct-to-consumer tobacco marketing, including direct mail and email coupons, is a potentially influential marketing strategy. We examined the associations between receipt of tobacco direct mail/email coupons and trajectories of smoking behavior among US adults.

Methods

Data were from the US Population Assessment on Tobacco and Health (PATH) Study adult sample (n = 32160) collected during 2013-2014. Participants self-reported their smoking status (every day, some days, not at all) 12 months prior to the survey (T0) and at the time of the survey (T1). Three smoking trajectories were identified: nonsmokers progressing to current smokers, current smokers continuing to smoke, and among current smokers at T0, progressing to or continuing with daily smoking. Participants also reported receipt of direct mail/email tobacco coupons in the 6 months preceding T1 (yes/no). Weighted multiple logistic regression models were used to test the associations between receiving direct mail/email tobacco coupons and different smoking trajectories adjusted for demographic characteristics.

Results

One in eight (12.4%) US adult nonsmokers and 36.2% adult smokers at T0 reported receiving tobacco coupons. Receipt of tobacco coupons was negatively associated with poverty status. Receipt of tobacco coupons was associated with increased odds of progression to current smoking (AOR = 1.76, 95% CI = 1.45 to 2.12), continuation of smoking (AOR = 1.34, 95% CI = 1.09 to 1.65), and current smokers' progression to or continuation with daily smoking (AOR = 1.70, 95% CI = 1.50 to 1.91).

Conclusions

Direct-to-consumer tobacco coupons may promote progression of smoking among nonsmokers, and continuation of smoking and progression to daily smoking among smokers in US adults.

Implications

Distributing direct mail coupons is a strategy employed by tobacco companies to promote their products. We found, in a US national study, that many adults received tobacco coupons, and receiving these coupons was associated with subsequent progression of smoking among nonsmokers, and continuation of smoking and daily smoking among smokers. Scrutiny over the use of direct mail coupons and its effects on population health is warranted. Future research is needed to evaluate the effect of different interventions to reduce the impact of these coupons on smoking behaviors.

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

BACKGROUND

We assessed whether receipt of coupons-via direct mail or e-mail-was prospectively related to trajectories of smoking behaviours.

METHODS

Data were from a cohort of US adults (n=26 447) who participated in wave 1 (2013-2014) and wave 2 (2014-2015) of the Population Assessment of Tobacco and Health Study. Participants reported receipt of tobacco direct mail/email coupons in the past 6 months in wave 1 and their smoking status in both waves. Weighted multiple logistic regressions were used to examine demographic correlates of receiving tobacco direct mail/email coupons at wave 1 and to examine the prospective effect of receiving tobacco coupons on trajectories of smoking behaviours.

FINDINGS

At wave 1, 10.7% of never smokers, 13.9% of experimental smokers, 37.1% of current smokers and 16.5% of former smokers reported receiving tobacco direct mail/email coupons. Lower education and higher poverty adults and non-Hispanic white current smokers were more likely to have received these coupons (p<0.05). Receiving tobacco direct mail/email coupons at wave 1 was associated with increased odds of smoking initiation among never smokers (adjusted odds ratio (AOR)=2.28, 95% CI 1.36 to 3.83), becoming established smokers among experimenters (AOR=1.62, 95% CI 1.29 to 2.04), becoming daily smokers among non-daily smokers (AOR=1.56, 95% CI 1.23 to 1.99) and smoking relapse among former smokers between waves (AOR=1.91, 95% CI 1.39 to 2.65). Receiving these coupons at wave 1 was associated with reduced odds of smoking cessation ≥6 months among current smokers (AOR=0.71, 95% CI 0.58 to 0.88).

CONCLUSIONS

Tobacco direct mail/email coupons encourage and sustain smoking and disproportionately affect lower socioeconomic populations.

Banning tobacco price promotions, smoking-related beliefs and behaviour: findings from the International Tobacco Control Four Country (ITC 4C) Survey

BACKGROUND

Ecological models emphasise multilevel influences on health behaviours. While studies show that exposure to price promotions is associated with smoking behaviour and its antecedents, less is known about whether these associations differ by macro-level factors such as national price promotion policies.

METHODS

Current and former smokers (N=4698) from the International Tobacco Control Policy Evaluation Project four-country cohort were included in weighted multivariate logistic regression models to examine individual-level associations between exposure to price promotions at waves 7 and 8 (conducted in 2008-2009 and 2010-2011) and beliefs (social and injunctive norms, functional value of smoking, misconceptions around smoking and beliefs of tobacco industry and its regulations) and behaviour at wave 8, stratified by whether countries allow (Australia and USA) or ban (Canada and UK) price promotions.

RESULTS

Associations between exposure to price promotions and smoking-related beliefs and behaviour differed by national price promotion policies. In countries that allow price promotions, participants repeatedly exposed to price promotions at waves 7 and 8 were more likely to associate functional values to smoking (ie, calms down when stressed (adjusted OR (AOR) 1.83) and to be current smokers at wave 8 (AOR 1.94). In countries that ban price promotions, participants repeatedly exposed to price promotions were less likely to hold misconceptions around smoking (ie, harsher smoke is more dangerous).

CONCLUSIONS

Differential associations emerged between exposure to price promotions, smoking-related beliefs and behaviour across countries with and without a price promotions ban. Adopting price promotion bans could ameliorate the associations between exposure to price promotions and smoking beliefs and behaviours.

Trends in point-of-sale tobacco marketing around college campuses: Opportunities for enhanced tobacco control efforts

OBJECTIVE

Colleges have implemented policies to limit tobacco use on-campus; however, the off-campus environment is often overlooked in tobacco control efforts. We assessed availability, marketing, and promotion of cigarettes, snus, and traditional smokeless tobacco (SLT) in a sample of communities surrounding 11 college campuses in North Carolina and Virginia.

PARTICIPANTS

Between January-March of 2011, 2012 and 2013, 481 tobacco-selling retailers, including convenience stores, pharmacies and supermarkets, located near campuses were assessed.

METHODS

Trained observers completed annual point-of-sale assessments.

RESULTS

The percentage of stores selling (81.4% to 58.6%; p < .0001) and advertising snus (80.1% to 53.11%; p < .0001) significantly decreased over time. Convenience stores increased promotions of cigarettes (65.4% to 72.8%; p = 0.04) and SLT (3.1% to 23.3%; p = 0.02).

CONCLUSIONS

Off-campus environments have abundant tobacco availability and marketing. Colleges should collaborate with state and local tobacco control advocates to address tobacco promotion near campuses to potentially decrease product appeal and access among young adults.

Real Time Assessment of Young Adults' Attitudes toward Tobacco Messages

Objectives

We used ecological momentary assessment (EMA) to examine young adults' attitudes towards pro-tobacco messages encountered in real time and their association with intentions to use tobacco.

Methods

Young adults (N = 92, ages 18-29) recorded sightings of marketing or social media related to tobacco in real time via mobile app for 28 days. Participants reported message characteristics, their attitudes towards the message, and intentions to use the depicted product for each submission. We used generalized linear mixed models to examine factors related to attitude towards message and intentions to use tobacco.

Results

Messages depicting e-cigarettes (p < .001) or hookah (p < .05) were associated with significantly more favorable attitudes compared with traditional cigarettes. Positive attitude towards the message was significantly associated with intention to use the depicted product (p < .001). Messages depicting e-cigarettes and hookah were significantly associated with higher intention to use. Message source was not significantly related to attitudes towards the message or product use intentions.

Conclusions

Marketing featuring e-cigarettes and hookah is an important target for future regulation. Given that pro-tobacco and e-cigarette messages are prevalent online, future research should consider the Internet and social media as important venues for counter-marketing and intervention efforts.

Historical declines and disparities in cigarette coupon saving among adolescents in the United States, 1997-2013

Exposure to cigarette coupons is associated with smoking initiation and likelihood of cigarette purchase among adolescents. Some adolescents who are exposed to cigarette coupons take a step further by choosing to save or collect these coupons, a further risk factor for cigarette smoking. This study examines historical trends and disparities in cigarette coupon saving among adolescents in the United States from 1997 to 2013. National samples of 10th and 12th grade students (n=129,111) were obtained from Monitoring the Future surveys in 1997-2013. Prevalence of lifetime and current cigarette coupon saving was estimated in each year in the overall adolescent population, and in race/ethnicity, parent education level, sex, and urban/rural subgroups. Prevalence of lifetime and current cigarette coupon saving was then estimated in each year based on smoking status. Prevalence of cigarette coupon saving has decreased dramatically among adolescents; only 1.2% reported currently saving coupons in 2013. However, disparities in cigarette coupon saving remain with prevalence higher among rural, White, and low parental education level students. Adolescent smokers continue to save coupons at high rates; 21.2% had ever saved coupons and 6.9% currently saved coupons as of 2013. Despite overall declines in adolescent cigarette coupon saving, existing sociodemographic disparities and the considerably high prevalence of coupon saving among adolescent smokers suggest that cigarette coupons remain a threat to smoking prevention among youth. Additional research is needed to further elucidate longitudinal associations between cigarette coupon saving and smoking initiation and maintenance among adolescents.

Sources and Number of Coupons for Cigarettes and Snus Received by a Cohort of Young Adults

PURPOSE

To examine the sources of tobacco coupons and their influence on susceptibility to snus use.

DESIGN

Cohort study.

SETTING

Minnesota Adolescent Community Cohort Study.

SUBJECTS

A population-based sample of US Midwest young adults in 2011 to 2012 and 2012 to 2013 (aged 22-28; n = 2384).

MEASURES

Exposure to coupons for various tobacco products through various sources in the past 6 months, susceptibility to snus use.

ANALYSIS

Multiple logistic regressions.

RESULTS

During the 6 months prior to 2012 to 2013 survey, 11% of the sample received coupons for cigarettes, 5% received coupons for snus, 3% received coupons for other smokeless tobacco products, and <1% received coupons for little cigars. Direct mail was the most commonly cited source of cigarette and snus coupons. Tobacco product packaging provided the highest number of tobacco coupons for current and former smokers. Participants without a 4-year college education (compared to those who had a 4-year college education) were more likely to have received coupons for cigarettes and snus and received more coupons for both products ( P < .05). Racial/ethnic minority young adults (vs non-Hispanic white) received more cigarette and snus coupons ( P < .05). Receiving snus coupons was positively associated with susceptibility to snus use ( P < .05).

CONCLUSION

Tobacco companies are successful in reaching young adults using coupons for various tobacco products. Snus coupons may influence snus use, similar to how cigarette coupons influence smoking.

A Risk-Continuum Categorization of Product Use Among US Youth Tobacco Users

INTRODUCTION

To examine prevalence and correlates of five mutually exclusive tobacco-use patterns among US youth tobacco users.

METHODS

A nationally representative sample of tobacco users (N = 3202, 9-17 years) was classified into five product-use patterns. Weighted multinominal and multivariate logistic regression models were used to examine prevalence of product-use patterns by gender, race and ethnicity, and grade level; and associations between product-use patterns and perceived accessibility of tobacco products, exposure and receptivity to pro-tobacco marketing, social benefits of smoking, and tobacco-associated risks.

RESULTS

Dual use (ie, use of two product categories) was the most prevalent pattern (30.5%), followed by non-cigarette combustible only (26.7%), polytobacco (ie, use of three product categories; 17.5%), cigarette only (14.9%), and noncombustible only (10.4%) use. Product-use patterns differed by gender, race, and ethnicity. Compared to cigarette only users, dual and polytobacco users were more likely to be exposed to and be receptive to pro-tobacco marketing, and were less likely to acknowledge tobacco-use related risks (Ps < .05).

CONCLUSIONS

Curbing tobacco use warrants research on users of more than one tobacco-product categories according to the risk-continuum categorization.

IMPLICATIONS

We present a risk-continuum categorization of product-use patterns among tobacco users not older than 17 years. We classify tobacco users into five mutually exclusive product-use patterns: cigarette only users, non-cigarette combustible only users, noncombustible only users, dual use, and polytobacco use. This categorization overcomes limitations in current literature on tobacco-use patterns, which include exclusion of certain products (eg, e-cigarettes) and product-use patterns (eg, exclusive users of non-cigarette products), and inconsistent classification of tobacco users. It is parsimonious yet complex enough to retain differential characteristics of sub-tobacco users based on number (single, dual, polytobacco) and categories (cigarettes, non-cigarette combustibles, noncombustibles) of tobacco products consumed.

Review of hookah tobacco smoking among college students: policy implications and research recommendations

BACKGROUND

About 30% of college students have smoked hookah tobacco. Although most students perceive this product to be innocuous and non-addictive, hookah tobacco increases the risk for disease and nicotine dependence. Currently, the US Food and Drug Administration (FDA) does not regulate the manufacture, distribution, or sale of hookah tobacco.

OBJECTIVE

Empirical literature pertaining to hookah tobacco smoking is reviewed with a focus on the implications for regulatory policy.

METHODS

PubMed, PsycINFO, and Scopus databases were searched to locate articles published in English. The literature search combined several key words including "hookahs", "college", "advertising", "health effects", and "health policy".

RESULTS

Smoking hookah tobacco may play a role in the initiation of smoking among tobacco-naïve college students and may portend persistent smoking among those who have smoked cigarettes. College students are typically nondaily, social smokers. They do not perceive that their heightened risk for tobacco diseases and nicotine dependence relates to their smoking behavior. However, few public health messages target college-age adults to counter media messages that endorse hookah tobacco smoking.

CONCLUSION

Given that the FDA is not authorized to ban specific tobacco products, policy actions should focus on the development of effective risk communication strategies that target college-age adults and on limiting the accessibility of hookah tobacco products to these adults. Accordingly, a research agenda that would inform these policy actions is proposed.

Snus use and smoking behaviors: preliminary findings from a prospective cohort study among US Midwest young adults

The effect of snus use on smoking behaviors among US young adults is largely unknown. Data from the Minnesota Adolescent Community Cohort Study collected in 2010 to 2011 and 2011 to 2012 (participants aged 20-28 years) showed that young adult nonsmokers who had tried snus were subsequently more likely than those who had not tried snus to become current smokers (n = 1696; adjusted odds ratio = 1.79; 95% confidence interval = 1.01, 3.14). Snus use was not associated with subsequent smoking cessation or reduction among young adult current smokers (n = 488; P > .46).