Tobacco industry marketing at point of purchase after the 1998 MSA billboard advertising ban

Exposure to tobacco retail outlet tobacco marketing and initiation of cigarette and e-cigarette use: Depressive symptoms as a moderator

INTRODUCTION

While tobacco retail outlet (TRO) marketing exposure has been associated with tobacco use, little research has explored how this relationship may vary by the experience of depressive symptoms. The purpose of this study was to examine if the relationship between TRO tobacco marketing exposure and tobacco use initiation is moderated by depressive symptoms among young adults.

METHODS

Participants were drawn from 24 colleges in Texas who were participating in a multi-wave cohort study (2014-2019). The present study included 2020 cigarette or ENDS naïve participants at wave 2 (69.2% female; 32.1% white; m age=20.6 [SD=2.0] at wave 1). Generalized mixed-effects logistic regression analyses were used to examine the association between cigarette and ENDS TRO marketing exposure and subsequent initiation for both products with depressive symptoms as a moderator.

RESULTS

The interaction between cigarette marketing and depressive symptoms was significant (OR=1.38 95% CI=[1.04,1.83]). Cigarette marketing did not impact cigarette initiation among participants with low depressive symptoms (OR=0.96 95% CI= [0.64,1.45]), but did impact cigarette initiation among participants with high depressive symptoms (OR=1.83 95% CI=[1.23,2.74]). There was no interaction effect for ENDS initiation. Main effects showed that ENDS marketing exposure predicted ENDS initiation (OR=1.43 95% CI=[1.10,1.87]).

CONCLUSIONS

Exposure to tobacco marketing at TROs is an important risk factor for initiation of cigarette and ENDS use, particularly for cigarette initiation among those who experience greater levels of depressive symptoms. Future work is needed to better understand why this type of marketing is influential for this group.

Association between school-based tobacco retailer exposures and young adolescent cigarette, cigar and e-cigarette use

BACKGROUND

Associations between retail tobacco availability and tobacco use have been mixed. This study examined associations between school-based retail environment exposures and current use of cigarettes, cigar products and e-cigarettes among middle school youth in Cleveland, OH.

METHODS

Retailers selling tobacco products were identified using the 2015 Cleveland Food Retail Database (n=639 stores). Youth survey data were drawn from the 2016 Cleveland Youth Risk Behavior Survey, administered to all 7th/8th graders across the Cleveland Metropolitan School District (n=3778, response rate=83.0%). Past 30-day cigarette, cigar product and e-cigarette use were assessed. Student demographics, number of days walking to/from school each week and number of times youth stopped at a retailer to/from school each week were included. For each school (n=63), tobacco retail density (TRD) and proximity (TRP) to nearest retailer were calculated for each product. Multiple regression analysis assessed associations between retail exposures and youth tobacco use.

RESULTS

Across all schools, 3.9%, 10.2% and 8.6% of students currently use cigarettes, cigar products and e-cigarettes, respectively, and 15.2% currently use at least one tobacco product. TRD and TRP were not associated with current use; frequency of walking to school and stopping at retailers were strongly associated with current use.

CONCLUSIONS

Although TRD and TRP were not significantly associated with tobacco product use, youth who reported regularly walking to/from school or who reported stopping at a retail store before/after school were significantly more likely to be a current tobacco product user. This may be due to increased exposure to exterior and point-of-sale marketing.

Tobacco messages encountered in real-time among low socio-economic position groups: a descriptive study

BACKGROUND

Tobacco advertising disproportionately targets low socio-economic position (SEP) groups, causing higher rates of tobacco use in this population. Anti-tobacco public health education campaigns persuade against use. This study measured real-time exposure of pro- and anti-tobacco messages from low SEP groups in two American cities.

METHODS

Individuals in low SEP groups (N = 95), aged 18-34 years old, who were smokers and non-smokers, from the Boston and Houston areas, took part in a mobile health study. They submitted images of tobacco-related messages they encountered via a mobile application for a 7-week period. Two coders analyzed the images for message characteristics. Intercoder reliability was established using Krippendorff's alpha and data were analyzed descriptively.

RESULTS

Of the submitted images (N = 131), 83 were pro-tobacco and 53 were anti-tobacco. Of the pro-tobacco messages, the majority were cigarette ads (80.7%) seen outside (36.1%) or inside (30.1%) a convenience store or gas station and used conventional themes (e.g., price promotion; 53.2%). Of the anti-tobacco messages, 56.6% were sponsored by public health campaigns or were signage prohibiting smoking in a public area (39.6%). Most focused on the health harms of smoking (28.3%).

CONCLUSION

Low SEP groups in this study encountered more pro-tobacco than anti-tobacco messages at places that were point-of-sale using price promotions to appeal to this group. Anti-tobacco messages at point-of-sale and/or advertising regulations may help combat tobacco use.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of social and neighborhood contexts on smoking cessation among urban minorities

A range of individual, social, and neighborhood factors influence the smoking-related health inequities of urban minorities. Yet little is known about how these factors interact to influence smoking behaviors, including cessation. Hierarchical linear modeling was used to estimate the variance in cessation service utilization among a sample of primarily African American adults accounted for by individual, social, and neighborhood factors. Findings showed individual and social factors were important predictors of cessation service utilization. Social contexts have significant effects on smoking cessation service use, and social influences were more significant predictors of cessation service use than neighborhood factors.

Billboard advertising: an avenue for communicating healthcare information and opportunities to disadvantaged populations

Background

Healthcare communications directed toward the disadvantaged have the potential to elevate the health status of these underprivileged and highly-challenged individuals. From conveying advice which encourages healthy lifestyles to communicating the location and availability of various medical resources, healthier lives and communities can be realized. Success on this front first requires establishing an effective communications link, something that is made more difficult as communications options available to the disadvantaged are more limited than those available to advantaged populations.

Discussion

One avenue which shows exceptional promise for successfully engaging the disadvantaged is that of billboard advertising. Willis-Knighton Health System’s experiences and insights indicate that the characteristics and qualities of billboards, paired with the environmental circumstances typically faced by the less fortunate, create unique combinations which amplify consumption of billboard advertising content. Further, research suggests that the less privileged place greater reliance on the medium than do their more privileged counterparts, escalating the value and impact potential of billboard advertising directed toward the disadvantaged.

Conclusions

Given the value afforded by health and wellness information successfully reaching the disadvantaged, opportunities to better distribute content to targeted audiences could very well improve community health. Billboard advertising appears to be well suited to engage the less fortunate, providing a productive pathway for the conveyance of helpful, supportive details, yielding healthier populations, enhanced opportunities, and better communities.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Marketing activities of vape shops across racial/ethnic communities

INTRODUCTION

There has been a surge in the number of vape shops in the USA. Research on the marketing practices of e-cigarette manufacturers is scarce and even less known are the practices of vape shop retailers. Past research on tobacco marketing has shown differences in the amount and content of marketing material, based on a community’s demographic profile. This study examined marketing strategies in vape shops and explored differences among vape shops located in communities that differ by ethnic composition.

METHODS

Data was gathered in 2014 from a pilot-study on vape shops (n=77) in Los Angeles, which documented the characteristics of shops through employee interviews and in-store observations. Data were collected from shops located in communities that were predominantly, African-American (n=20), Hispanic (n=17), Korean (n=18), or non-Hispanic White (n=22).

RESULTS

Sixty-one percent of vape shops had advertisements (print ads and posters) for e-cigarettes and 84% offered discounts. Vape shops in Hispanic communities were more likely to have ethnic specific marketing material compared to shops in other communities. All the shops provided customers with free samples, however those in Korean and non-Hispanic White communities had a significantly higher prevalence of customer accessible free samples.

CONCLUSIONS

Vape shop marketing practices differed by ethnic community. A large majority of shops provided free samples to their customers, a practice which is now banned by the FDA. It will be important to monitor how vape shops will adjust their marketing strategy because of this ban. Future research should expand on the findings presented here to provide regulators with further crucial information.

Prices for Tobacco and Nontobacco Products in Pharmacies Versus Other Stores: Results From Retail Marketing Surveillance in California and in the United States

OBJECTIVES

To examine disparities in the price of tobacco and nontobacco products in pharmacies compared with other types of stores.

METHODS

We recorded the prices of Marlboro, Newport, the cheapest cigarettes, and bottled water in a random sample of licensed tobacco retailers (n = 579) in California in 2014. We collected comparable data from retailers (n = 2603) in school enrollment zones for representative samples of US 8th, 10th, and 12th graders in 2012. Ordinary least squares regressions modeled pretax prices as a function of store type and neighborhood demographics.

RESULTS

In both studies, the cheapest cigarettes cost significantly less in pharmacies than other stores; the average estimated difference was $0.47 to $1.19 less in California. We observed similar patterns for premium-brand cigarettes. Conversely, bottled water cost significantly more in pharmacies than elsewhere. Newport cost less in areas with higher proportions of African Americans; other cigarette prices were related to neighborhood income and age. Neighborhood demographics were not related to water prices.

CONCLUSIONS

Compared with other stores, pharmacies charged customers less for cigarettes and more for bottled water. State and local policies to promote tobacco-free pharmacies would eliminate an important source of discounted cigarettes.

Electronic nicotine delivery system landscape in licensed tobacco retailers: results of a county-level survey in Oklahoma

OBJECTIVES

Electronic nicotine delivery systems (ENDS) have recently emerged as a component of the tobacco retail environment. The aims of this study were to describe the availability, types of ENDS and placement of ENDS relative to traditional tobacco products at franchised licensed tobacco retailers and non-franchised licensed tobacco retailers.

DESIGN

Observational study.

SETTING

Franchised and non-franchised tobacco retailers in Cleveland County, Oklahoma, USA.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number of stores selling ENDS, the variability in brands of ENDS sold, the location of the ENDS within the retailers, the quantity of ENDS sold compared with traditional tobacco products, and the presence of outdoor signage.

RESULTS

Data from 57 randomly sampled tobacco retailers were used to describe the presence of ENDS at independent non-franchised and franchised tobacco retailers. The overwhelming majority (90%) of licensed tobacco retailers sold ENDS, and differences were observed between franchised and non-franchised stores. 45 of the 51 retailers (88%) selling ENDS had them placed at the point of sale. 2 of the 21 franchised retailers (9.5%) had ENDS placed at ≤3½ feet above floor level compared to none of the 30 non-franchised retailers (0%).

CONCLUSIONS

This small study is the first to characterise ENDS within the tobacco retail environment in a county in Oklahoma, USA. The results from this study demonstrate the complexity of the tobacco retail landscape and generate questions for future studies regarding the incorporation and placement of ENDS in tobacco retail environments.

Point-of-Sale Cigarette Marketing, Urge to Buy Cigarettes, and Impulse Purchases of Cigarettes: Results From a Population-Based Survey

AIMS

Our aim was to examine the association of exposure to point-of-sale (POS) cigarette marketing for one's regular brand, as well as any brand of cigarettes, with the urge to buy cigarettes and frequency of impulse purchases of cigarettes.

METHODS

Nine hundred ninety-nine smokers in Omaha, Nebraska were interviewed via telephone. Cigarette marketing was measured by asking respondents questions about noticing pack displays, advertisements, and promotions such as discounts for their regular brand as well as any brand of cigarettes in their neighborhoods stores. We measured urge to buy cigarettes with the question "When you are in a store in your neighborhood that sells tobacco products, how often do you get an urge to buy cigarettes?" We measured frequency of impulse purchases of cigarettes with the question "When you are shopping in a store in your neighborhood for something other than cigarettes, how often do you decide to buy cigarettes?" We estimated ordinary least squares linear regression models to address the study aim.

RESULTS

Higher levels of POS marketing for one's regular brand and any brands of cigarettes were associated with more frequent urges to buy (P < .001 and P < .001, respectively) and impulse purchases of cigarettes (P = .01 and P = .013, respectively), after adjusting for covariates.

CONCLUSION

Exposure to POS marketing for one's own brand of cigarette as well as any brand is associated with urges to buy and impulse purchases of cigarettes.

IMPLICATIONS

Existing studies on the association of POS cigarette marketing with urge to buy and an impulse purchase of cigarettes only focus on cigarette pack displays, not on advertisements and promotions. Also, these studies make no distinction between marketing for the smokers' regular brand and any brand of cigarettes. This study found that Exposure to POS marketing for one's own brand of cigarette as well as any brand is associated with urges to buy and impulse purchases of cigarettes. Our findings can provide part of the evidence-base needed by the Food and Drug Administration or local authorities to regulate POS marketing.

Point-of-sale cigarette marketing and smoking-induced deprivation in smokers: results from a population-based survey

BACKGROUND

Strict restrictions on outdoor cigarette marketing have resulted in increasing concentration of cigarette marketing at the point-of-sale (POS). The association between POS cigarette marketing and smoking-induced deprivation (SID) has never been studied. The aim of this study was to examine this association and how it is mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes.

METHODS

Data from a telephone survey of 939 smokers were collected in Omaha, Nebraska. POS cigarette marketing was measured by asking respondents three questions about noticing pack displays, advertisements, and promotions such as cigarette price discounts within their respective neighborhoods. SID was measured with the following question: "In the last six months, has there been a time when the money you spent on cigarettes resulted in not having enough money for household essentials such as food? [yes/no]" We used structural equation modeling to examine the study aim.

RESULTS

There was overwhelming evidence for an association between higher levels of POS cigarette marketing and a higher probability of SID (p < 0.001). This association was partly mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes during a visit to a neighborhood store (p < 0.001).

CONCLUSION

Given that POS cigarette marketing is associated with a higher probability of experiencing SID, policies that ban POS cigarette marketing might help some smokers afford essentials household items such as food more easily and thus have better standards of living.

The inequitable distribution of tobacco outlet density: the role of income in two Black Mid-Atlantic geopolitical areas

OBJECTIVES

Studies have shown that communities with higher concentrations of low-income racial and ethnic minorities correlate with a greater presence of tobacco outlets. Community-level income has consistently been among the strongest predictors of tobacco outlet density. This study analyzes two Maryland geopolitical areas with similar racial concentrations yet differing income levels in an attempt to disentangle the race-income relationship with tobacco outlet density.

STUDY DESIGN

In this cross-sectional examination of tobacco outlet and census tract-level sociodemographic data, Baltimore City, Maryland, and Prince George's County, Maryland, were geocoded to determine tobacco outlet density.

METHODS

Tobacco outlet density was defined as the mean number of tobacco outlets per 1000 persons per census tract. Comparisons of tobacco outlet density and sociodemographic variables were analysed via two-sample t-tests, and the direct effect of sociodemographic variables on tobacco outlet density for each area was analysed via spatial lag regressions.

RESULTS

Prince George's County, the area with the higher income level ($77,190 vs $43,571), has a significantly lower tobacco outlet density than Baltimore City (P < 0.001). Prince George's County has a 67.5% Black population and an average of 3.94 tobacco outlets per 1000 persons per tract. By contrast, Baltimore City has a 65.3% Black population and an average of 7.95 tobacco outlets per 1000 persons per tract. Spatial lag regression model results indicate an inverse relationship between income and tobacco outlet density in Baltimore City and Prince George's County (β = -0.03, P < 0.01 &β = -0.01, P = 0.02, respectively), and a significant interaction term indicating a greater magnitude in the relationship between income and tobacco outlet density in Baltimore City (β = -0.05, P < 0.01).

CONCLUSION

Results suggest that higher socio-economic status, even in primarily underrepresented racial and ethnic geopolitical areas, is linked to lower tobacco outlet density.

Why We Must Continue to Investigate Menthol's Role in the African American Smoking Paradox

BACKGROUND

The disproportionate burden of tobacco use among African Americans is largely unexplained. The unexplained disparities, referred to as the African American smoking paradox, includes several phenomena. Despite their social disadvantage, African American youth have lower smoking prevalence rates, initiate smoking at older ages, and during adulthood, smoking rates are comparable to whites. Smoking frequency and intensity among African American youth and adults are lower compared to whites and American Indian and Alaska Natives, but tobacco-caused morbidity and mortality rates are disproportionately higher. Disease prediction models have not explained disease causal pathways in African Americans. It has been hypothesized that menthol cigarette smoking, which is disproportionately high among African Americans, may help to explain several components of the African American smoking paradox.

PURPOSE

This article provides an overview of the potential role that menthol plays in the African American smoking paradox. We also discuss the research needed to better understand this unresolved puzzle.

METHODS

We examined prior synthesis reports and reviewed the literature in PubMed on the menthol compound and menthol cigarette smoking in African Americans.

RESULTS

The pharmacological and physiological effects of menthol and their interaction with biological and genetic factors may indirectly contribute to the disproportionate burden of cigarette use and diseases among African Americans.

CONCLUSIONS

Future studies that examine taste sensitivity, the menthol compound, and their effects on smoking and chronic disease would provide valuable information on how to reduce the tobacco burden among African Americans.

IMPLICATIONS

Our study highlights four counterintuitive observations related to the smoking risk profiles and chronic disease outcomes among African Americans. The extant literature provides strong evidence of their existence and shows that long-standing paradoxes have been largely unaffected by changes in the social environment. African Americans smoke menthols disproportionately, and menthol's role in the African American smoking paradox has not been thoroughly explored. We propose discrete hypotheses that will help to explain the phenomena and encourage researchers to empirically test menthol's role in smoking initiation, transitions to regular smoking and chronic disease outcomes in African Americans.

Global Evidence on the Association between POS Advertising Bans and Youth Smoking Participation

Background: Point-of-sale (POS) tobacco advertising has been linked to youth smoking susceptibility and experimental smoking. However, there is limited evidence of the association between POS advertising bans and youth smoking participation. This study aims to examine how such bans are associated with current smoking, daily smoking, and regular smoking (≥1 cigarettes per day) participation among youth. Methods: one to two waves (primarily one wave) of the Global Youth Tobacco Survey were conducted in 130 countries between 2007 and 2011. These surveys were linked to the WHO “MPOWER” data using country and year identifiers to analyze the association between POS advertising bans (a dichotomous measure of the existence of such bans) and smoking participation in the past month. Weighted logistic regressions were employed to analyze this association while controlling for age, gender, parents’ smoking status, 6 MPOWER policy scores, and GDP per capita. Results and Conclusions: We find that in countries with POS advertising bans, current smoking (OR = 0.73, p ≤ 0.1), daily smoking (OR = 0.70, p ≤ 0.1), and regular smoking (OR = 0.75, p ≤ 0.05) participation in the past month is significantly lower, suggesting that POS promotion bans can potentially reduce youth smoking. This study provides evidence to support the implementation of POS promotion regulations by the US FDA and implementation of the WHO FCTC guidelines regarding restrictions on tobacco POS promotion.

The Association of Exposure to Point-of-Sale Tobacco Marketing with Quit Attempt and Quit Success: Results from a Prospective Study of Smokers in the United States

The aim was to assess the association of exposure to point-of-sale (POS) tobacco marketing with quit attempt and quit success in a prospective study of smokers in the United States. Data were collected via telephone-interview on exposure to POS tobacco marketing, sociodemographic and smoking-related variables from 999 smokers in Omaha, Nebraska, in the United States. Exposure to POS tobacco marketing was measured by asking respondents three questions about noticing pack displays, advertisements, and promotions in their respective neighborhoods stores. These three variables were combined into a scale of exposure to POS tobacco marketing. About 68% of the respondents participated in a six-month follow-up phone interview and provided data on quit attempts and smoking cessation. At the six-month follow-up, 39.9% of respondents reported to have made a quit attempt, and 21.8% of those who made a quit attempt succeeded in quitting. Exposure to POS marketing at baseline was not associated with the probability of having made a quit attempt as reported at the six-month follow-up (p = 0.129). However, higher exposure to POS marketing was associated with a lower probability of quit success among smokers who reported to have attempted to quit smoking at six-month follow-up (p = 0.006). Exposure to POS tobacco marketing is associated with lower chances of successfully quitting smoking. Policies that reduce the amount of exposure to POS marketing might result in higher smoking cessation rates.

A Community-Based Participatory Research on Smoking Cessation Intervention for Urban Communities

Smoking disproportionally affects minority and underserved populations but only a handful of interventions tailored to these populations have demonstrated effectiveness in real-life situations. We use community-based participatory research (CBPR) to test two interventions delivered by a community-based health care center.

METHODS

Participants randomly assigned to individual or group-based intervention for smoking cessation (N= 400). Both included cessation counseling and health education, a contingency behavioral program, Nicotine Replacement Therapy, and health care for other comorbidities. Smoking cessation was verified by expired carbon monoxide at the end of the program.

RESULTS

No differences were observed between the two treatment modalities (8.9% and 8.6%, respectively). Those with greater attendance had 1.4 times better odds of cessation per additional session. Retention and follow up proved to be challenging with this population.

The Association between Point-of-Sale Advertising Bans and Youth Experimental Smoking: Findings from the Global Youth Tobacco Survey (GYTS)

BACKGROUND AND OBJECTIVES

while existing research has demonstrated a positive association between exposure to point-of-sale (POS) tobacco advertising and youth smoking, there is limited evidence on the relationship between POS advertising restrictions and experimental smoking among youth. This study aims to fill this research gap by analyzing the association between POS advertising bans and youths' experimental smoking.

METHODS

Global Youth Tobacco Surveys from 130 countries during 2007-2011 were linked to the WHO "MPOWER" tobacco control policy measures to analyze the association between POS advertising bans (a dichotomous measure of the existence of such bans) and experimental smoking using weighted logistic regressions. All analyses were clustered at the country level and controlled for age, parents' smoking status, GDP per capita, and country-level tobacco control scores in monitoring tobacco use, protecting people from smoke, offering help to quit, warning about the dangers of tobacco, enforcing promotion/advertising bans, and raising taxes on tobacco.

RESULTS

The results suggest that a POS advertising ban is significantly associated with reduced experimental smoking among youth (OR = 0.63, p < 0.01), and that this association is seen for both genders (boys OR = 0.74, p < 0.1; girls OR = 0.52, p < 0.001).

CONCLUSIONS

POS advertising bans are significantly associated with reduced experimental smoking among youth. Adopting POS advertising bans has the potential to reduce tobacco use among their youth in countries currently without such bans.

The association of point-of-sale cigarette marketing with cravings to smoke: results from a cross-sectional population-based study

OBJECTIVE

To examine the association between recalled exposure to point-of-sale (POS) cigarette marketing (ie, pack displays, advertisements and promotions such as discounts) and reported cravings to smoke while visiting a store.

METHODS

Data were collected using a telephone survey of a cross-sectional sample of 999 adult smokers in Omaha, Nebraska. Recalled exposure to POS cigarette marketing was measured by asking respondents about noticing (a) pack displays, (b) advertisements and (c) promotions in store in their neighbourhood. A 3-item scale indicating the frequency of experiencing cravings to smoke in locations where cigarettes are sold was created by asking respondents: (1) "feel a craving for a cigarette?" (2) "feel like nothing would be better than smoking a cigarette?" and (3) "feel like all you want is a cigarette?" The association between recalled exposure to POS cigarette marketing and cravings was estimated using ordinary least squares linear regression models, controlling for nicotine dependence, gender, age, race/ethnicity, income, education, frequency of visiting stores in one's neighbourhood and method of recruitment into the study.

RESULTS

Recalled exposure to POS cigarette displays (p<0.001) and advertisements (p=0.002), but not promotions (p=0.06), was associated with more frequent cravings to smoke.

CONCLUSIONS

Recalled exposure to POS cigarette marketing is associated with cravings to smoke as predicted by laboratory studies on the effects of smoking cues on cigarette craving. Policies that reduce or eliminate POS cigarette marketing could reduce cigarette cravings and might attenuate impulse buying of cigarettes.

Exposure to point-of-sale displays and changes in susceptibility to smoking: findings from a cohort study of school students

AIMS

To investigate the association between frequency of visiting shops and noticing of tobacco point-of-sale (PoS) displays and the development of susceptibility to smoking, or smoking uptake, in secondary school students.

DESIGN

Two surveys of a school based cohort study carried out in 2011 and 2012.

SETTINGS

Nottinghamshire, UK.

PARTICIPANTS

A total of 2270 children aged 11-16 years from eight schools in Nottinghamshire.

MEASUREMENTS

We investigated changes in susceptibility to smoking and smoking status in relation to frequency of visiting shops and noticing PoS displays and number of tobacco brands recognized, controlling for a range of potential confounders. Susceptibility to smoking was defined using a set of three questions covering intentions to try smoking, to smoke within the next year and likelihood of smoking if a best friend offered a cigarette. For the analysis we used multinomial logistic regression.

FINDINGS

Among non-susceptible never smokers, noticing PoS displays more frequently was associated independently with an increased risk of becoming susceptible to smoking [adjusted relative risk ratio (RRR) = 1.74; 99% confidence interval (CI) = 1.13-2.69], but was not associated with smoking uptake. Recognizing a higher number of brands among non-susceptible never smokers doubled the risk of becoming susceptible to smoking and of becoming a smoker, but this did not have a significant effect on transition to smoking among susceptible never smokers. Frequency of noticing tobacco PoS displays was not associated significantly with smoking uptake among those who were susceptible never smokers at baseline.

CONCLUSIONS

Noticing tobacco point-of-sale displays more often and recognizing a higher number of tobacco brands is associated with an increased risk of becoming susceptible to smoking among adolescents in the United Kingdom, and recognizing a higher number of brands is associated positively with an increased risk of smoking uptake.

Evaluation of measurement tools for tobacco product displays: is there an app for that?

Tobacco product displays are a pervasive presence in convenience stores, supermarkets, pharmacies, and other retailers nationwide. The influence that tobacco product displays have on purchases and tobacco product initiation, particularly on young people and other vulnerable populations, is well known. An objective measurement tool that is valid, reliable, and feasible to use is needed to assess product displays in the retail setting. This study reports on the relative accuracy of various tools that measure area and/or distance in photos and thus could be applied to product displays. We compare results of repeated trials using five tools. Three tools are smartphone apps that measure objects in photos taken on the device; these are narrowed down from a list of 284 candidate apps. Another tool uses photos taken with any device and calculates relative area via a built-in function in the Microsoft Office Suite. The fifth uses photos taken with the Narrative Clip, a "life-logging" wearable camera. To evaluate validity and reliability, we assess each instrument's measurements and calculate intra-class correlation coefficients. Mean differences between observed measurements (via tape measure) and those from the five tools range from just over one square foot to just over two square feet. Most instruments produce reliable estimates though some are sensitive to the size of the display. Results of this study indicate need for future research to test innovative measurement tools. This paper also solicits further discussion on how best to transform anecdotal knowledge of product displays as targeted and disproportionate marketing tactics into a scientific evidence base for public policy change.

Off-premise alcohol outlets on and around tribal land: risks for rural California Indian youth

Investigating the alcohol environment for rural American Indian youth, we conducted 70 interviews with leading members and youth representatives of nine Southern California tribes. We also conducted brief observations in all 13 stores licensed to sell alcohol on and close to the reservation lands of the nine tribes. Underage youth may obtain alcoholic beverages at stores either directly through illegal sales to minors or indirectly through social sources. Stores are also environments within which alcoholic beverages and heavy drinking may become normalized for youth. Limitations and implications for convenience store-based prevention research on alcohol retail environment for youth in rural populations areas are discussed.

E-cigarette availability and promotion among retail outlets near college campuses in two southeastern states

INTRODUCTION

E-cigarettes are relatively new products that simulate the smoking experience. This descriptive study assessed changes in e-cigarette availability and promotions among retailers in 11 college communities in North Carolina and Virginia during a 1-year period.

METHODS

During the spring of 2012 and 2013, observers completed assessments in 320 tobacco-selling retailers, including grocery and convenience stores, pharmacies, and tobacco shops. Assessors collected e-cigarette availability, advertising, price, and promotions.

RESULTS

E-cigarette availability increased among retailers from 24.7% in 2012 to 59.9% in 2013. They were available in the form of disposables and reusable kits and were most frequently available in tobacco shops, convenience stores, and pharmacies. The average price for disposables was $9.70 (SD = 1.07) in 2012 and $9.61 (SD = 2.10) in 2013; the average price for kits was $39.58 (SD = 15.79) in 2012 and $32.59 (SD = 18.65) in 2013. The presence of interior advertising increased from 12.7% to 50.6% (p < .0001), and the presence of exterior advertising increased from 7.6% to 22.8% (p = .0002). Convenience stores with gas (16.4%-70.4%; p < .0001) and without gas (6.0%-48.4%; p < .0001) had significant increases in the presence of interior advertising. Convenience stores with gas also had a significant increase in the presence of exterior advertising (8.2%-33.3%; p < .0001). Only 3% of retailers offered price promotions.

CONCLUSIONS

Availability of e-cigarettes, including rechargeable kits and disposables, more than doubled during the study. The presence of interior and exterior advertising also significantly increased. Results underscore the need for further surveillance to understand how these environmental characteristics impact individual exposure and use of e-cigarettes.

A systematic review of store audit methods for assessing tobacco marketing and products at the point of sale

OBJECTIVE

Over four-fifths of reported expenditures for marketing tobacco products occur at the retail point of sale (POS). To date, no systematic review has synthesised the methods used for surveillance of POS marketing. This review sought to describe the audit objectives, methods and measures used to study retail tobacco environments.

METHODS

We systematically searched 11 academic databases for papers indexed on or before 14 March 2012, identifying 2906 papers. Two coders independently reviewed each abstract or full text to identify papers with the following criteria: (1) data collectors visited and assessed (2) retail environments using (3) a data collection instrument for (4) tobacco products or marketing. We excluded papers where limited measures of products and/or marketing were incidental. Two abstractors independently coded included papers for research aims, locale, methods, measures used and measurement properties. We calculated descriptive statistics regarding the use of four P's of marketing (product, price, placement, promotion) and for measures of study design, sampling strategy and sample size.

RESULTS

We identified 88 store audit studies. Most studies focus on enumerating the number of signs or other promotions. Several strengths, particularly in sampling, are noted, but substantial improvements are indicated in the reporting of reliability, validity and audit procedures.

CONCLUSIONS

Audits of POS tobacco marketing have made important contributions to understanding industry behaviour, the uses of marketing and resulting health behaviours. Increased emphasis on standardisation and the use of theory are needed in the field. We propose key components of audit methodology that should be routinely reported.

Exposure to tobacco retail outlets and smoking initiation among New York City adolescents

This study was designed to estimate the relationship between exposure to tobacco retail outlets and smoking initiation in a racially diverse urban setting. Using data from the 2011 NYC Youth Risk Behavior Survey, multivariable logistic regression analyses were conducted to estimate the exposure-initiation relationship and test for effect modification, while controlling for covariates. The predicted probability of smoking initiation from the multivariable model increased from 7.7 % for zero times a week exposed to tobacco retailers to 16.0 % for exposure seven times or more per week. The odds of initiation were significantly higher among adolescents exposed to tobacco retail outlets two times or more a week compared with those exposed less often (AOR = 1.41; 95 % CI: 1.08, 1.84). Risk-taking behavior modified the relationship between exposure and initiation, with the odds of initiation highest among those low in risk-taking (AOR = 1.78; 95 % CI: 1.14, 1.56). These results are consistent with past research, showing that frequent exposure to tobacco marketing in retail settings is associated with increased odds of initiation. Reducing exposure to tobacco retail marketing could play an important role in curtailing smoking among adolescents, especially those less prone to risk-taking.

Point-of-sale tobacco advertising in Beirut, Lebanon following a national advertising ban

Background

The objective of this study was to conduct an audit of point-of-sale (POS) tobacco advertising and assess compliance with an advertising ban in a large district of Beirut, Lebanon.

Methods

The audit was conducted 3 months following the ban on tobacco advertising. Trained students observed all tobacco retail outlets (n = 100) and entered data into a web-based form using iPad® technology. Presence of tobacco advertisements was assessed to determine compliance with the national advertising ban.

Results

Among the 100 tobacco retail outlets, 62% had tobacco advertisements, including 7% with a tobacco brand logo as part of the main exterior store sign.

Conclusions

POS tobacco advertising is widespread in Beirut despite the national advertising ban. These findings point to an urgent need for the enforcement of the advertisement ban with tobacco retail outlets in Lebanon.

Tobacco sales and marketing within 100 yards of schools in Ahmedabad City, India

OBJECTIVES

The Government of India passed the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COPTA 2003), which prohibits the sale of tobacco products within 100 yards of educational institutions and regulates tobacco advertising. The aim of this research was to monitor compliance with the section of COPTA 2003 regarding the advertisement, display and sale of tobacco products around educational institutions in Ahmedabad City, India.

STUDY DESIGN

Observational study around 30 randomly selected schools.

METHODS

In March 2010, an observational study was conducted to assess compliance with COPTA 2003 in Ahmedabad City, India. All vendors within a 100-yard radius of 30 randomly selected schools were identified. At locations where tobacco was sold, information was collected regarding type of product sold, sale of tobacco in single units and advertising.

RESULTS

Twenty public schools and 10 private schools were sampled. Of these, 87% [n = 26, 95% confidence interval (CI) 69-95%] had tobacco sales within 100 yards of their entrance. Of the 771 vendors observed, 24% (n = 185, 95% CI 18-32%) sold tobacco products. Tobacco advertising in violation of the law was found around 57% of schools (n = 17, 95% CI 39-73%), product displays around 83% of schools (n = 25, 95% CI 65-93%) and single sales around 70% of schools (n = 21, 95% CI 51-84%).

CONCLUSIONS

Violation of the sections of COPTA 2003 regarding sale of tobacco products around educational institutions and advertising in general is widespread in Ahmedabad City, India. Effective enforcement of the existing law is necessary to protect the children in India from widespread exposure to the sale and marketing of tobacco products.

Implementation and research priorities for FCTC Articles 13 and 16: tobacco advertising, promotion, and sponsorship and sales to and by minors

INTRODUCTION

Article 13 of the Framework Convention on Tobacco Control (FCTC) calls for a comprehensive ban on tobacco advertising, promotion, and sponsorship (TAPS), and Article 16 calls for prohibition of tobacco sales to and by minors. Although these mandates are based on sound science, many countries have found provision implementation to be rife with challenges.

OBJECTIVE

This paper reviews the history of tobacco marketing and minor access restrictions in high-, middle-, and low-income countries, identifying past challenges and successes. We consider current challenges to FCTC implementation, how these barriers can be addressed, and what research is necessary to support such efforts. Specifically, we identify implementation and research priorities for FCTC Articles 13 and 16.

DISCUSSION

Although a solid evidence base underpins the FCTC's call for TAPS bans and minor access restrictions, we know substantially less about how best to implement these restrictions. Drawing on the regulatory experiences of high-, middle-, and low-income countries, we discern several implementation and research priorities, which are organized into 4 categories: policy enactment and enforcement, human capital expertise, the effects of FCTC marketing and youth access policies, and knowledge exchange and transfer among signatories. Future research should provide detailed case studies on implementation successes and failures, as well as insights into how knowledge of successful restrictions can be translated into tobacco control policy and practice and shared among different stakeholders.

CONCLUSION

Tobacco marketing surveillance, sales-to-minors compliance checks, enforcement and evaluation of restriction policies, and capacity building and knowledge transfer are likely to prove central to effective implementation.

Tobacco environment for Southeast Asian American youth: results from a participatory research project

Despite reports of high rates of smoking among Southeast Asian refugees in the United States, few studies have described the environmental aspects of tobacco use among this population, particularly for the second-generation youths. This absence is notable because the social environment within which second-generation youths are exposed to tobacco products differs radically from the natal environment of their parents. We describe results of a youth-led community participatory research project for Southeast Asians in Northern California. Using multiple data sources, second-generation youths documented the salience of tobacco products in their social environment, notably products such as blunts and mentholated cigarettes.

A store cohort study of compliance with a point-of-sale cigarette display ban in Melbourne, Australia

INTRODUCTION

This study aimed to evaluate compliance with legislation which restricted cigarette displays in retail outlets, and to assess prevalence of pro- and anti-tobacco elements in stores pre- and post-legislation. METHODS Three audits of 302 stores in Melbourne, Australia by trained observers who gathered information on point-of-sale tobacco displays 2-3 months before and 3-4 and 11-12 months after the enactment of new restrictions.

RESULTS

Between the first and second audits, nine stores stopped selling tobacco and three stores had either shut down or were closed for renovations. Of the remaining 290 stores, 94.1% observed the full ban on cigarette package visibility, while new restrictions on price board size and new requirements for graphic health warnings were followed in 85.9% and 67.2% of stores, respectively. Between the second and third audits, another seven stores ended tobacco sales and two stores closed. In Audit 3, 89.7% of the remaining 281 stores complied with price board restrictions, and 82.2% of stores followed requirements for graphic health warnings. Overall, the prevalence of anti-tobacco signage increased and pro-tobacco features decreased between audits for every store type and neighborhood socio-economic status.

CONCLUSIONS

Tobacco retailers were almost universally compliant with placing cigarettes out of sight and a substantial majority were compliant with regulations on price board size and display of graphic health warnings, demonstrating that such legislation can be implemented successfully.

Out of sight, out of mind? Removal of point-of-sale tobacco displays in Norway

Aim

To evaluate retailer's compliance and consumer's perceptions of and experiences with the point-of-sale (POS) tobacco display ban in Norway, implemented 1 January 2010.

Methods

Retailer compliance was measured using audit surveys. Consumer's perceptions of the ban were assessed in three web surveys: one conducted before and two after implementation of the ban. The sample for each of these consisted of about 900 people aged 15–54 years and an extra sample of smokers and snus users. 10 focus group interviews with male and female daily, occasional and former smokers aged 16–50 years (N=62) were also conducted, before and after implementation of the ban.

Results

Immediately following implementation of the POS display ban, compliance was 97% for cigarettes and rolling tobacco and 98% for snus. Preimplementation, young people were tempted by tobacco products when seeing them in the shop more often than older people. Postimplementation, young people also more often found it difficult to choose brand. The POS tobacco display ban was supported by a majority of the population, and by one out of three daily smokers. The removal of POS tobacco displays was perceived as a barrier for young people's access to tobacco products, as affecting attachment to cigarette brands and as contributing to tobacco denormalisation.

Conclusions

Retailer's compliance with the POS display ban in Norway was high, and the ban was well supported in the population. Consumers believed that the ban could contribute to preventing smoking initiation among young people and to some extent also support cessation efforts.

Measuring exposure to protobacco marketing and media: a field study using ecological momentary assessment

INTRODUCTION

The aims of this study were to validate ecological momentary assessment (EMA) as a method for measuring exposure to tobacco-related marketing and media and to use this method to provide detailed descriptive data on college students' exposure to protobacco marketing and media.

METHODS

College students (n = 134; ages 18-24 years) recorded their exposures to protobacco marketing and media on handheld devices for 21 consecutive days. Participants also recalled exposures to various types of protobacco marketing and media at the end of the study period.

RESULTS

Retrospectively recalled and EMA-based estimates of protobacco marketing exposure captured different information. The correlation between retrospectively recalled and EMA-logged exposures to tobacco marketing and media was moderate (r = .37, p < .001), and EMA-logged exposures were marginally associated with the intention to smoke at the end of the study, whereas retrospective recall of exposure was not. EMA data showed that college students were exposed to protobacco marketing through multiple channels in a relatively short period: Exposures (M = 8.24, SD = 7.85) occurred primarily in the afternoon (42%), on weekends (35%), and at point-of-purchase locations (68%) or in movies/TV (20%), and exposures to Marlboro, Newport, and Camel represented 56% of all exposures combined and 70% of branded exposures.

CONCLUSIONS

Findings support the validity of EMA as a method for capturing detailed information about youth exposure to protobacco marketing and media that are not captured through other existing methods. Such data have the potential to highlight areas for policy change and prevention in order to reduce the impact of tobacco marketing on youth.

Research gaps related to tobacco product marketing and sales in the Family Smoking Prevention and Tobacco Control Act

This paper is part of a collection that identifies research priorities that will help guide the efforts of the U.S. Food and Drug Administration (FDA) as it regulates tobacco products. This paper examines the major provisions related to tobacco product advertising, marketing, sales, and distribution included in Public Law 111-31, the "Family Smoking Prevention and Tobacco Control Act". This paper covers 5 areas related to (a) marketing regulations (e.g., ban on color and imagery in ads, ban on nontobacco gifts with purchase); (b) granting FDA authority over the sale, distribution, accessibility, advertising, and promotion of tobacco and lifting state preemption over advertising; (c) remote tobacco sales (mail order and Internet); (d) prevention of illicit and cross-border trade; and (e) noncompliant export products. Each of the 5 sections of this paper provides a description and brief history of regulation, what is known about this regulatory strategy, and research opportunities.

Storefront cigarette advertising differs by community demographic profile

PURPOSE

Tobacco manufacturers have targeted youth and ethnic/racial minorities with tailored advertising. Less is known about how characteristics of storefront tobacco advertisements, such as location, position, size, and content, are used to appeal to demographic subgroups.

DESIGN

The occurrence and characteristics of storefront cigarette advertising were observed for all licensed tobacco retailers in two defined communities.

SETTING

Measures were taken in two Boston, Massachusetts, area urban communities: a low-income, minority community and a high-income, nonminority community.

SUBJECTS

No human subjects were involved in this study.

MEASURES

Advertisement position (attached or separated from storefront), size (small, medium, or large), mentholation, and price were recorded. Geographic coordinates of tobacco retailers and schools were mapped using ArcGIS 9.2.

ANALYSIS

Differences between the communities in advertisement number and characteristics were assessed using bivariate analyses. Logistic regression was used to ascertain the odds of specific advertising features occurring in the low-income/minority community.

RESULTS

The low-income/minority community had more tobacco retailers, and advertisements were more likely to be larger, promote menthol products, have a lower mean advertised price, and occur within 1000 feet of a school.

CONCLUSION

Storefront cigarette advertising characteristics that increase exposure and promote youth initiation were more prominent in a low-income/minority community. The findings emphasize the need for more effective regulation of storefront tobacco advertising.

A longitudinal study of exposure to retail cigarette advertising and smoking initiation

OBJECTIVES

Accumulating evidence suggests that widespread advertising for cigarettes at the point of sale encourages adolescents to smoke; however, no longitudinal study of exposure to retail tobacco advertising and smoking behavior has been reported.

METHODS

A school-based survey included 1681 adolescents (aged 11-14 years) who had never smoked. One measure of exposure assessed the frequency of visiting types of stores that contain the most cigarette advertising. A more detailed measure combined data about visiting stores near school with observations of cigarette advertisements and pack displays in those stores. Follow-up surveys 12 and 30 months after baseline (retention rate: 81%) documented the transition from never to ever smoking, even just a puff.

RESULTS

After 12 months, 18% of adolescents initiated smoking, but the incidence was 29% among students who visited convenience, liquor, or small grocery stores at least twice per week and 9% among those who reported the lowest visit frequency (less than twice per month). Adjusting for multiple risk factors, the odds of initiation remained significantly higher (odds ratio: 1.64 [95% confidence interval: 1.06-2.55]) for adolescents who reported moderate visit frequency (0.5-1.9 visits per week), and the odds of initiation more than doubled for those who visited > or = 2 times per week (odds ratio: 2.58 [95% confidence interval: 1.68-3.97]). Similar associations were observed for the more detailed exposure measure and persisted at 30 months.

CONCLUSIONS

Exposure to retail cigarette advertising is a risk factor for smoking initiation. Policies and parenting practices that limit adolescents' exposure to retail cigarette advertising could improve smoking prevention efforts.

Tobacco point-of-sale advertising in Guatemala City, Guatemala and Buenos Aires, Argentina

OBJECTIVES

To determine tobacco point of sale advertising prevalence in Guatemala City, Guatemala and Buenos Aires, Argentina.

METHODS

Convenience stores (120 per city) were chosen from randomly selected blocks in low, middle and high socioeconomic neighbourhoods. To assess tobacco point of sale advertising we used a checklist developed in Canada that was translated into Spanish and validated in both countries studied. Analysis was conducted by neighbourhood and store type.

RESULTS

All stores sold cigarettes and most had tobacco products in close proximity to confectionery. In Guatemala, 60% of stores had cigarette ads. High and middle socioeconomic status neighbourhood stores had more indoor cigarette ads, but these differences were determined by store type: gas stations and supermarkets were more prevalent in high socioeconomic status neighbourhoods and had more indoor cigarette ads. In poorer areas, however, more ads could be seen from outside the stores, more stores were located within 100 metres of schools and fewer stores had 'No smoking' or 'No sales to minors' signs. In Argentina, 80% of stores had cigarette ads and few differences were observed by neighbourhood socioeconomic status. Compared to Guatemala, 'No sales to minors' signs were more prevalent in Argentina.

CONCLUSIONS

Tobacco point of sale advertising is highly prevalent in these two cities of Guatemala and Argentina. An advertising ban should also include this type of advertising.

Tobacco marketing in California and implications for the future

BACKGROUND

Tobacco marketing influences tobacco use initiation, maintenance of use, and it undermines comprehensive tobacco control programmes. Policies to ban the impact of tobacco marketing are most likely to be more effective if they are comprehensive, as partial bans shift marketing to non-banned forms of media. A comprehensive approach to reducing tobacco marketing includes documentation through monitoring, media and policy interventions and aggressive enforcement of existing laws.

METHODS

This paper summarises California tobacco industry monitoring of events and retail outlets, and findings about exposure to and beliefs about tobacco industry marketing among youths and adults conducted during the period 2000 through 2008.

RESULTS

There was no overall change in the average number of cigarette materials per store, and an increase in the percentage of stores with advertisements promoting price discounts for cigarettes. Stores with cigarette advertisements near candy displays declined from 12.5% (95% CI 9.8% to 15.2%) to 1% (95% CI 0.2% to 1.9%) of stores, and advertisements at or below the eye-level of children declined from 78.6% (95% CI 75.2% to 82.0%) to 31% (95% CI 27.1% to 34.9%) of stores. Overall, the number of public events with tobacco sponsorship declined from 77.3% to 48.1%. This trend was consistent with a significant decline noted among high school students and adults who reported seeing tobacco advertisements at events or attending a tobacco company-sponsored event.

CONCLUSIONS

Tobacco industry monitoring, media, policy and enforcement interventions may have contributed to observed changes in tobacco marketing and to declines in reported exposure to tobacco marketing.

Monitoring the tobacco use epidemic IV. The vector: Tobacco industry data sources and recommendations for research and evaluation

OBJECTIVE

This Vector paper (IV of V on monitoring the tobacco use epidemic) presents the data sources and methods that can be used to monitor tobacco marketing and makes recommendations for creating a national surveillance system.

METHODS

In 2002, the Vector Work Group of the National Tobacco Monitoring, Research and Evaluation Workshop identified priority indicators of tobacco marketing: tobacco brand pricing strategies, retail environment advertising and promotional allowances, gray market or smuggling activities, lobbying, direct mail marketing, tobacco brand placements in films, Internet promotions, and sponsorship at bars and events. This paper reviews and identifies data sources and gaps for these priority indicators and for 12 other indicators of interest.

RESULTS

There are 38 commercial data sites and Internet sources, as well as individual research efforts that address the priority indicators. These sources are not integrated, often costly, and limited in standardization.

CONCLUSIONS

Tobacco marketing could be more effectively monitored with the development of a national research network. Surveillance of the tobacco industry's methods to push tobacco and pull consumers can help the public health community identify new markets and campaigns, justify and tailor effective tobacco control strategies, and evaluate existing counter-marketing efforts.

Tobacco promotions at point-of-sale: the last hurrah

OBJECTIVES

The retail environment provides important opportunities for tobacco industry communication with current, former, and potential smokers. This study documented the extent of tobacco promotions at the retail point-of-sale and examined associations between the extent of tobacco promotions and relevant city and store characteristics.

METHODS

In each of 20 Ontario cities, 24 establishments were randomly selected from lists of convenience stores, gas stations, and grocery stores. Trained observers captured the range, type and intensity of tobacco promotions from April to July 2005. The extent of tobacco promotions was described using weighted descriptive statistics. Weighted t-tests and ANOVAs, and hierarchical linear modeling, were used to examine the relationships between tobacco promotions and city and store characteristics.

RESULTS

Extensive tobacco promotions were found in Ontario stores one year prior to the implementation of a partial ban on retail displays, particularly in chain convenience stores, gas station convenience stores and independent convenience stores. The multivariate hierarchical linear model confirmed differences in the extent of tobacco promotions by store type (p < 0.01); in addition, tobacco promotions were found to be higher among stores close to a school (p = 0.01) and in neighbourhoods with lower median household incomes (p < 0.01). Independent convenience stores with a greater number of employees had more tobacco promotions; however, the relationship was reversed for grocery stores.

DISCUSSION

Tobacco promotions were extensive at the point-of-sale. Public health messages about the harms of tobacco use may be compromised by the pervasiveness of these promotions.

The effect of retail cigarette pack displays on impulse purchase

AIMS

To assess the extent to which point-of purchase (POP) cigarette displays stimulate impulse purchases.

DESIGN

Telephone-administered population survey.

SETTING

Victoria, Australia.

PARTICIPANTS

A total of 2996 adults, among whom 526 smoked factory-made cigarettes and 67 were recent quitters (quit in the past 12 months).

MEASUREMENTS

Reported cigarette purchase behaviour; perceived effect on smoking of removing cigarettes from view in retail outlets; reported urges to buy cigarettes as a result of seeing the cigarette display.

FINDINGS

When shopping for items other than cigarettes, 25.2% of smokers purchased cigarettes at least sometimes on impulse as a result of seeing the cigarette display. Thirty-eight per cent of smokers who had tried to quit in the past 12 months and 33.9% of recent quitters experienced an urge to buy cigarettes as a result of seeing the retail cigarette display. One in five smokers trying to quit and one in eight recent quitters avoided stores where they usually bought cigarettes in case they might be tempted to purchase them. Many smokers (31.4%) thought the removal of cigarette displays from stores would make it easier for them to quit.

CONCLUSIONS

POP cigarette displays act as cues to smoke, even among those not explicitly intending to buy cigarettes, and those trying to avoid smoking. Effective POP marketing restrictions should encompass cigarette displays.

The tobacco epidemic in the United States

Tobacco use, primarily in the form of cigarettes and exposure to tobacco smoke pollution, has caused the premature deaths of more than 14 million Americans since 1964. The major diseases caused by tobacco and tobacco smoke include lung cancer, other cancers, coronary heart disease, other cardiovascular diseases, chronic respiratory diseases, pregnancy complications, and respiratory diseases in children. Per capita consumption of various tobacco products has declined substantially since 1950, with current consumption at approximately 3.7 pounds per capita. Whereas approximately two in five adults smoked cigarettes in 1965, approximately one in five did so in 2005. Several factors can influence initiation and cessation, including product factors (e.g., ventilation holes, additives, and flavorings); host factors (intention to use, level of dependence); tobacco company activities (e.g., marketing strategies, efforts to undermine public health activities); and environmental factors (e.g., peer and parental smoking, smoke-free air laws and policies). Efforts to prevent initiation, promote quitting, and protect nonsmokers should reduce exposure to pro-tobacco marketing and increase (1) the price of tobacco products, (2) protection from tobacco smoke pollution, (3) effective mass media strategies, (4) provision of effective cessation support, (5) effective regulation, and (6) litigation that holds the industry responsible for its misdeeds. Adequate implementation of effective tobacco-control strategies and useful scientific advances will help to ensure that per capita consumption decreases to the lowest level possible. The economic benefits of tobacco in our society are replaceable and they pale in comparison to the extent of human life lost.

Tobacco Point-of-Purchase marketing in school neighbourhoods and school smoking prevalence: a descriptive study

BACKGROUND

Point of Purchase (PoP) promotional and advertising activities are a sophisticated tobacco marketing strategy. This study describes tobacco PoP activities in school neighbourhoods and compares PoP activities in retail stores between schools with high and low smoking prevalence.

METHODS

A cross-sectional study was conducted in 81 randomly selected schools across five provinces. Students in grades 10-11 completed a questionnaire on smoking. Observations were made in all retail stores located within a one-kilometre radius around the school. ANOVA tests were used to detect differences on PoP variables between high (> 20.6%) and low (< or = 20.6%) smoking prevalence schools, defined as percentage of students reporting at least a few puffs on > 2 days in the last 30 days.

RESULTS

Approximately half of retail stores in each school neighbourhood exhibited tobacco PoP activities. Average school smoking prevalence was 20.99%. There were significant main effects on PoP variables between schools with high and low smoking prevalence, Wilk's lambda = 0.81, F (6,74) = 2.89, p < 0.01, eta2 = 0.19. Stores near schools with high smoking prevalence had significantly lower prices per cigarette (F (1,79) = 15.34, p < 0.01, eta2 = 0.16), more in-store promotions (F (1,79) = 6.73, p < 0.01, eta2 = 0.08), and fewer government-sponsored health warnings (F (1,79) = 6.26, p < 0.01, eta2 = 0.07) compared to schools with low smoking prevalence.

CONCLUSION

Higher levels of PoP activities in stores located in the school neighbourhood are related to school smoking prevalence. Schools with low smoking prevalence had more stores that posted government health warning signs and higher cigarette prices. Legislation regulating PoP activities and health warnings in school neighbourhoods should be considered.

Bridging the Gap: research informing practice and policy for healthy youth behavior

BACKGROUND

Bridging the Gap (BTG) is a collaborative research initiative supported by the Robert Wood Johnson Foundation. Ten years ago, BTG was created to assess the impact of policies, programs, and other environmental influences on adolescent alcohol, tobacco, and illicit drug use and related outcomes. This multidisciplinary, multisite initiative examines these factors at multiple levels of social organization, including schools, communities, and states. More recently, the significant increases in obesity among children, adolescents, and adults led BTG to expand its efforts to include research on the role of policies, programs, and other factors on adolescent obesity and the physical inactivity and dietary habits that contribute to this growing problem. Eleven papers resulting from BTG's obesity-related research are contained in this supplement, along with two papers describing the National Cancer Institute-supported efforts to track relevant state policies.

METHODS

Bridging the Gap involves a variety of data-collection efforts built largely around the Monitoring the Future (MTF) surveys of 8th-, 10th-, and 12th-grade students. These include: surveys of administrators in the MTF schools that gather extensive information on the school food environment, physical education in schools, and other relevant information; collection of contextual information from the communities in which the MTF schools are located; tracking of relevant state policies; and gathering of a wide variety of data from archival and commercial databases. These databases are analyzed individually and in various combinations.

DISCUSSION

Bridging the Gap's extensive research has shown the importance of a range of school, community, state, and other influences in affecting adolescent substance use and related outcomes. BTG's early research on adolescent diet, physical activity, and obesity--much of which is contained in this supplement--similarly demonstrates the role of environmental factors in influencing these outcomes and in explaining observed racial/ethnic and socioeconomic-related disparities in them.

CONCLUSIONS

The growing recognition of the public health and economic consequences of childhood, adolescent, and adult obesity has led to a variety of policies, programs, and other interventions to stimulate healthy eating and physical activity, often despite the lack of evidence on their impact. BTG and others are working to build the evidence base for effective interventions to address this significant problem, but much remains to be learned.