Young people's exposure to point-of-sale tobacco products and promotions

OBJECTIVES

Point of sale (POS) displays are one of the most important forms of tobacco marketing still permitted in many countries. Reliable methods for measuring exposure to such displays are needed in order to assess their potential impact, particularly on smoking attitudes and uptake among young people. In this study we use a novel method for evaluating POS exposure based on young people's use of retail outlets and recall of tobacco displays and observational data on the characteristics of displays.

STUDY DESIGN

Observational audit of retail outlets (n = 96) and school-based pupil survey (n = 1482) in four Scottish communities reflecting different levels of social deprivation and urbanisation, conducted in 2013 before legislation to remove POS displays was implemented in supermarkets.

METHODS

Measures were taken of: visibility and placement of tobacco displays; internal and external advertising; display unit size, branding and design; visibility of pack warnings; proximity of tobacco products to products of potential interest to children and young people; pupils' self-reported frequency of visiting retail outlets; and pupils' recall of tobacco displays. Variation in POS exposure across social and demographic groups was assessed.

RESULTS

Displays were highly visible within outlets and, in over half the stores, from the public footway outside. Tobacco products were displayed in close proximity to products of interest to children (e.g. confectionery, in 70% of stores). Eighty percent of pupils recalled seeing tobacco displays, with those from deprived areas more likely to recall displays in small shops. When confectioners, tobacconists and newsagents (CTNs) and grocery/convenience stores (two of the outlet types most often visited by young people) were examined separately, average tobacco display unit sizes were significantly larger in those outlets in more deprived areas.

CONCLUSIONS

POS displays remain a key vector in most countries for advertising tobacco products, and it is important to develop robust measures of exposure. The data reported in this paper provide a baseline measure for evaluating the efficacy of legislation prohibiting such displays.

Does exposure to cigarette brands increase the likelihood of adolescent e-cigarette use? A cross-sectional study

OBJECTIVE

To examine the relationship between tobacco cigarette brand recognition, and e-cigarette use in adolescents.

DESIGN

Cross-sectional observational study.

SETTING

High schools in Scotland.

PARTICIPANTS

Questionnaires were administered to pupils in Secondary 2 (S2 mean age: 14.0 years) and Secondary 4 (S4 mean age: 15.9 years) across 4 communities in Scotland. An 86% response rate with a total sample of 1404 pupils was achieved.

MAIN OUTCOME MEASURES

Self-reported previous use of e-cigarettes and self-reported intention to try e-cigarettes in the next 6 months.

RESULTS

75% (1029/1377) of respondents had heard of e-cigarettes (69.5% S2, 81.1% S4), and of these, 17.3% (10.6% S2, 24.3% S4 n=1020) had ever tried an e-cigarette. 6.8% (3.7% S2, 10.0% S4 n=1019) reported that they intended to try an e-cigarette in the next 6 months. Recognition of more cigarette brands was associated with greater probability of previous e-cigarette use (OR 1.20, 99% CI 1.05 to 1.38) as was having a best friend who smoked (OR 3.17, 99% CI 1.42 to 7.09). Intention to try e-cigarettes was related to higher cigarette brand recognition (OR 1.41, 99% CI 1.07 to 1.87), hanging around in the street or park more than once a week (OR 3.78, 99% CI 1.93 to 7.39) and living in areas of high tobacco retail density (OR 1.20, 99% CI 1.08 to 1.34). Never having smoked was a protective factor for both future intention to try, and past e-cigarette use (OR 0.07, 99% CI 0.02 to 0.25; and OR 0.10, 99% CI 0.07 to 0.16, respectively).

CONCLUSIONS

Higher cigarette brand recognition was associated with increased probability of previous use and of intention to use e-cigarettes. The impact of tobacco control measures such as restricting point-of-sale displays on the uptake of e-cigarettes in young people should be evaluated.

E-cigarette marketing in UK stores: an observational audit and retailers' views

OBJECTIVES

To explore how e-cigarettes are being promoted at point of sale in the UK and how retailers perceive market trends.

SETTING

Fixed retail outlets subject to a ban on the display of tobacco products.

PARTICIPANTS

Observational audit of all stores selling tobacco products (n=96) in 4 Scottish communities, conducted over 2 waves 12 months apart (2013-2014), and qualitative interviews with small retailers (n=25) in 4 matched communities.

PRIMARY AND SECONDARY OUTCOME MEASURES

The audit measured e-cigarette display characteristics, advertising materials and proximity to other products, and differences by area-level disadvantage. Interviews explored retailers' perceptions of e-cigarette market opportunities and risks, and customer responses.

RESULTS

The number of e-cigarette point-of-sale display units and number of brands displayed increased between waves. E-cigarettes were displayed close to products of interest to children in 36% of stores. Stores in more affluent areas were less likely to have external e-cigarette advertising than those in deprived areas. Although e-cigarettes delivered high profit margins, retailers were confused by the diversity of brands and products, and uncertain of the sector's viability. Some customers were perceived to purchase e-cigarettes as cessation aids, and others, particularly low-income smokers, as a cheaper adjunct to conventional tobacco.

CONCLUSIONS

E-cigarette point-of-sale displays and number of brands displayed increased over 12 months, a potential cause for concern given their lack of regulation. Further scrutiny is needed of the content and effects of such advertising, and the potentially normalising effects of placing e-cigarettes next to products of interest to children.

Secondhand smoke exposure and survival following acute coronary syndrome: prospective cohort study of 1261 consecutive admissions among never-smokers

OBJECTIVE

To determine whether exposure to secondhand smoke is associated with early prognosis following acute coronary syndrome.

DESIGN, SETTING AND PARTICIPANTS

We interviewed consecutive patients admitted to nine Scottish hospitals over 23 months. Information was obtained, via questionnaire, on age, sex, smoking status, postcode of residence and admission serum cotinine concentration was measured. Follow-up data were obtained from routine hospital admission and death databases.

RESULTS

Of the 5815 participants, 1261 were never-smokers. Within 30 days, 50 (4%) had died and 35 (3%) had a non-fatal myocardial infarction. All-cause deaths increased from 10 (2.1%) in those with cotinine < or =0.1 ng/ml to 22 (7.5%) in those with cotinine >0.9 ng/ml (chi(2) test for trend p<0.001). This persisted after adjustment for potential confounders (cotinine >0.9 ng/ml: adjusted OR 4.80, 95% CI 1.95 to 11.83, p = 0.003). The same dose response was observed for cardiovascular deaths and death or myocardial infarction.

CONCLUSIONS

Secondhand smoke exposure is associated with worse early prognosis following acute coronary syndrome. Non-smokers need to be protected from the harmful effects of secondhand smoke.

Management of alcohol misuse in Scotland: the role of A&E nurses

Despite national targets to reduce excessive drinking in Scotland, rates have increased dramatically since the mid-eighties. The role of Accident and Emergency (A&E) departments in the management of alcohol misuse is much debated. This postal survey was conducted with senior medical and nursing staff in A&E departments and minor injury units throughout Scotland to examine the prevalence of alcohol-related attendances and staff's attitudes towards identifying and responding to alcohol-related attendances. A 57% response rate was achieved, representing 87% of all A&E institutions in Scotland (n = 84). The results reveal an estimated 1 in 7 attendances in A&E in Scotland are alcohol-related, and 1 in 5 of these result in admission. However, over two-fifths of departments do not routinely screen for, or keep records of, patients who attend with alcohol problems. Intervention is normally limited to a brief dialogue and referral to the patient's GP. Despite considerable barriers, A&E nursing staff express a willingness to assume a preventive role, but acknowledge lack of appropriate training and sources of support. It is concluded that there is scope for developing identification and brief intervention services within A&E. However, such developments are dependent upon alcohol issues assuming a higher priority among senior A&E staff.

A comparison of the prevalence of HIV infection and injecting risk behaviour in urban and rural samples in Scotland

AIMS

To compare the prevalence of HIV infection and injecting risk behaviour among injecting drug users from urban and rural areas.

DESIGNS

Two samples of injecting drug users were recruited using a multi-site sampling strategy. Respondents were first interviewed by trained interviewers then specimens of saliva were collected for anonymous testing for antibodies to HIV.

SETTING

Respondents were recruited from drug treatment services and street sites.

PARTICIPANTS

Respondents were eligible for inclusion in the study if they had "ever" injected a drug and were currently using drugs.

MEASUREMENTS

Measurements taken included self-reported patterns of drug use and injecting risk behaviour. Specimens of saliva were tested for the presence of HIV infection using GACELISA with reactive specimens confirmed by Western blot analysis.

FINDINGS

Our data indicate that there are two separate populations which are geographically discrete but broadly similar in profile and current injecting risk behaviour. The prevalence of HIV infection among IDUs from Dundee city was found to be 26.8% (95% CI, 20.2%-33.0%) compared with 3.7% (95% CI, 0.13%-15.8%) for IDUs from rural Tayside. This marked difference in prevalence of HIV infection we attribute to a high level of injecting risk among urban IDUs between 1980 and 1984, limited migration from the urban epicentre of infection and a reluctance among rural IDUs to share with IDUs outside their immediate social and kinship networks.

CONCLUSIONS

Although current levels of injecting risk behaviour are similar in our urban and rural samples, rural IDUs may be less likely to contract HIV from their fellow injectors because of the lower prevalence of HIV infection and more closed sharing networks within the rural population. The implications of this for the development and expansion of drug services are considered.

HIV prevalence and HIV risk behaviour among injecting drug users in London and Glasgow

This paper reports on the British findings from a cross-national study of HIV prevalence and HIV risk behaviour among 1,037 injecting drug users (IDUs) recruited from a variety of treatment- and community-based settings during 1990. Confirmed HIV saliva test results show 12.8% (63) of London respondents and 1.8% (8) of Glasgow respondents to be HIV antibody positive. Among London respondents, a higher rate of prevalence was found in those with no experience of drug treatment. A greater proportion of Glasgow respondents (68%) than London respondents (47%) reported sharing used injecting equipment in the 6 months prior to interview. The majority (88% in both cities) attempted cleaning borrowed equipment, although less than a third (31% in London and 30% in Glasgow) usually used bleach. The majority of respondents (71% in London and 82% in Glasgow) were sexually active with partners of the opposite sex in the last 6 months, and respondents had a mean number of 2.4 non-commercial sexual partners in London and 2.1 in Glasgow. Levels of reported condom use were comparable with reports in the heterosexual population as a whole, with 70% of London respondents and 75% of Glasgow respondents never using condoms with primary partners, and 34% of London and 52% of Glasgow respondents never using condoms with casual partners. Half (48%) of London respondents and 42% of Glasgow respondents reported sexual intercourse with non-injecting private sexual partners, while 14% of female respondents in London and 22% in Glasgow had engaged in prostitution. Levels of risk-taking in each of the two cities indicate the potential for further transmission of HIV among drug injectors, and their sexual and sharing partners.

Modeling the behavior and attributes of injecting drug users: a new approach to identifying HIV risk practices

The behaviors and attributes of 503 Scottish injecting drug users were modeled using the linear structural equations program LISREL. Drug use was directly related to prison experience, sexual activity, sharing of injecting equipment, and prostitution. Although the prevalence of HIV among the sample was low (2.0%), the pattern of risk behaviors observed in the data affords potential for future spread of the virus. Harm reduction measures taken by injectors in response to the threat posed by AIDS were inversely related to drug use but, more encouragingly, directly related to awareness of the disease, treatment for drug use, and prostitution.

HIV testing among injecting drug users in Glasgow

The use of saliva rather than blood for epidemiological studies of HIV prevalence, especially among injecting drug users, has several practical advantages. In a cross-sectional, behavioural and prevalence study among drug users in Glasgow during 1990, salivary samples were therefore obtained by the use of salivettes. Such samples were requested for anonymous anti-HIV testing from 498 persons in locations varying from residential rehabilitation centres to the open streets. Of this number, 35 refused to give a sample, resulting in a compliance rate of 93%. Of the 463 salivettes received by the laboratory, eight were found to be dry. Of the remaining 455 specimens, eight were found to be positive for HIV-1 antibody by means of an IgG antibody capture ELISA, so giving a prevalence rate of 1.8%. The results of testing saliva and blood spot samples collected at the same time on filter paper from 98 persons for HIV-1 antibody were 100% concordant. The study confirms the experience of others that specimens of saliva are easy to collect under variable conditions by non-medical staff and demonstrates that the salivette can provide an HIV antibody test result the same as that obtained from a blood spot. The prevalence of HIV antibody determined in this study is similar to that of other studies taking place in the city during the same period of time.

Estimates of HIV infection among injecting drug users in Glasgow, 1985-1990

OBJECTIVE

To use research and surveillance studies in Glasgow (Scotland, UK) to estimate the number of current injectors infected with HIV, the total number of injectors infected up to the end of 1990 and the recent incidence of infection.

DESIGN

(A) Prevalence of injecting drug use was estimated using log-linear modelling. (B) Prevalence of HIV infection was determined from voluntary testing of a community-wide sample of injectors. (C) The number of infected current injectors was predicted by combining the distributions generated by (A) and (B). (D) Data on known HIV-positive injectors were used in conjunction with (C) to forecast the cumulative number of infected injectors.

RESULTS

The number of current injectors was estimated to be 9400; the prevalence of HIV infection among 447 injectors recruited to the HIV prevalence study during 1990 was 1.1%. From these data, the number of HIV-positive current injectors in 1990 was estimated to be between 52 and 138. Between 1985 and 1990, 110 known HIV-positive injectors were registered or received treatment in Glasgow for HIV-related diseases; the total number of cases estimated to have occurred during this period was between 110 and 300. The incidence of infection in Glasgow during 1990 was likely to have been low in light of the finding that only one case in the prevalence study had not previously been diagnosed HIV-positive.

CONCLUSIONS

Linkage of datasets from a variety of sources and studies has enabled the substantial refinement of estimates of the number of injectors and the proportion infected with HIV in Glasgow up to 1990.

A new method of estimating prevalence of injecting drug use in an urban population: results from a Scottish city

Using modelling techniques derived from behavioural ecology, unnamed identifier data from a variety of partial samples of injecting drug users [IUDs] were used to estimate the prevalence of this population in Glasgow during 1989. The model yielded an estimate of 9424 [95% confidence interval +/- 2460] which represents a prevalence rate of 15 per 1000 population aged 15-55. The estimated male:female ratio was 2.64:1 and the modal IDU aged 20-24. These figures should facilitate assessment of the service requirements of this group and provide a basis from which the number of IDUs infected with HIV and the number likely to progress to AIDS can be determined. As the methodology required to facilitate reliable prevalence estimates utilizes relatively easy to obtain information it could be repeated in other urban centres where drug injecting is known to occur.