Single Cigarette Sales: State Differences in FDA Advertising and Labeling Violations, 2014, United States

"The ban is there, but it is not there": perceptions of cigarette users and tobacco vendors regarding ban on the sale of loose cigarettes in India

Introduction

Banning the sales of loose cigarettes is recommended by Article 16 of the World Health Organization - Framework Convention on Tobacco Control. This study aims to understand the perceptions of cigarette users and tobacco vendors regarding such a ban.

Methods

Using a systematic recruitment and interview protocol, we interviewed cigarette users (n = 28) and tobacco vendors (n = 28) from two Indian cities where sales of loose cigarettes were banned (Mumbai) or not banned (Delhi). Separate semi-structured interview guides were used for users and vendors. Interview questions focused on reasons for purchasing loose cigarettes, preference for buying and selling loose vs. packs, thoughts on the necessity of banning loose cigarettes, and the perceived impact of the policy ban for vendors and cigarette users. We performed thematic analysis and used NVivo for organizing transcript coding.

Results

The main reasons users cited for purchasing loose cigarettes were financial constraints, social restrictions (fear of getting caught), and limiting cigarette consumption. In Mumbai, awareness of the existing ban was poor among both users and vendors. Those who were aware did not think the policy had been implemented. Users thought that loose cigarettes promoted smoking initiation and prevented them from quitting. Both users and vendors reported that a ban on loose cigarettes would reduce cigarette consumption and promote quit attempts as it would not be possible for everyone to purchase packs because of financial and social reasons.

Conclusion

Users in both cities reported easy access to and widespread availability of loose cigarettes. Low awareness of the ban in Mumbai suggested inadequate enforcement. A country-wide ban on the sale of loose cigarettes could be highly effective in preventing smoking initiation and promoting quitting.

Underutilisation of no-tobacco-sale orders against retailers that repeatedly sell to minors, 2015-2019, USA

IMPORTANCE

Research demonstrates that policies aimed at retailers who sell to minors must be strongly enforced to have an impact on youth usage rates.

OBJECTIVES

In the USA, the Food and Drug Administration (FDA) conducts compliance checks, issues fines, and can order retailers to stop selling tobacco products (ie, no-tobacco-sale orders (NTSOs)) to enforce the Family Smoking Prevention and Tobacco Control Act. We sought to assess FDA's utilisation of NTSOs.

METHODS

We conducted a quantitative content analysis of FDA's enforcement actions for inspections decided between 1 October 2015 and 29 March 2019. From the 536 134 inspection records we identified 148 NTSOs and 249 720 unique retailer locations, of which 2095 had three or more violations. We randomly sampled NTSOs (n=76) and retail locations (n=152) with frequent violations. We calculated the proportion of NTSOs that could have been issued earlier by FDA. We then calculated the proportion of retailers that could have been issued an NTSO, and the proportion actually issued an NTSO using FDA's approach and a more stringent approach.

RESULTS

Among NTSOs, 94.7% (95% CI: 89.8% to 97.4%) of NTSOs could have been issued earlier under a more stringent approach. On average, when an NTSO could have been issued earlier, it could have been issued 453 days earlier (95% CI: 418 to 489; range: 89-1159). Among frequently violating retail locations, 73.6% (95% CI: 66.0% to 80.0%) were eligible for an NTSO. Of those, 1.9% (95% CI: 0.5% to 7.0%) had received an NTSO.

CONCLUSIONS

The FDA's failure to fully leverage its powers to address retailers' underage sales of tobacco products has weakened efforts to curb the youth e-cigarette epidemic.

The Reshaping of the E-Cigarette Retail Environment: Its Evolution and Public Health Concerns

E-cigarette use represents a public health controversy in the US and globally. Despite the potential of e-cigarettes to support cigarette cessation, their use increases health risks and risk for addiction, particularly in young people. Various federal, state, and local laws have impacted tobacco retail in general and e-cigarettes in particular. In the US, 2019–2020 federal laws increased in the minimum legal sales age for tobacco to 21 and banned flavored cartridge-based e-cigarettes. Many states and localities were early adopters of Tobacco 21 and implemented more comprehensive flavor restrictions than the federal ban. Meanwhile, cannabis retail is increasingly being legalized in the US—while cannabis-based product regulation has notable gaps at the federal, state, and local levels. These regulatory complexities have impacted specialized retailers selling e-cigarettes, including “vape shops” that exclusively sell e-cigarettes, “smoke shops” that sell e-cigarettes and other tobacco (and potentially CBD/THC and other un- or under-regulated products), and online retail. This commentary outlines public health concerns related to: (1) youth access; (2) consumer exposure to a broader range of tobacco products and marketing in retail settings where they may seek products to aid in cigarette cessation (i.e., such broad product exposure could hinder cessation attempts); (3) consumer exposure to un-/under-regulated products (e.g., delta-8-THC, kratom); and (4) federal, state, and local regulations being undermined by consumer access to prohibited products online and via the mail. These concerns underscore the need for ongoing surveillance of how retailers and consumers respond to regulations.

Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.

IMPLICATIONS

The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.

Single cigarette purchasers among adult U.S. smokers

Cigarette smoking remains the leading preventable cause of morbidity and mortality. The purchase of single cigarettes, known as loosies, allows for a more affordable cost than a pack of cigarettes. Many of the existing studies on loose cigarettes have used a small non-generalizable sample. This study examined the sociodemographic characteristics of loosie purchasers among adult cigarette smokers in the United States. Data from the 2006/07-2014/15 Tobacco Use Supplement to the Current Population Survey were analyzed. The sociodemographic characteristics of loosie users were examined by multivariable logistic regression. In 2014-2015, approximately 5.4% of adult smokers reported purchasing loosies compared to 3.7% in 2006-2007. Men (OR 1.22, 95% CI 1.10-1.35), non-Hispanic Blacks (OR 3.30, 95% CI 2.89-3.77), Hispanics (OR 1.97, 95% CI 1.67-2.32), and those living in a metropolitan area (OR 1.16, 95% CI 1.02-1.33) had significantly higher odds of single cigarette purchase. Single cigarette use also varied by age, marital status, employment, and geographic region. Menthol cigarette smokers had higher odds of purchasing loosies compared to non-menthol smokers. Likewise, cigarette quit intention was significantly associated with odds of buying loosies. The prevalence of single cigarette purchases among smokers appears to be lower in a national sample compared to previous estimates reported in specific populations. However, certain subpopulations were more likely to purchase a single cigarette and may contribute to persistent disparities among racial and ethnic minorities. Preventing the sale of loosies may improve the health outcomes of underserved communities, specifically those with low socioeconomic status.

Parent Education and Future Transition to Cigarette Smoking: Latinos' Diminished Returns

Background: High parent education is protective against youth health risk behaviors such as tobacco use. According to the Minorities' Diminished Returns theory, however, higher parent education seems to exert less protection for the ethnic minority relative to the majority groups. Objectives: To explore ethnic differences in the effects of parent education on the transition to cigarette smoking in a national sample of American never-smoker adolescents. Methods: This longitudinal study used data of waves 1 and 4 of the Population Assessment of Tobacco and Health (PATH 2013-2018). This analysis included 5,021 American youth who were never smokers at baseline (2013) and were followed for 4 years. Transition to cigarette smoking was the dependent variable. Parent education was the independent variable. Youth age, youth gender, and family structure were the covariates. Ethnicity was the moderating variable. Results: From the 5,021 American youth who were never smokers at baseline (2013), 89.4% continued as never smokers, and 10.6% became ever-smokers. Overall, 4.0% were current smokers at wave 4. Overall, a higher parent education was associated with lower odds of transitioning to ever and current cigarette smoker at the end of the 4th year. Parent education, however, showed significant interaction with Latino ethnicity on both outcomes suggesting smaller protective effects of high parent education against transitioning to tobacco use for Latino than for non-Latino youth. Conclusions: In the U.S., ethnicity alters the magnitude of the protective effect of parent education against youth transition to tobacco use. While high parent education is protective against transitioning to become a cigarette smoking overall, non-Latinos (a socially privileged group) gain more and Latino youth (a socially marginalized group) gain least from such a resource. In addition to addressing the SES gap, policymakers should identify and address mechanisms by which ethnic minority youth remain at risk of tobacco use, even when they are from highly educated families.

Little filtered cigars: US sales, flavours, package sizes and prices

OBJECTIVE

At least four varieties of little filtered cigars (LFCs) violate the US prohibition on flavoured cigarettes other than menthol. This study characterises the sales of prohibited products and other LFCs by flavour category and pack size, as well as the price of LFCs relative to cigarettes.

METHODS

Using retail sales data for 2016, we computed the sales volume in dollars and equivalent units and the percentage of total sales by flavour and pack size for the USA by region and state. Paired t-tests compared the prices for LFCs and cigarettes sold in same-sized packs and cartons.

RESULTS

LFC sales totalled 24 033 equivalent units per 100 000 persons in 2016. Flavoured LFC varieties accounted for almost half (47.5%) of the total sales. LFCs were sold in 12 different pack sizes, but 79.7% of sales were packs of 20. The price of 20-packs averaged $2.41 (SD=$1.49), which was significantly less than cigarettes (M=$5.90, SD=$0.85). Regional differences suggest a greater proportion of menthol/mint LFCs and lower prices in the South than in other regions.

CONCLUSION

Classifying all LFCs as cigarettes would require that they be offered in a minimum package of 20, eliminate flavoured varieties other than menthol and increase prices through applicable state and local cigarette taxes.

The effects of assurances of voluntary compliance on retail sales to minors in the United States: 2015-2016

Multiple state attorneys generals have entered assurances of voluntary compliance (AVCs) with numerous national retail chains as an application of consumer protection laws to help prevent tobacco sales to minors. Little is known about the effectiveness of AVCs in reducing the violations of tobacco retailers for underage sales. We collected inspection data involving minors (n=53,832) on tobacco retailers in 2015 and 2016 from the Food and Drug Administration (FDA) compliance check database. Inspections on 13 national retail chains were classified into four categories: gas stations from oil companies, convenience stores, pharmacy stores, and supermarkets. Multilevel logistic regression models were performed to examine the effectiveness of AVCs, adjusted for state tobacco control policies, state youth smoking rates, and socio-economic status (SES) at census tracts. Overall the Retail Violation Rate for sales to minors (RVRm) significantly varied by retail category from 7.7% in pharmacy stores to 18.9% in gas stations from oil companies. Retailers that entered an AVC had lower odds of underage sales violations in convenience stores (aOR=0.75, 95% CI [0.61-0.93]) and supermarkets (aOR=0.74, 95% CI [0.59-0.93]). For gas stations from oil companies and pharmacy stores, there were no significant differences in RVRm between stores with an AVC and stores without an AVC. We found that entering into AVCs is associated with fewer retail violations of underage sales for convenience stores and pharmacy stores. Continued efforts to strengthen the enforcement of AVCs and to expand AVCs to more states and other retail chains may improve youth tobacco control.

Adolescents' Perceptions of an On-cigarette Health Warning

INTRODUCTION

In most countries, health warnings have been on cigarette packs for decades. We explored adolescents' perceptions of a health warning on cigarettes.

METHODS

Data come from the 2014 wave of a cross-sectional in-home survey with 11- to 16-year olds (N = 1205) from across the UK, with participants recruited from the general population using random location quota sampling. Participants were shown an image of a standard cigarette which displayed the warning "Smoking kills" and asked whether they thought this would (not) put people off starting to smoke, (not) make people want to give up smoking, and whether all cigarettes should (not) have health warnings on them.

RESULTS

Most (71%) thought that an on-cigarette warning would put people off starting, although this decreased with age. Never smokers were more likely than current smokers to think that it would put people off starting. Approximately half (53%) thought that an on-cigarette warning would make people want to give up smoking, with this higher for never smokers and experimenters/past smokers than for current smokers. Most (85%) supported a warning on all cigarettes. There was support among each smoking group, although this was higher for never smokers and experimenters/past smokers than for current smokers, and higher for those indicating that most of their close friends do not smoke than for those indicating that most of their close friends do smoke.

CONCLUSIONS

The perception among adolescents that an on-cigarette warning could deter smoking, and the high support for a warning on all cigarettes, warrants further research.

IMPLICATIONS

Research on dissuasive cigarettes is at a nascent stage. This is the first study to explore how adolescents perceive a health warning ("Smoking kills") on cigarettes. Almost three quarters of participants indicated that on-cigarette health warnings would deter people from starting to smoke, and 85% supported the inclusion of a warning on all cigarettes. While further research is clearly needed, these findings suggest that the inclusion of health warnings on cigarettes is considered appropriate by young people and may have a dissuasive effect.

The effects of tobacco control policies on retailer sales to minors in the USA, 2015

BACKGROUND

Under the 2009 Family Smoking Prevention and Tobacco Control Act, the Food and Drug Administration (FDA) has been routinely inspecting tobacco retailers' compliance with under-age sales laws. We seek to identify factors associated with Retail Violation Rate for sale to minors (RVRm).

METHODS

We collected the tobacco retailer inspection data for 2015 from the FDA compliance check database. RVRm was calculated at the census tract level and overlaid with tobacco regulations and youth smoking prevalence at the state level. Multi-level spatial analysis was performed to examine the impacts of tobacco jurisdiction variations, youth smoking rates and neighbourhood social characteristics on RVRm.

RESULTS

A total of 136 816 compliance checks involving minors conducted by the FDA in 2015 were analysed. A higher RVRm was associated with higher youth smoking prevalence (aRR=1.04, p<0.0001). Tobacco regulations show significant relationships with RVRm. For every one dollar increase in cigarette tax per pack, the likelihood of retail violations was reduced by 2% (aRR=0.98, p=0.03). For every 10% increase in tobacco prevention spending towards Centers for Disease Control recommended funding targets, the likelihood of retail violations was reduced by 1% (aRR=0.99, p=0.01). RVRm increased in states that enacted stronger smoke-free air policies (aRR=1.08, p<0.0001).

CONCLUSION

We observed associations of tobacco regulations and neighbourhood social characteristics with tobacco retailers' compliance with under-age sales laws. This study provides evidence to support stronger tobacco regulations and control policies in reducing youth access to tobacco products.

Inequities in tobacco retailer sales to minors by neighbourhood racial/ethnic composition, poverty and segregation, USA, 2015

OBJECTIVE

Tobacco retailers are an important source of tobacco products for minors. Previous research shows racial discrimination in sales to minors, but no national study has examined neighbourhood correlates of retailer under-age sales.

METHODS

We accessed publicly available results of 2015 US Food and Drug Administration (FDA) inspections of tobacco retailers (n=108 614). In this cross-sectional study, we used multilevel logistic regression to predict the likelihood of retailer sale to a minor based on tract characteristics. We assessed the proportion of residents identifying as American Indian, Asian, Black, Latino and White; Isolation Index scores for each racial/ethnic group; the proportion of people less than age 65 living in poverty; and the proportion of residents age 10-17 in relation to retailer inspection results.

RESULTS

The proportion of American Indian residents, Black residents, Latino residents and residents less than age 65 under the poverty line in a neighbourhood are independently, positively associated with the likelihood that a retailer in that neighbourhood will fail an under-age buy inspection. The proportion of White residents and residents age 10-17 are independently, negatively associated with the likelihood of sale of tobacco products to a minor. Isolation Index scores show a similar pattern. In multivariable models holding neighbourhood characteristics constant, higher proportions of Black (+), Latino (+) and age 10-17 (-) residents remained significant predictors of the likelihood of under-age sale.

DISCUSSION

Regulatory agencies should consider oversampling retailers in areas with higher likelihood of sales to minors for inspection. Interventions with tobacco retailers to reduce inequities in youth access should be implemented.

"May I Buy a Pack of Marlboros, Please?" A Systematic Review of Evidence to Improve the Validity and Impact of Youth Undercover Buy Inspections

Most smokers become addicted to tobacco products before they are legally able to purchase these products. We systematically reviewed the literature on protocols to assess underage purchase and their ecological validity. We conducted a systematic search in May 2015 in PubMed and PsycINFO. We independently screened records for inclusion. We conducted a narrative review and examined implications of two types of legal authority for protocols that govern underage buy enforcement in the United States: criminal (state-level laws prohibiting sales to youth) and administrative (federal regulations prohibiting sales to youth). Ten studies experimentally assessed underage buy protocols and 44 studies assessed the association between youth characteristics and tobacco sales. Protocols that mimicked real-world youth behaviors were consistently associated with substantially greater likelihood of a sale to a youth. Many of the tested protocols appear to be designed for compliance with criminal law rather than administrative enforcement in ways that limited ecological validity. This may be due to concerns about entrapment. For administrative enforcement in particular, entrapment may be less of an issue than commonly thought. Commonly used underage buy protocols poorly represent the reality of youths' access to tobacco from retailers. Compliance check programs should allow youth to present themselves naturally and attempt to match the community's demographic makeup.