Reducing Disparities in Tobacco Retailer Density by Banning Tobacco Product Sales Near Schools

Tobacco retail outlet marketing exposure and growth of e-cigarette and cigarette use over adolescence and early young adulthood

OBJECTIVES

To determine if cigarette and e-cigarette tobacco retail outlet (TRO) marketing influenced past 30-day (P30D) cigarette and e-cigarette use trajectories across early adolescence through young adulthood.

METHODS

A prospective cohort design in the five major counties in Texas was conducted using 12 survey waves from 2014 to 2020 with 3892 students in 6th, 8th and 10th grade at baseline. Growth curve modelling was used to determine the association between self-reported exposure to TRO marketing and P30D use and whether this relationship varied by age.

RESULTS

Across ages 11-22, exposure to TRO cigarette marketing increased the odds of P30D cigarette use (OR=1.05, 95% CI 1.01 to 1.09) and TRO e-cigarette marketing increased the odds of P30D e-cigarette use (OR=1.06, 95% CI 1.03 to 1.09), on average. The effect of marketing on P30D cigarette use was stable across ages, while the effect on P30D e-cigarette use was stronger at younger ages.

CONCLUSIONS

Exposure to TRO marketing increases the odds of tobacco product use for youth ageing into young adulthood. E-cigarette marketing may be particularly influential in early adolescence. TRO marketing restrictions are needed to reduce tobacco use among youth and young adults.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Identities, drinking behaviors and cancer beliefs among African-American and White American adults: A qualitative analysis

BACKGROUND

Alcohol consumption is causally linked to multiple cancers. African-Americans are at greater risk of cancer than other demographic groups and suffer more serious consequences. Awareness and knowledge of the alcohol-cancer link are low, especially among African-Americans compared to other racial/ethnic groups. This study built on the theory of identity-based motivation (TIBM) to explore how people think about alcohol consumption in relation to their social identities and beliefs about cancer.

METHODS

Data come from 20 in-depth interviews with current drinkers (10 White and 10 African-American adults) in a major mid-Atlantic city in the summer of 2021, using race- and gender-concordant interviewers. An abductive and iterative approach identified salient themes about how drinkers thought about alcohol, social identities, and cancer.

RESULTS

While most participants discussed alcohol use as an important part of American culture, African-American participants were more likely to discuss drinking as a way to cope with racism and other hardships. Participants also noted the need to address structural issues that would make it difficult to cut back on drinking. Both White and African-American participants talked about stressors in life that drive them to drink and make cutting back difficult, and African-American participants discussed how the location of liquor stores in their neighborhoods made alcohol too readily available.

CONCLUSIONS

Insights from these interviews confirm the relevance of racial and other identities in shaping responses to alcohol-cancer messaging, and emphasize the need to consider both behavior change and policy change to create supportive environments for such changes.

Gaps in Awareness of the United States Minimum Legal Age of E-Cigarette and Cigarette Sales: Implications for Public Health Messaging

PURPOSE

In 2019, the United States raised the minimum legal age (MLA) of sales for all tobacco products from 18 to 21. Public awareness of the federal MLA of tobacco sales overall and by demographics is understudied.

METHODS

A national, cross-sectional 2023 survey in which 6,098 participants aged 13-40 years responded to the question, "at which age is it legal to purchase [e-cigarettes; cigarettes; alcohol] in the United States?" Participants also reported age, sex, race/ethnicity, and prior use of each substance.

RESULTS

Sixty-one percent, 64.6%, and 88.7% correctly identified the MLA of sales for e-cigarettes, cigarettes, and alcohol, respectively. Differences in awareness of the MLA were found by age, sex, race/ethnicity, and prior use status.

DISCUSSION

Gaps in awareness of the MLA of tobacco sales, particularly among adolescents and adults, suggest messaging regarding the federal Tobacco 21 law is needed.

Marketing Strategies and Consumer and Sellers Perception About Oral Nicotine Pouches in Karachi, Pakistan

Background: The availability of novel nicotine products like oral nicotine pouches (ONP) has been rising in South Asian countries, including Pakistan. We aimed to assess ONP marketing strategies at point-of-sale (POS) and understand the perceptions among consumers and sellers regarding its use in Karachi, Pakistan. Methods: We conducted a mixed-methods study in low, middle, and high socioeconomic neighborhoods of District East Karachi. For the quantitative component, we used a cross-sectional design, collecting data through observations and surveys. The observation checklist included items about advertising, product placement, display, and promotional aids. The survey questionnaire included questions on marketing tactics, product placement, and advertising strategies for ONP. For the qualitative component, we conducted in-depth interviews with ONP consumers and sellers to explore their perceptions and understand marketing strategies. Frequencies and percentages were used to report quantitative data, while thematic analysis was conducted for qualitative findings. Results: We observed 90 POS of ONP and found that 20% (n = 18) were located within 200 meters of schools. ONP advertisements were found in 67% (n = 60) of the surveyed shops, 59% (n = 53) displayed ONP next to candy, and 70% (n = 63) displayed at child's eye level. A higher proportion of consumers (n = 66, 73%) use ONP as a cessation aid for tobacco. Most sellers (n = 48, 53%) were approached by the companies to sell ONP, and 40% received a commission while achieving the targets on ONP sell. About one-fourth of sellers (n = 21, 23%) reported selling ONP to students less than 18 years. Our qualitative findings revealed marketing strategies, peer influence, ease of use in tobacco-restricted areas, and the perception of reduced harm compared to cigarettes as key drivers of ONP consumption. Conclusion: Our study highlights a critical public health concern and offers valuable insights that could inform the development of policies to regulate tobacco sales.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Socioeconomics of e-cigarette use in Colombia: 2019 National Substance Use Survey

Background

E-cigarettes have been extensively marketed and popularized worldwide despite their harmful effects. To effectively plan and implement preventive measures, comprehensive analyses are needed to understand the influence of individual and contextual factors on their use.

Objective

This study aimed to analyze the influence of poverty and demographic and socioeconomic patterns on e-cigarette use in Colombia.

Methods

This study is based on a secondary analysis of the 2019 Colombian Survey on Psychoactive Substance Use, which included 49,756 individuals aged between 12 and 68. State-level multidimensional poverty and individual health-related, socioeconomic, and demographic characteristics were analyzed. Two-level regression models adjusted for the individual and contextual effects.

Results

The prevalence of vaping was 4.4% (95% CI: 4.2%-4.6%), with substantial variation across departments, ranging from 0.0% to 9.6%. In the multilevel models, younger age, male sex, technical or higher education, middle-income stratum, not contributing economically to the household, affiliation with the subsidized health scheme, history of tobacco smoking, alcohol consumption, and self-reported use of other drugs were all significantly associated with vaping. The estimated median odds ratio for multidimensional poverty was 1.23 (95% CI: 1.14-1.33; p= 0.012).

Conclusions

E-cigarette use in Colombia is a health risk and an indicator of social vulnerability that is influenced by structural determinants. Urgent action from health authorities, the education system, regulatory bodies, and civil society is needed to prevent the normalization of vaping among youth. If left unaddressed, vaping could worsen health inequalities and lead to chronic addiction-related disorders in underserved communities.

Racial, ethnic, and neighborhood socioeconomic disparities in local cannabis retail policy in California

BACKGROUND

Policies governing legal cannabis commerce can vary widely within a U.S. state when local control exists. Disproportionate distribution of policies allowing retail sale, protecting public health, or promoting equity in licensing may contribute to differences in health and economic outcomes between sociodemographic subgroups. This cross-sectional study jointly examined racial, ethnic, and neighborhood socioeconomic characteristics of Californians subject to specific local cannabis policies to identify such disparities.

METHODS

Local laws in effect January 1, 2020, governing retail cannabis sales (bans, expanding buffers from youth-serving sites, restricting advertising, promoting equity in licensing, and capping outlets) were determined for California's 539 jurisdictions. The number of Asian, Black, Latinx, and white residents in socioeconomic advantaged versus disadvantaged neighborhoods (Census block groups) was determined using 2015-2019 American Community Survey data. We estimated proportions of the sociodemographic subpopulations covered by specific policies based on the block group's jurisdiction. To ascertain disparities in coverage proportions were compared across subgroups using Z-tests with the Bonferroni correction.

RESULTS

Residents of socioeconomically advantaged neighborhoods were more likely to live in jurisdictions allowing retail cannabis commerce than those in disadvantaged neighborhoods (61.7 % versus 54.8 %). Black residents in advantaged neighborhoods were most likely to live where retailing was allowed (69 %), and white residents in disadvantaged neighborhoods least likely (49 %). Latinx and Black populations from disadvantaged neighborhoods were most likely to live in jurisdictions with stronger advertising restrictions (66 %). Equity in licensing policy was more prevalent for Black residents living in advantaged neighborhoods (57 %) than disadvantaged neighborhoods (49 %).

CONCLUSIONS

Local cannabis policies potentially protecting public health and social equity are unequally distributed across race, ethnicity, and socioeconomic characteristics in California. Research examining whether differential policy exposure reduces, creates, or perpetuates cannabis-related health and socioeconomic disparities is needed.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS/FINDINGS

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

CONCLUSIONS

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

Should tobacco sales be restricted to state-run alcohol outlets? Perspectives from 10 US alcohol control states

BACKGROUND AND AIMS

The ubiquity of tobacco retailers helps to sustain the tobacco epidemic. A tobacco retail reduction approach that has not been tried is transitioning tobacco sales to state-controlled alcohol stores (TTS), which are limited in number and operate under some restrictions, e.g. regarding opening hours or marketing materials. This study summarizes policy experts' and advocates' views of TTS, including (1) advantages and disadvantages; (2) feasibility; and (3) potential implementation obstacles.

DESIGN

This study was a qualitative content analysis of semi-structured interviews.

SETTING

Ten US states with alcoholic beverage control systems were included.

PARTICIPANTS

The participants comprised a total of 103 tobacco control advocates and professionals, public health officials, alcohol policy experts and alcohol control system representatives, including two tribal community representatives.

MEASUREMENTS

Interviewees' perspectives on their state's alcoholic beverage control agency (ABC, the agency that oversees or operates a state alcohol monopoly) and on TTS were assessed.

FINDINGS

Interviewees thought TTS offered potential advantages, including reduced access to tobacco products, less exposure to tobacco advertising and a greater likelihood of successful smoking cessation. Some saw potential long-term health benefits for communities of color, due to the smaller number of state alcohol stores in those communities. Interviewees also raised concerns regarding TTS, including ABCs' limited focus on public health and emphasis on revenue generation, which could conflict with tobacco use reduction efforts. Some interviewees thought TTS could enhance the power of the tobacco and alcohol industries, increase calls for alcohol system privatization or create difficulties for those in recovery.

CONCLUSIONS

In the United States, transitioning tobacco sales to state-controlled alcohol stores (TTS) could have a positive public health impact by reducing tobacco availability, marketing exposure and, ultimately, tobacco use. However, tensions exist between alcohol control system goals of providing revenue to the state and protecting public health. Should a state decide to pursue TTS, several guardrails should be established, including building into the legislation an explicit goal of reducing tobacco consumption.

Perceptions of African American Youth and Adults Regarding Tobacco Use-Related Factors in Their Community: A Mixed-Methods Approach in Richmond, Virginia

INTRODUCTION

The US Food and Drug Administration is poised to restrict the availability of menthol cigarettes and flavored cigars, products disproportionately used by Black/African American (B/AA) individuals. We examined B/AA youth and adult perceptions regarding factors contributing to tobacco use, as well as prevention/cessation resources.

METHODS

In 2 mixed-methods studies in Richmond, Virginia, we conducted cross-sectional surveys among youth (n = 201) and adult (n = 212) individuals who were primarily B/AA and reported past 30-day cigar smoking or nontobacco use, followed by focus groups with a subset (youth: n = 30; adults: n = 24). Focus groups were analyzed using a thematic analysis framework, and descriptive survey data provided context to themes.

RESULTS

Among focus group participants, 20% of youth and 75% of adults reported current cigar smoking. Six themes emerged across the groups: advertising/brands, sensory experiences, costs, social factors, youth-related factors, and dependence/cessation. Youth and adults perceived cigars as popular; cigar use was attributed to targeted advertising, flavors, affordability, and accessibility. While adults expressed concern regarding youth tobacco use, youth did not perceive tobacco prevention programs as helpful. Adults and youth reported limited access to community tobacco prevention/cessation programs.

DISCUSSION

Expanded tobacco prevention and cessation resources for B/AA people who smoke could leverage federal regulatory actions to ban tobacco products targeted toward this group and decrease disparities in tobacco-related morbidity and mortality.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spatial Clustering of Tobacco Retailers Near US Public Schools

INTRODUCTION

Previous studies have found that tobacco retailers cluster near schools. However, all retail outlets may be located near each other and near schools due to existing infrastructure and zoning policies. We assessed whether tobacco retailers cluster near schools in the United States more than expected when accounting for existing retail locations.

AIMS AND METHODS

We identified 322 056 probable tobacco retailers, 95 110 public schools, and more than 3.8 million businesses comparable to tobacco retailers in land use and business type. We created 500 simulated tobacco retailer datasets by randomly selecting from the larger list of businesses. For each simulated dataset, we calculated the distance from schools to the nearest tobacco retailer (proximity) and the count of tobacco retailers within 800 m of schools (density). Observed proximity and density values were compared to 95% coverage intervals from the 500 simulations. We stratified analyses by urbanicity, percentage of students in the free and reduced-priced lunch program (FRLP), and percentage of Hispanic/Latino, non-Hispanic Black, and non-Hispanic white students.

RESULTS

Tobacco retailers were closer to schools in rural areas, cities, and towns and more dense around schools in rural areas, cities, and suburbs compared to random locations in potential retail space. Schools with more students receiving FRLP had higher density than expected while schools with fewer students receiving FRLP had lower density than expected. Within rural areas, clustering did not vary across sociodemographic groups. Within non-rural areas, there were inequities in clustering by racial, ethnic, and socioeconomic school composition.

CONCLUSIONS

Tobacco retailers cluster near schools after accounting for existing business patterns. There are inequities in clustering by sociodemographic school composition.

IMPLICATIONS

This study provides compelling evidence that tobacco retailers cluster near US public schools and that there are racial, ethnic, and socioeconomic inequities in clustering, even when accounting for overall retail location patterns. Given that public schools tend to reflect neighborhood demographics, policies to limit tobacco retailers near schools may reduce both school-based and neighborhood-based inequities.

Ex ante evaluation of the impact of tobacco control policy measures aimed at the point of sale in the Netherlands

INTRODUCTION

The Netherlands aims to implement stricter tobacco control policies targeting the retail environment. This paper is an ex ante policy evaluation of the potential impact of the current tobacco display and advertising ban as well as future tobacco sales bans on tobacco outlet visibility and availability.

METHODS

Between September 2019 and June 2020, all potential tobacco retailers in four Dutch cities (Amsterdam, Eindhoven, Haarlem and Zwolle) were visited and mapped using Global Positioning System. For each retailer selling tobacco, we completed a checklist on the visibility of tobacco products and advertising. Expected reductions in tobacco outlet visibility and availability were calculated per policy measure in absolute numbers (percentage or percentage point decrease) as well as density and proximity.

RESULTS

Out of 870 tobacco outlets, 690 were identified with visible tobacco products/advertising. The display ban in supermarkets and small outlets (respectively) is expected to decrease the number (-15; -42 percentage points), outlet density per 10 000 capita (-0.9; -2.6) and proximity in metres (+27 m; +400 m) of outlets with visible products/advertising. The upcoming bans on vending machines and sales in supermarkets are expected to decrease the number (-12%; -31%), density (-0.7; -1.9) and proximity (+12 m; +68 m) of tobacco outlets. Further changes in the number, density and proximity (respectively) of tobacco outlets may be achieved with future sales bans in petrol stations (-7%; -0.4; +60 m) and particularly with a ban on sales in small outlets (-43%; -2.7; +970 m).

CONCLUSION

A display ban and a sales ban in small outlets will contribute most to reducing tobacco outlet visibility and availability, assuming that no market shift towards other tobacco outlets will take place.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) and co-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remain unclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis. We combined 2018 statewide California (US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders. Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis. Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

Is the neighbourhood context important for a tobacco retailer proximity policy?

A spatial modelling approach was used to explore how a proximity limit (150 m, 300 m, and 450 m) between tobacco retailers may impact different neighbourhoods in New Zealand. Neighbourhoods were categorised into three density groups (0, 1-2, 3+ retailers). As the proximity limit increases, there is a progressive redistribution of neighbourhoods in the three density groups with, the 3+ density group incorporating fewer neighbourhoods and the 0 and 1-2 density groups conversely each consisting of more. The differing measures available at the neighbourhood level enabled our study to discern potential inequities. More directed policies targeting these inequities are needed.

Birth Cohort‒Specific Smoking Patterns by Family Income in the U.S

INTRODUCTION

In the U.S., low-income individuals generally smoke more than high-income individuals. However, detailed information about how smoking patterns differ by income, especially differences by birth cohort, is lacking.

METHODS

Using the National Health Interview Survey 1983-2018 data, individual family income was calculated as a ratio of the federal poverty level. Missing income data from 1983 to 1996 were imputed using sequential regression multivariate imputation. Age‒period‒cohort models with constrained natural splines were used to estimate annual probabilities of smoking initiation and cessation and smoking prevalence and intensity by gender and birth cohort (1900-2000) for 5 income groups: <100%, 100%-199%, 200%-299%, 300%-399%, and ≥400% of the federal poverty level. Analysis was conducted in 2020-2021.

RESULTS

Across all income groups, smoking prevalence and initiation probabilities are decreasing by birth cohort, whereas cessation probabilities are increasing. However, relative differences between low- and high-income groups are increasing markedly, such that there were greater declines in prevalence among those in high-income groups in more recent cohorts. Smoking initiation probabilities are lowest in the ≥400% federal poverty level group for males across birth cohorts, whereas for females, this income group has the highest initiation probabilities in older cohorts but the lowest in recent cohorts. People living below the federal poverty level have the lowest cessation probabilities across cohorts.

CONCLUSIONS

Smoking prevalence has been decreasing in all income groups; however, disparities in smoking by family income are widening in recent birth cohorts. Future studies evaluating smoking disparities should account for cohort differences. Intervention strategies should focus on reducing initiation and improving quit success among low-income groups.

Prevalence and Associated Factors of E-Cigarette Use among Adolescents in Southeast Asia: A Systematic Review

The use of e-cigarettes in adolescents remains a major public health concern. Like other tobacco products, e-cigarettes pose health risks to adolescents. Understanding the magnitude of this problem and identification of its associated factors will serve as a guide for development of preventive interventions. This systematic review aims to identify and discuss current epidemiological data on the prevalence and associated factors of e-cigarette use among adolescents in Southeast Asia. The reporting of this systematic review is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. We carried out a literature search through three databases (Scopus, PubMed, Web of Science) and targeted original English-language articles published between 2012 and 2021. A total of 10 studies were included in this review. The prevalence of current e-cigarette uses ranges from 3.3% to 11.8%. Several associated factors of e-cigarette use were identified, including sociodemographic factors, traumatic childhood experience, peer and parental influence, knowledge and perception, substance use, and accessibility of e-cigarettes. These factors should be addressed though multifaceted interventions which simultaneously target multiple factors. Laws, policies, programs, and interventions must be strengthened and tailored to the needs of adolescents at risk of using e-cigarettes.

Restricting Tobacco Retail Outlets Around Middle and High Schools as a Way to Reduce Tobacco Marketing Disparities: A Simulation Study

INTRODUCTION

Communities with more people of color and economically disadvantaged residents are disproportionately exposed to tobacco marketing from tobacco companies. This study examined if banning tobacco retail outlets (TROs) within 1000 ft of schools would reduce these marketing disparities through a greater reduction in the amount of tobacco advertising around schools in these communities.

METHODS

Data from objectively audited advertisement data from 106 convenience stores and gas stations around 42 middle and high schools located in the four major metropolitan areas of Texas were linked with schools' enrollment data. ArcGIS (Aeronautical Reconnaissance Coverage Geographic Information System) was used to simulate a 1000-ft ban of tobacco sales around the schools. Independent sample T-tests and Mann-Whitney U tests were used to test mean differences where appropriate.

RESULTS

Schools with a higher enrollment of Hispanic/Latino (mean = 171.6, SD = 96.9) and economically disadvantaged students (mean = 168.9, SD = 102.3) were surrounded with significantly greater advertising at TROs than schools with lower enrollment of these groups (mean = 82.8, SD = 49.1 and mean = 89.2, SD = 50.6, respectively). A simulated 1000 ft ban of TROs around schools led to greater advertising reduction around schools with a higher enrollment of Hispanic/Latino students (13.3%-29.4% reductions) in comparison to schools with lower Hispanic/Latino student enrollment. However, the more economically disadvantaged schools had a smaller reduction in the number of advertisements (5.9%-21.9% reductions) in comparison to schools with less economically disadvantaged students.

CONCLUSION

The implementation of a ban of tobacco sales at TROs within 1000 ft of schools is one policy approach to reduce youth exposure to tobacco marketing, particularly among students of color.

STUDY IMPLICATION

Tobacco retail outlets (TROs) around schools with a higher enrollment of Hispanic/Latino and economically disadvantaged students had significantly more tobacco advertisements in comparison to schools with lower enrollment of these student groups. A simulated ban of TROs within 1000 ft of schools led to greater advertising reduction around schools with a higher enrollment of Hispanic/Latino students. For schools with more economically disadvantaged students, the ban led to a smaller reduction in advertisements in comparison to schools with less economically disadvantaged students. This proposed place-based strategy could be a successful means to reduce tobacco advertising and marketing disparity among communities of color.

Longitudinal analysis of tobacco and vape retail density in California

INTRODUCTION

Tobacco retailer density may be associated with greater youth initiation and reduced success during quit attempts; however, the extent to which tobacco retailer density has changed overtime across multiple categories of retailers has not been reported.

METHODS

Data on licensed tobacco retailers within California from 2015–2019 were obtained from the California Department of Tax and Fee Administration. Store type was categorized by automated cross-referencing with Yelp. Geolocations were aggregated at county level for analyzing longitudinal trends in changes in tobacco retail density including demographic characteristics.

RESULTS

The number of active CA tobacco retailer licenses increased from 19825 in 2015 to 25635 in 2019. The highest percent increase in tobacco retailer licenses (9.1%) was observed in 2017. The number of specialized tobacco stores was highest in Los Angeles, San Diego, and Riverside counties. We observed a significant increase in the number of active licenses for non-specialized and specialized tobacco stores, both overall and after controlling for the size of populations within each region. Time was a statistically significant predictor for the number of active licenses for only non-specialized stores, after adjusting for covariates. Regional volume of retailers was positively associated with higher proportion of women, lower median household income, and higher proportion of Hispanic residents.

CONCLUSIONS

Monitoring the changes in tobacco retail density and associated sociodemographic factors over time can help to identify communities at higher risk for tobacco and nicotine product exposure and access, and its associated health disparities.

Evaluation of Restrictions on Tobacco Sales to Youth Younger Than 21 Years in Cleveland, Ohio, Area

Importance

Tobacco 21 (T21) policies raise the minimum legal age to purchase tobacco from 18 to 21 years to curb youth access to tobacco products. While some studies have found that T21 is associated with reducing prevalence of youth tobacco use, little is known about the impact it may have on youth of different racial and ethnic identities.

Objective

To evaluate the association of T21 policy with the prevalence of high school youth tobacco use across sex, race, and ethnicity.

Design, Setting, and Participants

This survey study used representative survey data collected from the local biennial Youth Risk Behavior Survey from 2013 to 2017 comparing Cleveland, Ohio (which has a T21 policy), to proximal jurisdictions in the first-ring suburbs in Cuyahoga County (which do not have T21 policies). Within-Cleveland demographic information was also collected for 2013 to 2019. Overall high school youth tobacco use rates were compared between Cleveland and the first-ring suburbs and then examined within Cleveland among Hispanic, non-Hispanic Black, and non-Hispanic White high school students. Percentage data were adjusted to more closely align with local population demographics. Data were analyzed from January to June 2022.

Exposures

T21 was implemented in Cleveland in 2016 and not adopted in proximal jurisdictions or at the state and federal level until at least 1 year later.

Main Outcomes and Measures

The main outcomes were prevalence of past 30-day cigarette, cigar product, or e-cigarette use, measured using geographically representative high school youth survey data from 2013 to 2015 (prelegislation) and 2017 to 2019 (postlegislation) and compared using a difference-in-differences analysis.

Results

The unweighted sample included 12 616 high school students (27.0% [95% CI, 26.9%-28.0%] in 10th grade; 50.9% [95% CI, 50.3%-51.6%] females) participating in 1 or more Youth Risk Behavior Surveys from 2013 to 2019, including 7064 students in Cleveland and 5552 students in the first-ring suburbs. Compared with the first-ring suburbs, Cleveland had a greater proportion of younger students (1623 [28.5%] ninth grade students vs 2179 [34.0%] ninth grade students) and Hispanic students (436 students [1.1%] vs 1433 students [12.6%]) and non-Hispanic Black students (2000 students [53.1%] vs 3971 students [75.1%]). Cigars were the most commonly used tobacco product in Cleveland, with use reported by 6201 students (19.8%) in 2013, 5877 students (21.3%) in 2015, and 5784 students (16.8%) in 2019. Compared with the first-ring suburbs, there was a greater decline in prevalence of use of cigars in Cleveland (β = 0.18 [SE, 0.05]; P < .001). The disparity across race, ethnicity, and sex decreased for all current tobacco product use. For example, the maximum difference between demographic subpopulations in current cigarette use was 11.6 (95% CI, 9.5-13.7) percentage points in 2013 between White females (16.1% [95% CI, 11.3%-20.8%]) and Black males (4.5% [95% CI, 3.5%-5.4%]). This maximum difference in current cigarette use decreased significantly to 5.1 (95% CI, 3.5-6.7) percentage points in 2019 between White females (6.9% [95% CI, 3.4%-10.3%]) and Black females (1.8% [95% CI, 0.7%-2.8%]).

Conclusions and Relevance

This survey study found that there was a decline in youth-reported tobacco use across every tobacco product category from 2013 to 2019. This decline changed the trajectory of use among several demographic groups and brought the youth populations with the highest tobacco product use to similar rates of others.

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

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

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

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

A Simulation of the potential impact of restricting tobacco retail outlets around middle and high schools on tobacco advertisements

OBJECTIVE

To examine (1) if tobacco retail outlets (TROs) closer to middle and high schools have more tobacco advertisements than TROs farther away and (2) the potential impact of two place-based tobacco control strategies on tobacco advertisements: a simulated ban of TROs (1) within 1000ft of schools and (2) within 500 ft of other TROs.

METHODS

TROs within half-mile of 53 middle and high schools in the four largest Metropolitan areas in Texas were audited for all tobacco marketing. ArcGIS was used for mapping and grouping TROs by distance from the schools and simulating the ban. Mean differences in the number of tobacco advertisements were examined with t-tests. Percentage reductions in tobacco advertisements were calculated after simulation of both bans, reported by school type and by location, product and flavour.

RESULTS

TROs within 1000 ft of schools had significantly more tobacco advertisements as compared with TROs located within 1000-2000 ft (p=0.03) for all schools combined and middle schools. Simulation of the 1000 ft ban of TROs led to a slightly greater reduction in advertisements (19.4%) as compared with the 500 ft ban of TROs from other TROs (17.9%). The reduction in all advertisement types was greater around middle schools and greatest for e-cigarettes (23.6%).

CONCLUSION

Students can be exposed to a great deal of tobacco advertising in TROs around their schools. The implementation of a 1000 ft ban of TROs, or at minimum a ban on tobacco advertising outside and within these outlets, is one way to prevent or reduce the use of tobacco among adolescents.

Evaluating how licensing-law strategies will impact disparities in tobacco retailer density: a simulation in Ohio

OBJECTIVES

To assess tobacco licensing-law strategies (eg, restricting the sale of tobacco near schools, banning the sale of tobacco in pharmacies) in terms of the equity of their impact and ability to correct existing disparities in tobacco retailer density.

METHODS

We geocoded all 11 392 tobacco retailers in Ohio, categorised neighbourhoods based on their demographic characteristics and calculated current disparities in tobacco retailer density. We next simulated the four main types of licensing-law strategies (capping-based, declustering-based, school-based and pharmacy-based), as well as strategy combinations. Finally, using statistical methods that account for residual spatial dependence, we evaluated how each strategy would impact density disparities.

FINDINGS

The most impactful licensing-law strategy depended on the type of community. School-based reductions were equitable for low-income, African-American and urban neighbourhoods (eg, eliminating retailers from 1000 feet of all schools produced a 9.2% reduction in the log retailer rate for neighbourhoods with a low prevalence of African-Americans and a 17.7% reduction for neighbourhoods with a high prevalence of African-Americans). Conversely, capping-based reductions were equitable for rural neighbourhoods. Pharmacy-based reductions demonstrated inequitable impacts.

CONCLUSION

Licensing-law strategies could be a central tobacco control effort that benefits both the overall population and vulnerable communities. Policymakers will need to consider their community's characteristics when selecting licensing-law strategies to correct (rather than inadvertently widen) density disparities. But when matched with the appropriate strategy, high-risk communities could remove over 20% of their tobacco retailers.

Simulating the density reduction and equity impact of potential tobacco retail control policies

BACKGROUND

Reducing the provision of tobacco is important for decreasing inequalities in smoking and smoking-related harm. Various policies have been proposed to achieve this, but their impacts-particularly on equity-are often unknown. Here, using national-level data, we simulate the impacts of potential policies designed to reduce tobacco outlet density (TOD).

METHODS

Tobacco retailer locations (n=9030) were geocoded from Scotland's national register, forming a baseline. Twelve policies were developed in three types: (1) regulating type of retailer selling tobacco, (2) regulating location of tobacco sales, and (3) area-based TOD caps. Density reduction was measured as mean percentage reduction in TOD across data zones and number of retailers nationally. Equity impact was measured using regression-based Relative Index of Inequality (RII) across income deprivation quintiles.

RESULTS

Policies restricting tobacco sales to a single outlet type ('Supermarket'; 'Liquor store'; 'Pharmacy') caused >80% TOD reduction and >90% reduction in the number of tobacco outlets nationally. However, RIIs indicated that two of these policies ('Liquor store', 'Pharmacy') increased socioeconomic inequalities in TOD. Equity-promoting policies included 'Minimum spacing' and exclusion zones around 'Child spaces'. The only policy to remove statistically significant TOD inequalities was the one deliberately targeted to do so ('Reduce clusters').

CONCLUSIONS

Using spatial simulations, we show that all selected policies reduced provision of tobacco retailing to varying degrees. However, the most 'successful' at doing so also increased inequalities. Consequently, policy-makers should consider how the methods by which tobacco retail density is reduced, and success measured, align with policy aims.

Regulating tobacco retail outlets in Bangladesh: retailers' views and implications for tobacco control advocacy

BACKGROUND

Tobacco products are ubiquitously available in Bangladesh. There are currently no restrictions on who can sell tobacco products and where they are allowed to be sold. The objective of this study was to explore tobacco retailers' views regarding tobacco retail licensing (TRL) in Bangladesh.

METHODS

A two-stage cluster sampling procedure was used to collect data from a representative sample of 472 tobacco retailers (97% response rate) in Dhaka city in 2018 through face-to-face interviews using a semistructured questionnaire. Data were analysed using descriptive statistics, X2 tests and logistic regression.

RESULTS

The majority (79%) of the retailers reported that they would support TRL, and 68% were interested in applying for TRL if adopted. Support for TRL was higher among those with a university degree (OR 2.1, 95% CI 0.8 to 5.3) and among those with knowledge about existing tobacco control regulations (OR 1.8, 95% CI 1.1 to 2.8). Furthermore, support for TRL was significantly higher among those who believed that it would restrict tobacco retailing locations (AOR 1.9, 95% CI 1.3 to 3.0) and prevent tobacco sales to minors (AOR 3.5, 95% CI 2.2 to 5.5).

CONCLUSION

This sample of tobacco retailers in Bangladesh supported TRL. TRL advocacy efforts could draw on this support.

Black, white, or green? The effects of racial composition and socioeconomic status on neighborhood-level tobacco outlet density

Objective: To compare predominantly-Black and predominantly-White Maryland areas with similar socioeconomic status to examine the role of both race and socioeconomic status on tobacco outlet availability and tobacco outlet access.Design: Maryland tobacco outlet addresses were geocoded with 2011-2015 American Community Survey sociodemographic data. Two-sample t-tests were conducted comparing the mean values of sociodemographic variables and tobacco outlet density per Census Tract, and spatial lag based regression models were conducted to analyze the direct association between covariables and tobacco outlet density while accounting for spatial dependence between and within jurisdictions.Results: Predominantly-White jurisdictions had lower tobacco outlet availability and access than predominantly-Black jurisdictions, despite similar socioeconomic status. Spatial lag model results showed that median household income and vacant houses had consistent associations with tobacco outlet density across most of the jurisdictions analyzed, and place-based spatial lag models showed direct associations between predominantly-Black jurisdictions and tobacco outlet availability and access.Conclusion: Predominantly-White areas have lower levels of tobacco outlet density than predominantly-Black areas, despite both areas having similar socioeconomic statuses.

Is Youth Smoking Related to the Density and Proximity of Outdoor Tobacco Advertising Near Schools? Evidence from Indonesia

BACKGROUND

Smoking was among the top contributors to deaths and disability as the prevalence among male adults remains high, and that among male youth increases in Indonesia. While local studies have shown high visibility of outdoor tobacco advertising around schools, the country still has no outdoor tobacco advertising ban.

OBJECTIVE

To examine the association between youth smoking behavior and measures of outdoor tobacco advertising density and proximity in Indonesia.

METHODS

We combined two primary data sources, including outdoor tobacco advertising and smoking behavior among male youth in Semarang city. We randomly selected and interviewed 400 male students at 20 high schools in the city. In addition, we interviewed 492 male adults who lived near the schools for comparison.

RESULTS

We found significant associations between smoking use among youth (but not among adults) and measures of outdoor tobacco advertising density and proximity in Semarang city. Youth at schools with medium and high density of outdoor tobacco advertising were up to 2.16 times more likely to smoke, compared to those with low density. Similarly, youth at senior high schools with proximity to outdoor tobacco advertising were 2.8 times more likely to smoke. Also, young people at poorer-neighborhood schools with a higher density of and proximity to outdoor tobacco advertising were up to 5.16 times more likely to smoke.

CONCLUSIONS

There were significant associations between smoking use among male youth (but not among male adults) and measures of outdoor tobacco advertising density and proximity in Indonesia. This highlights the need to introduce an outdoor tobacco advertising ban effectively, at least near schools.

Retailer density reduction approaches to tobacco control: A review

Tobacco retailer density is consistently associated with poor tobacco-use outcomes. The aim of this review was to synthesize the international evidence on density reduction policies. Searches in multiple databases resulted in 31 studies covering various policy approaches evaluated for their impact on retailer density. Findings indicate that bans on tobacco sales in pharmacies reduced retailer density, but perhaps not equitably. Prohibiting sale of tobacco near schools produced greater density reductions in higher-risk neighborhoods. Policies in combination were most effective. Future studies should measure the impact of these policies on tobacco use. Density-reduction policies offer a promising approach to tobacco control.

Are Waterpipe Café, Vape Shop, and Traditional Tobacco Retailer Locations Associated with Community Composition and Young Adult Tobacco Use in North Carolina and Virginia?

PURPOSE

We examined whether waterpipe café, vape shop, and traditional tobacco retailer (e.g. stores selling cigarettes, cigars, smokeless tobacco) locations were associated with census tract composition and tobacco use among young adults in North Carolina and Virginia. Methods: We identified waterpipe cafés, vape shops, and traditional tobacco retailers in North Carolina and Virginia and conducted multivariable analyses between community characteristics (gender, race, ethnicity, education, college enrollment, and poverty) and density per 1000 population. Using fall 2017 data from 1099 young adults residing in North Carolina and Virginia, we conducted logistic regression analyses to determine whether tobacco retailer density and proximity were associated with tobacco use. Results: Waterpipe café, vape shop, and traditional retailer density were higher in communities with more people who were Hispanic, college-educated, and college-enrolled (each p < .05). Waterpipe café and traditional retailer density were higher in communities with more people living below the poverty level (each p < .05). Waterpipe café density was higher in communities with more people who were male (p < .05), while traditional retailer density was lower (p < .05). Waterpipe café and vape shop proximity were associated with increased likelihood of waterpipe tobacco use in the past 6 months (each p < .05; unadjusted). Traditional retailer proximity and waterpipe café, vape shop, and traditional retailer density were not associated with tobacco use. Conclusions: Waterpipe cafés and vape shops are located in both impoverished and college-educated communities in North Carolina and Virginia, similar to where traditional tobacco retailers are located. Further research is needed to examine associations with tobacco use.

Racial/Ethnic Differences in Associations of Non-cigarette Tobacco Product Use With Subsequent Initiation of Cigarettes in US Youths

Introduction

Understanding which non-cigarette tobacco products precede smoking in youth across different racial/ethnic groups can inform policies that consider tobacco-related health disparities.

Methods

We used nationally representative, longitudinal data from the Population Assessment of Tobacco and Health Study waves 1–4. The sample was a dynamic cohort of cigarette-naïve youth aged 12–17 years. Mixed-effects models were used to assess non-cigarette product (e-cigarette, cigar product, or other product) use with cigarette use over 1-year intervals.

Results

Of the 28 788 observations pooled across waves 1–4, respondents were 48.7% non-Hispanic white, 13.9% non-Hispanic black, and 23.1% Hispanic. Odds of cigarette initiation over 1-year follow-up were higher among youth with prior use of e-cigarettes (odds ratio [OR], 2.76; 95% confidence interval [CI], 2.21–3.45), cigars (OR, 2.00; 95% CI, 1.42–2.80), or other products (OR, 1.66; 95% CI, 1.28–2.14) compared to never users. At the population level, 20.6% of cigarette initiation was attributable to e-cigarette use among white youth and 21.6% among Hispanic youth, while only 3.5% of cigarette initiation was attributable to e-cigarette use among black youth. In contrast, 9.1% of cigarette initiation for black youth was attributable to cigar use compared to only 3.9% for both white and Hispanic youth.

Conclusions

Prior use of e-cigarettes, cigars, and other non-cigarette products were all associated with subsequent cigarette initiation. However, white and Hispanic youth were more likely to initiate cigarettes through e-cigarette use (vs. cigar or other product use), while black youth were more likely to initiate cigarettes through cigar use (vs. e-cigarette or other product use).

Implications

Our findings suggest that previous studies on effects of non-cigarette tobacco products may overlook the critical role of cigar products as a pathway into cigarette smoking among US youth, particularly black youth. While our data support the importance of e-cigarette use as a pathway into smoking, regulatory actions aimed at addressing youth e-cigarette use alone may contribute to disparities in black versus white tobacco use and further exacerbate inequities in tobacco-related disease. Thus, contemporary policy development and discourse about the effects of non-cigarette tobacco products on cigarette initiation should consider cigar and other non-cigarette products as well as e-cigarettes.

Tobacco Retailers Near Schools and the Violations of Tobacco Retailing Laws in Thailand

A growing body of evidence indicates that the location of tobacco retailers may influence tobacco access among youths.

Disentangling individual and neighborhood differences in the intention to quit smoking in Asian American male smokers

Numerous studies have assessed individual-level factors associated with intention to quit smoking. However, fewer studies have assessed how neighborhood and built environment also contribute towards individual-level behavior. We used baseline data of 340 Chinese and Vietnamese male daily smokers from August 2015 to November 2017 living in the San Francisco Bay Area, who enrolled in a lifestyle intervention trial. The outcome variable was intention to quit in 30 days. To understand the role of contextual factors participants' residential addresses were geocoded, and neighborhood median income, ethnic composition, and tobacco retail density were computed. Individual level analysis suggested that Vietnamese American men had greater intention to quit smoking (OR = 2.90 CI = 1.59, 5.26) in comparison to Chinese Americans. However, after adding neighborhood level factors to the model, no ethnic group difference was observed. Neighborhood household median income (OR = 0.74, CI = 0.64, 0.86) and tobacco retail counts (OR = 0.79, CI = 0.67, 0.94) were negatively associated with intention to quit. Years lived in the U.S. was the only individual level factor associated with intention to quit. By comparing two Asian American groups that live in heterogeneous neighborhoods, we identify key environmental and policy drivers that are associated with quit intention. Future studies aimed at influencing individual-level behavior should take into consideration the neighborhood context and built environment characteristics.

School proximity and census tract correlates of e-cigarette specialty retail outlets (vape shops) in central Texas

E-cigarettes are the most widely used tobacco product among middle and high school students in the United States. This study investigates the proximity of e-cigarette retail outlets (vape shops) to middle and high schools in Austin, Texas, as well as the sociodemographic determinants of outlet presence, at the census tract level. A proximity analysis was conducted using school geo-data derived from the Texas Education Agency and vape shop geo-data derived from a validated online search. Logistic regressions using 5-year estimates of the 2014 American Community Survey were performed to determine the correlates of vape shop presence in census tracts. Overall, 20% of the census tracts in Austin, Texas, had at least one vape shop. The proportion of vape shop-containing census tracts that met the criteria for classification as a “poverty area” (36.5%) was greater than that of vape shop-free census tracts (26.3%). Vape shops were more likely to be present in census tracts classified as poverty areas; however, the odds of vape shop presence declined as the percentage of the non-Hispanic Black population and the percentage of persons aged 10–14 years in census tracts increased. About 40% of the vape shops were located within 0.5 miles of a middle or high school. Sociodemographic disparities exist in the e-cigarette retail environment. In addition to the need to address the disparities identified in this study, our results showing the presence of vape shops within walkable distances of schools calls for tighter regulations and continued surveillance around the marketing practices of e-cigarette retailers.

Removal of point-of-sale tobacco displays in Bogor city, Indonesia: A spatial analysis

INTRODUCTION

Indonesia contributes over 61 million smokers to global tobacco users, and the smoking prevalence is increasing among young people. In October 2017, Bogor city started the ban on tobacco displays at point-of-sale (POS), starting with modern cigarette retailers. This study aims to assess compliance with the ban and the visibility of POS with tobacco displays around educational facilities.

METHODS

We included 266 modern retailers surveyed throughout the city during November and December 2017. Compliance indicators included no tobacco product displays, advertisements, promotions, and sponsorship. We conducted spatial and quantitative analyses in ArcMap 10.6 and Stata 15.1, respectively.

RESULTS

Immediately following the ban, the compliance with all four criteria was high (83%). However, POS in areas with higher population density and poverty rates had significantly lower compliance. We also found that the ban reduced the visibility of tobacco displays around schools and universities.

CONCLUSIONS

Compliance with the ban was high, which helped to reduce the visibility of tobacco displays around educational facilities.

Tobacco Retail Density and Initiation of Alternative Tobacco Product Use Among Teens

PURPOSE

The rise of noncigarette, alternative tobacco product (ATP) use among adolescents may be due in part to an increase in retail availability of ATPs. We examined whether proximity and density of tobacco retailers near students' homes are associated with a higher likelihood of initiating ATP use over time.

METHODS

Using data from 728 adolescents (aged 13-19 years at baseline) residing in 191 different neighborhoods and attending 10 different California high schools, longitudinal multilevel and cross-classified random effect models evaluated individual-level, neighborhood-level, and school-level risk factors for ATP initiation after 1 year. Covariates were obtained from the American Community Survey and the California Department of Education.

RESULTS

The sample was predominantly female (63.5%) and was racially and ethnically diverse. Approximately one third of participants (32.5%) reported ever ATP use at baseline, with 106 (14.5%) initiating ATP use within 1 year. The mean number of tobacco retailers per square mile within a tract was 5.66 (standard deviation = 6.3), and the average distance from each participant's residence to the nearest tobacco retailer was .61 miles (standard deviation = .4). Living in neighborhoods with greater tobacco retailer density at baseline was associated with higher odds of ATP initiation (odds ratio = 1.22, 95% confidence interval = 1.07-2.12), controlling for individual and school factors.

CONCLUSIONS

Tobacco retailers clustered in students' home neighborhood may be an environmental influence on adolescents' ATP use. Policy efforts to reduce adolescent ATP use should aim to reduce the density of tobacco retailers and limit the proximity of tobacco retailers near adolescents' homes and schools.

Neighborhood racial, ethnic, and income disparities in accessibility to multiple tobacco retailers: Mecklenburg County, North Carolina, 2015

•Existing studies assess an individual's proximity to a single tobacco retailer.•Measuring proximity to more than one retailer may better capture accessibility.•Disparities in multi-retailer proximity exist by neighborhood race and income.•Policies to address disparities in tobacco retailer exposure are needed.

Development of a computational modeling laboratory for examining tobacco control policies: Tobacco Town

A key focus of recent policy efforts to curb tobacco product usage has been the role of place-specifically the density of retail and advertising and the resulting spatial pattern of access and exposure for consumers. Policies can alter the environment by reducing density or shifting distribution of tobacco retail and thus limiting access and exposure. Since little empirical evidence exists for the potential impact of these policies across potentially heterogeneous places, we develop and apply an original spatial computational model to simulate place-based retail tobacco control policies. The model is well-grounded in theory and available empirical evidence. We apply the model in four representative settings to demonstrate the utility of this approach as a policy laboratory, to develop general insights on the relationship between retailer density, retail interventions, and tobacco costs incurred by consumers, and to provide a framework to guide future modeling and empirical studies. Our results suggest that the potential impact on costs of reducing tobacco retailer density are highly dependent on context. Projected impacts are also influenced by assumptions made about agent (smoker) purchasing decision-making processes. In the absence of evidence in this area, we tested and compared three alternative decision rules; these interact with environmental properties to produce different results. Agent properties, namely income and cigarettes per day, also shape purchasing patterns before and after policy interventions. We conclude that agent-based modeling in general, and Tobacco Town specifically, hold much potential as a platform for testing and comparing the impact of various retail-based tobacco policies across different communities. Initial modeling efforts uncover important gaps in both data and theory and can provide guidance for new empirical studies in tobacco control.

Retailers' perspectives on selling tobacco in a low-income San Francisco neighbourhood after California's $2 tobacco tax increase

BACKGROUND

California's tobacco tax increased by $2.00 per pack in 2017. Although such increases are among the most effective tobacco control strategies, little is known about their impact from the perspective of corner store owners in low-income neighbourhoods with high concentrations of tobacco outlets.

METHODS

We interviewed 38 corner store owners and managers in San Francisco's Tenderloin, the district with the city's highest tobacco outlet density, 60-90 days following implementation of the tax increase. Questions focused on perceptions of the impact of the higher tobacco tax on their revenues, customers and tobacco company promotions. We used qualitative content analysis to identify, compare and reconcile key themes.

RESULTS

Most retailers reported a decline in cigarette sales, with customers buying fewer cigarettes, switching to cheaper brands or other products like marijuana, or trying to quit smoking. Retailers described challenges associated with running a small business and selling tobacco and concerns about selling a product that is 'bad' for customers' health. Contrary to expectation, tobacco companies appeared to be offering few product promotions in this neighbourhood.

CONCLUSIONS

Small, independent retailers' concerns, about selling tobacco and about the health and well-being of customers, suggest that such retailers may be important allies in tobacco control efforts,particularly those focused on the point-of-sale.

Examining the role of a retail density ordinance in reducing concentration of tobacco retailers

Neighborhood characteristics and the built environment are important determinants in shaping health inequalities. We evaluate the role of a retail density ordinance in reducing concentration of tobacco stores based on neighborhood characteristics and land use pattern in San Francisco. The study evaluated the spatial distribution of tobacco retailers before and after the ordinance to identify geographic pockets where the most significant reduction had occurred. A generalized additive model was applied to assess the association between the location of the closure of tobacco retailer and socio-demographic characteristics and land use pattern. We did not find a meaningful change in the overall concentration of retailers based on neighborhood income and ethnicity but found a significant association based on patterns of land use. Our findings suggest that future polices must account for the differential distribution of retailers based on land use mix to lower concentration in areas where it is needed the most.

Visibility and hotspots of outdoor tobacco advertisement around educational facilities without an advertising ban: Geospatial analysis in Surabaya City, Indonesia

INTRODUCTION

Despite having over 60 million smokers in 2018, Indonesia still lacks tobacco control measures, including an outdoor tobacco advertising ban. This study aimed to provide evidence on the visibility and hotspots of advertisements around educational facilities in a city without a ban.

METHODS

We collected data on the locations of outdoor tobacco advertisements and schools and universities in Surabaya city. We conducted buffer and hotspots analyses using ArcMap. Using Getis-Ord Gi* statistics, hotspot analysis identifies significant clusters with a high number of advertisements.

RESULTS

We found 307 large and medium-sized outdoor tobacco advertisements and 1287 educational facilities (1199 schools, 88 universities). Almost 80% of those advertisements (237 units) were just 300 m away (10-minute walk) from primary schools and high schools in the city. More than half of all schools (652) and two-thirds of all universities (59) were inside hotspots where there were statistically significant clusters with a high number of advertisements. These hotspots were more densely populated and more-deprived areas.

CONCLUSIONS

There was high visibility of large and medium-sized outdoor tobacco advertisements around educational facilities in the city without the ban.

Comparison of Sampling Strategies for Tobacco Retailer Inspections to Maximize Coverage in Vulnerable Areas and Minimize Cost

Introduction

In the United States, tens of thousands of inspections of tobacco retailers are conducted each year. Various sampling choices can reduce travel costs, emphasize enforcement in areas with greater noncompliance, and allow for comparability between states and over time. We sought to develop a model sampling strategy for state tobacco retailer inspections.

Methods

Using a 2014 list of 10,161 North Carolina tobacco retailers, we compared results from simple random sampling; stratified, clustered at the ZIP code sampling; and, stratified, clustered at the census tract sampling. We conducted a simulation of repeated sampling and compared approaches for their comparative level of precision, coverage, and retailer dispersion.

Results

While maintaining an adequate design effect and statistical precision appropriate for a public health enforcement program, both stratified, clustered ZIP- and tract-based approaches were feasible. Both ZIP and tract strategies yielded improvements over simple random sampling, with relative improvements, respectively, of average distance between retailers (reduced 5.0% and 1.9%), percent Black residents in sampled neighborhoods (increased 17.2% and 32.6%), percent Hispanic residents in sampled neighborhoods (reduced 2.2% and increased 18.3%), percentage of sampled retailers located near schools (increased 61.3% and 37.5%), and poverty rate in sampled neighborhoods (increased 14.0% and 38.2%).

Conclusions

States can make retailer inspections more efficient and targeted with stratified, clustered sampling. Use of statistically appropriate sampling strategies like these should be considered by states, researchers, and the Food and Drug Administration to improve program impact and allow for comparisons over time and across states.

Implications

The authors present a model tobacco retailer sampling strategy for promoting compliance and reducing costs that could be used by US states and the Food and Drug Administration (FDA). The design is feasible to implement in North Carolina. Use of the sampling design would help document the impact of FDA's compliance and enforcement program, save money, and emphasize inspections in areas where they are needed most. FDA should consider requiring probability-based sampling in their inspections contracts with states and private contractors.

Pro-tobacco marketing and anti-tobacco campaigns aimed at vulnerable populations: A review of the literature

INTRODUCTION

We reviewed research literature on pro-tobacco marketing and anti-tobacco campaigns targeting eight vulnerable populations to determine key findings and research gaps. Results can inform tobacco policy and control efforts and the design of public education campaigns for these groups.

METHODS

Five journal databases in medicine, communication, and science, were used to identify 8875 peer-reviewed, original articles in English, published in the period 2004-2018. There were 144 articles that met inclusion criteria on pro-tobacco marketing or anti-tobacco campaigns aimed at eight US groups: women of reproductive age, racial/ethnic minority groups (African American, Hispanic/Latino, Asian/Pacific Islander and American Indian/Alaska Native), Lesbian/Gay/Bisexual/Transgender (LGBT) populations, groups with low socioeconomic status, rural/inner city residents, military/veterans, and people with mental health or medical co-morbidities. We summarized the number of articles for each population, type of tobacco, and pro-tobacco or anti-tobacco focus. Narrative summaries were organized by population and by pro-tobacco or anti-tobacco focus, with key strategies and gaps by group.

RESULTS

There were more studies on pro-tobacco marketing rather than anti-tobacco campaigns, and on cigarettes rather than other tobacco products. Major gaps included studies on Asian Americans, American Indian/Alaska Natives, pregnant women, LGBT populations, and those with mental health or medical co-morbidities. Gaps related to tobacco products were found for hookah, snus, and pipe/roll-your-own tobacco in the pro-tobacco studies, and for all products except cigarettes in anti-tobacco studies. Common tobacco industry methods used were tailoring of product and package design and messages that were used to reach and appeal to different sociodemographic groups. Studies varied by research design making it difficult to compare results.

CONCLUSIONS

We found major research gaps for specific groups and tobacco products. Public education campaigns need a stronger foundation in empirical studies focused on these populations. Research and practice would benefit from studies that permit comparisons across studies.

Evaluating the impact and equity of a tobacco-free pharmacy law on retailer density in New York City neighbourhoods

BACKGROUND

In 2018, New York City (NYC) implemented a tobacco-free pharmacy law as part of a comprehensive policy approach to curb tobacco use. This study models the reduction in tobacco retailer density following the ban to examine differences in the policy's impact across neighbourhoods.

METHODS

Tobacco retailer density per 1000 residents was calculated in July 2017 for each of NYC's Neighborhood Tabulation Areas (NTAs, n=188) before and after removing pharmacies as licensed tobacco retailers. Pearson correlations and linear regression (with predictors scaled to 10 unit increments) measured associations between the projected change in retailer density after the ban and NTA demographic characteristics.

RESULTS

On average, retailer density decreased by 6.8% across neighbourhoods (SD: 6.3), with 17 NTAs experiencing reductions over 15%. Density reduction was greater in NTAs with higher median household income (r: 0.41, B: 1.00, p<0.0001) and a higher proportion of non-Hispanic white residents (r: 0.35, B: 0.79, p<0.0001). NTAs with a higher percentage of adults with less than a high school education (r: -0.44, B: -2.60, p<0.0001) and a higher proportion of Hispanic residents (r: -0.36, B: -1.07, p<0.0001) benefited less from the policy. These relationships held after assessing absolute changes in density (vs per cent change).

CONCLUSIONS

NYC's tobacco-free pharmacy law substantially reduces tobacco retailer density overall, but the impact is not equal across neighbourhoods. In order to minimise disparities in the tobacco retail environment, local governments considering a similar ban should supplement this strategy with other retailer restrictions to achieve equitable outcomes.

Cigarette retailer density around schools and neighbourhoods in Bali, Indonesia: A GIS mapping

INTRODUCTION

The presence and density of tobacco retailers is associated with the perception of high availability of cigarettes and ease of purchase. Indonesia is the second largest cigarette market in the world with an increasing smoking rate among young people aged 10-18 years. Our study aims to assess density of cigarette outlets in neighbourhoods and around schools, and to evaluate correlation between retailer proximity to schools and retailer selling practices.

METHODS

We conducted a geographical mapping and then an audit survey of 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia. We measured neighbourhood retailer density, and retailer proximity to schools. We linked the coordinate data to the audit data to assess the association between retailer distance from schools with likelihood of selling tobacco to young people and selling single cigarette sticks.

RESULTS

We mapped 4114 cigarette retailers in Denpasar, the most common type was a kiosk, 3199 (77.8%), followed by mini market/convenience stores, 606 (14.7%). Retailer density was 32.2/km² and 4.6/1000 population. We found that 37 (9.7 %) of the 379 schools in Denpasar have at least one cigarette retailer within a 25 m radius and 367 (96.8%) within a 250 m radius. Of the 485 audited retailers within a 250 m radius of a school, 281 (57.9%) admitted selling cigarettes to young people and 325 (67.0%) sold cigarettes as single sticks. Cigarette retailers were less likely to sell cigarettes to young people based on distance from schools, but this was only significant at the furthest distance of more than 500 m from schools.

CONCLUSIONS

In an unregulated retailer setting such as Indonesia, cigarette retailers are ubiquitous and selling to young people is commonplace. The Indonesian government should enforce the prohibition on selling to young people and should regulate cigarette retailers to reduce youth access to cigarettes.

Socioeconomic inequalities in children's exposure to tobacco retailing based on individual-level GPS data in Scotland

BACKGROUND

Identifying factors shaping knowledge of and attitudes towards tobacco products in preadolescence is a key component supporting tobacco control policies aimed at preventing smoking initiation. This study quantified exposure to tobacco retailing environments within the individual-level activity spaces of children across a socioeconomic gradient.

METHODS

One week of global positioning system (GPS) tracking data were collected at 10 s intervals from a nationally representative sample of 10-11-year olds (n=692). Proximity of GPS locations (n=~16 M) to the nearest tobacco retailer (n=9030) was measured and exposure defined when a child came within 10 m of a retailer. Duration, frequency, timing and source of exposure were compared across income deprivation quintiles, along with retail density within children's home neighbourhoods.

RESULTS

On average, children were exposed to tobacco retailing for 22.7 min (95% CI 16.8 to 28.6) per week in 42.7 (35.2-50.1) independent encounters. However, children from the most deprived areas accumulated six times the duration and seven times the frequency of exposure as children from the least deprived areas. Home neighbourhood retail densities were 2.6 times higher in deprived areas, yet the average number of businesses encountered did not differ. Most exposure came from convenience stores (35%) and newsagents (15%), with temporal peaks before and after school hours.

CONCLUSIONS

By accounting for individual mobility, we showed that children in socially disadvantaged areas accumulate higher levels of exposure to tobacco retailing than expected from disparities in home neighbourhood densities. Reducing tobacco outlet availability, particularly in areas frequently used by children, might be crucial to policies aimed at creating 'tobacco-free' generations.