Tobacco outlet density, retailer cigarette sales without ID checks and enforcement of underage tobacco laws: associations with youths' cigarette smoking and beliefs

Loose cigarette purchase and adolescent smoking in Indonesia: a mixed-methods study

OBJECTIVES

To investigate the relationship between purchasing loose cigarettes and adolescent smoking habits in Indonesia.

DESIGN AND SETTING

This study employed a mixed-methods sequential explanatory design. We analysed the secondary data from a national survey, the 2019 Global Youth Tobacco Survey, using multivariable logistic regression models to examine the association between loose cigarette purchase and smoking frequency and intensity and nicotine dependence. Based on the quantitative findings, we arranged focus group discussions (FGDs) in junior and senior high schools located in South Jakarta, Indonesia. The qualitative data were analysed using thematic analysis with an inductive approach to explore experiences in purchasing loose cigarettes and how it affected their smoking initiation and current cigarette consumption.

PARTICIPANTS

For quantitative study, we included 785 samples after excluding the non-current smokers and those who had missing responses. For qualitative study, a total of 49 eligible students who met inclusion criteria (ever or current smokers, buying loose cigarettes and living with parents) and agreed to participate in FGD were later divided into 12 FGD groups.

RESULTS

Most students who smoked in the past 30 days are male (95%). More than half of the students (68%) reported buying loose cigarettes in the past 30 days, including 36% who smoked 1-2 days in a month and 34% who usually consumed one cigarette a day. One-third of the students had nicotine dependence (30%), with an average smoking duration of 3 years. Purchasing loose cigarettes in the past 30 days was significantly correlated with smoking for <20 days in the past month (adjusted OR (AOR)=1.56; 95% CI=1.17 to 2.07), consuming ≤5 sticks per day (AOR=2.15; 95% CI=1.54 to 3.00) and having lower nicotine dependence (AOR=1.55; 95% CI=1.08 to 2.22). Our qualitative findings further reported that affordability and accessibility were the main reasons that encouraged current student smokers to opt for loose cigarettes over other types of cigarettes (packs, cartons or rolled tobacco). Students reported the extensive selling of loose cigarettes and such a situation persuaded them to buy tobacco products more frequently, thus spending at least half of their weekly allowance on tobacco products, ranging from 30 000 to 200 000 Indonesian rupiah or equivalent to US$2-13 per week. Finally, our study highlighted that only a few students in this study either had to show their identity card or were denied when purchasing loose cigarettes in informal retailers.

CONCLUSION

Our study demonstrates that students purchasing loose cigarettes is significantly associated with non-daily smoking, consuming five or fewer sticks per day, and lower addiction which could be interpreted as smokers in the experimental phase. They possessed a higher risk of becoming regular smokers. Our qualitative findings supported the quantitative study by shedding light on the role of loose cigarettes in smoking initiation and continuation among young people. In this case, we supported the notion of prohibiting loose cigarette sales in the country in order to reduce smoking uptake and tobacco consumption among the younger generation.

Flavored Tobacco Sales Restrictions and Youth E-cigarette Behavior: Impact by Tobacco Retailer Density in Diverse Communities in California

INTRODUCTION

Factors that impact flavored tobacco sales restriction (flavor restrictions) effectiveness on youth e-cigarette behavior are unclear. Tobacco retailer density (retailer density) is a health equity issue with greater retailer density in high-minority, low-income areas. We examined the association between flavor restrictions and youth e-cigarette behavior by retailer density across diverse communities in the California Bay Area.

AIMS AND METHODS

We analyzed data from the California Healthy Kids Survey using a difference-in-differences (DID) strategy. We compared pre- and post-policy changes in e-cigarette access and use one-year post-implementation among high school students in the Bay Area with a flavor restriction (n = 20 832) versus without (n = 66 126). Separate analyses were conducted for students in cities with low and high retailer density, with a median cutoff of 3.3 tobacco retailers/square mile.

RESULTS

Students with high retailer density were more likely to identify as a minority and have parents with lower education. Among students with low retailer density, flavor restrictions were associated with 24% lower odds in the pre- to post-policy increase in ease of access relative to unexposed students (DID = 0.76, 95% CI: 0.58, 0.99). Among students with high retailer density, flavor restrictions were associated with 26% higher odds in ease of access (DID: 1.26, 95% CI: 1.02, 1.56) and 57% higher odds of current use (DID = 1.57, 95% CI: 1.31, 1.87).

CONCLUSIONS

Flavor restrictions had positive impacts on youth e-cigarette access in low, but not high retailer density cities. From a health equity perspective, our results underscore how flavor restrictions may have uneven effects among vulnerable groups.

IMPLICATIONS

In diverse communities in the California Bay Area, our results suggest a protective association between flavored tobacco sales restrictions and youth access to e-cigarettes in low, but not high tobacco retailer density cities one-year post-implementation. These results underscore how flavor restrictions may have uneven effects, and when implemented in high retailer density areas, may disproportionately place already vulnerable groups at heightened exposure to e-cigarette use and access. In high retailer density areas, additional tobacco control efforts may need to be included with flavor restriction implementation, such as increased education, youth prevention and cessation programs, policies to reduce tobacco retailer density, or stronger tobacco retailer enforcement or compliance monitoring.

Tobacco retailer density and smoking behaviour: how are exposure and outcome measures classified? A systematic review

INTRODUCTION

To date only a limited number of reviews have focused on how exposure and outcome measures are defined in the existing literature on associations between tobacco retailer density ('density') and smoking behaviour ('smoking'). Therefore this systematic review classified and summarised how both density and smoking variables are operationalised in the existing literature, and provides several methodological recommendations for future density and smoking research.

METHODS

Two literature searches between March and April 2018 and April 2022 were conducted across 10 databases. Inclusion and exclusion criteria were developed and keyword database searches were undertaken. Studies were imported into Covidence. Cross-sectional studies that met the inclusion criteria were extracted and a quality assessment was undertaken. Studies were categorised according to the density measure used, and smoking was re-categorised using a modified classification tool.

RESULTS

Large heterogeneity was found in the operationalisation of both measures in the 47 studies included for analysis. Density was most commonly measured directly from geocoded locations using circular buffers at various distances (n = 14). After smoking was reclassified using a smoking classification tool, past-month smoking was the most common smoking type reported (n = 26).

CONCLUSIONS

It is recommended that density is measured through length-distance and travel time using the street network and weighted (e.g. by the size of an area), or by using Kernel Density Estimates as these methods provide a more accurate measure of geographical to tobacco and e-cigarette retailer density. The consistent application of a smoking measures classification tool, such as the one developed for this systematic review, would enable better comparisons between studies. Future research should measure exposure and outcome measures in a way that makes them comparable with other studies.

IMPLICATIONS

This systematic review provides a strong case for improving data collection and analysis methodologies in studies assessing tobacco retailer density and smoking behaviour to ensure that both exposure and outcome measures are clearly defined and captured. As large heterogeneity was found in the operationalisation of both density and smoking behaviour measures in the studies included for analysis, there is a need for future studies to capture, measure and classify exposure measures accurately, and to define outcome measures in a manner that makes them comparable with other studies.

Tobacco retail availability and cigarette and e-cigarette use among youth and adults: a scoping review

OBJECTIVE

States and localities are formulating strategies to reduce the widespread retail availability of tobacco products. Evidence of associations between retailer density/proximity and tobacco use outcomes can help inform those strategies. We conducted a scoping review on tobacco retail availability and cigarette/e-cigarette use in adults and youth, and considered variations in spatial units, measures of retailer exposure and outcomes across studies.

METHODS

A systematic search for studies examining the association between retailer density/proximity and youth and adult cigarette/e-cigarette use was conducted across MEDLINE (PubMed), Web of Science and Google Scholar through 27 August 2020 with no restrictions.

RESULTS

Thirty-five studies were included in our qualitative synthesis. While there were differences in neighbourhood definitions (eg, egocentric vs administrative), there is evidence for a positive association between higher retailer density in egocentric neighbourhoods around homes and current smoking in adults and adolescents. Administrative unit measures in some studies showed associations with adult current smoking, and adolescent lifetime and current smoking. Studies on tobacco outlet proximity to homes obtained mixed results. Density/proximity of tobacco outlets around schools showed no or inverse association with adolescent smoking, but suggests higher susceptibility to smoking. Evidence of an association between e-cigarette retail availability and e-cigarette use is limited due to a small number of studies.

CONCLUSION

The current literature provides limited empirical evidence of the association between tobacco retailer availability and smoking or e-cigarette use. More research with uniform measures of environmental exposure to tobacco retailers is needed to allow for greater comparability between studies.

Density of Cigarette Retailers Near Facilities for Children and Adolescents in Urban and Rural Areas in Indonesia: A Geospatial Analysis

The lack of regulation banning cigarette retailers near facilities for children and adolescents has made cigarettes easily accessible to youth in Indonesia. This study aimed to investigate the density of cigarette retailer near children and adolescent facilities in urban and rural areas in the country. We mapped all cigarette retailers and facilities for children and adolescents in Surabaya city (urban) and Banyuwangi district (rural) in East Java province. All types of facilities for children and adolescents and retailers visible from the streets in the study areas were mapped. We conducted geospatial analysis of the density of retailers to the facilities for children and adolescents in QGIS 2.8 and STATA 14. We found that the density of cigarette retailers was 81% higher in the areas within 100 m from the facilities for children and adolescents, compared with the areas within 100 to 250 m from facilities. We also found that the density of cigarette retailers within 100 m from facilities was 2.35 times higher in the rural setting, compared with the urban setting. Controlling cigarette retailers through zoning and licensing is urgently needed in Indonesia.

Tobacco Retail Environment and Smoking: A Systematic Review of Geographic Exposure Measures and Implications for Future Studies

INTRODUCTION

To review the geographic exposure measures used to characterize the tobacco environment in terms of density of tobacco outlets and proximity to tobacco outlets, and its association with smoking-related outcomes.

METHODS

We used PubMed and Google Scholar to find articles published until December 2019. The search was restricted to studies that (1) measured the density of and/or proximity to tobacco outlets and (2) included associations with smoking outcomes. The extraction was coordinated by several observers. We gathered data on the place of exposure, methodological approaches, and smoking outcomes.

RESULTS

Forty articles were eligible out of 3002 screened papers. Different density and proximity measures were described. 47.4% density calculations were based on simple counts (number of outlets within an area). Kernel density estimations and other measures weighted by the size of the area (outlets per square kilometer), population, and road length were identified. 81.3% of the articles which assessed proximity to tobacco outlets used length distances estimated through the street network. Higher density values were mostly associated with higher smoking prevalence (76.2%), greater tobacco use and smoking initiation (64.3%), and lower cessation outcomes (84.6%). Proximity measures were not associated with any smoking outcome except with cessation (62.5%).

CONCLUSION

Associations between the density of tobacco outlets and smoking outcomes were found regardless of the exposure measure applied. Further research is warranted to better understand how proximity to tobacco outlets may influence the smoking outcomes. This systematic review discusses methodological gaps in the literature and provides insights for future studies exploring the tobacco environment.

IMPLICATIONS

Our findings pose some methodological lessons to improve the exposure measures on the tobacco outlet environment. Solving these methodological gaps is crucial to understand the influence of the tobacco environment on the smoking outcomes. Activity spaces should be considered in further analyses because individuals are exposed to tobacco beyond their residence or school neighborhood. Further studies in this research area demand density estimations weighted by the size of the area, population, or road length, or measured using Kernel density estimations. Proximity calculations should be measured through the street network and should consider travel times apart from the length distance.

The Association Between Tobacco Outlet Density and Smoking Among Young People: A Systematic Methodological Review

Aim

Evidence on the association between tobacco outlet density and proximity and smoking behavior among youth is inconsistent, which may be due to methodological problems in some studies. We assessed the association of outlet density or proximity with smoking behavior among young people while taking into account the methodological quality of studies.

Methods

MEDLINE, EMBASE, and Google Scholar were systematically searched for studies on the relationship between outlet density or proximity and smoking behavior among 12- to 25-year-olds, published between 1997 and 2017. Methodological quality of the included studies was evaluated independently by two reviewers.

Results

Twenty studies were included in the review. The quality assessment identified five primary sources of potential bias: overadjustment for mediators (problems identified in 14 studies), underadjustment for confounders (six studies), poor statistical model fit (four studies), selection bias (three studies), and misclassification of exposure measurements (eight studies). Four studies were of high methodological quality. In studies with relatively high quality, 10 associations were reported, of which seven were nonsignificant, two positive, and one negative. Similarly, the complete body of evidence demonstrated mostly nonsignificant associations, but a larger proportion of positive associations than negative.

Conclusion

Although there is some support for a positive direction, current literature does not provide consistent evidence for a positive association between outlet density and smoking among youth. This is not necessarily due to bias in specific studies, but more to fundamental challenges in study design and exposure measurements. These issues need to be addressed in future studies using more rigorous methods.

Implications

Our findings suggest that, although there is some evidence for a positive association, current scientific literature does not provide consistent support to claim an effect of tobacco outlet density or proximity on youth smoking. This underlines the need for more research with improved methodology. There is a need for quasiexperimental studies, in which the outlet density changes substantially, studies measuring the actual exposure of youth to tobacco outlets, and qualitative research on the mechanisms underlying any association.

Association between density and proximity of tobacco retail outlets with smoking: A systematic review of youth studies

BACKGROUND

Reducing the retail availability of tobacco has been proposed as a component of tobacco endgame, yet it is not known whether retail availability has a direct impact on smoking behaviours. A narrative review and a meta-analysis have been undertaken to examine the density and proximity of tobacco retail outlets, but were limited in scope, exposure and outcome variables. The aim of this current study was to undertake a systematic review of the international literature on the density and proximity of tobacco retail outlets to homes, schools and communities and their association with smoking behaviours among youth.

METHODS

We reviewed and critically appraised the evidence documenting the association between density or proximity of tobacco retail outlets and smoking behaviours among school-age youth (18 and under), between 1 January 1990 and 21 October 2019. We reviewed original quantitative research that examined the associations of tobacco retail outlet density and proximity with individual smoking status or population-level smoking prevalence; initiation of smoking; frequency of tobacco use; sales to minors; purchasing by minors; susceptibility to smoking among non-smokers; perceived prevalence of smoking, and quitting behaviours.

FINDINGS

Thirty-five peer-reviewed papers met the inclusion criteria. This review provided evidence of a relationship between density of tobacco retail outlets and smoking behaviours, particularly for the density near youths' home. A study using activity spaces also found a significant positive association between exposure to tobacco retail outlets and daily tobacco use. The review did not provide evidence of an association between the proximity of tobacco retail outlets to homes or schools and smoking behaviours among youth.

CONCLUSIONS

The existing evidence supports a positive association between tobacco retail outlet density and smoking behaviours among youth, particularly for the density near youths' home. This review provides evidence for the development and implementation of policies to reduce the density of tobacco retail outlets to reduce smoking prevalence among youth.

Youth daily exposure to tobacco outlets and cigarette smoking behaviors: does exposure within activity space matter?

AIMS

To examine whether daily exposure to tobacco outlets within activity spaces is associated with cigarette smoking and with the number of cigarettes smoked by youth that day.

DESIGN

The study used geographic ecological momentary assessment (GEMA) data that combined daily surveys with ecological momentary assessment of global positioning systems (GPS) using geographic information systems (GIS) to allow for real-time data collection of participants' environments and behaviors.

SETTING

Eight mid-sized California (USA) city areas.

PARTICIPANTS

The analytical sample included 1065 days, which were clustered within 100 smoker and non-smoker participants (aged 16-20 years, 60% female).

MEASUREMENTS

Any cigarette smoking and number of cigarettes smoked on a given day, the number of tobacco outlets within 100 m of activity space polylines each day, the number of minutes participants spent within 100 m of tobacco outlets each day and demographic characteristics (age, sex, race/ethnicity and perceived socio-economic status).

FINDINGS

Controlling for demographic characteristics, the findings of multi-level mixed effects logistic models were inconclusive, whether or not the number of tobacco outlets within 100 m of youths' activity space polylines or the number of minutes spent within 100 m of tobacco outlets were associated with whether the participant smoked cigarettes on a given day [odds ratio (OR) = 1.05, P = 0.24; OR = 0.99, P = 0.81, respectively]. However, in multi-level zero-inflated negative binomial models, the risk of smoking an additional cigarette on a given day increased with each additional tobacco outlet [incidence rate ratio (IRR) = 1.04, P < 0.05] and each additional minute spent within 100 m of tobacco outlets (IRR = 1.01, P < 0.001) each day.

CONCLUSIONS

Among young people in urban California, differences in day-to-day exposure to tobacco outlets within activity spaces does not seem to be significantly associated with whether a person smokes a cigarette on a given day, but higher exposure to tobacco outlets appears to be positively associated with the number of cigarettes smoked on that day.

Youth's Proximity to Marijuana Retailers and Advertisements: Factors Associated with Washington State Adolescents' Intentions to Use Marijuana

The current study explored the influences of advertising exposure, numbers of marijuana retailers, distance to retailers, and constructs from the integrative model of behavioral prediction, including outcome beliefs, perceived norms, and efficacy, on youth's intentions to use marijuana in a state in which the use of recreational marijuana is legal. A state-wide online cross-sectional survey of 350 adolescents ages 13-17, residing in Washington state, was conducted in June 2018. The results of the regression analysis suggest that exposure to marijuana advertising, positive and negative outcome beliefs, and perceived peer norms were associated with intention to use marijuana. Distances to retailers moderated the relationships between exposure to advertising and intentions, as well as between positive outcome beliefs and intentions. States that have legalized recreational marijuana should continue considering the location of retailers in relation to neighborhoods and advertising regulations to reduce the appeal to youth. Additionally, prevention efforts could aim to influence outcome beliefs and norms in an attempt to reduce adolescents' intentions to use recreational marijuana.

How Is Exposure to Tobacco Outlets Within Activity Spaces Associated With Daily Tobacco Use Among Youth? A Mediation Analysis

INTRODUCTION

We investigated associations between exposure to tobacco outlets within activity spaces and daily tobacco use, and whether exposure to adults or peers using tobacco mediate these relationships.

METHODS

We used Geographic Ecological Momentary Assessment data over 14 days from 85 youth aged 16-20 years in eight mid-sized California city areas. Tobacco outlet addresses and global positioning systems locations were geocoded and activity spaces were constructed by joining sequential points. We assessed daily number of tobacco outlets within 50 or 100 m of activity space polylines and number of minutes participants were within 50 or 100 m of tobacco outlets each day; daily use of tobacco; and whether participants saw (1) adults and (2) people their age (peers) using tobacco each day.

RESULTS

Controlling for demographics, results of multilevel structural equation models showed no association between number of tobacco outlets within 50 m of polylines and tobacco use (probit regression coefficient: 0.01, p = .82). However, we found evidence of an indirect effect (p = .001) through daily exposure to peers using tobacco. Specifically, greater number of tobacco outlets within 50 m of polylines was positively associated with seeing peers use tobacco (probit regression coefficient: 0.10, p < .001). In turn, seeing peers use tobacco was positively associated with tobacco use on that day (probit regression coefficient: 2.23, p < .001). Similar results were found for number of tobacco outlets within 100 m of polylines.

CONCLUSIONS

Exposure to tobacco outlets within activity spaces affects youth tobacco use through daily exposure to peers who use tobacco.

IMPLICATIONS

Using real-time-ordered data, this article examines whether exposure to adults and peers using tobacco mediate associations between exposure to tobacco outlets within activity spaces and daily tobacco use among youth. Results suggest that exposure to tobacco outlets within activity spaces affects daily tobacco use through exposure to peers who use tobacco. These findings provide additional significant support for policy makers who are considering regulating the number and density of tobacco retailers and point to the importance of interventions focused on peer tobacco use and youths' daily environments to reduce tobacco use.

Density of cigarette retailers near schools and sales to minors in Banyuwangi, Indonesia: A GIS mapping

INTRODUCTION

There are weak regulations and controls on tobacco sales to adolescents in Indonesia, and these may have contributed to the increase in smoking prevalence among adolescents in the country. Our study aims to calculate the density of cigarette retailers near schools and ascertain the factors associated with sales to minors.

METHODS

We conducted geographical mapping by recording the GPS position of cigarette retailers in 15 locations in Banyuwangi District, Indonesia, to assess the density and proximity of cigarette retailers to schools. We interviewed randomly selected retailers, from the geographical mapping, for information on sales to minors, the cheapest price cigarettes are sold and the most popular cigarette brand purchased by adolescents, as well as owners/keepers knowledge of the regulation regarding sales to minors.

RESULTS

We identified 770 retailers of consumer goods in the study location; 28.1% (216) sold cigarettes, with mean density of 1.1 cigarette retailers per 100 m. Of the cigarette retailers, 6.9% were located <25 m from schools and all schools had at least one retailer within a 250 m radius. Owners/keepers of 107 cigarette retailers agreed to be interviewed for information on sales to minors. Brands from Gudang Garam were the most popular among adolescents and the brand from Bentoel, part of British American Tobacco, was the cheapest. The median of the cheapest price sold was US$0.7 per pack. Only 43.6% of retailers ever refused to sell cigarettes to adolescents. Within a school complex, retailers’ refusal to sell cigarettes to adolescents was higher than in other locations.

CONCLUSIONS

Schools in Banyuwangi are surrounded by cigarette retailers. Half of the retailers sell cigarettes at a price affordable by adolescents, attracting adolescents to initiate smoking. There needs to be strict regulation to control cigarette sales to minors, through zoning and licensing in Indonesia.

Mind the Gap: Changes in Cigarette Prices After California's Tax Increase

Objective

To investigate whether California's 2017 cigarette tax increase was passed onto smokers equally.

Methods

Auditors recorded 4 cigarette prices in the same random sample of licensed tobacco retailers (N = 1049) before the tax increase (January-March 2017) and after (April-September 2018): Natural American Spirit (ultra-premium), Newport menthol (premium), and Pall Mall (value) all from the same manufacturer, and Marlboro (premium). Ordinary least squares regressions examined how the gap in prices (increase greater or less than $2.00 tax) varied by market segment and neighborhood demographics, controlling for store type and months since implementation. Paired t-tests assessed whether industry/retail revenue (price in excess of state and federal excise taxes) increased.

Results

Over-shifting (increase greater than tax) was evident for all 4 brands and was significantly greater for ultra-premium (Mean = $0.40, SD = 0.75) than premium (Mean = $0.25, SD = 0.78) and greater for premium than value brand (Mean = $0.16, SD = 0.67). However, under-shifting (increase less than tax) was evident for Newport in African-American neighborhoods and Pall Mall in Hispanic neighborhoods. After the tax increase, prices were significantly more likely to be discounted and significantly more stores advertised a discount on cigarettes.

Conclusion

California's tax increase was not passed onto consumers equally. Non-tax mechanisms to increase price could support intended effects of tobacco taxes.

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.

Density of Medical Marijuana Dispensaries and Current Marijuana Use among Young Adult Marijuana Users in Los Angeles

Background: While tobacco and alcohol studies have focused on density of outlets as a determinant of consumption, research has begun examining the effects of medical marijuana (MM) dispensaries on marijuana use. Objectives: Examine the relationship between density of MM dispensaries and frequency of marijuana use among young adult medical marijuana patients (MMP) and nonpatient users (NPU). Methods: Young adult marijuana users (n = 329) aged 18- to 26-year old were sampled in Los Angeles in 2014-2015 and separated into MMP (n = 198) and NPU (n = 131). In 2014, 425 operational MM dispensaries were identified within the City of Los Angeles. Sequential multilevel Poisson random effect models examined density of MM dispensaries per square mile and 90 d marijuana use among MMP and NUP at the ZIP code level while controlling for demographic, behavioral, and community characteristics. Results: Density of MM dispensaries was not related to 90 d use of marijuana (days of use or hits per day) among either MMP or NPU. MMP reported significantly greater days of marijuana use in the past 90 d compared to NPU but no differences were found for hits per day. African-Americans reported significantly greater hits per day compared to whites. Hispanics reported significantly fewer hits per day compared to non-Hispanics. Conclusion: Concentration of MM dispensaries surrounding young adult marijuana users in Los Angeles was unrelated to days of marijuana use irrespective of having a MM recommendation or not. Rather, individual factors related to consumer choices and behaviors were more important in determining recent marijuana use among MMP and NPU.

Tobacco outlet density and adolescents' cigarette smoking: a meta-analysis

OBJECTIVE

We conducted meta-analyses of studies that investigated the associations between tobacco outlet density around homes and schools and adolescents' past-month cigarette smoking.

DATA SOURCES

Systematic literature searches of eight databases were carried out in February 2017. Searches were not limited by date, language, country or peer-reviewed status.

STUDY SELECTION

After screening for quality, studies that examined the relationship between tobacco outlet density and adolescents' past-month smoking were selected for inclusion.

DATA EXTRACTION

Two investigators screened study abstracts and full texts and independently extracted data. Consensus was reached at each stage.

DATA SYNTHESIS

Random-effects meta-analyses were conducted on 11 studies that provided 13 effect sizes. Results showed that there was a significant association between tobacco outlet density around homes and adolescents' past-month smoking behaviour, with an overall effect size of OR=1.08 (95% CI 1.04 to 1.13; P<0.001; I2=0%). For density around schools, the association was not statistically significant (OR=1.01, 95% CI 0.98 to 1.03; P=0.53; I2=39%).

CONCLUSIONS

These findings suggest that exposure to tobacco outlets near home environments may be important for understanding adolescents' past-month smoking. Restricting access to tobacco outlets and controlling the number of outlets in residential areas may be an effective preventive strategy to help reduce adolescents' smoking.

Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England

INTRODUCTION

England introduced a tobacco display ban for shops with >280 m² floor area ('partial ban') in 2012, then a total ban in 2015. This study assessed whether these were linked to child awareness of and access to cigarettes.

METHODS

Data come from the Smoking, Drinking and Drug Use survey, an annual survey of children aged 11-15 years for 2010-2014 and 2016. Multivariate logistic regression models assessed changes in having seen cigarettes on display, usual sources and ease of access to cigarettes in shops RESULTS: During the partial display ban in 2012, 89.9% of children reported seeing cigarettes on display in the last year, which was reduced to 86.0% in 2016 after the total ban (adjusted OR 0.58, 95% CI 0.50 to 0.66). Reductions were similar in small shops (84.1% to 79.3%)%) and supermarkets (62.6% to 57.3%)%). Although the ban was associated with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops (57.0% in 2010 to 39.8% in 2016), we did not find evidence of changes in perceived difficulty or being refused sale among those who still did.

DISCUSSION

Tobacco point-of-sale display bans in England reduced the exposure of children to cigarettes in shops and coincided with a decrease in buying cigarettes in shops. However, children do not report increased difficulty in obtaining cigarettes from shops, highlighting the need for additional measures to tackle tobacco advertising, stronger enforcement of existing laws and measures such as licencing for tobacco retailers.

The "here and now" of youth: the meanings of smoking for sexual and gender minority youth

BACKGROUND

The mainstream tobacco field in the USA tends to situate youth as passive, particularly in terms of their susceptibility to industry manipulation and peer pressure. However, failing to acknowledge youths' agency overlooks important meanings youth ascribe to their tobacco use and how those meanings are shaped by the circumstances and structures of their everyday lives.

METHODS

This article is based on analysis of 58 in-depth qualitative interviews conducted with sexual and gender minority youth living in the San Francisco Bay area in California. Topics covered in interviews focused on meanings of tobacco in the lives of youth. Interviews lasted approximately 2.5 h and were transcribed verbatim and linked with ATLAS.ti, a qualitative data analysis software. Following qualitative coding, narrative segments were sorted into piles of similarity identified according to principles of pattern-level analysis to interpret to what extent meanings of smoking for young people may operate as forms of resistance, survival, and defense.

RESULTS

Analysis of our participants' narratives highlights how smoking is connected to what Bucholtz calls the "'here-and-now' of young people's experience, the social and cultural practices through which they shape their worlds" as active agents (Bucholtz, Annu Rev Anthropol31:525-52, 2003.). Specifically, narratives illustrate how smoking signifies "control" in a multitude of ways, including taking control over an oppressor, controlling the effects of exposure to traumatic or day-to-day stress, and exerting control over the physical body in terms of protecting oneself from violence or defending one's mental health.

CONCLUSIONS

These findings call into question the universal appropriateness of foundational elements that underlie tobacco control and prevention efforts directed at youth in the USA, specifically the focus on abstinence and future orientation. Implications of these findings for research, prevention, and policy are discussed, emphasizing the risk of furthering health inequities should we fail to acknowledge the "here and now" of youth.

How do tobacco power walls influence adolescents? A study of mediating mechanisms

OBJECTIVES

Tobacco power walls display hundreds of tobacco products and are known to be a key part of the impact of point-of-sale tobacco advertising on risk for smoking in adolescents. The current study examined factors that are hypothesized to mediate the effect of tobacco power wall exposure on adolescents' susceptibility for smoking in the future.

METHOD

Participants (N = 148) aged 11-17 years were invited to shop in the RAND StoreLab, a life-sized replica of a convenience store. They were randomized to 1 of 2 conditions: one in which the power wall was located in its typical position behind the cashier and the other in which it was hidden behind an opaque wall. Participants shopped in the RAND StoreLab and then completed measures of susceptibility for smoking in the future, perceived smoking norms, and perceived accessibility of cigarettes. Participants' movements in the store were electronically tracked.

RESULTS

Having the tobacco power wall behind the cashier increased adolescents' susceptibility for smoking in the future by 14.3% (total effect) compared with when the power wall was hidden (p = .01), and 14% of this effect was mediated by participants' perceived smoking norms. Time spent in front of the cashier and perceived accessibility of cigarettes did not play a role in the association between study condition and susceptibility for smoking in the future.

CONCLUSIONS

The tobacco power wall increases adolescents' smoking risk, and this effect is partly explained by the effect of the power wall on adolescents' perceptions of how normative smoking is. (PsycINFO Database Record

E-cigarette use among students and e-cigarette specialty retailer presence near schools

OBJECTIVE

This study examined the association between presence of e-cigarette specialty retailers near schools and e-cigarette use among middle and high school students in Orange County (OC), CA.

METHODS

The OC subsample of the 2013-2014 California Healthy Kids Survey (N=67,701) was combined with geocoded e-cigarette retailers to determine whether a retailer was present within one-quarter mile of each public school in OC. Multilevel logistic regression models evaluated individual-level and school-level e-cigarette use correlates among middle and high school students.

RESULTS

Among middle school students, the presence of an e-cigarette retailer within one-quarter mile of their school predicted lifetime e-cigarette use (OR=1.70, 95% CI=1.02, 2.83), controlling for confounders but no effect for current use. No significant effect was found for high school students.

CONCLUSIONS

E-cigarette specialty retailers clustered around schools may be an environmental influence on student e-cigarette experimentation.