The neighbourhood effects of geographical access to tobacco retailers on individual smoking behaviour

A longitudinal analysis of the impact of the local tobacco retail availability and neighbourhood deprivation on male smoking behaviours in Shanghai, China

Some evidence from Western high-income countries suggests local tobacco retail availability and neighbourhood deprivation may influence smoking behaviours. However, this assertion has not been considered in China, where 44% of males continue to smoke. Data were analysed from Chinese males (n = 2054) who participated in Waves 3-5 (2009-2015) of the International Tobacco Control (ITC) China Survey by linking information on tobacco retail availability (estimated through population weighted Kernel Density of tobacco retailers in 2019) and neighbourhood deprivation (calculated as a composite score derived from the 2010 Chinese census) across Shanghai. Generalised Estimating Equation models were fitted to examine the impacts of local tobacco availability and neighbourhood deprivation on smoking behaviours (current smoking versus current non-smoking, quitting versus current smoking, longer durations of smoking abstinence versus current smoking) using the longitudinal data. Examining the impacts separately, participants living in neighbourhoods with greater availability and higher levels of deprivation were less likely to maintain longer durations of smoking abstinence in both unadjusted and adjusted models. Neighbourhood deprivation, but not availability, was found to be associated with higher odds of being a current smoker. Examining the impacts jointly, neighbourhood deprivation was still positively associated with current smoking and negatively associated with longer durations of smoking abstinence, but the negative association between availability and longer durations of smoking abstinence disappeared. The findings offer some evidence that greater tobacco retail availability and deprivation are obstacles on prolonged smoking cessation among males in Shanghai, China. Policymakers should consider small-area level place-based restrictions in China, such as reducing the availability of tobacco, as part of a comprehensive tobacco control strategy aimed at addressing the high prevalence of smoking.

Associations of tobacco retailer density and proximity with adult tobacco use behaviours and health outcomes: a meta-analysis

OBJECTIVE

We sought to conduct a systematic review and meta-analysis of evidence to inform policies that reduce density and proximity of tobacco retailers.

DATA SOURCES

Ten databases were searched on 16 October 2020: MEDLINE via PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus, plus grey literature searches using Google and the RAND Publication Database.

STUDY SELECTION

Included studies used inferential statistics about adult participants to examine associations between tobacco retailer density/proximity and tobacco use behaviours and health outcomes. Of 7373 studies reviewed by independent coders, 37 (0.5%) met inclusion criteria.

DATA EXTRACTION

Effect sizes were converted to a relative risk reduction (RRR) metric, indicating the presumed reduction in tobacco use outcomes based on reducing tobacco retailer density and decreasing proximity.

DATA SYNTHESIS

We conducted a random effects meta-analysis and examined heterogeneity across 27 studies through subgroup analyses and meta-regression. Tobacco retailer density (RRR=2.55, 95% CI 1.91 to 3.19, k=155) and proximity (RRR=2.38, 95% CI 1.39 to 3.37, k=100) were associated with tobacco use behaviours. Pooled results including both density and proximity found an estimated 2.48% reduction in risk of tobacco use from reductions in tobacco retailer density and proximity (RRR=2.48, 95% CI 1.95 to 3.02, k=255). Results for health outcomes came from just two studies and were not significant. Considerable heterogeneity existed.

CONCLUSIONS

Across studies, lower levels of tobacco retailer density and decreased proximity are associated with lower tobacco use. Reducing tobacco supply by limiting retailer density and proximity may lead to reductions in tobacco use. Policy evaluations are needed.

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.

A Cross-sectional Analysis of Socio-spatial Patterning of Tobacco Retail in Shanghai, China

INTRODUCTION

International evidence from high-income countries demonstrates that the availability of tobacco tends to be greater in more urban and more deprived neighborhoods. However, little is known about the socio-spatial disparities in other settings, including megacities in China. This study investigated the patterning of tobacco retailers across Shanghai by types of tobacco retailers, including the relationship with levels of urbanity and neighborhood deprivation.

AIMS AND METHODS

Tobacco retailer data (n = 19 413) was extracted from a web-scraped Points-of-Interest database. For all communities (n = 5432) across Shanghai, neighborhood tobacco retail availability was calculated using population-weighted kernel density estimation and grouped by quintiles of neighborhood deprivation and a 3-level urban classification. Associations were analyzed using the Kruskal-Wallis tests and epsilon squared.

RESULTS

Across Shanghai, tobacco retail availability decreased from more urbanized areas to less urbanized areas. There was a statistical difference (p < .001) in the availability of tobacco retail across quintiles of deprivation, with the highest availability in the less deprived neighborhoods, and the lowest availability in the most deprived neighborhoods. However, this trend was reversed in the urban center, where retail availability was greatest in the most deprived areas. Convenience stores were the most common type of tobacco retailer across the city, while tobacco-only outlets were most strongly associated with levels of neighborhood deprivation.

CONCLUSIONS

The results show an association between tobacco retail availability and neighborhood deprivation, which varied with levels of urbanity and types of tobacco retailers. These findings provide supportive evidence for further interventions that target reducing inequalities in exposure to tobacco retail.

IMPLICATIONS

This is the first study to examine the relationship between tobacco retail availability and neighborhood deprivation in the context of Chinese megacities. Using data from Shanghai, China, we found a significant non-linear association between tobacco retail availability and neighborhood deprivation across the city. It is plausible that the socio-spatial disparities in tobacco retail availability at the neighborhood level may be a key factor explaining differences in smoking behaviors between sociodemographic groups. The findings emphasize the need for greater efforts in regulating neighborhood-level tobacco retailing in China.

Piloting a spatial mixed method for understanding neighborhood tobacco use disparities

The tobacco retail environment is where most advertising dollars are spent. However, most research on the retail environment has not methodologically situated tobacco retailers as part of a larger community, and few studies have incorporated community member perspectives of their own tobacco use in relation to their local environments. The purpose of this study is to describe and evaluate a multilevel, multimodal, mixed methods approach for understanding tobacco use in context. We combine quantitative data collected from tobacco retailer audits and geographically-explicit interviews with neighborhood residents to tell a more complete story of tobacco use behavior among adults in San Francisco's Marina district, and the Oakland Coliseum neighborhood in Alameda County, California. We find that while area-level and retail data provide a broad snapshot of two distinct communities with respect to sociodemographic characteristics and tobacco availability, interviews with community residents who use tobacco add important perspectives regarding how tobacco retailers are viewed and how residents interact with their neighborhood landscapes on a daily basis. The method we describe and critique has the potential to be scaled to incorporate a broader set of geographies, or tailored to address a multitude of health-related questions. Our approach further demonstrates the utility of including geolocated participant narratives as a means of understanding where researcher interpretations of urban environments diverge from those of community residents.

Why Tasmanian retailers stop selling tobacco and implications for tobacco control

INTRODUCTION

The retail availability of tobacco is at odds with the health harms associated with tobacco smoking and undermines tobacco control efforts. Evidence suggests ease of access to tobacco through retail outlets contributes to smoking prevalence.

OBJECTIVE

This study aimed to understand why retailers stop selling tobacco and explore possible implications for tobacco control.

METHODS

The Tobacco Licensing Database maintained by the Department of Health Tasmania was used to identify and recruit past retailers who no longer held licences. Semistructured interviews were conducted to explore business demographics and the reasons they stopped selling tobacco. Interview findings were analysed using a thematic framework.

RESULTS

Twenty former tobacco retailers participated, representing all business types except specialist tobacconists and large supermarkets. Retailers gave multiple reasons for ending tobacco sales, related to business considerations, security, tobacco regulations, ethics and health. Most often, the decision was business-related; health or ethical considerations were rarely a factor. Most retailers felt they played no role in mitigating tobacco-related harm.

CONCLUSIONS

This study provides insights into factors that make tobacco sales unattractive or unfeasible for low-volume outlets and may inform supply-focused tobacco control policy. A campaign that emphasises the possible business benefits of ending tobacco sales in favour of other higher-margin products may support retailers to transition away from tobacco sales. The regulatory obligations of selling tobacco are disincentives and create a less favourable retail environment.

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 legacy of redlining: Associations between historical neighborhood mapping and contemporary tobacco retailer density in Ohio

In the 1930s United States, urban neighborhoods were graded on their desirability for investment (often based on race), a process known as "redlining." This study examined how historical redlining relates to current disparities in an important health determinant: tobacco retailer density. Analyses were conducted for thirteen Ohio cities using negative binomial models that accounted for retailer spatial dependence and controlled for present-day sociodemographic characteristics. Findings indicated that as grades increased from "Best" to "Still Desirable" to "Definitely Declining" and "Hazardous," retailer density increased monotonically. These results highlight the persisting impacts of redlining and how disparities, once intentionally created, can be perpetuated over time.

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.

The impact of the point-of-sale tobacco display ban on young people in Scotland: before-and-after study

Background

Tobacco displays at point of sale have been shown to increase young people’s pro-smoking attitudes, susceptibility to smoking and smoking initiation. In Scotland, legislation that prohibited tobacco point-of-sale displays was implemented in large stores (i.e. those > 280 m2) in April 2013 and in small retailers in April 2015.

Objective

To assess the impact of the point-of-sale tobacco display ban on young people’s exposure to tobacco advertising, their attitudes to smoking and smoking susceptibility, and their risk of smoking initiation.

Design

Multimodal before-and-after study design using mixed methods to collect data at baseline (2013) and then longitudinally for 4 years.

Setting

Four main study communities in the central belt of mainland Scotland, UK, purposively selected to reflect two levels of urbanity (urban vs. small town) and two levels of deprivation (high vs. medium/low). Four matched communities.

Participants

In the main study communities, 94 tobacco retail outlets. All Secondary 2 (aged 13 years) and Secondary 4 (aged 15 years) pupils in 2013 and 2014 together with all Secondary 1 to Secondary 6 (aged 12–17 years) pupils in 2015–17. This included 6612 pupils who completed 14,344 questionnaires over 5 years. Three hundred and eighty-two participants in 80 focus groups who were recruited from Secondary 2 and Secondary 4 in 2013–17. In matched communities, 24 retail panel members in 2013–17.

Main outcome measures

Tobacco product and tobacco storage visibility, density of retail outlets (the number of retailers in a pre-defined area such as a residential neighbourhood), tobacco product exposure, brand awareness, perceived accessibility of tobacco, pro-smoking attitudes, pro-smoking norms, smoking susceptibility and smoking initiation.

Data platform and methods

The study had four components – a mapping and spatial analysis of retail outlets; a tobacco marketing audit, including retail panel interviews in matched communities; school surveys; and focus group discussions with secondary school pupils.

Limitations

The study was based on a small number of communities and did not include communities in remote areas.

Results

Compliance with the point-of-sale legislation in Scotland was high. This led to a large reduction in the visibility of tobacco products in retail outlets. However, when the results were stratified by socioeconomic status, declines in retailer density, weighted by total product visibility, were restricted to the least disadvantaged tertile of participants. Nevertheless, the implementation of the legislation was associated with a reduction in risk of both smoking susceptibility and smoking initiation in young people, as well as a reduction in the perceived accessibility of tobacco and in pro-smoking attitudes after both the partial and the comprehensive bans were introduced.

Conclusions

The Scottish point-of-sale legislation has been successful in reducing the overall visibility of tobacco products and is associated with improvements in attitudinal and behavioural outcomes in young people. However, cues that tobacco is for sale are still highly visible, particularly in retail outlets in areas of deprivation. In addition, the increase in retailer density that was observed after 2015 increased inequalities in product visibility. There was also evidence that the emergence of e-cigarettes may have disrupted the full impact of the legislation.

Future work

Our research indicates that further research is needed to examine the longitudinal relationships between tobacco outlet availability and product visibility inequalities; and the impact of e-cigarettes and standardised packaging on smoking initiation and prevalence.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.

County-level associations between tobacco retailer density and smoking prevalence in the USA, 2012

We examine whether county-level tobacco retailer density and adult smoking prevalence are positively associated in the United States and determine whether associations differ in metropolitan vs. nonmetropolitan counties. We merged a list of likely tobacco retailers from the 2012 National Establishment Time-Series with smoking prevalence data from the Behavioral Risk Factor Surveillance System for 2828 US counties, as well as state tobacco policy information and county-level demographic data for the same year. We modeled adult smoking prevalence as a function of tobacco retailer density, accounting for clustering of counties within states. Average density in US counties was 1.25 retailers per 1000 people (range = 0.3–4.5). Smoking prevalence was 0.86 percentage points higher in the most retailer-dense counties, compared to the least. This association, however, was only significant for metropolitan counties. Metropolitan counties in the highest tobacco retailer density quartile had smoking prevalence levels that were 1.9 percentage points higher than metropolitan counties in the lowest density quartile. Research should examine whether policies limiting the quantity, type and location of tobacco retailers could reduce smoking prevalence.

Social and Physical Environmental Characteristics Associated With Adult Current Cigarette Smoking

INTRODUCTION

Our objective was to identify social and physical environmental factors associated with current cigarette smoking among adults by metropolitan county in the United States.

METHODS

We linked cigarette smoking data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan Area Risk Trends (SMART) data set to 7 social and physical environmental characteristics: county type (metropolitan designation), primary care physician density, income inequality, percentage of the population that was a racial/ethnic minority, violent crime rate, education, and percentage of county residents with low income and no health insurance, all obtained from several county data sets. Spatial regression and hierarchical logistic regression modeling were performed.

RESULTS

Results showed that metropolitan counties with a high proportion of non-Hispanic white adults (P < .001), lower education levels (high school graduate or less) (P < .001), and high violent crime rates (P < .001) had a higher adult cigarette smoking prevalence than other metropolitan counties. Spatial models showed 63.3% of the variability in county cigarette smoking prevalence was explained by these 3 factors as well as county type (based on population size of the of metropolitan area), primary care physician density, and percentage of county residents with low income and no health insurance. At an individual level, results showed that as the density (population) of primary care physicians increased in a county, the odds of being a current smoker decreased (OR, 0.980; P = .02).

CONCLUSION

We found a significant association between adult cigarette smoking and county social and physical environmental factors. These place-based factors, especially social environmental characteristics, may reveal tobacco-related disparities to be considered when developing strategies to reduce tobacco use.

Residential environments and smoking behaviour patterns among young adults: A prospective study using data from the Interdisciplinary Study of Inequalities in Smoking cohort

Young adults have the highest prevalence of smoking among all age groups. Studies have shown associations between presence/density of tobacco retail and presence of smoker accommodation and smoking prevalence. However, little is known about their potential to influence different smoking patterns including initiation, maintenance, or cessation. This is important because smoking behaviour patterns in young adults may be subject to ongoing changes. Moreover, smoking pattern determinants may be different to those of smoking prevalence, and feature-pattern associations may be scale-dependent, requiring the consideration of different analytical spatial units. We examined associations between prospectively-measured smoking behaviour patterns and presence/density of tobacco retail, and presence of smoker accommodation facilities across 2 nested spatial units in Montreal, Canada. Data were from 18 to 25 year-old Montreal residents who had participated in the Interdisciplinary Study of Inequalities in Smoking cohort both at baseline in 2011-2012 and follow-up in 2014 and resided in the same area at follow-up. 2-year smoking behaviour patterns were assessed for 2 cohorts based on participants' smoking status at baseline. Associations were examined using multilevel logistic models. Young adults who were smokers at baseline residing in areas with higher local-level presence of tobacco retail were less likely to quit smoking (i.e.: to be non-smokers for fewer than 2 years). Higher presence of smoker accommodation was not associated with smoking patterns at any scale. Findings provide evidence of scale-specific associations between residential environment features and smoking behaviour patterns in young adults, which may point to specific exposure-outcome processes underlying these associations.

The Relationship between Tobacco Retailer Density and Neighborhood Demographics in Ohio

INTRODUCTION

Studies from various parts of the country suggest that tobacco-related health disparities are exacerbated by disparities in the distribution of tobacco retailers (convenience stores, tobacco shops, etc.). The purpose of the present study was to use advanced spatial modeling techniques for count data to estimate current disparities in tobacco retailer density in Ohio.

METHODS

We identified and geocoded 11,392 tobacco retailers in Ohio. Next, we obtained census tract-level information on race/ethnicity, poverty, and age and obtained county-level information on whether an area was Urban, Suburban, or Rural. Finally, we used negative binomial generalized linear models, adapted for residual spatial dependence, to determine the association between per capita tobacco retailer density and demographic characteristics-summarized by adjusted rate ratios.

RESULTS

There were more (from 1.4-1.9 times as many) retailers per capita in high-poverty, vs. low-poverty tracts. Poverty also interacted with age: the association between high poverty and high retailer density was stronger for tracts with a low youth population. Density was also greater in tracts with a high (vs. low) prevalence of African Americans (1.1 times as many) and Hispanics (1.2 times as many). Finally, density was generally greater in rural (vs. suburban or urban) tracts, although the effect was modified by a three-way interaction: density was particularly high for rural tracts that also had both a high prevalence of poverty and a low youth population.

DISCUSSION

Overall, our findings indicate that Ohio's vulnerable populations are exposed to a greater per capita density of tobacco retailers.

PUBLIC HEALTH IMPLICATIONS

There is a need for state and local-level tobacco control policies that will improve equity and reduce health disparities.

Epidemiological trends and risk factors for tobacco, alcohol and drug use among adolescents in Scotland, 2002-13

BACKGROUND

This study estimates trends in prevalence, and patterns, of individual and multiple substance use between 2002 and 2013 amongst adolescents in Scotland.

METHODS

The study uses data from 134 387 participants of the biennial national 'Scottish Schools Adolescent Lifestyle and Substance Use Survey' on smoking, alcohol and illicit drug use. Current regular use and current heavy use of smoking, alcohol, illicit drugs and multiple substances was measured. Time trends in the prevalence of each outcome were estimated using univariate and multivariate logistic regression.

RESULTS

Regular smoking, alcohol, illicit drug and multiple substance use declined significantly amongst adolescents in Scotland. However, multivariate analyses that focussed upon high-risk levels of these behaviours revealed an upward linear trend in heavy alcohol (OR = 1.06; 95% CI: 1.04, 1.07) and heavy illicit drug (OR = 1.04; 95% CI: 1.00, 1.08) use (P < 0.05). Non-white pupils were more likely to be involved in individual and multiple substance use than ethnically white British pupils. In comparison to pupils from the least deprived socioeconomic quintile, pupils from the most deprived quintile had increased odds of 1.41 (95% CI: 1.02, 1.97; P < 0.05) and 1.62 (95% CI: 1.14, 2.29; P < 0.05) of being regular and heavy multiple substance users, respectively.

CONCLUSIONS

Further effort is required to tackle heavy alcohol and heavy illicit drug use amongst adolescents in Scotland. Prevention strategies should be informed by the risk profiles of substance misusers and evidence around the clinical and cost-effectiveness of preventive interventions.

The Influence of Tobacco Retailer Density and Poverty on Tobacco Use in a Densely Populated Urban Environment

OBJECTIVES

Researchers have identified associations between neighborhood-level factors (eg, income level, tobacco retailer density) and smoking behavior, but few studies have assessed these factors in urban environments. We explored the effect of tobacco retailer density, neighborhood poverty, and housing type (multiunit and public) on smoking in a large urban environment (New York City).

METHODS

We used data on smoking prevalence and individual sociodemographic characteristics from the 2011-2013 New York City Community Health Survey, data on tobacco retailers from the 2012 New York City Department of Consumer Affairs, data on neighborhood sociodemographic characteristics and population density from the 2009-2013 American Community Survey, and data on multiunit and public housing from the 2012 New York City Primary Land Use Tax Lot Output data set. We used aggregate neighborhood-level variables and ordinary least squares regression, geographic weighted regression, and multilevel models to assess the effects of tobacco retailer density and neighborhood poverty on smoking prevalence, adjusting for sociodemographic characteristics (age, sex, race/ethnicity, and education) and neighborhood population density. We also assessed interactions between tobacco retailer density and poverty and each housing type on smoking.

RESULTS

Neighborhood poverty positively and significantly modified the association between tobacco retailer density and prevalence of neighborhood smoking ( β = 0.003, P = .01) when we controlled for population density, sociodemographic characteristics, and types of housing. Neighborhood poverty was positively associated with the prevalence of individual smoking ( β = 0.0099, P < .001) when we adjusted for population density, sociodemographic characteristics, and type of housing.

CONCLUSION

More research is needed to determine all the environmental factors associated with smoking prevalence in a densely populated urban environment.

Neighbourhood tobacco supply and individual maternal smoking during pregnancy: a fixed-effects longitudinal analysis using routine data

BACKGROUND

Tobacco policy is increasingly focusing on the 'tobacco endgame' which commits to eradicating tobacco use (prevalence below 5%) within the next two decades. Strategies for achieving the endgame are likely to include addressing the supply of tobacco products, yet current evidence to support this approach is primarily cross-sectional.

METHODS

We use longitudinal smoking information from routine maternity records of all women who gave birth in Scotland between 2000 and 2015. We linked this data to the residential density of retailers selling tobacco products and the neighbourhood prevalence of smoking during pregnancy. In the analysis, individual mothers act as their own controls because we compare changes in their smoking behaviour between pregnancies to changes in exposure to tobacco retailing that arises from residential movement between pregnancies.

RESULTS

Adjusted ORs showed an increased risk of being a smoker associated with increases in exposure to retailer density (OR 1.67, 95% CI 1.27 to 2.20).

CONCLUSIONS

The results provide the strongest evidence to date of an association between the neighbourhood availability of tobacco and smoking, and the first to do so among pregnant women. These findings provide supportive evidence for interventions targeting the supply of tobacco products in achieving the endgame.

Regulating the local availability of tobacco retailing in Madrid, Spain: a GIS study to evaluate compliance

Background

In Spain, tobacco sales are limited to tobacco-exclusive stores and associated vending machines. A minimum of 150 m between stores is required, unless they exceed a legal sales threshold. Minimum distances to schools are recommended but not defined. We evaluated compliance with these regulations in Madrid, Spain.

Methods

Information about tobacco-exclusive stores and their sales volume was obtained in 2014. We used geographic information system to identify stores closer than 150 m between them and examine whether they exceeded the sales threshold. We estimated distances between stores and schools, considering different distance intervals (<150 m, 150–300 m and >300 m) and calculations (crow flies and street network). We assessed the association of area-level demographic and socioeconomic characteristics with the distribution of tobacco stores.

Results

5.3% (34/638) of tobacco stores were within 150 m of each other. Among those, 76% (26/34) did not meet the regulation sales threshold. These stores were in areas with lower proportion of young population (<15 years) and higher proportion of people with university-level education. 75% (476/638) of stores were situated closer than 300 m to schools. No differences were identified in sociodemographic and economic characteristics by the store distance to schools.

Conclusion

Most tobacco stores are compliant with the regulations in Spain. However, these regulations are insufficient to reduce tobacco availability. More restrictive regulations are needed to limit the geographic distribution of tobacco retailers, and health criteria should also be considered in the current legislation. The evaluation of the Spanish regulatory model may provide useful insights for other jurisdictions looking to decrease the tobacco retail availability.

Is neighbourhood access to tobacco outlets related to smoking behaviour and tobacco-related health outcomes and hospital admissions?

OBJECTIVES

Although the harms of tobacco use are widely accepted, few studies have examined the relationship between access to tobacco outlets and hospital admissions. This study aimed to examine the relationship between neighbourhood access to tobacco outlets, smoking and hospital admissions and self-reported morbidity.

METHODS

Responses as to smoking behaviour were obtained from 12,270 adult participants in Western Australia (2003-2009) and individually record-linked to hospital admissions and geographically linked to tobacco outlets.

RESULTS

Neighbourhood access to tobacco outlets was marginally positively associated with being a current versus a past smoker. Tobacco outlet access was also positively associated with heart disease for smokers but not non-smokers. For smokers, each additional outlet within 1600m of home was associated with a 2% increase in the odds of heart disease.

CONCLUSION

Smokers with greater access to tobacco outlets were more likely to be diagnosed with or admitted to hospital for heart disease. Regulating the density of tobacco outlets in the community has immense potential to improve health benefits and our results motivate the need for future longitudinal studies to confirm this hypothesis.

Geographic density and proximity of vape shops to colleges in the USA

BACKGROUND

Vape shops have been spreading rapidly in the USA since 2008, catering to the fast-growing market for electronic cigarettes. Little is known about the geographic density and proximity of vape shops near colleges.

METHODS

Names and addresses of vape shops were collected from 3 online directories: Yelp.com, Yellowpages.com and Guidetovaping.com. We identified the prevalence of US-based vape shops and their density and proximity to colleges using a geographic information system. General linear model and negative binomial regression were performed to examine the factors associated with proximity and density of vape shops near colleges.

RESULTS

We identified 9945 vape shops in the USA as of December 2015, a nearly threefold increase from 2013. Among the 2755 colleges included in this study, 66.5% had at least 1 vape shop within a 3-mile radius. The median proximity of the nearest vape shop to each college/university was 1.8 miles. Proximity increased by student population, private as compared to public institutions, and location (city vs rural). Within a 1-mile radius, colleges with smoke-free campus policies had a lower density of vape shops (RR=0.6, p=0.002) than those without smoke-free campus policies. Private institutions had a higher density of vape shops (RR=7.8, p<0.0001) than did public institutions. Colleges with campus housing had a lower density of vape shops (RR=0.4, p<0.0001) than those without campus housing, and colleges located in cities had a much higher density of vape shops than those located in rural areas (RR=6.6, p<0.0001). Smoke-free and e-cigarette-free campus policies had significant interactions with college type (private vs public) and campus housing in reducing vape shop density.

CONCLUSIONS

Vape shops are more likely to be located near private institutions and colleges in cities as opposed to rural areas. Smoke-free and e-cigarette-free campus policies have had significant effects in reducing the density of vape shops but have not reduced the proximity of vape shops to colleges. Regulations on the sale and advertisement of e-cigarettes to youth and young adults are critically needed.

Neighbourhood disadvantage and smoking: Examining the role of neighbourhood-level psychosocial characteristics

PURPOSE

This study aims to determine if neighbourhood psychosocial characteristics contribute to inequalities in smoking among residents from neighbourhoods of differing socioeconomic disadvantage.

METHODS

This cross-sectional study includes 11,035 residents from 200 neighbourhoods in Brisbane, Australia in 2007. Self-reported measures were obtained for smoking and neighbourhood psychosocial characteristics (perceptions of incivilities, crime and safety, and social cohesion). Neighbourhood socioeconomic disadvantage was measured using a census-derived index. Data were analysed using multilevel logistic regression random intercept models.

RESULTS

Smoking was associated with neighbourhood disadvantage; this relationship remained after adjustment for individual-level socioeconomic position. Area-level perceptions of crime and safety and social cohesion were not independently associated with smoking, and did not explain the higher prevalence of smoking in disadvantaged areas; however, perceptions of incivilities showed an independent effect.

CONCLUSIONS

Some neighbourhood psychosocial characteristics seem to contribute to the higher rates of smoking in disadvantaged areas.

Geographic Variation in Maternal Smoking during Pregnancy in the Missouri Adolescent Female Twin Study (MOAFTS)

Objective

Despite well-known adverse health effects of maternal smoking during pregnancy (MSP), it is still unclear if MSP varies geographically and if neighborhood socioeconomic deprivation (SED) plays an important role in MSP. This study aims to investigate small-area geographic variation in MSP and examine the association of SED with MSP.

Methods

The Missouri Adolescent Female Twin Study (MOAFTS) is a cohort study of female like-sex twins born in Missouri to Missouri-resident parents during 1975–1985. Biological mothers completed a baseline interview in 1995–1998 and reported MSP with the twins. Residential address of the mother at birth was geocoded. We developed a census tract-level SED index using a common factor approach based on 21 area-level socioeconomic variables from the 1980 Census data. Multilevel logistic regressions estimated geographic heterogeneity (random effect) in MSP and the odds ratios (ORs, fixed effects) of neighborhood SED associated with MSP.

Results

Of 1658 MOAFTS mothers, 35.2% reported any MSP and 21.9% reported MSP beyond the first trimester. Neighborhood SED was associated with any MSP (the highest vs. the lowest quartile: OR = 1.90, 95% confidence interval [CI] = 1.40–2.57, P_trend<0.001) and MSP beyond the first trimester (OR = 1.98, 95% CI = 1.38–2.85, P_trend = 0.002) in unadjusted analyses. After adjusting for individual covariates (demographics, socioeconomic conditions, alcohol use, and parents’ cohabitation), neighborhood SED was not associated with MSP, but geographic variation still persisted in MSP (variance = 0.41, P = 0.003) and in MSP beyond the first trimester (variance = 0.82, P<0.001).

Conclusions

Neighborhood SED was associated with MSP in unadjusted analyses but this association could be explained by individual socioeconomic conditions. Nonetheless, significant geographic variation in MSP persisted and was not accounted for by differences in neighborhood SED. To develop effective interventions to reduce MSP, further studies are necessary to explore underlying reasons for its geographic variation.

Beyond Smoking Prevalence: Exploring the Variability of Associations between Neighborhood Exposures across Two Nested Spatial Units and Two-Year Smoking Trajectory among Young Adults

Young adults have the highest prevalence of smoking amongst all age groups. Significant uptake occurs after high school age. Although neighborhood exposures have been found to be associated with smoking behavior, research on neighborhood exposures and the smoking trajectories among young adults, and on the role of geographic scale in shaping findings, is scarce. We examined associations between neighborhood exposures across two nested, increasingly large spatial units and smoking trajectory over two years among young adults living in Montreal, Canada. A sample of 2093 participants aged 18-25 years from the Interdisciplinary Study of Inequalities in Smoking (ISIS) was surveyed. The dependent variable was self-reported smoking trajectory over the course of two years. Residential addresses, data on presence of tobacco retail outlets, and the presence of smoking accommodation facilities were coded and linked to spatial units. Three-level multinomial models were used to examine associations. The likelihood of being a smoker for 2+ years was significantly greater among those living in larger spatial unit neighborhoods that had a greater presence of smoking accommodation. This association was not statistically significant at the smaller spatial units. Our findings highlight the importance of studying young adults' smoking trajectories in addition to static smoking outcomes, and point to the relevance of considering spatial scale in studies of neighborhoods and smoking.

The density of tobacco retailers in home and school environments and relationship with adolescent smoking behaviours in Scotland

BACKGROUND

Neighbourhood retailing of tobacco products has been implicated in affecting smoking prevalence rates. Long-term smoking usually begins in adolescence and tobacco control strategies have often focused on regulating 'child spaces', such as areas in proximity to schools. This cross-sectional study examines the association between adolescent smoking behaviour and tobacco retail outlet density around home and school environments in Scotland.

METHODS

Data detailing the geographic location of every outlet registered to sell tobacco products in Scotland were acquired from the Scottish Tobacco Retailers Register and used to create a retail outlet density measure for every postcode. This measure was joined to individual responses of the Scottish Schools Adolescent Lifestyle and Substance Use Survey (n=20 446). Using logistic regression models, we explored the association between the density of retailers, around both home and school address, and smoking behaviours.

RESULTS

Those living in the areas of highest density of retailers around the home environment had 53% higher odds of reporting having ever smoked (95% CI 1.27 to 1.85, p<0.001) and 47% higher odds of reporting current smoking (95% CI 1.13 to 1.91 p<0.01). Conversely, those attending schools in areas of highest retail density had lower odds of having ever smoked (OR 0.66, 95% CI 0.50 to 0.86 p<0.01) and lower odds of current smoking (OR 0.75, 95% CI 0.59 to 0.95, p<0.05).

CONCLUSIONS

The density of tobacco retail outlets in residential neighbourhoods is associated with increased odds of both ever smoked and current smoking among adolescents in Scotland. Policymakers may be advised to focus on reducing the overall density of tobacco outlets, rather than concentrating on 'child spaces'.

Do changes in neighborhood and household levels of smoking and deprivation result in changes in individual smoking behavior? A large-scale longitudinal study of New Zealand adults

Health behavior takes place within social contexts. In this study, we investigated whether changes in exposure to neighborhood deprivation and smoking prevalence and to household smoking were associated with change in personal smoking behavior. Three waves of biannual data collection (2004-2009) in a New Zealand longitudinal study, the Survey of Family, Income and Employment (SoFIE)-Health, were used, with 13,815 adults (persons aged ≥15 years) contributing to the analyses. Smoking status was dichotomized as current smoking versus never/ex-smoking. Fixed-effects regression analyses removed time-invariant confounding and adjusted for time-varying covariates (neighborhood smoking prevalence and deprivation, household smoking, labor force status, income, household tenure, and family status). A between-wave decile increase in neighborhood deprivation was significantly associated with increased odds of smoking (odds ratio (OR) = 1.08, 95% confidence interval (CI): 1.02, 1.14), but a between-wave increase in neighborhood smoking prevalence was not (OR = 1.04, 95% CI: 0.98, 1.10). Changing household exposures between waves to live with another smoker (compared with a nonsmoker (referent)) increased the odds of smoking (OR = 2.48, 95% CI: 1.84, 3.34), as did changing to living in a sole-adult household (OR = 1.52, 95% CI: 1.07, 2.14). Tobacco control policies and programs should address the broader household and neighborhood circumstances within which individual smoking takes place.

The added value of accounting for activity space when examining the association between tobacco retailer availability and smoking among young adults

BACKGROUND

Despite a declining prevalence in many countries, smoking rates remain consistently high among young adults. Targeting contextual influences on smoking, such as the availability of tobacco retailers, is one promising avenue of intervention. Most studies have focused on residential or school neighbourhoods, without accounting for other settings where individuals spend time, that is, their activity space. We investigated the association between tobacco retailer availability in the residential neighbourhood and in the activity space, and smoking status.

METHODS

Cross-sectional baseline data from 1994 young adults (aged 18-25) participating in the Interdisciplinary Study of Inequalities in Smoking (Montreal, Canada, 2011-2012) were analysed. Residential and activity locations served to derive two measures of tobacco retailer availability: counts within 500 m buffers and proximity to the nearest retailer. Prevalence ratios for the association between each tobacco retailer measure and smoking status were estimated using log-binomial regression.

RESULTS

Participants encountering high numbers of tobacco retailers in their residential neighbourhood, and both medium and high retailer counts in their activity space, were more likely to smoke compared to those exposed to fewer retailers. While residential proximity was not associated with smoking, we found 36% and 42% higher smoking prevalence among participants conducting activities within medium and high proximity to tobacco retailers compared to those conducting activities further from such outlets.

CONCLUSIONS

This study adds to the sparse literature on contextual correlates of smoking among young adults, and illustrates the added value of considering individuals' activity space in contextual studies of smoking.

"Dinner's ready!" A qualitative exploration of the food domain across the lifecourse

The influence of the childhood food domain on adult food-related practices is only partially understood. Through an interpretive study using in-depth life-story interviewing and narrative analysis, we aimed to discover how preferences and perceptions relating to the food domain become embodied during childhood, and once embodied, how these influence practices in adulthood. We observed distinct 'food mood' pathways seemingly anchored in childhood memories about dinnertime. One pathway led to food philosophies participants perceived to be beneficial for their health and wellbeing, whilst another led to perceptions of food as a chore and bore they would rather ignore. Parental attitudes were very important to the food domain of childhood, as this is now recalled through life-story narratives. Our findings suggest a positive relationship with the food domain needs to be fostered during childhood for the long-term protection and promotion of health and wellbeing in adulthood.

Tobacco Retail Environments and Social Inequalities in Individual-Level Smoking and Cessation Among Scottish Adults

INTRODUCTION

Many neighborhood characteristics may constrain or enable smoking. This study investigated whether the neighborhood tobacco retail environment was associated with individual-level smoking and cessation in Scottish adults, and whether inequalities in smoking status were related to tobacco retailing.

METHODS

Tobacco outlet density measures were developed for neighborhoods across Scotland using the September 2012 Scottish Tobacco Retailers Register. The outlet data were cleaned and geocoded (n = 10,161) using a Geographic Information System. Kernel density estimation was used to calculate an outlet density measure for each postcode. The kernel density estimation measures were then appended to data on individuals included in the 2008-2011 Scottish Health Surveys (n = 28,751 adults aged ≥16), via their postcode. Two-level logistic regression models examined whether neighborhood density of tobacco retailing was associated with current smoking status and smoking cessation and whether there were differences in the relationship between household income and smoking status, by tobacco outlet density.

RESULTS

After adjustment for individual- and area-level confounders, compared to residents of areas with the lowest outlet densities, those living in areas with the highest outlet densities had a 6% higher chance of being a current smoker, and a 5% lower chance of being an ex-smoker. There was little evidence to suggest that inequalities in either current smoking or cessation were narrower in areas with lower availability of tobacco retailing.

CONCLUSIONS

The findings suggest that residents of environments with a greater availability of tobacco outlets are more likely to start and/or sustain smoking, and less likely to quit.

Theoretical impacts of a range of major tobacco retail outlet reduction interventions: modelling results in a country with a smoke-free nation goal

OBJECTIVE

To inform endgame strategies in tobacco control, this study aimed to estimate the impact of interventions that markedly reduced availability of tobacco retail outlets. The setting was New Zealand, a developed nation where the government has a smoke-free nation goal in 2025.

METHODS

Various legally mandated reductions in outlets that were phased in over 10 years were modelled. Geographic analyses using the road network were used to estimate the distance and time travelled from centres of small areas to the reduced number of tobacco outlets, and from there to calculate increased travel costs for each intervention. Age-specific price elasticities of demand were used to estimate future smoking prevalence.

RESULTS

With a law that required a 95% reduction in outlets, the cost of a pack of 20 cigarettes (including travel costs) increased by 20% in rural areas and 10% elsewhere and yielded a smoking prevalence of 9.6% by 2025 (compared with 9.9% with no intervention). The intervention that permitted tobacco sales at only 50% of liquor stores resulted in the largest cost increase (∼$60/pack in rural areas) and the lowest prevalence (9.1%) by 2025. Elimination of outlets within 2 km of schools produced a smoking prevalence of 9.3%.

CONCLUSIONS

This modelling merges geographic, economic and epidemiological methodologies in a novel way, but the results should be interpreted cautiously and further research is desirable. Nevertheless, the results still suggest that tobacco outlet reduction interventions could modestly contribute to an endgame goal.

Spatial and temporal patterns of smoking prevalence in Ontario

BACKGROUND

Smoking prevalence varies over time and place due to various social, environmental and policy influences. However, its spatio-temporal patterns at small-area level are poorly understood. This paper attempts to describe spatio-temporal patterns of adult (age > 18) and youth (age 12-18) smoking prevalence at the municipality level in Ontario, Canada and identify potential socio-demographic, environmental, and policy factors that may affect the patterns.

METHODS

Multilevel temporal and spatio-temporal models were fitted to the Canadian Community Health Surveys (2000-2008) data. In total, approximately 160,000 respondents 12 years of age and over living in Ontario were used for this analysis.

RESULTS

The results indicate that during the time period 2003-2008, age-sex stratified smoking prevalence dropped for both the adult and youth populations in Ontario. The tendency is more obvious for youth than for adults. Smoking restriction at home is a leading factor associated with the decline of adult smoking prevalence, but does not play the same role for youth smoking. Despite the overall reduction, smoking prevalence varies considerably across the province and inequalities among municipalities have increased. Clusters of high and low smoking prevalence are both found within the study region.

CONCLUSION

The identified spatial and temporal variations help to indicate problems at the local level and suggest future research directions. Identifying these variations helps to strengthen surveillance and monitoring of smoking behaviours and the evaluation of policy and program development at the small-area level.

Neighborhood environment perceptions and the likelihood of smoking and alcohol use

Neighborhood characteristics are important correlates for a variety of health outcomes. Among several health risk behaviors, smoking and alcohol use have significant consequences. Perceptions of neighborhood problems are associated with depressive symptoms, lower physical activity, and lower quality of life. However, it is unclear which perceived aspects of neighborhoods might be related to smoking and drinking. We examined whether perceived neighborhood characteristics were associated with smoking and drinking patterns using data from US metropolitan Midwestern area adults. Participants completed surveys including sociodemographic characteristics, neighborhood perceptions, behavioral and psychological health. For men, negative perceptions of neighborhood infrastructures were significant predictors for smoking and binge drinking. Among women, no perceived environmental factors were associated with smoking or drinking. However, education was a significant negative predictor for smoking. As age increased, the likelihood of using cigarettes, heavy and binge drinking in women decreased significantly. Depression was a positive predictor for smoking and heavy drinking in men and women, respectively. These findings indicate that the perceived neighborhood infrastructure was predictive of health behaviors among men, even after adjusting for key confounders. Closer attention may need to be paid to the role of neighborhood environmental characteristics along with individual-level characteristics in influencing unhealthy behaviors.

The impact of the tobacco retail outlet environment on adult cessation and differences by neighborhood poverty

AIMS

This study examined the impact of tobacco retail outlets on cessation outcomes over time among non-treatment-seeking smokers and assessed differences by neighborhood poverty and individual factors.

DESIGN

Observational longitudinal cohort study using geospatial data. We used generalized estimating equations to examine cessation outcomes in relation to the proximity and density of tobacco retail outlets near the home.

SETTING

Eight large Designated Media Areas across the United States.

PARTICIPANTS

A total of 2377 baseline smokers followed over three waves from 2008 to 2010.

MEASUREMENTS

Outlet addresses were identified through North American Industry Classification System codes and proximity and density measures were constructed for each participant at each wave. Outcomes included past 30-day abstinence and pro-cessation attitudes.

FINDINGS

Smokers in high poverty census tracts living between 500 m and 1.9 km from an outlet were over two times more likely to be abstinent than those living fewer than 500 m from an outlet (P < 0.05). Density within 500 m of home was associated with reduced abstinence [odds ratio (OR) = 0.94; confidence interval (CI) = 0.90, 0.98) and lower pro-cessation attitudes (Coeff = -0.07, CI = -0.10, -0.03) only in high poverty areas. In low poverty areas, density within 500 m was associated with greater pro-cessation attitudes (OR = 0.06; CI = 0.01, 0.12). Gender, education and heaviness of smoking did not moderate the impact of outlet proximity and density on cessation outcomes.

CONCLUSIONS

In the United States, density of tobacco outlets within 500 m of the home residence appears to be negatively associated with smoking abstinence and pro-cessation attitudes only in poor areas.

Is access to alcohol associated with alcohol/substance abuse among people diagnosed with anxiety/mood disorder?

OBJECTIVES

To investigate the relationship between access to off-license alcohol outlets and areas with dual treatment for alcohol/drug abuse and anxiety/mood disorder compared to areas with anxiety/mood disorder only in an urban setting in New Zealand.

STUDY DESIGN

Ecologic study.

METHODS

Within small areas (2840 meshblocks, mean size 0.05 km(2)) in the city of Auckland, New Zealand, counts of adults receiving anxiety/mood disorder treatment (2008-9) were identified and the proportions of these individuals also receiving treatment for alcohol/drug abuse were generated. Access to off-license alcohol outlets were defined as: 1) shortest road distance from the population-weighted centroid of each small area to an outlet; 2) count of outlets within a 3 km road network buffer; and 3) relative density of outlets across Auckland (determined through kernel density estimates). To test for the relationship between access to alcohol outlets and dual diagnosis, meshblocks without any cases of anxiety/mood disorder were excluded from analyses. Remaining meshblocks were dichotomized into any or no dual diagnosis. Logistic regression was used to estimate the association between access to alcohol outlets and treatment for the dual conditions.

RESULTS

Neighbourhoods with dual diagnosis were generally similar to those with anxiety/mood disorder only, in terms of ethnic and gender/age composition. Regression analyses indicated statistically significant decreased risk of dual diagnosis for those areas with the lowest density (using a buffer) of alcohol outlets (OR = 0.75, P-value = 0.027) compared with areas with the highest density, after adjustment for deprivation and population density. All access measures also indicated significant linear trends where dual diagnosis was more likely in areas with greater access.

CONCLUSIONS

Generally, decreased access to alcohol outlets was associated with decreased odds of dual diagnosis of alcohol/drug abuse and anxiety/mood disorder. Measures to control access to alcohol outlets may be an important area for alcohol/substance abuse intervention, particularly for vulnerable sub-populations.

Smoking during pregnancy was up to 70% more common in the most deprived municipalities - a multilevel analysis of all singleton births during 2005-2010 in Finland

OBJECTIVE

We investigated whether there was an association between maternal smoking habits during pregnancy and municipality level deprivation defined based on education, income and unemployment after adjustment for individual level covariates, including socioeconomic status (SES), in Finland, a Nordic welfare state.

METHODS

Data were gathered from the Medical Birth Register and comprised all singleton births (n=337,876) during 2005-2010. To account for any correlation of women clustered within a municipality, we fitted generalized estimating equation (GEE) models.

RESULTS

In total, 15.3% of the women with singleton pregnancies smoked during pregnancy. After adjustment for individual level confounders, smoking during pregnancy was 5.4-fold higher among women with the lowest as compared with highest individual SES. Controlling for individual SES, age and year of birth, women living in municipalities defined as intermediately and highly deprived based on education were 53.7% (adjusted odds ratio [aOR] 1.537, 95% confidence interval [CI] 1.493-1.583) and 71.5% (aOR 1.715, 95% CI 1.647-1.785), respectively, more likely to smoke during pregnancy than women in the least deprived municipalities.

CONCLUSIONS

Individual SES is the strongest correlate of smoking during pregnancy but conditional on individual variables; lower municipality aggregate education is associated with up to 70% higher smoking prevalence.

Increasing availability and consumption of single cigarettes: trends and implications for smoking cessation from the ITC Mexico Survey

OBJECTIVE

Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers.

METHODS

We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272).

FINDINGS

The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p<0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant.

CONCLUSIONS

Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.

We do not smoke but some of us are more susceptible than others: a multilevel analysis of a sample of Canadian youth in grades 9 to 12

BACKGROUND

Smoking susceptibility has been found to be a strong predictor of experimental smoking. This paper examined which student- and school-level factors differentiated susceptible never smokers from non-susceptible never smokers among a nationally representative sample of Canadian students in grades 9 to 12.

METHODS

Student-level data from the 2008-2009 Canadian Youth Smoking Survey were linked with school-level data from the 2006 Census, and one built environment characteristic (the density of tobacco retailers surrounding schools). These data were examined using multilevel logistic regression analyses.

RESULTS

The likelihood of a never smoker being susceptible to smoking significantly varied across schools (p=0.0002). Students in this study were more likely to be susceptible never smokers if they reported low self-esteem, held positive attitudes towards smoking, used alcohol or marijuana, had close friends who smoked, and came from homes without a total ban on smoking. The school location (rural versus urban), the socioeconomic status of the neighbourhood surrounding a school, and the density of tobacco retailers that were located within 1-km radius of each school were not associated with students' smoking susceptibility.

CONCLUSION

These findings underscore the continued need to develop school-based tobacco use prevention policies and/or programs that enhance students' self-esteem, address tobacco use misinformation and substance use, and include strategies targeting friends who smoke, and students who come from homes without a total ban on smoking.

Neighbourhood deprivation and smoking and quit behaviour among smokers in Mexico: findings from the ITC Mexico Survey

BACKGROUND

In high-income countries (HICs), higher neighbourhood socioeconomic deprivation is associated with higher levels of smoking. Few studies in low-income and middle-income countries (LMICs) have investigated the role of the neighbourhood environment on smoking behaviour.

OBJECTIVE

To determine whether neighbourhood socioeconomic deprivation is related to smoking intensity, quit attempts, quit success and smoking relapse among a cohort of smokers in Mexico from 2010 to 2012.

METHODS

Data were analysed from adult smokers and recent ex-smokers who participated in waves 4-6 of the International Tobacco Control (ITC) Mexico Survey. Data were linked to the Mexican government's composite index of neighbourhood socioeconomic deprivation, which is based on 2010 Mexican Census data. We used generalised estimating equations to determine associations between neighbourhood deprivation and individual smoking behaviours.

FINDINGS

Contrary to past findings in HICs, higher neighbourhood socioeconomic deprivation was associated with lower smoking intensity. Quit attempts showed a U-shaped pattern whereby smokers living in high/very high deprivation neighbourhoods and smokers living in very low deprivation neighbourhoods were more likely to make a quit attempt than smokers living in other neighbourhoods. We did not find significant differences in neighbourhood deprivation on relapse or successful quitting, with the possible exception of people living in medium-deprivation neighbourhoods having a higher likelihood of successful quitting than people living in very low deprivation neighbourhoods (p=0.06).

CONCLUSIONS

Neighbourhood socioeconomic environments in Mexico appear to operate in an opposing manner to those in HICs. Further research should investigate whether rapid implementation of strong tobacco control policies in LMICs, as occurred in Mexico during the follow-up period, avoids the concentration of tobacco-related disparities among socioeconomically disadvantaged groups.

Cigarette smoking prevalence in US counties: 1996-2012

BACKGROUND

Cigarette smoking is a leading risk factor for morbidity and premature mortality in the United States, yet information about smoking prevalence and trends is not routinely available below the state level, impeding local-level action.

METHODS

We used data on 4.7 million adults age 18 and older from the Behavioral Risk Factor Surveillance System (BRFSS) from 1996 to 2012. We derived cigarette smoking status from self-reported data in the BRFSS and applied validated small area estimation methods to generate estimates of current total cigarette smoking prevalence and current daily cigarette smoking prevalence for 3,127 counties and county equivalents annually from 1996 to 2012. We applied a novel method to correct for bias resulting from the exclusion of the wireless-only population in the BRFSS prior to 2011.

RESULTS

Total cigarette smoking prevalence varies dramatically between counties, even within states, ranging from 9.9% to 41.5% for males and from 5.8% to 40.8% for females in 2012. Counties in the South, particularly in Kentucky, Tennessee, and West Virginia, as well as those with large Native American populations, have the highest rates of total cigarette smoking, while counties in Utah and other Western states have the lowest. Overall, total cigarette smoking prevalence declined between 1996 and 2012 with a median decline across counties of 0.9% per year for males and 0.6% per year for females, and rates of decline for males and females in some counties exceeded 3% per year. Statistically significant declines were concentrated in a relatively small number of counties, however, and more counties saw statistically significant declines in male cigarette smoking prevalence (39.8% of counties) than in female cigarette smoking prevalence (16.2%). Rates of decline varied by income level: counties in the top quintile in terms of income experienced noticeably faster declines than those in the bottom quintile.

CONCLUSIONS

County-level estimates of cigarette smoking prevalence provide a unique opportunity to assess where prevalence remains high and where progress has been slow. These estimates provide the data needed to better develop and implement strategies at a local and at a state level to further reduce the burden imposed by cigarette smoking.

Socioeconomic and geographic inequalities in adolescent smoking: a multilevel cross-sectional study of 15 year olds in Scotland

The objective of the study was to present socioeconomic and geographic inequalities in adolescent smoking in Scotland. The international literature suggests there is no obvious pattern in the geography of adolescent smoking, with rural areas having a higher prevalence than urban areas in some countries, and a lower prevalence in others. These differences are most likely due to substantive differences in rurality between countries in terms of their social, built and cultural geography. Previous studies in the UK have shown an association between lower socioeconomic status and smoking. The Scottish Health Behaviour in School-aged Children study surveyed 15 year olds in schools across Scotland between March and June of 2010. We ran multilevel logistic regressions using Markov chain Monte Carlo method and adjusting for age, school type, family affluence, area level deprivation and rurality. We imputed missing rurality and deprivation data using multivariate imputation by chained equations, and re-analysed the data (N = 3577), comparing findings. Among boys, smoking was associated only with area-level deprivation. This relationship appeared to have a quadratic S-shape, with those living in the second most deprived quintile having highest odds of smoking. Among girls, however, odds of smoking increased with deprivation at individual and area-level, with an approximate dose-response relationship for both. Odds of smoking were higher for girls living in remote and rural parts of Scotland than for those living in urban areas. Schools in rural areas were no more or less homogenous than schools in urban areas in terms of smoking prevalence. We discuss possible social and cultural explanations for the high prevalence of boys' and girls' smoking in low SES neighbourhoods and of girls' smoking in rural areas. We consider possible differences in the impact of recent tobacco policy changes, primary socialization, access and availability, retail outlet density and the home environment.

The association of recreational space with youth smoking in low-socioeconomic status neighborhoods in Santiago, Chile

OBJECTIVES

This study examines the relationship of neighborhood recreational space with youth smoking in mid- to low-income areas in the capital of Chile, Santiago.

METHODS

A unique data set of adolescents (n = 779, mean age = 14, 51 % male) provided home addresses of study participants which were geocoded and mapped. Satellite maps of neighborhoods were used to identify open spaces for recreational use (e.g., soccer fields and plazas). Thiessen polygons were generated to associate study participants with the nearest available open space using ArcGIS. Regression models, with smoking as a dependent variable, were estimated in which age, sex, family socioeconomic status, peer substance usage, neighborhood crime, and accessibility of open space were covariates.

RESULTS

The results show that residential proximity to recreational space was significantly and inversely associated with tobacco consumption among female, but not male, adolescents. Age and neighborhood crime were both positively associated with tobacco consumption among both male and female adolescents.

CONCLUSIONS

This study suggests that recreational spaces in proximity to residences may have a positive impact on reducing adolescents' inclination to consume tobacco. The relationship of the accessibility to such spaces with smoking appears to vary by adolescents' sex.

Tobacco retail availability and smoking behaviours among patients seeking treatment at a nicotine dependence treatment clinic

Background

Availability of tobacco may be associated with increased smoking. Little is known about how proximity to a retail outlet is associated with smoking behaviours among smokers seeking treatment.

Methods

A cross sectional study was conducted using chart data was extracted for 734 new clients of a nicotine dependence clinic in Toronto, Canada who visited during the period April 2008 to June 2010. Using a tobacco retail licensing list, clients were coded as to whether there were 0, 1, or more than 1 retail outlet located 250 m from their postal code address. Conditional fixed effects regression analyses were used to assess the association between proximity and quit status, number of previous quit attempts, number of cigarettes per day, and time to first cigarette, controlling for demographic characteristics and neighbourhood.

Results

72% of patients lived within 250 m of a retail outlet. Those who had more than one outlet with 250 m of their address were less likely to be abstinent at the initial assessment (OR = 0.45; 95% CI: 0.23, 0.87; p = 0.014) and less likely to have a longer time to first cigarette (OR = 0.60; 95% CI: 0.45, 0.79), both before and after adjustment for covariates. Smokers who had at least one outlet within 250 m of their address smoked 3.4 cigarettes more per day than smokers without an outlet after controlling for neighbourhood and covariates. There was no significant association between proximity and lifetime number of quit attempts.

Conclusions

Proximity to a tobacco retail outlet was associated with smoking behaviours among a heavily addicted, treatment seeking population. Environmental factors may have a substantial impact on the ability of smokers to quit smoking.

Availability of convenience stores and adolescent alcohol use in Taiwan: a multi-level analysis of national surveys

AIM

To examine the association between alcohol in school environments and adolescent alcohol use over the previous 6 months.

DESIGN

A multi-level logistic regression analysis was performed of cross-sectional surveys conducted in 2004, 2005 and 2006.

PARTICIPANTS AND SETTING

A total of 52 214 students aged 11-19 years from 387 middle or high schools were selected from a nationally representative, multi-stage, stratified probability sampling across Taiwan.

MEASUREMENTS

Information on socio-demographic features and substance use experiences was collected using self-administered questionnaires. The alcohol in the environment was measured using the availability of convenience stores surrounding the schools. Using geographical information systems, the weighted numbers of convenience stores within 1 km, a 12-15-minute walk, of a school were calculated. The schools were later categorized into three subgroups via the tertile of nearby convenience stores.

FINDINGS

Considering the compositional characteristics, the availability of convenience stores was found to account for 1.5% of the school-level variance of youthful drinking. The odds ratios (95% confidence interval) of alcohol use over the previous 6 months among youth attending schools with medium and high availability were 1.04 (0.96-1.13) and 1.08 (1.00-1.17), respectively, with a P-value of 0.04 in the trend test.

CONCLUSION

The greater availability of convenience stores near a school is associated with an increased risk of alcohol use among adolescents over the previous 6 months.

Predictors of tobacco outlet density nationwide: a geographic analysis

OBJECTIVE

To elucidate how demographics of US Census tracts are related to tobacco outlet density (TOD).

METHOD

The authors conducted a nationwide assessment of the association between socio-demographic US Census indicators and the density of tobacco outlets across all 64,909 census tracts in the continental USA. Retail tobacco outlet addresses were determined through North American Industry Classification System codes, and density per 1000 population was estimated for each census tract. Independent variables included urban/rural; proportion of the population that was black, Hispanic and women with low levels of education; proportion of families living in poverty and median household size.

RESULTS

In a multivariate analysis, there was a higher TOD per 1000 population in urban than in rural locations. Furthermore, higher TOD was associated with larger proportions of blacks, Hispanics, women with low levels of education and with smaller household size. Urban-rural differences in the relation between demographics and TOD were found in all socio-demographic categories, with the exception of poverty, but were particularly striking for Hispanics, for whom the relation with TOD was 10 times larger in urban compared with rural census tracts.

CONCLUSIONS

The findings suggest that tobacco outlets are more concentrated in areas where people with higher risk for negative health outcomes reside. Future studies should examine the relation between TOD and smoking, smoking cessation, as well as disease rates.

Using student and school factors to differentiate adolescent current smokers from experimental smokers in Canada: a multilevel analysis

OBJECTIVE

In order to understand the factors that differentiate adolescents who have tried smoking from those who have become established smokers, this study examined which student- and school-level factors differentiated current smokers from experimental smokers among a nationally representative sample of Canadian secondary school students.

METHOD

Student-level secondary data from the 2008-2009 Canadian Youth Smoking Survey was linked with school-level data from the 2006 Census and one built environment characteristic, and examined using multilevel logistic regression analyses.

RESULTS

The current smoking rates varied (P<0.001) across schools. The number of tobacco retailers surrounding the schools was associated with current smoking when adjusting for student characteristics. Additionally, students were more likely to be current smokers if they were: male, in higher grades, believed that smoking can help when they are bored, reported low school connectedness, used marijuana, had a sibling or close friend who smoked, and had no smoking bans at home.

CONCLUSIONS

These study findings suggest that school anti-smoking strategies need to target males, increase students' attachment to their school, address tobacco-related beliefs, and include interventions targeting smoking siblings and friends. The government should consider zoning restrictions to limit sales of tobacco products near schools.

Tobacco smoking and its association with illicit drug use among young men aged 15-24 years living in urban slums of Bangladesh

Background

Tobacco smoking (TS) and illicit drug use (IDU) are of public health concerns especially in developing countries, including Bangladesh. This paper aims to (i) identify the determinants of TS and IDU, and (ii) examine the association of TS with IDU among young slum dwellers in Bangladesh.

Methodology/Principal Findings

Data on a total of 1,576 young slum dwellers aged 15–24 years were extracted for analysis from the 2006 Urban Health Survey (UHS), which covered a nationally representative sample of 13,819 adult men aged 15–59 years from slums, non-slums and district municipalities of six administrative regions in Bangladesh. Methods used include frequency run, Chi-square test of association and multivariable logistic regression. The overall prevalence of TS in the target group was 42.3%, of which 41.4% smoked cigarettes and 3.1% smoked bidis. The regression model for TS showed that age, marital status, education, duration of living in slums, and those with sexually transmitted infections were significantly (p<0.001 to p<0.05) associated with TS. The overall prevalence of IDU was 9.1%, dominated by those who had drug injections (3.2%), and smoked ganja (2.8%) and tari (1.6%). In the regression model for IDU, the significant (p<0.01 to p<0.10) predictors were education, duration of living in slums, and whether infected by sexually transmitted diseases. The multivariable logistic regression (controlling for other variables) revealed significantly (p<0.001) higher likelihood of IDU (OR = 9.59, 95% CI = 5.81–15.82) among users of any form of TS. The likelihood of IDU increased significantly (p<0.001) with increased use of cigarettes.

Conclusions/Significance

Certain groups of youth are more vulnerable to TS and IDU. Therefore, tobacco and drug control efforts should target these groups to reduce the consequences of risky lifestyles through information, education and communication (IEC) programs.

Characteristics of tobacco retailers in New Zealand

Using data on known tobacco outlets throughout NZ, GIS was used to map outlets, deprivation and secondary schools. A total of 5008 tobacco outlets were identified, giving a density of one outlet per 617 people or one outlet per 129 smokers. One-half of secondary schools had an outlet within 500 m. Tobacco outlets were more densely located in areas of higher socioeconomic deprivation. One third of all tobacco outlets had a licence to sell alcohol. This study indicates the widespread retail availability of tobacco and the need for a mandatory system of registration for better enforcement of smokefree legislation.

Comparing GIS-based measures in access to mammography and their validity in predicting neighborhood risk of late-stage breast cancer

Background

Assessing neighborhood environment in access to mammography remains a challenge when investigating its contextual effect on breast cancer-related outcomes. Studies using different Geographic Information Systems (GIS)-based measures reported inconsistent findings.

Methods

We compared GIS-based measures (travel time, service density, and a two-Step Floating Catchment Area method [2SFCA]) of access to FDA-accredited mammography facilities in terms of their Spearman correlation, agreement (Kappa) and spatial patterns. As an indicator of predictive validity, we examined their association with the odds of late-stage breast cancer using cancer registry data.

Results

The accessibility measures indicated considerable variation in correlation, Kappa and spatial pattern. Measures using shortest travel time (or average) and service density showed low correlations, no agreement, and different spatial patterns. Both types of measures showed low correlations and little agreement with the 2SFCA measures. Of all measures, only the two measures using 6-timezone-weighted 2SFCA method were associated with increased odds of late-stage breast cancer (quick-distance-decay: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.01–1.32; slow-distance-decay: OR = 1.19, 95% CI = 1.03–1.37) after controlling for demographics and neighborhood socioeconomic deprivation.

Conclusions

Various GIS-based measures of access to mammography facilities exist and are not identical in principle and their association with late-stage breast cancer risk. Only the two measures using the 2SFCA method with 6-timezone weighting were associated with increased odds of late-stage breast cancer. These measures incorporate both travel barriers and service competition. Studies may observe different results depending on the measure of accessibility used.