Tobacco availability and point of sale marketing in demographically contrasting districts of Massachusetts

Relapse to problem drinking or trading up to spirits? Using U.S. national cross-sectional survey data to highlight possible negative impacts of potential tobacco retail changes

BACKGROUND

According to the National Alcohol Beverage Control Association, twelve states in the United States (U.S.) have government retail monopolies on spirits/liquor sales. With a new federal minimum legal sales age for tobacco (raised from 18 to 21, the minimum legal sales age for alcohol), we examine possible unintended consequences of a hypothetical policy change restricting retail tobacco sales to state-run spirits/liquor stores in alcohol control states, which has been proposed as a tobacco endgame strategy.

METHODS

We used cross-sectional survey data from 14,821 randomly-selected adults ages 21 and older who responded to the 2015 or 2020 U.S. National Alcohol Survey (51.8% female; 65.8% identified as non-Hispanic White, 12.4% as Black or African American, 14.2% as Hispanic or Latinx; 34.0% had a low level of education), including 2,274 respondents (18.9%) residing in one of the alcohol control states (representing 42.2 million (M) adults ages 21+). We estimated associations between tobacco measures (lifetime smoking status, lifetime daily smoking, past-year daily smoking) and alcohol measures (drinking status, beverage choices, lifetime alcohol use disorder (AUD) status, recovery status) overall and for specific subgroups.

RESULTS

In control states, 55.1% of people who smoked daily in the past year also reported lifetime AUD, including an estimated 3.56 M adults ages 21 + who reported prior (but not current) AUD. The association of daily smoking with lifetime AUD was stronger among those with low education compared to those with higher education. Further, 58.8% of people in recovery from an alcohol and/or drug problem (1.49 M adults ages 21+) smoked daily, and this was more marked among women than men in control states.

CONCLUSION

There could be negative consequences of an endgame strategy to restructure tobacco retail sales, including increased risk for relapse to drinking among people who smoke daily, especially among women and people with low levels of education. Strategies to mitigate unintended harms would be needed if such a policy were implemented.

Spatial Disparities: The Role of Nativity in Neighborhood Exposure to Alcohol and Tobacco Retailers

Studies of retail environment, one of the social determinants of health, document racial/ethnic disparities in exposure to alcohol and tobacco (A and T) retailers, but have largely overlooked nativity. We examined associations between A and T retailer density and rates of foreign-born Latinx and foreign-born Asian residents in California census tracts (N = 7888), using spatial regressions and controlling for population and ecological confounders (e.g., population density, zoning, residential instability, urbanicity). Socio-demographic data came from the American Community Survey (2012-2016); census tract density of A and T retailers came from geocoded addresses from state license data for off-sale alcohol distributors and purchased data on tobacco retailers from a commercial provider. Models predicting A and T tract retailer density showed that the rate of foreign-born Latinx residents was associated with higher tobacco retailer density but lower alcohol retailer density, and demonstrate no significant associations between rate of foreign-born Asian residents tobacco and alcohol retail density. Retail environment could contribute to observed declines in immigrant health over time in the US and across generations.

A scoping review on disparities in exposure to advertising for e-cigarettes and heated tobacco products and implications for advancing a health equity research agenda

Background

Disparities in exposure to and density of tobacco advertising are well established; however, it is still unclear how e-cigarette and heated tobacco product (HTP) advertising vary by age, education, sex, gender identity, race/ethnicity, sexual orientation, socioeconomic status (SES), and/or urban/rural area. Through a scoping review, we sought to identify potential disparities in exposure to e-cigarette and HTP advertising and promotion across populations.

Methods

In January 2020, a systematic literature search was conducted in five databases: PubMed, Scopus, Embase, Web of Science, and the Cochrane Library. The search was updated in October 2020. Articles reporting on exposure to e-cigarette and/or HTP advertising and promotion across age, education, sex, gender identity, race/ethnicity, sexual orientation, SES, and/or urban/rural areas were included for full-text review (n = 25). Of those, 15 were deemed relevant for data extraction.

Results

The majority of the studies were from the U.S. (n = 12) and cross-sectional (n = 14). Studies were published between 2014 and 2020 and focused on determining causal relationships that underlie disparities; only one study assessed HTP advertising and promotion. Exposure to e-cigarette and HTP advertising was assessed at the individual-level (e.g., recall seeing ads on television) and at the neighborhood-level (e.g., ad density at the point-of-sale). Studies addressed differences across age (n = 6), education (n = 2), sex (n = 6), gender identity and sexual orientation (n = 3), race/ethnicity (n = 11), SES (n = 5), and urban/rural (n = 2). The following populations were more likely to be exposed to e-cigarette advertising: youth, those with more than a high school diploma, males, sexual and gender minorities, Whites, and urban residents. At the neighborhood-level, e-cigarette advertisements were more prevalent in non-White neighborhoods.

Conclusions

Exposure to e-cigarette/HTP advertising varies based on sociodemographic characteristics, although the literature is limited especially regarding HTPs. Higher exposure among youth might increase tobacco-related disparities since it can lead to nicotine/tobacco use. Research should incorporate and apply a health equity lens from its inception to obtain data to inform the elimination of those disparities.

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

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

National Support for a Menthol Cigarette Sales Ban

OBJECTIVES

The US Food and Drug Administration (FDA) and local jurisdictions have different authorities to regulate menthol cigarettes, and a growing number of localities and the FDA are considering these policy options. The objective of this study was to update previous research on public support for a menthol ban, including examining differences in support by demographic factors, geographic region, and smoking status.

METHODS

We assessed policy support among a cross-sectional sample of 2871 adults aged 18-64 from a nationally representative online panel. We calculated weighted estimates of support by demographic factors, political ideology, region (Northeast, Midwest, South, West), and smoking status (never, former, current nonmenthol, current menthol). We used weighted adjusted logistic regression analysis to examine correlates of support for a menthol ban.

RESULTS

Overall, 56.4% (95% CI, 54.4%-58.3%) of participants supported a government policy to ban menthol cigarette sales. Support was significantly higher among women than among men (62.5% vs 50.1%; P < .001); among Hispanic/Latino (69.3%), non-Hispanic African American (60.5%), and non-Hispanic other (65.8%) people than among non-Hispanic White people (50.4%; P < .001); and among never (64.8%) and former (47.0%) smokers than among current nonmenthol cigarette smokers (30.1%; P < .001). A significant proportion (28.5%; P < .001) of current menthol cigarette smokers supported a ban. After controlling for other factors, geographic region was not significantly associated with support for a ban.

CONCLUSIONS

Efforts are needed to further increase support for a ban among current menthol cigarette smokers. These findings can be used to assist policy makers and communities in efforts to ban menthol cigarettes in their jurisdictions.

Examining differences in attentional bias to smoking-related cues among black and white cigarette smokers: An event-related potential pilot study

Black cigarette smokers experience higher craving, lower cessation rates, and increased health complications from tobacco use than Whites. We examined psychophysiological and behavioral differences in attentional bias to smoking cues between Black and White smokers. Thirty-one participants (Blacks, n = 20; MAge = 45 and Whites, n = 11, MAge = 47.64) discriminated line orientations while ignoring temporally flanking lines and smoking-related, positive-, negative-, and neutral-images as behavioral responses and event-related potentials (ERPs) were recorded. Results revealed a three-way interaction in reaction time among Group (White, Black), Congruity (congruent vs. incongruent flankers) and Cue (smoking-related, positive, negative) factors, F(2,58) = 3.63, p = .03, MSe = .001, η2 = .002. Smoking-related cues yielded the largest congruity effects in Whites, but the smallest congruity effects in Blacks. Random presentation of smoking-related cues (re: baseline) weakened P1 ERP amplitude (125 ms after stimulus onset) in Whites, but not Blacks (Cue x Group x Task, F(3,87) = 3.44, p < .05, MSe = 65.96, η2 = .01), suggesting an early sensory effect of smoking cues in Whites. The difference between Whites and Blacks in P2 amplitude (226 ms; amplitude weaker in Whites) was greatest to the smoking-related cues (Cue x Group, F(3,87) = 2.81, p < .05, MSe = 60.68, η2 = .01), indicating a stronger draw in attention from smoking cues in Whites. Findings suggest White and Black smokers respond differently to smoking-related cues during early sensory processing. Findings need to be replicated.

Association between neighborhood socioeconomic status, tobacco store density and smoking status in pregnant women in an urban area

Smoking during pregnancy can lead to serious health consequences. Given such health risks, an understanding of factors that influence maternal smoking behaviors during pregnancy is critical. The objective of this study is to assess the relationship between tobacco store density, neighborhood socioeconomic status, and neighborhood rates of maternal smoking during pregnancy. Fifty-five community areas in Baltimore City were summarized using data from the Neighborhood Health Profiles. Associations between tobacco store density and smoking while pregnant in a community were determined using Moran's I and spatial regression analyses to account for autocorrelation. The fully adjusted model took into account the following community-level socioeconomic variables as covariates: neighborhood median income, percentage of those living in poverty, percentage of uninsured, and percentage of persons with at least a college degree. In regards to the findings, the percentage of women by community area who identified as actively smoking while pregnant was 10.4% ± 5.8%. The tobacco store density was 21.0 ± 12.7 per 10,000 persons (range 0.0-49.1 tobacco store density per 10,000 persons). In the adjusted model, an increase in density of 1 tobacco store per 10,000 persons was associated with a 10% increase in women who reported smoking during pregnancy (β = 0.10, p = 0.04). In conclusion, tobacco store density and neighborhood socioeconomic factors were associated with prevalence of maternal smoking while pregnant. These findings support the need to further assess and develop interventions to reduce the impact of tobacco store density on smoking behaviors and health risks in communities.

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.

Health in the United States: Are Appeals to Choice and Personal Responsibility Making Americans Sick?

The United States suffers high rates of preventable lifestyle disease despite widespread calls for people to take responsibility for their health. The United States also stands out in its rejection of government action to guide industry practices and consumer choices. Why? We examine how deeply rooted cultural narratives about “free choice” and “personal responsibility” infuse policymaking, advertising, media, social norms, and individual attitudes about health in the United States. We argue that these narratives contribute to ill health in the United States: They encourage stress and worry over health, blame and stigmatization of the unhealthy, widened health disparities, and the failure to adopt policies that could save lives. Psychologists can play a major role in expanding narratives about health so that they include the role of personal choice and responsibility but also reflect current science about the physical, social, and cultural drivers of health. These broader narratives can be used to promote a more comprehensive understanding of health and to better inform the design, communication, and implementation of effective health-supportive policies.

Similarities Between Alcohol and Tobacco Advertising Exposure and Adolescent Use of Each of These Substances

OBJECTIVE

Underage alcohol use is a major public health problem and substantial corporate money supports alcohol advertising across multiple venues. A diverse research literature demonstrates that adolescent exposure to such advertising is associated with drinking attitudes and behavior, but no scientific body has determined these associations to be causal. The objective of this study was to assess the association between alcohol advertising and teen drinking in the context of the "Analogy" criterion of the Bradford Hill criteria and consider a determination that the association between exposure to alcohol advertising and alcohol use is causal.

METHOD

This study was a narrative review on the association between adolescent exposure to alcohol advertising and subsequent alcohol use in the context of domains utilized in the Surgeon General's 2012 Report, Preventing Tobacco Use Among Youth and Young Adults, which concluded, "Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults."

RESULTS

In every aspect compared (i.e., adolescent knowledge; attitudes toward; initiation of use; continuation of use; mediums of advertisement; the use of mascots, celebrities, and themes; and frequency and density of advertisements and retailers), the findings for both tobacco and alcohol and their association with exposure to advertising are analogous.

CONCLUSIONS

Application of the Analogy criterion of the Bradford Hill criteria comparing alcohol and tobacco supports a judgment that the association between exposure to alcohol advertising and increased adolescent knowledge, attitudes toward, initiation, and continuation of alcohol use are causal in nature.

Does Tobacco Outlet Inequality Extend to High-White Mid-Atlantic Jurisdictions? A Study of Socioeconomic Status and Density

Tobacco outlet density research has evolved to require a more refined examination of socioeconomic status' influence beyond median household income. This study investigates the effects of SES on census-tract-level tobacco outlet density in five predominantly White Maryland jurisdictions. Tobacco license addresses and demographic data were analyzed via t tests and spatial lag modeling. Results showed that higher SES jurisdictions had lower tobacco outlet density than lower SES jurisdictions despite similar White populations and that median household income had consistent associations with tobacco outlet density. This study corroborates findings that differences in SES correlate with differences in tobacco outlet density between racially similar areas.

Income as a moderator of psychological stress and nicotine dependence among adult smokers

BACKGROUND

Perceived stress and psychological distress are associated with more cigarette craving and withdrawal, higher nicotine dependence, and less success during quit attempts. Low income smokers have disproportionately higher rates of smoking and may be particularly vulnerable to the effects of stress on smoking dependence. The aim of the current study was to assess if lower income smokers have a stronger association between stress and nicotine dependence than higher income smokers.

METHODS

Data were obtained from the Pennsylvania Adult Smoking Study, which included 351 daily smokers. Subjects completed PhenX Toolkit and other self-report measures of socioeconomic factors, the 10-item Perceived Stress Scale, Kessler Psychological Distress Scale (K6), Fagerstrom Test for Nicotine Dependence (FTND), and the Hooked on Nicotine Checklist (HONC). Moderation analyses using linear regression examined income-related differences in the association between stress and nicotine dependence.

RESULTS

Income groups were categorized by an annual household income of $50,000 based on visual-inspection of scatter plots of income by nicotine dependence. Compared to higher income smokers, lower income smokers had significantly higher mean levels of nicotine dependence on the FTND [3.74 vs. 4.79, p < 0.001], perceived stress [15.63 vs. 17.95, p = 0.004], and psychological distress [5.30 vs. 6.86, p = 0.001], respectively. There were interaction effects, such that lower income smokers had a strong, positive associations between FTND and perceived stress (B = -0.11, CI = -0.17 to -0.04, p = 0.002) and psychological distress (B = -0.13, CI = -0.25 to -0.02, p = 0.022) whereas no association was found in higher income smokers. No significant moderation effects were found for the HONC or when income groups were categorized by U.S. federal poverty level.

CONCLUSIONS

The results highlight that the relationship between increasing stress and FTND was found in lower but not higher income groups. Future research should examine socioeconomic, environmental and psychosocial factors that may facilitate increased smoking during stress-induced craving.

Disparities in retail marketing for menthol cigarettes in the United States, 2015

This study describes retail marketing for menthol cigarettes and its relationship with neighborhood demographics in a national sample of tobacco retailers in the United States. Mixed-effects models were used to examine three outcomes: menthol cigarette exterior advertising, menthol cigarette price promotions, and the pack price of menthol and non-menthol cigarettes. Thirty-eight percent of retailers displayed at least one menthol advertisement on the store exterior and 69% advertised price promotions. Retail advertising was more common in neighborhoods in the second (OR = 1.5 [1.1, 2.0]) and fourth (OR = 1.9 [1.3, 2.7]) quartiles of Black residents as compared to the lowest quartile. Menthol advertising was more prevalent in the third (OR = 1.4 [1.0, 1.9]) and lowest (OR = 1.6 [1.2, 2.2]) income quartiles as compared to the highest quartile. Price promotions for Newport were more common in neighborhoods with the highest quartile of Black residents (OR = 1.8 [1.2, 2.7]). Prices of Newport were cheaper in neighborhoods with the highest quartiles of youth, Black residents, and lower-income households. Policies that restrict the sales and marketing of menthol cigarettes are needed to address disparities.

The use of ambulatory assessment in smoking cessation

Ambulatory assessment of smoking behavior has greatly advanced our knowledge of the smoking cessation process. The current article first provides a brief overview of ecological momentary assessment for smoking cessation and highlights some of the primary advantages and scientific advancements made from this data collection method. Next, a discussion of how certain data collection tools (i.e., smoking topography and carbon monoxide detection) that have been traditionally used in lab-based settings are now being used to collect data in the real world. The second half of the paper focuses on the use of wearable wireless sensors to collect data during the smoking cessation process. Details regarding how these sensor-based technologies work, their application to newer tobacco products, and their potential to be used as intervention tools are discussed. Specific focus is placed on the opportunity to utilize novel intervention approaches, such as Just-In-Time Adaptive Interventions, to intervene upon smoking behavior. Finally, a discussion of some of the current challenges and limitations related to using sensor-based tools for smoking cessation are presented, along with suggestions for future research in this area.

Compliance with the City of Chicago's partial ban on menthol cigarette sales

INTRODUCTION

In the USA, menthol cigarettes are associated with smoking initiation and decreased likelihood of cessation, particularly for low-income and non-White populations. Local ordinances to restrict menthol cigarette sales are an emergent policy option. In July 2016, Chicago, Illinois became the first major US city to ban menthol cigarette sales within 500 feet of schools. This study assessed ban compliance in June 2017.

METHODS

We randomly selected 100 of 154 stores within 500 feet of a high school. Ninety stores were included in the analysis, excluding permanently closed stores or stores that did not sell tobacco prior to the ban. Compliance was determined by whether a menthol cigarette pack was purchased. We also assessed presence of menthol cigarette replacement packs. Multivariable logistic regression modelled compliance by store type, school (distance to high school, school type) and neighbourhood-level factors (poverty level, proportion of non-White residents).

RESULTS

Compliance rate was 57% (weighted, n=53) and no replacement packs were observed. Non-compliant stores were more likely to advertise menthol cigarettes, but ads were present in eight compliant stores. Gas stations had 81% lower odds (OR=0.19, 95% CI 0.06 to 0.58) of complying with the menthol cigarette ban compared with larger/chain stores. School-level and neighbourhood factors were not associated with compliance.

DISCUSSION

The poor compliance observed with Chicago's partial menthol cigarette ban highlights the need for comprehensive efforts. Optimising local resources to target enforcement efforts in gas stations could improve compliance. Ordinances that also restrict advertising could potentially enhance ban impact by reducing exposure to product and promotions.

The Association of Point-of-Sale E-cigarette Advertising with Socio-Demographic Characteristics of Neighborhoods

Electronic cigarettes (e-cigarettes) marketing expenditure is skyrocketing in the United States. However, little is understood about the geographic and socio-demographic patterns of e-cigarette advertising. We examined the associations between point-of-sale (POS) e-cigarette advertising and neighborhood socio-demographic characteristics in the Omaha Metropolitan Area of Nebraska. In 2014, fieldworkers collected comprehensive POS e-cigarette advertising data from all stores that sell tobacco (n = 463) in the Omaha Metropolitan Area. We used Geographic Information Systems to map POS e-cigarette advertisement density for the entire study area. Linear regression was used to examine the association between socio-demographic factors and POS e-cigarette advertising density. E-cigarette advertising density exhibited an obviously uneven geographic pattern in Omaha. Higher level of POS e-cigarette advertising was significantly related to lower median household income, higher percentage of Hispanics, and higher percentage of young adults. However, after adjusting for covariates, only median household income remained significantly associated with POS e-cigarette advertising. We found geographic, socioeconomic, and racial and ethnic disparities in exposure to POS e-cigarette advertising in Omaha, Nebraska. Future studies are needed to understand how these disparities influence e-cigarette adoption by different social groups and how to use such information to inform e-cigarette prevention strategies.

Standardized Tobacco Assessment for Retail Settings (STARS): dissemination and implementation research

Objective

The Standardized Tobacco Assessment for Retail Settings (STARS) was designed to characterise the availability, placement, promotion and price of tobacco products, with items chosen for relevance to regulating the retail tobacco environment. This study describes the process to develop the STARS instrument and protocol employed by a collaboration of US government agencies, US state tobacco control programmes (TCPs), advocacy organisations, public health attorneys and researchers from the National Cancer Institute's State and Community Tobacco Control (SCTC) Research Initiative.

Methods

To evaluate dissemination and early implementation experiences, we conducted telephone surveys with state TCP leaders (n=50, response rate=100%), and with individuals recruited via a STARS download registry on the SCTC website. Website registrants were surveyed within 6 months of the STARS release (n=105, response rate=66%) and again after ∼5 months (retention rate=62%).

Results

Among the state TCPs, 42 reported conducting any retail marketing surveillance, with actual or planned STARS use in 34 of these states and in 12 of the 17 states where marketing surveillance was not previously reported. Within 6 months of the STARS release, 21% of surveyed registrants reported using STARS and 35% were likely/very likely to use it in the next 6 months. To investigate implementation fidelity, we compared data collected by self-trained volunteers and by trained professionals, the latter method being more typically in retail marketing surveillance studies. Results suggest high or moderate reliability for most STARS measures.

Conclusion

The study concludes with examples of states that used STARS to inform policy change.

Disparities in tobacco marketing and product availability at the point of sale: Results of a national study

OBJECTIVE

Neighborhood socioeconomic and racial/ethnic disparities exist in the amount and type of tobacco marketing at retail, but most studies are limited to a single city or state, and few have examined flavored little cigars. Our purpose is to describe tobacco product availability, marketing, and promotions in a national sample of retail stores and to examine associations with neighborhood characteristics.

METHODS

At a national sample of 2230 tobacco retailers in the contiguous US, we collected in-person store audit data on: Availability of products (e.g., flavored cigars), quantity of interior and exterior tobacco marketing, presence of price promotions, and marketing with youth appeal. Observational data were matched to census tract demographics.

RESULTS

Over 95% of stores displayed tobacco marketing; the average store featured 29.5 marketing materials. 75.1% of stores displayed at least one tobacco product price promotion, including 87.2% of gas/convenience stores and 85.5% of pharmacies. 16.8% of stores featured marketing below three feet, and 81.3% of stores sold flavored cigars, both of which appeal to youth. Stores in neighborhoods with the highest (vs. lowest) concentration of African-American residents had more than two times greater odds of displaying a price promotion (OR=2.1) and selling flavored cigars (OR=2.6). Price promotions were also more common in stores located in neighborhoods with more residents under age 18.

CONCLUSIONS AND RELEVANCE

Tobacco companies use retail marketing extensively to promote their products to current customers and youth, with disproportionate targeting of African Americans. Local, state, and federal policies are needed to counteract this unhealthy retail environment.

Racial and Ethnic Differences in Tobacco Information Seeking and Information Sources: Findings From the 2015 Health Information National Trends Survey

This article describes sources of health information, types of tobacco information sought, and trust in sources of tobacco information among U.S. racial/ethnic groups (Whites, Blacks, Hispanics, Asian and Pacific Islanders, and Other). Cross-sectional data (N = 3,788) from a nationally representative survey, HINTS-FDA 2015, were analyzed to examine unadjusted and adjusted associations between race/ethnicity and (a) first source of health information, (b) tobacco information seeking, and (c) trust in sources of tobacco information. Adjusted associations controlled for current tobacco product use and sociodemographic variables. Findings indicated that the Internet was the most common first source of health information while health care providers were the second most common source for all racial/ethnic groups. Tobacco-related health information seeking was more prevalent than other tobacco product information seeking. Unadjusted analyses indicated that a higher proportion of Whites sought other tobacco product information compared to Asians and Pacific Islanders. Trust was rated highest for doctors while trust for health organizations was rated second highest. Asians and Pacific Islanders had higher trust in the government compared to all other groups. Blacks had higher trust in religious organizations compared to all other groups besides Hispanics. Blacks had higher trust for tobacco companies compared to Whites and Other. Many of these differences were attenuated in adjusted analyses. This research has implications for tobacco control practice and policymaking by identifying potential dissemination strategies.

The Effects of Discrimination Are Associated With Cigarette Smoking Among Black Males

Previous research has demonstrated that experiencing interpersonal discrimination is associated with cigarette smoking. Few studies have examined the relationship between the effects of physical and emotional discrimination and cigarette usage, and none have examined this relationship among Black men. The aim of this study was to examine the association between the effects of physical and emotional discrimination and cigarette smoking.

METHODS

Data from the Indiana Black Men's Health Study, a community-based sample of adult Black men, was used to conduct multivariate logistic regression to examine the relationship between the physical and emotional effects of discrimination and smoking, net of healthcare and workplace discrimination, age, education, household income, and being married.

RESULTS

After adjusting for having an emotional response to discrimination, health care and workplace discrimination, age, education, household income, and being married, males who had a physical response to discrimination (e.g., upset stomach or headache) had higher odds of cigarette use (odds ratio (OR): 1.95, 95% confidence interval (CI): 1.15-3.30) than men who did not have a physical response to discrimination.

CONCLUSION

Findings from the study suggest that Black males may use cigarette smoking as a means to mitigate the stress associated with experiences of discrimination. Future research is needed further to explore if and how Black males use cigarette smoking to cope with unfair treatment.

Social Disparities in Exposure to Point-of-Sale Cigarette Marketing

While most ecological studies have shown that higher levels of point-of-sale (POS) cigarette marketing are associated with larger proportions of residents from lower socioeconomic and minority backgrounds in neighborhoods, there are no studies that examine individual-level social disparities in exposure to POS cigarette marketing among smokers in the United States. Our aim was to examine these disparities in a Midwestern metropolitan area in the United States. We conducted a telephone survey to collect data on 999 smokers. Cigarette marketing was measured by asking respondents three questions about noticing advertisements, promotions, and displays of cigarettes within their respective neighborhoods. The questions were combined to create a summated scale. We estimated ordered logistic regression models to examine the association of sociodemographic variables with exposure to POS cigarette marketing. Adjusted results showed that having a lower income (p < 0.003) and belonging to a race/ethnicity other than "non-Hispanic White" (p = 0.011) were associated with higher levels of exposure to POS cigarette marketing. The results highlight social disparities in exposure to POS cigarette marketing in the United States, which can potentially be eliminated by banning all forms of cigarette marketing.

Association Between Any Major Discrimination and Current Cigarette Smoking Among Adult African American Men

BACKGROUND

Findings from previous research has demonstrated a positive relationship between interpersonal discrimination and cigarette smoking. Cigarette smoking is proposed to be an externalizing coping mechanism used to alleviate discrimination. At the national level, it is unclear if discrimination is associated with cigarette smoking among African American men.

OBJECTIVE

The aim of the study was to examine the association between discrimination and cigarette smoking among a national sample of African American men.

METHODS

Using data from the National Survey of American Life (n = 1,271), multivariable logistic regression was used to examine the relationship between discrimination and cigarette smoking.

RESULTS

Thirty-two percent of the men were current smokers. Controlling for everyday discrimination, major discrimination, major stress, depressive symptoms, age, being married, household income, and education, African American men who experienced major discrimination had a higher odd of being a current smoking (odds ratio: 1.11, 95% confidence interval: 1.02-1.21) than African American men who did not experience major discrimination. Conclusion/Importance: Findings suggest that African American men may use cigarette smoking as a mechanism to alleviate the experiences of discrimination. Future studies should continue to examine factors associated with African American men's smoking behavior in efforts to inform culturally relevant interventions.

Retail Pharmacy Policy to End the Sale of Tobacco Products: What Is the Impact on Disparity in Neighborhood Density of Tobacco Outlets?

BACKGROUND

Population-level research on the implications of retail pharmacy policies to end the sale of tobacco products is scant, and the impact of such policies on racial/ethnic and socioeconomic disparities across neighborhoods in access to tobacco products remains unexplored.

METHODS

We investigated the association between neighborhood sociodemographic characteristics and tobacco retail density in Rhode Island (RI; N = 240 census tracts). We also investigated whether the CVS Health (N = 60) policy to end the sale of tobacco products reduces the disparity in the density of tobacco retail across neighborhoods, and we conducted a prospective policy analysis to determine whether a similar policy change in all pharmacies in RI (N = 135) would reduce the disparity in tobacco retail density.

RESULTS

The results revealed statistically significant associations between neighborhood sociodemographic characteristics and tobacco retail outlet density across RI neighborhoods. The results when excluding the CVS Health locations, as well as all pharmacies as tobacco retailers, revealed no change in the pattern for this association.

CONCLUSIONS

The results of this study suggest that while a commendable tobacco control policy, the CVS Health policy appears to have no impact on the neighborhood racial/ethnic and socioeconomic disparities in the density of tobacco retailers in RI. Prospective policy analyses showed no impact on this disparity even if all other pharmacies in the state adopted a similar policy.

IMPACT

Policy efforts aimed at reducing the disparity in access to tobacco products should focus on reducing the density of tobacco outlets in poor and racial/ethnic neighborhoods. Cancer Epidemiol Biomarkers Prev; 25(9); 1305-10. ©2016 AACR.

Youth Advocates' Perceptions of Tobacco Industry Marketing Influences on Adolescent Smoking: Can They See the Signs?

Point-of-sale (POS) advertising at retail stores is one of the key marketing avenues used by the tobacco industry. The United States Surgeon General urges actions to eliminate POS tobacco advertisements because of their influence on youth smoking. Many youth empowerment programs are implemented to address tobacco industry marketing influences, including POS tobacco advertisements. While youth are asked to take on such collective action, little is known regarding their perceptions and understanding of tobacco industry marketing influences and related advocacy activities. This mixed methods study examined Oklahoma's tobacco control youth empowerment program members' perceptions of tobacco industry marketing influences. Four focus groups were held with active program members from rural and urban areas. Overall, the focus group participants viewed the program as purposeful, as an avenue to help others, and as a way to make a difference. Specifically, the older participants (median age = 18 years) identified tobacco industry marketing influences such as POS, movies, and magazine advertisements and reported participating in activities that counter POS tobacco advertisements at retail stores. Likewise younger participants (median age = 16 years), identified similar tobacco industry marketing influences, but also included tobacco use by friends and family as tobacco industry marketing influences. Moreover, the younger participants did not report engaging in activities that addressed POS tobacco advertisements. The study results suggest that the empowerment program should tailor its programming, training, materials, and activities with input from youth of various ages. Thoughtfully developed messages and specific activities can truly empower youth and maximize their contribution as change agents who address POS or other initiatives at the retail environments to prevent chronic diseases.

Associations between smoking behaviors and financial stress among low-income smokers

OBJECTIVE

Many American households struggle to bring in sufficient income to meet basic needs related to nutrition, housing, and healthcare. Nicotine addiction and consequent expenditures on cigarettes may impose extra financial strain on low-income households. We examine how cigarette use behaviors relate to self-reported financial stress/strain among low-income smokers.

METHODS

At baseline in 2011/12, OPT-IN recruited adult smokers age 18-64 from the administrative databases of the state-subsidized Minnesota Health Care Programs (N = 2406). We tested whether nicotine dependency, type of cigarettes used, and smoking intensity were associated with self-reported difficulty affording food, healthcare, housing, and living within one's income. All regression models were adjusted for race, education, income, age, and gender.

RESULTS

Difficulty living on one's income (77.4%), paying for healthcare (33.6%), paying for housing (38.4%), and paying for food (40.8%) were common conditions in this population. Time to first cigarette and cigarettes smoked per day predicted financial stress related to affording food, housing, and living within one's income (all p < 0.05). For instance, those whose time to first cigarette was greater than 60 minutes had about half the odds of reporting difficulty paying for housing compared to those who had their first cigarette within five minutes of waking (adjusted odds ratio = 0.55 [95% CI: 0.41, 0.73]). Type of cigarette used was not associated with any type of financial stress/strain.

CONCLUSIONS

Smoking and particularly heavy smoking may contribute in an important way to the struggles that low-income households with smokers face in paying for necessities.

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity). Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities. There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.

Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities

INTRODUCTION

Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smokings (e.g., those with lower education and incomes).

METHODS

Education and income are the 2 main social determinants of health that negatively impact health. However, there are other social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This article will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control.

RESULTS

Tobacco control policy interventions can be effective in addressing the social determinants of health in tobacco prevention and control to achieve equity and eliminate tobacco-related disparities when they are implemented consistently and equitably across all population groups.

CONCLUSIONS

Taking a social determinants of health approach in tobacco prevention and control will be necessary to achieve equity and eliminate tobacco-related disparities.

Tobacco retailer proximity and density and nicotine dependence among smokers with serious mental illness

OBJECTIVES

We examined the density and proximity of tobacco retailers and associations with smoking behavior and mental health in a diverse sample of 1061 smokers with serious mental illness (SMI) residing in the San Francisco Bay Area of California.

METHODS

Participants' addresses were geocoded and linked with retailer licensing data to determine the distance between participants' residence and the nearest retailer (proximity) and the number of retailers within 500-meter and 1-kilometer service areas (density).

RESULTS

More than half of the sample lived within 250 meters of a tobacco retailer. A median of 3 retailers were within 500 meters of participants' residences, and a median of 12 were within 1 kilometer. Among smokers with SMI, tobacco retailer densities were 2-fold greater than for the general population and were associated with poorer mental health, greater nicotine dependence, and lower self-efficacy for quitting.

CONCLUSIONS

Our findings provide further evidence of the tobacco retail environment as a potential vector contributing to tobacco-related disparities among individuals with SMI and suggest that this group may benefit from progressive environmental protections that restrict tobacco retail licenses and reduce aggressive point-of-sale marketing.

A systematic review of store audit methods for assessing tobacco marketing and products at the point of sale

OBJECTIVE

Over four-fifths of reported expenditures for marketing tobacco products occur at the retail point of sale (POS). To date, no systematic review has synthesised the methods used for surveillance of POS marketing. This review sought to describe the audit objectives, methods and measures used to study retail tobacco environments.

METHODS

We systematically searched 11 academic databases for papers indexed on or before 14 March 2012, identifying 2906 papers. Two coders independently reviewed each abstract or full text to identify papers with the following criteria: (1) data collectors visited and assessed (2) retail environments using (3) a data collection instrument for (4) tobacco products or marketing. We excluded papers where limited measures of products and/or marketing were incidental. Two abstractors independently coded included papers for research aims, locale, methods, measures used and measurement properties. We calculated descriptive statistics regarding the use of four P's of marketing (product, price, placement, promotion) and for measures of study design, sampling strategy and sample size.

RESULTS

We identified 88 store audit studies. Most studies focus on enumerating the number of signs or other promotions. Several strengths, particularly in sampling, are noted, but substantial improvements are indicated in the reporting of reliability, validity and audit procedures.

CONCLUSIONS

Audits of POS tobacco marketing have made important contributions to understanding industry behaviour, the uses of marketing and resulting health behaviours. Increased emphasis on standardisation and the use of theory are needed in the field. We propose key components of audit methodology that should be routinely reported.

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.

Tobacco retail outlets and vulnerable populations in Ontario, Canada

Interest has been increasing in regulating the location and number of tobacco vendors as part of a comprehensive tobacco control program. The objective of this paper is to examine the distribution of tobacco outlets in a large jurisdiction, to assess: (1) whether tobacco outlets are more likely to be located in vulnerable areas; and (2) what proportion of tobacco outlets are located close to schools. Retail locations across the Province of Ontario from Ministry of Health Promotion data were linked to 2006 Census data at the neighbourhood level. There was one tobacco retail outlet for every 1,000 people over age 15 in Ontario. Density of outlets varied by public health unit, and was associated with the number of smokers. Tobacco outlets were more likely to be located in areas that had high neighbourhood deprivation, in both rural and urban areas. Outlets were less likely to be located in areas with high immigrant populations in urban areas, with the reverse being true for rural areas. Overall, 65% of tobacco retailers were located within 500 m of a school. The sale of tobacco products is ubiquitous, however, neighbourhoods with lower socio-economic status are more likely to have easier availability of tobacco products and most retailers are located within walking distance of a school. The results suggest the importance of policies to regulate the location of tobacco retail outlets.

Disparities and menthol marketing: additional evidence in support of point of sale policies

This study examined factors associated with point-of-sale tobacco marketing in St. Louis, an urban city in the United States. Using spatial analysis, descriptive statistics, and multilevel modeling, we examined point-of-sale data and the proportion of mentholated cigarette and total cigarette marketing from 342 individual tobacco retail stores within St. Louis census tracts characterized by the percent of black adults and children. Menthol and total tobacco product marketing was highest in areas with the highest percentages of black residents. When examining menthol marketing to children, we did not find as strong of a relationship, however results of multilevel modeling indicate that as the proportion of black children in a census tract increased, the proportion of menthol marketing near candy also increased. These results indicate the need for communities globally to counter this targeted marketing by taking policy action specifically through the enactment of marketing restrictions provided by the 2009 Family Smoking Prevention and Tobacco Control Act and the Framework Convention of Tobacco Control.

Availability, accessibility and promotion of smokeless tobacco in a low-income area of Mumbai

OBJECTIVE

To examine the role of accessibility, product availability, promotions and social norms promotion, factors contributing to the use of smokeless tobacco (ST) products in a typical low-income community of Mumbai community using Geographic Information System (GIS), observational and interview methodologies and to assess implementation of Cigatettes and other Tobacco Products Act (COTPA) legislation.

RATIONALE

In India, the third largest producer of tobacco in the world, smokeless tobacco products are used by men, women and children. New forms of highly addictive packaged smokeless tobacco products such as gutkha are inexpensive and rates of use are higher in low-income urban communities. These products are known to increase rates of oral cancer and to affect reproductive health and fetal development.

METHODS

The study used a mixed methods approach combining ethnographic and GIS mapping, observation and key informant interviews. Accessibility was defined as density, clustering and distance of residents and schools to tobacco outlets. Observation and interview data with shop owners and community residents produced an archive of products, information on shop histories and income and normative statements.

RESULTS

Spatial analysis showed high density of outlets with variations across subcommunities. All residents can reach tobacco outlets within 30-100 feet of their homes. Normative statements from 55 respondents indicate acceptance of men's, women's and children's use, and selling smokeless tobacco is reported to be an important form of income generation for some households. Multilevel tobacco control and prevention strategies including tobacco education, community norms change, licensing and surveillance and alternative income generation strategies are needed to reduce accessibility and availability of smokeless tobacco use.

Marketing little cigars and cigarillos: advertising, price, and associations with neighborhood demographics

OBJECTIVES

We have documented little cigar and cigarillo (LCC) availability, advertising, and price in the point-of-sale environment and examined associations with neighborhood demographics.

METHODS

We used a multimodal real-time surveillance system to survey LCCs in 750 licensed tobacco retail outlets that sold tobacco products in Washington, DC. Using multivariate models, we examined the odds of LCC availability, the number of storefront exterior advertisements, and the price per cigarillo for Black & Mild packs in relation to neighborhood demographics.

RESULTS

The odds of LCC availability and price per cigarillo decreased significantly in nearly a dose-response manner with each quartile increase in proportion of African Americans. Prices were also lower in some young adult neighborhoods. Having a higher proportion of African American and young adult residents was associated with more exterior LCC advertising.

CONCLUSIONS

Higher availability of LCCs in African American communities and lower prices and greater outdoor advertising in minority and young adult neighborhoods may establish environmental triggers to smoke among groups susceptible to initiation, addiction, and long-term negative health consequences.

Environmental influences on tobacco use among Asian American and Pacific Islander youth

There is growing interest in understanding individual and environmental influences on youth risk behaviors, including tobacco use. The purpose of this article is to describe the processes and findings from a study that sought to increase the capacity of Asian American and Pacific Islander (AAPI) community-based organizations to understand and address the environmental influences on tobacco use among AAPI youth. Using a multimethod approach to data collection that included GIS (geographic information system) mapping, Photovoice, and individual youth surveys, a team of community and university researchers conducted a 3-year study to assess and address the environmental influences of tobacco use among youth. Community-based participatory research principles guided the study and facilitated unique capacity building and analyses throughout the study period. Results in Long Beach from all three methods highlighted the associations between youth smoking and environmental factors: GIS mapping identified at least 77 separate locations of pro-tobacco influences, photographs captured many of these locations and provided youth leaders with opportunities to identify how other influences contributed to smoking risk, and surveys of youth indicated that perceived community safety and proximity to pro-tobacco influences were associated with smoking in the past 30 days. Subsequent community-based organization activities undertaken by study partners are also discussed, and lessons learned summarized.

A historical review of R.J. Reynolds' strategies for marketing tobacco to Hispanics in the United States

Hispanics are the fastest growing racial/ethnic group in the United States, and smoking is the leading preventable cause of morbidity and mortality among this population. We analyzed tobacco industry documents on R. J. Reynolds' marketing strategies toward the Hispanic population using tobacco industry document archives from the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) between February-July 2011 and April-August 2012. Our analysis revealed that by 1980 the company had developed a sophisticated surveillance system to track the market behavior of Hispanic smokers and understand their psychographics, cultural values, and attitudes. This information was translated into targeted marketing campaigns for the Winston and Camel brands. Marketing targeted toward Hispanics appealed to values and sponsored activities that could be perceived as legitimating. Greater understanding of tobacco industry marketing strategies has substantial relevance for addressing tobacco-related health disparities.

Racial differences in cigarette brand recognition and impact on youth smoking

Background

African Americans are disproportionately exposed to cigarette advertisements, particularly for menthol brands. Tobacco industry documents outline strategic efforts to promote menthol cigarettes to African Americans at the point of sale, and studies have observed more outdoor and retail menthol advertisements in neighborhoods with more African-American residents. Little research has been conducted to examine the effect of this target marketing on adolescents’ recognition of cigarette brand advertising and on smoking uptake. To our knowledge, this is the first study to examine racial differences in brand recognition and to assess the prospective relationship between brand recognition and smoking uptake.

Methods

School-based surveys assessing tobacco use and environmental and social influences to smoke were administered to 6th through 9th graders (ages 11 to 15) in an urban and racially diverse California school district. The primary outcome for the cross-sectional analysis (n = 2,589) was brand recognition, measured by students’ identification of masked tobacco advertisements from the point of sale. The primary outcome for the longitudinal analysis (n = 1,179) was progression from never to ever smoking within 12 months.

Results

At baseline, 52% of students recognized the Camel brand, 36% Marlboro, and 32% Newport. African-American students were three times more likely than others to recognize Newport (OR = 3.03, CI = 2.45, 3.74, p < 0.01) and less likely than others to recognize Marlboro (OR = 0.60, CI = 0.48, 0.73, p < 0.01). At follow-up, 17% of never smokers reported trying smoking. In this racially diverse sample, brand recognition of Camel and Marlboro did not predict smoking initiation. Regardless of race, students who recognized the Newport brand at baseline were more likely to initiate smoking at follow-up (OR = 1.49, CI = 1.04, 2.15, p < 0.05) after adjusting for shopping frequency and other risk factors.

Conclusions

The study findings illustrate that African-American youth are better able to recognize Newport cigarette advertisements, even after adjustment for exposure to smoking by parents and peers. In addition, recognition of Newport cigarette advertising predicted smoking initiation, regardless of race. This longitudinal study contributes to a growing body of evidence that supports a ban on menthol flavored cigarettes in the US as well as stronger regulation of tobacco advertising at the point of sale.

Tobacco advertising and sales practices in licensed retail outlets after the Food and Drug Administration regulations

To assess retailer compliance with Food and Drug Administration (FDA) regulations on tobacco sales and advertising practices, including point-of-sale advertisements, in two distinct Columbus, Ohio neighborhood groups by income. Data were gathered from a random sample of 129 licensed tobacco retailers, which included data on both exterior and interior advertisements as well as sales practices. Descriptive analyses compared retail outlets by high and low income neighborhood locations. Compliance with FDA regulations was high in the random sample of urban tobacco retail outlets. None of the retail outlets sold loose cigarettes or offered free items with purchase. Less than 10% of the outlets surveyed offered self-service access to cigarettes or smokeless tobacco products. From all surveyed retail outlets 95% had cigarette, 57% had smokeless, and 57% had cigar advertisements at the point-of-sale. There were no significant differences in compliance by income, but the mean number of advertisements on the building and self-service access to cigars was significantly different by neighborhood income. There was a high degree of compliance with the new FDA regulation on tobacco marketing and sales practices in urban retail tobacco outlets in Columbus, Ohio. Tobacco advertising and marketing remain highly prevalent in retail outlets, with some significant differences between high and low income neighborhoods.

Tobacco outlet density and demographics: a geographically weighted regression analysis

Previous studies have indicated that tobacco outlets seem to be clustered in low-income minority neighborhoods. This study utilized a cross-sectional design to examine the relationships among minority status, median household income, population density, commercial land use, and location of tobacco outlets at the census tract level in Polk County, Iowa. Using geographically weighted regression, this study re-examines one previously carried out in the same location by Schneider et al. (Prevention Science 6: 319-325, 2005). Contrary to that and some other previous studies, this research found no relationship between tobacco outlet density and percent Hispanic, and found a negative relationship with regard to two variables-that of being African American and median household income. Positive significant relationships were found with population density and land use.

Socioeconomic, Rural-Urban, and Racial Inequalities in US Cancer Mortality: Part I-All Cancers and Lung Cancer and Part II-Colorectal, Prostate, Breast, and Cervical Cancers

We analyzed socioeconomic, rural-urban, and racial inequalities in US mortality from all cancers, lung, colorectal, prostate, breast, and cervical cancers. A deprivation index and rural-urban continuum were linked to the 2003-2007 county-level mortality data. Mortality rates and risk ratios were calculated for each socioeconomic, rural-urban, and racial group. Weighted linear regression yielded relative impacts of deprivation and rural-urban residence. Those in more deprived groups and rural areas had higher cancer mortality than more affluent and urban residents, with excess risk being marked for lung, colorectal, prostate, and cervical cancers. Deprivation and rural-urban continuum were independently related to cancer mortality, with deprivation showing stronger impacts. Socioeconomic inequalities existed for both whites and blacks, with blacks experiencing higher mortality from each cancer than whites within each deprivation group. Socioeconomic gradients in mortality were steeper in nonmetropolitan than in metropolitan areas. Mortality disparities may reflect inequalities in smoking and other cancer-risk factors, screening, and treatment.

Targeted advertising, promotion, and price for menthol cigarettes in California high school neighborhoods

OBJECTIVES

To describe advertising, promotions, and pack prices for the leading brands of menthol and nonmenthol cigarettes near California high schools and to examine their associations with school and neighborhood demographics.

METHODS

In stores (n = 407) within walking distance (0.8 km [1/2 mile]) of California high schools (n = 91), trained observers counted ads for menthol and nonmenthol cigarettes and collected data about promotions and prices for Newport and Marlboro, the leading brand in each category. Multilevel modeling examined the proportion of all cigarette advertising for any menthol brand, the proportion of stores with sales promotions, and the lowest advertised pack price in relation to store types and school/neighborhood demographics.

RESULTS

For each 10 percentage point increase in the proportion of Black students, the proportion of menthol advertising increased by 5.9 percentage points (e.g., from an average of 25.7%-31.6%), the odds of a Newport promotion were 50% higher (95% CI = 1.01, 2.22), and the cost of Newport was 12 cents lower (95% CI = -0.18, -0.06). By comparison, the odds of a promotion and the price for Marlboro, the leading brand of nonmenthol cigarettes, were unrelated to any school or neighborhood demographics.

CONCLUSIONS

In high school neighborhoods, targeted advertising exposes Blacks to more promotions and lower prices for the leading brand of menthol cigarettes. This evidence contradicts the manufacturer's claims that the availability of its promotions is not based on race/ethnicity. It also highlights the need for tobacco control policies that would limit disparities in exposure to retail marketing for cigarettes.

Marketing of menthol cigarettes and consumer perceptions

In order to more fully understand why individuals smoke menthol cigarettes, it is important to understand the perceptions held by youth and adults regarding menthol cigarettes. Perceptions are driven by many factors, and one factor that can be important is marketing. This review seeks to examine what role, if any, the marketing of menthol cigarettes plays in the formation of consumer perceptions of menthol cigarettes. The available literature suggests that menthol cigarettes may be perceived as safer choices than non-menthol cigarettes. Furthermore, there is significant overlap between menthol cigarette advertising campaigns and the perceptions of these products held by consumers. The marketing of menthol cigarettes has been higher in publications and venues whose target audiences are Blacks/African Americans. Finally, there appears to have been changes in cigarette menthol content over the past decade, which has been viewed by some researchers as an effort to attract different types of smokers.

The impact of local U.S. tobacco policies on youth tobacco use: A critical review

Tobacco use continues to be the leading preventable cause of premature death in the United States, killing over 430,000 people annually. Tobacco initiation and use among youth remains a significant public health concern. Despite declines in U.S. youth tobacco use in recent years, state and national survey results are still cause for alarm. Although traditional school-based curricular programs are the most common strategy to prevent or reduce youth tobacco use, their effectiveness may be limited because young people are immersed in a broader social context in which tobacco is readily available. Environmental strategies change this social context by focusing on policy, enforcement, and media. A compelling body of evidence suggests that interventions at the state and federal levels can, when implemented in combination, reduce youth tobacco use. The impact of policies implemented at the local levels is less well understood and effects of environmental strategies on smokeless tobacco consumption have been largely ignored. The purpose of this paper is to review the literature on environmental strategies implemented at the local level on youth use of both cigarettes and smokeless tobacco. We highlight results of the extant literature, hypothesize possible effects where research is lacking, and suggest where future studies might be warranted.

Tobacco point-of-sale advertising in Guatemala City, Guatemala and Buenos Aires, Argentina

OBJECTIVES

To determine tobacco point of sale advertising prevalence in Guatemala City, Guatemala and Buenos Aires, Argentina.

METHODS

Convenience stores (120 per city) were chosen from randomly selected blocks in low, middle and high socioeconomic neighbourhoods. To assess tobacco point of sale advertising we used a checklist developed in Canada that was translated into Spanish and validated in both countries studied. Analysis was conducted by neighbourhood and store type.

RESULTS

All stores sold cigarettes and most had tobacco products in close proximity to confectionery. In Guatemala, 60% of stores had cigarette ads. High and middle socioeconomic status neighbourhood stores had more indoor cigarette ads, but these differences were determined by store type: gas stations and supermarkets were more prevalent in high socioeconomic status neighbourhoods and had more indoor cigarette ads. In poorer areas, however, more ads could be seen from outside the stores, more stores were located within 100 metres of schools and fewer stores had 'No smoking' or 'No sales to minors' signs. In Argentina, 80% of stores had cigarette ads and few differences were observed by neighbourhood socioeconomic status. Compared to Guatemala, 'No sales to minors' signs were more prevalent in Argentina.

CONCLUSIONS

Tobacco point of sale advertising is highly prevalent in these two cities of Guatemala and Argentina. An advertising ban should also include this type of advertising.

Understanding adolescent parenthood from a multisystemic perspective

PURPOSE

This study examined the associations between social, behavioral, and environmental factors and adolescent parenthood.

METHODS

We analyzed data from a subsample of participants, 18-30 years of age (n=7,937), who took part in the 2001-2002 National Epidemiologic Study on Alcohol and Related Conditions, a nationally representative survey of adults. An extended Cox proportional hazards model was used to model time until becoming an adolescent parent (i.e., age at which first child was born if < or =18 years). Predictor variables of interest included initiation of alcohol, marijuana, cocaine, and daily cigarette use, age of earliest conduct disorder symptom, having a parent with alcohol and/or drug problems, parental death, divorce and/or separation, race/ethnicity, and gender.

RESULTS

Several variables were associated with adolescent parenthood, including initiation of daily cigarette smoking, age of first antisocial/conduct disorder symptom, and race/ethnicity. Parental alcohol/drug problems and parental death were also associated with adolescent parenthood for women. A significant interaction between initiation of daily cigarette smoking and ethnicity was present for women. Daily cigarette smoking was associated with adolescent parenthood to a greater degree than nondaily cigarette smoking for white and Hispanic women but not African American women. No significant associations were found between adolescent parenthood and initiation of drinking, marijuana, or cocaine and parental divorce/separation.

CONCLUSIONS

Prevention efforts should focus on adolescents who are at highest risk of adolescent parenthood.

Mechanisms linking socioeconomic status to smoking cessation: a structural equation modeling approach

OBJECTIVE

Although there has been a socioeconomic gradient in smoking prevalence, cessation, and disease burden for decades, these disparities have become even more pronounced over time. The aim of the current study was to develop and test a conceptual model of the mechanisms linking socioeconomic status (SES) to smoking cessation.

DESIGN

The conceptual model was evaluated using a latent variable modeling approach in a sample of 424 smokers seeking treatment (34% African American; 33% Latino; 33% White). Hypothesized mechanisms included social support, neighborhood disadvantage, negative affect/stress, agency, and craving.

MAIN OUTCOME MEASURE

The primary outcome was Week 4 smoking status.

RESULTS

As was hypothesized, SES had significant direct and indirect effects on cessation. Specifically, neighborhood disadvantage, social support, negative affect/stress, and agency mediated the relation between SES and smoking cessation. A multiple group analysis indicated that the model was a good fit across racial/ethnic groups.

CONCLUSION

The present study yielded one of the more comprehensive models illuminating the specific mechanisms that link SES and smoking cessation. Policy, community, and individual-level interventions that target low SES smokers and address the specific pathways identified in the current model could potentially attenuate the impact of SES on cessation.

Real-time craving differences between black and white smokers

Black and White smokers may experience aspects of nicotine dependence, including craving, differently. This study used a naturalistic technique, ecological momentary assessment (EMA), to explore differences in craving, mood, expectancy, and smoking enjoyment between Black and White smokers. Participants carried personal digital assistants (PDAs) programmed to obtain multiple daily assessments. Black smokers reported higher craving after smoking and at random assessment times and higher cigarette enjoyment. No differences were found in mood or expectancy. Racial differences in psychological factors related to smoking are explored in the contexts of genetic, sociological, and psychophysiological distinctions. Implications for practice and research are discussed. (Am J Addict 2010;00:1-5).