Advertising Receptivity and Youth Initiation of Smokeless Tobacco

Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review

PURPOSE

While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps.

METHODS

We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded.

RESULTS

A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco.

CONCLUSIONS

This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Digital marketing of smokeless tobacco: A longitudinal analysis of exposure and initiation among young adults

OBJECTIVES

This study examines the relationships between recall of exposure to digital marketing of smokeless tobacco, via the internet and social media, and subsequent initiation of smokeless tobacco use at one-year follow-up, among young adult never users of smokeless tobacco in Texas.

METHODS

Data were from waves 6 (Spring 2017) and 7 (Spring 2018) of the Marketing and Promotions Across Colleges in Texas Study (Project M-PACT); a longitudinal study of two- and four-year Texas college students. Participants were 2731 young adult never smokeless tobacco users (ages 20-32) with complete data at both assessment periods. A multi-level, multiple logistic regression model was applied, accounting for school clustering, to examine the relationship between recall of exposure to digital marketing of smokeless tobacco at baseline (wave 6) and smokeless tobacco use initiation at one-year follow-up (wave 7). Analyses controlled for important baseline covariates (socio-demographic factors, other marketing exposure, other tobacco product use).

RESULTS

Overall, 14.6% of never smokeless tobacco users reported exposure to smokeless tobacco marketing via digital media. Exposure to digital marketing of smokeless tobacco at baseline was associated with greater odds of smokeless tobacco use initiation among young adult never users (AOR: 2.14; 95%CI: 1.12 - 4.06) at one-year follow-up.

CONCLUSIONS

Findings reveal exposure to smokeless tobacco marketing via digital media was common. Further, there appears to be a strong relationship between this exposure and subsequent smokeless tobacco use among young adult never smokeless tobacco users.

Smokeless Tobacco Point of Sale Advertising, Placement and Promotion: Associations With Store and Neighborhood Characteristics

Introduction: Objectives of this study were to determine retail and neighborhood characteristics associated with smokeless tobacco (ST) product promotion, price promotion, and storefront advertising among retailers in Oklahoma.

Methods: In this statewide point-of-sale study, we collected data from 1,354 ST retailers. Using store characteristics and census tract information, we estimated summary statistics and adjusted prevalence ratios during 2019–2020.

Results: Of ST retailers audited, 11.0% demonstrated ST youth promotion, 43.0% ST price promotions, and 19.6% ST storefront advertising. The adjusted prevalence ratio (aPR) for convenience stores was higher for all three ST strategies: youth promotion (aPR = 3.4, 95% CI 1.9, 6.2), price promotion (aPR = 3.8, 95% CI 2.9, 5.0), and storefront advertising (aPR=16.4, 95% CI 6.7, 40.3) compared to other store types. Metropolitan tobacco retailers had higher aPRs for youth promotion (aPR = 1.7, 95% CI 1.12 2.6) and storefront advertising (aPR = 1.5, 95% CI 1.2, 1.9).

Conclusions: Findings of this study suggest there are currently ample opportunities for youth and adults at risk for tobacco initiation to be exposed to ST products in the retail environment. Convenience stores, more likely to be found and utilized in rural areas compared to metropolitan areas, are disproportionately more likely to engage in marketing strategies that could lure youth into trying smokeless tobacco.

Exposure to the advertisement of toombak at the point-of-sale among adolescents in Khartoum State, Sudan: A cross-sectional study

INTRODUCTION

This study aimed to assess the association between toombak (smokeless tobacco) advertisement at point-of-sale (PoS) and its use among adolescents in Sudan.

METHODS

A cross-sectional school-based and self-administered questionnaire study was conducted. Schools were randomly selected using a one-stage stratified sampling procedure, during 2013–2014, as part of a larger research project focusing on the use of toombak among secondary school students in Khartoum State, Sudan. The sample size was 1526 students. Data were collected on exposure to toombak advertisement, social acceptability, perceived accessibility to toombak, susceptibility, and toombak use.

RESULTS

A total of 41.8% of the adolescents were exposed to an advertisement at PoS, while 12.5% perceived direct access to toombak, 5.3% reported that they were susceptible to use toombak, and 10.9% were ever toombak users. Exposure to the advertisement of toombak at PoS was found to be associated with the older age group (44.3%) (p≤0.05). Males were more than females (45.2% vs 38.8%; p≤0.05). Those exposed to toombak advertisements at PoS reported more social acceptability towards toombak (48.9% vs 37.6%; p≤0.001) and direct accessibility to toombak (68.8% vs 47.2%; p≤0.05). Ever toombak users reported higher exposure to advertisements than non-users (54.5% vs 40.3%; p≤0.001).

CONCLUSIONS

Exposure to toombak advertisements at PoS was found to be high and associated with increased toombak use in Khartoum State, Sudan, in addition to increasing social acceptability to its use and perceived easy accessibility. The current law, which bans toombak advertisement and promotion at PoS, needs to be enforced.

Marketing exposure and smokeless tobacco use initiation among young adults: A longitudinal analysis

OBJECTIVES

This study examines the relationships between self-reported exposure to smokeless tobacco marketing and initiation/onset of smokeless tobacco use/susceptibility at 6-month follow-up, among a cohort of young adults in urban Texas.

METHODS

Participants were 3597 18-25 year old never smokeless tobacco users, attending 24 Texas two-year colleges and four-year universities. A multi-level, multivariate logistic regression model, accounting for school clustering, examined the impact of self-reported recall of smokeless tobacco marketing exposure at baseline and subsequent initiation of smokeless tobacco use. A subsample analysis of non-susceptible never users (n = 3097) examined the impact of self-reported exposure to smokeless tobacco marketing at baseline and onset of susceptibility to use smokeless tobacco. Both outcomes were assessed at 6-month follow-up. Baseline covariates included age, race/ethnicity, sex, two-/four-year institution, and other tobacco use. For the full analysis, susceptibility to use smokeless tobacco at baseline was included as a covariate.

RESULTS

From baseline to 6-month follow-up, 6.1% of never users initiated smokeless tobacco use (n = 219) and 7.0% of non-susceptible never users became susceptible to smokeless tobacco use (n = 221). Self-reported recall of smokeless tobacco marketing exposure at baseline was associated with initiation of smokeless tobacco (Adj OR: 1.17; 95% CI: 1.08-1.27) and onset of susceptibility to use smokeless tobacco (Adj OR: 1.11; 95% CI: 1.02-1.21) at 6-month follow-up, controlling for all covariates.

CONCLUSIONS

Findings build on previous research by demonstrating an association between recall of smokeless tobacco marketing and subsequent use. Findings are concerning given the 300% increase in smokeless tobacco marketing expenditures from 2006 to 2016.

Associations of Tobacco Advertising Appeal With Intentions to Use Alternative Tobacco Products Among Young Tobacco Users Experiencing Homelessness

PURPOSE

Virtually nothing is known about the potential effects of tobacco advertising on tobacco use among youth experiencing homelessness, a vulnerable population with high tobacco use rates. This study examines associations between the appeal of advertising for 5 classes of tobacco product (electronic cigarettes, hookah, cigars, cigarillos, and smokeless tobacco) and future intentions to use those products again among homeless youth who had indicated any level of lifetime use.

DESIGN

A cross-sectional design was used.

SETTING

Settings were 25 service and street sites in Los Angeles County.

PARTICIPANTS

A probability sample of 469 young tobacco users experiencing homelessness (mean age = 22; 71% male; 29% non-Hispanic White) was recruited.

MEASURES

Assessments included product-specific tobacco advertising appeal and future intentions to use the product again, as well as a range of covariate controls (eg, demographics, homelessness severity, current tobacco use, general advertising exposure).

ANALYSIS

Linear regression tested for associations between the appeal of advertising for a specific tobacco product and intentions to use that product again in the future, controlling for myriad covariates.

RESULTS

Advertising appeal was positively associated with future intentions to use again for electronic cigarettes (P = .006) and hookah (P = .001), but not cigars (P = .486), cigarillos (P = .126), or smokeless tobacco (P = .109).

CONCLUSION

Results suggest that advertising appeal may increase use of certain tobacco products among youth experiencing homelessness. However, differences in themes emphasized by advertising for specific tobacco products could differentially influence use in this population.

Predictors of Smokeless Tobacco Susceptibility, Initiation, and Progression Over Time Among Adolescents in a Rural Cohort

BACKGROUND

Use of smokeless tobacco (ST, moist snuff and chewing tobacco) is elevated among male rural youth, particularly participants in certain sports, including baseball.

OBJECTIVES

This study aimed to assess factors associated with adolescent male athletes' ST-related behaviors over time, including: baseline use, initiation, and progression in use intensity in a school-based longitudinal cohort.

METHODS

Baseline and one-year follow-up questionnaires assessed sociodemographic characteristics, environmental factors, and tobacco-related perceptions and behaviors among 9- to12th-grade interscholastic baseball players in 36 rural California schools. Population characteristics were compared among ST use categories (never, experimental, and experienced users). Multivariable models using generalized estimating equations were estimated for outcomes among baseline ST never-users (ST susceptibility and future initiation) and experimenters (ST expectations and progression in ST use).

RESULTS

Of 594 participants, over half (57%) had ever tried a tobacco product and the most common products tried were ST (36%) and electronic cigarettes (36%). Being older, perceiving less ST harm, being Non-Hispanic White, using alcohol or other tobacco products, having family or friends who use ST, and being receptive to advertising were associated with greater baseline ST use. Baseline alcohol consumption, lower perceived ST harm, peer use, and susceptibility and expectations were predictive of ST initiation and/or progression at one-year follow-up. Conclusion/Importance: Certain environmental, socio-demographic, cognitive, and behavioral factors predict ST susceptibility and later initiation and progression in use. Interventions addressing these factors have potential to prevent ST uptake and continued use within this high-risk adolescent population.

The magnitude and impact of tobacco marketing exposure in adolescents' day-to-day lives: An ecological momentary assessment (EMA) study

PURPOSE

Research indicates that tobacco marketing contributes to higher pro-tobacco attitudes and behaviors among adolescents, but no studies have been able to assess the impact of real-world tobacco marketing exposures in real-time. The purpose of this study was to examine the magnitude and impact of tobacco marketing exposure on adolescents using ecological momentary assessment (EMA). Our primary hypotheses were that (1) youth would most frequently report tobacco marketing at the retail points-of-sale and (2) greater exposures to tobacco marketing would be associated with more favorable tobacco-related attitudes, use, and expectancies.

METHODS

Participants were adolescent males from rural and urban Ohio (N = 176, ages 11-16). For ten days, these adolescents were prompted at two-three random times/day to complete a brief smartphone-based survey about their exposures and responses to tobacco-related advertising.

RESULTS

Adolescents reported exposures to tobacco marketing an average of 1.9 times over the 10-day EMA period, with over 10% seeing a tobacco advertisement 5 or more times. Reports of marketing exposures occurred most frequently at the point-of-sale; exposures were higher among tobacco users and rural adolescents. Consistent with hypotheses, marketing exposure was related to more positive attitudes to the tobacco advertisements, more tobacco use, and higher expectancies to use in the future.

CONCLUSIONS

Overall, these findings signal the magnitude of tobacco marketing exposures and their pernicious impact on youth. Findings underscore the importance of federal, state, and local-level tobacco regulatory policies to protect youth from the marketing that puts them at risk for a lifetime of nicotine addiction and tobacco-related diseases.

Association Between Receptivity to Tobacco Advertising and Progression to Tobacco Use in Youth and Young Adults in the PATH Study

IMPORTANCE

Cigarette marketing contributes to initiation of cigarette smoking among young people, which has led to restrictions on use of cigarette advertising. However, little is known about other tobacco advertising and progression to tobacco use in youth and young adults.

OBJECTIVE

To investigate whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking.

DESIGN, SETTING, AND PARTICIPANTS

The Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10 989). Household interviews using audio computer-assisted self-interviews were conducted.

EXPOSURES

Advertising for conventional cigarettes, electronic cigarettes (e-cigarettes), cigars, and smokeless tobacco products at wave 1.

MAIN OUTCOMES AND MEASURES

Progression to susceptibility or ever tobacco use at 1-year follow-up in wave 2.

RESULTS

Of the 10 989 participants (5410 male [weighted percentage, 48.3%]; 5579 female [weighted percentage, 51.7%]), receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years (44.0%; 95% confidence limit [CL], 42.6%-45.4%) but highest for those aged 18 to 21 years (68.7%; 95% CL, 64.9%-72.2%). e-Cigarette advertising had the highest receptivity among all age groups. For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products. Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2 (conventional cigarettes: adjusted odds ratio [AOR], 1.43; 95% CL, 1.23-1.65; e-cigarettes: AOR, 1.62; 95% CL, 1.41-1.85; cigars: AOR, 2.01; 95% CL, 1.62-2.49; and smokeless [males only]: AOR, 1.42; 95% CL, 1.07-1.89) and with use of the product (conventional cigarettes: AOR, 1.54; 95% CL, 1.03-2.32; e-cigarettes: AOR, 1.45; 95% CL, 1.19-1.75; cigars: AOR, 2.07; 95% CL, 1.26-3.40). Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2 (AOR, 1.60; 95% CL, 1.08-2.38).

CONCLUSIONS AND RELEVANCE

Receptivity to tobacco advertising was significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.

A Policy Perspective on the Global Use of Smokeless Tobacco

Background

Globally, over 300 million people consume diverse smokeless tobacco (ST) products. They are addictive, cause cancer, increased cardiovascular mortality risks and poor pregnancy outcomes.

Purpose of Review

To identify gaps in implementing key ST demand-reduction measures, focused literature reviews were conducted and findings synthesized according to relevant WHO Framework Convention on Tobacco Control (FCTC) Articles.

Recent Findings

The literature supports implementation of ST demand-reduction measures. For taxation, labelling and packaging, most administrations have weaker policies for ST than cigarettes. Capacity to regulate ST contents and offer cessation support is lacking. There is poor compliance with bans on ST advertising, promotion and sponsorship.

Summary

The literature on implementation of WHO FCTC for ST is limited. Although strengths of ST demand-control activities are currently identifiable from available literature, full implementation of FCTC is lacking. A wider evidence-based response to WHO FCTC is proposed, particularly for countries facing the greatest disease burdens.

Socio-cognitive correlates of intention to use Toombak: a cross-sectional study among students (13-16 years) in Khartoum State, Sudan

BACKGROUND

Toombak is a form of smokeless tobacco, locally made and consumed in Sudan. It is associated with a number of health hazards, particularly oral cancer. This study was set out to assess the prevalence and socio-demographic distribution of its use, and to explore the socio-cognitive factors affecting the intention to use Toombak among secondary school students in Khartoum State, Sudan.

METHODS

A cross-sectional school-based study was conducted in 2013-2014 where schools were randomly selected using a one-stage stratified sampling procedure. The sample size was calculated to consist of 1526 students. Data were collected through a self-administered questionnaire, which contained some cognitive constructs; information received, social image, attitudes, normative social influence, accessibility to Toombak, socio-demographics and Toombak use related variables.

RESULTS

A total of 1670 secondary school students participated in the study. More than half of them 53.4% were <15-years-old and 53.6% were females. Only 5.3% of the students reported intention to use Toombak. Among the students 10.9% were ever Toombak users, 81.6% reported a positive attitude towards its use and 60.7% had received information about its harmful effects. A total of 72.6% reported normative social influence towards using Toombak and 62.5% perceived a negative social image attached to its use. Most of the students, 70.8% reported exposure to anti-Toombak information, 41.8% confirmed exposure to Toombak advertisement and 87.5% reported indirect access to its sale. Younger students reported ever use of Toombak less frequently than their older counterparts (38.4% versus 61.6%), p < 0.001. Males reported ever use of Toombak more frequently than did females (74.3% versus 25.7%), p < 0.001. According to the regression model, individuals who perceived a positive social image of Toombak users and had past experience were more likely to intend to its use.

CONCLUSIONS

The present study suggested that the prevalence of Toombak use among Sudanese secondary school students is low and that male and older students are more frequent users. Students' decision to use Toombak was based upon past experience with Toombak use and the social image attached to its use. Easy access to Toombak and encouragement from friends and classmates were among the factors which support intention to use Toombak but only in the unadjusted analyses.

Tracking Young Adults' Attitudes Toward Tobacco Marketing Using Ecological Momentary Assessment (EMA)

BACKGROUND

Decades of research demonstrate the pernicious effects of targeted cigarette marketing on young people. Now, with tobacco marketing shifting toward greater incorporation of alternative products, it is critical to identify current attitudes toward the new landscape of tobacco advertisements.

OBJECTIVES

The purpose of this study was to understand the present landscape of tobacco marketing to which young adults are exposed, and to assess how they respond to it.

METHOD

During 2015-2016, we used ecological momentary assessment (EMA), in which 44 young adults (aged 18-28) carried smartphones equipped with a survey app. Seventy-seven percent were ever-users of tobacco and 29.5% were intermittent users of tobacco (someday users of cigarettes and/or those who used another tobacco product >5 times within the past year). For ten days, participants were prompted at three random times/day to complete a brief survey about their exposures and responses to tobacco-related advertising. Analyses used t-test and multilevel modeling.

RESULTS

Intermittent users reported greater exposure than non-intermittent users to tobacco advertising. Further, both intermittent and ever-users reported more positive attitudes toward the tobacco advertising. Of the tobacco advertisements reported, 22% were for products unregulated by the FDA at the time of data collection. Conclusions/Importance: These findings indicate that young adults, and especially young adults who use tobacco, are exposed to a fair amount of tobacco advertising on a weekly basis. As the tobacco users in our sample were largely experimental and occasional users, these marketing exposures could put young adults at risk for progression toward regular use.