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

BACKGROUND AND AIMS

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

DESIGN

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

SETTING

Ten US states with alcoholic beverage control systems were included.

PARTICIPANTS

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Prohibition no, abolition yes! Rethinking how we talk about ending the cigarette epidemic

As public health advocates struggle over how best to end the cigarette epidemic, one persistent obstacle to developing appropriate policies has been the lingering spectre of 'prohibition'. A misunderstanding of the USA's experience with the national ban on sales of alcohol more than a century ago has led even public health advocates to claim that we cannot end the sale of cigarettes because 'prohibition does not work': a ban on sales, we hear, would lead to crime and to black markets, among many other negatives. In this Special Communication, we show how the tobacco industry has carefully constructed and reinforced this imagined impossibility, creating a false analogy between cigarettes and alcohol. This improper analogy, with its multiple negative associations, continues to block intelligent thinking about how to end cigarette sales. Instead of prohibition, we propose abolition as a term that better captures what ending sales of the single most deadly consumer product in history will actually do: enhance human health and freedom.

Tobacco industry and public health responses to state and local efforts to end tobacco sales from 1969-2020

BACKGROUND

In June 2019, Beverly Hills, California, became the first American city in the 21st century to pass an ordinance ending the sale of most tobacco products, including cigarettes, and it is unlikely to be the last. Knowledge of previous efforts to ban tobacco sales in the US, both successful and unsuccessful, may help inform tobacco control advocates' approach to future efforts.

METHODS

We retrieved and analyzed archival tobacco industry documents. We confirmed and supplemented information from the documents with news media coverage and publicly available state and local government materials, such as meeting minutes and staff reports, related to proposed bans.

RESULTS

We found 22 proposals to end the sale of cigarettes or tobacco products from 1969-2020 in the US. Proposals came from five states, twelve cities or towns, and one county. Most came from elected officials or boards of health, and were justified on public health grounds. In opposing tobacco sales bans, the tobacco industry employed no tactics or arguments that it did not also employ in campaigns against other tobacco control measures. Public health groups typically opposed sales ban proposals on the grounds that they were not evidence-based. This changed with Beverly Hills' 2019 proposal, with public health organizations supporting this and other California city proposals because of their likely positive health impacts. This support did not always translate into passage of local ordinances, as some city council members expressed reservations about the impact on small businesses.

CONCLUSION

Tobacco control advocates are likely to encounter familiar tobacco industry tactics and arguments against tobacco sales ban proposals, and can rely on past experience and the results of a growing body of retail-related research to counter them. Considering how to overcome concerns about harming retailers will likely be vital if other jurisdictions are to succeed in ending tobacco sales.

An argument for phasing out sales of cigarettes

The successes of tobacco control in some countries and locales have led to discussions of ending the tobacco epidemic, often called the 'endgame'. In this paper, we recommend articulating the endgame goal as phasing out sales of cigarettes, a goal once called 'unthinkable'. We develop a logic and argumentation for ending cigarette sales intended to move the discussion beyond the shadow of 'prohibition', proposing an approach that appeals to consumer protection standards and suggesting that the effort be led by low-prevalence communities. While phasing out cigarettes will not happen everywhere all at once, and may unfold differently along several lines, we argue that the gradual phase-out approach we propose will reduce the likelihood of the negative consequences often predicted to come with such a policy. To continue permitting widespread sales of the single most deadly consumer product in history is a public health failure that must be addressed.

Philip Morris International-funded 'Foundation for a Smoke-Free World': analysing its claims of independence

The Foundation for a Smoke-Free World was launched in September 2017 with an announced 12-year funding commitment of $1 billion from Philip Morris International (PMI). The Foundation claims that its governing documents (certificate of incorporation, bylaws and a pledge agreement) ensure that it has an independent research agenda and stringent protections from conflicts of interest. We analysed the text of these governing documents. Their provisions have multiple loopholes, particularly regarding conflicts of interest. Further, these documents cannot substitute for other important documentation such as information about PMI's internal business case for investing $1 billion in the Foundation, an unwaivable conflict of interest policy, annual disclosure statements, copies of pre-Foundation establishment correspondence between key individuals, all signed contracts or salary information, none of which, as of July 2018, the Foundation has made publicly available. Even if these were released, however, it is problematic that the Foundation's fundamental purpose was decided on and its leader selected following a tobacco company-paid, privately negotiated arrangement with the Foundation's president. It cannot be regarded as independent.

"You Want Your Guests to Be Happy in This Business": Hoteliers' Decisions to Adopt Voluntary Smoke-Free Guest-Room Policies

PURPOSE

To explore why some hotels have implemented 100% smoke-free policies voluntarily, the perceived consequences of doing so, and media responses.

DESIGN

Qualitative study of hotel management and quantitative content analysis of media coverage of smoke-free hotels.

SETTING

Hotels and media based in the United States.

PARTICIPANTS

Eleven representatives of 5 independent and 4 chain hotels. Other data included 265 news items about smoke-free hotels.

METHOD

We conducted 30-minute semi-structured interviews with hotel representatives and analyzed the data using qualitative content analysis. We also searched 3 online news databases for news items about hotels in our study, and collaboratively coded retrieved items; we analyzed the content and slant of news items.

RESULTS

Business considerations, including guest requests, competitor action, and cost savings, were the primary motivations for implementing 100% smoke-free guest-room policies. Health concerns played a minimal role. Hotels received positive feedback from customers and employees. Media coverage was favorable, emphasizing positive aspects of going smoke-free; the overall slant of news items was positive or neutral. However, few hotels marketed the change.

CONCLUSIONS

Since hotel customers and employees are likely to experience long periods of smoke exposure and smoke-free hotels appear to be so well received, it may be timely to pursue policies making all hotels smoke-free.

Veterans' views on military tobacco use and tobacco control policy

National military and veteran service organizations (MVSOs) have the potential to be advocates for stronger military tobacco control. This study consisted of qualitative analysis of interviews with 5 MVSO leaders (or their designees) and 6 focus groups conducted with veterans, to explore the opinions of MVSO leaders and veterans about military tobacco use and tobacco control policy, and to assess their current knowledge, attitudes, and likelihood of engaging with civilian tobacco control. Themes discussed include the impact of tobacco use on the military mission and on veterans; the possibility of stronger military tobacco control policies; and the idea that such policies would affect the rights of military personnel. Participants considered whether tobacco use impacts the military mission in the most literal sense (e.g., giving away patrol locations), ignoring larger scale effects on long term health and costs. While familiar with tobacco's impacts on veterans' health, MVSO leaders did not endorse stronger policies, although some veterans did. Participants were largely unaware of the impact of tobacco use on military readiness. Establishment of better alliances among MVSOs and civilian public health groups for mutual education about tobacco's many negative effects on the military's mission may be necessary to achieve a tobacco-free military.

Health Care Organizations and Policy Leadership: Perspectives on Nonsmoker-Only Hiring Policies

PURPOSE

To explore employers' decisions to base hiring policies on tobacco or nicotine use and community perspectives on such policies, and analyze the implications for organizational identity, community engagement, and health promotion.

METHOD

From 2013 to 2016, 11 executives from six health care organizations and one non-health-care organization with nonsmoker-only hiring policies were interviewed about why and how their policies were created and implemented, concerns about the policies, and perceptions of employee and public reactions. Focus groups were conducted with community members (n = 51) who lived in or near cities where participating employers were based, exploring participants' opinions about why an employer would stop hiring smokers and their support (or not) for such a policy.

RESULTS

Most employers excluded from employment those using all forms of nicotine. Several explained their adoption of the policy as a natural extension of a smoke-free campus and as consistent with their identity as health care organizations. They regarded the policy as promoting health. No employer mentioned engaging in a community dialogue before adopting the policy or reported efforts to track the policy's impact on rejected applicants. Community members understood the cost-saving appeal of such policies, but most opposed them. They made few exceptions for health care organizations.

CONCLUSIONS

Policy decisions undertaken by health care organizations have influence beyond their immediate setting and may establish precedents that others follow. Nonsmoker-only hiring policies may fit with a health care organization's institutional identity but may not be congruent with community values or promote public health.

Installation Tobacco Control Programs in the U.S. Military

Tobacco use prevalence is unacceptably high in the U.S. military, and the Department of Defense and service branches have implemented tobacco control policies and cessation programs. To explore aspects of programs regarded as exemplary by their services, we visited four installations, nominated by their service's health promotion leaders, and conducted interviews, observations, and focus groups. Installations included Naval Hospital Guam, Tripler Army Medical Center, MacDill Air Force Base, and the Naval Hospital at Marine Corps Air Ground Combat Center Twentynine Palms. The tobacco control managers (TCMs) at the programs studied were all civilian employees, highly motivated and enthusiastic, and had remained in their positions for approximately a decade. Other commonalities included support from command, a "culture" of health, and location in warm climates. Programs varied in their involvement in establishing designated tobacco use areas, and length and requirement of attending cessation classes; however, no evaluation of cessation programs is currently underway. TCMs should be more engaged in policy discussions for the larger installations they serve. A strong policy framework and command support for TCMs will be necessary to achieve the goal of a tobacco-free military.

"It doesn't seem to make sense for a company that sells cigarettes to help smokers stop using them": A case study of Philip Morris's involvement in smoking cessation

BACKGROUND

In the late 1990s, American tobacco companies began offering limited cessation assistance to smokers by posting links on their company websites to government-sponsored smoking cessation resources. Philip Morris USA (PM) went further, funding youth cessation programs and creating its own online cessation program, QuitAssist. We explore why PM entered the cessation arena, and describe the variety of options considered and how PM-supported cessation programs were evaluated and promoted.

METHODS

We retrieved and analyzed archival PM documents from 1998-2005. We supplemented information from the documents with scholarly articles assessing QuitAssist and archived versions of the PM and QuitAssist websites.

RESULTS

PM's Youth Smoking Prevention department began funding youth cessation projects and programs soon after its creation in 1998, motivated by the same issue that drove its interest in youth smoking prevention: regulatory threats posed by public and policymaker concern about youth smoking. The department took a similar approach to youth smoking cessation as it did with prevention, rejecting curricula with "anti-industry" themes. In 2002, a "cessation exploration team" examined a variety of rationales for and approaches to company support for adult smoking cessation. Ultimately, PM chose QuitAssist, a limited and less expensive option that nonetheless provided opportunities for engagement with a variety of public health and government officials. Independent research indicates that QuitAssist is not an effective cessation tool.

CONCLUSIONS

While the transformation of ambitious plans into a mundane final product is a recurring theme with PM's corporate responsibility efforts, it would be inappropriate to dismiss PM's smoking cessation endeavors as half-hearted attempts to appear responsible. Such endeavors have the potential to inflict real harm by competing with more effective programs and by helping to maintain a tobacco-favorable policy environment. If PM truly wanted to support cessation, it could drop legal and other challenges to public policies that discourage smoking.

US Media Coverage of Tobacco Industry Corporate Social Responsibility Initiatives

Media coverage of tobacco industry corporate social responsibility (CSR) initiatives represents a competitive field where tobacco control advocates and the tobacco industry vie to shape public and policymaker understandings about tobacco control and the industry. Through a content analysis of 649 US news items, we examined US media coverage of tobacco industry CSR and identified characteristics of media items associated with positive coverage. Most coverage appeared in local newspapers, and CSR initiatives unrelated to tobacco, with non-controversial beneficiaries, were most commonly mentioned. Coverage was largely positive. Tobacco control advocates were infrequently cited as sources and rarely authored opinion pieces; however, when their voices were included, coverage was less likely to have a positive slant. Media items published in the South, home to several tobacco company headquarters, were more likely than those published in the West to have a positive slant. The absence of tobacco control advocates from media coverage represents a missed opportunity to influence opinion regarding the negative public health implications of tobacco industry CSR. Countering the media narrative of virtuous companies doing good deeds could be particularly beneficial in the South, where the burdens of tobacco-caused disease are greatest, and coverage of tobacco companies more positive.

Tobacco use policy in military housing

Secondhand smoke and thirdhand smoke (e.g., smoke residues found on walls and floors) are known to pose health hazards. Some landlords and cities have therefore established smoke-free policies for multiunit housing. The military is in effect the largest landlord in the United States, with approximately 630,000 units of housing. We reviewed the service-level tobacco control policies of the Army, the Air Force, and the Navy and Marine Corps (which share a policy) for references to housing, to see if personnel are adequately protected from secondhand and thirdhand smoke. Policies covering most family housing and all housing for single enlisted personnel fail to fully protect residents from secondhand or thirdhand smoke. The current review of tobacco control policy in the military should recommend a consistent policy of tobacco-free living quarters.

Cigarette prices and community price comparisons in US military retail stores

BACKGROUND

Tobacco pricing impacts use, yet military retailers sell discounted cigarettes. No systematic research has examined how military retail stores use internal community comparisons to set prices. We analysed data obtained through a Freedom of Information Act request on community price comparisons used by military retail to set cigarette prices.

METHODS

Data on cigarette prices were obtained directly from military retailers (exchanges) from January 2013 to March 2014. Complete pricing data were obtained from exchanges on 114 military installations.

RESULTS

The average price for a pack of Marlboro cigarettes in military exchanges was US$5.51, which was similar to the average lowest community price (US$5.45; mean difference=-0.06; p=0.104) and almost a US$1.00 lower than the average highest price (US$6.44). Military retail prices were 2.1%, 6.2% and 13.7% higher than the lowest, average and highest community comparisons, respectively, and 18.2% of exchange prices violated pricing instructions. There was a negative correlation (r=-0.21, p=0.02) between the number of community stores surveyed and exchange cigarette prices.

CONCLUSIONS

There was no significant difference between prices for cigarettes on military installations and the lowest average community comparison, and in some locations, the prices violated Department of Defense (DoD) policy. US Marine Corps exchanges had the lowest prices, which is of concern given that the Marines also have the highest rates of tobacco use in the DoD. Given the relationship between tobacco product prices and demand, a common minimum (or floor) shelf price for tobacco products should be set for all exchanges and discount coupon redemptions should be prohibited.