Changes in retail tobacco product sales and market share among retail payroll establishments in the U.S. Economic Census between 1997 and 2017.

The tobacco industry spends the vast majority of their marketing and promotional budget at retail outlets. However, few studies have used publicly available data to examine trends in the number and types of retail establishments where tobacco products are sold. Using the U.S. Economic Census for 1997, 2002, 2007, 2012 and 2017 (the latest year), we examined the number, type, and sales of payroll establishments selling tobacco products. Nine store types accounted for 94% - 99% of tobacco product sales between 1997 and 2017. Gas/convenience stores had the greatest market share (33% - 49% of tobacco sales). The number of warehouse clubs selling tobacco quadrupled; however, market share only increased from 9.6% to 10.3%. Supermarkets experienced the largest decrease in percent of stores selling tobacco. Pharmacy tobacco sales increased in 2012 then decreased in 2017; per store sales volume more than doubled between 1997 and 2012. Online shopping accounted for less than 1% of the market share between 1997 and 2012, but rose to 6.3% in 2017. Between 1997 and 2017, consumers shifted where they purchased tobacco products. Declining tobacco sales in supermarkets is a promising trend for consumers seeking healthy food without exposure to tobacco product marketing; however, the consistently large number of tobacco retailers, and thus widespread tobacco availability, is concerning. Consumer tobacco purchase changes over time support the case for point-of-sale policies that affect different retail types, including pharmacy bans, to reduce tobacco retailer density. Additionally, the rapid shift to online tobacco purchasing in 2017 identifies a new target for enhanced regulation and enforcement.

Tobacco company agreements with tobacco retailers for price discounts and prime placement of products and advertising: a scoping review.

OBJECTIVE: The objectives of this scoping review are to examine existing research on the often-secretive contracts between tobacco manufacturers and retailers, to identify contract requirements and incentives, and to assess the impact of contracts on the sales and marketing of tobacco products in the retail setting. DATA SOURCES: The systematic search was conducted in PubMed/MEDLINE, Web of Science, Scopus, ProQuest Political Science Database, Business Source Premier, ProQuest Agricultural & Environmental Science Collection, and Global Health through December 2020. STUDY SELECTION: We included studies that collected and analysed empirical data related to tobacco contracts, tobacco manufacturers, and tobacco retailers. Two reviewers independently screened all 2786 studies, excluding 2694 titles and abstracts and 65 full texts resulting in 27 (0.97%) included studies. DATA EXTRACTION: Study characteristics, contract prevalence, contract requirements and incentives, and the influence of contracts on the retail environment were extracted from each study. DATA SYNTHESIS: We created an evidence table and conducted a narrative review of included studies. CONCLUSIONS: Contracts are prevalent around the world and handsomely incentivise tobacco retailers in exchange for substantial manufacturer control of tobacco product availability, placement, pricing and promotion in the retail setting. Contracts allow tobacco companies to promote their products and undermine tobacco control efforts in the retail setting through discounted prices, promotions and highly visible placement of marketing materials and products. Policy recommendations include banning tobacco manufacturer contracts and retailer incentives along with more transparent reporting of contract incentives given to retailers.

Urban-rural differences in tobacco product availability in food retailers, United States, 2017.

PURPOSE: Tobacco use prevalence is higher in rural compared to urban settings, possibly due to differences in tobacco availability, including the option to purchase food and other essential items in stores that do not sell tobacco (tobacco-free food retailers). The goal of this research is to determine whether tobacco-free food retailer availability varies by urbanicity/rurality. METHODS: Using the 2017 National Establishment Time-Series database, we identified food retailers across all census tracts containing food retailers in the United States (n = 66,053). We used multivariable logistic and linear regression models to test whether tobacco-free food retailer availability varied across 4-levels of census tract urbanicity/rurality (urban, suburban, large town, and small town/rural) for 2 outcomes: (1) the presence of at least 1 tobacco-free food retailer and (2) the percent of all food retailers that were tobacco-free. FINDINGS: Compared to urban core census tracts, suburban census tracts had a lower odds (aOR = 0.77, 95% CI = 0.73, 0.81) of having at least 1 tobacco-free food retailer, while small town/rural census tracts had greater odds (aOR = 1.23, 95% CI = 1.15, 1.32). Suburban census tracts (B = -2.29, P < .001) and large town census tracts (B = -1.90, P < .001) also had a lower percentage of tobacco-free food retailers compared to urban census tracts. CONCLUSIONS: Compared to urban cores, tobacco-free food retailers were less prevalent in suburban and large town areas, though similarly or slightly more available in rural areas. Future research should assess whether these differences depend on varying store types.

Evidence-Based Point-of-Sale Policies to Reduce Youth Tobacco Use in North Carolina.

Many states and localities in the United States are implementing evidence-based tobacco control policies at the retail level, including Tobacco 21 laws, tobacco retailer licensing, restrictions on point-of-sale promotions, and bans on flavored tobacco products. With the passage of new point-of-sale tobacco control policies, North Carolina could reduce youth tobacco use rates.

Trends in Cigarette Marketing Expenditures, 1975-2019: An Analysis of Federal Trade Commission Cigarette Reports.

INTRODUCTION: With tightened regulations on cigarette marketing and decreased smoking, the major tobacco companies quickly shifted their marketing expenditures in recent decades to maintain profits. We investigated cigarette marketing expenditures in the United States from 1975 through 2019 to examine the trends in cigarette marketing expenditures over the past 45 years. AIMS AND METHODS: Cigarette marketing expenditure data were obtained from the Federal Trade Commission (FTC) cigarette reports, 1975-2019. Based on individual expenditure categories included in the FTC reports, we created seven aggregate categories for marketing expenditures: Retail; Print; Out of home; Free tobacco products and gifts; Sports, public entertainment, and sponsorships; Telephone and digital; and Other. Dollar amounts and percentages by category were examined to assess trends in marketing expenditures. RESULTS: Cigarette marketing expenditures increased since 1975 and peaked in 2003 at $21.1 billion (adjusted dollars); afterward, they declined dramatically until 2010 and remained stable at around $9 billion through 2019. While all other expenditures decreased, retail expenditures increased, comprising more than 50% of expenditures in 1988 and reaching about 98% in 2019. In the retail category, tobacco companies spent the most on promotional allowances, coupons, and retail-value-added bonuses between 1988 and 2003, after which price discounts dominated retail spending. CONCLUSIONS: Overall, cigarette marketing expenditures peaked in 2003 and retail first became the leading category in 1988. Tobacco companies adapted their marketing strategies in retail and allocated most of their retail spending on price discounts since 2003 to lower cigarette prices. IMPLICATIONS: The major US tobacco companies directed the bulk of their vast spending on the retail environment since 1988. Moreover, they have dramatically shifted their marketing strategies within the retail category from cigarette advertising before 2003 to customer-directed price discounts since then. This shift may imply a change in focus from recruiting new smokers to retaining current smokers, in response to tax increases and government regulations. Accordingly, restrictions on price-related promotions in retail and nontax strategies should be implemented to counter tobacco companies' marketing efforts in retail.

Sociodemographic Disparities in Tobacco Retailer Density in the United States, 2000-2017.

INTRODUCTION: Studies find differences in tobacco retailer density according to neighborhood sociodemographic characteristics, raising issues of social justice, but not all research is consistent. AIMS AND METHODS: This study examined associations between tobacco retailer density and neighborhood sociodemographic characteristics in the United States at four timepoints (2000, 2007, 2012, and 2017) and investigated if associations remained stable over time. Data on tobacco retailers came from the National Establishment Time-Series Database. Adjusted log-linear models examined the relationship between retailer density and census tract sociodemographic characteristics (% non-Hispanic Black [Black], % Hispanic, % vacant housing units, median household income), controlling for percentage of youth, urbanicity, and US region. To examine whether the relationship between density and sociodemographic characteristics changed over time, additional models were estimated with interaction terms between each sociodemographic characteristic and year. RESULTS: Tobacco retailer density ranged from 1.22 to 1.44 retailers/1000 persons from 2000 to 2017. There were significant, positive relationships between tobacco retailer density and the percentage of Black (standardized exp(b) = 1.05 [95% CI: 1.04% to 1.07%]) and Hispanic (standardized exp(b) = 1.06 [95% CI: 1.05% to 1.08%]) residents and the percentage of vacant housing units (standardized exp(b) =1.08 [95% CI: 1.07% to 1.10%]) in a census tract. Retailer density was negatively associated with income (standardized exp(b) = 0.84 [95% CI: 0.82% to 0.86%]). From 2000 to 2017, the relationship between retailer density and income and vacant housing units became weaker. CONCLUSIONS: Despite the weakening of some associations, there are sociodemographic disparities in tobacco retailer density from 2000 to 2017, which research has shown may contribute to inequities in smoking. IMPLICATIONS: This study examines associations between tobacco retailer density and neighborhood sociodemographic characteristics in the United States at four timepoints from 2000 to 2017. Although some associations weakened, there are sociodemographic disparities in tobacco retailer density over the study period. Research suggests that sociodemographic disparities in retailer density may contribute to inequities in smoking. Findings from this study may help identify which communities should be prioritized for policy intervention and regulation.

Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment.

BACKGROUND: In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message. OBJECTIVES: To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics. DESIGN: Randomized experiment. PARTICIPANTS AND SETTING: During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White). METHODS: Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels. MAIN OUTCOME MEASURES: Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish. STATISTICAL ANALYSES PERFORMED: Ordinary least squares regression. RESULTS: The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12). CONCLUSIONS: San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.

Barriers and facilitators to achieving food security during the COVID-19 pandemic.

The COVID-19 pandemic has considerably increased food insecurity. To identify where intervention and policy solutions are most needed, we explored barriers to obtaining food and predictors of experiencing food insecurity due to the COVID-19 pandemic. Between May and July 2020, we conducted cross-sectional online surveys with two convenience samples of U.S. adults (Study 1: n = 2,219, Study 2: n = 810). Roughly one-third of participants reported experiencing food insecurity due to the COVID-19 pandemic (Study 1: 32%, Study 2: 35%). Between one-third and half reported using the charitable food system (Study 1: 36%, Study 2: 46%). The majority of participants experienced barriers to getting food (Study 1: 84%, Study 2: 88%), of which the most commonly reported were not having enough money to buy food (Study 1: 48%; Study 2: 53%) and worrying about getting COVID-19 at the store (Study 1: 50%; Study 2: 43%). Higher education was associated with greater risk of food insecurity in both studies (all p < 0.05). Receipt of aid from SNAP buffered against the association between financial struggles and food insecurity in Study 1 (p = 0.03); there was also some evidence of this effect in Study 2 (p = 0.05). Our findings suggest that food insecurity might be reduced by mitigating financial struggles (e.g., by increasing access to SNAP) and by addressing barriers to obtaining food (e.g., by expanding accessibility of food delivery programs).

Implementation of a Transitional Care Model for Stroke: Perspectives From Frontline Clinicians, Administrators, and COMPASS-TC Implementation Staff.

BACKGROUND AND OBJECTIVES: Stroke is a chronic, complex condition that disproportionally affects older adults. Health systems are evaluating innovative transitional care (TC) models to improve outcomes in these patients. The Comprehensive Post-Acute Stroke Services (COMPASS) Study, a large cluster-randomized pragmatic trial, tested a TC model for patients with stroke or transient ischemic attack discharged home from the hospital. The implementation of COMPASS-TC in complex real-world settings was evaluated to identify successes and challenges with integration into the clinical workflow. RESEARCH DESIGN AND METHODS: We conducted a concurrent process evaluation of COMPASS-TC implementation during the first year of the trial. Qualitative data were collected from 4 sources across 19 intervention hospitals. We analyzed transcripts from 43 conference calls with hospital clinicians, individual and group interviews with leaders and clinicians from 9 hospitals, and 2 interviews with the COMPASS-TC Director of Implementation using iterative thematic analysis. Themes were compared to the domains of the RE-AIM framework. RESULTS: Organizational, individual, and community factors related to Reach, Adoption, and Implementation were identified. Organizational readiness was an additional key factor to successful implementation, in that hospitals that were not "organizationally ready" had more difficulty addressing implementation challenges. DISCUSSION AND IMPLICATIONS: Multifaceted TC models are challenging to implement. Facilitators of implementation were organizational commitment and capacity, prioritizing implementation of innovative delivery models to provide comprehensive care, being able to address challenges quickly, implementing systems for tracking patients throughout the intervention, providing clinicians with autonomy and support to address challenges, and adequately resourcing the intervention. CLINICAL TRIAL REGISTRATION: NCT02588664.