Relationship between e-cigarette point of sale recall and e-cigarette use in secondary school children: a cross-sectional study.

BACKGROUND: There has been a rapid increase in the retail availability of e-cigarettes in the UK and elsewhere. It is known that exposure to cigarette point-of-sale (POS) displays influences smoking behaviour and intentions in young people. However, there is as yet no evidence regarding the relationship between e-cigarette POS display exposure and e-cigarette use in young people. METHODS: This cross sectional survey was conducted in four high schools in Scotland. A response rate of 87 % and a total sample of 3808 was achieved. Analysis was by logistic regression on e-cigarette outcomes with standard errors adjusted for clustering within schools. The logistic regression models were adjusted for recall of other e-cigarette adverts, smoking status, and demographic variables. Multiple chained imputation was employed to assess the consistency of the findings across different methods of handling missing data. RESULTS: Adolescents who recalled seeing e-cigarettes in small shops were more likely to have tried an e-cigarette (OR 1.92 99 % CI 1.61 to 2.29). Adolescents who recalled seeing e-cigarettes for sale in small shops (OR 1.80 99 % CI 1.08 to 2.99) or supermarkets (OR 1.70 99 % CI 1.22 to 2.36) were more likely to intend to try them in the next 6 months. CONCLUSIONS: This study has found a cross-sectional association between self-reported recall of e-cigarette POS displays and use of, and intention to use, e-cigarettes. The magnitude of this association is comparable to that between tobacco point of sale recall and intention to use traditional cigarettes in the same sample. Further longitudinal data is required to confirm a causal relationship between e-cigarette point of sale exposure and their use and future use by young people.

Are Retail Outlets Complying with National Legislation to Protect Children from Exposure to Tobacco Displays at Point of Sale? Results from the First Compliance Study in the UK.

BACKGROUND: From April 6th 2015, all small shops in the UK were required to cover up tobacco products at point of sale (POS) to protect children from exposure. As part of a larger 5-year study to measure the impact of the legislation in Scotland, an audit was conducted to assess level and nature of compliance with the ban immediately following its introduction. MATERIALS AND METHODS: A discreet observational audit was conducted 7-14 days post implementation which took measures of physical changes made to cover products, server/assistant practices, tobacco signage and advertising, and communication of price information. The audit was conducted in all small retail outlets (n = 83) selling tobacco in four communities in Scotland selected to represent different levels of urbanisation and social deprivation. Data were analysed descriptively. RESULTS: Compliance with the legislation was high, with 98% of shops removing tobacco from permanent display and non-compliance was restricted almost entirely to minor contraventions. The refurbishment of shops with new or adapted tobacco storage units resulted in the removal of nearly all commercial brand messages and images from POS, dropping from 51% to 4%. The majority of shops stored their tobacco in public-facing storage units (81%). Most shops also displayed at least one generic tobacco message (88%). CONCLUSIONS: Compliance with Scottish prohibitions on display of tobacco products in small retail outlets was high immediately after the legislation implementation date. However, although tobacco branding is no longer visible in retail outlets, tobacco storage units with generic tobacco messages are still prominent. This points towards a need to monitor how the space vacated by tobacco products is utilised and to better understand how the continuing presence of tobacco storage units influences people's awareness and understanding of tobacco and smoking. Countries with existing POS bans and who are considering such bans should pay particular attention to regulations regarding the use of generic signage and where within the retail setting tobacco stocks can be stored.

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

INTRODUCTION: Many neighborhood characteristics may constrain or enable smoking. This study investigated whether the neighborhood tobacco retail environment was associated with individual-level smoking and cessation in Scottish adults, and whether inequalities in smoking status were related to tobacco retailing. METHODS: Tobacco outlet density measures were developed for neighborhoods across Scotland using the September 2012 Scottish Tobacco Retailers Register. The outlet data were cleaned and geocoded (n = 10,161) using a Geographic Information System. Kernel density estimation was used to calculate an outlet density measure for each postcode. The kernel density estimation measures were then appended to data on individuals included in the 2008-2011 Scottish Health Surveys (n = 28,751 adults aged ≥16), via their postcode. Two-level logistic regression models examined whether neighborhood density of tobacco retailing was associated with current smoking status and smoking cessation and whether there were differences in the relationship between household income and smoking status, by tobacco outlet density. RESULTS: After adjustment for individual- and area-level confounders, compared to residents of areas with the lowest outlet densities, those living in areas with the highest outlet densities had a 6% higher chance of being a current smoker, and a 5% lower chance of being an ex-smoker. There was little evidence to suggest that inequalities in either current smoking or cessation were narrower in areas with lower availability of tobacco retailing. CONCLUSIONS: The findings suggest that residents of environments with a greater availability of tobacco outlets are more likely to start and/or sustain smoking, and less likely to quit.

A cross-sectional analysis of the relationship between tobacco and alcohol outlet density and neighbourhood deprivation.

BACKGROUND: There is a strong socio-economic gradient in both tobacco-and alcohol-related harm. One possible factor contributing to this social gradient may be greater availability of tobacco and alcohol in more socially-deprived areas. A higher density of tobacco and alcohol outlets is not only likely to increase supply but also to raise awareness of tobacco/alcohol brands, create a competitive local market that reduces product costs, and influence local social norms relating to tobacco and alcohol consumption. This paper examines the association between the density of alcohol and tobacco outlets and neighbourhood-level income deprivation. METHODS: Using a national tobacco retailer register and alcohol licensing data this paper calculates the density of alcohol and tobacco retail outlets per 10,000 population for small neighbourhoods across the whole of Scotland. Average outlet density was calculated for neighbourhoods grouped by their level of income deprivation. Associations between outlet density and deprivation were analysed using one way analysis of variance. RESULTS: There was a positive linear relationship between neighbourhood deprivation and outlets for both tobacco (p <0.001) and off-sales alcohol (p <0.001); the most deprived quintile of neighbourhoods had the highest densities of both. In contrast, the least deprived quintile had the lowest density of tobacco and both off-sales and on-sales alcohol outlets. CONCLUSIONS: The social gradient evident in alcohol and tobacco supply may be a contributing factor to the social gradient in alcohol- and tobacco-related disease. Policymakers should consider such gradients when creating tobacco and alcohol control policies. The potential contribution to public health, and health inequalities, of reducing the physical availability of both alcohol and tobacco products should be examined in developing broader supply-side interventions.

Determining the impact of smoking point of sale legislation among youth (Display) study: a protocol for an evaluation of public health policy.

BACKGROUND: Tobacco advertising and product promotions have been largely banned in the UK but point of sale (POS) tobacco advertising is one of the few places where tobacco products may be legitimately advertised. POS displays have been shown to increase susceptibility to smoking, experimentation and initiation into smoking. These displays may also influence perceived prevalence of smoking and the perception that tobacco products are easily obtained and are a 'normal' product. A ban of POS tobacco advertising was introduced in Scotland in large tobacco retail outlets of over 280 m2 internal sales floor areas (mainly supermarkets) in April 2013 and will be extended to include smaller tobacco retail outlets in April 2015. However, the impact of POS bans on smoking attitudes, behaviours and prevalence has yet to be determined. METHODS/DESIGN: This study has a multi-modal before and after design and uses mixed methods to collect data, at baseline and then with longitudinal follow-up for 4 years, in four purposively selected communities. For the purposes of the study, community is defined as the catchment areas of the secondary schools selected for study. There are four main components to the on-going study. In each of the four communities, at baseline and in follow-up years, there will be: mapping and spatial analyses of tobacco retail outlets; tobacco advertising and marketing audits of tobacco retail outlets most used by young people; cross-sectional school surveys of secondary school pupils; and focus group interviews with purposive samples of secondary school pupils. The tobacco audit is supplemented by interviews and observations conducted with a panel of tobacco retailers recruited from four matched communities. DISCUSSION: This study examines the impact of the implementation of both a partial and comprehensive ban on point of sale (POS) tobacco advertising on attitudes to smoking, brand awareness, perceived ease of access to tobacco products and youth smoking prevalence. The results will be of considerable interest to policy makers both from the UK and other jurisdictions where they are considering the development and implementation of similar legislation.

Suicide by poisoning in New Zealand--a toxicological analysis.

AIM: Determine major substances and risk factors for suicide by chemical overdose in New Zealand between 2001 and 2005. METHOD: All intentional deaths between 2001 and 2005 were reviewed. Primary substances causing death were verified from toxicology reports. RESULTS: The chemical suicide rate was higher among older Europeans, women and those in paid work than other groups. Carbon monoxide and tricyclic antidepressants (TCAs) continue to be the most common chemicals used, in spite of market changes. Anaesthetics and cyanide deaths among workers were noted. CONCLUSION: Restricted access to work-related chemicals and stricter prescription/dispensing controls for TCAs may reduce self-poisoning in New Zealand.

Have geographical inequalities in cause-specific mortality in New Zealand increased during the period 1980-2001?

AIMS: To monitor geographical inequalities in cause-specific mortality in New Zealand during the period 1980 to 2001, a time of rapid social and economic change. METHODS: Age-standardised rates of all-cause mortality, as well as for nine of the leading causes of death among males and females, were calculated for District Health Boards (DHBs) for the periods 1980-1982, 1985-1987, 1990-1992, 1995-1997, and 1999-2001. Geographical inequalities in health were evaluated using the DHB-level cause-specific Rate Ratio (RR; age standardised rates 1999-2001:1980-1982), and the Relative Index of Inequality (RII). RESULTS: Between 1980 and 2001, all-cause mortality rates fell for both males and females. However, age-standardised rates have risen for chronic obstructive pulmonary disease, diabetes mellitus, and cancer. The overall reductions in mortality rates have not been uniform across all regions as the all-cause mortality RR for each DHB ranged from 0.98 to 0.69 for males and 1.10 to 0.69 for females. The RRs for cause-specific mortality are more varied with large decreases and increases in mortality attributable to specific causes in some DHBs. There has also been a sharp rise in geographical inequalities in health measured using the RII, and this trend is consistent for most types of mortality. CONCLUSIONS: Although overall mortality rates decreased over the 1980s and 1990s, this trend has not been consistent for all causes of mortality or in all regions of the country resulting in higher geographical inequalities in all-cause and most types of mortality.

Spatial implications of covariate adjustment on patterns of risk: respiratory hospital admissions in Christchurch, New Zealand.

Epidemiological studies that examine the relationship between environmental exposures and health often address other determinants of health that may influence the relationship being studied by adjusting for these factors as covariates. While disease surveillance methods routinely control for covariates such as deprivation, there has been limited investigative work on the spatial movement of risk at the intraurban scale due to the adjustment. It is important that the nature of any spatial relocation be well understood as a relocation to areas of increased risk may also introduce additional localised factors that influence the exposure-response relationship. This paper examines the spatial patterns of relative risk and clusters of hospitalisations based on an illustrative small-area example from Christchurch, New Zealand. A four-stage test of the spatial relocation effects of covariate adjustment was performed. First, relative risks for respiratory hospitalisations from 1999 to 2004 at the census area unit level were adjusted for age and sex. In three subsequent tests, admissions were adjusted for annual exposure to particulate matter less than 10 microm in diameter (PM10), then for a deprivation index, and finally for both PM10 and deprivation. Spatial patterns of risk, disease clusters and cold and hot spots were generated using a spatial scan statistic and a Getis-Ord Gi* statistic. In all disease groups tested (except the control disease), adjustment for chronic PM10 exposure and deprivation modified the position of clusters substantially, as well as notably shifting patterns and hot/cold spots of relative risk. Adjusting for PM10 and/or for deprivation shifted clusters in a similar spatial fashion. In Christchurch, the resulting shift relocated the cluster from a purely residential area to a mixed residential/industrial area, possibly introducing new environmental exposures. Researchers should be aware of the potential spatial effects inherent in adjusting for covariates when considering study design and interpreting results.