How Internet Contracts Impact Research: Content Analysis of Terms of Service on Consumer Product Websites.

BACKGROUND: Companies use brand websites as a promotional tool to engage consumers on the web, which can increase product use. Given that some products are harmful to the health of consumers, it is important for marketing associated with these products to be subject to public health surveillance. However, terms of service (TOS) governing the use of brand website content may impede such important research. OBJECTIVE: The aim of this study is to explore the TOS for brand websites with public health significance to assess possible legal and ethical challenges for conducting research on consumer product websites. METHODS: Using Statista, we purposefully constructed a sample of 15 leading American tobacco, alcohol, psychiatric pharmaceutical, fast-food, and gun brands that have associated websites. We developed and implemented a structured coding system for the TOS on these websites and coded for the presence versus absence of different types of restriction that might impact the ability to conduct research. RESULTS: All TOS stated that by accessing the website, users agreed to abide by the TOS (15/15, 100%). A total of 11 out of 15 (73%) websites had age restrictions in their TOS. All alcohol brand websites (5/15, 33%) required users to enter their age or date of birth before viewing website content. Both websites for tobacco brands (2/15, 13%) further required that users register and verify their age and identity to access any website content and agree that they use tobacco products. Only one website (1/15, 7%) allowed users to display, download, copy, distribute, and translate the website content as long as it was for personal and not commercial use. A total of 33% (5/15) of TOS unconditionally prohibited or put substantial restrictions on all of these activities and/or failed to specify if they were allowed or prohibited. Moreover, 87% (13/15) of TOS indicated that website access could be restricted at any time. A total of 73% (11/15) of websites specified that violating TOS could result in deleting user content from the website, revoking access by having the user's Internet Protocol address blocked, terminating log-in credentials, or enforcing legal action resulting in civil or criminal penalties. CONCLUSIONS: TOS create complications for public health surveillance related to e-marketing on brand websites. Recent court opinions have reduced the risk of federal criminal charges for violating TOS on public websites, but this risk remains unclear for private websites. The public health community needs to establish standards to guide and protect researchers from the possibility of legal repercussions related to such efforts.

Awareness of Marketing of Heated Tobacco Products and Cigarettes and Support for Tobacco Marketing Restrictions in Japan: Findings from the 2018 International Tobacco Control (ITC) Japan Survey.

Japan is one of the world's largest cigarette markets and the top heated tobacco product (HTP) market. No forms of tobacco advertising, promotion, and sponsorship (TAPS) are banned under national law, although the industry has some voluntary TAPS restrictions. This study examines Japanese tobacco users' self-reported exposure to cigarette and HTP marketing through eight channels, as well as their support for TAPS bans. Data are from the 2018 ITC Japan Survey, a cohort survey of adult exclusive cigarette smokers (n = 3288), exclusive HTP users (n = 164), HTP-cigarette dual users (n = 549), and non-users (n = 614). Measures of overall average exposure to the eight channels of cigarette and HTP advertising were constructed to examine differences in exposure across user groups and products. Dual users reported the highest exposure to cigarette and HTP advertising. Tobacco users (those who used cigarettes, HTPs, or both) reported higher average exposure to HTP compared to cigarette advertising, however non-users reported higher average exposure to cigarette compared to HTP advertising. Retail stores where tobacco or HTPs are sold were the most prevalent channel for HTP and cigarette advertising, reported by 30-43% of non-users to 66-71% of dual users. Non-users reported similar exposure to cigarette advertising via television and newspapers/magazines as cigarette smokers and dual users; however, advertising via websites/social media was lower among non-users and HTP users than among cigarette smokers and dual users (p < 0.05). Most respondents supported a ban on cigarette (54%) and HTP (60%) product displays in stores, and cigarette advertising in stores (58%).

Influence of Tobacco Marketing on Nepalese Adolescents: Cigarette Use and Susceptibility to Cigarette Use.

BACKGROUND: Tobacco advertising, promotion, and sponsorship (TAPS) are common tactics of the tobacco industry to encourage adolescents to use tobacco products. OBJECTIVE: The objective of the study is to assess the influence of TAPS on cigarette use and susceptibility to cigarette use among Nepalese adolescents. MATERIALS AND METHODS: Data (n=2,878) were drawn from the Global Youth Tobacco Survey for Nepal (GYTS, 2011). Channel-specific and cumulative TAPS exposure were the primary exposures of the study. Six multivariate logistic regression analyses were performed to examine current and ever cigarette use outcome with exposure to TAPS. Six binary logistic regression analyses were applied to determine the susceptibility to cigarette use when exposed to TAPS. RESULTS: Channel-specific TAPS analyses show that indirect TAPS increases the odds of all the three outcomes; current cigarette use (OR=1.68, 95% CI=1.10-2.58), ever cigarette use (OR=1.81, 95% CI=1.23-2.65) and susceptibility to cigarette use (OR=1.65, 95% CI=1.25-2.19) after adjusting for the covariates. Television (TV) and movies exposure decreases the odds of susceptibility to cigarette use (OR=0.55, 95% CI=0.31-0.97). Cumulative TAPS analyses show that exposure to 5 sources of TAPS increases the odds of current cigarette use (OR=2.53, 95% CI=1.21-5.29). Being male increases the odds of all the three outcomes; current (OR=3.52, 95% CI=2.11-5.87), ever (OR=2.51, 95% CI=1.69-3.73) and susceptibility to cigarette use (OR=1.31, 95% CI=1.01-1.69). Social influence is likely to increase current (OR=6.47, 95% CI=2.50-16.74), ever (OR=1.79, 95% CI=1.10-2.93) and susceptibility to cigarette use (OR=1.66, 95% CI=1.25-2.21). CONCLUSION: Indirect TAPS exposure increased the current, ever, and susceptibility to cigarette use among Nepalese adolescents. Overall, the current use of cigarettes followed a dose-response relationship with TAPS exposure. The result implies a requirement of active surveillance of tobacco products and future research on adolescent-focused tobacco marketing in Nepal.

Impact of tobacco industry pricing and marketing strategy on brand choice, loyalty and cessation in global south countries: a systematic review.

OBJECTIVES: We undertook this review to assess the impact of pricing strategies on brand choice, loyalty and quitting behaviour in Global South countries. METHODS: We systematically retrieved articles from Medline, CENTRAL, ScienceDirect, Google Scholar from inception up to January 2020. Studies which reported tobacco industry's pricing strategies were eligible. We summarized the data as themes and codes using the principles of inductive qualitative thematic analysis within structured rational constructivist framework. RESULTS: In total, 13 studies met inclusion criteria were included. Major strategies adopted by tobacco industries to tackle the pricing and taxation changes were increased tax absorption, differential taxation based on price, cigarette length/size which ensures modest increase in the net price of cigarettes. This in turn influences the tobacco users in terms of brand loyalty and switching as they prefer to stay with factory-made cigarettes or shift to a cheaper alternative or illegal product rather than decreasing/quitting tobacco use. CONCLUSIONS: Absorption of excise tax and differential taxation are the common pricing strategies adopted by tobacco industries in Global South. These strategies together with external determinants impact the price-related tobacco control interventions.

Online media use and HPV vaccination intentions in mainland China: integrating marketing and communication perspectives to improve public health.

This study investigates the role of media in shaping human papilloma virus vaccination intentions in mainland China by applying both communication and marketing-focused theoretical frameworks in order to better understand ways to increase vaccine uptake across young men and women in China. An online survey (N = 359) revealed direct effects of online information consumption on perceived scarcity of the vaccine, as well as an indirect effect via perceived influence of media on others. Scarcity perceptions, in turn, predicted vaccine attitudes and behavioral intentions. Additionally, gender differences emerged in the data. Compared with women, men's intent to be vaccinated were not high, even if they realized the vaccine shortage. Implications for theory and practice are discussed.

Do tobacco industry websites target content to specific demographic groups?

BACKGROUND: Prior research has not examined whether tobacco brand websites vary content based on audience demographics. This study explored whether marketing content on tobacco brand websites varied by user ethnicity, gender or age group. METHODS: Participants (n = 32) were adult smokers, representing equal numbers of eight demographic groups: user ethnicity (Non-Hispanic White, Hispanic, African American, Asian), gender (women, men) and age (age 21-35, age 36+). This study examined 12 tobacco brand websites representing four tobacco product categories (cigarettes, cigar/cigarillos, smokeless tobacco, and e-cigarettes). From January 2016 to January 2017, participants coded websites for themes, interactive activities, and links to social media sites (n = 874 website visits). Logistic regression was used to analyze observed content by participant ethnicity, age and gender. RESULTS: All themes, all interactive activities and all links to social media were observed at least once for each demographic category. Male participants were more likely to observe Harm reduction themes, while female participants were more likely to observe Promotion themes. Older participants were more likely to observe website features allowing them to select music, and request coupons. Compared to Non-Hispanic White participants, African American participants were more likely to observe links to social media sites. CONCLUSION: Tobacco brand website content varied across ethnic, age and gender groups. These findings suggest that other factors, such as tobacco use behaviors, may influence marketing strategies participants recall or find appealing. The findings from this study can inform future regulatory activities and communication strategies aimed at countering pro-tobacco content online.

Retail Tobacco Marketing in Rural Versus Nonrural Counties: Product Availability, Discounts, and Prices.

Objectives. To assess tobacco product availability, advertised discounts, and prices in rural and nonrural stores, comparing results for two definitions of rural. Method. This geospatial study linked data from marketing surveillance in a representative sample of licensed tobacco retailers in California (n = 1,276) and categorized rural/nonrural stores at the county and tract levels. Data were collected from January to March, 2017, and mixed-models analyses tested for differences by location (rural vs. nonrural). Results. Compared to nonrural stores, rural-county stores were 2.1 (95% confidence interval [CI; 1.2, 3.6]) times more likely to sell chewing tobacco and 2.5 (95% CI [1.4, 4.2]) times more likely to sell roll-your-own. Rural-county stores sold larger packs of cigarillos for less than $1 (coefficient = 0.22, 95% CI [0.05, 0.39]) and charged less for the cheapest cigarette pack regardless of brand (estimated mean difference = $-0.21, 95% CI [-0.39, -0.03]). Contrary to expectation, a popular brand of chewing tobacco cost more in rural-county stores. A tract-level definition of rural reclassified only 1 in 10 stores, and did not substantially alter the results. Overall, 32.9% of stores advertised discounts on chewing tobacco, but this was more common in rural than nonrural census tracts (adjusted odds ratio = 1.81, 95% CI [1.14, 2.88]). Discussion. Evidence that $1 buys more cigarillos in rural-county stores than elsewhere adds to health equity concerns that the prevalence of cheap, flavored tobacco is not limited to neighborhoods characterized by socioeconomic disadvantage, higher proportions of African Americans, and higher proportions of school-age youth. Policies that focus on the retail environment for tobacco are needed to make tobacco less attractive and more costly everywhere, including rural areas.

Cigarette and E-Cigarette Retail Marketing on and Near California Tribal Lands.

Introduction. Retail settings are major channels for the tobacco industry to market commercial tobacco products. However, few studies have examined marketing strategies on Tribal lands. The resulting evidence is important, especially given that American Indian/Alaska Native (AI/AN) youth and adults have the highest smoking prevalence of any racial/ethnic group in the United States. In this study, we examined cigarette, e-cigarette, and vape/vaporizer availability, advertising, and price-reducing promotions in retail settings on and within a 1-mile radius of Tribal lands in California. Method. Trained AI/AN community health representatives (n = 8) conducted store observations (n = 96) using a checklist adapted from the Standardized Tobacco Assessment for Retail Settings observation tool. Chi-square analyses were performed to look for potential differences in availability, exterior advertising, and price promotions for cigarettes, e-cigarettes, and vapes between stores. Results. All stores sold cigarettes and over 95% sold menthol cigarettes. Nearly 25% of stores on Tribal lands were located inside a casino, and 40.4% of stores on Tribal lands offered a Tribal member discount. Stores within a 1-mile radius of Tribal lands sold significantly (p < .01) more e-cigarettes (69.8%), including flavored e-cigarettes (53.4%), compared to stores on Tribal lands (37.7% and 28.3%, respectively). Price promotions for cigarettes were significantly (p < .01) more common in stores located within a 1-mile radius of Tribal lands (46.5%) than stores on Tribal lands (22.6%). Discussion. To our knowledge, this study is the first to use store observations to examine cigarette and e-cigarette availability, advertising, and price promotions in retail settings on and near California Tribal lands. We recommend future studies build on our initial efforts to take an AI/AN Tribal community-engaged approach in assessing and documenting tobacco marketing practices on and near Tribal lands. Tribal governments can consider tobacco policies to help reduce smoking disparities and advance health equity for their communities.

History and Current Trends in the Electronic Cigarette Retail Marketplace in the United States: 2010-2016.

INTRODUCTION: The US market for electronic nicotine delivery systems (ENDS) has grown rapidly in the last decade. There is limited published evidence examining changes in the ENDS marketplace prior to the US Food and Drug Administration's (FDA) deeming rule in 2016. This study describes US ENDS retail market trends from 2010 to 2016. METHODS: National data were obtained from Nielsen retail scanners for five product types: (1) disposables, (2) rechargeables, (3) cartridge replacements, (4) e-liquid bottle refills, and (5) specialty vapor products. We examined dollar sales, volume, price, brand, and flavor. RESULTS: Adjusted national sales increased from $11.6 million in 2010 to $751.2 million in 2016. The annual rate of sales growth rapidly increased before slowing through 2015. The rate of growth spiked in 2016. Market share for menthol products and other assorted flavors increased from 20% in 2010 to 52.1% by 2016. NJOY's early market dominance shifted as tobacco industry brands entered the market and eventually captured 87.8% of share by 2016. Rechargeables and accompanying products comprised an increased proportion of total volume sold over time while disposable volume declined. Specialty vapor products appeared at retail in 2015. CONCLUSIONS: Findings show strong early growth in the ENDS retail market followed by considerable slowing over time, despite a slight uptick in 2016. Trends reflect shifts to flavored products, newer generation "open-system" devices, lower prices, and tobacco industry brands. This study provides a baseline against which to compare the impact of FDA's 2016 deeming rule and future actions on the ENDS marketplace. IMPLICATIONS: This study uses market scanner data from US retail outlets to describe trends in the ENDS retail market from 2010 to 2016, providing a baseline against which to compare the impact of FDA's 2016 deeming rule and future actions on the ENDS marketplace. Understanding historical market trends is valuable in assessing how future regulatory efforts and advances in ENDS technology may impact industry response and consumer uptake and use.

Tobacco Industry Marketing Exposure and Commercial Tobacco Product Use Disparities among American Indians and Alaska Natives.

Background: Non-Hispanic American Indians and Alaska Natives (NH AI/AN) have the highest commercial tobacco use (CTU) among U.S. racial/ethnic groups. Tobacco marketing is a risk factor, however few studies examine it among NH AI/AN. Objective: We identified prevalence of tobacco industry marketing exposure and correlates of CTU among NH AI/AN compared to other racial/ethnic groups. Methods: Data were from wave 1 (2013-2014; N = 32,320) of the Population Assessment of Tobacco and Health Study, analyzing self-reported exposure to tobacco ads from stores, tobacco package displays, direct mail and email marketing. Correlates of CTU were identified and interactions between racial/ethnic groups and tobacco marketing were assessed. Results: NH AI/AN (n = 955) had a higher prevalence of exposure to retail tobacco ads (64.5% vs 59.3%; p < 0.05), mail (20.2% vs.14.3%; p < 0.001) and email (17.0% vs.10.6%; p < 0.001) marketing than NH Whites (n = 19,297). Adjusting for tobacco use and related risk factors, exposure to email marketing remained higher among NH AI/AN than NH Whites. Interactions between racial/ethnic groups and marketing exposures on CTU were nonsignificant. CTU was higher among NH AI/AN than NH Whites and among adults who reported exposure to tobacco ads, mail, and email marketing. Conclusions/importance: There is higher tobacco marketing exposure in stores and via mail for NH AI/AN. Email marketing exposure was higher, even after controlling for tobacco-related risk factors. The tobacco industry may be targeting NH AI/AN through emails, which include coupons and other marketing promotions. Culturally relevant strategies that counter-act tobacco industry direct marketing tactics are needed to reduce disparities in this population.

An Analysis of E-Cigarette Marketing in New Zealand Tobacco Retail Outlets Prior to Legislative Change.

INTRODUCTION: In 2017, the New Zealand (NZ) Government announced its intention to liberalize the sale and promotion of electronic nicotine delivery systems (ENDS), including permitting any outlet to sell ENDS. This research estimated the proportion of tobacco outlets selling ENDS prior to legislative change, documented ENDS point-of-sale (POS) marketing, and examined associations between ENDS availability and outlet type, area-level deprivation, study region, and proximity to a secondary school. AIMS AND METHODS: After drawing a proportional random sample of 281 tobacco outlets from two NZ regions that included convenience stores, supermarkets, and petrol stations, we conducted observational in-store assessments to record ENDS product ranges and promotions. Data were collected between October and December 2017 and analyzed using descriptive statistics and regression modeling. RESULTS: Of tobacco outlets sampled, 22% sold ENDS; these were typically convenience stores (85%) and located in high deprivation areas (53%). Of stores selling ENDS, products were visible at POS in 89% of stores, including 15% with self-service displays and 15% with displays adjacent to children's products. ENDS advertising was present in 31% of the outlets and generally promoted ENDS as cheaper than smoked cigarettes. CONCLUSIONS: Liberalizing access to ENDS could reduce harms caused by smoking; however, extensive use of POS promotions will reach children and young people as well as smokers. While reducing harm among smokers is important, policy makers also need to ensure that regulations protect children from ENDS promotions. IMPLICATIONS: Careful regulation is required to ensure increases in ENDS availability are not accompanied by an increase in young people's exposure to ENDS marketing at the POS.

Interferência da Indústria do Tabaco no Brasil: a Necessidade do Ajuste de Contas / Tobacco Industry Interference in Brazil: the Necessity of Settling Accounts / Interferencia de la Industria Tabacalera en Brasil: la Necesidad del Ajuste de Cuentas

Introdução: No Brasil, cada vez mais são identificadas ações ilegais de publicidade, propaganda e patrocínio por parte da indústria do tabaco em eventos musicais e por meio das redes sociais, voltadas a atrair principalmente o público jovem para o uso do cigarro. Objetivo: Desenvolver uma metodologia que permita estabelecer um parâmetro de quantificação dos impactos negativos para o setor saúde desse descumprimento da lei. Método: Combinaram-se as informações nacionais existentes sobre i) a equivalência entre "custo direto médio da assistência médica" e "mortes por doenças atribuíveis ao tabagismo" e ii) a equivalência entre "a parcela do lucro revertido em ações de marketing" e "mortes de fumantes que contribuíram para a geração desse lucro por meio da compra de cigarros", de forma a se obter a relação "custo direto do tratamento" vs "parcela do lucro revertido em ações de marketing". As doenças selecionadas foram aquelas que apresentam os maiores custos diretos de tratamento atribuíveis ao fumo. Resultados: Para cada centavo investido em marketing pela indústria do tabaco, o Brasil tem um gasto com tratamento de doenças relacionadas ao tabaco 1,93 vezes superior ao dinheiro investido pela indústria. Conclusão: A mensuração da responsabilização dos violadores da legislação nacional para o controle do tabaco é fundamental para compensar parte dos custos associados ao tratamento de pacientes e aos programas de cessação ao fumo, favorecendo assim a redução do tabagismo no país.

Introduction: In Brazil, illegal actions of advertising, promotion, and sponsorship by part of the tobacco industry are increasingly identified in music events, and through social media, aimed mainly to attract young people to use cigarettes. Objective: To develop a methodology that allows the creation of a parameter of quantification of the negative impacts to the health sector of non-compliance with the law. Method: Combination of the current national information about i) the equivalence between "mean direct cost of medical care" and "deaths by diseases attributable to tobacco addiction" and ii) the equivalence between "the portion of the profit translated into marketing actions" and "deaths of smokers who contributed for the generation of this profit through purchase of cigarettes" in order to obtain the relation between "direct cost of the treatment" vs "portion of the profit translated into market actions". The diseases selected were those that presented the biggest direct cost of treatment attributable to tobacco. Results: For every cent invested in marketing strategies by the tobacco industry, Brazil spends 1.93 times more financial resources to treat tobacco-related diseases. Conclusion: The measurement of the liability for non-compliance of the tobacco national legislation is essential to offset part of the associated costs of the treatment of patients and programs of tobacco cessation to favor the reduction of smoking prevalence in Brazil.

Introducción: En Brasil, es cada vez más común identificar acciones ilegales de publicidad, promoción y patrocinio del tabaco por parte de la industria tabacalera en eventos musicales y a través de redes sociales, destinadas principalmente a atraer al público joven al consumo de cigarrillos. Objetivo: Desarrollar una metodología que permita establecer un parámetro para cuantificar los impactos negativos al setor de la salud de esa acción ilegal de la ley. Método: El artículo integra la información nacional existente sobre i) la equivalencia entre el "costo directo promedio de asistencia médica" y "muertes por enfermedades atribuibles al tabaquismo" y ii) la equivalencia entre "la parte del ingreso usado en acciones de marketing" y "las muertes de fumadores que han contribuido a la generación de estos ingresos a través de la compra de cigarrillos", para obtener la relación "costo directo del tratamiento" vs "parte de los ingresos usados en acciones de marketing". Las enfermedades seleccionadas fueron las que presentaron los costos más altos de tratamiento directo atribuibles al uso del tabaco. Resultados: Por cada centavo invertido en marketing por la industria tabacalera, Brasil tiene un gasto en tratamiento de enfermedades relacionadas con el tabaco 1,93 veces mayor que el monto invertido por la industria. Conclusión: Medir la responsabilidad de los infractores de la legislación nacional de control del tabaco es esencial para compensar parte de los costos asociados con el tratamiento de los pacientes y com los programas para dejar de fumar, favoreciendo así la reducción del consumo de tabaco en el país.

Advertising Restrictions and Market Concentration in the Cigarette Industry: A Cross-Country Analysis.

There has been a large increase in the adoption of tobacco advertising restrictions worldwide over the last two decades. Much of the literature studies their direct effect on cigarette demand. This paper investigates the indirect effect of advertising restrictions by evaluating the effect of the policies on the degree of concentration in the tobacco market. By using the variation between countries in timing of adoption of advertising restrictions, I estimate difference-in-difference models to examine the effect of an advertising ban on market-concentration, as measured by HHI. I find that advertising bans lead to an increase in market-concentration: HHI increased by 0.06 points for countries that adopted a ban between 2001 and 2017 conditional on trade and socio-economic characteristics, representing a 13% increase with respect to the mean (0.44). The effect is higher in developing countries (0.08 points increase). Further, I find that 'comprehensive' restrictions have a stronger impact on concentration, and 'limited' restrictions have little or no impact. These findings point to an important trade-off for policymakers: on one hand, advertising restrictions are likely to reduce consumption of cigarettes; on the other hand, due to an increase in market-concentration, they may be giving more power to tobacco companies.

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.

Effect of Prices, Distribution Strategies, and Marketing on Demand for HIV Self-testing in Zimbabwe: A Randomized Clinical Trial.

Importance: HIV self-testing is a promising approach for increasing awareness of HIV status in sub-Saharan Africa, particularly in Zimbabwe, where HIV prevalence is 13%. Evidence is lacking, however, on the optimal pricing policies and delivery strategies for maximizing the effect of HIV self-testing. Objective: To assess demand for HIV self-testing among adults and priority-population subgroups under alternative pricing and distribution strategies. Design, Setting, and Participants: This randomized clinical trial recruited study participants between February 15, 2018, and April 25, 2018, in urban and rural communities in Zimbabwe. A factorial design was used to randomize participants to a combination of self-test price, distribution site, and promotional message. Individuals and their household members had to be at least 16 years old to be eligible for participation. This intention-to-treat population comprised 3996 participants. Interventions: Participants were given a voucher that could be redeemed for an HIV self-test within 1 month at varying prices (US $0-$3) and distribution sites (clinics or pharmacies in urban areas, and retail stores or community health workers in rural areas). Vouchers included randomly assigned promotional messages that emphasized the benefits of HIV testing. Main Outcomes and Measures: Proportion of participants who obtained self-tests in each trial arm, measured by distributor records. Results: Among the 4000 individuals enrolled, 3996 participants were included. In total, the mean (SD) age was 35 (14.7) years, and most participants (2841 [71.1%]) were female. Self-testing demand was highly price sensitive; 260 participants (32.5%) who were offered free self-tests redeemed their vouchers, compared with 55 participants (6.9%) who were offered self-tests for US $0.50 (odds ratio [OR], 0.14; 95% CI, 0.10-0.19), a reduction in demand of more than 25 percentage points. Demand was below 3% in the $1, $2, and $3 groups, which was statistically significantly lower than the demand in the free distribution group: in pooled analyses, demand was considerably lower among participants in higher-than-$0 price groups compared with the free distribution group (2.8% vs 32.5%; OR, 0.05; 95% CI, 0.04-0.07). In urban areas, demand was statistically significantly higher with pharmacy-based distribution compared with clinic-based distribution (6.8% vs 2.9%; adjusted OR, 2.78; 95% CI, 1.74-4.45). Price sensitivity was statistically significantly higher among rural residents, men, and those who had never received testing before. Promotional messages did not influence demand. Conclusions and Relevance: This study found that demand for HIV self-testing in Zimbabwe was highly price sensitive, suggesting that free distribution may be essential for promoting testing among high-priority population groups; additionally, pharmacy-based distribution was preferable to clinic-based distribution in urban areas. Trial Registration: ClinicalTrials.gov identifier: NCT03559959.

Cartoon-based e-cigarette marketing: Associations with susceptibility to use and perceived expectations of use.

BACKGROUND: Manufacturers of e-cigarette-related products are using cartoons as a marketing strategy, despite restrictions on cartoon marketing for combustible cigarettes. Here, we examined associations between exposure to e-liquid packaging with cartoons (operationally defined as recognition of actual marketing images) and e-cigarette use, susceptibility to use, and expectations of benefits and risks of use. METHODS: U.S. adults completed online surveys assessing e-cigarette use. In Study 1, participants (N = 778; Mean age = 23.5 years; 62% women) completed a questionnaire assessing expectations about benefits and risks of use. Then they were presented with 22 e-liquid package images (with and without cartoons) and were asked to endorse whether they recognized the products. In Study 2, participants (N = 522; Mean age = 30.4; 55% women) were presented with 24 e-liquid images (with and without cartoons) and asked to rate product appeal. RESULTS: For Study 1, among never users, cartoon recognition was associated with greater likelihood of being susceptible to use e-cigarettes, and with expectations of taste enjoyment and social facilitation. For Study 2, there was no significant difference between cartoon and non-cartoon images on appeal ratings. CONCLUSIONS: Cartoon-based marketing exposure - as measured by recognition of e-liquid package images - was associated with susceptibility to use e-cigarettes, which is consistent with previous research on the use of cartoons to promote combustible cigarettes. These data suggest that restrictions on the use of cartoon-based marketing strategies for e-cigarettes should be similar to those for cigarettes, to reduce susceptibility and perceived benefits among non-users.

From glass boxes to social media engagement: an audit of tobacco retail marketing in Indonesia.

OBJECTIVE: To assess tobacco promotion intensity, retailer behaviours and tobacco company efforts to link retailer marketing to online channels. METHODS: We completed an audit of tobacco advertisements and promotions at 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia that included an observation checklist, digital photos and structured interviews with retailers. We then calculated the tobacco promotion index for each retailer and made comparisons based on store types. Next, we conducted a photo analysis from 100 randomly selected retailers to explore links to online channels and other promotional cues to engage young people. RESULTS: Mini-markets have both the highest total number of promotions and the highest indoor promotion index with a mean score of 5.1 and 3.7, respectively. Kiosks have the highest outdoor promotion index with a mean score of 1.6. Most of the retailers (98.9%) displayed cigarettes, more than half of kiosk retailers (54.8%) and mini-market retailers (56.3%) admitted selling cigarettes to young people, and 74% of kiosk retailers sell single stick cigarettes. We found links to online marketing, including two hashtags and a company website. Promotional materials also included youth-focused content such as English taglines, new products and small packs. CONCLUSION: Tobacco companies in Indonesia have strategically differentiated their advertisements based on retailer type and have bridged conventional retailer marketing to online channels. Reforming Indonesian tobacco laws to include bans on single sticks and small pack sales, point-of-sale advertising, including displays, and enforcement of laws on sales to minors is urgently required.

Health claims made in vape shops: an observational study and content analysis.

BACKGROUND: Prior to the final deeming rule, federal law in the USA prohibited electronic cigarettes (e-cigarettes) from being marketed as smoking cessation products; for other therapeutic purposes and in ways that conveyed Food and Drug Administration (FDA) approval/endorsement. After August 2016, additional federal prohibitions were added including false/misleading and unauthorised modified risk tobacco product (MRTP) claims. No systematic investigation of e-cigarette health claims has been conducted in the retail environment. We sought to document and characterise claims made in vape shops. METHODS: Between November 2015 and February 2016, before final deeming rule implementation, two trained data collectors conducted unannounced observational assessments of 46 vape shops in North Carolina. Data collectors used wearable imaging technology to document health claims about e-cigarettes. Photos were coded for five claim types: (1) cessation device; (2) drug effect/device; (3) FDA-approved/endorsed; (4) false/misleading and (5) MRTP. Photos were double coded; differences between coders were adjudicated and reviewed by an expert panel. RESULTS: At least one health claim was displayed in 41.3% (n=19) of retailers, ranging from 0 to 27 claims per retailer. All claim types were found. Cessation device claims were the most prevalent (62.2%, n=84), followed by MRTP (27.4%, n=37), drug effect/device (8.1%, n=11), false/misleading (1.5%, n=2), and FDA approved/endorsed (0.7%, n=1). Retail chains made the majority of claims compared with independent shops (88.9% vs 11.1%). CONCLUSIONS: Many vape shops displayed e-cigarette health claims, which are all now FDA prohibited. These claims could mislead consumers and influence behaviour. Findings highlight the need for retailer education, continued surveillance, enforcement specific to advertising and research on consumer perceptions of claims.

Inter-brand competition in the convenience store industry, store density and healthcare utilization.

We investigate the impact of access to convenience stores and competition between convenience store chains on the use of medical care in Taiwan. Using insurance claims from 0.85 million individuals and administrative data on store sales, we find that greater store density and more inter-brand competition reduced expenditures on outpatient medical services and prescription drugs. In support of these findings, we demonstrate that convenience store competition was associated with greater consumption of healthy foods and lower obesity rates. Our estimates suggest that the rise in convenience store competition from 2002 to 2012 reduced outpatient expenditures in Taiwan by 0.44 percent and prescription drug expenditures by 0.85 percent.