Retail Marketing of Menthol Cigarettes in Los Angeles, California: a Challenge to Health Equity.

INTRODUCTION: Sales of menthol cigarettes continue to increase, accounting for a third of the US cigarette market. Retail marketing of menthol cigarettes is a contributing factor to tobacco-related health disparities. To inform regulation to address associated disparities, we examined retail marketing strategies for menthol cigarettes and their features and characteristics in relation to neighborhood racial/ethnic composition. METHODS: We used multilevel regression models to examine associations of neighborhood racial/ethnic composition and store type with menthol cigarette sales outcomes, including availability, exterior advertising, price promotions, and price in a sample of tobacco retailers (N = 673) in Los Angeles County neighborhoods with a median or below-median household income. We also recorded the prices of Newport cigarettes (the highest selling menthol cigarette brand in the United States) and blu disposable menthol e-cigarettes. RESULTS: Overall, 94.5% of retailers sold menthol cigarettes, 31.2% displayed menthol cigarette price promotions, and 30.2% displayed at least one menthol cigarette advertisement on their exterior. Adjusting for racial/ethnic zip code cluster and store type, stores located in predominantly African American neighborhoods showed significantly higher odds in the availability of Newport cigarettes than stores in Hispanic neighborhoods (OR = 0.21; 95% CI, 0.09-0.53; P = .001) or non-Hispanic White (OR = 0.12; 95% CI, 0.05-0.31; P < .001) neighborhoods. Stores located in predominantly African American neighborhoods displayed significantly higher odds of having price promotions for menthol cigarettes and storefront advertisements than those in Hispanic neighborhoods (OR = 0.51; 95% CI, 0.30-0.88; P = .02 and OR = 0.25; 95% CI, 0.13-0.48; P < .001, respectively). CONCLUSION: In 2016 and 2017, menthol cigarettes were widely available in Los Angeles County across racial/ethnic neighborhoods. We found a disproportionate number of storefront advertisements and price promotions for menthol cigarettes in stores located in predominantly African American neighborhoods along with the lowest advertised pack price. This evidence supports tobacco control policies that restrict menthol cigarette sales in the retail environment.

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.

Disparities in retail marketing for little cigars and cigarillos in Los Angeles, California.

INTRODUCTION: Evidence of a concentration of cigarette advertising in predominantly low-income, non-White neighborhoods underscores the need to examine retail marketing and promotions for novel tobacco products like little cigars and cigarillos (LCCs). We sought to investigate neighborhood racial/ethnic disparities in LCC marketing at retail, including availability, advertising, price promotions, and product placement in Los Angeles, California. METHODS: Between January 2016 and April 2017, community health workers (n = 19) conducted in-person observational audits from tobacco retail stores (n = 679) located in zip codes with a high percentage of non-Hispanic White (n = 196), Black (n = 194), Hispanic/Latino (n = 189), or Korean American (n = 100) residents. To account for clustering effect of zip codes, multilevel modeling approach for a dichotomized outcome was conducted to evaluate the association between racial/ethnic neighborhood sample and dependent variables. RESULTS: Stores located in zip codes with a high percentage of non-Hispanic Blacks had more than eight times higher odds of selling LCCs (OR = 8.10; 95% CI = 3.10-21.11 vs. non-Hispanic White), more than five times higher odds of selling flavored LCCs (OR = 5.20; 95% CI = 2.33-11.61 vs. non-Hispanic White), and more than six times higher odds of displaying storefront exterior LCC signage (OR = 6.03; 95% CI = 2.93-12.40 vs. non-Hispanic White). Stores in Hispanic/Latino and Korean American communities had about three times higher odds of selling LCCs (OR = 3.02; 95% CI = 1.15-7.93 vs. non-Hispanic White; OR = 2.99; 95% CI = 1.33-6.71 vs. non-Hispanic White). CONCLUSIONS: LCCs are heavily marketed in retail establishments in Los Angeles, with disproportionate targeting of predominantly non-White neighborhoods, especially stores in neighborhoods with a higher proportion of African Americans. Local, state, and federal flavor restrictions, minimum pack size standards, preventive messages, and campaigns could counter the influence of LCC marketing in retail establishments.

Tobacco Retail Licensing and Youth Product Use.

BACKGROUND: Restricting youth access to tobacco is a central feature of US tobacco regulatory policy, but impact of local tobacco retail licensing (TRL) regulation on cigarette smoking rates remains uncertain. Effects of TRL on other tobacco product use and use as adolescents reach the age to legally purchase tobacco products has not been investigated. METHODS: Prevalences of ever and past 30-day cigarette, electronic cigarette (e-cigarette), cigar, and hookah use were assessed in a survey of a cohort of 1553 11th- and 12th-grade adolescents (mean age: 17.3 years); rates of initiation were evaluated 1.5 years later. An American Lung Association (2014) youth access grade was assigned to each of 14 political jurisdictions in which participants lived on the basis of the strength of the local TRL ordinance. RESULTS: At baseline, participants living in 4 jurisdictions with "A" grades (ie, with most restrictive ordinances) had lower odds of ever cigarette use (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.41-0.90) and of past 30-day use (OR 0.51; 95% CI 0.29-0.89) than participants in 10 D- to F-grade jurisdictions. At follow-up at legal age of purchase, lower odds of cigarette use initiation (OR 0.67; 95% CI 0.45-0.99) occurred in jurisdictions with stronger TRL policy. Lower odds of e-cigarette initiation at follow-up (OR 0.74; 95% CI 0.55-0.99) and of initiation with past 30-day use (OR 0.45; 95% CI 0.23-0.90) were also associated with better regulation. CONCLUSIONS: Strong local TRL ordinance may lower rates of cigarette and e-cigarette use among youth and young adults.

Return of cartoon to market e-cigarette-related products.

INTRODUCTION: The tobacco industry's use of cartoons to market products has been shown to be effective at increasing awareness and appeal of combustible cigarettes among youth. While the Master Settlement Agreement placed restrictions on the use of cartoons for major cigarette and smokeless (chew) tobacco brands in the USA, no such restrictions exist for electronic cigarettes (e-cigarettes). Research has shown that e-cigarette manufacturers are using cartoons to market products, but limited data exist on the extent of these practices. This study examined the extent of the use of cartoons to market e-liquids on Instagram. METHODS: Instagram posts with the hashtag #ejuice or #eliquid were collected from 3 November 2017 to 17 November 2017. Rules were established to identify Cartoon (the post contained a cartoon), Logo (the post was labelled a cartoon due to the logo) and Promo (the image of the post or accompanying text indicated it was a promotion) in the data (n=3481). RESULTS: Among all posts, 723 (20.77%) contained a Cartoon, and 479 (13.76%) were coded as a cartoon because of the Logo. In other words, 479/723 or (66.25%) of Cartoon were coded as cartoons due to the vendor's or manufacture's logo. Among all posts, 2360 (67.80%) were Promo. CONCLUSION: Findings indicate that e-cigarette companies are using cartoons to market their products and many of these companies' logos are cartoons. Empirical data are needed to determine whether cartoon marketing strategies impact perceived risk and benefits, product appeal, the intention to use and actual use of e-cigarettes.

The Why We Retweet scale.

BACKGROUND: Twitter offers a platform for rapid diffusion of information and its users' attitudes and behaviors. Insights about information propagation via retweets (the message forwarding function) offer observable explanations of ways in which modern human interactions get organized in the form of online networks, and contextualized in the form of public health, policy decisions, disaster management, and civic participation. This study conceptualized and validated the Why We Retweet Scale to contextualize retweeting behavior. OBJECTIVE: Twitter users were identified using clustering algorithms that consider a users' position in their network and invited for an online survey. Participants (N = 1433) responded to 19 questions about why they retweet. Exploratory factor Analysis (EFA) was conducted on a scale development sample (70% of original sample), which informed the Confirmatory Factor Analysis (CFA) on a scale testing sample (30% of the original sample). Varimax rotation was used to obtain a rotated factor solution, which resulted in interpretable factors. Demographic differences among scale factors were analyzed using one-way ANOVA or independent samples t-tests. RESULTS: The final model (χ221 = 28, RMSEA = .03 [90% CI, 0.00-0.06], CFA = .99, TLI = 0.99) represented a parsimonious solution with 4 factors, measured by 2-3 items each, creating a final scale consisting of 9 items. Factor labels and definitions were: (1) Show approval, "Show support to the tweeter"; (2) Argue, "To argue against a tweet that I disagree with"; (3) Gain attention, "Add followers or gain attention"; and (4) Entertain, "Create humor/amusement". Demographic differences were also reported. CONCLUSIONS: The Why We Retweet Scale offers a useful conceptualization and assessment of motivations for retweeting. In the future, communication strategists might consider the factors associated with information propagation when designing campaign messages to maximize message reach and engagement on Twitter.

Monitoring Tobacco Brand Websites to Understand Marketing Strategies Aimed at Tobacco Product Users and Potential Users.

Introduction: Limited information exists about strategies and methods used on brand marketing websites to transmit pro-tobacco messages to tobacco users and potential users. This study compared age verification methods, themes, interactive activities and links to social media across tobacco brand websites. Methods: This study examined 12 tobacco brand websites representing four tobacco product categories: cigarettes, cigar/cigarillos, smokeless tobacco, and e-cigarettes. Website content was analyzed by tobacco product category and data from all website visits (n = 699) were analyzed. Adult smokers (n = 32) coded websites during a one-year period, indicating whether or not they observed any of 53 marketing themes, seven interactive activities, or five external links to social media sites. Results: Most (58%) websites required online registration before entering, however e-cigarette websites used click-through age verification. Compared to cigarette sites, cigar/cigarillo sites were more likely to feature themes related to "party" lifestyle, and e-cigarette websites were much more likely to feature themes related to harm reduction. Cigarette sites featured greater levels of interactive content compared to other tobacco products. Compared to cigarette sites, cigar/cigarillo sites were more likely to feature activities related to events and music. Compared to cigarette sites, both cigar and e-cigarette sites were more likely to direct visitors to external social media sites. Conclusion: Marketing methods and strategies normalize tobacco use by providing website visitors with positive themes combined with interactive content, and is an area of future research. Moreover, all tobacco products under federal regulatory authority should be required to use more stringent age verification gates. Implications: Findings indicate that the Food and Drug Administration (FDA) should require brand websites of all tobacco products under its regulatory authority use more stringent age verification gates by requiring all visitors be at least 18 years of age and register online prior to entry. This is important given that marketing strategies may encourage experimentation with tobacco or deter quit attempts among website visitors. Future research should examine the use of interactive activities and social media on a wide variety of tobacco brand websites as interactive content is associated with more active information processing.

Second and Thirdhand Smoke Exposure, Attitudes and Protective Practices: Results from a Survey of Hispanic Residents in Multi-unit Housing.

Secondhand and third hand smoke (SHS, THS) exposure is prevalent in multi-unit housing (MUH). Minorities and low-income MUH residents are disproportionally exposed to SHS and THS compared to other populations. This study describes the characteristics, attitudes, knowledge, and behaviors related to SHS, THS and marijuana smoke exposure (MSHS) of a sample of Hispanic tenants in randomly selected MUH units in eastern metro Los Angeles (n = 402). Although most participants (97%) banned smoking inside their homes, 80% reported infiltration of SHS inside their apartments within the last year. Most (85%) favored a complete ban on smoking in apartment buildings. Twenty-eight percent did not know that marijuana (MSHS) smoke exposure is also harmful to their health. Knowledge scores were higher among Spanish-speakers (p < 0.05). Given the interpersonal barriers to advocating for change, widespread policy and communication interventions are also necessary to protect Hispanic MUH residents' rights to clean air in their living space.

Perceptions of Secondhand and Thirdhand Smoke Among Hispanic Residents of Multiunit Housing.

Despite the progressive adoption of smoking bans in public spaces, children living in multi-unit housing remain at risk of exposure to secondhand smoke (SHS) and thirdhand smoke (THS). Hispanic populations in California are particularly vulnerable to the harmful effects of SHS and THS because a large proportion of Hispanics live in multi-unit housing. Three focus groups were conducted in the fall of 2012 (in Spanish and English, N = 24) to understand Hispanics' knowledge of and experiences with SHS and THS, including barriers to avoiding smoke exposure and strategies for protecting their homes from smoke. Hispanic residents reported unpleasant experiences with SHS and THS and were generally knowledgeable about the adverse health effects, although they were not familiar with the term "thirdhand smoke." Some participants also mentioned marijuana smoke as a potential health hazard. Hispanic cultural values made participants reluctant to confront their neighbors but also motivated them to find ways to protect their families from smoke. Potential solutions included working with the smokers to designate a smoking area and gaining support from the building owners. Broad smoking policies should be implemented to help Hispanic residents overcome cultural and social barriers to smoke free air.

Development and validation of a scale to assess attitudes and beliefs about menthol cigarettes among african american smokers.

To develop more effective smoking cessation interventions for the 70% of African American smokers who smoke menthol cigarettes, it is important to understand smokers' reasons for choosing menthols verses nonmenthols. This study conducted a focus group of African American smokers about their attitudes and beliefs about menthol cigarettes. These attitudes and beliefs, along with others from the literature, were included in a survey of 720 African American smokers in Los Angeles County, California. Five common factors emerged-Medicinal Effects, Image, Less Harmful, Tradition, and Taste/Sensation. Menthol smokers had significantly higher scores on the Taste/Sensation, Medicinal Effects, and Less Harmful scales than nonmenthol smokers did. Men were significantly more likely than women to endorse Medicinal Effects, Image, and Tradition, whereas women were significantly more likely to endorse Taste/Sensation. Education was inversely associated with endorsement of Medicinal Effects, Image, Less Harmful, and Tradition. Respondents aged 40 years or older had significantly higher scores on Medicinal Effects, Image, and Less Harmful, compared with younger respondents. Smoking cessation interventions for African American menthol smokers should address commonly held myths that menthols have medicinal effects and are less harmful than nonmenthols, especially among smokers who are older, male, and/or have low levels of education. The new measures presented in this article could be useful for tailoring cessation interventions to individual smokers' attitudes and beliefs about menthol cigarettes.

Tobacco marketing in California and implications for the future.

BACKGROUND: Tobacco marketing influences tobacco use initiation, maintenance of use, and it undermines comprehensive tobacco control programmes. Policies to ban the impact of tobacco marketing are most likely to be more effective if they are comprehensive, as partial bans shift marketing to non-banned forms of media. A comprehensive approach to reducing tobacco marketing includes documentation through monitoring, media and policy interventions and aggressive enforcement of existing laws. METHODS: This paper summarises California tobacco industry monitoring of events and retail outlets, and findings about exposure to and beliefs about tobacco industry marketing among youths and adults conducted during the period 2000 through 2008. RESULTS: There was no overall change in the average number of cigarette materials per store, and an increase in the percentage of stores with advertisements promoting price discounts for cigarettes. Stores with cigarette advertisements near candy displays declined from 12.5% (95% CI 9.8% to 15.2%) to 1% (95% CI 0.2% to 1.9%) of stores, and advertisements at or below the eye-level of children declined from 78.6% (95% CI 75.2% to 82.0%) to 31% (95% CI 27.1% to 34.9%) of stores. Overall, the number of public events with tobacco sponsorship declined from 77.3% to 48.1%. This trend was consistent with a significant decline noted among high school students and adults who reported seeing tobacco advertisements at events or attending a tobacco company-sponsored event. CONCLUSIONS: Tobacco industry monitoring, media, policy and enforcement interventions may have contributed to observed changes in tobacco marketing and to declines in reported exposure to tobacco marketing.

Menthol and non-menthol cigarette use among Black smokers in Southern California.

INTRODUCTION: Menthol cigarette smoking is more prevalent among Blacks than among other groups in the United States. This study examined associations between demographic, psychological, attitudinal, social, and cultural factors and menthol smoking among Black adults. METHODS: This study recruited 720 Black smokers from community intercept locations throughout Los Angeles County, California, and surveyed them by telephone. RESULTS: Fifty-seven percent of respondents were menthol-only smokers, 15% were regular-only smokers, and 28% smoked both menthols and regular cigarettes (combined smokers). In bivariate models, menthol-only and combined smokers had stronger beliefs in the medicinal effects of menthols relative to regular-only smokers. Menthol-only smokers held stronger beliefs, relative to regular-only smokers, that menthols were less harmful than regular cigarettes. Menthol-only smokers preferred the menthol taste/sensation more than combined smokers, who preferred the menthol taste/sensation more than regular-only smokers. Menthol-only and combined smokers had more menthol smokers in their current social networks compared with regular-only smokers. In multivariate analyses, preference for menthol taste/sensation, belief in medicinal effects of menthols, and menthol smokers in current social network differentiated menthol-only and combined smokers from regular-only smokers, controlling for confounding variables. Correlates of menthol smoking varied across genders and age groups. DISCUSSION: Health education efforts are needed to dispel the myth that menthol cigarettes are more medicinal and less harmful than regular cigarettes. Prevention and cessation efforts in Black communities can be tailored to reflect predictors of menthol smoking to reduce tobacco-related morbidity and mortality. In the era of Food and Drug Administration regulation of cigarettes, research is needed to prevent health disparities associated with menthol cigarette smoking.

Monitoring the tobacco use epidemic IV. The vector: Tobacco industry data sources and recommendations for research and evaluation.

OBJECTIVE: This Vector paper (IV of V on monitoring the tobacco use epidemic) presents the data sources and methods that can be used to monitor tobacco marketing and makes recommendations for creating a national surveillance system. METHODS: In 2002, the Vector Work Group of the National Tobacco Monitoring, Research and Evaluation Workshop identified priority indicators of tobacco marketing: tobacco brand pricing strategies, retail environment advertising and promotional allowances, gray market or smuggling activities, lobbying, direct mail marketing, tobacco brand placements in films, Internet promotions, and sponsorship at bars and events. This paper reviews and identifies data sources and gaps for these priority indicators and for 12 other indicators of interest. RESULTS: There are 38 commercial data sites and Internet sources, as well as individual research efforts that address the priority indicators. These sources are not integrated, often costly, and limited in standardization. CONCLUSIONS: Tobacco marketing could be more effectively monitored with the development of a national research network. Surveillance of the tobacco industry's methods to push tobacco and pull consumers can help the public health community identify new markets and campaigns, justify and tailor effective tobacco control strategies, and evaluate existing counter-marketing efforts.

Longitudinal effects of pro-tobacco and anti-tobacco messages on adolescent smoking susceptibility.

We examined the longitudinal impact of self-reported exposure to pro- and anti-tobacco media on adolescents' susceptibility to smoking, using in-school surveys from a culturally diverse sample. Ethnicity and acculturation also were examined as potential moderators. Middle-school students (N = 2,292) completed self-report questionnaires during the 6th, 7th, and 8th grades. Chi-square analyses were conducted to determine whether reported exposure to pro- and anti-tobacco media varied according to ethnicity, acculturation, and immigration status. Logistic regression models were used to examine whether pro- and anti-tobacco media exposure in 6th grade was associated with susceptibility to smoking by later grades. Recall of people smoking in television programs and pro-tobacco advertisements in stores was associated with adolescent smoking susceptibility. Exposure to anti-tobacco advertisements on television protected against susceptibility. No significant interaction effects between pro- and anti-tobacco media exposure on smoking susceptibility were found. Ethnicity and acculturation did not moderate these associations. Our longitudinal study provides evidence that pro-tobacco media and advertising increases susceptibility to smoking over time. More important, anti-tobacco advertisements are not sufficient to reduce the harmful effects of adolescent exposure to pro-tobacco media. Policy-level interventions such as restrictions in tobacco advertising may be necessary to prevent adolescent smoking.

Countering tobacco industry sponsorship of Hispanic/Latino organizations through policy adoption: a case study.

Restricted by Master Settlement Agreement (MSA) provisions, the tobacco industry employs corporate sponsorship of communities of color (e.g., sponsoring community cultural events and/or chambers of commerce) to secure their stronghold. The Hispanic/Latino Tobacco Education Network (H/LaTEN) initiated efforts to counter these marketing forms within the Hispanic community. In 1998, 38 California Hispanic Chambers of Commerce (CHCCs) were contacted to assess the tobacco industry's marketing tactics and penetration. CHCCs reported receiving tobacco funding in the past, making them susceptible to future protobacco industry influence. Subsequently, an intervention was implemented to inoculate the CHCCs against industry influence by encouraging an antitobacco corporate sponsorship policy adoption. Six CHCCs representing approximately 400 businesses in the community adopted this policy. Targeting susceptible organizations including and beyond the Hispanic community and advocating for an antitobacco corporate sponsorship policy adoption are strategies that can be used in tandem with MSA enforcement to effectively build resistance.

Independent evaluation of the California Tobacco Control Program: relationships between program exposure and outcomes, 1996-1998.

OBJECTIVES: This study sought to determine the effects of the California Tobacco Control Program on tobacco-related attitudes and behaviors. METHODS: In 1996 and 1998, a telephone survey was conducted among adults in randomly selected households in 18 California counties. Tenth-grade youths in 84 randomly selected high schools completed a written survey. In analyses conducted at the county level, differences in outcomes were regressed on an index of program exposure. RESULTS: Among adults, program exposure was associated with decreased smoking prevalence rates, increased no-smoking policies in homes, and decreased violations of workplace no-smoking policies. Among youths, there was no effect of program exposure on outcomes. CONCLUSIONS: These results suggest that the California Tobacco Control Program may have reduced adult smoking prevalence rates and exposure to environmental tobacco smoke.