Impact of New York City Cigarette Floor Price Policy on Reducing Smoking Disparities.

INTRODUCTION: In 2017, New York City (NYC) passed a minimum floor price law (MFPL) to raise the minimum price of a pack of cigarettes to $13.00. Evaluation of the MFPL in NYC is limited and has yet to examine its potential as a pro-equity policy. METHODS: Data (n = 20,241; pre-policy n =15,037, post-policy n =5,204) were obtained from the New York State Adult Tobacco Survey, a quarterly repeated cross-sectional survey. Using the Difference-in-Differences approach, we compared changes in reported cigarette prices, cigarette consumption, and smoking status among NYC residents before and after policy implementation to changes in the same outcomes among residents in the rest of the state (ROS) over the same period. RESULTS: For some smokers, cigarette price increased in NYC for post-policy period; moreover, prices increased more in NYC than in ROS. NYC smokers who reported higher income, more education, or White or "Other" race, reported a bigger price increase than their ROS counterparts. Cigarette consumption decreased more in the post-policy period for people in the ROS, in general and among certain groups. Everyday smoking status decreased similarly in both NYC and ROS, whereas someday smoking status decreased primarily in the ROS during the analysis period. CONCLUSIONS: Cigarette prices in NYC increased after the 2017 MFPL; these increases were greater than those occurring elsewhere in the state, suggesting the policy might be a factor in the change. However, the increases were concentrated among relatively higher priced purchases, and groups with lower smoking prevalence. Changes in smoking status and cigarette consumption did not correspond to study hypotheses. IMPLICATIONS: This study provides an empirical analysis of a real-world policy in tobacco control. It examines the potential of the MFPL in New York City as a pro-equity policy. Findings extend the current MFPL literature and suggest that they may be able to raise cigarette prices for some purchases, but also may have a limited impact on smoking behaviors.

Correlation Among Neighborhood-level Measures of the Tobacco Retail Environment.

INTRODUCTION: Tobacco retailer density and distance to tobacco retailers are understood to influence tobacco-related behaviors; however, there is no general agreement on how to best characterize or measure the tobacco retail environment (TRE). In this data-driven analysis, we examine similarities among neighborhood-level measures of the TRE and assess how geographic resolution of the neighborhood units may affect them. METHODS: We used locations of likely tobacco retailers in the United States (US) to calculate multiple retailer count, density, and distance measures. Measures were calculated at the Census block group, tract, and county (including county equivalents) levels of geographic aggregation. Spearman's correlation was used to evaluate similarity among the TRE measures. RESULTS: At the block group and tract level, correlation among all TRE measures ranged from slightly negative (ρ = -0.03) to nearly perfect (ρ = 0.99). At both levels of aggregation, distance-based TRE measures were highly correlated (ρ > 0.76). At the block group level, simple count of retailers was highly correlated with the density measures (ρ > 0.83), and at the tract level, simple count was moderately to highly correlated with the density measures (ρ > 0.5). Findings were generally similar at the county level; a notable deviation was that retailers per person was negatively correlated with all other TRE measures (range from ρ = -0.08 to ρ = -0.32). CONCLUSIONS: Some common measures were not correlated, suggesting they capture different aspects of the TRE; similarity among the various measures also varied by level of geographic aggregation. IMPLICATIONS: Because the tobacco retail environment shapes people's tobacco-related behaviors, using appropriate measures to characterize it at a neighborhood-level is paramount. Our work highlights both the similarities and differences among a set of common measures, thereby suggesting the measures may be capturing different aspects of the overall retail environment. Our findings regarding geographic level of aggregation underscore the importance of neighborhood definition in any tobacco retail environment analysis.

Supply and demand effects between tobacco retailer density and smoking prevalence.

OBJECTIVE: Places with more tobacco retailers have higher smoking prevalence levels, but whether this is because retailers locate where people who smoke live or whether tobacco availability prompts tobacco use is unknown. In this study, we compare the role of consumer demand with that of tobacco supply in longitudinal, area-based associations of tobacco retailer density with smoking prevalence. METHODS: We merged annual adult smoking prevalence estimates derived from the USA Behavioural Risk Factor Surveillance System data with annual county estimates of tobacco retailer density calculated from the National Establishment Time Series data for 3080 counties between 2000 and 2010. We analysed relationships between retailer density and smoking in 3080 counties, using random intercept cross-lagged panel models and employing two measures of tobacco retailer density capturing the number of likely tobacco retailers in a county divided by either the population or land area. RESULTS: Both density models provided evidence of significant demand and supply effects; in the population-based model, the association of smoking prevalence in 1 year with tobacco retailer density in the next year (standardised coefficient=0.038, p<0.01) was about double the association between tobacco retailer density with subsequent smoking prevalence (0.017, p<0.01). The reverse was true in the land area-based model, where the supply effect (0.042, p<0.01) was more than 10 times stronger than the demand effect (0.003, p<0.01). CONCLUSIONS: Policies that restrict access to retail tobacco have the potential to reduce smoking prevalence, but pairing such policies with interventions to reduce consumer demand remains important.

Tobacco retailer density and its association with birth outcomes in the USA: 2000-2016.

INTRODUCTION: Significant progress has been made in reducing maternal exposure to tobacco smoke and subsequent adverse birth outcomes, however, reductions may require strategies that reduce the availability of tobacco retailers. In this study, we investigated the relationship between tobacco retailer density and birth outcomes across the USA and predicted the potential impact of a tobacco retailer density cap on these outcomes. METHODS: Annual US county (n=3105), rates of preterm birth, low birth weight, small-for-gestational age, all-cause infant mortality and sudden infant death syndrome (SIDS) were calculated using National Vital Statistics System data. Tobacco retailers were identified from the National Establishment Time-Series Database. We used Poisson regression to estimate the effect of capping retailer density at 1.4 retailers per 1000 population, controlling for county demographics and air pollution, using propensity score weighting. RESULTS: Tobacco retailer density was positively associated with most adverse birth outcomes. We estimate that a nationwide cap on tobacco retailer density, implemented in 2016, would have resulted in a reduction of 4275 (95% CI 2210 to 6392) preterm births, 6096 (95% CI 4421 to 7806) small-for-gestational-age births, 3483 (95% CI 2615 to 4378) low birthweight births, 538 (95% CI 345 to 733) all-cause infant deaths and 107 (95% CI 55 to 158) SIDS deaths in that year. CONCLUSION: Higher rates of adverse birth outcomes were seen in counties with high tobacco retailer density compared with those with low density. These results provide further support for regulating tobacco retail density to reduce adverse health outcomes associated with tobacco use.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking.

OBJECTIVES: Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies. METHODS: We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies. RESULTS: The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking. CONCLUSIONS: The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Institutional Reform to Promote Antiracism: A Tool for Developing an Organizational Equity Action and Accountability Plan.

Racism is a public health problem. Systems, structures, policies, and practices perpetuate a culture built on racism. Institutional reform is needed to promote antiracism. This article describes 1) a tool used to develop an equity action and accountability plan (EAAP) that promotes antiracism in the Department of Health Behavior at the University of North Carolina at Chapel Hill's Gillings School of Global Public Health, 2) strategies that were developed, and 3) short-term outcomes and lessons learned. A study coordinator, not affiliated with the Department of Health Behavior, was hired to collect qualitative data that documented the lived experiences of students and alumni of color (ie, racial and ethnic minority students) over time in the department. Seeking action from faculty and departmental leadership, students engaged in collective organizing covered the department chair's office door with notes describing microaggressions, and visited faculty one-on-one to demand action. In response, 6 faculty members volunteered to form the Equity Task Force (ETF) to explicitly address students' concerns. The ETF identified priority areas for action based on 2 student-led reports, gathered resources from other institutions and the public health literature, and examined departmental policies and procedures. The ETF drafted the EAAP, solicited feedback, and revised it according to 6 priority strategies with actionable steps: 1) transform culture and climate, 2) enhance teaching, mentoring, and training, 3) revisit performance and evaluation of faculty and staff, 4) strengthen recruitment and retention of faculty of color, 5) increase transparency in student hiring practices and financial resources, and 6) improve equity-oriented research practices. This planning tool and process can be used by other institutions to achieve antiracist reform.

Did the 2015 USPSTF Abnormal Blood Glucose Recommendations Change Clinician Attitudes or Behaviors? A Mixed-Method Assessment.

BACKGROUND: In 2015, the US Preventive Services Task Force (USPSTF) revised clinical recommendations to more broadly recommend abnormal blood glucose screening and more clearly recommend referral to behavioral interventions for adults with prediabetes. OBJECTIVE: To assess the effects of the 2015 USPSTF recommendation changes on abnormal blood glucose screening and referral to behavioral interventions, and to examine physicians' perceptions of the revised recommendation. DESIGN: We utilized a sequential, dependent mixed-methods triangulation design. PARTICIPANTS: A total of 33,444 patients meeting USPSTF abnormal blood glucose screening criteria within 15 health system-affiliated primary care practices and 20 primary care physicians in North Carolina. MAIN MEASURES: We assessed monthly abnormal blood glucose screening rate and monthly referral rate to behavioral interventions. To estimate trend changes in outcomes, we used segmented linear regression analysis of interrupted time-series data. We gathered physicians' perspectives on the 2015 USPSTF abnormal blood glucose recommendation including awareness of, agreement with, adoption of, and adherence to the recommendation. To analyze qualitative data, we used directed content analysis. KEY RESULTS: There was a slight significant change in trend in abnormal blood glucose screening rates post-recommendation. There was a slight, statistically significant decrease in referral rates to behavioral interventions post-recommendation. Physicians were generally unaware of the revisions to the 2015 USPSTF abnormal blood glucose recommendation; however, once the recommendations were described, physicians agreed with the screening recommendation but felt that the behavioral intervention referral recommendation was hard to implement. CONCLUSION: The 2015 USPSTF abnormal blood glucose guideline had little to no effect on abnormal blood glucose screening or referral to behavioral interventions in North Carolina practices. Potential interventions to improve these rates could include clinical decision tools embedded in the electronic health record and better referral systems for community-based diabetes prevention programs.

Trends in the Number and Type of Tobacco Product Retailers, United States, 2000-2017.

INTRODUCTION: Tobacco product retailers provide access to tobacco products and exposure to tobacco marketing. Without a national tobacco retailer licensing system in the United States, there are no estimates of national trends in tobacco retailer numbers and store type over time. METHODS: We developed a protocol to identify likely tobacco retailers across the United States between 2000 and 2017 using industry codes and retailer names in the annual National Establishment Time Series (NETS) database. We calculated annual counts of tobacco retailers in seven store-type categories and annual numbers of tobacco retailers that opened and closed. RESULTS: We estimate that there were 317 492 tobacco product retailers in 2000; the number grew to 412 536 in 2009 before falling to 356 074 in 2017, for a net 12% increase overall. Gas/convenience stores and grocery stores accounted for more than two thirds of all retailers. On average, new openings accounted for 8.0% of the total retailers, whereas 7.3% of retailers closed or stopped selling tobacco each year, with stronger market volatility following the Great Recession. Since 2011, there was a disproportionate reduction in tobacco-selling pharmacies and an increase in both tobacco-specialty shops and tobacco-selling discount stores. CONCLUSIONS: During two decades when smoking declined, tobacco retailer availability increased in the United States. The economic climate, corporate and public policies, and new tobacco products may all contribute to trends in tobacco retailer availability. State and local jurisdictions considering tobacco retailer policies may find retailer trend information useful for forecasting or evaluating potential policy impacts. IMPLICATIONS: This study provides historic data tracking tobacco retailers in the United States between 2000 and 2017, documenting trends that unfolded as the general economic market contracted and grew, with greater regulation of the tobacco retailer environment. These data provide a context for better understanding future changes in the tobacco retailer market. In addition, the protocol established in this study could be applied in any US-based location without tobacco retailer licensing to allow identification of stores and tracking of trends.

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.

Cheaper tobacco product prices at US Air Force Bases compared with surrounding community areas, 2019.

INTRODUCTION: In March 2017, the US Department of Defense (DoD) implemented a policy requiring all military stores to set tobacco prices equal to 'prevailing prices' in the 'local community' adjusted for state and local taxes. We compared tobacco product prices in a sample of retailers located on five Air Force Bases (AFBs) in Texas and Mississippi with those sold in nearby off-base stores. METHODS: We constructed a list of on-base and off-base tobacco retailers. Off-base retailers included stores that were located within a 1.5-mile road network service area from main AFB gates. Between July and September 2019, a trained auditor visited 23 on-base and 50 off-base retailers to confirm tobacco product sales, and documented the price of cigarettes and Copenhagen smokeless tobacco. For each area, the median price for each product, as well as the difference in median prices by on-base versus off-base status, was calculated. RESULTS: The median price of cigarettes and smokeless products was cheaper at on-base retailers. All products were cheaper at on-base stores in Fort Sam Houston and Lackland AFB. Similarly, all products were cheaper in on-base stores at Keesler AFB, with the exception of Marlboro Red packs ($0.22 more), and at Sheppard AFB with the exception of cheapest cigarette cartons ($6.26 more). CONCLUSION: Despite the implementation of the new DoD policy, tobacco products are cheaper in on-base retailers compared with off-base retailers. Refining of the definitions used and improved compliance with the new DoD policy are needed.

Associations of tobacco retailer density and proximity with adult tobacco use behaviours and health outcomes: a meta-analysis.

OBJECTIVE: We sought to conduct a systematic review and meta-analysis of evidence to inform policies that reduce density and proximity of tobacco retailers. DATA SOURCES: Ten databases were searched on 16 October 2020: MEDLINE via PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus, plus grey literature searches using Google and the RAND Publication Database. STUDY SELECTION: Included studies used inferential statistics about adult participants to examine associations between tobacco retailer density/proximity and tobacco use behaviours and health outcomes. Of 7373 studies reviewed by independent coders, 37 (0.5%) met inclusion criteria. DATA EXTRACTION: Effect sizes were converted to a relative risk reduction (RRR) metric, indicating the presumed reduction in tobacco use outcomes based on reducing tobacco retailer density and decreasing proximity. DATA SYNTHESIS: We conducted a random effects meta-analysis and examined heterogeneity across 27 studies through subgroup analyses and meta-regression. Tobacco retailer density (RRR=2.55, 95% CI 1.91 to 3.19, k=155) and proximity (RRR=2.38, 95% CI 1.39 to 3.37, k=100) were associated with tobacco use behaviours. Pooled results including both density and proximity found an estimated 2.48% reduction in risk of tobacco use from reductions in tobacco retailer density and proximity (RRR=2.48, 95% CI 1.95 to 3.02, k=255). Results for health outcomes came from just two studies and were not significant. Considerable heterogeneity existed. CONCLUSIONS: Across studies, lower levels of tobacco retailer density and decreased proximity are associated with lower tobacco use. Reducing tobacco supply by limiting retailer density and proximity may lead to reductions in tobacco use. Policy evaluations are needed.

Excise Taxes as a Policy Lever for Reaching Healthy North Carolina 2030 Targets.

Excise taxes can raise the price of unhealthy products, reducing consumption and associated health risks and costs. Raising state excise taxes on tobacco, alcohol, and sugary drinks and allowing local governments to do the same are win-win strategies for achieving three Healthy North Carolina 2030 health behavior targets while increasing state revenues.

Race and gender differences in abnormal blood glucose screening and clinician response to prediabetes: A mixed-methods assessment.

The projected three-fold increase in diabetes burden by 2060 in the United States will affect certain race and gender groups disproportionately. The objective of this mixed-methods study was to assess differences in prediabetes screening and clinician response to prediabetes by patient race and gender. We utilized data from 18,742 patients seen between 11/1/15 and 4/30/17 who met criteria for blood glucose screening by the 2015 US Preventive Service Task Force recommendation and had at least one visit to a primary care practice within a large, academic health system located in North Carolina. We utilized generalized estimating equations with logistic regression to assess race and gender differences in two outcomes: prediabetes screening and clinician response to prediabetes. We conducted twenty in-depth interviews (October 2018-May 2019) with physicians to assess their approach to screening for and treating prediabetes. Black patients had 11% higher odds (95% CI:1.02-1.20) of being screened for prediabetes than White patients. Men had 19% higher odds (95% CI:1.09-1.30) of being screened for prediabetes than women. There were no significant differences in clinician response to prediabetes by patient race or gender. Qualitatively, physicians reported a non-systematic approach to prediabetes screening and follow-up care related to: 1) System-level barriers to screening and treatment; 2) Implicit bias; 3) Patient factors; and 4) Physician preferences for prediabetes treatment. Targeted risk-based screening for prediabetes along with increased treatment for prediabetes are critical for preventing diabetes and reducing diabetes-related disparities.

Are state-level income-based disparities in adult smoking declining?

The United States (US) has identified income-based disparities in smoking as a critical public health issue, but the extent to which these disparities are changing over time within states is not well documented. This study examined recent trends in current cigarette smoking in each state and the District of Columbia by self-reported annual household income. Data came from the Behavioral Risk Factor Surveillance System, a state-representative survey of US adults. Sample sizes for each state and year ranged from 2914 to 36,955 participants. We fit logistic regression models to examine linear time trends in cigarette smoking status in each state between 2011 and 2017. In every state, the odds of smoking were 1.4 to 3.0 times greater in the lower-income group as compared to the higher-income group in 2017. Among 47 states, linear time trends in smoking did not significantly differ by income group, suggesting no change in income-based disparities. In three states (Florida, Maine, West Virginia) disparities widened, primarily because smoking prevalence only dropped among higher-income groups. Disparities declined in only one state. In New York, smoking prevalence declined more for lower-income groups compared to higher-income groups. Findings from this study suggest that little progress has been made toward reducing income-based differences in smoking and additional policy and tobacco control efforts may be required to meet national disparity reduction goals.

Neighborhood Disparities in the Availability, Advertising, Promotion, and Youth Appeal of Little Cigars and Cigarillos, United States, 2015.

INTRODUCTION: Between 2012 and 2016, sales of cigars increased by 29% in the United States. In small local studies, greater little cigar and cigarillo (LCC) availability and marketing has been documented in neighborhoods with a greater proportion of Hispanic or Latino and black residents, and near schools. This national study of cigarette retailers assesses whether LCC availability and marketing at the point of sale is associated with neighborhood racial, ethnic, income, and percent youth demographics. METHODS: In 2015, we collected LCC availability and marketing data through retailer audits of a nationally representative sample of 2128 cigarette retailers. Using 2011-2015 American Community Survey census tract estimates, we modeled associations of neighborhood demographics (in quartiles) with availability of LCC-flavored products, and presence of exterior advertisements, youth marketing, and promotions. RESULTS: Nearly 90% of retailers sold LCCs, 83.0% sold flavored LCCs, and 30.9% had youth marketing. Controlling for retailer type and other neighborhood characteristics, neighborhoods with the highest proportion of black residents had significantly higher odds of flavored LCC availability (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.52, 3.30); exterior advertisements (AOR = 2.84, 95% CI = 1.94, 4.16); price promotions (AOR = 1.62; 95% CI = 1.07-2.45), and youth appeal (AOR = 1.49, 95% CI 1.08-2.08) compared to the lowest. Disparities in flavored LCC availability, exterior advertising, and youth appeal were also present for lower income neighborhoods. CONCLUSION: Neighborhoods with a greater proportion of black or lower income residents have greater flavored LCCs availability and LCC marketing. Without stronger LCC regulation, residents of these neighborhoods may be at a greater risk of LCC use. IMPLICATIONS: LCCs are harmful combustible tobacco products that are less regulated than cigarettes (eg, lower taxation, cheaper outlay due to small package sizes, availability of flavors), which makes them an affordable and appealing product to youth. This study documents greater availability, advertising, and marketing of LCCs in neighborhoods with a higher proportion of black or lower-income residents, potentially putting these populations at a greater risk of using or switching to these products in the face of increasing cigarette regulations. These findings underscore the need for local, state, and federal LCC regulatory action.

Simulating the Impact of a Cigarette Minimum Floor Price Law on Adult Smoking Prevalence in California.

INTRODUCTION: Minimum floor price laws (MFPLs) are an emerging tobacco control policy that sets a minimum price below which a specific tobacco product cannot be sold. MFPLs target cheaper products and may disproportionately impact consumers choosing low price brands or using discounts to reduce prices. We developed a static microsimulation model for California, United States to project short-term effects of different MFPL options for a 20-stick pack of cigarettes on adult smoking behaviors. AIMS AND METHODS: We simulated 300 000 individuals defined by race and ethnicity, sex, age, and poverty status. Smoking behaviors and cigarette prices were assigned based on demographic distributions in the 2014-2016 California Behavioral Risk Factor Surveillance System. We drew 100 random samples (n = 30 000), weighted to state-level California demographic characteristics. We simulated six MFPL options and modeled impacts on smoking prevalence and cigarette consumption, in general, and separately for those in households below or above 250% of the federal poverty level, assuming a price elasticity of -0.4. RESULTS: Predicted changes in prices, prevalence, and consumption increased exponentially as the floor price increased from $7.00 to $9.50. Assuming 15% policy avoidance, projected increases in average cigarette prices ranged from $0.19 to $1.61. Decreases in smoking prevalence ranged from 0.05 to 0.43 percentage points, and decreases in average monthly cigarette consumption ranged from 1.4 to 12.3 cigarettes. Projected prices increased, and prevalence and consumption decreased, more among individuals in households below 250% federal poverty level. CONCLUSIONS: MFPLs are a promising tobacco control strategy with the potential to reduce socioeconomic disparities in cigarette smoking prevalence and consumption. IMPLICATIONS: Despite reductions in adult smoking prevalence, significant socioeconomic disparities remain, with lower-income groups smoking at substantially higher levels than higher-income groups. Policies that set a floor price below which a tobacco product cannot be sold could reduce socioeconomic disparities in smoking, depending on variation in prices paid by smokers prepolicy. By using a microsimulation model to predict changes in smoking for different population groups in California under several floor price scenarios, this study demonstrates that MFPLs have the potential to reduce adult smoking prevalence overall, and especially for lower-income tobacco users.

Availability, price and promotions for cigarettes and non-cigarette tobacco products: an observational comparison of US Air Force bases with nearby tobacco retailers, 2016.

INTRODUCTION: Active duty military personnel have higher cigarette and smokeless tobacco use rates than civilian populations. Although US Airmen (called Airmen regardless of gender or rank) are required to be tobacco-free during initial training, many resume use once this period ends, perhaps as a result of easy access to cheap tobacco products. METHODS: Between July and September 2016, we collected tobacco product, price and promotion information by visiting on-base (n=28) and off-base (n=80) tobacco retailers near the eight technical training bases where approximately 99% of Airmen attend training. We conducted mixed linear effects models to examine on-base versus off-base differences. RESULTS: Cigarette packs were 11%-12% cheaper at on-base retailers compared with off-base retailers. Newport Menthol and Marlboro Red cigarette packs were $0.87 and $0.80 lower on-base (p<0.001) while the cheapest pack available was $0.54 lower on-base (p<0.01). Copenhagen smokeless tobacco was also significantly cheaper on-base (B=-0.65, p<0.01). Interior price promotions were more common on-base. CONCLUSIONS: Retail stores located on Air Force bases sell cigarettes and smokeless tobacco products at prices well below those in nearby off-base retailers: the vast majority of these retailers feature interior price promotions for these products. Federal policies regulating prices of on-base tobacco sales, if implemented more effectively, have the potential to protect the health of Airmen by helping them remain tobacco-free after technical training.

Impact of Pharmacists on Access to Vaccine Providers: A Geospatial Analysis.

Policy Points: Policymakers in the United States should consider expanding pharmacy practice laws to allow pharmacists to vaccinate adolescents as a way to improve geographic access to adolescent vaccines, particularly for human papillomavirus (HPV) vaccine, which has low uptake. Our state-level analysis showed that pharmacists are more geographically dispersed than primary care physicians in the US state of Texas. Including pharmacists among available adolescent vaccine providers would improve the geographic distribution of vaccine providers, especially in areas with an inadequate number of primary care physicians. CONTEXT: The largest disparities in human papillomavirus (HPV) vaccination in the United States are due to geography. One potential way of addressing these disparities is by improving geographic access to HPV vaccination. Two federal panels have recommended including community pharmacists as HPV vaccine providers as a strategy to improve opportunities for HPV vaccination for adolescents. We sought to evaluate whether community pharmacists can improve the number of vaccine providers in areas with primary care physician shortages in the US state of Texas. METHODS: We gathered publicly available physician and pharmacist 2016 workforce data from the Texas Medical Board and Board of Pharmacy. We conducted geospatial analysis of census tracts to analyze the distribution of physicians and pharmacists and how pharmacists change vaccine provider coverage across the state. FINDINGS: Census tracts with high numbers of physicians per capita tended to be located near one another, in 5 of 5 analyses of Moran's I (median = .04). In contrast, pharmacist rates were not spatially dependent on census tract in any of our analyses. If pharmacists were added to primary care physicians as vaccine providers, 35% of urban census tracts that previously had inadequate coverage would be adequately covered, while 18% of inadequately covered rural census tracts would become adequately covered. Overall, when pharmacists were included with primary care physicians as vaccine providers, vaccine providers per capita increased in 2,413 of the 4,508 urban census tracts (54%), while the rate increased in 223 of 746 rural census tracts (30%). CONCLUSIONS: Pharmacists are more geographically dispersed across census tracts than primary care physicians. As a result, adding pharmacists to the workforce would increase the availability of vaccine providers in areas with inadequate primary care provider coverage.

The impact of psychosocial characteristics in predicting smoking cessation in long-term cancer survivors: A time-to-event analysis.

OBJECTIVE: Smoking poses significant health risks to cancer survivors. Cancer survivorship may heighten psychological distress and reduce social support and health-related quality of life (HRQOL) for years after diagnosis, which could inhibit long-term successful smoking cessation. Understanding longitudinal associations between these psychosocial characteristics and successful cessation could help clinicians tailor cessation interventions for their patients. METHODS: Time-to-event analyses using data from the American Cancer Society Study of Cancer Survivors-I (SCS-I)-a longitudinal nationwide study-examined the relationship of psychosocial characteristics with cessation likelihood and amount of time from diagnosis to quitting in cancer survivors diagnosed 7 to 10 years prior. RESULTS: Cancer survivors with high physical HRQOL were more likely to quit smoking within 10 years from cancer diagnosis than survivors with low physical HRQOL, controlling for cancer type and number of comorbid conditions at baseline (HR = 1.96; 95% CI: 1.10-2.70; P = .02). Survivors with high physical HRQOL also took less time to quit than survivors with low physical HRQOL. Survivors of tobacco-related cancers with low physical HRQOL were the least likely group to quit. No significant relationships between other psychosocial predictors and cessation outcomes were observed. CONCLUSIONS: Smoking cessation programs are needed for all cancer survivors who smoke, but survivors with low physical HRQOL 1 year after diagnosis may need more intensive long-term smoking cessation interventions with multiple check-in points after smoking relapses. Cessation interventions that include strategies to mitigate physical symptoms in those with poor physical HRQOL deserve consideration in research and practice.

Disparities in cigarette tax exposure by race, ethnicity, poverty status and sexual orientation, 2006-2014, USA.

Cigarette excise taxes are an effective tobacco control strategy but they vary geographically due to differences in state and local taxation. There are also pronounced sociodemographic differences in community composition, suggesting that different population groups might face vastly different cigarette excise tax rates. In this study, we examine how cigarette excise tax rates differ for population groups defined by race, ethnicity, poverty status, and sexual orientation, and how these differences have evolved over time. We constructed annual cigarette tax rates in 109 mutually exclusive jurisdictions within the United States (U.S.) between 2006 and 2014. After merging with Census sociodemographic data, we calculated annual cigarette excise tax exposures for each population group as the average of each place-based tax, weighted by the proportion of the group living there. In 2014, the average U.S. resident was required to pay $2.68 in cigarette taxes, more than 60% of which was due to state and local taxation. On average, Asian/Native Hawaiian and Other Pacific Islander populations faced the highest average tax ($2.95), which was $0.44 more than American Indian populations. Local taxes disproportionately augmented state and federal taxes for non-White populations, same-sex couples, and people living in poverty. Geographic variation in cigarette excise taxes produces sociodemographic variation in cigarette tax exposure. Raising cigarette taxes specifically in those places where groups at risk for tobacco-related disease are more likely to live, or otherwise creating geographically uniform tax levels, could reduce important disparities in cigarette smoking.