What is the impact of e-cigarette adverts on children's perceptions of tobacco smoking? An experimental study.

OBJECTIVE: Exposure to e-cigarette adverts increases children's positive attitudes towards using them. Given the similarity in appearance between e-cigarettes and tobacco cigarettes, we examined whether exposure to e-cigarette adverts has a cross-product impact on perceptions and attitudes towards smoking tobacco cigarettes. METHODS: Children aged 11-16 (n=564) were interviewed in their homes and randomised to one of three groups: two groups saw different sets of 10 images of e-cigarette adverts and one group saw no adverts. Of the 20 e-cigarette adverts, 10 depicted the product as glamorous and 10 depicted it as healthy. The children then self-completed a questionnaire assessing perceived appeal, harms and benefits of smoking tobacco cigarettes. RESULTS: The analyses were conducted on 411 children who reported never having smoked tobacco cigarettes or used e-cigarettes. Exposure to the adverts had no impact on the appeal or perceived benefits of smoking tobacco cigarettes. While the perceived harm of smoking more than 10 cigarettes per day was similar across groups, those exposed to either set of adverts perceived the harms of smoking one or two tobacco cigarettes occasionally to be lower than those in the control group. CONCLUSIONS: This study provides the first evidence that exposure to e-cigarette adverts might influence children's perceptions of smoking tobacco cigarettes, reducing their perceived harm of occasional smoking. These results suggest the potential for e-cigarette adverts to undermine tobacco control efforts by reducing a potential barrier (ie, beliefs about harm) to occasional smoking.

Adolescents' interest in trying flavoured e-cigarettes.

BACKGROUND: More US adolescents use e-cigarettes than smoke cigarettes. Research suggests flavoured e-cigarettes appeal to youth, but little is known about perceptions of and reasons for attraction to specific flavours. METHODS: A national sample of adolescents (n=1125) ages 13-17 participated in a phone survey from November 2014 to June 2015. We randomly assigned adolescents to respond to survey items about 1 of 5 e-cigarette flavours (tobacco, alcohol, menthol, candy or fruit) and used regression analysis to examine the impact of flavour on interest in trying e-cigarettes and harm beliefs. RESULTS: Adolescents were more likely to report interest in trying an e-cigarette offered by a friend if it were flavoured like menthol (OR=4.00, 95% CI 1.46 to 10.97), candy (OR=4.53, 95% CI 1.67 to 12.31) or fruit (OR=6.49, 95% CI 2.48 to 17.01) compared with tobacco. Adolescents believed that fruit-flavoured e-cigarettes were less harmful to health than tobacco-flavoured e-cigarettes (p<0.05). Perceived harm mediated the relationship between some flavours and interest in trying e-cigarettes. A minority of adolescents believed that e-cigarettes did not have nicotine (14.6%) or did not know whether they had nicotine (3.6%); these beliefs did not vary by flavour. DISCUSSION: Candy-flavoured, fruit-flavoured and menthol-flavoured e-cigarettes appeal to adolescents more than tobacco-flavoured or alcohol-flavoured e-cigarettes. This appeal is only partially explained by beliefs about reduced harm. Given adolescents' interest in trying e-cigarettes with certain flavours, policymakers should consider restricting advertisements promoting flavoured products in media that reach large numbers of young people. Future research should examine other reasons for the appeal of individual flavours, such as novelty and perceived luxury.

An examination of the effect on cigarette prices and promotions of Philip Morris USA penalties to stores that sell cigarettes to minors.

OBJECTIVE: The purpose of this study was to assess the potential impact of public policies to regulate price discounting strategies on retail cigarette prices and advertising. Philip Morris USA (PM USA) has a policy designed to sanction stores violating state laws banning illegal tobacco sales to minors by temporarily suspending price discounting incentives. This study examined the impact of those sanctions on retail cigarette prices and sales promotion advertising. METHOD: In November 2006, the California Attorney General's Office informed PM USA that 196 stores were found guilty of illegal underage sales. Of these, 109 stores that participated in the PM USA Retail Leaders Program were notified that their merchandising and/or promotional resources would be suspended for the month of April 2007. The remaining 87 stores were not sanctioned and served as a comparison group. Trained raters assessed advertising and prices of selected PM USA brands in these stores pre-penalty and during the penalty phase. RESULTS: There were no significant differences between sanctioned and non-sanctioned stores on median changes in price and sales promotion advertising from the pre-penalty to the penalty phase. CONCLUSION: The lack of impact on cigarette prices and advertising indicate that the PM USA policy may be flawed in its design or execution. If public policies are developed to restrain cigarette price discounting strategies, they should be crafted to ensure compliance and preclude possible compensatory actions by retailers.

How do minimum cigarette price laws affect cigarette prices at the retail level?

OBJECTIVES: Half of US states have minimum cigarette price laws that were originally passed to protect small independent retailers from unfair price competition with larger retailers. These laws prohibit cigarettes from being sold below a minimum price that is set by a formula. Many of these laws allow cigarette company promotional incentives offered to retailers, such as buydowns and master-type programmes, to be calculated into the formula. Allowing this provision has the potential to lower the allowable minimum price. This study assesses whether stores in states with minimum price laws have higher cigarette prices and lower rates of retailer participation in cigarette company promotional incentive programmes. DESIGN: Retail cigarette prices and retailer participation in cigarette company incentive programmes in 2001 were compared in eight states with minimum price laws and seven states without them. New York State had the most stringent minimum price law at the time of the study because it excluded promotional incentive programmes in its price setting formula; cigarette prices in New York were compared to all other states included in the study. RESULTS: Cigarette prices were not significantly different in our sample of US states with and without cigarette minimum price laws. Cigarette prices were significantly higher in New York stores than in the 14 other states combined. CONCLUSIONS: Most existing minimum cigarette price laws appear to have little impact on the retail price of cigarettes. This may be because they allow the use of promotional programmes, which are used by manufacturers to reduce cigarette prices. New York's strategy to disallow these types of incentive programmes may result in higher minimum cigarette prices, and should also be explored as a potential policy strategy to control cigarette company marketing practices in stores. Strict cigarette minimum price laws may have the potential to reduce cigarette consumption by decreasing demand through increased cigarette prices and reduced promotional activities at retail outlets.

The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth campaign.

BACKGROUND: Adolescents who live in tobacco producing regions may not respond favourably to anti-industry ads. OBJECTIVE: To examine whether state level involvement in tobacco production appears to limit the effectiveness of anti-industry ads to prevent tobacco use among adolescents in the USA. DESIGN: Time trend analyses were done using repeated cross sectional data from six waves of the Legacy Media Tracking Survey, which were collected between 1999 and 2003. SETTING AND PARTICIPANTS: 28,307 adolescents, ages 12-17 years, were classified as living in: tobacco producing states (TPS) (n = 1929); non-tobacco producing states (non-TPS) with low tobacco control funding comparable to TPS (n = 5323); non-TPS with relatively high funding (n = 15,076); and non-TPS with established anti-industry ad campaigns (n = 5979). MAIN OUTCOME MEASURES: Reactions to anti-industry ads; strength of anti-industry attitudes/beliefs; changes in anti-industry attitudes/beliefs over time. RESULTS: Ad reactions did not differ by state type. Multivariate adjusted time trend analyses indicated significant, comparable increases in anti-industry attitudes/beliefs since the onset of the truth campaign, in both TPS and non-TPS. Mediation analyses indicated that these increases were due, in part, to campaign exposure. CONCLUSIONS: Adolescents who live in tobacco producing regions appear to be as responsive to anti-industry ads as their counterparts in non-tobacco producing regions. This study provides further evidence for the effectiveness of such ads.

How tobacco companies ensure prime placement of their advertising and products in stores: interviews with retailers about tobacco company incentive programmes.

BACKGROUND: About 81% of cigarette manufacturers' marketing expenditures in the USA is spent to promote cigarette sales in stores. Relatively little is known about how these expenditures help the manufacturers achieve their marketing goals in stores. A better understanding of how tobacco companies influence the retail environment would help researchers and tobacco control activists to monitor industry presence in stores. OBJECTIVE: To describe the types of tobacco company incentive programmes offered to retailers, how these programmes impact the store environments, and possible visual indicators of retailer participation in incentive programmes. STUDY DESIGN: In-depth qualitative interviews with a convenience sample of 29 tobacco retailers were conducted in 2001. SETTING: USA. MAIN OUTCOME MEASURES: The types and requirements of retailer incentive programmes provided by tobacco companies, and how participation in a programme alters their stores. RESULTS: The retailers provided insights into how tobacco companies convey promotional allowances and special offers to them and how these incentives shape the retail environment. Retailers noted that tobacco companies exert substantial control over their stores by requiring placement of products in the most visible locations, and of specific amounts and types of advertising in prime locations in the store. Retailers also described how tobacco companies reduce prices by offering them volume based discounts, "buy two, get one free" specials, and "buying down" the price of existing product. CONCLUSIONS: Tobacco companies are concentrating their marketing dollars at the point-of-sale to the extent that the store is their primary communication channel with customers. As a result, all shoppers regardless of age or smoking status are exposed to pro-smoking messages. Given the financial resources spent by tobacco companies in stores, this venue warrants closer scrutiny by researchers and tobacco control advocates.

The potential of the internet as a medium to encourage and discourage youth tobacco use.

The internet is fast becoming a new battleground between tobacco control advocates and pro-tobacco forces, and this new media will certainly have a greater impact on tobacco use behaviour in the future. This paper reviews how the internet can encourage youth smoking by providing youth access to tobacco products and offering content that glamorises smoking lifestyle and culture, particularly in hundreds of websites and chat rooms. These sites feature pictures of celebrity smokers, provide information about smoking in movies, and provide smoking advice to teen smokers. In contrast, youth smoking is discouraged on online grassroots advocacy and countermarketing websites. Although these strategies show promise, more research is needed to evaluate their impact. Recommendations are made for future research to study pro-smoking internet content and ways to counteract it, as well as to monitor the online activities of the tobacco companies. Finally, some of the challenges in addressing tobacco related internet content are discussed.

Web sites selling cigarettes: how many are there in the USA and what are their sales practices?

OBJECTIVES: To estimate the number and geographic location of web sites selling cigarettes in the USA, and to examine their sales and marketing practices. METHODS: Comprehensive searches were conducted using four keyword terms and five popular internet search engines, supplemented by sites identified in a news article. Over 1800 sites were examined to identify 88 internet cigarette vendors. MEASURES: Trained raters examined the content of each site using a standardised coding instrument to assess geographic location, presence of warnings, products sold, and promotional strategies. SETTING: USA. RESULTS: Internet cigarette vendors were located in 23 states. Nearly half (n = 43) were located in New York state, and many were in tobacco producing states with low cigarette excise taxes. Indian reservations housed 49 of the 88 sites. Only 28.4% of sites featured the US Surgeon General's health warnings and 81.8% featured minimum age of sale warnings. Nearly all sites (96.6%) sold premium or value brand cigarettes, 21.6% sold duty-free Marlboros, and 8.0% sold bidis. Approximately one third featured special promotional programmes. CONCLUSIONS: Internet cigarette vendors present new regulatory and enforcement challenges for tobacco control advocates because of the difficulty in regulating internet content and because many vendors are on Indian reservations.

Are adolescents attempting to buy cigarettes on the internet?

OBJECTIVE: To assess the prevalence of, and demographic and smoking behaviour correlates of, attempting to purchase cigarettes via the internet among adolescent current smokers. METHODS: A representative sample of 17 181 10th and 12th grade California students completed a written questionnaire on tobacco related attitudes and behaviour during the 1999-2000 school year. Logistic regression analyses were used to determine the variables associated with attempting to purchase cigarettes on the internet. RESULTS: Among youth under 18 years of age who were current smokers (n = 1689), 2.2% (95% confidence interval 1.5% to 2.9%) reported attempting to purchase cigarettes on the internet. Attempted internet purchases were more likely among younger respondents, males, frequent smokers, and respondents reporting lower perceived availability of tobacco products from retail and social sources. CONCLUSIONS: Few adolescent smokers in California surveyed during the 1999-2000 school year had attempted to obtain cigarettes from the internet. As internet access increases, future studies should examine whether internet cigarette vendors sell to minors and whether adolescents are purchasing cigarettes on the internet.

Teen empowerment movement to prevent tobacco use by North Carolina's youth.

Strong youth and adult leadership and exemplary policy and program interventions put a unique synergy to work in North Carolina. The state aspires to be a model for the nation in overcoming barriers related to tobacco use prevention by empowering its greatest resource--youth. New grant funding is building the foundation for youth empowerment programs, and increased and sustained funding is being sought to significantly expand these efforts. Youth speak with a fresh voice, bringing energy and conviction, as well as non-traditional ideas and strategies to the achievement of their goals. By changing public opinion and influencing the actions of leaders in the nation's leading tobacco state, the North Carolina Tobacco Prevention and Control Branch will develop leadership for tobacco use prevention that will serve the entire nation.

What factors are associated with local enforcement of laws banning illegal tobacco sales to minors? A study of 182 law enforcement agencies in California.

OBJECTIVES: The aims of this study were to understand the attitudes of local law enforcement staff regarding policies to reduce youth access to tobacco, to determine what proportion of these agencies have conducted unannounced compliance checks in the past year, and to examine factors associated with conducting compliance checks. METHODS: A written questionnaire was completed by 182 law enforcement officials representing 200 cities and counties in California (some officials represented multiple jurisdictions). Logistic regression analyses were conducted to identify factors associated with conducting compliance checks. RESULTS: Only 36% of local enforcement agencies reported conducting one or more compliance checks in the previous year. Agencies were more likely to conduct compliance checks if they perceived fewer barriers to enforcement, reported more frequent collaboration with other community agencies to enforce youth access laws, and believed that youth access to tobacco is a problem in their community. CONCLUSIONS: Because active enforcement of youth access laws using unannounced compliance checks has been shown to reduce the rate of illegal tobacco sales to minors and may reduce youth smoking, efforts to increase the level of enforcement should be promoted. These study results may be used to inform efforts to encourage local agencies to enforce existing youth access laws.

Cigarette advertising and promotional strategies in retail outlets: results of a statewide survey in California.

OBJECTIVE: To examine the extent and types of cigarette advertising materials in stores and to assess tobacco company compliance with the 1998 Master Settlement Agreement (MSA). DESIGN: A cross-sectional analysis of a random sample of 586 stores that sold cigarettes. SETTING: US state of California. MAIN OUTCOME MEASURES: Trained data collectors classified cigarette advertising materials by type (signs, displays, functional items), location (interior or exterior), and placement (below 3 feet (1 m) or near candy). RESULTS: California retail outlets featured 17.2 (SD 16.1) tobacco advertising materials on average, and 94% of stores featured at least some advertising. About 85% of these were within 4 feet (1.3 m) of the counter. About 50% of the stores had ads at or below 3 feet, and 23% had cigarette product displays next to candy. In violation of the MSA, 3% of stores featured signs with cartoons and 11% had large exterior signs. CONCLUSIONS: Tobacco companies are aggressively using stores to market cigarettes. Moreover, the spirit of the MSA-to protect children from cigarette advertising-has not been realised. Future studies should monitor industry use of this venue and assess the impact of exposure to cigarette advertising materials in stores on adult smokers and youth.

English language use as a risk factor for smoking initiation among Hispanic and Asian American adolescents: evidence for mediation by tobacco-related beliefs and social norms.

Acculturation increases the risk of smoking among Hispanic and Asian American adolescents, but the underlying mechanisms are not understood. This study examined associations between English language use and smoking among 4,167 Hispanic and 2,836 Asian American adolescents in California. Potential mediators were assessed, including access to cigarettes, perceived consequences, friends' smoking, cigarette offers, refusal self-efficacy, and prevalence estimates of peer smoking. English language use was associated with increased risk of lifetime smoking in both groups. This association became nonsignificant after access, perceived consequences, friends' smoking, and offers were controlled for. The acculturation process (as indicated by English language use) may be associated with smoking-related psychosocial variables, which may lead to an increased risk of experimentation with smoking.

Opinion leaders' support for tobacco control policies and participation in tobacco control activities.

OBJECTIVES: Because opinion leaders hold positions from which they may influence tobacco control efforts, this study examined their support for tobacco control policies and their involvement in tobacco control activities. METHODS: A telephone survey was administered to 712 California opinion leaders who were randomly selected from constructed lists representing 8 types of organizations: health, education, law enforcement, media, government, business, ethnic, and youth. Hierarchical regression analysis was used to identify predictors of support for and participation in tobacco control activities. RESULTS: Approximately one half to two thirds of opinion leaders supported the tobacco control policies queried; 60% reported involvement in tobacco control-related activities during the previous year. Organizational affiliation was a strong predictor of support and involvement, with leaders from health and educational organizations reporting the highest levels and business and media leaders reporting the lowest. Tobacco issue involvement variables (e.g., having a friend or family member with a smoking-related illness) were significantly associated with the outcomes, while sociodemographics, for the most part, were not. CONCLUSIONS: Study results can be used to mobilize opinion leaders' support for tobacco control more effectively.

Longitudinal effects of integrated treatment on alcohol use for persons with serious mental illness and substance use disorders.

A randomized experimental design was used to assign participants to an integrated mental health and substance use treatment program or to standard hospital treatment. A multilevel, nonlinear model was used to estimate hospital treatment effects on days of alcohol use for persons with serious mental illness and substance use disorders over 18 months. The integrated treatment program had a significant effect on the rate of alcohol use at 2 months postdischarge, reducing the rate of use by 54%. Motivation for sobriety at hospital discharge, posttreatment self-help attendance, and social support for sobriety were also found to reduce the rate of use during the follow-up period. Implications for mental health treatment and aftercare support are discussed.

The relationship between home smoking bans and exposure to state tobacco control efforts and smoking behaviors.

PURPOSE: To examine the relationship between home smoking bans and adult smokers' exposure to the statewide California Tobacco Control Program (TCP) and their cigarette smoking behavior. DESIGN: Cross-sectional survey that was part of the statewide Independent Evaluation of the California Tobacco Control, Prevention and Education Program. SETTING: Random telephone interviews within 18 California counties. SUBJECTS: A representative sample of 1315 adult smokers, aged 25 years and older. MEASURES: The telephone survey included questions about smoking behavior, quitting smoking, exposure to tobacco control program components, home smoking rules, and attitudes related to tobacco use and environmental tobacco smoke (ETS). RESULTS: Smokers with a home smoking ban were twice as likely (OR = 2.29; 95% CI 1.22, 4.29) to have heard of TCP community programs and three times more likely (OR = 3.18; 95% CI 1.34, 7.57) to have seen and talked about the ETS media spot than smokers with no home smoking policy. Multivariate regression models indicated that having a home smoking ban was related to smoking fewer cigarettes per day and greater interest in quitting smoking compared with smokers with no smoking rules in the home (p < .05). CONCLUSIONS: These findings suggest that smokers reporting exposure to the California TCP were more likely to have restrictive home smoking policies and that more restrictive home smoking policies were associated with reduced smoking behavior.

Smoking bans in the home and car: Do those who really need them have them?

BACKGROUND: This paper addresses the question of whether individuals who are most in need of household and car smoking bans, such as individuals with children living at home or who have many friends who smoke, are the ones who have them. METHOD: A representative sample of 6985 California adults ages 18 and older participated in telephone interviews. RESULTS: Overall, 76% of adults report having home smoking bans and 66% have car smoking bans. Being a smoker or African American, not having children in the home, having more friends who smoke, and lower household income were associated with lower prevalence of both home and car smoking bans (P < 0.01). In multivariate analyses, nonsmokers were 7.9 (95% CI = 3.56, 17.31) times more likely to have a home smoking ban when none of their friends were smokers compared to when most of their friends were smokers. Among smokers, there was an interaction between having children at home and the proportion of friends who smoke. Only 27 to 55% of smokers had home smoking bans unless most of their friends were smokers, then the odds of having a ban were 6.1 (95% CI = 2.76, 13.68) times higher for smokers with children (67% with home bans) than for smokers without children at home (25% with home bans). CONCLUSIONS: Efforts to increase home and car smoking bans for nonsmokers who have friends who smoke and smokers with children living at home are needed.

Do blue-collar workers perceive the worksite health climate differently than white-collar workers?

A mail survey was distributed to a random sample of 497 both blue- and white-collar workers employed at a large manufacturing company to measure dimensions of worksite health climate: organizational and interpersonal support, and health norms. Statistically significant differences were observed for nearly all aspects of the dimensions with white-collar workers having more positive perceptions than blue-collar workers. The study suggests that future research explore how these perceptions may be enhanced and what role they may play in promoting worker health.

Which adults do underaged youth ask for cigarettes?

OBJECTIVES: This study identified adults' demographic and smoking behavior characteristics that are related to being asked to provide tobacco to a minor. METHODS: Telephone interviews were conducted with 6352 California adults. Predictors included age, sex, household income, and smoking status. RESULTS: Only 10.1% of California adults had been asked to provide tobacco to a minor in the previous year. Fewer than 3% of individuals 55 years and older had been asked to provide tobacco, but among younger smokers 59.0% of 18- and 19-year-olds and 39.3% of 20- to 24-year-olds had been approached. CONCLUSIONS: Interventions to reduce the social availability of tobacco are needed.