Restricting Sales of Menthol Tobacco Products: Lessons Learned from Policy Passage and Implementation in Minneapolis, St. Paul, and Duluth, Minnesota.

Purpose: Commercial tobacco products have historically been target marketed to African American, Latinx, Asian American Pacific Islander, Indigenous, and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) communities, as well as to youth. Menthol cigarettes increase smoking initiation and decrease smoking cessation, particularly among African Americans who smoke menthol cigarettes at higher rates than their white peers. Due to disproportionate tobacco-related health consequences for members of these communities, effective tobacco control policies that restrict availability of menthol products by focusing on retail sales are an important element of addressing health disparities, and require policy efforts informed by leadership and the voice of communities most impacted. This study examines the organizing efforts of three successful policy initiatives in 2017-2018 in Minneapolis, St. Paul, and Duluth, Minnesota, and identifies facilitators and barriers of these campaigns. Methods: We conducted 50 key informant interviews with city council/staff, advocates, and community members and analyzed them for emerging themes. The analysis employed a process-oriented qualitative matrix process to identify emerging themes and divergent perspectives. Results: Following policy implementation, outlets selling commercial menthol tobacco products substantially decreased. Facilitators included strong city council support, leadership from impacted communities, community awareness-building campaigns, and understanding tobacco industry counter-tactics. Challenges included the need to counter tobacco industry misinformation and retailer attempts to circumvent the intent of restrictions. Conclusion: Well-planned advocacy campaigns led by community members most impacted by commercial tobacco can overcome opposition and challenges to restrict sales of menthol tobacco products and successfully reduce availability of these products in their communities.

Local sales restrictions significantly reduce the availability of menthol tobacco: findings from four Minnesota cities.

BACKGROUND: In 2017 and 2018, Minneapolis, St. Paul, Duluth and Falcon Heights, Minnesota were among the first US cities to restrict the sale of menthol tobacco to adult-only stores. The study examined changes in the availability and marketing of these products following policy implementation. METHODS: Retail store audits were conducted approximately 2 months pre-policy and post-policy implementation. Tobacco retail stores (n=299) were sampled from tobacco licensing lists in Minneapolis, St. Paul, Duluth and Falcon Heights, as well as six comparison cities without menthol policies. The presence of menthol tobacco was assessed, along with the number of interior and exterior tobacco ads and promotions at each store. RESULTS: The majority of policy intervention stores (grocery, convenience stores and pharmacies) were compliant (Minneapolis, 84.4%; Duluth, 97.5%; and St. Paul and Falcon Heights, 100.0%) and did not sell menthol tobacco. In contrast, menthol tobacco was available in all comparison city stores, and most (96.0%) exempted tobacco shops and liquor stores post-policy implementation. Two Minneapolis convenience stores added interior tobacco shops, allowing them to continue selling menthol tobacco. Significant decreases in menthol tobacco marketing post-policy were observed in the stores' interior in Minneapolis, St. Paul and Duluth (p<0.001) and on the stores' exterior in Duluth (p=0.023). CONCLUSIONS: Findings demonstrate high rates of compliance, indicating that sales restrictions can significantly reduce the availability of menthol tobacco. However, challenges to policy adherence underscore the need for continued monitoring and enforcement action.

A tale of two cities: exploring the retail impact of flavoured tobacco restrictions in the twin cities of Minneapolis and Saint Paul, Minnesota.

BACKGROUND: Flavoured tobacco is increasingly popular with youth. The twin cities of Minneapolis and Saint Paul, Minnesota restricted the sale of flavoured tobacco to adult-only tobacco shops in an effort to reduce youth access and exposure to these products. This observational study explores the impact of these policies on the retail environment. METHODS: Between November 2015 and April 2017, observational assessments were conducted at convenience and grocery stores preimplementation and postimplementation of flavoured tobacco restrictions in Minneapolis (n=41), Saint Paul (n=37) and the comparison city of Brooklyn Park, Minnesota (n=14). RESULTS: After policy implementation, significantly fewer of the convenience and grocery stores sold flavoured tobacco in Minneapolis (85.4% vs 39.0%, p<0.001, n=41) and Saint Paul (97.3% vs 8.1%, p<0.001, n=37). The average proportion of tobacco inventory that was unflavoured increased significantly in Minneapolis (42.9%±2.7% vs 56.7%±3.1%, p=0.002) and Saint Paul (40.8%±2.5% vs 70.3%±1.9%, p<0.001). Flavoured tobacco was available at significantly fewer convenience and grocery stores in Minneapolis (39.0%, p<0.001) and Saint Paul (8.1%, p<0.001) than in the comparison city of Brooklyn Park (100%, n=14). Most retailers complied with these policies by removing flavoured tobacco from their shelves. CONCLUSIONS: Policies that restrict the sale of flavoured tobacco to adult-only tobacco shops are associated with decreased availability of flavoured tobacco in convenience and grocery stores and increased proportion of tobacco inventory that is unflavoured.

Effectiveness of Local Policy Efforts to Increase the Price of Cheap Cigars in Minnesota.

OBJECTIVES: To evaluate the effect of novel policies designed to increase cheap cigar prices by setting minimum prices at the local level. METHODS: Between June 2013 and July 2015, we conducted assessments at tobacco retailers in Minnesota cities of Brooklyn Center (n = 26 in sample; n = 18 assessed before and after policy implementation), Saint Paul (n = 25 in sample; n = 14 assessed pre- and postpolicy), and Maplewood (n = 22 in sample; n = 18 assessed pre- and postpolicy), before and after the adoption of policies setting minimum cigar pricing. RESULTS: After policy implementation across all cities (n = 50), significantly fewer retailers sold single cigars (46% vs 80%; P < .01) and 2- or 3-packs (52% vs 74%; P = .01). In Saint Paul and Maplewood, the average price of the cheapest available single cigars increased significantly by $1.17 (P = .03) and $1.27 (P < .01), respectively; the average price of the cheapest 2-pack increased by $2.46 (P = .02) in Saint Paul and by $3.08 (P < .01) in Maplewood. Policy compliance was high in all cities. CONCLUSIONS: This study highlights the potential of policies setting minimum cigar prices to decrease cigar availability and increase price through nontax approaches. Results indicate that these policies are successful in cities of various sizes.

Reaching consumers: How the tobacco industry uses email marketing.

Tobacco companies are restricted from engaging in many traditional forms of marketing. Direct marketing is one way tobacco companies can reach consumers while complying with regulation and avoiding negative public perception. There is little research on this type of opt-in marketing, which includes mail marketing, email marketing, web marketing, and mobile marketing, and its impact is not well understood. This study examined 6990 tobacco company emails received by individuals living in the state of Minnesota, US between January 2010 and May 2015 to determine email frequency by brand. These emails were gathered as part of ongoing surveillance of tobacco industry direct marketing. A subset of these emails received between October 2014 and May 2015 (n = 1646) were content analyzed to identify the purpose of the email communication along with type of product promoted. Tobacco companies use email to communicate with consumers on a regular basis. This communication was observed to be as frequent as nine times per month. Emails are most commonly used to promote contests (54.1%), content on tobacco company websites (39.1%), and tobacco coupons (15.7%). Email promotion of menthol-flavored tobacco products was common and was associated with promotion of coupons. Emails promoting menthol had a 1.9 times higher prevalence of also promoting coupons (95% CI: 1.52-2.37). Little is known about tobacco company email marketing and this study fills an identified research gap. A deeper understanding of this type of marketing is needed in order to counter tobacco industry messaging and advance tobacco control.

Tobacco product prices before and after a statewide tobacco tax increase.

BACKGROUND: In 2013, the State of Minnesota Legislature passed a tobacco tax increase that increased the combined cigarette excise and sales tax by US$1.75 (from US$1.60 to US$3.35) and increased the tax on non-cigarette tobacco products from 70% to 95% of the wholesale price. The current study explores the change in tobacco prices in retail locations and whether the tax increase was fully passed to consumers. METHODS: An observational study of tobacco retail prices was performed in a sample of 61 convenience stores in Minnesota, North Dakota, South Dakota and Wisconsin. Six rounds of data were collected between May 2013 and January 2014. In each round, purchases were made at the same stores for the same four tobacco products (Camel Blue cigarettes, Marlboro Gold cigarettes, Grizzly Wintergreen moist smokeless tobacco and Copenhagen Wintergreen moist smokeless tobacco). RESULTS: For all studied tobacco products, prices in Minnesota increased significantly after the tax increase (Round 1-Round 6). After controlling for price changes in neighbouring states, the average price difference in Minnesota for the two cigarette brands increased by US$1.89 and US$1.81, which are both more than the US$1.75 tax increase. For moist smokeless, the average price difference increased by US$0.90 and US$0.94. Significant price changes were not observed in the comparison states. After the introduction of the minimum moist smokeless tax, a significantly higher proportion of Minnesota stores offered price promotions on smokeless tobacco. CONCLUSIONS: A large tobacco tax resulted in an average retail cigarette price exceeding the tax, suggesting the industry over-shifted the cigarette tax increase to consumers in Minnesota. The findings support the known public health benefit of tobacco tax increases while highlighting the need for additional information about how, or if, tobacco companies use price promotions to blunt the impact of tax increases.

Higher price, fewer packs: evaluating a tobacco tax increase with cigarette sales data.

In 2013, Minnesota increased cigarette taxes by $1.75, the largest US state increase since 2000. We obtained convenience store data of cigarette sales from January 2012 to December 2013 from the Nielsen Company. Analysis revealed significantly greater year-to-year reductions in numbers of packs purchased during posttax (-12.1%) than pretax (-3.2%; P<.001) periods. The results provide contemporary evidence that, despite reduced prevalence and increased tobacco control efforts, tax increases remain an effective tobacco control strategy.

Tobacco industry marketing: an analysis of direct mail coupons and giveaways.

BACKGROUND: Despite marketing prohibitions, tobacco company marketing expenditures in the USA have continued to grow with tobacco companies shifting focus towards point-of-sale-marketing and direct marketing to consumers through the mail and on the web. The purpose of this observational study was to investigate the content of direct marketing sent in response to registrations on select industry websites. METHODS: An analysis of 659 tobacco company direct mail marketing pieces received between July 2011 and June 2012 was conducted. Mailings were coded for type and value of tobacco coupons, type of tobacco products promoted with coupons and number and type of giveaways offered. RESULTS: The most common type of mailing was tobacco coupon distribution; 86.5% of the mailings contained at least one coupon. Mailings with coupons had an average estimated coupon value of $4.17. The total coupon value of each mailing varied by the type of coupon offer and product promoted. The Camel and Marlboro coupon mailings heavily promoted snus, with over half of Camel coupon mailings (60.9%) and nearly half (44.8%) of Marlboro coupon mailings promoting snus alone. In addition, 47.9% of Marlboro coupon mailings and 11.4% of Camel mailings promoted snus alongside cigarettes. DISCUSSION: Tobacco companies use direct mail marketing to communicate with consumers and provide valuable tobacco coupons. More research is needed to understand the content of these mailings and how they are used by tobacco consumers in order to develop effective policy solutions.

Availability of snus and its sale to minors in a large Minnesota city.

INTRODUCTION: Previous studies examining tobacco retailers' compliance with youth tobacco access policies have mostly evaluated retailers' likelihood of selling cigarettes to minors, and none have evaluated the likelihood of selling snus (a new smokeless tobacco product) to minors. We assessed the availability of snus and the likelihood of selling snus to adolescents in tobacco retailers in a large city in Minnesota. METHODS: We randomly selected 71 eligible retailers located in a large city in Minnesota, and assessed the availability of snus through Camel snus retailer listings and phone inquiry. Purchase attempts by an underage buyer were used to assess the likelihood of selling snus to minors. χ2 tests were used to examine the store and neighbourhood characteristics associated with availability of snus. RESULTS: We found that 31 retailers (43.7%) carried snus in the store, and 4 (12.9%) sold snus to the underage buyer. Retailers who sold gasoline were more likely to carry snus in the store (p<0.01). Neighbourhood demographic characteristics were not associated with availability of snus (p>0.10). CONCLUSIONS: Prevalence of snus sales to minors appeared to be higher than that of cigarette sales to minors according to the 2011 Synar report. Futures studies are needed to determine whether tobacco retailers are more likely to sell snus than cigarettes to minors. Interventions such as public and retailer policies are needed to reduce the likelihood of tobacco retailers selling snus to minors.

The relationship of neighborhood demographic characteristics to point-of-sale tobacco advertising and marketing.

OBJECTIVES: Exposure to tobacco marketing has been associated with an increased likelihood that youth start smoking and may interfere with tobacco cessation. We aimed to describe the prevalence, placement, and features of tobacco advertising at the point of sale by race, ethnicity, and other neighborhood demographics, as well as by store type. DESIGN: A cross-sectional assessment of the advertising environment in establishments that held tobacco licenses in our study region (a metropolitan area in the Midwest USA) was conducted in 2007. Stores were geocoded and linked with block group demographic data taken from the Year 2000 US census. We calculated associations between our hypothesized predictors, race, ethnicity, and other neighborhood demographics, and two types of outcomes (1) amount and (2) characteristics of the advertising. RESULTS: Tobacco advertising at the point of sale was most common in gas stations/convenience stores, liquor stores, and tobacco stores. A 10% difference in a block group's African-American/Black population was associated with 9% (95% confidence interval [CI]=3%, 16%) more ads as well as a greater likelihood that ads would be close to the ground (prevalence ratio [PR]=1.15 [95% CI=1.04, 1.28]). Block groups with greater African-American/Black, Asian, people on public assistance or below 150% of the poverty threshold, or people under the age of 18 years had more ads for menthol brands. Block groups with greater proportions of Whites were more likely to have ads that used health words, such as 'light' or 'natural' (PR for 10% difference in White population=1.41 [95% CI=1.17-1.70]). Chain stores were more likely to have greater amounts of advertising, ads close to the ground, ads for price deals, or ads that use words that imply health. CONCLUSION: Tobacco advertising targets communities with various racial and ethnic profiles in different ways. Now that US Food and Drug Administration has the authority to regulate the marketing and sale of tobacco products, there is new opportunity to reduce the harmful impact of tobacco advertising.

Secondhand smoke and smokefree policies in owner-occupied multi-unit housing.

BACKGROUND: Studies have documented movement of secondhand smoke (SHS) between units in multi-unit buildings, but none has focused on owner-occupied units in common-interest communities (CICs). In Minnesota, approximately 170,000 households (8%) live in such units. CIC households may experience long-term SHS exposure because owner-occupants typically live in the same unit for many years. PURPOSE: This study estimated the prevalence of SHS incursion in CICs and assessed residents' attitudes toward SHS incursions and interest in smokefree policies. METHODS: A stratified sample of Minnesota CIC owner-occupants was surveyed in 2009, with analysis in 2010-2011. Data were weighted to account for differing sampling, response, and coverage rates by stratum, then calibrated to population control totals for housing type, age, and smoking status. RESULTS: The response rate was 35.6%, with 495 completions. Twenty-eight percent of households reported SHS incursion into their unit in the preceding 6 months; 59% of these said this bothers them a lot. Only 6% report that their CIC has a smokefree policy for residents' units. Forty-two percent would prefer such a policy whereas 26% would prefer smoking-permitted. Sixty-three percent definitely and 17% probably would choose a no-smoking building over a smoking-permitted building if they were buying a new unit, and 46% would be willing to pay more for such a unit. CONCLUSIONS: Secondhand smoke incursion is common in CICs, and interest in smokefree CICs greatly exceeds the supply. Given the known health risks of SHS exposure, tobacco control efforts in multi-housing should address CICs as well as rental households.

The relationship of point-of-sale tobacco advertising and neighborhood characteristics to underage sales of tobacco.

Our objective was to determine how point-of-sale tobacco marketing may relate to sales to minors. The authors used data from a 2007 cross-sectional study of the retail tobacco marketing environments in the St. Paul, MN metropolitan area matched with a database of age-of-sale compliance checks (random, covert test purchases by a minor, coordinated by law enforcement) of tobacco retailers and U.S. Census data to test whether certain characteristics of advertising or neighborhoods were associated with compliance check failure. The authors found that tobacco stores were the most likely type of store to fail compliance checks (44% failure), supermarkets were least likely (3%). Aside from a marginally significant association with Hispanic population proportion, there was no other association between either store advertising characteristics or neighborhood demographics and stores' compliance check failure. Though our findings were null, the relationship between advertising and real youth sales may be more nuanced as compliance checks do not perfectly simulate the way youth attempt to purchase cigarettes.

Smokeless tobacco advertising at the point of sale: prevalence, placement, and demographic correlates.

INTRODUCTION: We aimed to describe the prevalence, in-store location, and neighborhood predictors of point-of-sale smokeless tobacco advertising. METHODS: In 2007, we conducted assessments of smokeless tobacco advertising at the point of sale in 484 establishments, which held tobacco licenses and sold tobacco products in a Midwest metropolitan area. Associations between store characteristics, neighborhood characteristics (based on U.S. 2000 census block groups), and smokeless tobacco advertising were calculated. RESULTS: Advertisements for smokeless tobacco were found in 21% (n = 103) of stores. Approximately, 12% (n = 58) of stores had ads within 6 feet of the counter, 3% (n = 14) had ads less than 3 feet from the ground, and 2% (n = 9) had advertisement less than 1 foot from candy or snacks. The racial/ethnic composition and number of households on public assistance within the block group in which a store was situated were related to the amount of smokeless advertising in stores. For instance, having a higher proportion of the population identifying as White was associated with more advertising. Gas stations/convenience stores had more advertising than any other store types. Chain stores had double the amount of advertising as independent stores (p < .05) even after adjustment for other factors. CONCLUSIONS: Smokeless tobacco advertising is not uncommon even in an urban metropolitan community. These products are being advertised in a way that youth, especially those living in neighborhoods with certain demographic characteristics, can encounter. With Food and Drug Administration regulation, there are new opportunities to regulate advertising at the point of sale.

Talking to Iraq and Afghanistan war veterans about tobacco use.

INTRODUCTION: Our goal in this study was to examine beliefs and attitudes about tobacco use in the newest generation of combat veterans, those who served in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]). METHODS: We held 5 focus groups (n = 17) with Minnesota Army National Guard soldiers who had recently returned from combat deployment in support of OEF/OIF. Sessions were audiorecorded, transcribed, coded, and analyzed using a grounded theory approach. RESULTS: We found that it is common to use tobacco in the combat zone for stress and anger management and boredom relief. Tobacco was also a tool for staying alert, a way to socialize, and provided a chance to take breaks. Participants recognized the culture of tobacco use in the military. Stress, nicotine dependence, the tobacco environment at drill activities, and perceived inaccessibility of cessation tools perpetuated use at home and served as a barrier to cessation. Repeatedly, participants cited tobacco policies (such as increased taxes and smoke-free workspaces) as motivators for quitting. CONCLUSIONS: There are specific circumstances common to combat zones that promote tobacco use. Results suggest that environmental changes that address the prominence of tobacco in military culture, the acceptance of nonsmoking breaks, and cessation programs that address stress issues and make cessation aids available may be effective in reducing tobacco use.