Neighborhood racial, ethnic, and income disparities in accessibility to multiple tobacco retailers: Mecklenburg County, North Carolina, 2015.

•Existing studies assess an individual's proximity to a single tobacco retailer.•Measuring proximity to more than one retailer may better capture accessibility.•Disparities in multi-retailer proximity exist by neighborhood race and income.•Policies to address disparities in tobacco retailer exposure are needed.

Tapping Into Multiple Data "Springs" to Strengthen Policy Streams: A Guide to the Types of Data Needed to Formulate Local Retail Tobacco Control Policy.

In 2015, the tobacco industry spent $8.24 billion to market tobacco products in convenience stores, supermarkets, pharmacies, and other retail or point-of-sale settings. Community tobacco control partnerships have numerous evidence-based policies (eg, tobacco retailer licensing and compliance, tobacco-free-school buffer zones, eliminating price discounts) to counter point-of-sale tobacco marketing. However, deciding which point-of-sale policies to implement - and when and in what order to implement them - is challenging. The objective of this article was to describe tools and other resources that local-level tobacco use prevention and control leaders can use to assemble the data they need to formulate point-of-sale tobacco policies that fit the needs of their communities, have potential for public health impact, and are feasible in the local policy environment. We were guided by Kingdon's theory of policy change, which contends that windows of policy opportunity open when 3 streams align: a clear problem, a solution to the problem, and the political will to work for change. Community partnerships can draw on 7 data "springs" to activate Kingdon's streams: 1) epidemiologic and surveillance data, 2) macro retail environment data, 3) micro retail environment data, 4) the current policy context, 5) local legal feasibility of policy options, 6) the potential for public health impact, and 7) political will.

Tobacco Marketing at SNAP- and WIC-Authorized Retail Food Stores in the United States.

Background. Lower-income families in the United States are at increased risk for food insecurity and have higher rates of tobacco use. Many retailers accepting government food assistance benefits also sell tobacco products, whose marketing promotes smoking initiation and undermines quit attempts. We examined the presence of tobacco marketing in authorized retailers in the Supplemental Nutrition Assistance Program (SNAP) and/or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), compared with nonauthorized retailers. Method. A nationally representative sample of tobacco retailers in the contiguous United States (N = 2,054) were audited for tobacco marketing in 2015. Using generalized estimating equations, we examined the association between WIC and SNAP authorization and presence of tobacco marketing, adjusted for store type and neighborhood demographics. Results. Both WIC-authorized (odds ratio [OR] 1.7, 95% confidence interval [CI] [1.1, 2.4]) and SNAP-authorized retailers (OR 2.3, 95% CI [1.7, 3.1]) had greater odds of displaying interior tobacco price promotions, compared with stores that were not WIC/SNAP authorized. SNAP-authorized stores (compared with nonauthorized) had almost 3 times greater odds of displaying interior tobacco advertisements (OR 2.9, 95% CI [1.9, 4.5]), while WIC-authorized retailers had 80% lower odds of displaying exterior tobacco advertisements (OR 0.2, 95% CI [0.1, 0.3]). Conclusion. Millions of lower-income American families may be disproportionately exposed to tobacco marketing at food retailers. Federal, state, and local policies could create healthier retail environments by restricting the marketing and availability of tobacco products and increasing promotions and access to healthy food options.

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.

State-Level Point-of-Sale Tobacco News Coverage and Policy Progression Over a 2-Year Period.

BACKGROUND: Mass media content may play an important role in policy change. However, the empirical relationship between media advocacy efforts and tobacco control policy success has rarely been studied. We examined the extent to which newspaper content characteristics (volume, slant, frame, source, use of evidence, and degree of localization) that have been identified as important in past descriptive studies were associated with policy progression over a 2-year period in the context of point-of-sale (POS) tobacco control. METHOD: We used regression analyses to test the relationships between newspaper content and policy progression from 2012 to 2014. The dependent variable was the level of implementation of state-level POS tobacco control policies at Time 2. Independent variables were newspaper article characteristics (volume, slant, frame, source, use of evidence, and degree of localization) and were collected via content analysis of the articles. State-level policy environment contextual variables were examined as confounders. RESULTS: Positive, significant bivariate relationships exist between characteristics of news content (e.g., high overall volume, public health source present, local quote and local angle present, and pro-tobacco control slant present) and Time 2 POS score. However, in a multivariate model controlling for other factors, significant relationships did not hold. DISCUSSION: Newspaper coverage can be a marker of POS policy progression. Whether media can influence policy implementation remains an important question. Future work should continue to tease out and confirm the unique characteristics of media content that are most associated with subsequent policy progression, in order to inform media advocacy efforts.

Attitudes towards Potential New Tobacco Control Regulations among U.S. Adults.

Favorable attitudes towards tobacco control policies can facilitate their implementation and success. We examined attitudes toward four potential U.S. Federal tobacco regulations (banning menthol from cigarettes, reducing nicotine levels in cigarettes, banning candy and fruit flavored electronic cigarettes, and banning candy and fruit flavored little cigars and cigarillos) and associations with individual and state variables. A nationally representative phone survey of 4337 adults assessed attitudes toward potential policies. Weighted logistic regression was used to assess relationships between attitudes and demographic factors, smoking behavior, beliefs about the government (knowledge, trust, and credibility), exposure to tobacco control campaigns, and state variables from the US Centers for Disease Control and Prevention (CDC) State Tobacco Activities Tracking and Evaluation (STATE) System. Most respondents supported three out of four policies. Respondents that were female, non-white, Latino, living below the poverty line, had less than high school education, were of older age, did not smoke, had higher trust in government, and were exposed to national tobacco control campaigns had higher odds of expressing favorable attitudes toward potential new tobacco regulations than did their counterparts. No state-level effects were found. While differences in attitudes were observed by individual demographic characteristics, behaviors, and beliefs, a majority of participants supported most of the potential new tobacco regulations surveyed.

Should the Legal Age for Tobacco Be Raised? Results From a National Sample of Adolescents.

Raising the minimum age of legal access to tobacco products may reduce smoking initiation and save lives. In a national telephone survey (2014-2015), US adolescents aged 13 to 17 years (N = 1,125; response rate, 66%) were asked about raising the age of legal access to tobacco products and randomized to hear one of 3 ages (19, 20, or 21 y). Most adolescents, across all US regions, favored raising the minimum age of legal access to 19 (75.7%), 20 (80.6%), or 21 (76.4%). These supportive attitudes may be useful to tobacco prevention and control practitioners who seek to reduce tobacco use among adolescents.

Setting the agenda for a healthy retail environment: content analysis of US newspaper coverage of tobacco control policies affecting the point of sale, 2007-2014.

BACKGROUND: Tobacco control policies affecting the point of sale (POS) are an emerging intervention, yet POS-related news media content has not been studied. PURPOSE: We describe news coverage of POS tobacco control efforts and assess relationships between article characteristics, including policy domains, frames, sources, localisation and evidence present, and slant towards tobacco control efforts. METHODS: High circulation state (n=268) and national (n=5) newspapers comprised the sampling frame. We retrieved 917 relevant POS-focused articles in newspapers from 1 January 2007 to 31 December 2014. 5 raters screened and coded articles, 10% of articles were double coded, and mean inter-rater reliability (IRR) was 0.74. RESULTS: POS coverage emphasised tobacco retailer licensing (49.1% of articles) and the most common frame present was regulation (71.3%). Government officials (52.3%), followed by tobacco retailers (39.6%), were the most frequent sources. Half of articles (51.3%) had a mixed, neutral or antitobacco control slant. Articles presenting a health frame, a greater number of protobacco control sources, and statistical evidence were significantly more likely to also have a protobacco control slant. Articles presenting a political/rights or regulation frame, a greater number of antitobacco control sources, or government, tobacco industry, tobacco retailers, or tobacco users as sources were significantly less likely to also have a protobacco control slant. CONCLUSIONS: Stories that feature procontrol sources, research evidence and a health frame also tend to support tobacco control objectives. Future research should investigate how to use data, stories and localisation to encourage a protobacco control slant, and should test relationships between content characteristics and policy progression.

Diagnosis and Management of Ovarian Cancer.

Ovarian cancer is the most lethal gynecologic cancer. Less than one-half of patients survive for more than five years after diagnosis. Ovarian cancer affects women of all ages but is most commonly diagnosed after menopause. More than 75% of affected women are diagnosed at an advanced stage because early-stage disease is usually asymptomatic and symptoms of late-stage disease are nonspecific. The strongest risk factors are advancing age and family history of ovarian and breast cancer. Women who have symptoms concerning for ovarian cancer should undergo a physical examination, transvaginal ultrasonography, and measurement of biomarkers such as cancer antigen 125. If results are suspicious for ovarian cancer, the patient should be referred to a gynecologic oncologist. Despite the low rate of early diagnosis, guidelines recommend against routine screening for ovarian cancer in average-risk women because screening, including routine pelvic examinations, is ineffective and associated with harm. However, a recent trial found a potential benefit of annual screening using an algorithm based on serial cancer antigen 125 measurements followed by transvaginal ultrasonography for women at increased risk, as determined by the algorithm. Women with an increased-risk family history should be referred for genetic counseling and, if genetic mutations (e.g., BRCA mutations) are identified, bilateral salpingo-oophorectomy can be considered for risk reduction. In both average- and high-risk women, long-term hormonal contraceptive use reduces risk by about 50%. The treatment of ovarian cancer usually involves surgery, with or without intraperitoneal and intravenous chemotherapy. Primary care physicians have important roles in posttreatment surveillance and end-of-life care.

Integrating Tobacco Control and Obesity Prevention Initiatives at Retail Outlets.

Tobacco products are sold in approximately 375,000 US retail outlets, including convenience stores and pharmacies, which often sell energy-dense, low-nutrient foods and beverages. The Food and Drug Administration's (FDA's) increased authority over tobacco product sales and marketing, combined with declining smoking rates, provides an opportunity to transition tobacco retailers toward healthier retail environments. Unfortunately, research into improving consumer retail environments is often conducted in isolation by researchers working in tobacco control, nutrition, and physical activity. Interdisciplinary efforts are needed to transform tobacco retailers from stores that are dependent on a declining product category, to the sale and promotion of healthful foods and creating environments conducive to active living. The objective of this article is to describe the potential for interdisciplinary efforts to transition retailers away from selling and promoting tobacco products and toward creating retail environments that promote healthful eating and active living.

A comparison of three policy approaches for tobacco retailer reduction.

BACKGROUND: The Institute of Medicine recommends that public health agencies restrict the number and regulate the location of tobacco retailers as a means of reducing tobacco use. However, the best policy strategy for tobacco retailer reduction is unknown. PURPOSE: The purpose of this study is to test the percent reduction in the number and density of tobacco retailers in North Carolina resulting from three policies: (1) prohibiting sales of tobacco products in pharmacies or stores with a pharmacy counter, (2) restricting sales of tobacco products within 1000 ft of schools, and (3) regulating to 500 ft the minimum allowable distance between tobacco outlets. METHODS: This study uses data from two lists of tobacco retailers gathered in 2012, one at the statewide level, and another "gold standard" three-county list. Retailers near schools were identified using point and parcel boundaries in ArcMap. Python programming language generated a random lottery system to remove retailers within 500 ft of each other. Analyses were conducted in 2014. RESULTS: A minimum allowable distance policy had the single greatest impact and would reduce density by 22.1% at the state level, or 20.8% at the county level (range 16.6% to 27.9%). Both a pharmacy and near-schools ban together would reduce density by 29.3% at the state level, or 29.7% at the county level (range 26.3 to 35.6%). CONCLUSIONS: The implementation of policies restricting tobacco sales in pharmacies, near schools, and/or in close proximity to another tobacco retailer would substantially reduce the number and density of tobacco retail outlets.

Disseminating policy and environmental change interventions: insights from obesity prevention and tobacco control.

BACKGROUND: Public health and other practitioners increasingly are being asked to implement policy and environmental change interventions, yet many practitioners lack the knowledge, skills, and resources to do so. In response to this need, a growing number of organizations are disseminating evidence-based interventions (EBIs) and building practitioners' capacity to use those interventions in practice. Although advances have been made on approaches to disseminating individual-level EBIs, little is known about the optimal way to disseminate EBIs to promote policy and environmental change. PURPOSE: This paper describes the approach that two projects developed to disseminate policy and environmental change interventions. The Center for Training and Research Translation (Center TRT) disseminates EBIs to promote physical activity and healthy eating. Counter Tobacco disseminates EBIs to counter tobacco product sales and marketing in the retail environment. METHOD: Both Centers (1) identify the best available evidence, (2) disseminate menus of intervention strategies, (3) provide implementation guidance, (4) incorporate stories from the field, (5) build practitioners' capacity, and (6) integrate dissemination into practitioners' existing social networks. The Centers' process evaluations included website analytics and online surveys. RESULT: Over 26,000 unique visitors accessed the Center TRT website in 2012 and over 17,000 have accessed Counter Tobacco's site since its launch in August 2011. The majority of respondents to Centers' surveys agreed that resources were easy to access and use. CONCLUSION: Both Centers have had success reaching their intended audiences. Research is now needed to assess the extent of practitioners' use of Center resources and the impact of the resulting interventions.

Surveillance of tobacco retail density in Beirut, Lebanon using electronic tablet technology.

BACKGROUND: Lebanon has alarmingly high rates of tobacco use. The objective of this study is to examine the density of tobacco retail outlets and distance to schools as well as to survey retail pricing in a large district of Beirut, Lebanon. FINDINGS: We observed 100 tobacco retail outlets and collected data using iPad® technology. Store locations were recorded with Global Positioning System coordinates. The distances between all pairs of tobacco retail outlets and all schools were calculated. For 52% of tobacco outlets, the nearest distance to other tobacco retail outlets was < 50 meters and 17% were within a 100-meter radius of a school. We found a high proportion of tobacco retailers with close proximity to schools. The overall retailer density was 1.25 stores per 1,000 people. CONCLUSIONS: These findings call for additional regulation including the establishment of strict density standards.

A systematic review of store audit methods for assessing tobacco marketing and products at the point of sale.

OBJECTIVE: Over four-fifths of reported expenditures for marketing tobacco products occur at the retail point of sale (POS). To date, no systematic review has synthesised the methods used for surveillance of POS marketing. This review sought to describe the audit objectives, methods and measures used to study retail tobacco environments. METHODS: We systematically searched 11 academic databases for papers indexed on or before 14 March 2012, identifying 2906 papers. Two coders independently reviewed each abstract or full text to identify papers with the following criteria: (1) data collectors visited and assessed (2) retail environments using (3) a data collection instrument for (4) tobacco products or marketing. We excluded papers where limited measures of products and/or marketing were incidental. Two abstractors independently coded included papers for research aims, locale, methods, measures used and measurement properties. We calculated descriptive statistics regarding the use of four P's of marketing (product, price, placement, promotion) and for measures of study design, sampling strategy and sample size. RESULTS: We identified 88 store audit studies. Most studies focus on enumerating the number of signs or other promotions. Several strengths, particularly in sampling, are noted, but substantial improvements are indicated in the reporting of reliability, validity and audit procedures. CONCLUSIONS: Audits of POS tobacco marketing have made important contributions to understanding industry behaviour, the uses of marketing and resulting health behaviours. Increased emphasis on standardisation and the use of theory are needed in the field. We propose key components of audit methodology that should be routinely reported.

An observational study of retail availability and in-store marketing of e-cigarettes in London: potential to undermine recent tobacco control gains?

OBJECTIVES: E-cigarette companies and vendors claim the potential of e-cigarettes to help smokers reduce or quit tobacco use. E-cigarettes also have the potential to renormalise smoking. The purpose of this study was to describe the availability and in-store marketing of e-cigarettes in London, UK stores selling tobacco and alcohol. DESIGN: Observational study. SETTING: Small and large stores selling alcohol and tobacco in London, UK. PRIMARY AND SECONDARY OUTCOME MEASURES: The number of stores selling e-cigarettes, the number of stores with an interior or exterior e-cigarette advertisement, the number of stores with an e-cigarette point-of-sale movable display, store size, deprivation index score for store's corresponding lower super output area. RESULTS: Audits were completed in 108 of 128 selected stores. 62 of the audited stores (57%) sold e-cigarettes. E-cigarette availability was unrelated to store size. There was a statistically non-significant trend towards increased availability in more deprived areas (p=0.069). 31 of the 62 stores (50%) selling e-cigarettes had a point-of-sale movable display, with all but one found in small stores. Two small stores had interior advertisements and eight had exterior advertisements. No advertisements were observed in large stores. CONCLUSIONS: This audit revealed widespread availability of e-cigarettes and in-store marketing in London, UK. Even if e-cigarettes prove to be an effective cessation aid, their sale and use are resulting in an increasing public presence of cigarette-like images and smoking behaviour. After decades of work to denormalise smoking, these findings raise the question of whether e-cigarettes are renormalising smoking.

Point-of-sale tobacco advertising in Beirut, Lebanon following a national advertising ban.

BACKGROUND: The objective of this study was to conduct an audit of point-of-sale (POS) tobacco advertising and assess compliance with an advertising ban in a large district of Beirut, Lebanon. METHODS: The audit was conducted 3 months following the ban on tobacco advertising. Trained students observed all tobacco retail outlets (n = 100) and entered data into a web-based form using iPad(®) technology. Presence of tobacco advertisements was assessed to determine compliance with the national advertising ban. RESULTS: Among the 100 tobacco retail outlets, 62% had tobacco advertisements, including 7% with a tobacco brand logo as part of the main exterior store sign. CONCLUSIONS: POS tobacco advertising is widespread in Beirut despite the national advertising ban. These findings point to an urgent need for the enforcement of the advertisement ban with tobacco retail outlets in Lebanon.

Retailer adherence to Family Smoking Prevention and Tobacco Control Act, North Carolina, 2011.

INTRODUCTION: The Family Smoking Prevention and Tobacco Control Act regulates the sales and marketing of tobacco products in the United States; poor adherence by tobacco retailers may reduce the effectiveness of the Act's provisions. The objectives of this study were 1) to assess whether and to which provisions retailers were adherent and 2) to examine differences in adherence by county, retailer neighborhood, and retailer characteristics. METHODS: We conducted multivariate analysis of tobacco retailers' adherence to 12 point-of-sale provisions of the Tobacco Control Act in 3 North Carolina counties. We conducted observational audits of 324 retailers during 3 months in 2011 to assess adherence. We used logistic regression to assess associations between adherence to provisions and characteristics of each county, retailer neighborhood, and retailer. RESULTS: We found 15.7% of retailers did not adhere to at least 1 provision; 84.3% adhered to all provisions. The provisions most frequently violated were the ban on sales of cigarettes with modified-risk labels (eg, "light" cigarettes) (43 [13.3%] retailers nonadherent) and the ban on self-service for cigarettes and smokeless tobacco (6 [1.9%] retailers nonadherent). We found significant differences in rates of nonadherence by county and type of retailer. Pharmacies and drug stores were more than 3 times as likely as grocery stores to be nonadherent. CONCLUSION: Most tobacco retailers have implemented regulatory changes without enforcement by the US Food and Drug Administration. Monitoring rates of adherence by store type and locale (eg, county) may help retailers comply with point-of-sale provisions.