The impact of tobacco promotion at the point of sale: A systematic review

Transcription

1 Nicotine & Tobacco Research, Volume 11, Number 1 (January 2009) Review The impact of tobacco promotion at the point of sale: A systematic review Janine Paynter & Richard Edwards Abstract Introduction: Tobacco promotion increases the likelihood that adolescents will start smoking. Much of the tobacco industry s promotional budget is spent on point of sale (PoS) promotion in many jurisdictions. Consequently, tobacco is an eye-catching feature at the PoS in many places. Methods: We reviewed the evidence that PoS tobacco promotion influences key smoking-related behaviors and beliefs, increases susceptibility to smoking in youth, undermines smokers quit attempts, and promotes relapse among ex-smokers. Results: We found 12 peer-reviewed studies, 10 of which were focused on children. Seven of 8 observational studies found statistically significant associations between exposure to tobacco promotion at the PoS and smoking initiation or susceptibility to smoking. Two experimental studies of children found statistically significant associations between exposure to PoS tobacco promotions and beliefs about ease of getting tobacco and smoking prevalence among their peers. An experimental study with adults found that a picture of collected tobacco pack elicited cravings for cigarettes among smokers. A cross-sectional study found that 25% of adult smokers reported impulse purchasing and a third of recent ex-smokers reported urges to start smoking after seeing tobacco displayed. Discussion: More prospective studies are needed to clarify the temporal relationship between exposure to PoS tobacco and outcome. However, given the addictiveness of tobacco, the severity of the health hazards posed by smoking, the evidence that tobacco promotion encourages children to start smoking, and the consistency of the evidence that PoS promotion influences children s smoking, we believe that ample justification exists for banning PoS advertising and displays of smoked tobacco products. Introduction Published studies consistently show that tobacco promotion increases the likelihood that adolescents will start to smoke ( DiFranza et al., 2006 ; Lovato, Linn, Stead, & Best, 2006 ; Pierce, Choi, Gilpin, Farkas, & Berry, 1998 ). For example, Lovato et al. (2006) reviewed nine longitudinal studies that measured exposure, receptivity, or attitudes to advertising at baseline and followed up with measures of smoking behavior. They found statistically significant evidence that exposure to tobacco promotion increased the odds of smoking initiation by youth in seven of the nine studies. Restricting tobacco promotion is generally accepted to be a key strategy for tobacco control (Article 13 of the World Health Organization Framework Convention on Tobacco Control). Increasing numbers of countries have implemented restrictions on advertising or comprehensive advertising bans in which tobacco promotion is typically banned from print media, radio, television, billboards, and other locations. The tobacco industry s promotional budget has been increasingly spent on point of sale (PoS) promotion and retailer communication ( Bloom, 2001 ; Carter, 2003 ; Feighery, Ribisl, Clark, & Haladjian, 2003 ; Lavack & Toth, 2006 ; Loomis, Farrelly, Nonnemaker, & Mann, 2006 ; Pollay, 2007 ), suggesting that the industry sees this approach as an important marketing strategy. As a consequence of this investment in PoS promotion, tobacco product displays are highly visible at the PoS in many jurisdictions, including the United States, Canada ( Dewhirst, 2004 ), Australia ( Carter, 2003 ), and New Zealand ( Paynter, Freeman, & Hughes, 2006 ; Quedley et al., in press ). In 1987, U.S. retail promotions accounted for 33% (US$856 million) of the promotion budget. This had increased to 43% ($3.54 billion) in 1999 ( Bloom, 2001 ). Recent data from the Federal Trade Commission (2007) reveal that U.S. tobacco firms now spend 85% of their promotional budget in the retail environment. Most of this money (75%) goes to providing discounted prices. PoS advertising expenditures increased from $163.6 million (1.2% of the promotional budget) to $182.2 million (1.4%) in Retailers in the United States are a target for aggressive marketing by tobacco companies, including receiving payments for stocking and displaying tobacco products ( Feighery et al., 2003 ), and evidence indicates that retailers receive significantly more money for displaying tobacco products than they do for other product categories ( Feighery, Ribisl, Achabal, & Tyebjee, 1999 ). About $430 million (3.3% of the promotional budget) was paid to retailers in 2005 to facilitate Janine Paynter, Ph.D., Action on Smoking and Health New Zealand, Auckland, New Zealand Richard Edwards, M.D., Director of Health Promotion and Policy Research Unit, Department of Public Health, University of Otago, Wellington, New Zealand Corresponding Author: Janine Paynter, Action on Smoking and Health New Zealand, Box , Newmarket, Auckland 1149, New Zealand. Telephone: Fax: jpaynter@ ash.org.nz doi: /ntr/ntn002 Received 5 December 2007 ; accepted 3 August 2008 The Author Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please journals.permissions@oxfordjournals.org 25

2 Impact of tobacco promotion at the point of sale the sale or placement of cigarettes (i.e., stocking, shelving, and displays; Federal Trade Commission, 2007 ). Evidence also indicates the considerable investment in PoS activities in other jurisdictions. For example, in Australia, tobacco companies provide display units and considerable assistance with PoS marketing ( Carter, 2003 ). Tobacco company sales representatives provide information about legal aspects of displays and provide display units that orient the packs toward the customer so that the brands are immediately obvious. The industry representatives also assist with placement and arrangement of the display in store. All three Australian tobacco manufacturers frequently advertise in retail trade journals. They promise better service and urge retailers to work with their representatives to maximize retailer profits ( Carter, 2003 ). In New Zealand, which has a comprehensive advertising ban and some restrictions on PoS displays ( Paynter et al., 2006 ), tobacco at the PoS has been described in a retail sector journal as the industry s most important sphere of influence. There were claims in the same article that even these restricted displays succeed in increasing tobacco consumption under the headline: Tobacco still smokes its competition in service stations (Means, 2006 ). Concern about the impact of advertising and tobacco at the PoS has led to the implementation of bans on tobacco displays and advertising at the PoS in several Canadian provinces, Thailand, and Iceland ( Paynter et al., 2006 ). Bans are under consideration in Ireland and UK. Other jurisdictions such as New Zealand and Australia have banned PoS advertising but continue to allow PoS tobacco displays. The concerns are that tobacco pack displays (often called power walls ) are, in effect, tobacco advertising. Tobacco displays are present in the most commonly visited retail environments, such as convenience stores, local stores, mini markets, gas stations, and supermarkets. Children frequently visit convenience stores and supermarkets, and adolescents often work in them ( Henriksen, Feighery, Schleicher, Haladjian, & Fortmann, 2004 ), raising the possibility that PoS tobacco advertising and displays could promote smoking experimentation and uptake among children. This theoretical risk is supported by evidence that tobacco product displays can effectively communicate brand imagery to children ( Cunningham & Kyle, 1995 ; Lavack & Toth, 2006 ; Pollay, 2007 ; Wakefield, Morley, Horan, & Cummings, 2002 ). Even low levels of exposure to brand communication (e.g., being able to name one brand) have been shown to increase the risk that an adolescent will smoke ( Pierce et al., 1998 ). Wakefield, Ruel, Chaloupka, Slater, and Kaufman (2002) found that teenage smokers preferred to smoke the brand that was most heavily advertised in the convenience store nearest their school. U.S. studies have found that stores where adolescents shopped most frequently contain more tobacco marketing than other stores in the same community ( Henriksen, Feighery, Schleicher, et al., 2004 ). In New Zealand, a study of compliance with PoS regulations for tobacco displays found almost two-thirds of stores to be noncompliant ( Quedley et al., in press ). The same study found greater noncompliance in stores situated in areas with the highest proportion of children. These stores also had particularly high noncompliance with the requirement for tobacco products to be a meter or more away from products attractive to children, such as sweets or chocolate. In addition, there are concerns that PoS promotions may encourage increased consumption among established smokers and tempt ex-smokers or recent quitters to start smoking again. Such concerns are supported by evidence (largely from studies of nontobacco products) that unplanned purchases are common and that PoS stimuli, especially vibrant visual images like those seen on cigarette packaging, encourage unplanned purchases ( McCarville & Bee, 1999 ). The importance of PoS displays is underlined by the use of sophisticated methods to display tobacco products by tobacco manufacturers and retailers. For example, these include the use of planograms, which are computerized diagrams of display fixtures and products that illustrate how and where retail products should be displayed to ensure uniformity of displays and increase customer purchases (Eichelsheim, 2006 ). We conducted a systematic review to investigate the evidence that PoS tobacco promotion (including displays) influences perceptions about tobacco availability and use, influences behaviors such as experimentation with tobacco and uptake of regular smoking by children, undermines smokers quit attempts, and promotes relapse among ex-smokers. Methods Relevant literature was identified using searches of the ProQuest 5000 International ( ) and Medline databases ( ), searches of printed copies of the journals Tobacco Control ( ) and Nicotine & Tobacco Research ( ), searches of bibliographies of retrieved articles, and consultation with experts in the field. We chose to search for papers published in the past 15 years because we determined that research carried out on this topic before 1992 would now be of limited relevance, due to increasing contextual differences. For example, the retailing and marketing of tobacco products and general tobacco control policy context have changed markedly in most jurisdictions over time. The individual search terms we used were tobacco or smoking, cigarette/s, point-of-purchase, point-of-sale, point of purchase, point of sale, power wall, POP, POS, and retail. A second search was conducted looking for articles on PoS and quitting and relapse using the preceding terms and quit, relapse, or cessation. Our inclusion criteria were original quantitative or qualitative research published in peer-reviewed journals and written in English, French, or Spanish. Quantitative research was eligible if it included a quantitative assessment of the degree of association between a direct or indirect measure of exposure to PoS tobacco promotion or product displays and smoking-related beliefs and behaviors, including susceptibility to smoking, experimentation with smoking, regular smoking, quitting, or relapse. Qualitative research was eligible if it explored the impact of exposure to PoS tobacco promotion or displays on smoking-related beliefs and attitudes. Titles and abstracts were used to identify relevant articles, and the full text was obtained for clarification if the abstract had an ambiguous description of measures and analysis. Both 26

3 Nicotine & Tobacco Research, Volume 11, Number 1 (January 2009) authors independently reviewed the articles for eligibility for inclusion, with disagreements resolved by discussion. Each article was independently appraised and key data extracted to a summary table by both authors, and a final summary agreed upon after discussion. We used six commonly advocated criteria ( Hill, 1965 ; Susser, 1991 ) to assess whether a causal relationship existed between PoS promotion and smoking behaviors. These were strength and consistency of association, evidence of dose-response and reversibility of effect, evidence of a clear temporal relationship, and biological plausibility. We found a number of interesting papers about tobacco retailing that did not meet the criteria for inclusion. They provided important background and contextual material for the review but did not directly measure the association between PoS marketing or displays and smoking-related behaviors or beliefs. These included analyses of tobacco documents about PoS ( Carter, 2003 ; Lavack & Toth, 2006 ; Pollay, 2007 ; Wakefield, Morley, et al., 2002 ) and descriptions of the extent and nature of tobacco marketing in stores, and tobacco industry communication with retailers and spending on PoS in response to increasing restrictions on other advertising ( Bloom, 2001 ; Feighery et al., 1999, 2003 ; Feighery, Ribisl, Schleicher, & Clark, 2004 ; Feighery, Ribisl, Schleicher, Lee, & Halvorson, 2001 ; Loomis et al., 2006 ; Wakefield, Morley, et al., 2002 ). We also found three studies that investigated the degree of compliance with tobacco marketing restrictions ( Feighery et al., 2001 ; Letcher, Cameron, Inglis, & Wakefield, 2002 ; Quedley et al., 2008 ). Two papers examined how advertising at the PoS affected brand choice by youth ( Donovan, Jancey, & Jones, 2002 ; Wakefield, Ruel, et al., 2002 ). Wakefield and Germain (2006) conducted a survey to determine the extent to which adult smokers use the PoS to choose brands. These were not included in the review as they assessed the degree to which PoS marketing influences brand choice and not overall susceptibility to smoking or uptake of smoking. One study examined the density of retail outlets in neighborhoods of Chicago and found that higher density of outlets was associated with a greater probability of recent smoking among children, youth, and young adults aged years ( Novak, Reardon, Raudenbush, & Buka, 2006 ). However, the study had no direct or indirect measure of subjects PoS promotion exposure, so it was excluded. Results The searches yielded 569 potential articles. Of these articles, 12 met the inclusion criteria for the review; 10 studies addressed the impact of PoS tobacco promotion on children. Seven crosssectional studies and one prospective cohort study investigated the association between exposure to PoS tobacco promotion and smoking behaviors in children. There were two experimental studies investigating the impact on children of photos of retail tobacco displays, packages, or advertising. Two studies addressed the impact of PoS tobacco promotion on established adult smokers. One was an experimental study that investigated the impact of a photo of cigarette packs, arranged similarly to a tobacco product display, on cravings for cigarettes among adult smokers. One cross-sectional study investigated the degree to which PoS tobacco promotion influenced smoking-related behaviors among adult smokers and recent quitters. We found no qualitative articles explicitly examining smoking and attitudes elicited by PoS. Findings from studies investigating the impact of PoS marketing on children Findings of the cross-sectional studies. Six of the seven cross-sectional studies including children investigated the association between PoS marketing and individual smoking behavior. The exception was the study from Canada, which analyzed the association between level of local PoS marketing and smoking prevalence per school ( Lovato, Hsu, Sabiston, Hadd, & Nykiforuk, 2007 ). The cross-sectional studies of the impact of PoS promotion on children ( Table 1 ) were heterogeneous in time and place, method of analysis, and exposure and outcome measures used. However, most studies found statistically significant associations between exposure to retail tobacco promotion and one or more of the following: susceptibility to smoking, experimentation with smoking, occasional smoking, and regular smoking. The studies can be broadly categorized by the approach used to assess exposure to PoS marketing among participating subjects, with one study using more than one approach ( Feighery, Henriksen, Wang, Schleicher, & Fortmann, 2006 ). Four studies used self-reported exposure to PoS marketing ( Braverman & Aarø, 2004 ; Feighery et al., 2006 ; MacFadyen, Hastings, & MacKintosh, 2001 ; Schooler, Feighery, & Flora, 1996 ). Two studies used measures based on frequency of visiting stores with high levels of PoS marketing ( Feighery et al., 2006 ; Henriksen, Feighery, Wang, & Fortmann, 2004 ). Finally, two studies used area-based measures in which exposure levels were assigned to subjects according to the level of PoS marketing in stores close to the schools that they attended ( Lovato et al., 2007 ; Slater et al., 2007 ). In the study from the north of England ( MacFadyen et al., 2001 ), exposure was measured by prompted awareness of different types of tobacco marketing including some within the retail environment. The study appears to have been set up to assess exposure to the wide range of tobacco marketing that was allowed in the United Kingdom at that time and its impact on smoking, rather than to investigate the impact of PoS marketing specifically. The types of PoS marketing investigated were not comprehensive. For example, awareness of various coupon or free gift promotions or tobacco branding on in-store clocks was included, but not awareness of other in-store advertisements or tobacco displays. The findings, therefore, probably have limited relevance to situations where in-store tobacco advertisements are common or where direct in-store advertisements are restricted but PoS displays or power walls are present. The study from Norway ( Braverman & Aarø, 2004 ) and the 1994 California study ( Schooler et al., 1996 ) used measures of self-reported exposure to PoS marketing. The California study was conducted in the context of very limited restrictions on tobacco advertising, with no restrictions in the retail environment. The high levels of self-reported exposure are therefore highly plausible. The analysis adjusted for the effects of other tobacco marketing exposure and family and friend smoking, so the finding of an increased odds ratio (OR; 1.4) for exposure to in-store 27

4 Impact of tobacco promotion at the point of sale Table 1. Cross-sectional studies of smoking behavior and exposure to PoS marketing in children Author (date) Location and subjects Measurements Analysis and results Scho oler et al. (1996) MacFayden et al. (2001 ) Henriksen, Feighery, Wang, et al. (2004) Braverman and Aarø (2004) San Jose, CA, 1994; 571 children in seventh grade (mean age = 13 years, 8 months) Northern England, year of study not stated; 629 children, aged years Tracy, CA, 2003; 2,125 children in sixth to eighth grades (11 14 years) Norway, 1990 and 1995; National surveys of children in seventh ninth grades (13 15 years) Feighery et al. Tracy, CA, 2003; 2,063 (2006) b children in sixth to eighth grades (11 14 years) Slater et a l. (2007) Lovato et a l. (2007) National survey, USA, ; 26,301 children in 8th 12th grades (14 18 years) Five Canadian provinces, year of data collection not stated; 81 randomly selected schools with survey of 22,318 children in 10th 11th grades (15 17 years) Exposure: self-reported frequency of visiting andseeing advertising in stores. Outcome: smoking status (ever-smokers vs. never-smokers). Exposure: prompted self-reported awareness of 14 types of tobacco promotion (including PoS). Outcome: smoking status. Exposure: self-reported frequency of visits to store types with high levels of tobacco marketing. Outcome: smoking status (ever-smokers vs. never-smokers). Exposure: self-reported recent exposure to tobacco marketing in 10 locations, including shops. Outcomes: smoking status (daily, occasional, and nonsmokers). Exposure: (a) visits to store types associated with high levels of tobacco marketing, (b) and (c) two measures based on visits to specific stores in locality with observed high levels of tobacco marketing, and (d) self-reported exposure to PoS advertising. Outcomes: smoking status (ever-smokers vs. never-smokers) and susceptibility to smoking among never-smokers (susceptible vs. nonsusceptible). Exposure: Four indices of retail tobacco marketing and pricing in up to 30 stores in the vicinity of the respondent s school: (a) store-based tobacco advertising, (b) tobacco product accessibility in store, and (c) and (d) price discounting/promotions and mean price for two brands most commonly smoked by youth. Outcome: Transitions in smoking status between never-smoker, puffer, non recent experimenter, ex established smoker, recent experimenter, and current established smoker. Exposure: Proportion of stores within 1-km radius of school with any of (a) in-store tobacco promotions (discounts, free gifts, etc.), (b) internal or external tobacco advertising, (c) power wall tobacco displays, or (d) government health warning signs. Mean price of cigarettes in stores. Outcome: School smoking prevalence (at least a few puffs on 2 or more days in the last month) divided into high (>median) and low (<median). Logistic regression analysis: seeing in-store cigarette advertisements sometimes or a lot in stores increased odds of ever smoking (adjusted OR = 1.38, p =.0001) after adjustment for smoking by family and friends and exposure to other tobacco marketing. Univariate analysis: significant trend (current vs. ex-smoker vs. nonsmoker) for greater awareness of tobacco promotion by smoking status for 8 of 14 promotion methods including promotional logos on in-store clocks, free gifts, coupons, and special price offers. Logistic regression analysis: increased awareness among current smokers of coupon schemes (adjusted OR = 1.90, 95% CI = ), clothing and other items with cigarette logos (adjusted OR = 1.8, 95% CI = ), and more types of tobacco promotions (adjusted OR = 1.13, 95% CI = ) after adjustment for socioeconomic factors and smoking by family and friends. Logistic regression analysis: children visiting stores at least weekly had increased odds of ever smoking (OR = 1.5, 95% CI = ) after adjustment for demographic factors, smoking by family and friends, psychosocial correlates of smoking, and exposure to other tobacco marketing. Univariate analysis: children who reported recent exposure to tobacco marketing in shops were more likely to be daily smokers (1990 OR = 2.0, 95% CI = ; 1995 OR = 3.0, 95% CI = ) or occasional smokers (1990 OR = 1.6, 95% CI = ; 1995 OR = 1.7, 95% CI = ). a Logistic regression analysis: statistically significant positive association between being a daily or occasional smoker and tobacco marketing exposure in 1 2, 3 4, or 5 locations (e.g., for 5 locations, 1990 adjusted OR = 2.1, 95% CI = ; 1995 adjusted OR = 2.3, 95% CI = ) after adjustment for demographic factors and smoking by family and friends. Logistic regression analysis: statistically significant increase in odds of being an ever-smoker by all four measures (adjusted ORs = ) and of being susceptible to smoking for three measures of exposure to PoS tobacco marketing (adjusted ORs = ) after adjustment for demographic factors, smoking by family and friends, and amount of unsupervised time. Generalized ordered logit modeling to assess association of the exposures on transitions between smoking status categories, adjusted for demographic factors, socioeconomic factors, and state-level antitobacco programs. Increased odds of being an experimenter (puffer) compared with never-smoker when local stores have a higher (not further specified) mean store-based advertising score (adjusted OR = 1.08, 95% CI = ). Increased odds of being an ex established smoker (adjusted OR = 1.19, 95% CI = ), recent experimenter (adjusted OR = 1.22, 95% CI = ), and current established (adjusted OR = 1.38, 95% CI = ) compared with preceding category with any exposure to price discounting/promotions. No positive associations with price and in-store tobacco accessibility for any transition. Significant correlations between school smoking prevalence and the proportion of stores with in-store tobacco promotions ( r =.34), proportion of schools with government health warnings (.30), and with mean cigarette price (.43), but not with tobacco advertising or power wall displays. Univariate analysis of variance: stores in the neighborhood of schools with higher smoking prevalence had significantly lower cigarette prices ( p <.01), more in-store promotions ( p <.01), and fewer government-sponsored health warning signs ( p <.01). a Only chi-square tests were reported in the paper, ORs were calculated by the authors from data in the paper. b Same dataset as Henriksen, Feighery, Wang, et al. (2004). 28

5 Nicotine & Tobacco Research, Volume 11, Number 1 (January 2009) advertising among ever-smokers compared with never-smokers is convincing evidence of a true association ( Schooler et al., 1996 ). The Norway study ( Braverman & Aarø, 2004 ) occurred in the context of a comprehensive tobacco advertising ban in place since Participants were asked if they had seen anything recently that appeared to be a tobacco advertisement in various locations (e.g., TV, films, toys, bags, clothing, ashtrays, magazines, and newspapers) including shops. Moderately strong positive associations were found (ORs from 1.6 to 3.0) between reported exposure to marketing in shops and daily or occasional smoking. However, this relationship was investigated only in univariate analysis and did not take into account possible confounding factors such as exposure to other forms of tobacco marketing and smoking among family and friends. Also absent were verification of the self-reported exposures and information about the nature of the tobacco marketing that the children reported seeing in shops. The studies from Tracy, CA ( Feighery et al., 2006 ; Henriksen, Feighery, Wang, et al., 2004 ), appear to have been conducted using the same dataset. This description focuses on the second paper ( Feighery et al., 2006 ) because it largely incorporates the analysis in the earlier paper. The study provided compelling evidence of an association between PoS tobacco promotion and smoking behaviors in children. Exposure was measured in four different ways, including more neutral measures based on frequency of visiting stores known to have high rates of PoS tobacco promotion. Therefore, recall bias was less likely to be an issue than it would be in studies that rely on self-reports of awareness or exposure to tobacco marketing. In addition, association was tested both with a measure of smoking behavior and with an established measure of smoking susceptibility among never-smokers. Moderately strong associations were found among all four measures of exposure and smoking status (ORs of ) and for three of four measures of exposure and susceptibility to smoking (ORs of ). These analyses were adjusted for potential confounders (demographic factors, smoking by family and friends, and amount of unsupervised time). Finding an association between exposure to PoS and susceptibility to smoking among never-smokers is especially compelling because tobacco-purchasing behavior cannot have influenced PoS tobacco promotion exposure. Two of the cross-sectional studies measured exposure to PoS promotion by assessing the amount of tobacco marketing in stores within a defined area close to schools that survey participants attended ( Lovato et al., 2007 ; Slater et al., 2007 ). In the U.S. study ( Slater et al., 2007 ), four indices of exposure were constructed based on observation of retail tobacco marketing and pricing in up to 30 stores in the vicinity of 200 schools that had participants in a national cross-sectional survey of schoolchildren. The outcome measure was current smoking behaviors in which six levels of smoking behavior were defined and treated as ordered categories in a progression from never-smoker to current established smoker. The authors examined the association between each of the four PoS exposure indices and transitions between adjacent smoking behavior categories. The main positive finding was a weak but statistically significant association between the exposure to store-based advertising and the transition from nonsmoker to puffer (adjusted OR = 1.08). Exposure to store-based advertising was not associated with other transitions in smoking behaviors. Also found was a significant association between the price promotions or exposure to lower price premium cigarettes and the transition from recent experimenter to current smoker (adjusted OR = 1.4). However, the analysis of Slater et al. (2007) is questionable in many respects. First, some of the categories in the study do not represent logical transitions along a continuum. For example, former established smokers were compared with recent experimenters. Also, the use of the notion of transitions suggests that the study involved longitudinal follow-up over time, when the analysis modeled a theoretical transition between two groups of children assessed cross-sectionally. Finally, association with PoS marketing was only tested between adjacent categories, rather than with the baseline never-smoker category, thus reducing the chance of finding an association. The final cross-sectional study examining the impact of PoS on children used area-based exposure and outcome measures ( Lovato et al., 2007 ). Potential exposure to tobacco marketing was assessed from the proportion of stores within a kilometer of each school with in-store tobacco promotions, PoS advertising, and power walls. The outcome measure was the proportion of students at the school reporting any smoking in the previous month. This study found increased smoking prevalence at schools where local stores had lower cigarette prices, more instore promotions, and less or smaller health warnings, but not more power walls and in-store advertisements. Limitations of the study include the lack of adjustment for any potential confounding variables such as socioeconomic factors, school smoking policy, and school type and size. Also, school smoking prevalence was crudely dichotomized into high and low based on the median prevalence. The neighborhood measures of exposure used by Slater et al. (2007) and Lovato et al. (2007) have two advantages: They provide a measure of the overall retail tobacco marketing environment within the vicinity of the schools being studied, and the exposure measure is not dependent on individual recall of exposure and therefore is not susceptible to biased recall. However, any observed association could be confounded by increased adult smoking in the area, given that this could be associated with greater PoS marketing in local stores and greater smoking among children. For this reason, Slater et al. adjusted for factors that predict parental smoking, though this approach is less robust than adjusting for actual parental smoking rates. Neighborhood measures of exposure are also susceptible to measurement imprecision when used to assess association with an individually measured outcome, as in the study by Slater et al.. For example, this method does not take into account variations in visiting retail environments among individuals living in the same area. The estimates of association will therefore be biased toward no association. Findings of the cohort study. One prospective cohort study ( Weiss et al., 2006 ) followed up more than 2,000 Grade 6 children who were nonsusceptible never-smokers at baseline ( Table 2 ). Children with reported exposure at baseline to PoS advertising and TV tobacco advertising (adjusted OR = 3.3) or to PoS advertising or TV tobacco advertising (adjusted OR = 1.9) had increased susceptibility to smoking or ever smoking, although the independent effect of PoS advertising was not described. 29

6 Impact of tobacco promotion at the point of sale Table 2. Cohort study of relationship between smoking behavior and exposure to PoS marketing in children Aut hor (year) Weiss et al. (2006) Location and subjects Measurements Analysis and results Los Angeles, CA, 2-year follow-up, approximately ; 2,026 children in sixth grade (mean age = 11 years) who were nonsusceptible nonsmokers at baseline (stated they would definitely not smoke a cigarette in the next year) Exposure: Three levels of self-reported exposure to protobacco media; none, retail or TV, retail and TV. Retail exposure was measured on a 4-point scale from never to a lot for how often subjects reported seeing tobacco ads on visits to convenience-type stores. Outcome: self-reported susceptibility to smoking or ever smoking during follow-up. Generalized linear mixed models analysis found increased odds of ever smoking or susceptible to smoking with exposure to TV or retail advertising at baseline (adjusted OR = 1.89, 95% CI = ) and exposure to TV and retail advertising (adjusted OR = 3.33, 95% CI = ) after adjustment for demographic factors, school, and exposure to antitobacco programs and media. The measure of exposure was relatively crude, with PoS advertising exposure at baseline dichotomized into those who reported any current exposure and those who reported no exposure. However, a key advantage was the prospective design with assessment of exposure occurring among nonsusceptible never-smokers prior to the development of the outcome. This approach minimized the risk of recall bias and exposure status being affected by the smoking behavior. Findings of the experimental studies. The two experimental studies ( Table 3 ) were similar in design. One was conducted in California in 1998 ( Henriksen, Flora, Feighery, & Fortmann, 2002 ) and the other in Victoria, Australia, in 2003 ( Wakefield, Germain, Durkin, & Henriksen, 2006 ). Convenience samples of school students were shown photos of convenience stores under three conditions: (a) tobacco advertising and tobacco displays (U.S. study and Australian study), (b) a tobacco display but no advertisements (Australian study only), and (c) no tobacco displays or other promotion (U.S. study and Australian study). Following an examination of the photos, the students answered questionnaires about smoking and tobacco. The results from the two studies were consistent. Students who saw photos with tobacco displays and advertising were significantly more likely to believe that tobacco is more accessible and easier to buy in the featured stores or from stores in their neighborhood and to give a higher estimate of the percentage of teenagers and adults who smoke. Overestimation of smoking prevalence among peers and the general population is important, given that research shows that a correlation exists between the degree of overestimation and the likelihood of smoking ( Conrad, Flay, & Hill, 1992 ). Findings from studies investigating the impact of PoS marketing on adults Only two studies of adults met the inclusion criteria, one crosssectional study and one experimental study. The cross-sectional study by Wakefield, Germain, and Henriksen (2008) investigated the degree to which smokers and recent quitters reported the impact of PoS tobacco promotion on their smoking-related behaviors ( Table 4 ). This study found strong evidence from the self-reports of smokers and recent quitters of the impact of PoS tobacco displays on prompting impulse buying of tobacco and urges to smoke and on undermining quit attempts. These effects were greater among those who noticed PoS displays more often, among women, and among smokers from disadvantaged areas ( Wakefield et al., 2008 ). The experimental study ( Table 5 ) was carried out in a U.S. laboratory ( Carter et al., 2006 ) with a group of adult smokers. The investigators measured craving responses following exposure to various smoking-related photos, including a photo of a collection of tobacco packs, and other photos with no smokingor tobacco-related imagery. Photos of tobacco packs elicited a craving for cigarettes that was higher than cravings induced by neutral photos (no smoking or tobacco imagery), but slightly less than for most other smoking-related images such as pictures of lit cigarettes and people smoking. However, a limitation of this study was that the stimulus was not a full tobacco PoS display in a retail setting, but rather a collection of eight cigarette packs arranged as an isolated group. Therefore, the impact of a full PoS display on craving may be greater. Assessment of causality A moderately strong association between PoS and smoking susceptibility and uptake of smoking among youth was evident from studies conducted in different time periods and settings and using a range of exposure and outcome measures. In several studies, the association was robust to adjustment for wellknown risk factors for smoking uptake such as socioeconomic status and parental and friend smoking. None of the studies showed a dose response relationship between PoS promotion exposure and smoking or susceptibility to smoking. However, this was because the exposure measures generally split subjects into only two groups, so dose response was not investigated. None of the studies showed reversibility of the association between PoS promotion and smoking or susceptibility to smoking, but again this was because reversibility could not be investigated in these studies. Because most of the studies examining PoS exposure and smoking behavior or susceptibility were cross-sectional, the direction of causality was often not discernible. For example, it is plausible that starting to smoke causes increased visits to sales outlets or heightened awareness of PoS tobacco marketing. However, increased susceptibility to smoking among neversmokers is less credibly a cause of increased exposure to PoS marketing, since such subjects are not yet buying tobacco 30

7 Nicotine & Tobacco Research, Volume 11, Number 1 (January 2009) Table 3. Experimental studies examining children s responses to photos of the PoS Aut hor (year) Henriksen et al. (2002) Location and subjects California, USA, 1998; 385 students in eighth or ninth grade from five schools Exposure measurement Outcome measurement Analysis and results Wa kefield et al. (2006) Victoria, Australia, 2003; 605 students in ninth grade (14 15 years) from five schools Color photographs of the PoS and the storefront windows of a convenience store digitally altered to create a tobacco-saturated store (with multiple tobacco ads) and tobacco-free store with tobacco ads replaced by ads for snack foods, soda, and beer. Students randomly assigned to be shown one of three photos of a convenience store PoS with no cigarettes or cigarette advertisements, just cigarettes displayed, or cigarettes and advertisements displayed. Sum of measures used to create composite measure of perceived ease of access to tobacco. Perceived prevalence of smoking among classmates and acceptability of smoking among children of their age. Support for tobacco control policies assessed using sum of responses about degree of agreement with six tobacco control policies. Perceived access to and ease of purchase of cigarettes. Perceived prevalence of smoking among classmates, high school students, and adults. Approval of smoking from degree of agreement with statements about smokers. Perceived harm due to smoking. Perceived brand popularity among students of their age. Susceptibility to smoking. Experiment tested using 2 2 analysis of covariance (ANCOVA). ANCOVA adjusted for smoking susceptibility. No evidence of clustering and groups did not differ significantly in tobacco use, gender, or grade. Students exposed to tobacco-saturated photos were significantly more likely to think it was easy to buy tobacco from the pictured store and from stores in their neighborhood, to believe that the prevalence of smoking among their peers was higher, and to have a lesser degree of support for tobacco control policies. Generalized estimating equations with random effects to determine the adjusted effects of exposure to the three PoS conditions on outcomes. Logistic regression used to examine the relationship between cigarette brands thought most popular and those shown in the photos. Analyses adjusted for sex, parental and friend smoking, smoking susceptibility, and clustering effect of schools. Students exposed to cigarette displays and/or advertising were significantly more likely to believe it would be easy to purchase cigarettes at the store in the photo, believe they would not be asked for proof of age if buying cigarettes, report that a larger number of neighborhood stores would sell them cigarettes, give a higher estimate of the percentage of students and adults who smoked, report that they were likely to smoke in the next year, and report brands that were most prominently displayed or advertised in the photos as the most popular brand among students and adults. Associations with other outcome variables and exposure status were not statistically significant. Differences between the exposed group and control group were mostly small. products. Studies that examined susceptibility in never-smokers did find an association with exposure to PoS promotion after adjustment for other predictors of susceptibility to smoking ( Feighery et al., 2006 ; Weiss et al., 2006 ). By contrast, in prospective cohort studies, the exposure must have preceded the outcome and the temporal relationship is clear. One prospective study was found, and it supported the evidence of a positive association between exposure to PoS marketing and subsequent smoking initiation. The biological or theoretical plausibility of the association between PoS promotion and smoking initiation in children was supported by experimental evidence of an association between exposure to PoS displays and attitudes to smoking and perceptions of tobacco product accessibility among children. Similarly, the plausibility of exposure to PoS displays reducing and undermining quit attempts was supported by experimental evidence from one study among established smokers in which exposure to a photo of a collection of tobacco packs elicited increased craving for cigarettes. Discussion This review identified a number of quantitative studies that support an association between PoS marketing and displays and increased smoking susceptibility, experimentation, and uptake among children, even after adjustment for a range of plausible confounding factors. However, due to limitations in 31

8 Impact of tobacco promotion at the point of sale Table 4. Cross-sectional study of relationship between smoking behaviors and exposure to PoS marketing in adult smokers and quitters Aut hor (year) Location and subjects Measurements Analysis and results Slater et a l. (2007 ) Victoria, Australia; telephone survey of 2,996 adults in November 2006 ( 18 years), with 526 cigarette smokers, 209 who had tried to quit in the past 12 months, and 67 recent quitters (quit in past 12 months) Frequency of visiting supermarket, convenience stores, and gas stations. Smokers: whether PoS ban would make it easier to quit. Recent quit attempts and quitters: avoidance of shops where previously bought cigarettes and whether tobacco displays prompted urges to buy cigarettes. Table 5. Experimental study of craving responses in adult smokers 34% of smokers visited supermarket, convenience stores, and gas stations almost every day. 55% often or always and 75% at least sometimes noticed PoS tobacco displays. 25% of smokers sometimes or more often reported buying cigarettes due to seeing PoS displays. Multivariate logistic regression indicated that women (OR = 1.96, 95% CI = ) and smokers considering quitting (OR = 1.82, 95% CI = ) were more likely to report buying cigarettes due to seeing the displays. 31% of smokers thought removal of PoS displays would help them quit. Those who were more likely to agree that removing displays would help them quit were those who noticed the displays sometimes or more often (OR = 2.38, 95% CI = ), women (OR = 1.71, 95% CI = ), and those from lower socioeconomic status (SES) areas (35% low SES vs. 30% high SES; OR = 0.5, 95% CI = ). Among those who had tried to quit in the past year, 19% avoided stores where they usually bought cigarettes. 38% reported PoS displays resulting in the urge to buy cigarettes, of whom 61% reported buying cigarettes even though they were trying to quit. Of those who had quit in the past year, 34% stated that PoS displays gave them an urge to buy cigarettes and 12% avoided stores where they had previously bought cigarettes. Author (year) Location and subjects Exposures Outcome measurement Analysis and results Carter et al. (2006) Laboratory in Houston, TX; 63 participants recruited using newspaper advertisements; aged years, 55% male, diverse ethnicities, smoked 10+ cigarettes/ day, in good health Participants viewed 48 photos, 12 each of four types of stimuli (positive, negative, neutral, and smoking related). Smokingrelated pictures included pictures of people smoking, lit cigarettes in various settings, and a color photo of eight cigarette packs grouped together like in a PoS display. Participants viewed stimuli when nicotine deprived (for 12 hr) and non nicotine deprived. Self-reported craving response using the IAPS (Center for the Study of Emotion and Attention) 9-point scale for each image. Analysis of variance (ANOVA) (2 4) with post-hoc multiple dependent t tests with Bonferroni adjustment: smoking-related pictures produced significantly higher cravings than other picture types. There was a trend toward increased craving among nicotine-deprived subjects ( p =.087) in multivariate ANOVA. Hedges g coefficient used to estimate the effect of individual smoking-related pictures on craving versus the mean craving response to a neutral cue. All the smoking-related pictures increased craving compared with the neutral cue. The mean effect size was 0.80 among the non nicotine-deprived smokers and 0.88 among the nicotine-deprived smokers. The picture of eight cigarette packs increased craving by 0.63 among non nicotine-deprived smokers and by 0.61 among nicotinedeprived smokers. 32

9 Nicotine & Tobacco Research, Volume 11, Number 1 (January 2009) the available studies, several of the criteria for causality were met only partially or were not met. Little evidence was available about the effect of PoS marketing on quitting-related behaviors among established smokers and quitters, though the one observational study that investigated this issue suggested that a significant impact was possible. The results from experimental studies were consistent with the cross-sectional and longitudinal studies in children, showing a significant association between smoking initiation and tobacco at PoS. The one experimental study of adults found a weak association between exposure to cigarette packs and measures of craving. The two methodologically strongest studies of the impact of PoS on children were a cross-sectional study that used multiple methods of assessing exposure ( Feighery et al., 2006 ) and a prospective longitudinal study ( Weiss et al., 2006 ). Both studies found evidence of a positive association between PoS tobacco marketing and smoking susceptibility, initiation, and uptake. The evidence in the present review that PoS displays affect smoking initiation by children and may affect smoking behavior of established smokers is supported by evidence, from reviews of internal documents, of the increasing importance attached to PoS by the tobacco industry ( Carter, 2003 ; Lavack & Toth, 2006 ; Pollay, 2007 ; Wakefield, Morley, et al., 2002 ) and by the increasing tobacco industry resources expended on PoS marketing ( Bloom, 2001 ; Feighery, Ribisl, Achabal, et al., 1999 ; Feighery, Ribisl, Schleicher, Lee, et al., 2001 ; Feighery, Ribisl, Clark, et al., 2003 ; Feighery, Ribisl, Schleicher, & Clark, 2004 ; Loomis et al., 2006 ; Wakefield, Morley, et al., 2002 ). However, the review also revealed important limitations in the evidence and hence priority areas for further research to inform evidence-based policy making and advocacy. Most of the studies were conducted in jurisdictions in which tobacco-advertising restrictions were weak. As a result, the effect of PoS advertising and displays may have been diluted by noise from other advertising, making the independent effect of PoS marketing difficult to discern. Studies in countries with stronger restrictions on tobacco advertising should be a priority, particularly to investigate the impact of PoS tobacco displays, which are becoming increasingly important as a marketing tool in countries where other forms of tobacco marketing are banned or heavily restricted. The U.S. studies also have a potential problem with generalizability, given that all but one were conducted in California. The findings from those studies may be atypical given the low smoking prevalence and particularly strong tobacco control program in California, including leading-edge youth-orientated campaigns over the past years. Further studies using a prospective approach are required to strengthen the evidence that exposure to PoS promotion increases the risk of smoking. Studies of smoking behavior and susceptibility among children and of quit rates and outcomes in established smokers pre- and post-implementation of future bans on PoS promotion will provide invaluable evidence. A quasiexperimental design investigating PoS display may also be feasible if communities or groups of retailers can be persuaded to remove displays and other PoS advertising. Uncertainties exist regarding the form of PoS restrictions that best reduces the adverse health effects of tobacco use in populations. For example, should a ban on PoS marketing en- compass all tobacco products, or only smoked tobacco products and hazardous oral tobacco products, exempting less hazardous oral tobacco products? PoS displays may be an important means of promotion of less hazardous alternatives to smoked tobacco, particularly if strong, comprehensive regulation of nicotine and tobacco products, such as that outlined by the Royal College of Physicians ( Tobacco Advisory Group of the Royal College of Physicians, 2007 ), is implemented. However, given the addictiveness of tobacco, the severity of the health hazards posed by smoking, the evidence that tobacco promotion encourages children to start smoking, and the consistency of even the limited evidence available that PoS marketing influences children s smoking, we believe that there is ample justification for a ban on PoS marketing, including retail displays, of all smoked tobacco products. Funding Action on Smoking and Health New Zealand to J.P.; the University of Otago to R.E. Declaration of Interests Richard Edwards has previously undertaken work for the Ministry of Health and nongovernmental agencies working to improve tobacco control. Acknowledgments The authors thank Action on Smoking and Health New Zealand, the Department of Public Health, University of Otago, Becky Freeman, and Belinda Hughes. References Bloom, P. N. (2001 ). Role of slotting fees and trade promotions in shaping how tobacco is marketed in retail stores. Tobacco Control, 10, Braverman, M. T., & Aarø, L. E. (2004 ). Adolescent smoking and exposure to tobacco marketing under a tobacco advertising ban: Findings from 2 Norwegian national samples. American Journal of Public Health, 94, Carter, B. L., Robinson, J. D., Lam, C. Y., Wetter, D. W., Tsan, J. Y., Day, S. X., & Cinciripini, P. M. (2006 ). A psychometric evaluation of cigarette stimuli used in a cue reactivity study. Nicotine & Tobacco Research, 8, Carter, S. M. (2003 ). New frontier, new power: The retail environment in Australia s dark market. Tobacco Control, 12 (Suppl. 3 ), iii95 iii101. Conrad, K. M., Flay, B. R., & Hill, D. (1992 ). 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