Availability Of Tobacco Products Research Articles

Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019.

The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC. Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level. Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors. In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity. We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

Comparison of Tobacco Product Prices at Fort Liberty Army Installation and Surrounding Community Areas, 2021.

High rates of tobacco use persist in the U.S. military, with 18.4% of service members smoking cigarettes in 2018. The Department of Defense's (DoD) 2017 policy required that tobacco retailers on military installations set tobacco product prices equal to the most common community price, including tax, but there is limited evidence confirming whether local retailers are adhering to this policy. We examined tobacco product pricing in tobacco retailers on- and off-post at the largest U.S. Army installation, Fort Liberty, and Cumberland County, North Carolina. Between June-August 2021, we collected data on tobacco product availability, price, and promotions from retailers on Fort Liberty (n=14) and a random sample of off-post retailers within 10-miles of installation gates (n=52). We calculated the mode, mean, and median price of each product, plus the difference in these prices at on- and off-post retailers. We used Welch's t-test to test differences in mean prices between on- vs. off-post retailers. The mode, mean, and median prices of cigarette packs and cartons were lower on-post than off-post (e.g., $0.51-$0.55 cheaper for Marlboro cigarette packs on-post). However, the mode, mean, and median prices of smokeless tobacco products and little cigars were higher on-post than off-post (e.g., $0.82-$0.89 more costly for Swisher Sweets 2-packs on-post). Results highlight the need for continued enforcement to ensure compliance with the 2017 DoD policy. Comprehensive policy action to reduce tobacco price disparities on- and off-post is critical to reducing high rates of tobacco use among service members. Despite the implementation of the 2017 DoD pricing policy, some tobacco products remain cheaper at tobacco retailers on-post compared to off-post retailers. Our results highlight the need for greater routine surveillance to increase implementation of the policy-particularly for cigarettes-to reduce high rates of tobacco use among service members.

South Australia's tobacco retail landscape and its intersection with socioeconomic factors and smoking prevalence.

Tobacco product availability is higher in socioeconomically disadvantaged areas, which can further widen tobacco-related health and disease burden inequities. This study aimed to describe retail availability of tobacco products in South Australia and examine the association between tobacco vendor location, population's socioeconomic status (SES) and tobacco smoking prevalence. Cross-sectional 2022 tobacco vendor licence data and 2021-2022 state-wide population health survey data from the South Australian Department of Health were used. Tobacco vendors were enumerated by Statistical Area 2 (SA2) using geocoding software, with SA2s assigned health survey derived smoking prevalence, SES, remoteness category, area size, and population size. As of 2022, there were 1723 tobacco vendors in South Australia and the overall tobacco smoking prevalence across the state was 11.8%. Regression analyses indicated that tobacco vendor density increased with socioeconomic disadvantage and geographic remoteness, and that smoking prevalence was higher in low SES areas. Vendor density was not related to smoking prevalence. Findings are consistent with existing research indicating greater tobacco availability in socially disadvantaged areas. This supports that tobacco vendor saturation may be directed to areas in a way that promotes tobacco availability for vulnerable populations. Our finding that smoking prevalence was unrelated to tobacco availability contrasts existing literature and should be carefully interpreted. SO WHAT?: This is the first study to map tobacco retailers across South Australia, contributing needed evidence on the intersection of tobacco vendor density, social disadvantage, and smoking prevalence.

Environmental Factors Influencing Tobacco Usage among High School Children in Lucknow City: A Cross-sectional Study

Background: Evidence proves that the majority of adult tobacco users begin using tobacco as children or teens. Teenagers are drawn to tobacco products for a variety of reasons. Public health planners are gravely concerned about the current rapid trade and tobacco use among teenagers in a developing nation like India. Objective: The present paper focuses on the prevalence of tobacco use among children in the eighth to tenth grades and the various environmental factors that contribute to tobacco use among children. Material and Methods: Following ethical clearance, six government schools in Lucknow were chosen for this cross-sectional study, and data was gathered using the Global Youth Tobacco Survey (GYTS) to examine the relationship between tobacco use in children and other independent influencing factors. Logistic regression analysis was used. Results: 21.7% of the children used tobacco in some or the other way. Supari with tobacco was the most popular tobacco product consumed by children (48.3%). Statistical analysis showed that family members consuming tobacco at home and adults sending their kid to get tobacco had a high connection with tobacco use among children. The direct relationship between children watching individuals consuming tobacco on television and their arousal of interest for the same was also seen. Similarly, the presence of tobacco vendors outside the school and easy availability of tobacco products to children significantly influenced the tobacco consumption habit. Conclusion: Tobacco users in families, adults sending children to buy tobacco, children’s arousal of interest on seeing people using tobacco on media, tobacco vendors outside the school, and the easy availability of tobacco products have all been proven to be environmental triggering factors for tobacco consumption amongst high school students.

Changes in Retail Tobacco Product Availability Following a Chicago City Ordinance Restricting Sales of Menthol and Other Flavored Tobacco Products Near Schools.

In April 2016, the City of Chicago implemented an ordinance restricting the sale of all flavored (including menthol) tobacco products (FTPs), including electronic cigarettes, at retailers located within 500 feet of any public, private, or alternative elementary, middle ("primary"), or high ("secondary") school. We examined changes in retail availability of FTPs from before to after policy implementation among policy-affected retailers compared with retailers not subject to the policy. Observational data were collected in June to September 2015 (Wave 1; pre-policy) and November to December 2016 (Wave 2; post-policy) from a panel of 194 randomly selected policy-area stores (located within 500 feet of a school), and a panel of 199 randomly selected comparison-area stores (located more than 500 feet from a school). Using generalized estimation equation regression, we assessed differences in FTP availability changes across study areas. We observed a statistically significant policy effect on FTP availability (Area × Wave interaction, p < .05); however, more than half of policy-area retailers continued to display at least one FTP after policy implementation (87.11% at Wave 1, 57.73% at Wave 2, p < .05). Similar reductions were seen for the availability of flavored cigarillos/little cigars and menthol cigarettes, while policy effects varied across store types. FTP availability reductions appear to be associated with policy implementation, but FTPs remained readily available at retailers subject to the policy. This study contributes to the evidence base indicating that policies with exclusions or exemptions for certain flavors, products, store types, or retailer locations have a limited effect on retail availability of FTPs.

Prevalence of Smoking and its Associated Factors among Adolescent Males in Bangladesh: A Community Survey

Background:Smoking is considered the symbol of adulthood and a “friend” during stress and loneliness to many adolescent people. It is well established that most adults start tobacco use in late childhood or adolescence. This study aimed to determine the smoking prevalence and its influencing factors among Adolescent males in a selected community in Bangladesh.Methods:A descriptive cross-sectional study was conducted from January to December 2019 among adolescent males in Savar Upazila, Dhaka, Bangladesh. A total of 472 adolescent males were recruited through the household survey using a proportional probability sampling (P.P.S.) procedure. The sociodemographic and smoking information was collected using an interviewer-administered semi-structured questionnaire. Various statistical analyses were performed.Results:The Prevalence of smoking was 25.0%. The bivariate analysis showed that age, religion, education, occupation, peer influence, and social stigma for the attraction were all associated (P&lt;0.05) with smoking among adolescents. The multivariate analysis revealed that the smoking risk was six times higher (OR=6.46, 95% CI: 3.49-11.98) among the participants who see the smoking habit makes people more attractive and happier, about forty-two times (OR=41.9, 95% CI: 10.1-173.3) among those with a friend who smokes, about twenty times higher (OR=19.89, 95% CI: 9.2-42.8) among those who had a smoker in the family and more than two times higher (OR=2.721, 95% CI: 1.16-6.4) among respondents who had higher secondary &amp; above level of education.Conclusion:In Bangladesh, particularly in rural regions, little is known regarding the incidence of adolescent smoking and associated risk factors. Peer pressure, stress, anxiety, weight loss, copying popular culture, celebrity influence, and tobacco product availability were critical factors in the study participants' decision to smoke. As a result, special regulations and actions should be implemented to curb current adolescent smoking patterns.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis

IntroductionAotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know...

11.P. Workshop: Tobacco control policy strategies to contribute to the EU’s tobacco-free generation goal

Abstract In 2021, the European Union's (EU) ‘Europe's Beating Cancer Plan’ set the goal to achieve a tobacco-free generation in Europe by 2040, which means that less than 5% of people will use tobacco. The EU proposed policies to address internationally relevant issues such as tobacco taxation, cross-border purchases, packaging, flavours, and online advertising. However, many tobacco control policies need to be adopted and implemented at the national or local level. It is therefore important to exchange research findings and insights on national tobacco control policies. In this workshop we present results mainly from the Netherlands. With a 21% smoking prevalence and scores 53 out of 100 points on the Tobacco Control Scale, it may therefore be considered an average European country in terms of its tobacco control. However, the Netherlands has progressed its tobacco control policies in recent years, in part due to the 2018 National Prevention Agreement. This Agreement included the same goal as the European tobacco-free generation goal. Achieving a tobacco-free generation requires the prevention of smoking initiation among young people, but also smoking cessation among those who already smoke. This is especially important among lower socioeconomic groups, as the smoking prevalence in these groups is higher both in adults and adolescents. Therefore, smoking and tobacco products need to be less visible and available in the environment, and easily accessible smoking cessation support needs to be provided. With this workshop, we cluster very recent evidence on the EU's tobacco-free generation goal. We will present evidence on four policy strategies for the smoke-free generation, in which their potential impact and challenges in implementation will be discussed. These presentations will be followed by a plenary discussion on the implications and the relevance of the four strategies taking into account differences between international settings. The presentations will focus on four policy areas: • Policies to reduce smoke-exposure in and around sport clubs • Policies to reduce availability of tobacco products in the retail environment • Policies to reduce smoke-exposure in hospitality venues and homes • Policies to increase access to smoking cessation The objectives of the workshop are: 1. Present evidence of four tobacco control policies strategies 2. Discussion of the international relevance and implications of the results Key messages • We present on multiple settings that can be further capitalised on to achieve a non-smoking norm, including sports clubs, retail outlets, hospitality venues, and the home environment. • The majority of European countries currently does not have strong tobacco control policies in the presented settings, and the potential of such policies throughout Europe will be discussed.

Policies to reduce availability of tobacco products in the retail environment

Abstract Background After implementation of a tobacco vending machine ban in 2022 and a supermarket sales ban in 2024, the Dutch government intends to further phase out tobacco sales after 2030 by prohibiting sales in petrol stations and small outlets. This study aims to understand 1) the impact of these policies on tobacco outlet availability, and 2) differences in tobacco outlet availability by area socioeconomic status (SES) in the Netherlands. Methods Between September 2019 and June 2020, all potential tobacco retailers in four Dutch cities (Amsterdam, Eindhoven, Haarlem, and Zwolle) were visited and mapped using Global Positioning System (GPS). Expected reductions in tobacco outlet availability were calculated per policy measure. Tobacco outlet density was calculated using ESRI ArcMap version 10.4.1. The association between neighbourhood SES and tobacco outlet availability was estimated with linear and logistic regression model. Results We identified 870 tobacco outlets and an outlet density of 6.2/10.000 capita. The potential sales bans in petrol stations and small outlets would reduce the number of outlets (resp. -7% and -43%) and the outlet density (resp. -0.4 and -2.7). In Eindhoven, Haarlem, and Zwolle, neighbourhoods with high-SES compared to low-SES were less likely to contain a tobacco outlet (OR:0.71, 95%CI:0.59-0.85) and had a lower outlet density (ß:-1.20, 95%CI:-2.20;-0.20). In Amsterdam, the associations were inverse (OR:1.22, 95%CI:1.05-1.40; ß:3.50, 95%CI:0.81;6.20). Conclusions The availability of tobacco outlets varies within and between cities depending on the distribution of the built environment. Future tobacco control policies targeting the retail environment should focus on limiting the overall number tobacco outlets and especially small outlets, which may benefit low SES neighbourhoods in mid-sized cities most.

Policies restricting flavors and non-cigarette tobacco product availability: A study of vape shops in San Francisco and Alameda Counties, California, USA

We examined flavored non-cigarette tobacco availability in brick-and-mortar vape shops in San Francisco (SF) and Alameda Counties, California (USA), comparing cities organized by flavored tobacco sales restriction policy. A total of 22 brick-and-mortar vape shops were identified and audited in October-November 2019; shops were located in SF City-County and nine cities in Alameda County. Fisher Exact Tests were used to assess differences in the availability of products between vape shops in cities with versus without comprehensive or partial flavored tobacco sales restrictions enacted before November 21, 2019 (n = 15 shops in six cities with policies vs n = 7 shops in four cities without policies). In the six cities with any flavored sales restrictions, fewer vape shops sold menthol/mint flavored JUUL pods (27% vs 71%, p = 0.074), candy/fruit (53% vs 100%, p = 0.051) and menthol/mint (53% vs 100%, p = 0.051) nicotine e-cigarette liquids compared to cities without flavored tobacco sales restrictions, but results were borderline significant. Tobacco-flavored JUUL pods (47% vs 71%, p = 0.381), tobacco-flavored nicotine e-cigarette liquids (67% vs 100%, p = 0.135), and flavored e-cigarette liquids without nicotine (candy/fruit: 87% vs 71%, p = 0.565 and menthol/mint: 87% vs 57%, p = 0.274) were not included in the policies, and availability was not significantly different between cities with or without policies. Enactment of local policies was associated with lower flavored e-cigarette tobacco product availability but not tobacco-flavored or non-nicotine product availability; federal policies restricting sales of flavored tobacco products may reduce access to flavored e-cigarette products in vape shops.

Urban-rural differences in tobacco product availability in food retailers, United States, 2017.

Tobacco use prevalence is higher in rural compared to urban settings, possibly due to differences in tobacco availability, including the option to purchase food and other essential items in stores that do not sell tobacco (tobacco-free food retailers). The goal of this research is to determine whether tobacco-free food retailer availability varies by urbanicity/rurality. Using the 2017 National Establishment Time-Series database, we identified food retailers across all census tracts containing food retailers in the United States (n = 66,053). We used multivariable logistic and linear regression models to test whether tobacco-free food retailer availability varied across 4-levels of census tract urbanicity/rurality (urban, suburban, large town, and small town/rural) for 2 outcomes: (1) the presence of at least 1 tobacco-free food retailer and (2) the percent of all food retailers that were tobacco-free. Compared to urban core census tracts, suburban census tracts had a lower odds (aOR = 0.77, 95% CI = 0.73, 0.81) of having at least 1 tobacco-free food retailer, while small town/rural census tracts had greater odds (aOR = 1.23, 95% CI = 1.15, 1.32). Suburban census tracts (B = -2.29, P < .001) and large town census tracts (B = -1.90, P < .001) also had a lower percentage of tobacco-free food retailers compared to urban census tracts. Compared to urban cores, tobacco-free food retailers were less prevalent in suburban and large town areas, though similarly or slightly more available in rural areas. Future research should assess whether these differences depend on varying store types.

Tobacco retailers around schools in 10 cities across China

ObjectiveThis study explored the nature and extent of tobacco product availability at retailers near junior, senior and vocational high schools in rural and urban areas in 10 cities across China,...

Flavored Tobacco Sales Restrictions Reduce Tobacco Product Availability and Retailer Advertising.

Objective: This study examined differences in the availability and advertising of flavored tobacco products before and after flavored tobacco sales restrictions were enacted in Alameda and San Francisco Counties in California. Main outcome measures: Data were collected from a sample of tobacco retailers in Alameda and San Francisco Counties at two time points: 2015, before flavored tobacco policies were enacted, and in 2019–2020, after some cities had enacted policies. Retailers were separated by city into Category 1 (n = 442)—retailers in cities that enacted a flavored tobacco policy between the two data collection periods, and Category 2 (n = 89), those that had not. Means comparison tests were conducted to evaluate significant differences over time and by category. Results: There was significantly reduced availability of menthol cigarettes, flavored little cigars, smokeless tobacco, vape pens, and Blu brand menthol e-cigarettes between 2015 and 2020 in Category 1 retailers. Category 2 retailers had reduced availability only for Blu menthol e-cigarettes and demonstrated an increase in smokeless tobacco availability. Exterior store advertising for cigarettes, little cigars, cigars, and e-cigarettes also decreased significantly in Category 1 cities relative to Category 2 cities; 8.1% of Category 1 stores were advertising flavored tobacco products in 2019–2020 compared to 36.2% of Category 2 stores. There was also a 78% reduction in flavored ads between 2015–2019 in Category 1 cities compared to a 38% decrease in Category 2 cities. Tobacco advertising inside Category 2 stores increased. Finally, Category 2 cities had significantly greater availability of cigalikes, mod or tank vapes, flavored e-cigarettes, and e-liquids compared to Category 1 cities. Conclusions. Comprehensive flavored sales restriction policies reduce flavored tobacco availability and tobacco advertising, which may help prevent youth tobacco initiation and exposure.

Tobacco product use for weight control as an eating disorder behavior: Recommendations for future clinical and public health research.

Tobacco product use (TPU; e.g., smoking, e-cigarettes, other emerging products) is elevated in eating disorders (EDs), yet the phenomenology of tobacco use within EDs has not received much attention. Due to the appetite suppressant effects of tobacco products as well as the array of availability of tobacco products in hedonic flavors (e.g., gummy bear, fruit), TPU may be used for weight control, such as to suppress appetite, satisfy cravings, or for meal replacement. The purpose of this article was to outline theoretical research on TPU for weight control as a mechanism in EDs as well as key areas for future research. We discuss the conceptualization and nature of TPU for weight control and how it may be related to EDs and associated behaviors, TPU patterns and smoking for weight control in EDs, and the effectiveness of current interventions and development of novel intervention protocols for individuals with EDs who use tobacco. Overall, this article outlines novel research questions on TPU in EDs and as a weight control behavior and provides recommendations to clarify the conceptualization and role of TPU within EDs.

Sociodemographic inequities in tobacco retailer density: Do neighboring places matter?

We apply a spatial perspective to measure the extent to which the 2018 U.S. racial, ethnic, and socioeconomic composition of census tracts were each associated with tobacco retailer density within a tract and in its neighboring tracts (n=71,409). A 10-percentage point increase in the Black population was associated with 0.07 (p<0.05) more retailers per square mile within a focal tract and 0.35 (p<0.001) more retailers per square mile in its neighbors on average. A greater percent of Hispanic/Latino residents was associated with more retailers per square mile, both within a focal tract (b=0.95, p<0.001) and in its neighbors 0.39 (p<0.001). Inverse associations were observed for percent white. We also observed inequities by socioeconomic status. The overall magnitude of inequities may be underestimated if the spatial dependence between focal tracts and their neighbors are not taken into consideration. Policymakers should prioritize interconnected geographic areas experiencing high racialized and socioeconomic segregation when designing and implementing policies to reduce retail tobacco product availability.

Ability to Purchase Tobacco Products and Smoking Behavior of Cigarettes, E-cigarettes, and Heated Tobacco Products in Korean Adolescents.

Objectives: This study investigated the smoking behavior and its association with the availability of tobacco products purchases among Korean adolescents. Methods: The data of the 2019 Korea Youth Risk Behavior Survey were used (N =57,303). This study assessed 3 tobacco products: cigarettes, e-cigarettes, and heated tobacco products. Smoking behavior including lifetime, current, daily, heavy smoking, and attempting to quit and its association with the availability of tobacco products for purchase was assessed. Results: Overall, 92.9% did not try to purchase tobacco products during the past 30 days, 2.2% found it impossible to purchase, 0.8% could buy with a lot of effort, 1.7% could buy with little effort, and 2.3% could buy easily without any effort. Lifetime smokers were 13.8% (12.7% for cigarettes, 7.4% for e-cigarettes, and 4.9% for heated tobacco products). Among lifetime smokers, the current smoking rates for cigarettes, e-cigarettes, and heated tobacco products were 48.5%, 22.9%, and 19.0%, and the rates were lower in adolescents who responded that it was impossible to buy tobacco products. Among current smokers, the daily smoking rates were lower in adolescents who were found it impossible to buy tobacco products. Conclusions: The ease of access to tobacco products was associated with higher use of cigarettes, e-cigarettes, and heated tobacco products and lower attempts to quit smoking in Korean adolescents.

Tobacco retailer density and smoking behavior in a rural Australian jurisdiction without a tobacco retailer licensing system.

INTRODUCTIONAn emerging body of research has developed around tobacco retailer density and its contribution to smoking behavior. This cross-sectional study aimed to determine the association between tobacco retailer density and smoking behavior in a rural Australian jurisdiction without a tobacco retailer licensing system in place.METHODSA local government database (updated 2018) of listed tobacco retailers (n=93) was accessed and potential unlisted tobacco retailers (n=230) were added using online searches. All retailers (n=323) were visited in 2019 and GPS coordinates of retailers that sold tobacco (n=125) were assigned to suburbs in ArcMap. A community survey conducted in the Local Government Area provided smoking and sociodemographic data amongst adult respondents (n=8981). Associations between tobacco retailer density (calculated as the number of retailers per km2 based on respondents’ suburb of residence) and daily, occasional and experimental smoking were assessed using multilevel logistic regression analysis. Separate models with and without covariates were undertaken.RESULTSWithout adjusting for possible confounders, living in suburbs with greater retailer density did not increase the odds of daily smoking (OR=1.01; 95% CI: 0.92–1.12), occasional smoking (OR=1.05; 95% CI: 0.94–1.18), or experimental smoking (OR=0.98; 95% 0.92– 1.05). However, after adjustment, living in suburbs with greater retailer density increased the odds of occasional smoking behavior (AOR=1.37; 95% CI: 1.10–1.71) but not daily or experimental smoking.CONCLUSIONSThis study found a significant positive association between tobacco retailer density and the likelihood of occasional smoking in a rural Australian jurisdiction without a tobacco retailer licensing system in place. The findings strengthen calls for the introduction of a comprehensive, positive tobacco retailer licensing system to provide a framework for improving compliance with legislation and to reduce the overall availability of tobacco products in the community.

Flavored Tobacco Sales Prohibition (2009) and Noncigarette Tobacco Products in Retail Stores (2017), New York City.

Objectives. To assess explicit- (products clearly labeled flavored) and emergent concept- (products implying flavoring but not clearly labeled) flavored tobacco product availability following New York City's flavor restriction.Methods. We examined explicit- and concept-flavored tobacco product availability, with 2017 New York City Retailer Advertising of Tobacco Survey data (n = 1557 retailers). We assessed associations between block group-level demographic characteristics and product availability by using logistic regression.Results. Most retailers sold explicit-flavored (70.9%) or concept-flavored (69.3%) products. The proportion of non-Hispanic Black neighborhood residents predicted explicit- and concept-flavored product availability, as did having a high school within a retailer's block group for concept-flavored products.Conclusions. Explicit- and concept-flavored other tobacco products persisted throughout New York City, despite 2009 legislation restricting sales.Public Health Implications. Making local sales restrictions or federal production bans inclusive of all explicit and concept flavors would reduce retailer and industry evasion opportunities and protect the health of youths and others.

Dual Burden of Smoked and Smokeless Tobacco Use in India, 2009-2017: A Repeated Cross-Sectional Analysis Based on Global Adult Tobacco Survey.

The dual use of smoked and smokeless tobacco (SLT) poses a serious challenge to tobacco control efforts. This article examines the trends and patterns of this usage in India during the period 2009-2010 and 2016-2017. Data from two rounds of nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009-2010 and 2016-2017 have been used. Dual use was assessed based on current smokers and SLT users in both rounds. Findings reveal that dual use in India has dropped from 5.3% during 2009-2010 to 3.4% during 2016-2017, a decline of nearly 10 million dual users. However, some states have added nearly 4.6 million new dual users during this period. While dual use continues to remain high in rural areas, there has been a manifold increase in urban areas. Findings revealed that intention to quit tobacco was lower among dual tobacco users as compared to single users with considerable difference between urban and rural areas. Easy availability and affordability of SLT products compared to smoking products and restrictions on smoking in public places may have pushed current smokers and dual users to take to or intensify their SLT consumption. Measures relating to awareness, pricing, taxation, and enforcement of tobacco control laws should focus on all forms of tobacco, especially targeting high dual burden in rural and urban settings. Dual form of tobacco users represent 12% of all tobacco users in the country. The study reveals that intention to quit tobacco among dual users is significantly lower than that among single tobacco product users. This requires improving public awareness about the morbidity and mortality that arises from the use of all forms of tobacco products. Efforts to restrict the availability of tobacco products should focus on licensing the sale of all tobacco products. Reduction in dual tobacco use will not only result in multiplied health benefits but also help in achieving the Non-Communicable Diseases targets under the United Nations Sustainable Development Goals.

Retail Tobacco Marketing in Rural Versus Nonrural Counties: Product Availability, Discounts, and Prices.

Objectives. To assess tobacco product availability, advertised discounts, and prices in rural and nonrural stores, comparing results for two definitions of rural. Method. This geospatial study linked data from marketing surveillance in a representative sample of licensed tobacco retailers in California (n = 1,276) and categorized rural/nonrural stores at the county and tract levels. Data were collected from January to March, 2017, and mixed-models analyses tested for differences by location (rural vs. nonrural). Results. Compared to nonrural stores, rural-county stores were 2.1 (95% confidence interval [CI; 1.2, 3.6]) times more likely to sell chewing tobacco and 2.5 (95% CI [1.4, 4.2]) times more likely to sell roll-your-own. Rural-county stores sold larger packs of cigarillos for less than $1 (coefficient = 0.22, 95% CI [0.05, 0.39]) and charged less for the cheapest cigarette pack regardless of brand (estimated mean difference = $-0.21, 95% CI [-0.39, -0.03]). Contrary to expectation, a popular brand of chewing tobacco cost more in rural-county stores. A tract-level definition of rural reclassified only 1 in 10 stores, and did not substantially alter the results. Overall, 32.9% of stores advertised discounts on chewing tobacco, but this was more common in rural than nonrural census tracts (adjusted odds ratio = 1.81, 95% CI [1.14, 2.88]). Discussion. Evidence that $1 buys more cigarillos in rural-county stores than elsewhere adds to health equity concerns that the prevalence of cheap, flavored tobacco is not limited to neighborhoods characterized by socioeconomic disadvantage, higher proportions of African Americans, and higher proportions of school-age youth. Policies that focus on the retail environment for tobacco are needed to make tobacco less attractive and more costly everywhere, including rural areas.