The Importance of Point of sale Counter Tobacco Allison E. Myers, MPH Kurt M. Ribisl, PhD Adapted from a presentation given January 16, 2013 Office of Smoking and Health Centers for Disease Control and Prevention Atlanta, GA Updated March 26, 2019

3 Shelving Units: Marlboro. Camel. White Owl One dozen signs: Winston. 72’s. Special Blend One function item. E-cigarettes: Krave Flavored LCC SNUS/Smokeless

$7.3 Billion Tobacco Industry Marketing Expenditures Industry spends $1M/hour at retail $7.3 Billion Spent in 2017 on cigarette and smokeless tobacco marketing at the point of sale Cigarettes Smokeless Tobacco Federal Trade Commission Cigarette and Smokeless Tobacco Reports In fact they spend over $7 billion a year on this type of marketing-- equal to 89% of their TOTAL advertising and promotion budget and more than they spend in any other place. These numbers come from the Federal Trade Commission Reports which track expenditures by the big 6 tobacco companies. Our forty years of tobacco control success has squeezed the tobacco industry into retail stores– due to the MSA and TCA the industry can no longer advertise on TV or billboards. The store is one are left largely open to the industry. Obviously if the industry is spending that much money in one place, they think it is important and we do too. Federal Trade Commission Smokeless Tobacco Report for 2017. Washington, D.C. 2019 Federal Trade Commission Cigarette Report for 2017. Washington, D.C. 2019

Industry is buying health behavior impact Consider three customer segments: NEVER-SMOKER SMOKER TRYING TO QUIT

Consider three customer segments: NEVER-SMOKER

Kids are frequent c-store shoppers 2011-12 nationally representative sample of 13-16 year olds: Almost half (48%) visit at least once a week1 C-stores have more tobacco marketing materials than other store types2-5 Okay, I’ve already hinted that the tobacco industry is buying health behaviors and health outcomes – specifically, that they are purchasing youth initiation of tobacco products. Let’s talk about how that happens. First, you need to know that young people are frequent convenience store shoppers. (Remember when I said that most cigarettes are purchased from c-stores? That’s important.) There have been several studies over time about the frequency of kid visits to c-stores and I want to share data from the newest one with the most rigorous methods. These data come from a nationally representative sample of 2,772 13-16 year olds, conducted in 2011 and 2012. About half – 48% of the kids surveyed -- stated they visited a convenience store at least one a week. What this tells us is that half of our children in the US, at least, are routinely exposed to product displays and advertising for tobacco as well as alcohol, sugar sweetened beverages and other unhealthy products. Even worse, many studies have shown that c-stores have more tobacco marketing materials than other store types (e.g., a grocery store or pharmacy). Sanders-Jackson, et al., 2015; 2. Feighery, et al., 2008; 3. Henriksen, et al., 2008; 4. Henriksen, et al., 2010; 5. SGR Report, 2012.

Exposure to in-store marketing linked to tobacco use initiation Children and adolescents more frequently exposed to POS tobacco promotion have ~1.6 times higher odds of having tried smoking and ~1.3 times higher odds of being susceptible to future smoking compared to those less frequently exposed. I imagine you guessed this, and it’s important to know we have the empirical evidence to confirm that your guesses are true. Note we’ve measured initiation and smoking lots of different ways in this study – ever smoking, experimental smoking, initiation, becoming a daily smoker – all studies point to the same thing: the marketing and branding in the store environment WORKS to build a relationship with kids, and kids start smoking as a result of exposure to retail tobacco marketing. Robertson, et. al. Point-of-sale tobacco promotion and youth smoking: a meta-analysis. Tobacco Control, 2016

Shopping, brand impressions prompt initiation NEVER-SMOKER Henriksen, et al., 2010, Pediatrics GREATER VISIT FREQUENCY, GREATER BRAND IMPRESSIONS = HIGHER ODDS OF INITIATION

From never-smoker to established-smoker PUFFER Greater ADVERTISING in stores = 8% higher odds of becoming a puffer. Slater, et al. (2007) Arch Pediatr Adolesc Med

From never-smoker to established-smoker PUFFER EXPERIMENTER ESTABLISHED Greater ADVERTISING in stores = 8% higher odds of becoming a puffer. Greater PROMOTIONS in stores increase odds of youth moving towards higher levels of uptake. Slater, et al. (2007) Arch Pediatr Adolesc Med

Consider three customer segments: SMOKER TRYING TO QUIT

Cigarette display cues craving SMOKER Carter, et al., 2006, Nicotine & Tobacco Research PICTURE OF EIGHT CIGARETTE PACKS INCREASED CRAVING AMONG NICOTINE-DEPRIVED AND NON-NICOTINE DEPRIVED SMOKERS

Cigarette displays prompt impulse purchase SMOKER TRYING TO QUIT Wakefield, et al., 2008, Addiction SMOKERS NOTICE THE DISPLAY. SOME GET THE URGE TO BUY. SOME BUY, EVEN THOUGH TRYING TO QUIT

Close proximity associated with less long term quit success Retailer density and proximity are important in helping understand the negative environmental and community impact of tobacco retailers. We now have evidence that residential proximity to a tobacco retailer is correlated with a smokers’ ability to stay quit. On the slide here we see results from a study by Lorraine Reitzel and others from 2010. It shows us that if a recent quitter lives within 250 meters of a tobacco retailer, his or her odds of staying quit over 6 months are HALF that of someone who does NOT live within 250 meters of a retailer. As a reference point, 250 m (or 820 feet) is just shy of 3 football fields. Reitzel, et al., 2010, American Journal of Public Health

Retailer density near schools linked to prevalence NO RETAILERS (n=45) LOW DENSITY (1-5) (n=43) HIGH DENSITY (>5) (n=47) 11.9% prevalence 13.6% prevalence 15.1% prevalence Henriksen, et al., 2008: Preventive Medicine AREAS WITH HIGHER RETAILER DENSITY (>5) WITHIN WALKING DISTANCE HAD HIGHER OVERALL SMOKING PREVALENCE (15.1%)

Higher density associated with initiation among US young adults 2013 nationally representative sample of young adults aged 18-34, merged with 2012 US tobacco retailer list and home addresses Higher retailer density associated with higher likelihood of initiating cigarette use among 25-34 year olds (OR=3.75, 95% CI 1.18, 11.90) Higher retailer density associated with higher likelihood of initiating non-cigarette combustible use among 18-24 year olds (OR=3.16, 95% CI 1.03, 9.74) Higher density is also associated with initiation among US young adults – both for cigarettes, but also for non-cigarette combustible products like little cigars and cigarillos. In this study, the researchers compared where young adults lived with a tobacco retailer list on a national level, and found that where there was a higher density of tobacco retailers, young adults 25-34 yr old age range were over 3 times as likely to initiative cigarette use, and young adults 18-24 years old were over 3 times as like to initiate use with products like little cigars and cigarillos. (Note: that there was a positive correlation between the younger age group and cigarettes, but not significant enough to claim) Retail point of sale is designed to attract new tobacco users, discourage quitting, and create a normative environment [of acceptance and desirability]. Cantrell, et al., 2015.

Summary: $1M/hour well spent New York Data – What’s In Store Campaign Retail marketing: Prompts initiation Promotes daily consumption Discourages quitting