Background: Although the use of a geographical information systems (GIS) approach is usually applied to epidemiological disease outbreaks and environmental exposure mapping, it has significant potential as a tobacco control research tool in monitoring point-of-purchase (POP) tobacco advertising.
Design: An ecological study design approach was applied so as to primarily evaluate and interpret the spatial density and intensity of POP and tobacco industry advertisements within <300 m to high schools in Greece with the application of GIS methodology combining mapping, photographing and global positioning data.
Results: The GIS approach identified 133 POP and 44 billboards within 300 m of the school gates of Heraklion schools. On average 13 POP (range 4–21) and 4.4 billboards (range 1–9) were located per school, and all had at least 1 POP within 20 m of the school gate. On average (SD) 9 (6) tobacco advertisements per POP (range 0–25) were noted, and 80% of them were below child height. The GIS protocol identified that kiosks, that were excepted from the Greek ban on tobacco advertising, in comparison to other POP, were found not only to be closer and visible from the school gates (44.1% vs 10.8%, p<0.001) but were also found to have more external advertisements (8 (5) vs 5 (3), p<0.001).
Conclusions: This study demonstrates the effectiveness of a GIS system in monitoring tobacco industry advertising on a large population-based scale and implies its use as a standardised method for monitoring tobacco industry strategies and tobacco control efforts.
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The tobacco industry’s proliferation is undisputedly corroborated by the staggering fact that almost 20% of European 13–15 year olds are current tobacco users and that one in three non-smokers of that age report susceptibility to smoke within the next year.1 2 Tobacco use is currently the cause of the largest number of preventable deaths worldwide, and will be responsible for the deaths of more than 170 million children alive today if measures are not taken to reduce the current escalating pandemic.3
Many internal and external factors affect the risk for adolescent smoking. Peer pressure, parental smoking, depression, stress, promotional activities and exposure to tobacco advertising have all been correlated with increased smoking rates among adolescents.4 Among the above, tobacco industry advertising through points-of-purchase (POP) and billboards plays a crucial role in adolescent seduction, whereas subsequent tobacco experimentation is the next perilous step towards nicotine addiction, on which the tobacco industry’s future prosperity depends. Exposure to tobacco advertising, price and youth access to tobacco products are major factors that influence tobacco consumption, experimentation, relapse and increase smoking prevalence among youth, and it has been shown that teenage smokers prefer the cigarette brand most heavily advertised in the convenience store closest to their school.5–12
Since legislation banning advertising on television, radio and printed press is a fact in the majority of developed countries, the tobacco industry has focused a larger part of its expenditure towards POP advertising and promotional activities.13 Internal tobacco industry documents have illustrated that the European Union (EU) Directive 98/43/EC that proposed bans on all forms of direct and indirect tobacco advertising was severely undermined at the EU and local level. After the partial tobacco advertising ban of the EU directive 2003/33/EC, the tobacco industry shifted towards heavy advertising at POP, exploiting in Greece the exempted (by the previous directive) kiosks, as seen ubiquitously at the local level and clearly documented through tobacco industry internal reports.14 15
The community’s exposure to tobacco industry activities, such as POP advertising and promotional activities, is very similar to exposure from environmental pollutants. The higher the exposure to tobacco advertising, the higher the chance that the adolescent will experiment with smoking; a pattern very similar to, for example, the relationship between exposure to environmental pollutants and blood lead levels or sources of infection to disease outbreak. The more an individual is exposed to a pollutant or source of disease, the more likely he/she will suffer from the consequence of that exposure.12 16
A methodological approach commonly used by epidemiologists and public health advocates for monitoring exposure, outbreaks and access to health care services is the use of a geographical information system (GIS).16–18 A GIS combines multiple or complex data from different sources and then displays the spatial density of the above in the form of maps, which can be helpful for understanding and monitoring the spread of exposure or outcome and designing the future actions that need to take place to promote and protect public health.19
Taking the above into account the aim of this study was to apply standardised GIS methodology to measure the spatial density of tobacco industry advertisements within close proximity (<300 m) to high schools in Greece so as to evaluate its usefulness as a tool for monitoring tobacco control efforts.
Study area: sample
The city of Heraklion is the fourth largest city in Greece. Located on the island of Crete it has a population of 130 000. For the purpose of our study all 13 high schools within the municipality of Heraklion (9 junior high, ages 12–15; and 8 senior high schools, ages 15–18) that were housed in 10 school complexes—with a total of approximately 7000 adolescent students (12–18 years old)—were evaluated for their close proximity to tobacco POP and tobacco advertisements during the months of June and July 2007. Prior to the study ethics approval was obtained.
GIS methodology: study procedure
The location of each school was identified on a city map of Heraklion with the help of its global positioning system (GPS) coordinates and a circle of 300-m radius was calculated around the school location on the map so as to define the area of close proximity to the school gates and to subsequently calculate the density of POP and tobacco advertisements within this area. A 300 m radius from the school gate (approximately 1000 feet) was chosen, as it practically incorporates the immediate neighbourhood of the schools and is the area within short walking distance of the gate that an adolescent would usually take to go to and from school by foot (the city of Heraklion is densely populated, so foot travel to school is commonplace). Researchers travelled to each school and photographed it as close as possible to the front gate entrance using a Ricoh Caplio GPS camera (Ricoh, West Caldwell, New Jersey, USA). This position acted as the centre of the study area. In addition to a photographic image of the school, the camera recorded the school’s latitudinal and longitudinal coordinates via GPS. Researchers then travelled by foot and/or motorbike along every road within a school’s 300-m radius and identified all potential POP and points of tobacco advertisements (billboards, bus stops etc). Any store that could possibly (legally or illegally) sell cigarettes was identified, photographed and its GPS location stored. Any POP that was marginally on the outskirts of the 300 m boundary was also photographed and its GPS coordinates stored and subsequently included or excluded during data analysis if according to the final GPS coordinates the POP was in or out of range, respectively. All convenience stores, kiosks (periptera), betting parlours, supermarkets, billboards and bus stops within the area were visited. Additionally, Marlboro-owned stores, although counted as a POP of tobacco products in the study, were excluded from the tabular data due to the fact that it was impossible to count the exact number of adverts within as posters, display units, cigarette shelving and brand logos were on every available surface of the interior and exterior.
All GPS photographs were uploaded to a computer using the Caplio server software and then uploaded to Google Earth (http://earth.google.com/) via GPS Photo Link software (GeoSpatial Experts, Thornton, Colorado, USA) and processed and plotted-marked on existing satellite image photos.20
External–internal advertising intensity evaluation
Data elements that were recorded included their visibility from the street, location on the outside of the store (eg, doors, windows), illumination and number of total advertisements. The researchers then entered the POP and carefully observed all areas for internal advertisements of tobacco products and proceeded to purchase at least one item (<1 Euro) in the store, such as a bottle of water or a newspaper. All caution was taken so as not to provoke the curiosity of the storeowners or clerks, and the researchers were never questioned by the shop personnel. Observations of internal advertisements were also recorded using a POP survey questionnaire but the data collector (the same every time so as to eliminate inter-rater variability) did not take notes or complete the observation form until they left the store. Data elements in regards to tobacco products that were collected include the total number of advertisements, their illumination, possible motorisation (if the advertisement was spinning or moving), their height (at child’s eye level or not), their accessibility (whether the customer could manually select tobacco products), any single and multi-pack promotions along with any other promotional offers, possible functional objects (eg, change trays, counters, or storage areas) with industry logos or industry colours, and the location of shelving (next to the cash register or on the sales counter) within the store premises.
The statistical analysis was performed using the statistical package SPSS V. 15.0 (SPSS, Chicago, Illinois, USA). Statistical importance was defined as p = 0.05. χ2 tests were used during comparisons between different venues and Student t tests were applied in correlations when the number of advertisements per venue was taken into account.
GIS data on spatial density and intensity of tobacco industry activities
The exact number and position of POP and advertisement around all high schools in Heraklion, Crete was calculated and logged, allowing for the complete mapping of the city of Heraklion and the location of all 133 POP. All 17 schools of Heraklion had at least 1 POP within 20 m of the school gate, with 31.3% of all POP visible from the actual school grounds; this percentage differed according to the type of POP (kiosks vs convenience stores; p = 0.001), stressing the role of kiosks in providing tobacco products.
Two examples of the output of the GIS in regards to the final spatial density of POP and tobacco advertisements within 300 m of a high school can be seen in figs 1 and 2, where one can clearly note (clearer in fig 2) the marketing approach used by the tobacco industry as the majority of the tobacco advertisements and POP were positioned along the main walkways and bus routes that lead between the school and the city centre and along main traffic routes. The above spatial resolution seen in figs 1 and 2 in combination with the individual data collected for each POP allow for calculation not only of the density of POP venues but also of the intensity of tobacco industry advertising activities within each POP, as seen in table 1. On average, there were 13 POP within 300 m of each school gate, with the range of POP between schools being 4 (for a school in an under-built area in the outskirts of the municipality with few buildings in the area) to 21 within close proximity to the largest high school in suburban Heraklion (fig 1). As for other positions of tobacco advertisements, there were on average 4.4 on billboards or bus stop shelters within 300 m of the school gates that depicted tobacco advertisements (range 1–9 per school complex).
Almost 98% of POP had tobacco advertisements externally that could be seen from the street with the mean number of external tobacco advertisements per POP differing according to their type, with kiosks found to have a higher number of advertisements in comparison to convenience stores (mean (SD) 8 (5) vs 5 (3), p<0.001). Throughout all POP investigated in this study 80% of kiosks (externally) and almost 80% of convenience stores had advertisements at child’s eye level (below 1.30 m) as also elaborated in table 2. In addition to the data presented below, the three Marlboro-owned stores in Heraklion at the time the study heavily increased the number of advertisements found in each POP, as the whole store exterior acted as one large tobacco advert, as can be seen in fig 3A.
The mean number of advertisements within the tobacco POP ranged from 0 to 25, with an average of 9 (6) (11 (6) for convenience stores and 9 (5) for kiosks). Again, the three Marlboro-owned stores were excluded from the tabular data as the entire interior was dressed in company posters, logos, colours, TV screens and a “power wall” of tobacco packets behind the cashier as seen in fig 3B. Additionally, as seen in table 2, in 14% of POP one could directly access the tobacco products without having to ask the store clerk, and almost one in three POP provided some form of single sale tobacco product.
A GIS approach for monitoring exposure to tobacco sales and advertising is feasible and relatively easy to perform with minimal cost. The high number of tobacco POP and advertisements in close proximity to high schools in Greece was alarming but provided the ideal study population and catchment area for monitoring the usefulness of such a tool.
The importance of the kiosk (periptero) in providing a means for tobacco sales and tobacco advertising in Greece is clearly depicted by the fact that in comparison to convenience stores that sell tobacco products, kiosk are closer, more in view of the school gates and have a higher number of advertisements and prospective future customers, due to their immediate visibility and close proximity to school gates (<20 m). Our findings are in line with the internal tobacco industry documents that stressed the need for kiosks to be exempted from relevant EU legislation as they are an important mean of consumer/industry interaction.15–21 According to the 2005 Euromonitor results, the kiosks are responsible for 95% of the cigarette sales in Greece, although their definition of kiosks is slightly broader and also includes small convenience stores.22
GIS and advertising in Greece
When taking into account the fact that every school was found to have a POP for tobacco products within 20 m of their gates and that 44% of all kiosk POP within the 300 m radius of the school could be seen from the actual school playground, one can comprehend the level of tobacco industry advertisements Greek adolescents are exposed to. Preschool and primary school children living in the area are also exposed to this high level of tobacco marketing, and research has shown that they too are affected and are able to recall tobacco advertisements and familiarise themselves with tobacco products.23 24 According to the Greek Global Youth Tobacco Survey (GYTS) results, more than 70% of adolescents reported seeing a pro-cigarette advertisement on a billboard over the past 30 days, but firstly we find this number to be quite modest and secondly it does not include extensive POP advertising.25 Legislation in Greece currently permits billboard and POP advertising, as it also permits tobacco sales to minors and the sale of smaller/cheaper 10 packs, but—at least on paper—forbids the use of tobacco products in school premises, a bill that we have previously stated to be flagrantly ignored by school teachers and pupils.26 In addition to the above, health education as part of the high school curriculum is non-existent and no variations in either school policies on tobacco education and use on school grounds exist in the study catchment area, a fact corroborated by the general pro-smoking norm, especially among adolescents.27
Cigarette pack displays were found to play a central role in interior POP advertising and are recognised as crucial communication devices for creating and reinforcing brand imagery,28 as also seen by the recent introduction of “power walls” in Greece and in our study catchment area. It is of interest to state that although only approximately 8% of adult smokers consume Marlboro, 47.8% of smoking adolescents smoke Marlboro; a fact that might be attributed to the aggressive advertising campaigns and marketing strategies, a significant amount of which is centred around POP and Marlboro stores around Greek schools as depicted by our study.22 25 Almost 90% of POP in our study were found to have shelving with brand logos next to the cash register, identical to the findings of Feighery et al, who also stated that 85% to 90% of cigarette marketing materials are concentrated around counter areas where customer exposure is unavoidable.29 Indisputable research has shown that youth are especially susceptible to such POP marketing displays.6 30 31 According to a study by Wakefield et al, POP advertisements have been rated by smokers as a reason for impulse purchase and noted as a hindrance to their quitting attempts. Younger smokers are more likely to notice these cigarette displays and tend to be more likely to purchase on impulse at the same time as shopping for other goods.7
What this paper adds
Although geographical information systems (GISs) have been used in other forms of epidemiological studies they have not yet been applied in tobacco control monitoring efforts. As tobacco advertising is directly related to smoking initiation the prohibition of tobacco advertising is imperative.
The use of a GIS methodological approach can provide the community and the media with the necessary data on the geographical spatial density and intensity of tobacco industry marketing activities, which can be used to persuade local politicians to intensify tobacco control efforts and take action to protect public health.
In our case, the GIS approach successfully identified the kiosks, exempted from the Greek tobacco control legislation, as the key venues of tobacco product advertising in Greece.
Tobacco control implications of the use of a GIS
The significance of preventive public health policy measures in reducing adolescent smoking has been an area of increasing research interest over recent years, and the provision of spatial data through the use of a GIS can enhance the efficiency and effectiveness of public health surveillance relative to tobacco control.
Research has implied that limited advertising bans have only a narrow effect of consumption and a significant decrease in tobacco consumption is only possible with comprehensive advertising bans.32–34 Despite most countries abolishing tobacco advertising via the television and radio, tobacco advertising continues through POP, billboards and promotional and sponsorship activities.35 Mass media anti-tobacco campaigns may partially counterbalance the above, as exposure to state-funded anti-tobacco advertisements have been associated with lower perceived rates of friends smoking and a greater perceived harm of smoking.36 37 The Framework Convention on Tobacco Control (FCTC) has acknowledged the role of pro-tobacco and counter-tobacco-related advertising and has included such a directive in its protocol, which more than 150 countries have now ratified.38
The use of physical investigation, city maps and GPS coordinate systems in this GIS approach validated the accuracy of the number and exact position of POP or tobacco advertisements within close proximity to the school gate, and helped validate the use of this tool as a method for monitoring tobacco advertising on a large scale. This methodological approach is relatively inexpensive as limited training is necessary, and the software and photo-GPS recorder are easily available. Although the GIS protocol provides only a cross-sectional snapshot of the current situation, this can be repeated every few months and thus provide an insight in the trends over time. The only drawback that we could note is the fact that one would have to fund field researchers to perform the physical mapping each time the survey is performed. The approach we performed in the city of Heraklion by scanning the catchment area by motorbike and foot allowed us to avoid city traffic, and thus was practical and is highly recommended.
In addition to monitoring tobacco industry activities this GIS methodology could also be applied by tobacco control advocates so as to monitor the location of smuggled or counterfeit tobacco routes (for use by customs officers and police), effectively position anti-tobacco advertisements and smoking cessation clinics, and locate areas of high exposure where community or school-based health promotional activities could intensify. Subsequently, a tobacco control-oriented GIS can provide information across geopolitical regions and provide the community and the media with the necessary mapped data that locate regional variations that can be used to persuade local politicians to take action and promote public health.
The large study population which was assessed for exposure to tobacco advertisements and the use of all schools of the municipality of Heraklion, the fourth largest city in Greece, firstly allowed us to test the use of GIS protocol in a large-sized community that is highly exposed to tobacco advertising and secondly to generalise our findings and state that the level of exposure to tobacco POP and advertisements found in our study would be similar to that in other Greek cities. As advertising in Greece is rampant, improperly regulated and spatially very dense, Heraklion was selected as the ideal location for testing such a tool, thus proving practical evidence that the application of such a protocol in countries with high levels of industry advertising is very feasible and, in those with limited advertising, relatively easier.
Due to the current study’s cross-sectional design we could not examine the strength of associations between tobacco advertising and smoking initiation or experimentation, although this was not an aim of our study as evidence in the scientific literature has already proven such an association,7 8 10–12 which again can be calculated by following the trends in the relationship between repeated GIS data and regional smoking prevalence over time.
The use of the above GIS approach for monitoring tobacco advertising can be a helpful tool in monitoring the tobacco industry’s advertising strategies and the effectiveness of tobacco control efforts. As more and more countries move to ratify the FCTC protocol, an important part of which is a comprehensive ban on tobacco advertising, the use of such monitoring tools is warranted.
We would like to thank Eirini Iliaki from the Harvard School of Public Health for her help and support with training procedures and Mrs Katerina Vilanaki from the board of Secondary Education in Heraklion Crete for providing information on the schools. We would also like to thank Professor Christos Lionis and Professor Manolis Kogevinas from the University of Crete for their support.
Funding: This project was funded by a Levantes Foundation grant for international youth projects to the Harvard School of Public Health.
Competing interests: None.
Ethics approval: Ethics approval was obtained.
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