Objective To examine the association of point-of-sale tobacco marketing with median income and racial/ethnic composition at the neighbourhood level in Omaha Metropolitan Area, Nebraska.
Methods Fieldworkers collected comprehensive tobacco marketing data from all of the stores that were licensed to sell tobacco in 84 randomly selected neighbourhoods in the Omaha Metropolitan Area, Nebraska.
Results An increase of $10 000 in median household income was associated with a decrease of 14.3% in the number of tobacco marketing items per square mile in a neighbourhood (p=0.021). There was very little evidence that the percentages of African-American and Hispanic populations in the neighbourhoods were related to tobacco marketing.
Conclusion Banning tobacco marketing, as recommended by the Framework Convention on Tobacco Control, is likely to reduce tobacco use disparities.
- Tobacco marketing
- socioeconomic status
- advertising and promotion
- tobacco products
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- Tobacco marketing
- socioeconomic status
- advertising and promotion
- tobacco products
Although tobacco use causes an estimated 438 000 premature deaths each year, tobacco products remain one of the most heavily marketed products in the USA.1 In 2005, major tobacco companies in the USA spent more than $35 million a day to promote and advertise their products.2 About 1.4% of these expenditures were on point-of-sale promotion and advertising.3 In the wake of the 1998 Master Settlement Agreement (MSA), which banned billboard tobacco advertising and restricted sponsorship of events, the tobacco industry has increasingly focused its marketing activities on the point-of-sale environment.4–6 In the post-MSA era, the retail store is the major communication channel between the tobacco industry and the consumer.7
While before the MSA, there was ample evidence to suggest that billboard tobacco advertising was more prevalent in communities with a lower average income or a higher proportion of minorities,8–11 similar evidence is scant in the post-MSA period. Barbeau et al studied six communities in Boston, Massachusetts, and concluded that higher levels of point-of-sale advertising were associated with higher proportions of residents from lower socioeconomic and non-white backgrounds.12 Law et al examined 10 business districts in eastern Massachusetts and found that a higher proportion of businesses selling tobacco and displaying tobacco marketing advertisements was associated with a lower per capita income and a higher proportion of minorities.13 Similarly, John et al surveyed 110 convenience stores in Oklahoma County and found that that there were more point-of-sale advertisements in low-income and minority neighbourhoods than in better educated, higher-income, predominantly white neighbourhoods.14 15 Furthermore, there is some evidence that in the period between 2002 and 2005, the amount of advertising and promotion of stores with sales promotions increased more rapidly in stores located in neighborhoods with a larger proportion of African-Americans.15 The aim of the present study was to examine the association of point-of-sale tobacco marketing with median income and racial/ethnic composition of neighbourhoods in Omaha Metropolitan Area, Nebraska.
Neighbourhoods were defined as census tracts in this study.16 From the 144 neighbourhoods in Omaha Metropolitan Area, Nebraska, a random sample of 84 census tracts, with a total population of 273 832 (based on the 2000 census), were selected. The sampling was stratified to include neighbourhoods with a substantial number of African-Americans and Hispanics. The sampled neighbourhoods were similar to the population of neighbourhoods in Omaha. For example, the percentage of males in the sample and in the population was 49.2% and 48.9%, respectively, and the median age was 33.3 and 34.1 years, respectively. A list of establishments that were licensed to sell tobacco was obtained from the City of Omaha in October 2008. There were 313 such establishments in the selected neighbourhoods. A team of two fieldworkers visited the establishments between October 2008 and March 2009 to unobtrusively gather data on the extent of tobacco marketing. Complete data were obtained from all of the stores in the sample. Fieldworkers were trained to record all aspects of tobacco marketing, including advertising, promotions, placement and industry shelving. The bulk of the fieldworker training was through the website ‘StoreALERT’ developed by the Campaign for Tobacco-Free Kids and the Battelle Memorial Institute pursuant to grants from the National Cancer Institute. The website provided training guides and a comprehensive virtual tour of a store with extensive tobacco marketing. Fieldworkers also received extensive in-the-field training. During data collection, they used a printed form, the ‘StoreALERT Report Card’,17 to produce a detailed report of an establishment's tobacco marketing practices. The Report Card included a comprehensive set of questions indicating the presence or absence of a marketing item, such as exterior or interior tobacco advertisements (distinguishing mechanical or illuminated ads from print ads), special prices, multi-pack discounts, functional objects, industry shelving units and advertisements geared to children, such as those that are placed close to candy, toys or at a child's eye level. The presence of each of the marketing items, except industry shelving, contributed one point to the total score on the Report Card for a given establishment. Each industry shelf contributed two points to the total score. The lower limit of the score was zero, indicating an absence of tobacco marketing. The upper limit of the score was open-ended because an establishment could have a large number of shelving units or movable displays. The scores for all the establishments in a particular neighbourhood were summed and divided by the land area (square mileage) of that neighbourhood18 to create a variable indicating the amount of tobacco marketing per square mile. Neighbourhood median household income and the percentages of African-Americans and Hispanics were based on the 2000 census information.18
Multiple regression with robust variance was used to examine how household income and the percentages of African-Americans and Hispanics were related to tobacco marketing per square mile. We controlled for the percentage of males among the population 18 years or older, number of small stores (ie, convenience stores, gas stations and small grocery stores) and outlet density (number of stores that sell tobacco in a neighbourhood divided by the area of that neighbourhood in square miles) in each neighbourhood. Additionally, we examined spatial clustering. Using the coordinates of the census tract centroids, we computed Moran's I (p=0.278) and Geary's c (p=0.257) measures of spatial autocorrelation, which indicated no evidence of such autocorrelation.19
The amount of tobacco advertising per square mile had a mean of 20.5 (range: 0–99.9). The mean of the median household income and the percentages of African-Americans and Hispanics were $41 900 (range: $15 000–$114 100), 18.2% (range: 0.1%–90.8%) and 9.3% (0.7%–55.4%), respectively.
Because the amount of tobacco marketing per square mile had a positively skewed distribution, its natural logarithm was used in the regression analysis. There was no tobacco marketing in two of the selected neighbourhoods. In order to include these two cases in the regression analyses, a small constant was added to the advertising score of all neighbourhoods. Table 1 shows that while there was no evidence that the percentages of African-Americans and Hispanics in the neighbourhoods were related to levels of tobacco marketing, an increase of $10 000 in median household income was associated with a decrease of 14.3% (1–e−0.015*10) in the number of tobacco marking items per square mile in a neighbourhood (p=0.021). Neighbourhoods with a higher percentage of adult males had lower levels of marketing. Neighbourhoods with a larger number of small stores that sold tobacco and a higher outlet density had a greater amount of marketing.
The results showed that point-of-sale tobacco marketing is considerably more common in neighbourhoods with a lower average income in Omaha Metropolitan Area, Nebraska. Contrary to previous studies,12 13 we found little evidence of an association between tobacco marketing and minority composition of neighbourhoods.
Exposure to point-of-sale marketing practices is associated with susceptibility to smoke20 and increases the likelihood of smoking initiation among children.21 This increased receptiveness might occur because point-of-sale marketing can promote positive attitudes towards smoking and enhance perceptions of tobacco product accessibility among children.22 The presence of point-of-sale cigarette displays has also been associated with lower probability of smoking cessation.23 This is possibly because exposure to tobacco displays can increase the urge to smoke and promote unplanned buying of cigarettes,24 which can undermine quit attempts. Given the association between tobacco marketing and smoking initiation and cessation,25 the higher exposure of individuals from lower socioeconomic backgrounds to tobacco marketing is likely to exacerbate the existing disparities in smoking prevalence. Conversely, banning tobacco marketing, as recommended by the Framework Convention on Tobacco Control,26 is likely to reduce tobacco use disparities by reducing the exposure of lower socioeconomic smokers to advertisements that promote smoking. Policies that counter tobacco advertising, provide targeted cessation programmes for lower income individuals and limit the number of tobacco outlets in disadvantaged neighborhoods might also reduce tobacco disparities.
One limitation of the study is the temporal variation between the data sources used in the study. Our tobacco marketing observations were conducted 8 years after the 2000 census data, which might have led to biased results if the demographic composition of the neighbourhoods in the study has changed during this time. Another limitation of the study is the scores of the StoreALERT Report Card are not easy to interpret. While they allow rank ordering of stores in terms of the amount of marketing, they do not provide information on the prevalence of any particular type of marketing item in a store. Finally, the neighbourhoods in the study were selected in Omaha, Nebraska, and the results of this research may not be generalisable to the rest of the USA.
What is already known on this subject
Before the Master Settlement Agreement (MSA) of 1998, there was ample evidence to suggest that tobacco marketing was more prevalent in communities with a lower average income or a higher proportion of minorities. In the post-MSA era, the tobacco industry has increasingly focused its marketing activities on the point-of-sale environment. Research on the association of point-of-sale marketing and socioeconomic and racial characteristics of neighborhoods is scant.
What this study adds
The study showed that point-of-sale tobacco marketing is more common in neighbourhoods with a lower average income in Omaha Metropolitan Area, Nebraska. The study found little evidence of an association between tobacco marketing and minority composition of neighbourhoods.
Funding Center for Reducing Health Disparities, University of Nebraska Medical Center (2008-2009).
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.