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Tobacco use continues to be a leading cause of preventable deaths worldwide. Tobacco advertising and promotion are directly related to smoking in youth.1–3 In the USA, despite the advertising restrictions imposed by the 1998 Master Settlement Agreement (established between major tobacco companies and the states), and the 2009 Family Smoking Prevention and Tobacco Control Act, tobacco companies remain capable of reaching their target markets through less prominent channels, such as providing coupons for tobacco products that offer price discounts (eg, US$0.50 off per pack of cigarettes, buy-one-get one free). In 2011, tobacco companies spent US$208 million to provide these coupons (2.4% of the total marketing budget for 2011).4 ,5
Data from the 2012 US National Youth Tobacco Survey (NYTS) showed that 13.1% of US middle and high school students were exposed to tobacco coupons in the past 30 days through mail (6.0%), digital communication (eg, text messages; 7.4%), and tobacco packages (3.7%).6 Additionally, tobacco use status, living with tobacco users and being receptive to tobacco marketing were positively associated with exposure to tobacco coupons in the past 30 days for US youth. However, previous studies on tobacco coupons among youth6–9 did not explore the associations between exposure to tobacco coupons and smoking-related beliefs, susceptibility to cigarette smoking among never smokers, and intention to purchase cigarettes in the future, which are known predictors of youth smoking behaviours.2 Therefore, in this current analysis, the author reanalysed the 2012 US NYTS data to investigate the associations between exposure to tobacco coupons and these psychosocial predictors of smoking behaviours among US youth.
Details of the sampling approach can be found elsewhere.10 Briefly, the 2012 US NYTS used a stratified three-stage cluster sampling approach. At the first stage, school districts (primary sampling units, PSUs) were categorised into 16 strata defined by racial/ethnic composition and urban versus non-urban status, and 100 PSUs were selected from these strata with probabilities proportional to total number of students enrolled in eligible public and private schools. At the second stage, 284 schools were randomly selected from the 100 PSUs. At the third stage, one to two classes per grade were chosen for participation. School participation was voluntary (228 participated, 80.3%), and participating schools used either active or passive parental consent for students’ participation. Participating students completed a pencil-and-paper self-administered scannable questionnaire between February and June 2012 (n=24 658, participation rate=91.7%, overall school×student participation rate=73.6%).
Participants were asked, “During the past 30 days, did you receive coupons from a tobacco company through…?” with 7 response options: the mail, email, the Internet, social network (such as Facebook and Twitter), a text message, on a cigarette pack or other tobacco product, and “I did not received coupons from a tobacco company.” Participants were asked to choose all the options that applied to them. Participants were also asked whether smoking cigarettes makes young people look cool or to fit in, and whether young people who smoke cigarettes have more friends (definitely yes, probably yes, probably not, definitely not). Those who responded ‘definitely not’ were classified as denying the social benefit of smoking, consistent with the classification of the smoking susceptibility scale.11 Additionally, participants were asked to indicate how strongly they agreed with the statement that all tobacco products are dangerous (strongly agree, agree, disagree, strongly disagree). Those who responded ‘strongly agree’ were classified as agreeing with the statement. Participants were asked if they thought they would smoke a cigarette in the next year; if they would try a cigarette soon; and if they would smoke a cigarette offered by a best friend (definitely yes, probably yes, probably not, definitely not). Participants who responded to anything other than ‘definitely not’ in any of these three items were classified as susceptible to cigarette smoking.11 Participants were asked to report how likely they would purchase cigarettes in the next 30 days (very/somewhat likely vs somewhat/very unlikely). Current smokers reported how likely they would succeed if they decided to quit cigarettes for good, and responses were dichotomised into very/somewhat likely versus somewhat/very unlikely.
Information on demographics (age, gender, race), exposure to tobacco advertising (through the Internet, in newspapers or magazines, at a convenience store/supermarket/gas station, on an outdoor billboard), exposure to smoking depictions in movies, and living with someone who uses tobacco were collected. Smoking status was determined by self-reported ever tried cigarette smoking (even one or two puffs), and number of days smoked in the past 30 days. A current smoker was defined as smoking ≥1 day in the past 30 days, an experimenter was defined as having tried cigarette smoking but not smoking in the past 30 days, and a never smoker was defined as having never tried cigarette smoking.
Data were weighted to represent the US youth population. Analyses were stratified by smoking status. Logistic regression models were used to assess the associations between reported receipt of tobacco coupons and smoking-related outcomes: smoking-related beliefs, susceptibility to cigarette smoking (among never smokers), perceived likelihood of success in smoking cessation (among current smokers), and likelihood of purchasing cigarettes in the next 30 days (among experimenters and current smokers), while adjusting for demographics, living with tobacco users, and exposure to tobacco advertising and smoking depictions in movies. Analyses were performed in SAS V.9.3,12 using PROC SURVEYLOGISTIC.
Of the 24 658 participants, 51.1% were male; 58.8% were non-Hispanic White, 14.6% were non-Hispanic Black, 21.7% were Hispanic, 3.9% were Asian, and 1.0% were American Indian/Alaska Native/Native Hawaiian/ Pacific Islander; 9.5% were current smokers, 16% were experimenters, and 74.5% were never smokers (all estimates were weighted). Participants were aged between 9 and 19 years. Youth who had reported that they received tobacco coupons in the past 30 days had lower odds than those who did not report receiving tobacco coupons in the past 30 days to deny that smoking cigarettes makes young people look cool or to fit in, regardless of smoking status (p<0.05; table 1). Youth never smokers who reported receiving these coupons in the past 30 days, when compared to those who did not report receiving these coupons in the past 30 days, had lower odds to deny that young people who smoke cigarettes have more friends, and had lower odds to agree that all tobacco products are dangerous (p<0.05). Youth never smokers who reported receiving tobacco coupons in the past 30 days had twice the odds as those who did not report receiving tobacco coupons in the past 30 days to be susceptible to cigarette smoking (p<0.05). Youth current smokers who reported receiving tobacco coupons in the past 30 days had lower odds than those who did not report receiving these coupons in the past 30 days to feel that they would succeed in quitting cigarettes for good (p<0.05). Youth experimenters and current smokers who reported receiving tobacco coupons in the past 30 days had at least twice the odds as those who did not report receiving these coupons in the past 30 days to report that they were likely to purchase cigarettes in the next 30 days (p<0.01).
Findings from the current analysis revealed two potential mechanisms of which tobacco coupons can influence youth smoking behaviours. First, marketing theories suggest that through lowering the cost of products to consumers, coupons can induce initial trial of a product among non-users, and can shape repeated purchasing behaviours among current users.13 This hypothesis is supported by the current findings that exposure to tobacco coupons was positively associated with susceptibility to cigarette smoking among youth never smokers and with intention to purchase cigarettes in the future among youth experimenters and current smokers. Lowering of cigarette costs also may provide disincentives for youth to quit smoking, given that one of the most cited reasons for smoking cessation is cigarette costs.14 This hypothesis is supported by the current finding that youth current smokers who were exposed to these coupons were less likely than those who were unexposed to these coupons to be confident in quitting cigarettes for good. Second, tobacco coupons may shape tobacco-related beliefs. The current study suggests that exposure to tobacco coupons may promote positive tobacco-related beliefs in youth, which are predictive of smoking behaviours among young people.2 ,15
Some may argue that these coupons may be targeting adults in the households. While this may be true, the most common source of tobacco coupons among youth was digital communications (ie, the Internet, emails and text messages).6 Regardless of the source, tobacco coupons influence youth smoking behaviours, and current tobacco advertising restrictions are not enough to protect youth from tobacco coupon marketing. This is not unique to the USA: currently, 82 countries (42% of all countries and regions) have placed a complete ban on tobacco advertising on television, on radio, in magazines and newspapers and on billboards.16 Of these, 50 countries (61%; 26% of all countries and regions) have a complete ban on promotional discounts such as coupons.16 Countries that do not prohibit tobacco coupons or other promotional discounts allow tobacco companies to reach youth through direct-to-consumer strategies (including coupons) to promote tobacco use.
One policy option to combat the influence of tobacco coupons is to prohibit redemption of tobacco coupons (instead of the distribution of coupons, which could violate the First Amendment that protects the right to commercial speech).17 This option is particularly relevant to youth since the most common source of tobacco coupons was digital communication, which is very difficult to regulate. Recently, Providence, Rhode Island and New York City, New York, passed regulations that prohibit redemption of tobacco coupons, and were challenged by the tobacco companies. In both cases, the US courts upheld the regulations. This showed that states and localities can prohibit redemption of tobacco coupons to protect youth.
Given that 2012 US NYTS only sampled youth who were in schools, findings from this analysis may not be generalisable to youth who are not in schools. The cross-sectional study design limits the author's ability to make causal inference. Despite these limitations, this study shows that exposure to tobacco coupons is associated with predictors of smoking initiation and cessation among youth. Future longitudinal studies (eg, national prospective cohort studies to assess the effect of receiving and redeeming tobacco coupons on tobacco use behaviours) are needed to understand the effect of this tobacco promotional strategy on youth in the USA and internationally.
What this paper adds
A previous report based on data from the 2012 US National Youth Tobacco Survey showed that an unacceptably high proportion of youth (13.1% overall; 34% among those who currently use tobacco and 9.3% among those who do not currently use tobacco) were exposed to tobacco coupons in the past 30 days. However, it did not examine the associations between exposure to tobacco coupons and psychosocial predictors of smoking behaviours. The current analysis found that exposure to these coupons was associated with more positive smoking-related beliefs, susceptibility to smoking, intention to purchase tobacco in the future and lack of confidence in quitting smoking. Future longitudinal studies are needed to further examine the impact of tobacco coupons on youth.
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