Article Text

Has Boston's 2011 cigar packaging and pricing regulation reduced availability of single-flavoured cigars popular with youth?
1. Wenjun Li1,
2. Tami Gouveia2,
3. Cheryl Sbarra3,
4. Nikysha Harding4,
5. Kevin Kane1,
6. Rashelle Hayes1,
7. Margaret Reid4
1. 1Division of Preventive and Behavioral Medicine, Health Statistics and Geography Lab, University of Massachusetts Medical School, Worcester, Massachusetts, USA
2. 2Tobacco Free Mass, Framingham, Massachusetts, USA
3. 3Massachusetts Association of Health Boards, Winchester, Massachusetts, USA
4. 4Boston Public Health Commission, Boston, Massachusetts, USA
1. Correspondence to Dr Wenjun Li, Division of Preventive and Behavioral Medicine, Health Statistics and Geography Lab, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester 01655, MA, USA; Wenjun.Li{at}umassmed.edu

## Abstract

Objective We evaluated retailer compliance with a cigar packaging and pricing regulation in Boston, Massachusetts, enacted in February 2012, and the regulation's impact on availability of single cigars.

Methods Grape-flavoured Dutch Masters (DM) single-packaged cigars were examined as market indicator. At quarterly intervals from October 2011 to December 2014, availability and price of DM single cigars were observed through professional inspector visits to tobacco retailers in Boston (n=2232) and 10 comparison cities (n=3400). Differences in price and availability were examined between Boston and the comparison cities and across Boston neighbourhoods.

Results The mean price of DM single cigars sold in Boston increased from under $1.50 in 2011 to above$2.50 in 2014, consistent with regulation requirements. Rates of retailer compliance reached 100% within 15 months postpolicy enactment based on observed price, and 97% at 30 months postenactment based on final sale prices. There was a 34.5% net decrease in the percentage of Boston retailers selling single cigars from 2011 to 2014. The number of Boston neighbourhoods with 3 or more retailers selling single cigars per 100 youth residents decreased from 12 in 2011 to 3 in 2014. No change in price or per cent of retailers selling single cigars was observed in the comparison cities in the same period.

Conclusions Retailers throughout Boston are in compliance with the regulation. The regulation has been effective in reducing levels and disparities in availability of flavoured single cigars popular with youth across Boston neighbourhoods, regardless of socioeconomic status and racial/ethnic composition.

• Price
• Non-cigarette tobacco products
• Disparities
• Public policy
• Packaging and Labelling
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## Introduction

The USA has made significant strides in tobacco control, halving the prevalence of cigarette smoking among adults and youth since the 1960s.1 However, youth cigar use threatens to undo these public health gains.2 The prevalence of youth cigar use is currently higher and has increased faster than that of adults.3 ,4 Cigar use is not only harmful to the body and developing brain but also a possible entrée for youth use of cigarettes and other addictive tobacco products.1 ,5–7 An assessment conducted by the Boston Public Health Commission (BPHC) found that the prevalence of cigar use surpassed that of cigarette use in youth in 2011. For example, recent data showed increasing popularity of Dutch Masters (DM) grape among youth,8 ,9 and growth in flavoured cigar consumption and preference among youth and young adults for flavoured cigar brands.9 Greater Boston area-specific data showed that DM grape was especially popular among youth. From 2006 to 2010, sales of grape-flavoured cigars increased 360% in Greater Boston while sales of regular tobacco cigars decreased by 4.9%.8 Overall, there is a need to expand monitoring of product attributes as well as individual consumption.

The Food and Drug Administration (FDA) prohibited candy, fruit and other flavoured cigarettes largely because there was significant evidence in the tobacco industry's own documents that flavoured cigarettes were intentionally and successfully created for and marketed to youth. Consistent with state and local authority to regulate tobacco products, some municipalities (eg, New York City; Chicago, Illinois, USA; Providence, Rhode Island, USA; Sherborn, Massachusetts, USA) have implemented a sales restriction on other flavoured tobacco products, including flavoured cigars.10 ,11

In the past, state and federal policies effective at reducing teen use of cigarettes, such as minimum price laws, high excise taxes, minimum packaging requirements and prohibitions on flavours, have not been applied to cigars to control youth cigar use.1 ,12 ,13 As a result, single grape-flavoured and other fruit-flavoured cigars sell for as little as $1.25 in stores throughout Massachusetts. New tobacco users, especially youth, can avoid the harsh taste of burnt tobacco by experimenting with affordable, flavoured cigars that are similar in size and feel to traditional cigarettes.2 ,14 ,15 In addition, the lack of consistent policies applied to all tobacco products leads to product substitution by smokers who may have otherwise quit.2 ,14 ,16 To address policy gaps, decrease availability and discourage youth use of single, cheap cigars, the Boston Board of Health passed a city-wide cigar packaging and pricing regulation in December 2011. The regulation requires that all retail establishments sell cigars in an original package of at least four cigars unless the retail price meets the following minimum retail pricing requirements: (1) a single cigar package must be higher than$2.50; (2) a package of two must be higher than $5.00 and (3) a package of three must be higher than$7.50. Retailers can add the Massachusetts 6.25% sales tax rate to the cigar sales price to meet these minimum price requirements. Cigars sold with special promotional offerings are not excluded from this requirement. In the case of a first violation of this regulation, the retail establishment receives a fine of $200. In the case of a second violation within 24 months, the retail establishment receives a fine of$400 and the Permit for the Location and Sales of Tobacco and/or Nicotine Delivery Products shall be suspended for 7 consecutive business days. In the case of a third violation within 24 months, the retail establishment shall be fined $600 and the Permit shall be suspended for 30 consecutive business days. In the case of a fourth violation within 24 months, the retail establishment shall be fined$800 and the Permit shall be suspended for 60 consecutive business days. The Permit may be revoked on the fifth and subsequent violation within 24 months. The regulation was enacted on 1 February 2012.

In this paper, we report findings on retailer compliance with the new regulation and its impact on availability and price of single-flavoured cigars popular with youth in Boston. New York City prohibited all sales of flavoured tobacco products since November 2010, and recently reported significant declines in sales and use of the among teens 3 years after the first enforcement.10 To our knowledge, the effects of municipal packing and pricing regulations have not been reported in public health literature. Lessons learned from Boston's experience in implementing the regulation is of great value to other municipalities that are formulating or implementing similar regulations to reduce youth access to tobacco products.

## Methods

### Inspectional surveys of cigar availability and observed price

To examine rates of retailer compliance with the regulation, we analysed the availability and observed price of grape-flavoured DM single-packaged cigars among tobacco retailers in Boston and 10 comparison cities in Massachusetts before and after policy enactment.

The Massachusetts Department of Public Health's (MDPH) conducted tobacco retailer inspection surveys each year, quarterly during the study period (October 2011 through December 2014). Cigar availability and price data were collected by professional tobacco control inspectors. Each quarter they randomly surveyed 25% of tobacco retailers in the assigned municipalities. After 1 year, all licensed retailers had been inspected. Frequency and timing of the inspections were unknown to retailers. The inspectors were trained according to a standardised inspection protocol. Standardised data collection tools were used for documenting the observed price of several cigar brands. Grape-flavoured DM single-packaged cigars were chosen for this study because it is the only product for which MDPH had complete pricing and availability data during the study period. However, DM cigars are ideal to study because they are one of the top-selling machine-made flavoured cigars in the USA, available in a wide range of sizes and flavours. The products are also popular with youth.9

### Statistical analysis

We used a difference-in-difference approach to examining the impact of the regulation on the availability and price of single-packed DM cigars in Boston (n=2232 visits) compared with 10 Massachusetts cities without the regulation (n=3400 visits). We compared the pre-post temporal trends in availability of DM single cigars at retailers in Boston with the trends of the same time period in 10 comparison cities without the regulation. The comparison cities included most of the large cities in Massachusetts, which had cigar surveillance data available and sociodemographic profiles similar to Boston neighbourhoods. We assumed a similar stable secular trends between City of Boston (when absence of policy enactment) and comparison cities.

To address the hierarchical structure of the data, we analysed the data using three-level linear mixed-effects models. The basic unit of analysis was the yearly survey record of each retail store. The nested data structure (repeated surveys on retail stores nested within municipality) was handled by including store and municipality intercepts in the regression models. To estimate pre-post enactment price increases in Boston, we included a pre-post enactment indicator variable in the models. A statistically significant regression coefficient of the pre-post indicator signalled a possible significant price increase. To compare price changes between Boston and a comparison group of other municipalities, we included an indicator for pre-post periods, and an indicator for City of Boston versus other municipalities. A statistically significant interaction term between the two indicator variables signalled differences in pre-post price changes between Boston (enactment case) and other municipalities (non-enactment comparisons) that are of policy importance. All statistical analyses were carried out using STATA MP V.13.0 (StataCorp, College Station, Texas, USA).

## Results

Compliance and availability data are summarised in table 1, by year and Boston's 16 neighbourhoods, and 10 comparison communities.

Table 1

Availability of single Dutch Masters cigars and compliance with Boston cigar packaging and pricing regulations (2011–2014)

### Regulatory compliance

Data from MDPH's inspectional surveys show that 15 months postpolicy enactment, all (100%) of Boston tobacco retailers had an observed price above $2.50, inclusive of the 6.25% Massachusetts sales tax. In 2011, median price of DM single cigars was under$1.19 (mean (SD): $1.26 (0.21)). Immediately after the policy enactment, mean price increased to$2.64 by the end of March 2012 and stayed above $2.60 through the end of 2014 (figure 1). In the same period, however, the mean price in the comparison group of other municipalities remained at or below$1.50. Since enactment of the Boston regulation, the mean observed price in Boston has been at least $1.35 higher than the mean price in other large Massachusetts municipalities without the regulation (p<0.001). No difference in compliance rates in 2014 was observed between Boston neighbourhoods. Figure 1 Mean price of grape-flavoured Dutch Masters single-packaged cigars surveyed in Boston and comparison municipalities in Massachusetts (October 2011 to December 2014). Out of the 297 retail visits in August and 31 September 2014, DM single-packaged cigars were available for retail sale and purchased by the adult decoy. All of the 31 DM single cigars had an observed price of above$2.50, inclusive of sales tax, across all of the 16 neighbourhoods in Boston. Except for one, all retailers had a final sale price of above \$2.50 for DM single-packaged cigars. Among the 31 purchases, 30 (97%) had identical observed and final sale prices.

### Regulatory impact on availability

From the last quarter of 2011–2014, the per cent of Boston retailers selling grape-flavoured DM single cigars decreased from 75.5% (108 out of 143 surveyed in the last quarter of 2011) in 2011 to 41.1% (296 out of 720) in 2014. The overall pre-post change was 34.4% (p<0.01; table 1 and figure 2). No changes in per cent of retailers selling grape-flavoured DM single cigars occurred in the comparison cities. A sharp decline in availability occurred a month prior to the policy enactment (from 76% in the last quarter of 2011 to 30% in the first quarter of 2012), then to the lowest level at the enactment (20% in the second quarter of 2012). After the enactment, however, the availability increased slowly but steadily over time (p<0.01).

Figure 2

Per cent of retailers selling grape-flavoured Dutch Masters single cigars in Boston and a group of 10 comparison cities in Massachusetts (October 2011 to December 2014).

As shown in table 1, reductions in availability of DM single cigars occurred in every Boston neighbourhood (n=16). The reductions occurred regardless of neighbourhood median household income, per cent of college educated adults and per cent of racial/ethnic minority residents (see online supplementary figures S1 –S3). At the neighbourhood level, the largest reduction occurred in Charlestown (100% in 2011 and 33% in 2014, a net decrease of 67 percentage points), and the smallest reduction was in Fenway (38% in 2011 and 29% in 2014, a net decrease of 9 percentage points). Back Bay had no retailer selling single cigars during the study period. Excluding Back Bay, before the regulation enactment, neighbourhood-level per cent of retailers selling single cigars ranged from 38% (Fenway) to 100% (Hyde Park, Charlestown, Jamaica Plain, Mattapan and Roxbury), representing the largest neighbourhood difference of 62%. After the enactment, the per cent ranged from 29% (Fenway) to 72% (Jamaica Plain) in 2014, representing the largest neighbourhood difference of 43%. The regulation's effect on reducing neighbourhood disparities in per cent of stores selling single-flavoured cigars is evident.

### Supplementary figures

Figure 3 illustrates pre-post changes in availability (defined as number of retailers selling single cigars per 100 youth residents) across the 16 Boston neighbourhoods. In 2011, there were 12 neighbourhoods that had three or more retailers selling DM single cigars per 100 youth residents. In 2014, only three neighbourhoods (North End, Jamaica Plain and South Dorchester) had three or more retailers per 100 youths. North End is a popular tourism destination, which has a very high proportion of young professionals working in the nearby financial firms, hospitals and government centres. Jamaica Plan is racially diverse and has a high proportion of residents working in nearby hospitals and government centres and financial firms downtown. North Dorchester is one of the neighbourhoods with the lowest income and the highest concentration of blacks and other racial/ethnic minorities.

Figure 3

Number of tobacco retailers selling single Dutch Masters grape-flavoured cigars per 100 youth, before and after regulation enactment.

## Conclusions

Our analysis revealed multiple positive effects of Boston's innovative cigar packaging and pricing regulation. The results indicate consistent and city-wide retailer compliance since the regulation was enacted in February 2012. The regulation resulted in 34.4% reduction in the number of retailers selling single-flavoured cigars, and reduced the number of neighbourhoods with a large number of retailors that sold single-flavoured cigars (3 or more retailors per 100 youths aged 13–15 years) by a factor of four (from 12 in 2011 to 3 in 2014).

The legal basis and logic behind the cigar packaging and pricing policy draws on the effectiveness of minimum packaging and pricing policies that have had an overall positive effect on youth and ultimately adult cigarette smoking prevalence.1 ,13 The public health value of such packaging and pricing regulations is evident. Therefore, municipal regulations on cigar packaging and pricing is an important component of youth tobacco use prevention.1 ,13

It should be noted that a high level of compliance with the regulation is achieved throughout the city's socioeconomically, racially and ethnically diverse neighbourhoods, including the most socioeconomically disadvantaged (eg, Dorchester, Mattapan; see figure 3). The regulation significantly reduced numbers and percentages of tobacco retailers across Boston neighbourhoods, and reduced neighbourhood-level disparities in availability of single cigars in tobacco retail stores (see online supplementary figures S1 –S3). The regulation is potentially effective in reducing socioeconomic, racial, ethnic and geographic disparities in youth access to single-packaged flavoured cigars. Given the disparities in cigar use among African-American youth populations, the regulation's value in eliminating disparities in tobacco use should be further evaluated.18

While applauding the significant reductions in availability of single cigars across Boston neighbourhoods, the persistent neighbourhood disparities in availability of single cigars should not be overlooked. The most socioeconomically disadvantaged, least educated and racial minority-dominant neighbourhoods continue to have the highest availability of single-flavoured cigars 3 years after the regulation enactment. It remains a great public health challenge to further limit youth access to single cigars in these and other Boston neighbourhoods.

Boston's regulation increased the mean price of DM single cigars by over 115%. Policies that increase the price of tobacco products are an effective youth tobacco prevention strategy given that youth's sensitivity to price is three times that of adults.1 ,13 ,19 While we are not aware of any youth elasticity data for cigars, health econometric and tobacco control studies indicate that we are likely to see reductions in Boston youth's use of single cigars as a result of the increased price of products that had been popular with youth. Continued monitoring of the cigar markets is important for evaluation of the long-term impact of this regulation. For example, New York City recently reported significant declines in sales and use of flavoured tobacco products among teens 3 years after the City began to ban all sales of flavoured tobacco products in November 2010.10 It also is important to accumulate health survey data in order to evaluate the regulation's potential impact on actual youth purchase and use of cigars and other tobacco products, and whether there is any unintended consequence of the regulation, like switching to other alternative tobacco products.

Several limitations of this study should be considered. First, the Boston regulation does not address packages of four or more cigars. Youth may purchase this larger package due to the cost-effectiveness per cigar, and thus would alter their cigar use. To address this issue, we plan to conduct a follow-up study on youth purchasing and consumption behaviours, and gather data on unit size and price at purchase. It is also very important to monitor market sales data in Boston area, and examine whether the declines in sales of single-flavoured cigars are undesirably compensated by the increases in sales of larger package. In addition, our legal colleagues are making efforts on a possible amendment to the regulation to close the gap. Efforts have been made to educate the retailers regarding compliance. Second, the MDPH began its survey of observed cigar prices in October 2011, less than 6 months before the cigar packaging and pricing regulation was enacted. It is possible that the results might slightly differ due to seasonal variations if one full year of data before the enactment was available. However, secular trends in other municipalities without the regulation changed very little over time during the study period. It is thus expected that normal secular trends may have had very limited impact on the analytic results. Third, the observed cigar survey data are limited in that the price and availability of only one specific cigar product (DM grape cigar) is examined due to availability of data and feasibility of field inspection. It is possible that compliance rates of multipacks or of different cigar brands would have been different than what was observed. However, retailers were unaware of the inspection surveys. It is reasonable to assume that the effects observed on DM single cigars are applicable to other cigar products. Fourth, our survey of final purchase price also is limited in that the final sample was small due to availability of funding. It is possible that a larger sample size of final cigar purchases would have resulted in a different level of compliance. However, these limitations are unlikely to change the conclusions of this study because the analysis was mostly based on annual census of tobacco retailers in the study areas, and the fact that the temporal trends and pre-post changes were consistent across the municipalities under examination.

The cigar packaging and pricing regulation enacted in Boston is a practical and effective tool for reducing availability of single-packaged flavoured cigars that can serve as youth entrée into cigarette and other tobacco use. In the absence of high state and federal excise taxes, packaging requirements, and other price-mediating policies on cigars, Boston's packaging and pricing regulation is a potentially effective option to be considered by localities wishing to reduce availability of flavoured cigar products popular among youth. Such regulation could be considered by FDA to enhance its regulations on cigar products and better protect youth.

• Cigarette packaging and pricing policies implemented in recent years have been effective at reducing youth access to and use of tobacco products.1 ,13

• Enforcement of and compliance with local tobacco prevention policies are critical components to effectively reduce youth tobacco availability and use.20

• Packaging and pricing policies historically have not included cigars, and as such, the effect on youth availability of flavoured cigars and compliance with the local packaging and pricing policy has not been previously studied.

## Acknowledgments

The authors thank Jie Cheng for creating the Boston neighbourhood maps of availability of single-packaged cigars and Mark Paskowsky and Christy Fedor for advising on the use of the MDPH inspectional survey data.

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## Footnotes

• Corrrection notice This article has been corrected since it was published Online First. Figure 3 was updated as one of the Boston neighborhood units (Allston/Brighton) was labelled incorrectly.