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Original research
Cheaper tobacco product prices at US Air Force Bases compared with surrounding community areas, 2019
  1. Amanda Y Kong1,2,3,
  2. Shelley D Golden3,4,
  3. Kurt M Ribisl3,4,
  4. Rebecca A Krukowski5,
  5. Sara M Vandegrift3,
  6. Melissa A Little6
  1. 1 TSET Health Promotion Research Center, Stephenson Cancer Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
  2. 2 Family & Preventive Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
  3. 3 Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
  4. 4 Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  5. 5 Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
  6. 6 Public Health Sciences, University of Virginia, Charlottesville, VA, USA
  1. Correspondence to Dr Melissa A Little, Public Health Sciences, University of Virginia, Charlottesville, VA 22903, USA; mal7uj{at}virginia.edu

Abstract

Introduction In March 2017, the US Department of Defense (DoD) implemented a policy requiring all military stores to set tobacco prices equal to ‘prevailing prices’ in the ‘local community’ adjusted for state and local taxes. We compared tobacco product prices in a sample of retailers located on five Air Force Bases (AFBs) in Texas and Mississippi with those sold in nearby off-base stores.

Methods We constructed a list of on-base and off-base tobacco retailers. Off-base retailers included stores that were located within a 1.5-mile road network service area from main AFB gates. Between July and September 2019, a trained auditor visited 23 on-base and 50 off-base retailers to confirm tobacco product sales, and documented the price of cigarettes and Copenhagen smokeless tobacco. For each area, the median price for each product, as well as the difference in median prices by on-base versus off-base status, was calculated.

Results The median price of cigarettes and smokeless products was cheaper at on-base retailers. All products were cheaper at on-base stores in Fort Sam Houston and Lackland AFB. Similarly, all products were cheaper in on-base stores at Keesler AFB, with the exception of Marlboro Red packs ($0.22 more), and at Sheppard AFB with the exception of cheapest cigarette cartons ($6.26 more).

Conclusion Despite the implementation of the new DoD policy, tobacco products are cheaper in on-base retailers compared with off-base retailers. Refining of the definitions used and improved compliance with the new DoD policy are needed.

  • priority/special populations
  • advertising and promotion
  • environment

Data availability statement

No data are available.

http://dx.doi.org/10.1136/tobaccocontrol-2021-056984

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    Introduction

    The US Department of Defense (DoD) is the largest global employer, employing both active duty service members and civilian personnel.1 The DoD spends over $1.6 billion annually on tobacco-related medical care, increased hospitalisation and lost work days.2 In the most recent (2018) DoD Health Related Behavior Survey, 18.4% of military personnel currently smoked cigarettes and 13.4% used smokeless tobacco, though there is variation by branch.3 In the Air Force, 11.9% of personnel smoked cigarettes and 8.6% used smokeless tobacco.3 In a 2018 sample of enlisted non-prior service Airmen attending advanced career training (eg, Technical Training), 5.9% and 4.8% reported currently using cigarettes and smokeless tobacco, respectively,4 compared with 13.7% and 2.4% nationally in the same year.5 Despite having lower smoking and smokeless prevalence than other branches, Air Force personnel report the lowest rate of past-year smoking cessation attempts (40.1%) compared with all other branches (overall, 46.5%).3 The Air Force loses approximately 893 128 work days per year due to tobacco use.6 Additionally, tobacco use affects military readiness including reduced physical fitness,7 8 increased training injuries9 10 and premature discharge. These together result in over $130 million in excess training costs.11

    Increasing the price of tobacco products is one of the most effective tobacco control strategies for reducing use.12–14 However, targeted marketing by the tobacco industry through price promotions and discounted tobacco products on military bases has likely contributed to the high rates of tobacco use among this priority population.15–22 In fact, junior enlisted military personnel perceive that the military actually supports tobacco use by providing reduced tobacco prices in stores on base,23–26 even though a 2017–2018 study found trainees who smoked were about as likely to buy their cigarettes on base as off base (24.8% vs 28.7%, respectively).27 In 2005, the DoD issued Instruction 1330.09, which required retailers on military installations to set tobacco product prices to be no cheaper than 5% lower than the most competitive price in the local community.28

    Several factors prevented the 2005 DoD policy from raising tobacco prices and having substantial impacts on reducing tobacco use.29 First, military retailers were allowed to search for the most discounted price in their community and still set the price 5% lower. Additionally, explicitly stating that the price could be no higher than the lowest community price ensured that military tobacco prices could always remain cheaper on military bases. The final tobacco product price paid by consumers also did not account for local and state excise taxes, which are not charged at military retailers but can account for an average of 43.8% of the average price off base across the USA.30 Finally, the policy failed to establish regulatory oversight for the policy.

    Indeed, after the implementation of this DoD policy, phone surveys of tobacco retailers indicated that cigarette prices were 12.5%–24.5% cheaper on military bases compared with the most proximal Walmart store.25 31 32 In 2016, our team visited on-base and off-base DoD stores at Air Force Technical Training Bases in Texas and Mississippi and collected data on the prices of cigarettes and other tobacco products.33 We found that Marlboro Red and Newport Menthol packs were between $0.80 and 0.87 cheaper on base, which amounted to a $292–318 annual savings for an individual who smokes a pack a day. Additionally, a tin of Copenhagen smokeless tobacco was $0.65 cheaper at on-base retailers.

    In April 2016, the Secretary of Defense issued one of the most comprehensive tobacco policy reforms in DoD history.34 This policy, which was fully executed as of 30 March 2017, required all DoD stores to set all tobacco prices equal to ‘prevailing prices’, in the ‘local community’ adjusted for state and local taxes. Building on our previous work,33 we audited tobacco product prices on and near Air Force Technical Training Bases in 2019 to assess whether prices of cigarette and smokeless products sold in retailers on Air Force Bases (AFBs) were similarly priced to those being sold in off-base proximate retailers after the implementation of the new DoD policy.

    Methods

    Study area

    Tobacco product, price and promotion data were collected from on-base and nearby off-base tobacco retailers at five Air Force Technical Training bases in Texas (Fort (Ft) Sam Houston, Lackland AFB, Sheppard AFB and Goodfellow AFB) and Mississippi (Keesler AFB). We chose these five AFBs because 99% of all non-prior service enlisted Airmen receive Technical Training at one of them. To better approximate those off-base retailers where Airmen would be most likely to purchase tobacco, we included those tobacco retailers that were located within a 1.5-mile (plausible walking distance) road network service area of the primary 24-hour base gates through which Airmen enter and leave each AFB. To construct this service area, staff at each AFB used the Google Maps mobile application to take Global Positioning System (GPS) coordinates at each of the base’s primary gates. We then used these GPS coordinates to map the point location of each gate. Using Esri’s Street Map Premium, a road network file, and the Network Analyst tool in ArcMap V.10.5, we constructed 1.5-mile road network service areas from each gate (figure 1).

    Figure 1
    Figure 1

    Example of tobacco retailers (dark grey circles) located outside of Keesler Air Force Base (AFB) (solid black outline) and within a 1.5-mile road network service area (dashed line, shaded grey area) from two 24-hour primary base gates (black flags).

    Tobacco retailer data sources

    A census of on-base retailers was created using our previous 2016 work33 and by consulting AFB websites and staff who worked on each base. We then employed several strategies to identify all off-base retailers within the 1.5-mile road network service areas. To construct an off-base retailer sampling frame for each base, we used our 2016 ground-truthed list in addition to two other data sources. First, the Texas Department of Revenue has a publicly available tobacco retailer licensing list, and we integrated this state-wide list into our sampling frame for the Texas bases. Second, we supplemented this list with RefUSA, a business establishment database that contains store names, addresses, locations of retailers and business establishment type codes that have been used in previous work to identify tobacco retailers.35–37 Using this sampling frame, we mapped the location of each tobacco retailer and then included those that were located within each 1.5-mile road network service area.

    A trained data collector visited each on-base and off-base retailer. The data collector also ground-truthed each base area by visiting any retailers that they saw in the area but that might not have been on the preliminary sampling frames we created. The data collector verified that tobacco products were sold at each retailer visited. Finally, to confirm the geolocation of each retailer (on-base vs within 1.5-mile road network service areas from each gate), the data collector took a GPS coordinate using the Google Maps mobile application at the front entrance of each retailer.

    Outcome measures

    We visited identified off-base and on-base retailers between July 2019 and September 2019 and collected tobacco product availability and product price information at each retailer using a preprogrammed electronic survey.

    The data collector first indicated whether tobacco products were sold (yes/no). If tobacco products were sold, the data collector then indicated (yes/no) whether pack and cartons of cheapest cigarette product, Marlboro Red, Newport Menthol and Copenhagen smokeless tobacco were sold. Where sold, the data collector documented the advertised pack and carton price (in US dollars and cents) of the cheapest cigarette product, Marlboro Red, Newport Menthol and the advertised price of a single tin of Copenhagen smokeless tobacco. For all recorded prices, the data collector indicated whether sales tax was included in the advertised price.

    Descriptive data analysis

    The study data collector visited a total of 114 retailers. Primary eligibility criteria for the analytical sample included that the data collector could survey the store and the retailer sold tobacco products. We excluded 41 retailers for the following reasons: retailer did not exist (5); retailer was closed (6); retailer did not sell tobacco products (13); clerk refusal (2); duplicate entry or store (11); off-base retailer was not within 1.5-mile service area (4).

    While the DoD policy mandates that the off-base prevailing price is ‘the most common shelf price paid for a tobacco product by local consumers within the local community’,34 because we had a small number of product prices recorded on base and off base (range: 2–7) resulting in a skewed distribution with some more extreme values, we chose to calculate the median price instead of the mode or mean.

    We used SAS V.9.4 to calculate the recorded median price and range for tobacco products that were sold in on-base and off-base retailers for each AFB. For all off-base reported prices where sales tax was not indicated by the data collector, we added the state sales tax amount (7.00% in Mississippi; 8.25% in Texas). Since on-base retailers are exempt from local and sales taxes, we did not add local or state taxes to reported prices. However, on-base commissaries, or retailers that sell household goods and groceries to military personnel, include an additional 5% surcharge on all products purchase, which we accounted for in analyses.38 We additionally calculated location-based differences in prices by subtracting the base-specific median off-base price from the median on-base price. A negative difference indicates that the median price for a tobacco product was cheaper at retailers on base as compared with those off base.

    Results

    A total of 73 tobacco retailers were eligible for analysis, including 50 off-base retailers and 23 on-base retailers across the analytical sample (table 1).

    View this table:
    Table 1

    On/off-Air Force Base tobacco retailer counts, 2019

    Overwhelmingly, the median price of cigarette and smokeless products was cheaper at on-base retailers as compared with off-base retailers (table 2). For example, as compared with nearby off-base stores, all tobacco products were cheaper at on-base stores in Ft Sam Houston and Lackland AFB. Across all AFBs, on-base stores sold Newport Menthol packs and cartons, Marlboro Red cartons and Copenhagen at lower prices than off-base stores. Depending on the product and the base, on-base prices were up to 40.2% cheaper than their off-base counterparts (table 3).

    View this table:
    Table 2

    Median price paid and price difference for tobacco products by on/off-Air Force Technical Training Bases, 2019 (US$)

    View this table:
    Table 3

    Percent differences in median price paid for tobacco products by on/off-Air Force Technical Training Bases, 2019 (US$)

    In a small number of cases, on-base retailers reported higher median tobacco product prices as compared with off-base retailers. At Goodfellow on-base stores, the median cheapest cigarette pack and carton prices were $0.48 and $2.56 more (11.1% and 5.9% higher), respectively, as compared with those off base. Additionally, Keesler AFB sold Marlboro Red packs for $0.22 cents (3.7%) more on base as compared with off base, and on-base retailers on Shepard AFB sold cheapest cigarette cartons for $6.26 (12.3%) more as compared with off-base stores.

    Discussion

    Overall, our study results demonstrate that tobacco products remain cheaper at retailers on AFBs as compared with retailers in proximate community areas, despite the implementation of the reformed DoD policy that required all DoD stores to set all tobacco prices equal to prevailing local prices, adjusted for state and local taxes.34

    To the best of our knowledge, this is the first study to assess price differences after the implementation of the 2017 DoD policy. The tobacco product price differences we document are consistent with research conducted prior to the implementation of this policy that indicated cigarettes sold on base were cheaper than those off base.25 31–33 We also found that smokeless tobacco continues to be less expensive on-base compared with off-base retailers. Since pricing strongly impacts tobacco use,14 39 the persistent cheaper prices of tobacco products on base may be contributing to higher rates of tobacco use among military personnel than in the civilian population.3 40

    Two factors that may influence compliance with the reformed DoD pricing policy are the clarity of policy language and the resulting feasibility of tracking off-base tobacco product prices. First, the policy defines the local community as ‘an area no greater than a 20-mile radius from the installation’.34 Other than specifying a maximum, the DoD policy gives no guidance on the ideal radius size, which may greatly affect the number of tobacco retailers and prices recorded for comparison. As such, different radius sizes may result in prices that comply or do not comply with the policy. In the current study, we surveyed off-base retailers within a 1.5-mile road network service area of the main base gates after talking with base staff who believed this was within a reasonable walking distance of each base, and retailers within this area were therefore the ones where Airmen would be most likely to purchase tobacco (Airmen rarely have cars to travel farther). On the other hand, many service personnel do not live on base and may purchase their tobacco products near their home. The current 20 mile maximum is spatially large and may be difficult for bases to identify retailers and assess compliance with the policy. Overall, the DoD policy may want to consider requiring each base to have a tailored definition of local community 40 that reflects potential military personnel exposure to tobacco products and retail marketing. Additionally, setting a uniform minimum price for tobacco products that may discourage use may also be an effective intervention.40 41

    Second, the DoD policy mandates that the off-base prevailing price, defined as ‘the most common shelf price paid for a tobacco product by local consumers within the local community’, matches that of the prices at on-base retailers.34 The specification for the ‘most common’ shelf price implies that tobacco products are regularly priced at the same cost. However, a mode price may not be calculable, even with multiple measures of prices. For example, a community with tobacco products priced similarly but with different exact prices (eg, $5.20, $5.21, $5.22) has no ‘most common’ price. Furthermore, in a relatively small sample of stores in a given base’s area, a mode could be based on the same price at just two or three stores, and may not capture the central tendency of the prices. Employing another measure of central tendency, such as the mean or the median, which may be more feasible for to calculating and evaluating policy compliance.

    A limitation of our study is that we audited tobacco retailers at just the five AFBs where Technical Training is held, and we had a small sample size and limited statistical power to be able to statistically test any associations. Our study results may therefore not be generalisable to other AFBs or military bases. Pricing assessments are needed for other service branches, especially for those experiencing higher smoking and smokeless prevalence (eg, Marine Corps, Navy, Army).3 A strength of our study is that we were able to characterise the surrounding off-base retailer environment based on conversations with AFB staff. Since most Airmen (54.2%) initiate tobacco use or relapse during Technical Training,42 it is important to understand the tobacco environment around AFBs that may be contributing to tobacco use behaviour in the military. Finally, we were also able to demonstrate the feasibility of visiting tobacco retailers to record tobacco product prices without requiring clerk input or time.

    Overall, surveillance of tobacco product pricing for both cigarettes and smokeless tobacco products on and near military bases is critical to ensure compliance with the strengthened 2017 DoD policy. Our study indicates that tobacco products are still being sold at much lower prices on AFBs, which may contribute to high initiation and tobacco use rates among Airmen. Although Airmen can travel off base after completing Technical Training, the prices on base are important given that many service members live on base or regularly travel there. Due to COVID-19, most Airmen were not allowed to leave base for any reason. Given these restrictions, on-base tobacco products were the only option for purchase.

    Greater critical discussion on whether tobacco products should be available for sales on military bases is needed given the well-documented negative effects of tobacco product use on troop readiness and productivity. While the sales of e-cigarette and vapour products were halted for several branches during the “e-cigarette, or vaping, product-use associated lung injury” (EVALI) outbreak (later found to be primarily linked to vitamin E acetate found in tetrahydrocannabinol vapour products obtained informally), this did not extend to more lethal combustible tobacco products, such as cigarettes.43–45 Some local public communities (eg, Beverly Hills and Manhattan Beach, California)46 47 have prohibited the retail sales of tobacco products, and this may be an important ongoing policy consideration for the DoD. In the meantime, continued refining of the definitions used and compliance with the new DoD policy are needed to further prevent and reduce tobacco use and associated health costs among military personnel.

    What this paper adds

    • The prevalence of current tobacco use among US active duty military personnel is much higher than among civilian populations.

    • Tobacco products have been priced cheaper at tobacco retailers located on military bases as compared to off military bases, contributing to the higher prevalence of tobacco use among military personnel.

    • On 30 March 2017, the Department of Defense (DoD) price policy was revised such that all military stores need to set tobacco prices equal to ‘prevailing prices’ in the ‘local community’ adjusted for state and local taxes.

    • It was not known whether tobacco product prices were still cheaper on military bases.

    • Our results demonstrate that tobacco products still remain less expensive in a sample of retailers on Air Force Bases as compared with retailers in proximate community areas, despite the implementation of the revised policy.

    • Continued refining of the definitions used and compliance with the new DoD policy is needed to prevent and reduce tobacco use and associated health costs among military personnel.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Study procedures were approved by the 59th Medical Wing Institutional Review Board.

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    Footnotes

    • Twitter @AmandaYKong

    • Contributors AYK, SDG, KMR and MAL conceived of the idea and study design. SMV collected the data. AYK and SDG designed the analyses. AYK conducted the analyses. AYK, RAK, and MAL led the writing of the first draft of the paper. All authors contributed to data interpretation and revisions and approved of the manuscript. ML accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding This work was supported by funding from the National Institute on Drug Abuse (R01DA043468) of the National Institutes of Health. AYK was additionally supported by the National Cancer Institute (T32CA128582, P30CA225520) and the Oklahoma Tobacco Settlement Endowment Trust (TSET; R21-02).

    • Disclaimer The content is solely the responsibility of the authors and does not represent the official views of the funders. The research represents a Collaborative Research and Development Agreement with the US Air Force (CRADA #17-250-59MDW-C17004). The opinions expressed in this document are solely those of the authors and do not represent an endorsement by or the views of the US Air Force, the Department of Defence or the US Government.

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests KMR serves as an expert consultant in litigation against tobacco companies.

    • Provenance and peer review Not commissioned; externally peer reviewed.