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Abstract
Background Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression.
Methods The analysis included a nationally representative sample of youth never tobacco users (aged 12–16; n=9405) from wave 4 (2016–2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017–2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates.
Results At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation.
Discussion Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics.
- advertising and promotion
- non-cigarette tobacco products
- prevention
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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Introduction
The overall tobacco use among youth has risen over the past few years in the USA.1 Specifically, between 2017 and 2019, past 30-day use of any tobacco products among middle school and high school students rose from 5.6% to 24.3%, and 19.5% to 36.5%, respectively.2 This rapid increase was mainly driven by the surge in e-cigarette use, reaching a past 30-day e-cigarette use prevalence of 10.5% among middle school and 27.5% among high school students in 2019.3 This surge in youth e-cigarette use is concerning given that e-cigarette use can lead to nicotine addiction, respiratory and lung diseases and use of combustible tobacco products including cigarettes and cigars.4–6 Additionally, over the past years, combustible tobacco products (cigarettes and cigars) remained one of the most commonly used products among US youth,1–3 potentially leading to long-term adverse health outcomes such as cancers and cardiovascular diseases.7 Although youth past 30-day e-cigarette and tobacco use prevalence slightly decreased between 2019 and 2020,8 continued efforts to monitor the trend and identify and reduce risk factors of tobacco use among youth are greatly needed to protect public health.
One important factor shaping youth tobacco use is tobacco marketing. A substantial body of evidence has demonstrated the influence of tobacco marketing exposure on tobacco product uptake and continued use among US youth.9 In particular, tobacco price promotions or discounts (see figure 1 for examples) are heavily used by the tobacco industry to market its products to new and returning consumers. Each year the tobacco industry spends most of its marketing and promotion budget on price discounts (in 2018, 85.8% of the total budget, equalling US$7.2 billion).10 Receiving and/or using tobacco price promotions might prompt tobacco trials or continue use by keeping tobacco products affordable among price-sensitive populations, especially youth.11–15 Recent evidence has shown that between 2017 and 2018, seeing tobacco marketing materials, including those featuring appealing flavours and young models, prompted youth to try new tobacco products at substantially high rates.16–18 Little evidence is available, however, to examine the potential linkage between tobacco price promotions and youth’s tobacco uptake and continued use during this critical time period.
Examples of e-cigarette, cigarette and cigar product advertisements containing price promotions, 2017–2018 (source: https://www.trinketsandtrash.org/).
The literature examining the associations between tobacco price promotion exposure and tobacco use in the USA is also limited in several ways. First, most of these studies examining such associations focused on the adult population,15 19–21 rather than youth.12 Second, these studies examined tobacco initiation or current use as the main outcomes,12 15 19–21 rather than the more progressed, addictive tobacco use behaviour (eg, frequent and regular tobacco use) that may result in long-term use and difficulty quitting.22 23 Third, nearly all studies that examined these associations focused on exposure to price promotions for tobacco in general or cigarettes and e-cigarettes in particular,12 15 19–21 often not including cigar products. Cigars have recently become the most commonly smoked combustible tobacco products among US youth,1 and cigarillos, the most widely used cigar product type, are often sold in multipacks with price discount labels shown on their packaging (eg, ‘2 for $0.99’ and ‘Save on 5’).24 25 Finally, previous studies12 15 19–21 did not control for tobacco advertising exposure. As a result, little is known about whether youth’s tobacco use behaviour change is attributable primarily to tobacco price promotions or other youth-appealing marketing features such as models or flavours.
Considering these gaps in our knowledge, this study examined the associations between receiving price promotions and use progression for any tobacco products, cigarettes, e-cigarettes and cigars among youth during the national surge in tobacco use between 2017 and 2018. Cigarettes, e-cigarettes and cigars were chosen as specific product types to examine in this study mainly because US youth had the highest use prevalence of these products.2 3 We also accounted for youth’s overall tobacco advertising exposure to assess the independent associations between receiving tobacco price promotions and tobacco use.
Methods
Study sample
We used data from wave 4 (1 December 2016 to 3 January 2018) and wave 4.5 (1 December 2017 to 1 December 2018) youth survey public use files from the Population Assessment of Tobacco and Health (PATH) Study, which includes nationally representative, longitudinal cohorts of civilian, non-institutionalised youth in the USA. Respondents completed the wave 4.5 survey approximately 1 year following their wave 4 survey date.26 The PATH Study’s response rate at wave 1 was 78.4% for youth. The retention rates for waves 4 and 4.5 among wave 1 youth respondents were 79.5% and 74.5%, respectively.26 More details about the PATH Study can be found elsewhere.27 We restricted the sample to youth respondents (aged 12–16, n=9405) who completed both wave 4 and 4.5 surveys and had never used any type of tobacco products (cigarettes, e-cigarettes, cigars, hookah, smokeless tobacco, dissolvable tobacco, tobacco pipes, bidis or kreteks) at wave 4.
Predictor variables: past-year receipt of product price promotions
The wave 4.5 of the PATH Study measured receiving product price promotions in the past year by product type using the question: ‘In the past 12 months, have you received discounts or coupons for any of the following products. Choose all that apply.’ The tobacco product options were ‘Cigarettes’, ‘E-cigarettes or other electronic nicotine products (including e-liquid)’, ‘Cigars’, ‘Shisha or hookah tobacco’, ‘Snus’, ‘Other types of smokeless tobacco (such as dip, spit or chew)’ and ‘Some other type of tobacco product’. We created four variables to indicate receiving price promotions for any tobacco (Yes/No), cigarettes (Yes/No), e-cigarettes (Yes/No) and cigars (Yes/No) based on the specific product chosen by the respondents. We did not examine product-specific price promotions or behavioural use outcomes for shisha, snus or smokeless tobacco, as according to the current analysis, both the prevalence of receiving price promotions for these products and using these products were low.
Response variable: past-year product use progression
We created product use outcomes (initiation, current use, ever regular use) at wave 4.5 to capture product use progression over a 1-year period between waves 4 and 4.5. First, we created a new variable to measure any tobacco initiation by using the PATH Study’s ‘derived variables’26 that captured ever use of any type of tobacco products (cigarettes, e-cigarettes, cigars, hookah, smokeless tobacco, dissolvable tobacco, tobacco pipes, bidis or kreteks) between waves 4 and 4.5. Three variables of initiating cigarettes, e-cigarettes and cigars were also created by using the corresponding ‘derived variables’26 that captured ever use of specific products. Similarly, we created a new variable to measure current use of any tobacco by using the PATH Study’s ‘derived variables’ that captured past 30-day use of any type of tobacco products at wave 4.5. Three variables of current use of cigarettes, e-cigarettes and cigars were also created by using the ‘derived variables’ that captured past 30-day use of the corresponding products at wave 4.5. Finally, we measured ever regular use of tobacco products by using the question ‘Have you ever smoked or used [Tobacco Product] fairly regularly?’ with response options of ‘Yes’ and No.’ Specifically, we used these items to create variables that captured ever regular use of any tobacco, cigarettes, e-cigarettes and cigars. The PATH Study used three types of cigar products (large cigars, cigarillos and filtered cigars) for measuring behavioural use outcomes.28 In this analysis, we combined three types of cigar products and generated behavioural use outcomes of any cigar products.28
Respondent characteristics and covariates
We used the following respondent characteristics at wave 4 as covariates (see table 1 for variable categories). Demographic characteristics were age, gender identity, race/ethnicity, annual household income and highest educational attainment of parents. Psychosocial characteristics were self-reported past-year internalising problems (eg, depression, anxiety and distress; Yes/No) and externalising problems (eg, having a hard time paying attention, having a hard time listening to directions; Yes/No).29 Characteristics related to protobacco use social environment were living with someone using tobacco products (Yes/No) and having at least one best friend using tobacco (Yes/No). Finally, tobacco advertising exposure was measured by questions: ‘In the past 30 days, have you noticed [Product Name] being advertised in any of the following places?’ with ‘Product Name’ replaced with ‘E-cigarettes or other electronic nicotine products’ and ‘Cigarettes or other tobacco products’. Response options to both questions included a wide range of tobacco advertising exposure channels, including gas stations/convenience stores, newspapers/magazines and websites/social media sites.30 Respondents exposed to any type of advertising at any place were considered having tobacco advertising exposure in the past month (Yes/No).30
Respondent characteristics and receiving price promotions of any tobacco, cigarettes, e-cigarettes and cigars at wave 4.5 among never tobacco users aged 12–16 at wave 4: Population Assessment of Tobacco and Health Study youth survey wave 4 (2016–2018) and wave 4.5 (2017–2018; n=9405)*
Statistical analysis
First, we used Pearson χ2 tests to examine the respondent characteristics (wave 4) by receiving product price promotions by product type (wave 4.5). Second, we calculated the prevalence of product use progression among all respondents and among those who received the price promotions by product type (wave 4.5). We also implemented Pearson χ2 tests to assess the associations between receiving price promotions and product use progression by product type (wave 4.5). Lastly, we used multivariable logistic regression models to examine the associations between receiving price promotions and use progression by product type (wave 4.5), controlling for covariates (wave 4). We applied the recommended youth/parent wave 4 cohort single-wave weights for analysing wave 4 and 4.5 longitudinal data.26 Applying those weights also allowed us to adopt the balanced repeated replications method with a Fay adjustment of 0.3.26 To minimise missing data, we used imputed demographic variables and derived tobacco use variables included in the PATH public use data files26 and used an ‘undetermined’ category for measures with missing values larger than 5% of the sample. For the regression models, we used listwise deletion because missing data were minimal across all variables used for the analysis (<1%). We conducted the statistical analyses using Stata V.16.0 (StataCorp, College Station, Texas) with a statistical significance of 0.05. This research involved the use of deidentified data, which is not considered human subject research and requires no Institutional Review Board review per National Institutes of Health policy and 45 CFR 46.
Results
Respondent characteristics by receiving price promotions
The analytical sample of respondents (table 1) was balanced on biological sex (female: 49.7%; male: 50.3%) but had a higher portion of younger youth (12–14 years: 65.1%; 15–17 years: 34.9%). The prevalence of price promotion receipt in the past 12 months (figure 2) was 5.4%, 3.8%, 3.1% and 0.9% for any tobacco products, cigarettes, e-cigarettes and cigars, respectively. Youth never tobacco users who had past-year internalising and externalising problems, lived with tobacco users, had at least one best friend using tobacco and had past-month exposure to tobacco advertising were generally more likely to report receiving any tobacco price promotions and each product type of price promotions about 1 year later (p<0.05).
Weighted percentages of tobacco use progression by receiving tobacco price promotions at wave 4.5 among never tobacco users aged 12–16 at wave 4: Population Assessment of Tobacco and Health Study youth survey wave 4 (2016–2018) and wave 4.5 (2017–2018; n=9405) (Percentages are weighted estimates. Zero percentages were not shown. Χ2 test results for the associations between exposure to tobacco price promotions and tobacco use progression by product type (*p<0.05; **p<0.01; ***p<0.001)).
Prevalence of tobacco product use progression
Figure 2 shows the prevalence of tobacco use outcomes among all respondents and those who received product price promotions in the past year. Over the 1-year period, 9.4%, 1.8%, 7.8% and 0.9% of respondents initiated any tobacco products, cigarettes, e-cigarettes and cigars, respectively; 4.2%, 0.7%, 3.4% and 0.3% currently used any tobacco products, cigarettes, e-cigarettes and cigars, respectively; and 1.6%, 0.3%, 1.2% and 0.1% had ever used any tobacco products, cigarettes, e-cigarettes and cigars regularly before, respectively. Χ2 test results show that receiving any tobacco product price promotions was also associated with all stages of any product use progression (p<0.01), and receiving e-cigarette price promotions was associated with all stages of e-cigarette use progression (p<0.001).
Associations between receiving product price promotions and use progression
Table 2 shows the results from the multivariable logistic regressions for assessing the associations between receiving product price promotions and product use progression by product type, adjusting for covariates. Receiving any tobacco product price promotions was associated with any product initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41, p<0.001), current use (AOR=1.54; 95% CI 1.06 to 2.23, p=0.022) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10, p=0.047). Receiving e-cigarette price promotions was also associated with more progressed e-cigarette use outcomes, including current use (AOR=1.88; 95% CI 1.17 to 3.02, p=0.009) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40, p=0.048). An overall pattern of product-specific associations was also found for initiating cigarettes and cigar products. Specifically, receiving price promotions for cigarettes and cigars was respectively associated with initiating cigarettes (AOR=2.39; 95% CI 1.44 to 3.97, p=0.001) and cigars (AOR=7.36; 95% CI 2.50 to 12.89, p<0.001). Product-specific associations were not found for current use or ever regular use of cigarettes and cigar products.
Associations between receiving price promotions and use progression of any tobacco, cigarettes, e-cigarettes and cigars at wave 4.5 among never tobacco users aged 12–16 at wave 4: Population Assessment of Tobacco and Health Study youth survey wave 4 (2016–2018) and wave 4.5 (2017–2018; n=9405)*
Discussion
This is one of the first studies to examine the association between receiving tobacco product-specific price promotions and corresponding product use progression among tobacco-naïve youth. The results highlighted the high rates of any tobacco (9.4%) and e-cigarette (7.8%) initiation between 2017 and 2018 and showed that receiving any tobacco product price promotions was associated with any product use progression outcomes over the past year. Additionally, this study revealed the positive associations between receiving e-cigarette price promotions and all stages of e-cigarette use progression, as well as the associations between receiving cigarette and cigar price promotions and corresponding product initiation. The analyses controlled for youth’s overall tobacco advertising exposure, suggesting the independent associations between receiving price promotions and the use progression of the examined tobacco products.
Our study demonstrated that receiving tobacco price promotions, a marketing strategy pervasively used by tobacco companies,10 may play an important role in youth’s increased tobacco use. Tobacco price promotions may contribute to tobacco initiation by prompting youth’s spontaneous tobacco purchasing and trial. The affordable prices and bundled sales through price promotions may also help sustain youth’s escalated craving and increased consumption of tobacco products over time. The observed associations may also be explained by the formation of tobacco brand loyalty through youth’s repeated exposure to price promotion tactics associated with certain tobacco brands. Previous research has shown that brand loyalty may contribute directly to increased purchasing of tobacco products and escalated long-term use.22 31
This study also found that receiving e-cigarette price promotions was associated with all stages of e-cigarette use progression among tobacco-naïve youth. This finding generally aligns with previous research that shows reduced e-cigarette prices (regardless through price promotion strategies or not) may increase youth e-cigarette use as this group is sensitive to price changes.32–34 Additionally, in recent years, youth have become increasingly likely to receive and influenced by e-cigarette marketing messages through online platforms as opposed to traditional media (magazines and television).31 35 36 Through these platforms that market e-cigarettes, youth may be exposed to a ubiquitous offering of price promotion tactics such as price discounts, bundled sales for reduced prices and ‘buy one get one free’.11 14 37 In particular, social media influencers who promote e-cigarettes with discounted prices or promotion codes may attract youth to follow e-cigarette-related online content and potentially become exposed to an increased amount of pro-e-cigarette messages over time.38 39 This may conceivably contribute to youth’s increased curiosity and intention of using e-cigarettes as well as impulse purchasing and opportunistic product use. Moreover, research has identified the growing use of e-cigarette price promotions at brick-and-mortar points of sale,40 41 which further exposes tobacco-naïve youth to tobacco price promotion messages as they go about their daily activities. Finally, certain prominent e-cigarette brands, such as JUUL, adopted aggressive pricing strategies to lower the barrier for youth initiation and continued use by substantially reducing their prices of e-cigarette devices (eg, 40% off for JUUL starter kits).42 43 As a consequence, JUUL was reported to be the usual e-cigarette brand by more than half of current youth e-cigarette users,44 suggesting that the observed associations for current and ever regular e-cigarette users may be influenced by users’ loyalty towards certain brands.
This study also demonstrated that receiving price promotions for cigarettes was only associated with youth’s cigarette initiation as opposed to more progressed outcomes. This finding runs counter to previous research showing that cigarette smoking experimentation among youth may be price insensitive due to sparse consumption, whereas consistent smoking may be more sensitive to product price.45 This inconsistency may be related to the small sample sizes from the low prevalence of current and ever regular cigarette smoking over 1 year. Alternatively, this may reflect the fact that marketing practices and sales for conventional cigarettes, including those through traditional and online media and tobacco retailers, are heavily regulated and restricted,37 46 making it difficult for youth to receive or redeem cigarette price promotions for consistent use. Widespread anticigarette smoking social norms may also have counteracted the influence of any cigarette marketing messages received by youth.47
Furthermore, this study identified a relationship between receiving cigar price promotions and cigar initiation. Previous evidence has shown that cigar price discounts were ubiquitously found in cigar advertising and packaging on cigar sales websites, social media, print media and points of sale.48 49 Due to the affordability of many cigarillo and little cigar brands,50 cigar smokers may be more price sensitive than users of other tobacco products. This may partially explain why the effect size for the association between receiving price promotions and product initiation is the largest for cigar products, as compared with those for e-cigarettes and cigarettes.
This current study has several limitations. First, due to the PATH Study’s measure of receiving price promotions in the past year, we examined the associations between receiving tobacco product price promotions and behaviour change at wave 4.5. Therefore, although we restricted the analytical sample to those who had never used tobacco at wave 4, it is possible that youth had initiated tobacco prior to receiving price promotions within the 1-year period. Second, the PATH Study only included questions about receiving price promotions. Future research aimed at gaining an in-depth understanding of the influence of tobacco price promotions is warranted to examine seeing, receiving and using tobacco price promotions through various venues such as websites, social media and physical retailers. Finally, this study did not examine the product-specific associations for other types of tobacco products (eg, smokeless tobacco) because, according to the current analysis, both the prevalence of receiving price promotions for these products and using these products were comparatively lower than those for cigarettes, e-cigarettes and cigars.
The current state and evolving pattern of tobacco price promotion strategies through social media and other online platforms should be continuously monitored. If warranted by evidence of product promotion effects on youth tobacco use, these promotional efforts should be further intervened. Unlike other countries such as the UK and Canada,51 the USA currently does not have a national-level regulation for restricting the distribution or redemption of tobacco price promotions. Some US states (eg, New York and New Jersey), however, have recently passed laws to restrict retailers’ use of price promotions for selling tobacco products.52 53 Research is needed to assess the impact of those policy initiatives to inform tobacco price promotion regulations in the country. Enforcing the disclosure of industry sponsoring on social media54 may be a promising strategy to reduce the appeal of hidden price promotion messages. Regulations that restrict cigars’ multipack savings55 may be especially effective in reducing cigar initiation.
Conclusions
This nationally representative survey study among youth never tobacco users found significant associations between receiving price promotions (2016–2018) and use progression of any tobacco over 1 year (2017–2018). The product-specific associations were also found for all stages of e-cigarette use progression and cigarette and cigar initiation. This evidence adds to a growing body of work suggesting a need to continue monitoring various media platforms and retailers that market tobacco products, especially e-cigarettes, through price promotions.
What this paper adds
Tobacco price promotions may prompt tobacco product trial among price-sensitive populations such as youth.
Few studies are available assessing whether receiving price promotions for cigarettes, e-cigarettes and cigars is associated with use progression of these products among youth.
This study found that receiving any tobacco product promotions was associated with the progression of any tobacco use (including initiation, current use and ever regular use).
Receiving product promotions for e-cigarettes was associated with e-cigarette product use progression.
Receiving price promotions for cigarettes and cigars was respectively associated with cigarette and cigar product initiation.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
References
Footnotes
Contributors Concept and design: JCS, KC. Acquisition, analysis or interpretation of data: all authors. Drafting of the manuscript: JCS. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: JCS. Obtained funding: JCS, KC. Administrative, technical or material support: JCS, KC. Supervision: JCS, KC.
Funding JCS is supported by NCI/FDA grant K99CA242589. JCS and KC are supported by the Division of Intramural Research, National Institute on Minority Health and Health Disparities.
Disclaimer Comments and opinions expressed belong to the authors and do not necessarily represent the views of the US Government, National Institutes of Health, National Cancer Institute, or the Institute on Minority Health and Health Disparities, or the FDA.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.