Campaign for Tobacco-Free Kids, CC BY-NC-ND
The Research Brief is a short take about interesting academic work.
The big idea
The worldโs largest multinational tobacco companies are advertising cigarettes to kids near playgrounds and schools in 42 majority low- and middle-income countries. Thatโs the key finding of our recently published paper.
Through our on-the-ground data collection at 19,500 points of sale, we identified tobacco industry advertising and promotions demonstrating four common tactics. These include displaying cigarettes near snacks, sweets and sugary drinks; placing cigarette advertisements near childrenโs eye level; marketing flavored cigarettes through ads and/or product displays; and selling single cigarette sticks.
We collected data on how cigarettes are marketed and sold within 250 meters, or about 820 feet, of one or more schools and/or playgrounds in more than 100 cities around the globe. The locations included most capital cities and spanned Africa, Asia, Central America, Europe, North America and South America.
Our findings correspond with similar research conducted in high-income countries. Taken together, our research and that of others suggests that in the absence of strong restrictions and enforcement, the tobacco industry is employing similar marketing strategies all around the world with what we believe is the specific intention to attract and addict children and youth.
Why it matters
Many jurisdictions throughout the world have implemented laws prohibiting advertising of tobacco products on radio, television and billboards. As a result, comparably less restricted point-of-sale opportunities have become a critical component of tobacco company marketing strategies. This includes the โBig Fourโ global giants: Philip Morris International, British American Tobacco, Japan Tobacco International and Imperial Tobacco.
Previous research has established that in the face of advertising restrictions, the tobacco industry will refocus its marketing efforts โ and dollars โ on unregulated channels such as the point of sale. Tobacco companies themselves have acknowledged the effectiveness of the point-of-sale channel, developing effective marketing strategies and resources geared toward maximizing potential sales. Tobacco companies provide incentives to retailers to market their products in this manner.
Our findings, summarized below, show that the tobacco industry uses point-of-sale advertising widely, and consistently targets youth.
โข In 90% of the countries we studied, cigarettes were displayed near junk food or sugary drinks, including some self-serve displays within childrenโs reach.
โข We found ads or displays promoting flavored cigarettes, which are known to appeal to minors, in 76% of the countries we studied.
โข Stores selling tobacco in 78% of countries sold single cigarettes, making the product more affordable.
โข Points of sale in all 42 majority low- and middle-income countries displayed cigarette advertising at kidsโ eye level, featuring โBig Fourโ tobacco products or ads.
Research is clear that kids who are frequently exposed to tobacco advertising and promotion at points of sale have higher odds of trying smoking and are more likely to be susceptible to smoking in the future compared to those who are less frequently exposed. Smoking kills 8 million people worldwide each year and is the leading cause of preventable death.
Experts have also established links between point-of-sale advertising and smoking-related behaviors and beliefs, like misperceptions that smoking is less harmful than it really is and a lower likelihood of quitting smoking.
Whatโs next
Our work focused on what consumers see and did not differentiate between products that were on sale legally versus those sold illicitly.
The World Health Organization Framework Convention on Tobacco Control, an international treaty ratified by 182 parties and covering more than 90% of the worldโs population, recommends a variety of evidence-based strategies to counteract these marketing tactics. These include comprehensive bans on tobacco advertisement, promotion and sponsorship, plain tobacco packaging, large graphic health warnings on tobacco packs, bans on single-stick cigarette sales, and regulation of flavors.
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This work was supported with funding from Bloomberg Philanthropies' Bloomberg Initiative to Reduce Tobacco Use (bloomberg.org). Jennifer Brown consults with the Campaign for Tobacco-Free Kids.
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The 15 cities with the worst e-cigarette problem
Intro
UpdatedPhoto Credit: Alamy Stock Photo
Between 2017 and 2018, e-cigarette use among middle and high school students increased by a shocking 70 percent, representing 1.5 million new smokers, according to dataย from the National Youth Tobacco Surveyย conducted by the Centers for Disease Control and Prevention (CDC).
Electronic cigarettes are battery-powered vaporizers that create an aerosol usually containing nicotine, flavorings, and various additives. Experts originally believed that smoking e-cigarettes (or โvaping)โ was less harmful than using regular cigarettes. However, a series ofย recent incidents, in which otherwise healthy young adults developed severe lung ailments, is changing this attitude.
Unlike traditional cigarette use, which has largely been trending down for decades, use of e-cigarettes has grown. From 2012 to 2016, e-cigarette unit sales in the U.S. increased by 132 percent, from 667 units to 1,547 units per 100,000 people. New data suggests that sales of JUULโa USB-shaped e-cigarette device popular among teensโincreased by approximately 600 percent during 2016-2017ย and even more through 2018. Cigarette smoking, on the other hand, recently reached its lowest level ever recorded.
The sharp uptick in e-cigarette use among teens is especially troublesome as it has led to a net increase in overall tobacco use despite declining cigarette sales. Between 2017 and 2018, use of tobacco productsย increased by 38.3 percent among high school students and by 28.6 percent among middle school students, according to the National Youth Tobacco Survey. E-cigarette use among the adult population, on the other hand, remained flat in 2017 at 4.6 percent.
In 2018, e-cigarettes were the most commonly used tobacco product among middle and high school students at 13.5 percent, followed by traditional cigarettes (5.2 percent), cigars (4.9 percent), chewing tobacco (3.0 percent), and hookah (2.8 percent). Among the adult population, regular cigarettes still dominate peopleโs tastes at 16.1 percent, followed by e-cigarettes (4.6), and smokeless tobacco (4.1 percent), according to data from the Centers for Disease Control and Prevention, BRFSS Survey.
One reason e-cigarettes are gaining ground among young adults is that they are significantly less expensive than traditional cigarettes. Smoking a pack of cigarettes a day comes out to almostย $2,300ย a year on average, while the figure could be as low as a few hundred dollars with e-cigarettes. The CDC reports that increasing the price of tobacco products is the single most effective way to reduce consumption, especially among young adults who are two to three times more price sensitive to tobacco prices than adults.
Tobacco companies today offer such a wide range of products that appeal to a variety of preferencesโa trend thatโs a major challenge in slowing the growth of overall tobacco product use.ย For example, while e-cigarettes are most popular among teens, this analysis finds that among adults, the current use of e-cigarettes is positively correlated with the proportion of whites in a metropolitan area (correlation of 23 percent), while it is actually negatively correlated with the proportion of blacks (-7 percent), who, on average, prefer regular cigarettes (a positive correlation of 17 percent).
The analysis also finds a statistically significant relationship between the usage of electronic cigarettes and depression. This is consistent with CDC dataย reporting that among adults who report serious psychological distress, more than 40 percent used any tobacco product, compared with less than 20 percent of the population without serious mental distress.
The relationship between tobacco use and mental illness may suggest that those who suffer from psychological ailments are more likely to use e-cigarettes to alleviate stress; worse so, one could postulate that the actual use of e-cigarettes or other tobacco products increases the likelihood of mental health issues. Furthermore, this analysis discovered that smaller metropolitan areas are experiencing higher e-cigarette usage compared to larger ones. Coupled with smaller budgets for awareness campaigns and mental health care, small metropolitan areas might be the most vulnerable to the surge in e-cigarettes.
Given large differences across U.S. metropolitan areas and the skyrocketing e-cigarette usage, researchers at HeyTutorย wanted to find areas with the highest e-cigarette smoking rates and identify communities, which could be most vulnerable to lung ailments experienced across the nation. The researchers used data from the Centers for Disease and Control Prevention (SMART Survey), data from the U.S. Census American Community Survey, and the National Youth Tobacco Survey in its analysis. Due to data limitations, the metro-level data shown is for adults only. Here are the metropolitan areas with the highest e-cigarette usage.
15. Tampa-St. Petersburg-Clearwater, FL
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.4%
- Growth in e-cigarette use:ย 15.8%
- Rate of depression among all adults:ย 16.6%
- Percentage of total population thatโs white:ย 78.6%
- Population:ย 3,091,399
14. Cleveland-Elyria, OH
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.4%
- Growth in e-cigarette use: 20.1%
- Rate of depression among all adults: 21.6%
- Percentage of total population thatโs white: 73.3%
- Population: 2,058,844
13. Spokane-Spokane Valley, WA
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.6%
- Growth in e-cigarette use: -17.8%
- Rate of depression among all adults: 24.6%
- Percentage of total population thatโs white: 88.0%
- Population: 564,291
12. Oklahoma City, OK
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.6%
- Growth in e-cigarette use: No significant change
- Rate of depression among all adults: 23.1%
- Percentage of total population thatโs white: 73.5%
- Population: 1,383,737
11. South Bend-Mishawaka, IN-MI
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.7%
- Growth in e-cigarette use: Data not available
- Rate of depression among all adults: 23.1%
- Percentage of total population thatโs white: 80.4%
- Population: 321,815
10. Reno, NV
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.8%
- Growth in e-cigarette use: 9.4%
- Rate of depression among all adults: 19.5%
- Percentage of total population thatโs white: 78.0%
- Population: 465,208
9. Ogden-Clearfield, UT
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.8%
- Growth in e-cigarette use: 8.0%
- Rate of depression among all adults: 24.0%
- Percentage of total population thatโs white: 89.7%
- Population: 666,547
8. Tulsa, OK
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.9%
- Growth in e-cigarette use: No significant change
- Rate of depression among all adults: 24.6%
- Percentage of total population thatโs white: 71.2%
- Population: 990,773
7. Albany-Schenectady-Troy, NY
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 6.9%
- Growth in e-cigarette use: 69.5%
- Rate of depression among all adults: 24.0%
- Percentage of total population thatโs white: 82.5%
- Population: 886,188
6. Panama City, FL
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 7.7%
- Growth in e-cigarette use: 47.8%
- Rate of depression among all adults: 22.8%
- Percentage of total population thatโs white: 80.7%
- Population: 202,236
5. Kingsport-Bristol-Bristol, TN-VA
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 7.7%
- Growth in e-cigarette use: 97.7%
- Rate of depression among all adults: 29.7%
- Percentage of total population thatโs white: 94.7%
- Population: 305,914
4. Lexington-Fayette, KY
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 8.7%
- Growth in e-cigarette use: Data not available
- Rate of depression among all adults: 16.5%
- Percentage of total population thatโs white: 81.2%
- Population: 512,650
3. Evansville, IN-KY
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 8.9%
- Growth in e-cigarette use: Data not available
- Rate of depression among all adults: 29.8%
- Percentage of total population thatโs white: 87.9%
- Population: 315,669
2. Little Rock-North Little Rock-Conway, AR
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 9.1%
- Growth in e-cigarette use: Data not available
- Rate of depression among all adults: 23.3%
- Percentage of total population thatโs white: 70.1%
- Population: 738,082
1. Crestview-Fort Walton Beach-Destin, FL
UpdatedPhoto Credit: Alamy Stock Photo
- E-cigarette use among adults: 9.6%
- Growth in e-cigarette use: 57.0%
- Rate of depression among all adults: 16.3%
- Percentage of total population thatโs white: 80.5%
- Population: 271,346
Methodology and full results
UpdatedData on the proportion of adults who currently use e-cigarettes comes from the Centers for Disease and Control Prevention SMART Surveyย (Selected Metropolitan Area Risk Trends)ย conducted in 2017 and it is based on more than 400,000 interviews nationally. The growth in e-cigarette use was calculated as the percentage change between 2017 and 2016, which also came from the SMART survey. The SMART survey also contains information on the rates of depression by metropolitan area.
Demographic data is from the U.S. Census Bureau American Community Survey 1-Year Estimates. Furthermore, statistics on middle and high school tobacco use are from the Center for Disease Control and Prevention National Youth Tobacco Survey. This survey does not contain information about the adult population.
For a complete list of results across all available metropolitan areas, see the original version on HeyTutor.