Young People Exposure To Tobacco and Promotions
Young People Exposure To Tobacco and Promotions
Young People Exposure To Tobacco and Promotions
Public Health
Original Research
Article history: Objectives: Point of sale (POS) displays are one of the most important forms of tobacco
Received 2 November 2015 marketing still permitted in many countries. Reliable methods for measuring exposure to
Received in revised form such displays are needed in order to assess their potential impact, particularly on smoking
22 March 2016 attitudes and uptake among young people. In this study we use a novel method for eval-
Accepted 26 March 2016 uating POS exposure based on young people's use of retail outlets and recall of tobacco
Available online 10 May 2016 displays and observational data on the characteristics of displays.
Study design: Observational audit of retail outlets (n 96) and school-based pupil survey
Keywords: (n 1482) in four Scottish communities reflecting different levels of social deprivation and
Tobacco urbanisation, conducted in 2013 before legislation to remove POS displays was imple-
Marketing mented in supermarkets.
Point-of-sale Methods: Measures were taken of: visibility and placement of tobacco displays; internal and
Exposure external advertising; display unit size, branding and design; visibility of pack warnings;
Young people proximity of tobacco products to products of potential interest to children and young
Policy people; pupils' self-reported frequency of visiting retail outlets; and pupils' recall of tobacco
displays. Variation in POS exposure across social and demographic groups was assessed.
List of abbreviations: POS, Point of sale; CTNs, Confectioners, tobacconists and newsagents.
* Corresponding author.
E-mail addresses: martine.stead@stir.ac.uk (M. Stead), douglas.eadie@stir.ac.uk (D. Eadie), a.m.mackintosh@stir.ac.uk (A.M. MacK-
intosh), catherine.best2@stir.ac.uk (C. Best), m.a.miller-1@sms.ed.ac.uk (M. Miller), fh38@st-andrews.ac.uk (F. Haseen), jamie.pearce@ed.
ac.uk (J.R. Pearce), catherine.tisch@ed.ac.uk (C. Tisch), andy.macgregor@scotcen.org.uk (A. MacGregor), amanda.amos@ed.ac.uk
(A. Amos), wpmvds@st-andrews.ac.uk (W. van der Sluijs), john.frank@hgu.mrc.ac.uk (J.W. Frank), s.j.haw@stir.ac.uk (S. Haw).
http://dx.doi.org/10.1016/j.puhe.2016.03.032
0033-3506/ 2016 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
p u b l i c h e a l t h 1 3 6 ( 2 0 1 6 ) 4 8 e5 6 49
Results: Displays were highly visible within outlets and, in over half the stores, from the
public footway outside. Tobacco products were displayed in close proximity to products of
interest to children (e.g. confectionery, in 70% of stores). Eighty percent of pupils recalled
seeing tobacco displays, with those from deprived areas more likely to recall displays in
small shops. When confectioners, tobacconists and newsagents (CTNs) and grocery/con-
venience stores (two of the outlet types most often visited by young people) were examined
separately, average tobacco display unit sizes were significantly larger in those outlets in
more deprived areas.
Conclusions: POS displays remain a key vector in most countries for advertising tobacco
products, and it is important to develop robust measures of exposure. The data reported in
this paper provide a baseline measure for evaluating the efficacy of legislation prohibiting
such displays.
2016 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public
Health. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
selected communities. Baseline data collection was in 2013, observers comparing notes to verify key characteristics.
with follow-up data collected annually for four years. For the Where inconsistencies or gaps emerged these were addressed
purposes of the study, the communities were defined as the by an immediate follow-up visit to the study outlet. For most
catchment areas around four secondary schools selected to items, observers noted the presence or absence of particular
reflect two levels of urbanisation (urban vs small town) and features. The overall visibility of the display inside the outlet
two levels of social deprivation (high vs medium/low). Depri- was rated on a scale of 1e5 and the visibility of the display
vation was assessed using the population-weighted average from outside the shop rated as not very visible, fairly visible
Scottish Index of Multiple Deprivation (SIMD) scores derived or very visible. Retail outlets were linked to the Scottish
from the datazones (n 125; mean population 872) with Index of Multiple Deprivation (SIMD)24 by their postcode and
population-weighted centroids falling within each school grouped by SIMD quintile for the purpose of analysis by area
catchment area, and the proportion of children receiving free deprivation. Data analysis was conducted in IBM SPSS version
school meals. All data reported here were collected in 2013, 21. Ethical approval was provided by the University of Stirling
prior to the implementation of the POS legislation in super- School of Management Research Ethics Committee.
markets and when tobacco products were on display in all
types of retail outlets.
School-based survey
Table 4 e Observational audit: proximity of tobacco Table 6 e Young people's recall of cigarettes or tobacco in
products to products with potential appeal to children large supermarkets and small shops, by demographic
(number and percentage of outlets which display each and socio-economic factors.
product category immediately above, below, in front of or Large supermarkets Recall of cigarettes or tobacco
to the side of the display unit). displayed for sale
Product category No. of outlets with No of outlets as
Yes No P-valuea
items in proximity percentage of
to tobacco all outlets (n 96) n % n %
Gums & mints 76 79% Total sample 1180 79.6 286 19.5 0.09
Confectionery 67 70% Gender
Crisps & other 9 9% Boys 563 78.7 152 21.3
salty snacks Girls 614 82.3 132 17.7
Toys 9 9% Age group
Soft drinks 7 7% <15 years 551 78.5 151 21.5 0.07
Collectable 7 7% >15 years 567 82.3 122 17.7
cards & stickers SIMD quintile
Cakes & pastries 6 6% one low 191 78.6 52 21.4
Ice cream & frozen 5 5% 2 131 82.4 28 17.6 0.83
drinks 3 158 82.7 33 17.3
Hot pies & savouries 2 2% 4 223 83.2 45 16.8
Total number of product categories in proximity to tobacco display: 5 high 231 79.1 61 20.9
7 products 1 1% Small shops 1181 79.7 265 17.9
6 products 0 e Total sample
5 products 2 2% Gender
4 products 10 10% Boys 565 80.3 139 19.7 0.17
3 products 21 22% Girls 612 83.0 125 17.0
2 products 30 31% Age group
1 product 26 27% <15 years 547 78.9 146 21.1 0.004a
0 products 6 6% 15 years 576 85.0 102 15.0
Mean std dev 2.2 (1.3) SIMD quintile
1 most deprived 205 86.1 33 13.9
2 136 86.6 21 13.4 0.007b
Recall of cigarettes or tobacco displayed for sale in both large 3 160 84.2 30 15.8
supermarkets and in small shops did not vary by gender. 4 210 79.2 55 20.8
However, there was a patterning by social disadvantage. 5 least deprived 229 79.5 60 20.8
Recall of cigarette displays in small shops was higher in young a
Chi square value 8.4 with one df.
b
people living in areas of greater socio-economic deprivation Chi-squared test for trend value 7.3 with one df.
(P < 0.007). There was also a significant difference by age, with
pupils aged 15 and older more likely to recall seeing displays in
small shops than those aged under 15 years (P < 0.004). supermarkets more frequently than other types of retail out-
lets. Additional analyses were conducted for key measures to
Analysis by retail outlet category and by store level of assess whether displays in stores which young people visited
deprivation more often were different in any way. These analyses indi-
cated that in the stores which young people visited more
The school survey indicated that young people in the study often, tobacco displays were less likely to be visible from
areas visited CTNs, grocery/convenience stores and outside the store (P < 0.001), while pack health warnings were
* Significant difference males and females chi square 16.3, df 1, P < 0.001.
** Significant difference males and females chi square 16.2, df 1, P 0.001.
54 p u b l i c h e a l t h 1 3 6 ( 2 0 1 6 ) 4 8 e5 6
more likely to be visible (P < 0.001). There were no other sig- outlets since April 2015, the approach reported in this study is
nificant differences according to retail outlet category. providing a baseline measure for evaluating the efficacy of the
Display characteristics were analysed by the store SIMD legislation.21 It is important to note that although POS displays
quintile, to assess whether displays varied by area-level have been prohibited in the UK, this does not mean that
deprivation (Table 7). For most measures, there were no sig- consumers will in future have no exposure at all to tobacco-
nificant differences. However, as area deprivation increased, related messages in retail outlets; the vast majority of to-
the likelihood that cigarette pack warnings were obscured by bacco retailers are likely to retain a unit in a prominent posi-
the design of the display unit decreased (P < 0.001). When the tion which is identifiable as selling tobacco products, even
analysis by area level socio-economic deprivation included though packs will no longer be visible. Recent research from
only CTNs and groceries (two of the three categories of outlet Australia, where POS advertising is prohibited, suggests that
more frequently visited by young people), tobacco display even in the absence of this advertising, the mere sight of to-
units were of significantly larger average size in areas of more bacco retailers and cues that tobacco is for sale, such as price
deprivation than in areas of less deprivation (P 0.03). lists, can trigger cravings among smokers who are trying to
quit.25 This suggests that the effects of indicators of tobacco
products being on sale will still need to be monitored, even
Discussion where advertising and displays are prohibited.
In this study, conducted before the implementation of the
This study used a novel and comprehensive approach to legislation, tobacco displays were highly visible not only
examine exposure to tobacco displays. Marketing exposure is within the store but also, in over half the stores, from the
a multifaceted concept which comprises the customer's op- public footway outside, meaning that even customers who did
portunity to see the marketing, customer recall of the mar- not frequent a particular shop were exposed to tobacco
keting, and features of the marketing itself. We examined products while walking past. Within the study stores, nearly
opportunities to see displays using frequency of visiting all of the tobacco displays were behind till-points at customer
different types of retail outlets by young people, young peo- eye level, meaning that the vast majority of customers would
ple's self-reported recall of seeing displays in different types of see them even if they were not buying tobacco. Eye level
retail outlets, and the characteristics of the displays them- display of products is important for tobacco companies
selves, using a combination of mapping and observational because it ensures visibility and generates, according to one
research. A particular strength of the study was that all these industry document, a strong impulse to buy.5 The presence
measures were taken in the same four communities. In future of tobacco products in everyday settings alongside common
analysis we will link together changes in exposure derived household goods may suggest that tobacco is an ordinary
from both the observational audit and the school survey. product and therefore socially acceptable.12,26,27 In this study,
Given that POS advertising and displays of tobacco products tobacco products were also displayed in proximity to a range
are still permitted in many countries, it is important to of products of particular interest to children, most notably
develop robust methods for measuring exposure to them. In confectionery (in 70% of all stores, increasing to 72% of gro-
the UK, where POS displays have been prohibited in all retail cery/convenience stores and 81% of CTNs). This proximity
Internal visibility of display mean (sd) 2.9 2.9 3.3 3.3 2.9 Kruskal Wallis n.s.
Rated 5-high to 1-low (0.8) (0.8) (0.8) (1.2) (1.0)
n 26 n 23 n 12 n 21 n 13
Packs displayed upright and facing forward 96.2% 100% 100% 95.2% 92.3% Chi square n.s.
% stores in which pack warnings obscured 8.0% 22.7% 75% 57.1% 46.2% Chi square for trend 13.2
df 1
P 0.001
Size of display 2.1 2.0 2.2 2.0 2.1 Kruskal Wallis n.s.
mean (sd) (0.6) (1.3) (1.4) (1.3) (1.6)
n 26 n 23 n 12 n 21 n 13
Number of product categories in proximity 1.6 2.0 2.2 2.1 1.9 Kruskal Wallis n.s.
to tobacco display mean (sd) (1.0) (1.2) (1.1) (1.0) (0.5)
n 26 n 23 n 12 n 21 n 13
ensures that cigarette products have the potential to be the information required for the audit. However, conducting
noticed by children from a young age. Pollay5 has suggested observations in pairs meant that observers were able to
that recruitment of young smokers is enhanced by POS ma- compare findings immediately after each site visit, and to
terials which expose children to cigarette promotion with make a repeat visit if necessary to verify any gaps or anoma-
every store visit. Furthermore, exposure to point-of-sale lies in recording. The data collected are not nationally repre-
advertising increases young people's perception that tobacco sentative although they were obtained in four communities
is easy to buy.27 that varied according to levels of social deprivation, and de-
The majority of young people in the school survey (80%) gree of urbanisation.
recalled seeing tobacco products displayed for sale both in Internationally, POS displays remain a key vector for the
supermarkets and in smaller shops. Although the number of tobacco industry to promote its products. Developing robust
children taking up smoking has been falling since the 1990s, methods to measure exposure to POS displays, and using
an estimated 207,000 children aged 11e15 still start smoking these measures to examine variations in exposure amongst
each year in the UK,28 and there is a consistent socio- different sociodemographic groups, is an important priority
economic patterning, with more disadvantaged 11e15 year for tobacco researchers.20 Such measures not only help to
olds more likely to take up the habit.29 Given this, and the reveal insights into industry behaviour but also enable re-
evidence that exposure to POS displays increases suscepti- searchers to examine the influence of POS marketing on
bility to smoking initiation,8,9 it is of concern that young smoking initiation and cessation. The methods and measures
people from the least affluent backgrounds were more likely described in the current study are replicable in other countries
to recall seeing tobacco displays in our study. wanting to describe and assess exposure to POS displays, or
A Californian study30 found more tobacco advertising ma- interested in evaluating the impact of controls on POS
terials and greater shelf space devoted to popular brands in advertising and display. The measures of display character-
stores which adolescents visited frequently, compared with istics can be used to demonstrate changes over time or be-
stores which were less often visited by adolescents. The cur- tween different areas in display practices: e.g. to assess
rent study found few differences in marketing between the whether certain brands are promoted more heavily in some
stores more frequently visited by young people e CTNs, gro- areas than others, whether display practices differ between
cery/convenience stores and supermarkets e compared with different types of retail outlets, or to measure the effective-
the types of outlets less frequently visited by young people. ness of controls in reducing the impact of displays. The
However tobacco displays were less likely to be visible from methods are also potentially transferable to other product
outside the store, and pack health warnings more likely to be categories of concern, such as e-cigarettes, alcohol or high fat,
visible, in those outlet types more frequently visited by young salt and sugar foods.
people. One possible explanation for the first finding is that the
stores less frequently visited by young people included petrol
station shops, which tend to score highly on external visibility Author statements
of tobacco products because they have large windows to
enable the shop assistants to keep an eye on the pumps. Ethical approval
It has been suggested that small stores are a more impor-
tant source of exposure to tobacco for young people than su- Ethical approval for the retail audit was obtained from the
permarkets, because the latter tend to have numerous till- University of Stirling School of Management Research Ethics
points meaning that tobacco products can be avoided.8 Committee. Ethical approval for the schools' survey was ob-
When CTNs and grocery/convenience stores (two of the tained from the University of St Andrews, School of Medical
three types of outlets most often visited by young people) were Ethics Committee.
examined separately, those located in more deprived areas
(based on outlet postcode SIMD quintile) were found to have Funding
significantly larger average display unit size than CTNs and
grocery/convenience stores in areas of less deprivation. Again, The study was funded by the UK National Institute for Health
given the increased risk of youth smoking uptake in more Research (NIHR, PHR 10/3000/07).
disadvantaged groups, this is of concern.29 There were few
other differences between outlet types when display charac- Competing interests
teristics were analysed by store SIMD quintile. However,
where cigarettes were on sale in stores in more deprived The authors declare no competing interests.
areas, pack warnings were less likely to be obscured. This may
be because obscuring of pack warnings was more common in Authors' contributions
supermarkets (because of the design of certain supermarket
display units), which in these communities tended to be MS conceived of the paper, drafted the manuscript and con-
located in more affluent postcode areas. ducted some of the observational audit fieldwork; DE designed
There are some limitations of the study methodology. the observational audit tools and led the fieldwork; AMM and
Observer recall, supported by memory aids, was used, which CB conducted the observational audit data analysis; MM and
introduces the possibility of observer recall error. Other FH conducted the school survey data analysis; JP and CT
methods involving photography and video were piloted, but mapped the communities to identify the retailer sample;
proved unreliable and not necessarily capable of capturing all LMcD conducted observational audit data fieldwork; SH, AA,
56 p u b l i c h e a l t h 1 3 6 ( 2 0 1 6 ) 4 8 e5 6
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Appendix A. Supplementary data
and point of sale display of tobacco in the UK: a descriptive
study of small retailers. PloS One 2012;7(1):e29871. http:// Supplementary data related to this article can be found at
dx.doi.org/10.1371/journal.pone.0029871. http://dx.doi.org/10.1016/j.puhe.2016.03.032.