Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities

Objective : To estimate daily cigarette consumption among residents aged 15+ in five remote central Australian predominantly Aboriginal communities. Methods : Estimation of average daily cigarette consumption derived from a 12‐month (2007) complete sales audit of cigarettes in isolated communities where no other tobacco supplies are available, using two assumptions of smoking prevalence (50% and 70%). Results : Across the five communities, daily smoking consumption averaged 8.3 cigarettes per day (assuming a 50% smoking prevalence) or 5.9 cigarettes per day (assuming a 70% smoking prevalence). The corresponding amounts spent per smoker per day were $4.13 or $2.95, representing 12.7%‐9.1% of the maximum $453.30 per fortnight unemployment allowance for a single person. Conclusion : While smoking prevalence may be high in these Aboriginal communities, smoking frequency is low compared to that in the wider Australian community. These results are consistent with other studies. Approaches to cessation premised on assumptions of nicotine dependence in such populations are likely to be misconceived.     

Trends in purchasing patterns of sugar‐sweetened water‐based beverages in a remote Aboriginal community store following the implementation of a community‐developed store nutrition policy

Aim: Aboriginal people living in remote communities experience high levels of chronic illness partly as a result of diet‐related body mass index above 25 kg/m². Remote stores are typically the only source of food and store nutrition policies are effective in enabling better health for community residents by changing product lines. The aim of the present study was to examine trends in purchasing patterns of sugar‐sweetened water‐based beverages in a remote Aboriginal community store following the implementation of a community‐developed store nutrition policy. Methods: Documents outlining the objectives and strategies of the store policy were examined. Store sales data were quantified to determine changes in purchasing patterns, volume of beverages sold, sugar and energy purchased before and after the withdrawal of the three highest selling sugar‐sweetened water‐based beverages. Results: The community‐developed policy was effective in implementing changes to product lines sold in the remote Aboriginal store. The withdrawal of the three top selling sugar‐sweetened water‐based beverages did not affect the total volume of all beverages sold but a shift in purchasing trends towards beverages with lower or zero sugar content resulted in a reduction in sugar and kilojoules consumed through water‐based beverages. Conclusion: The approach of a community‐driven store nutrition policy described here was successful and could be applied to other products in store that provide excess kilojoules with minimal nutritional benefit. The policy and aspects of implementation could also be applied in other remote Aboriginal communities.     

Density of tobacco retail outlets near schools and smoking behaviour among secondary school students

Objective: To investigate whether the density of tobacco retail outlets near schools in Victoria, Australia, is associated with adolescent smoking behaviour. Methods: Cross‐sectional survey data of 2,044 secondary school students aged 12–17 years was combined with tobacco outlet audit data. Associations between students' self‐reported tobacco use and the density of tobacco outlets near schools was examined using multilevel logistic and negative binomial regression models, with cigarette price at local milk bars and key socio‐demographic and school‐related variables included as covariates. Results: Increased tobacco retail outlet density was associated with a significant increase in the number of cigarettes smoked in the previous seven days among students who smoked in the past month (IRR=1.13; 95% CI 1.02–1.26), but not the odds of smoking in the past month in the larger sample (OR=1.06; 95% CI 0.90–1.24), after controlling for local mean price of cigarettes and socio‐demographic and school‐related variables. Conclusions and implications: This study suggests there is a positive association between tobacco retail outlet density and cigarette consumption among adolescent smokers, but not smoking prevalence, in the Australian context. There is value in considering policy measures that restrict the supply of tobacco retail outlets in school neighbourhoods as a means of reducing youth cigarette consumption.     

Evaluation of an enforcement program to reduce tobacco sales to minors.

OBJECTIVES: This study evaluated an active enforcement program to increase retailers' compliance with the law prohibiting tobacco sales to minors. METHODS: Tobacco sales to minors were monitored in 319 outlets in 6 pairs of communities in Erie County, New York. One community in each pair was randomly assigned to an enforcement intervention. RESULTS: Retailers' compliance with the law increased from 35% in 1994 to 73% in 1995. However, the change in compliance rates was roughly the same for stores in the enforcement and nonenforcement communities. CONCLUSIONS: Active compliance checking of retail outlets as a strategy to reduce illegal tobacco sales to minors may only be necessary insofar as it contributes to an increase in retailers' perception that the threat of enforcement is real.     

Association between density and proximity of tobacco retail outlets with smoking: A systematic review of youth studies

BackgroundReducing the retail availability of tobacco has been proposed as a component of tobacco endgame, yet it is not known whether retail availability has a direct impact on smoking behaviours. A narrative review and a meta-analysis have been undertaken to examine the density and proximity of tobacco retail outlets, but were limited in scope, exposure and outcome variables. The aim of this current study was to undertake a systematic review of the international literature on the density and proximity of tobacco retail outlets to homes, schools and communities and their association with smoking behaviours among youth.MethodsWe reviewed and critically appraised the evidence documenting the association between density or proximity of tobacco retail outlets and smoking behaviours among school-age youth (18 and under), between 1 January 1990 and 21 October 2019. We reviewed original quantitative research that examined the associations of tobacco retail outlet density and proximity with individual smoking status or population-level smoking prevalence; initiation of smoking; frequency of tobacco use; sales to minors; purchasing by minors; susceptibility to smoking among non-smokers; perceived prevalence of smoking, and quitting behaviours.FindingsThirty-five peer-reviewed papers met the inclusion criteria. This review provided evidence of a relationship between density of tobacco retail outlets and smoking behaviours, particularly for the density near youths’ home. A study using activity spaces also found a significant positive association between exposure to tobacco retail outlets and daily tobacco use. The review did not provide evidence of an association between the proximity of tobacco retail outlets to homes or schools and smoking behaviours among youth.ConclusionsThe existing evidence supports a positive association between tobacco retail outlet density and smoking behaviours among youth, particularly for the density near youths’ home. This review provides evidence for the development and implementation of policies to reduce the density of tobacco retail outlets to reduce smoking prevalence among youth.     

Monitoring local trends in Indigenous tobacco consumption

Objective : To compare two methods of monitoring tobacco consumption in remote Indigenous communities.
Methods : We examined the monthly difference between wholesale invoice and point-of-sale data for tobacco products from three stores from remote Aboriginal communities in the Northern Territory. We assessed three measures of wholesale data.
Results : The average monthly difference between the sale data and the average of wholesale invoices for the previous, same and following month was -33 cigarettes per day (95% CI -157, 92). This average of three months' wholesale invoices provided a more precise estimate than either wholesale invoices from the same or previous month.
Conclusion : Tobacco wholesale data provided a close estimate of sales data in these stores.
Implications : This wholesale data could be used to monitor local trends in remote Indigenous tobacco consumption, facilitating the evaluation of the impact of tobacco control activities and informing future work to reduce Indigenous smoking and its harms.     

Cigarette availability and price in low and high socioeconomic areas

Objective: To determine whether tobacco retailer density and cigarette prices differ between low and high socioeconomic status suburbs in South‐East Queensland. Methods: A survey of retail outlets selling cigarettes was conducted in selected suburbs over a two‐day period. The suburbs were identified by geographical cluster sampling based on their Index of Relative Socio‐economic Advantage and Disadvantage score and size of retail complex within the suburb. All retail outlets within the suburb were visited and the retail prices for the highest ranking Australian brands were recorded at each outlet. Results: A significant relationship was found between Index of Relative Socioeconomic Advantage and Disadvantage score (in deciles) and the number of tobacco retail outlets (r=0.93, p=0.003), with the most disadvantaged suburbs having a greater number of tobacco retailers. Results also demonstrate that cigarettes were sold in a broader range of outlets in suburbs of low SES. The average price of the packs studied was significantly lower in the most disadvantaged suburbs compared to the most advantaged. While cigarettes were still generally cheaper in the most disadvantaged suburbs, the difference was no longer statistically significant when the average price of cigarette packs was compared according to outlet type (supermarket, newsagent, etc). Conclusions: In South‐East Queensland, cigarettes are more widely available in the most disadvantaged suburbs and at lower prices than in the most advantaged suburbs.     

The relationship between tobacco access and use among adolescents: a four community study

The objective of this study was to examine the effectiveness of a longitudinal community intervention on the reduction of tobacco sales to minors and subsequent effects on tobacco consumption by youths. The study was conducted in Monterey County, CA. Four rural communities were randomized into treatment and comparison arms of the study and middle and high school students in each of these communities completed surveys assessing knowledge, attitude, and behavior. The main outcome measures were retail tobacco sales to minors as measured through store visits (tobacco purchase surveys) and self-reported consumption of tobacco. Over a three-year period, a diverse array of community interventions were implemented in the intervention communities. These included community education, merchant education, and voluntary policy change. In the treatment communities, the proportion of stores selling tobacco to minors dropped from 75% at baseline to 0% at the final post-test. In the comparison communities, the proportions were 64% and 39%, respectively. Although the availability of tobacco through commercial outlets was reduced substantially in intervention communities, youths reported still being able to obtain tobacco from other sources. Predicted treatment effects on reported use of tobacco among youths were observed cross-sectionally and longitudinally for younger students (7th graders). The intervention did not impact tobacco use among older students (9th and 11th graders) although the trends were in the predicted direction for 9th graders. A significant intervention effect was found for sex--females in the intervention communities were less likely to use tobacco post-intervention than females in the comparison communities. Tobacco sales to minors can be reduced through a broad-based intervention. To prevent or reduce tobacco use by youths, however, multiple supply-and demand-focused strategies are needed.     

青岛市烟草零售点密度及公共场所控烟信息环境现状调查

目的了解山东省青岛市社区周边烟草零售点密度及主要公共场所吸烟相关的信息环境, 为青岛市实施公共场所全面禁烟提供基础数据。方法采用分层系统随机抽样方法对在青岛市市南区、市北区、四方区和李沧区4个中心城区抽取的27个社区周边932个烟草零售点和2 339个主要公共场所(1 568个餐馆、63家医院/社区卫生服务中心、142所学校、340个健身场所和226个路段)进行场所位置定位和控烟相关信息环境的调查。结果青岛市城区平均烟草零售点密度为5.7个/1 000人;932个烟草零售点中, 63.9%的零售点有明显的“此处售烟”标识, 有4.1%的零售点张贴了“禁止向未成年人售烟”的标识, 零售点烟草促销广告与吸烟警示标识的比例为142:1;青岛市调查的餐馆、医院和学校中, 仅1.1%的公共场所为无烟单位;有2.8%的公共场所张贴了“禁止吸烟”的标识, 有1.4%的公共场所发现烟草促销广告, 未发现“吸烟有害健康”等健康警示标识的公共场所。结论青岛市城区烟草零售点密度较高, 烟草促销广告普遍存在, 且公共场所吸烟警示信息缺乏, 控烟支持性信息环境亟需改善。     

Supporting healthy drink choices in remote Aboriginal and Torres Strait Islander communities: a community‐led supportive environment approach

Objective : To create supportive environments to reduce sugary drink consumption and increase water consumption by partnering with remote Aboriginal and Torres Strait Islander communities in Cape York. Methods : This paper applied qualitative and quantitative methods to evaluate a co‐designed multi‐strategy health promotion initiative, implemented over 12 months from 2017 to 2018. Outcome measures included changes in community readiness, awareness of the social marketing campaign and changes in drink availability. Changes in store drink sales were measured in one community and compared to sales in a control store. Results : Community readiness to address sugary drink consumption increased in two of the three communities. Awareness of social marketing campaign messaging was high (56–94%). Availability of drinking water increased in all communities. Water sales as a proportion of total drink volume sales increased by 3.1% (p<0.001) while sugary drink volume sales decreased by 3.4% (p<0.001). Conclusions : A multi‐component strategy with strong engagement from local government, community leaders and the wider community was associated with positive changes in community readiness, drink availability and sales. Implications for public health : Partnering with community leaders in the co‐design of strategies to create environments that support healthy drink consumption can stimulate local action and may positively affect drink consumption.     

Apparent dietary intake in remote Aboriginal communities

Abstract: Apparent per capita food and nutrient intake in six remote Australian Aboriginal communities using the ‘store-turnover’ method is described. The method is based on the analysis of community-store food invoices. The face validity of the method supports the notion that, under the unique circumstances of remote Aboriginal communities, the turnover of foodstuffs from the community store is a useful measure of apparent dietary intake for the community as a whole. In all Aboriginal communities studied, the apparent intake of energy, sugars and fat was excessive, while the apparent intake of dietary fibre and several nutrients, including folic acid, was low. White sugar, flour, bread and meat provided in excess of 50 per cent of the apparent total energy intake. Of the apparent high fat intake, fatty meats contributed nearly 40 per cent in northern coastal communities and over 60 per cent in central desert communities. Sixty per cent of the apparent high intake of sugars was derived from sugar per se in both regions. Compared with national Australian apparent consumption data, intakes of sugar, white flour and sweetened carbonated beverages were much higher in Aboriginal communities, and intakes of wholemeal bread, fruit and vegetables were much lower. Results of the store-turnover method have important implications for community-based nutrition intervention programs.     

Evaluation of a multi-component community tobacco intervention in three remote Australian Aboriginal communities

OBJECTIVES: To assess the effect of community tobacco interventions in Aboriginal communities. METHODS: The study consisted of a pre- and post-study of the effect of a multi-component tobacco intervention conducted in six Aboriginal communities in the Northern Territory (NT). The intervention included sports sponsorship, health promotion campaigns, training health professionals in the delivery of smoking cessation advice, school education about tobacco, and policy on smoke-free public places. The study was conducted in three intervention communities and three matched control communities. Surveys were used to measure changes in prevalence of tobacco use, changes in knowledge, and attitudes to cessation in intervention communities. RESULTS: Tobacco consumption decreased in one intervention community compared with the matched control community; the trends of consumption (as measured by tobacco ordered through points of sale) in these communities were significantly different (t = -4.5, 95% CI -33.6 - (-12.5), p < or = 0.01). Community samples in intervention communities included 920 participants. There was no significant change in the prevalence of tobacco use, although knowledge of the health effects of tobacco and readiness to quit increased. CONCLUSIONS: Although it is difficult to demonstrate a reduction in tobacco consumption or in the prevalence of tobacco use as a result of multi-component community tobacco interventions delivered in Aboriginal communities, such interventions can increase awareness of the health effects of tobacco and increase reported readiness to cease tobacco use.     

The effect of retail store managers on Aboriginal diet in remote communities

Abstract: Key nutrient densities of the diet of two remote northern coastal Aboriginal communities were measured using the store-turnover method during the periods that three store managers were responsible for each store respectively. Individual store managers were a greater determinant of nutrient density than the community itself. Furthermore, nutrient densities tended to be highest in both communities when their stores were administered by one particular store manager. The results support the notion that store managers wield considerable power over the food supply of remote Aboriginal communities, and raise questions concerning the ability of Aboriginal community members to influence their own food supplies in retail stores. However, the study also confirms that store managers can be important allies in efforts to improve Aboriginal dietary intake.     

Lukumbat marawana: a changing pattern of drug use by youth in a remote Aboriginal community

Objective: To examine marijuana use by youth in a remote Aboriginal community in Northern Australia over a 5‐year period. Design: Participant observation, structured and unstructured interviews. Setting: Remote Indigenous Australian community. Participants: Young Aboriginal people and adult community members. Main outcome measure: Emergent themes of the attitudes towards marijuana use among remote Indigenous residents are reported. Results: Restrictions in the availability of alcohol and petrol have led to increased use of marijuana with serious social and community consequences. Conclusions: Efforts to control licit substances, such as alcohol, in remote communities need to be addressed in the context of understanding of the dynamics of alcohol and drug use in totality as well as interventions that address underlying structural and social inequalities.     

Lessons for Aboriginal tobacco control in remote communities: an evaluation of the Northern Territory 'Tobacco Project'

Objective: To evaluate a Northern Territory (NT) government-led pilot 'Tobacco Project' in six remote communities.
Methods: Monthly surveys of staff, semi-structured interviews with staff and community members, observation of the delivery of tobacco control interventions, review of Project documents, and monitoring of tobacco consumption using sales (or wholesale orders) of tobacco.
Results: There was a substantive amount of tobacco control activity delivered in three of the Project communities. In two of these locations, the majority of work was primarily driven and undertaken by resident staff. Overall, most of the Project's efforts related to community education and awareness-raising. There was variable impact of the Project on tobacco consumption across the six communities. More tobacco control activity was consistently associated with a greater reduction in tobacco consumption. An important predictor of local activity was the presence of strong community drivers. A significant obstacle to the Project was the lack of new resources.
Conclusions: Despite the minimal impact of this Project on tobacco consumption overall, there was a consistent association between on-the-ground tobacco control activity and reductions in tobacco consumption.
Implications: New initiatives will not only need to provide new funding, but identify and then support local staff, who are central to improving local tobacco control activity and so reducing smoking and smoking-related illnesses and deaths.     

Review of the nutrition policy of the Arnhem Land Progress Association

Abstract: The process of implementation and the effect of the nutrition policy of the Arnhem Land Progress Association (ALPA) were reviewed three years after implementation of the policy in five remote Aboriginal community retail stores in May 1990. In 1993, compliance with the policy varied among stores. Recommended foods were available regularly in most communities; however, promotional and educational components of the policy were not widely implemented. Dietary improvements were evident in those communities where stores most complied with the policy. Some aspects of the ALPA nutrition policy require modification, and renewed commitment to the policy is likely to improve further the diet in the Aboriginal communities involved. The ALPA nutrition policy is a potential model for the development of other local food and nutrition policies in remote Aboriginal communities.     

Effects of publicity and a warning letter on illegal cigarette sales to minors

Abstract: The study aimed to assess rates of illegal cigarette sales to children and the impact on these rates of publicity and a warning letter threatening prosecution. Children aged 12 and 13 made two repeat purchasing attempts, three months apart, at 255 randomly selected tobacco retail outlets in Sydney. A randomly selected 50 per cent of retail outlets which sold cigarettes illegally at the first attempt were sent warning letters threatening prosecution. Publicity about the undercover buying operation was organised between the attempts. At the first attempts, 39 per cent of shops sold cigarettes to the children and 32 per cent sold them at the second attempt. Shops which sold on the first occasion and received warning letters reduced selling by 69 per cent compared to the 40 per cent reduction in shops which sold cigarettes on the first attempt and were not sent warning letters, a net reduction of 29 per cent seemingly attributable to the warning letters (95 per cent confidence interval 8 per cent to 50 per cent). It is extremely easy for children as young as 12 to buy cigarettes. The combined effects of publicity about undercover buying operations and warning letters threatening prosecution seem capable of reducing selling by about 29 per cent. Because of inconsistencies in selling or refusals, future attempts to measure selling rates to children should use repeat purchasing attempts and classify outlets as ‘selling’, ‘not selling’ or ‘sometimes selling’.