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.     

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.     

Density and Proximity of Tobacco Outlets to Homes and Schools: Relations with Youth Cigarette Smoking

This study investigated the associations of youth cigarette smoking with tobacco outlet densities and proximity of tobacco outlets to youth homes and schools across different buffers in 45 midsized California communities. The sample comprised 832 youths who were surveyed about their smoking behaviors. Inclusion criteria included both home and school addresses within city boundaries. Observations in the 45 cities were conducted to document addresses of tobacco outlets. City- and buffer-level demographics were obtained and negative binomial regression analyses with cluster robust standard errors were conducted. All models were adjusted for youth gender, age, and race. Greater densities of tobacco outlets within both a 0.75 and 1-mile buffer of youth homes were associated with higher smoking frequency. Neither tobacco outlet densities around schools nor distance to the nearest tobacco outlet from home or school were associated with youths past-30-day smoking frequency. Lower population density and percent of African Americans in areas around homes and lower percent of unemployed in areas around schools were associated with greater smoking frequency. Results of this study suggest that restricting outlet density within at least 1-mile surrounding residential areas will help to reduce youth smoking.     

The role of tobacco outlet density in a smoking cessation intervention for urban youth

This study investigates the role of tobacco outlet density in a randomized controlled trial of a text messaging-based smoking cessation intervention conducted among a sample of 187 primarily African American youth in a midsize U.S. city. A moderated mediation model was used to test whether the indirect effect of residential tobacco outlet density on future smoking was mediated by the intention to smoke, and whether this indirect effect differed between adolescents who received the intervention and those who did not. Results indicated that tobacco outlet density is associated with intention to smoke, which predicts future smoking, and that the indirect effect of tobacco outlet density on future smoking is moderated by the intervention. Tobacco outlet density and the intervention can be viewed as competing forces on future smoking behavior, where higher tobacco outlet density acts to mitigate the sensitivity of an adolescent to the intervention's intended effect. Smoking cessation interventions applied to youth should consider tobacco outlet density as a contextual condition that can influence treatment outcomes.     

State-level tobacco control policies and youth smoking cessation measures

ObjectiveResearch on the effects of state-level tobacco control policies targeted at youth has been mixed, with little on the effects of these policies and youth smoking cessation. This study explored the association between state-level tobacco control policies and youth smoking cessation behaviors from 1991 to 2006.MethodsThe study design was a population-based, nested survey of students within states. Study participants were 8th, 10th, and 12th graders who reported smoking “regularly in the past” or “regularly now” from the Monitoring the Future study. Main cessation outcome measures were: any quit attempt; want to quit; non-continuation of smoking; and discontinuation of smoking.ResultsResults showed that cigarette price was positively associated with a majority of cessation-related measures among high school smokers. Strength of sales to minors’ laws was also associated with adolescent non-continuation of smoking among 10th and 12th graders.ConclusionsFindings suggest that increasing cigarette price can encourage cessation-related behaviors among high school smokers. Evidence-based policy, such as tax increases on tobacco products, should be included as an important part of comprehensive tobacco control policy, which can have a positive effect on decreasing smoking prevalence and increasing smoking cessation among youth.     

The role of public policies in reducing smoking and deaths caused by smoking in Vietnam: results from the Vietnam tobacco policy simulation model

A simulation model is developed for Vietnam to project smoking prevalence and associated premature mortality. The model examines independently and as a package the effects of five types of tobacco control policies: tax increases, clean air laws, mass media campaigns, advertising bans, and youth access policies. Predictions suggest that the largest reductions in smoking rates will result from implementing a comprehensive tobacco control policy package. Significant inroads may be achieved through tax increases. A media campaign along with programs to publicize and enforce clean air laws, advertising bans and youth access laws would further reduce smoking rates. Tobacco control policies have the potential to make large dents in smoking rates, which in turn could lead to many lives saved. In the absence of these measures, deaths from smoking will increase. The model also helps to identify information gaps pertinent both to modeling and policy-making.     

Is neighbourhood access to tobacco outlets related to smoking behaviour and tobacco-related health outcomes and hospital admissions?

ObjectivesAlthough the harms of tobacco use are widely accepted, few studies have examined the relationship between access to tobacco outlets and hospital admissions. This study aimed to examine the relationship between neighbourhood access to tobacco outlets, smoking and hospital admissions and self-reported morbidity.MethodsResponses as to smoking behaviour were obtained from 12,270 adult participants in Western Australia (2003–2009) and individually record-linked to hospital admissions and geographically linked to tobacco outlets.ResultsNeighbourhood access to tobacco outlets was marginally positively associated with being a current versus a past smoker. Tobacco outlet access was also positively associated with heart disease for smokers but not non-smokers. For smokers, each additional outlet within 1600 m of home was associated with a 2% increase in the odds of heart disease.ConclusionSmokers with greater access to tobacco outlets were more likely to be diagnosed with or admitted to hospital for heart disease. Regulating the density of tobacco outlets in the community has immense potential to improve health benefits and our results motivate the need for future longitudinal studies to confirm this hypothesis.     

Rating the Effectiveness of Local Tobacco Policies for Reducing Youth Smoking

Important questions remain regarding the effectiveness of local tobacco policies for preventing and reducing youth tobacco use and the relative importance of these policies. The aims of this paper are to: (1) compare policy effectiveness ratings provided by researchers and tobacco prevention specialists for individual local tobacco policies, and (2) develop and describe a systematic approach to score communities for locally-implemented tobacco policies. We reviewed municipal codes of 50 California communities to identify local tobacco regulations in five sub-domains. We then developed an instrument to rate the effectiveness of these policies and administered it to an expert panel of 40 tobacco researchers and specialists. We compared mean policy effectiveness ratings obtained from researchers and prevention specialists and used it to score the 50 communities. High inter-rater reliabilities obtained for each sub-domain indicated substantial agreement among the raters about relative policy effectiveness. Results showed that, although researchers and prevention specialists differed on the mean levels of policy ratings, their relative rank ordering of the effectiveness of policy sub-domains were very similar. While both researchers and prevention specialists viewed local outdoor clean air policies as least effective in preventing and reducing youth cigarette smoking, they rated tobacco sales policies and advertising and promotion as more effective than the other policies. Moreover, we found high correlations between community scores generated from researchers’ and prevention specialists’ ratings. This approach can be used to inform research on local policies and prevention efforts and help bridge the gap between research and practice.     

The effect of tobacco outlet density and proximity on smoking cessation

Objectives. We examined the influence of tobacco outlet density and residential proximity to tobacco outlets on continuous smoking abstinence 6 months after a quit attempt.Methods. We used continuation ratio logit models to examine the relationships of tobacco outlet density and tobacco outlet proximity with biochemically verified continuous abstinence across weeks 1, 2, 4, and 26 after quitting among 414 adult smokers from Houston, Texas (33% non-Latino White, 34% non-Latino Black, and 33% Latino). Analyses controlled for age, race/ethnicity, partner status, education, gender, employment status, prequit smoking rate, and the number of years smoked.Results. Residential proximity to tobacco outlets, but not tobacco outlet density, provided unique information in the prediction of long-term, continuous abstinence from smoking during a specific quit attempt. Participants residing less than 250 meters (P = .01) or less than 500 meters (P = .04) from the closest tobacco outlet were less likely to be abstinent than were those living 250 meters or farther or 500 meters or farther, respectively, from outlets.Conclusions. Because residential proximity to tobacco outlets influences smoking cessation, zoning restrictions to limit tobacco sales in residential areas may complement existing efforts to reduce tobacco use.Although the prevalence of smoking has decreased substantially over the past few decades, smoking remains the leading cause of preventable death and disability among adults in the United States.¹ A key public health strategy to reduce the deleterious health effects of tobacco use is to decrease the prevalence of smoking by increasing smoking cessation rates.² Previous public health and policy approaches to affect smoking prevalence have included restrictions on tobacco advertising, counter-advertising campaigns, bans on smoking in public places, increases in federal and state cigarette excise taxes, and increases in the availability of treatment programs. The effectiveness of these approaches in increasing smoking cessation rates has been supported by the literature.^3–5 However, additional tobacco control strategies are needed to achieve national public health goals.²One potential area of expansion for tobacco control policies is the regulation of tobacco retail outlets. Regulation strategies are designed to facilitate behavior change by altering structural aspects of the community context in which problematic behavior occurs.⁶ An analogous area in which regulation strategies have been applied is alcohol beverage retail outlets. In this case, regulation strategies have included the implementation of zoning restrictions to reduce the density of alcohol outlets and the proximity of alcohol outlets to residential areas. It was hypothesized that such regulations would affect problematic alcohol use at a community level by decreasing residents’ access to alcohol, reducing exposure to on-site product marketing, and changing social norms about alcohol use.⁷ Ultimately, research supported the success of these policies in reducing problematic alcohol use and alcohol-related injury, crimes, and violence.^7–9 In contrast to the alcohol arena, little attention has been paid thus far to the potential utility of tobacco outlet regulation strategies as a supplement to existing tobacco control policies.The Family Smoking Prevention and Tobacco Control Act, signed into law in June 2009, greatly expands the federal government''s ability to enact new public health policies related to tobacco sales in the United States. If one considers the success of alcohol outlet regulation strategies on curbing alcohol use, an increased understanding of the effects of tobacco retail outlets on smoking behaviors may provide direction to emerging tobacco control policies. Thus far, studies largely support associations between tobacco retail outlets and smoking behaviors. For example, the density of tobacco retail outlets around schools has been linked to adolescent smoking initiation¹⁰ and purchasing habits.¹¹ Similarly, the density of tobacco outlets around the home, as well as the proximity of tobacco outlets to the home, has been associated with the number of cigarettes consumed per day among adult smokers.¹² In another study, greater smoker sensitivity to point-of-sale advertising at tobacco outlets predicted a reduced likelihood of having quit smoking 18 months later.¹³ However, no previous studies have directly examined the effects of tobacco outlet density and proximity on smoking cessation during a specific quit attempt.The purpose of our study was to examine the effect of tobacco retail outlet density and proximity on smoking cessation among a racially/ethnically diverse group of smokers undergoing a specific quit attempt. We had two hypotheses. The first was that greater density of tobacco outlets around participants’ homes would be associated with lower odds of cessation. The second was that close residential proximity to a tobacco retail outlet would be associated with lower odds of cessation. All analyses controlled for participant demographics and tobacco-related variables. To our knowledge, this is the first study to examine the effects of tobacco retail outlets on a smoking quit attempt using a prospective, longitudinal design and biochemically verified smoking abstinence.     

Retail tobacco outlet density and youth cigarette smoking: a propensity-modeling approach

OBJECTIVES: We examined whether retail tobacco outlet density was related to youth cigarette smoking after control for a diverse range of neighborhood characteristics. METHODS: Data were gathered from 2116 respondents (aged 11 to 23 years) residing in 178 census tracts in Chicago, Ill. Propensity score stratification methods for continuous exposures were used to adjust for potentially confounding neighborhood characteristics, thus strengthening causal inferences. RESULTS: Retail tobacco outlets were disproportionately located in neighborhoods characterized by social and economic disadvantage. In a model that excluded neighborhood confounders, a marginally significant effect was found. Youths in areas at the highest 75th percentile in retail tobacco outlet density were 13% more likely (odds ratio [OR]=1.13; 95% confidence interval [CI]=0.99, 1.28) to have smoked in the past month compared with those living at the lowest 25th percentile. However, the relation became stronger and significant (OR=0.21; 95% CI=1.04, 1.41) after introduction of tract-level confounders and was statistically significant in the propensity score-adjusted model (OR = 1.20; 95% CI = 1.001, 1.44). Results did not differ significantly between minors and those legally permitted to smoke. CONCLUSIONS: Reductions in retail tobacco outlet density may reduce rates of youth smoking.     

US Health Policy Related to Hookah Tobacco Smoking

Objectives. Although US cigarette smoking is decreasing, hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposure. We assessed how a representative sample of US tobacco control policies may apply to HTS.Methods. We examined municipal, county, and state legal texts applying to the 100 largest US cities. We developed a summary policy variable that distinguished among cities on the basis of how current tobacco control policies may apply to HTS and used multinomial logistic regression to determine associations between community-level sociodemographic variables and the policy outcome variable.Results. Although 73 of the 100 largest US cities have laws that disallow cigarette smoking in bars, 69 of these cities have exemptions that allow HTS; 4 of the 69 have passed legislation specifically exempting HTS, and 65 may permit HTS via generic tobacco retail establishment exemptions. Cities in which HTS may be exempted had denser populations than cities without clean air legislation.Conclusions. Although three fourths of the largest US cities disallow cigarette smoking in bars, nearly 90% of these cities may permit HTS via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS.A hookah, also known as a water pipe, consists of a head, body, bowl, and hose. Moist, sweetened, flavored tobacco is placed in the head, and lit charcoal is placed on it. Users inhale through the mouthpiece, drawing smoke through the hookah. This practice is associated with substantial inhalation of smoke. For example, the World Health Organization1 has estimated that a hookah smoker may inhale as much smoke during 1 standard hookah tobacco smoking (HTS) session as a cigarette smoker would from 100 cigarettes. Other studies have suggested that, compared with a single cigarette, 1 hookah smoking session may expose the user to more inhaled tar, carbon monoxide, nicotine, and polycyclic aromatic hydrocarbons.1–5 In vivo studies have shown HTS to be associated with plasma nicotine concentrations comparable to those seen with cigarette smoking and increases in carbon monoxide levels that are much higher than those typically observed with cigarette smoking.6 Secondhand smoke exposure from a hookah may also be a concern. Although more study is needed, a published report7 has suggested that expired air from nonsmokers in a hookah tobacco café had a higher concentration of carbon monoxide than expired air from nonsmokers in a regular bar allowing cigarette smoking.The increase in HTS in the United States8–13 has coincided with a decrease in the rate of cigarette smoking to its lowest level in nearly 60 years.14,15 The rate of HTS is highest among young people, with 30% of college students having ever used and 10% having used in the past 30 days, making HTS nearly as common as cigarette use.8,9,11,16 The rate of HTS has also increased substantially among high school students and noncollege populations,10,13,17 and it is popular across gender, age, race, geographic location, and socioeconomic status.9,11,16,18 Although some hookah users also smoke cigarettes, as many as half of users would have otherwise been naïve to nicotine.12,13Clean air policies have successfully curbed cigarette smoking in certain regions of the United States. As of July 1, 2011, 35 states and thousands of local municipalities had passed smoke-free laws. Whether HTS is affected by laws such as these or whether provisions included in these laws may have intentionally or unintentionally exempted HTS is, however, not known.19,20 Because of the importance of HTS establishments in promoting use of these products, these exemptions are likely to contribute to the prevalence of HTS.15,16Thus, a systematic assessment of extant clean air laws, with special attention paid to implications for HTS, would be valuable. Moreover, determining what community factors are associated with HTS policy status may be valuable; this information may ultimately help focus interventions on communities in which the need is greatest. The purposes of this study were to assess how a representative sample of US tobacco control policies may apply to HTS and to determine associations between community-level sociodemographic factors and HTS policy status.     

The role of public policies in reducing smoking prevalence in California: results from the California tobacco policy simulation model

Tobacco control policies are examined utilizing a simulation model for California, the state with the longest running comprehensive program. We assess the impact of the California Tobacco Control Program (CTCP) and surrounding price changes on smoking prevalence and smoking-attributable deaths. Modeling begins in 1988 and progresses chronologically to 2004, and considers four types of policies (taxes, mass media, clean air laws, and youth access policies) independently and as a package. The model is validated against existing smoking prevalence estimates. The difference in trends between predicted smoking rates from the model and other commonly used estimates of smoking prevalence for the overall period were generally small. The model also predicted some important changes in trend, which occurred with changes in policy. The California SimSmoke model estimates that tobacco control policies reduced smoking rates in California by an additional 25% relative to the level that they would have been if policies were kept at their 1988 level. By 2004, the model attributes 59% of the reduction to price increases, 28% of the overall effect to media policies, 11% to clean air laws, and only a small percent to youth access policies. The model estimates that over 5000 lives will be saved in the year 2010 alone as a result of the CTCP and industry-initiated price increases, and that over 50,000 lives were saved over the period 1988-2010. Tobacco control policies implemented as comprehensive tobacco control strategies have significantly impacted smoking rates. Further tax increases should lead to additional lives saved, and additional policies may result in further impacts on smoking rates, and consequently on smoking-attributable health outcomes in the population.     

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.     

Independent and Interactive Effects of Smoking Bans and Tobacco Taxes on a Cohort of US Young Adults

Objectives. We examined the mutual effects of smoking bans and taxes on smoking among a longitudinal cohort of young adults.Methods. We combined a repository of US tobacco policies at the state and local level with the nationally representative geocoded National Longitudinal Survey of Youth 1997 (2004–2011) from ages 19 to 31 years and Census data, to examine the impact of tobacco policies on any current and daily pack smoking. The analytic sample amounts to 19 668 observations among 4341 individuals within 487 cities.Results. For current smoking, we found significant effects for comprehensive smoking bans, but not excise taxes. We also found an interaction effect, with bans being most effective in locales with no or low taxes. For daily pack smoking, we found significant effects for taxes, but limited support for bans.Conclusions. Social smoking among young adults is primarily inhibited by smoking bans, but excise taxes only deter such smoking in the absence of a ban. Heavy smokers are primarily deterred by taxes. Although both policies have an impact on young adult smoking behaviors, their dual presence does not intensify each policy’s efficacy.The denormalization of tobacco use in Western nations has led to declines in both smoking and its public acceptability.1 Even with overall reductions in smoking, tobacco use remains the leading cause of preventable illness and death in the United States,2 making assessment of the efficacy of particular policies on actual smoking behavior an imperative. Tobacco-control policies have been described as intensifying the process of denormalization of smoking among young people.3 The focus on young people is much deserved, as those who begin smoking at younger ages are at higher risk for smoking, particularly heavy smoking, as adults.4,5 The identification of policies that affect smoking behavior among young people can have long-term implications for public health as those individuals age into later life.Estimates suggest that tobacco-control policies have likely had an impact on tobacco consumption in the aggregate.6 A wide array of research has suggested that excise taxes and clean air policies are efficacious tobacco-control policy tools, but these studies have come with several limitations that prohibit linking policy with actual individual-level behavior. For clean air policies, studies have inferred the effects of such prohibitions through cohort effects,7 have relied on cross-sectional data,8–10 have not considered city-level policy,9–13 or have used data within a single locality.14,15 Studies have also found robust effects of excise taxes on tobacco use.10,12,13,16–29 We note, however, that most studies of excise taxes used either aggregate time-series or repeated cross-sectional data, and often at the state or national level. Thus, for both bans and taxes, the literature has yet to link policy contexts at the local level to a longitudinal data set of the same individuals over time as well as account for potential interactive effects of these policies. Even studies using the same data sets used herein have not considered the interaction between smoking bans and excise taxes.12The local level is critically important, yet often is overlooked in studies of both clean air policies and excise taxes. Cities led the way in enacting smoking bans in the United States, such that the diffusion of clean air regulations began at the local level and spread vertically up to the state in an unusual example of “bottom-up federalism.”30 Chahine et al. suggested that

contextual covariates play a larger role more locally, for example at the level of towns or neighborhoods. This may especially be the case for indoor smoking restrictions, which are highly variable within states.^9(p757)

They later suggested that future research should consider contextual variables at the local level to “fully characterize social determinants of smoking variability across populations and places.”^9(p758) Furthermore, although prohibited in some states, cities in several states may levy taxes on tobacco products in addition to those imposed by the state, creating similar variability on the issue of taxation. Thus, without accounting for the city level, the policies to which an individual is subjected may be mischaracterized.In our study, we overcame the limitations of past studies by, first, combining a repository of all tobacco ordinances in the United States with a nationally representative annual survey of a single cohort of youths, allowing us to directly link a multilevel policy context to individual-level behavior over time in a manner not possible through aggregate or repeated cross-sectional data. Second, we considered the critical but underexplored policy context of the city level. Third, no studies have considered the independent and interactive effects of taxes and bans simultaneously. This is important as interaction analyses may lead to the identification of potential synergistic effects of tobacco policies. Thus, we used multilevel statistical modeling to identify the impact of these 2 important tobacco-control policies on smoking behaviors over time in a nationally representative sample of US youths.     

The role of tobacco promoting and restraining factors in smoking intentions among Ghanaian youth

ABSTRACT: BACKGROUND: In Western countries, the relationship between smoking intentions and smoking behaviour is well established. However, youth smoking intentions and associated factors in developing countries are largely unexplored and the former may occur for a variety of reasons. We investigated youth smoking intentions in Ghana with regard to several tobacco promoting and restraining factors, including environmental, familial, attitudinal and knowledge measures. METHODS: A school-based survey of a representative sample of 12-20-year-olds was conducted in 2008 in Ghana (N = 1338, response rate 89.7 %). RESULTS: In a bivariate model, both among ever and never smokers, allowing smoking on school compound, exposure to tobacco advertisement and parental smoking were associated with future intention to smoke. Compared to those who agreed that smoking is harmful to health, smoking is difficult to quit and that tobacco should not be sold to minors, those who disagreed or were not sure were more likely to have an intention to smoke. In the multivariate analyses, these associations persisted, except that the attitude measures concerning the difficulty of quitting smoking once started and tobacco sales ban were no longer significantly associated with smoking intentions. CONCLUSIONS: These findings underscore the importance of school smoking policy, parental smoking behaviour and knowledge of the harmful effects of tobacco use in determining Ghanaian youths' future smoking intentions. Because current high percentages of smoking intentions may turn into high smoking rates in the future, the introduction of effective tobacco control measures at all levels of society to prevent youth smoking in Ghana may be essential.     

Perceptions of ceremonial and nonceremonial uses of tobacco by American-Indian adolescents in California

BackgroundAmerican-Indian adolescents have the highest tobacco use prevalence of all ethnic groups in the United States. Although much has been written about the role of tobacco in traditional Native-American cultures, little is known about modern-day perceptions of tobacco among American-Indian adolescents.MethodsThis study conducted focus groups of 40 American-Indian adolescents in urban and rural areas of Southern California. Participants discussed the role of traditional ceremonial tobacco use in their lives, the use of commercial tobacco as a substitute for sacred tobacco, the perceived safety of traditional versus commercial tobacco, and the perceptions of American-Indian imagery in tobacco advertising.ResultsMany American-Indian adolescents may be introduced to traditional tobacco use at early ages. Smoking is viewed as a sign of respect for the elders, but there are acceptable ways for adolescents to participate in ceremonies without inhaling smoke. Commercial cigarettes often are substituted for homegrown tobacco at ceremonies and events. Traditional tobacco was perceived as less dangerous than commercial tobacco because it does not contain chemical additives. However, respondents still perceived that smoking traditional tobacco and breathing tobacco smoke conferred health hazards. Participants found the use of American-Indian imagery in tobacco advertising offensive and stereotypical. Indian casinos were mentioned frequently as places where smoking occurred.ConclusionsContinued health education efforts are needed to decrease habitual use of commercial tobacco products and secondhand smoke exposure among American-Indian youth. Further research is needed to identify ways for American-Indian youth to participate in their cultural traditions while minimizing their risk for tobacco-related diseases.     

Draining the tobacco swamps: Shaping the built environment to reduce tobacco retailer proximity to residents in 30 big US cities

Combining geospatial data on residential and tobacco retailer density in 30 big US cities, we find that a large majority of urban residents live in tobacco swamps – neighborhoods where there is a glut of tobacco retailers. In this study, we simulate the effects of tobacco retail reduction policies and compare probable changes in resident-to-retailer proximity and retailer density for each city. While measures of proximity and density at baseline are highly correlated, the results differ both between effects on proximity and density and across the 30 cities. Context, particularly baseline proximity of residents to retailers, is important to consider when designing policies to reduce retailer concentration.     

Are Tobacco Control Policies Effective in Reducing Young Adult Smoking?

PurposeWe examined the influence of tobacco control program funding, smoke-free air laws, and cigarette prices on young adult smoking outcomes.MethodsWe use a natural experimental design approach that uses the variation in tobacco control policies across states and over time to understand their influence on tobacco outcomes. We combine individual outcome data with annual state-level policy data to conduct multivariable logistic regression models, controlling for an extensive set of sociodemographic factors. The participants are 18- to 25-year-olds from the 2002–2009 National Surveys on Drug Use and Health. The three main outcomes are past-year smoking initiation, and current and established smoking. A current smoker was one who had smoked on at least 1 day in the past 30 days. An established smoker was one who had smoked 1 or more cigarettes in the past 30 days and smoked at least 100 cigarettes in his or her lifetime.ResultsHigher levels of tobacco control program funding and greater smoke-free-air law coverage were both associated with declines in current and established smoking (p < .01). Greater coverage of smoke-free air laws was associated with lower past year initiation with marginal significance (p = .058). Higher cigarette prices were not associated with smoking outcomes. Had smoke-free-air law coverage and cumulative tobacco control funding remained at 2002 levels, current and established smoking would have been 5%–7% higher in 2009.ConclusionsSmoke-free air laws and state tobacco control programs are effective strategies for curbing young adult smoking.