ARTICLE

International Reach of Tobacco Marketing Among Young Children

AUTHORS: Dina L.G. Borzekowski, EdD and Joanna E. WHAT’S KNOWN ON THIS SUBJECT: Prosmoking messages, Cohen, PhD delivered through marketing and the media, can reach very young Johns Hopkins Bloomberg School of Public Health, Baltimore, children and influence attitudes and behaviors around smoking. Maryland KEY WORDS WHAT THIS STUDY ADDS: Marketing of tobacco and cigarette advertising, smoking, media, cigarettes, tobacco, preschoolers, brands has successfully reached young children in low- and Marlboro, China, , India, Pakistan, Nigeria, Brazil middle-income countries. More effective measures are needed to ABBREVIATIONS restrict the reach of tobacco marketing. FCTC—Framework Convention on Tobacco Control LMIC—low- and middle-income country OR—odds ratio Dr Borzekowski originated the idea for this research study, developed the research protocol and instruments, obtained overall and local institutional review board clearance for this abstract work, subcontracted and trained researchers in the 6 countries BACKGROUND: to conduct data collection and data entry, and analyzed the data Prosmoking messages, delivered through marketing and prepared the manuscript; and Dr Cohen helped secure and the media, can reach very young children and influence attitudes funding for this work and assisted with protocol and instrument and behaviors around smoking. This study examined the reach of development, data analysis, and write-up of the findings. tobacco marketing to 5 and 6 year olds in 6 low- and middle-income www.pediatrics.org/cgi/doi/10.1542/peds.2013-1150 countries. doi:10.1542/peds.2013-1150 METHODS: Researchers worked one-on-one with 5 and 6 year olds in Accepted for publication Jul 25, 2013 Brazil, China, India, Nigeria, Pakistan, and Russia (N = 2423). The Address correspondence to Dina L.G. Borzekowski, EdD, children were asked to match logos with pictures of products, Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD 20742. including 8 logos for cigarette brands. Analyses examined, overall E-mail: [email protected] and by country, whether gender, age, location, household use of PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). tobacco, and knowledge of media characters were associated with Copyright © 2013 by the American Academy of Pediatrics awareness of cigarette brand logos. Additional analyses considered FINANCIAL DISCLOSURE: The authors have indicated they have the relationship between cigarette brand logo awareness and intentions no financial relationships relevant to the article to disclose. to smoke. FUNDING: Supported by a grant from the Institute for Global RESULTS: Overall, 68% of 5 and 6 year olds could identify at least 1 Tobacco Control with funding from the Bloomberg Initiative to cigarette brand logo, ranging from 50% in Russia to 86% in China. Reduce Tobacco Use. Across countries, being slightly older and having someone in the POTENTIAL CONFLICT OF INTEREST: The authors have indicated fi they have no potential conflicts of interest to disclose. household who used tobacco, were signi cantly associated with greater odds of being able to identify at least 1 cigarette brand logo. CONCLUSIONS: The majority of young children from low- and middle- income countries are familiar with cigarette brands. This study’s findings suggest that more effective measures are needed to restrict the reach of tobacco marketing. Pediatrics 2013;132:e825–e831

PEDIATRICS Volume 132, Number 4, October 2013 e825 Downloaded from www.aappublications.org/news by guest on September 28, 2021 Twenty-two years ago, a small study presence of the tobacco industry, can available parent or guardian to give made a huge impact on the way tobacco contribute to an overall high level of consent. In Brazil and China, all schools is marketed in the United States. protobacco influences.14,15 with students in our specified age Fischer et al1 found that 6-year-old boys If children living in LMICs have a high range from the selected low- and and girls recognized with similarly awareness of tobacco brands, positive middle-income neighborhoods were high rates logos of the Disney Channel’s attitudes, and intentions to smoke, then identified. Schools from this list were Mickey Mouse and Camel cigarettes’ stronger efforts need to be imple- randomly selected, and then re- Old Joe Camel. This and similar studies mented to protect this vulnerable cruitment occurred by asking all revealed sophisticated and effective population. This 6-country study in- parents if they and their children would marketing practices that were clearly vestigated young children’s recognition be willing to participate in a health – reaching young children.2 4 The upshot of tobacco brands and is the first at- survey. From among those willing of these studies and the publicity they tempt to our knowledge to gather data to participate, researchers randomly garnered was stricter regulations on the reach of tobacco marketing selected subjects and came to the around tobacco advertising in the among preschool-aged children in schools on consecutive mornings and United States.5,6 LMICs. afternoons to interview children and Although many factors are associated their parents/guardians. Data on eli- with tobacco use, research shows that METHODS gible participants and refusals by exposure to, interest in, and positive country are available upon request. Sample attitudes about protobacco marketing In each country, the study design and and media messages are associated The World Health Organization divides protocols were approved by official with increased odds of youth liking the world’s countries into 6 regions: in-country review boards. Additionally, smoking, early initiation, and increased Americas, Western Pacific, South-East an overall review and approval were use.7,8 This phenomenon seems to be Asia, Africa, the Eastern Mediterra- obtained through the Johns Hopkins global. Studies conducted around the nean, and Europe. This study was con- Institutional Review Board. Active pa- world have found that youth with high ducted in the LMICs (based on the rental and participant consent was exposure and awareness levels to World Bank classifications) with the obtained. protobacco messaging, whether through highest number of adult smokers.14,16 advertising, point-of-sale displays, depic- Information on number of smokers Procedures tions in movies, or promotional materials, was obtained through the World Health In person, one of the authors trained are more likely to smoke.8–11 Organization’s Global Tobacco Control local researchers, ensuring standard- 14 In 2003, the World Health Assembly Report. For this work, data collection ization but allowing for necessary responded to the global tobacco epi- occurred in Brazil, China, India, Nigeria, variations across countries. Addition- demic by adopting the Framework Pakistan, and the Russian Federation ally, pilot testing occurred in each Convention on Tobacco Control (FCTC). (hereafter referred to as Russia). country to test the feasibility and cul- Article13oftheFCTCaddressestobacco Working with in-country public health tural appropriateness of the protocols advertising, promotion, and sponsor- professionals, an area in each country and the instruments. In China, India, ship, whereas Article 11 focuses on was selected that would clearly rep- Nigeria,Pakistan,andRussia,datawere tobacco packaging and labeling; how- resent an urban and a rural population. collected in the spring of 2012; Brazil’s ever, there is evidence and concern Table 1 lists by country the geographic data collection was delayed until late that there is still a long way to go to areas from where the samples were fall of 2012 because of nationwide achieve full implementation of the drawn. Next, a cluster sample strategy strikes stalling institutional review recommended provisions.12 Tobacco was performed in which low- and board review. Data collection lasted, on use trends suggest that multinational middle-income regions were first average, 30 minutes with the child and tobacco companies have moved their identified and then neighborhoods for 8 minutes with the parent/guardian. promotional efforts from high-income, recruitment were randomly selected. For both the child and parent/guardian industrialized countries to low- and In India, Nigeria, Pakistan, and Russia, participants, researchers went through middle-income countries (LMICs).13 In researchers went on a specified path the survey instruments, interviewing many LMICs, weak tobacco control through selected neighborhoods and subjects one on one. Data collection was policies and/or poor enforcement of found households in which a 5- or performed in the local language and these policies, coupled with the strong 6-year-old child lived and there was an dialect of the participants. In addition to

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TABLE 1 Locations Where Data Collection Occurred Brazil China India Nigeria Pakistan Russia Urban Rio de Janeiro locations Center of Qi New Delhi locations (Rohini Osun State Islamabad locations including locations (Central, (North, South, and County Sec-1, Mangolpuri, Ranjeet locations Dhoke Ratta, Khayaban-e- East, North, Northeast, West districts) Nagar, Baljeet Nagar, (Aubiaro and sirsyed, Gujar Khane, Taxila Northwest, South, Paschim vihar, Multan Dada Estate) Sarai Kala, Taxila Mahra Southeast,Southwest,West, Nagar, Mayur vihar-3, DDA Shah, Afandi Colony, Millat Zelenograd) Flat Mayur vihar, Colony, and Dhoke Munshi Nizhniy Novgorod locations Mandawali, Vashist Park, Khan (Autozavodskiy, Kanavino, Sagarpur, and Nehru Leninskiy, Moscovskiy, Nagar) Nizhegorodskiy, Priokskiy, Sormovo, and Sovetskiy) Rural Seropedica County Jialing town Rawapindi locations (Hastsal, Osun State Rawalpindi District locations Moscow locations of Qi County Bindapur, Kutubgarh, Rani locations (Usman Khattar, Gujar Khan (, Vidnoye, Khera, Kanjhawla, Ghitorini, (Iloko Ijesa Noorwasla, Kotali Sattian Pavlov Posad, , Aya Nagar, Chattarpur, and Karore, Muree Numbal, Jeleznodorojniy, Dullupura, Samaspur, and Ijebu Ijesa) Katali Santh Saroola, Potha Dzerjinskiy, Orekhovo Karawal Nagar) Sharif, Chak Beli Khan, and Zuevo, Mytishy, Reutov, Thatha Khalil) Bolshiye Dvory) Nizhniy Novgorod locations (Balakhna, , Dzerjinsk, Gorbatovka, Lyskovo, Dalnee Konstantinovo, Zhdanovskiy, and Semenov) demographic information and owner- across in his or her country. Several or “no.” Along with the questions “Do ship of household items, parents/ logos involved English letters and you think you will drive a car?” and “Do guardians provided information on words, even though other languages you think you will be in trouble with the household members and their use of and characters were used in these police?” was the question “Do you think tobacco products. For the children, the countries. The researcher laid out pic- you will smoke cigarettes?” Children instruments were developmentally ap- ture cards of 12 different objects, in- who responded “yes” had a positive propriate; most questions involved cluding items not represented by any score on intentions to smoke ciga- showing pictures, and children’s brand logos. Children performed the rettes. answers could be offered through physical manipulation of matching the verbalizing a single word, manipulat- cards. A 13th picture card of a question Media Exposure ing cards, or pointing to a response. mark was available; this symbol was This study used an innovative approach After several warm-up questions, re- explained so that all participants un- to assess media exposure. This mea- searchers posed questions to assess derstood that they should use this card sure, which has been successfully used ’ the childs media exposure, familiarity when they did not know the brand logo with preschool-aged children in other with cigarette brand logos, and inten- (guessing was discouraged). Children countries,17,18 involved children who tions to use tobacco. received scores for their specific provided characters’ exact names. knowledge and overall familiarity with Researchers presented participants Measures tobacco logos. We observed the overall with a picture card featuring 12 cur- Familiarity With Tobacco Logos Cronbach’s a for the 8 cigarette brand rent and popular characters (5 do- Children played a matching game to items to be 0.77 (ranging from 0.45 in mestic, 5 international, and 2 foils). show familiarity with logos with their India to 0.89 in China). Media exposure scores were based on respective objects. In this game (of the number of characters a child could which there were 24 different brand Intentions to Smoke Cigarettes correctly name. In contrast to asking logos), there were 8 tobacco brands, 4 Researchers handedthe children a Yes/ self-report estimates of time spent domestic and 4 international brands No card and presented a series of 9 with media, this measure reflects not (except for Nigeria where we were questions about who they might be and only exposure but also receptivity, unable to offer domestic brands). The what they might do when they grew up meaning how well a person may or logos were the most common ones, and were “big people.” To indicate their may not recall media messages. Over- reflecting those a child would come answers, children could point to “yes” all, the Cronbach’s a for these 10 items

PEDIATRICS Volume 132, Number 4, October 2013 e827 Downloaded from www.aappublications.org/news by guest on September 28, 2021 (removing the foils) was 0.78 (ranging the participating children could iden- P , .05). In both India and Nigeria, from 0.52 in Brazil to 0.83 in Nigeria). tify at least 1 cigarette brand logo, children in urban locations were less ranging from 50.1% in Russia to 85.9% likely than those from rural locations to Statistical Analyses in China (Table 3). More than a quarter be able to identify at least 1 cigarette First we considered the internal con- (26.3%) could identify 2 to 3 brands, brand logo (OR = 0.4, P , .001, and OR = sistency of our measures by calculating and 18.2% could identify $4 brands. In 0.5, P , .01, respectively). In contrast, Cronbach’s a scores (as reported in Brazil and India (both P , .001), on rural children in Brazil were less likely the previous section). Whereas average average, children could identify more than urban children to know at least 1 Cronbach’s a scores were acceptable domestic compared with international cigarette brand (OR = 0.4, P , .001). (.0.70), some in-country scores fell cigarette brand logos; in China, chil- Having someone in one’s household below the acceptable range, most likely dren were more aware of international who used tobacco was significantly because of the heterogeneous nature cigarette brands (P , .001). related to awareness of a cigarette of the tested items.19 After preliminary Factorsassociatedwithcigarettebrand brand in Brazil (OR = 3.6, P , .001), exploration of the data, we used bi- awareness varied by country. A child’s Pakistan (OR = 1.8, P , .05), and Russia variate and multivariate analyses to gender was significantly associated (OR = 1.9, P , .01). In China, greater explore factors (gender, age, location, with identifying at least 1 cigarette media exposure was significantly as- household use of tobacco, and knowl- brand in just 3 countries: in Brazil and sociated with the higher likelihood of edge of media characters) associated Nigeria, being male was associated being able to identify at least 1 ciga- with awareness of cigarette brand with lower odds of identifying at least rette brand (OR = 1.6, P , .001), logos and intentions to smoke. Linear 1 cigarette brand (Brazil: odds ratio whereas in Nigeria (OR = 0.8, P , .001), and logistic regression models were [OR] = 0.5, P , .01; Nigeria: OR = 0.6, the reverse was true. There, greater created for the overall data set (by using P , .05); in Pakistan, being male was media exposure predicted a lower dummy variables for country) and for associated with higher odds identifying likelihood of cigarette brand aware- each individual country. Statistical sig- at least 1 cigarette brand (OR = 2.2, ness. nificance was judged at the P , .05 level. P , .01). Also, being 6 instead of 5 The greatest intention to smoke was years old was related to brand among the Indian children. Almost RESULTS awareness in Brazil (OR = 1.5, P , .06), a third (30.2%) indicated that they Information about the sample is shown China (OR = 3.2, P , .001), Nigeria (OR = would smoke cigarettes when they in Table 2. Overall, two-thirds (67.9%) of 1.5, P , .05), and Pakistan (OR = 2.0, were grown; interestingly, there were

TABLE 2 Description of the Sample, Demographics, and Awareness of Cigarette Brands Overall Brazil China India Nigeria Pakistan Russia (N = 2423) (n = 398) (n = 396) (n = 444) (n = 385) (n = 399) (n = 401) Gender , n (%) Male 1260 (52.0) 183 (46.0) 204 (51.5) 260 (58.6) 193 (50.1) 219 (54.9) 201 (50.1) Female 1163 (48.0) 215 (54.0) 192 (48.5) 184 (41.4) 192 (49.9) 180 (45.1) 200 (49.9) Age, n (%) 5 years 1119 (46.2) 169 (42.5) 152 (38.4) 224 (50.5) 195 (50.7) 179 (44.9) 200 (49.9) 6 years 1304 (53.8) 229 (57.5) 244 (61.6) 220 (49.5) 190 (49.3) 220 (55.1) 201 (50.1) Location, n (%) Urban 1195 (49.3) 200 (50.3) 198 (50.0) 222 (50.0) 189 (49.1) 186 (46.6) 200 (49.9) Rural 1228 (50.7) 198 (49.7) 198 (50.0) 222 (50.0) 196 (50.9) 213 (53.4) 201 (50.1) Someone in the children’s 832 (34.5) 73 (18.6) 280 (70.9) 87 (19.7) 9 (2.3) 200 (50.1) 183 (45.6) household uses tobacco, n (%) Parent uses tobacco, n (%) 723 (30.0) 61 (15.5) 258 (65.3) 54 (12.2) 6 (1.6) 177 (44.4) 167 (41.7) Knowledge of media charactersa, 5.9 (2.8) 7.9 (1.3) 7.5 (1.7) 5.8 (1.9) 3.4 (2.9) 3.1 (1.9) 8.0 (1.6) mean (SD) Intention to smoke, n (%) 327 (13.5) 32 (8.0) 86 (21.7) 134 (30.2) 40 (10.4) 21 (5.3) 14 (3.5) Identify any cigarette brand, n (%) 1646 (67.9) 236 (59.3) 340 (85.9) 337 (75.9) 197 (51.2) 335 (84.0) 201 (50.1) Knowledge of cigarette brandsb, 1.9 (2.1) 1.5 (1.7) 3.8 (3.0) 1.6 (1.4) 1.0 (1.3) 2.2 (1.6) 1.0 (1.4) mean (SD) Can identify Marlboro, n (%) 525 (21.7) 64 (16.1) 169 (42.7) 68 (15.3) 37 (9.6) 95 (23.9) 92 (22.9) a Range: 0–10, number of known characters. b Range: 0–8, number of known brands.

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TABLE 3 Factors Associated With Children’s that children in China, India, and someone in the household who smoked Ability to Identify at Least One Pakistan were more likely to be aware was associated with recognizing at Cigarette Brand (N 5 2423) of cigarette brands, compared with the least 1 cigarette brand. In contrast, this Overall Adj. Odds Ratio (95% Conf. Int.) reference of Brazil. Children in Nigeria factor was not significant in China, and Russia were less likely to correctly fi Country India, and Nigeria. This nding suggests Brazil 1.00 identify a cigarette brand. Being slightly that, for some children, exposure to China 3.1 (2.15, 4.49) older, having someone in the household cigarettes may occur in the home, and India 2.1 (1.53, 2.89) who used tobacco, and having greater for others, it can be through a variety of Nigeria 0.7 (0.47, 0.97) Pakistan 2.6 (1.71, 3.88) media exposure were associated with settings such as the neighborhood, Russia 0.6 (0.45, 0.80) greater odds of being able to identify at print and electronic media, as well as Gender least 1 cigarette brand. Models for each other acquaintances. In this study, only Male 1.00 Female 1.1 (0.91, 1.32) country are presented in Table 4. in China was greater media exposure Age Finally, considering the overall model associated with higherodds of knowing 5 years 1.00 examining intentions to smoke as an a cigarette brand. This result suggests 6 years 1.4 (1.16, 1.68) Location adult, we observed that being male and that the removal of cigarette commer- Urban 1.00 younger are significant predictors. Lo- cials is having a positive impact on Rural 1.1 (0.90, 1.31) cation (rural versus urban), having lessening children’s awareness of Someone in the child’s 1.9 (1.49, 2.37) household uses tobacco someoneinthehouseholdwhosmoked, brands. More work, though should be Knowledge of media 0.9 (0.91, 1.01) knowledge of media characters, or done to restrict the deliberate use of characters identification of at least 1 cigarette cigarette brands as props in television brand were not significant predictors. shows and movies.23 Although this study was conducted DISCUSSION no significant differences between in several countries, the participants Indian boys and girls. Gender, however, We found that among very young chil- came from a single rural and urban fl was significantly associated with dren from 6 LMICs, two-thirds can area and may not re ect the national smoking intentions in China (OR =1.7, identify at least 1 cigarette brand logo. populations in each country. Possibly in P , .05), Nigeria (OR = 2.2, P , .05), Whereas restrictions to tobacco mar- other areas one might find different Pakistan (OR = 5.3, P , .01), and Russia keting in high-income, industrialized awareness and relationships with (OR = 6.3, P , .05), where boys were countries have shown decreases in smoking intentions. In this study, how- more likely than girls to say that they logo recognition and has been associ- ever, efforts were made to measure would smoke later in life. Being 6 in- ated with smoking uptake by youth,20 “typical” children and not those from stead of 5 years old was significantly this study suggests that stronger reg- more wealthy, cosmopolitan commu- associated with a lower likelihood to re- ulations need to be instituted and bet- nities (where awareness of tobacco port smoking intentions in Brazil (OR = ter enforced in LMICs, where tobacco marketing would presumably be 0.3, P , .001), China (OR = 0.6, P , .05), companies have made great efforts to higher). Nigeria (OR = 0.4, P , .01), and encourage uptake of their products.13 A strength of this study is the mind- Pakistan (OR = 0.4, P , .05). Only in Of particular concern was the sample fulness involved in assessing young Russia was having someone in the from China, where .28% of the pop- children’s awareness and intentions. household who used tobacco signifi- ulation smokes (53% of men, 2% of Average reliability statistics were ac- cantly related to greater intentions to women) and there is concern over ceptable,19 confirming that the proto- smoke (OR = 4.6, P , .05). Higher me- whether there is sufficient adherence cols and instruments used were dia exposure was associated with to the FCTC articles.21,22 In China, 86% of developmentally and culturally appro- lower smoking intentions in Nigeria the sampled 5 and 6 year olds could priate, and reflected conventional (OR = 0.8, P , .01) and Russia (OR = 0.8, identify at least 1 cigarette brand. knowledge about cigarettes and media. P , .01) but with higher intentions in Claims are often made that parents As expected, we observed variability China (OR = 1.2, P , .01). and not governments or corporations across the countries. Not only do the By exploring multivariate models to shouldkeepchildrenawayfrom selected countries differ in their predict the ability to name at least 1 harmful products such as tobacco. In- smoking rates and public policies cigarettebrandlogo,weobservedinthe terestingly, in 3 of the country samples around tobacco advertising14 but they overall models (as shown in Table 3) (Brazil, Pakistan, and Russia), having also vary tremendously in children’s

PEDIATRICS Volume 132, Number 4, October 2013 e829 Downloaded from www.aappublications.org/news by guest on September 28, 2021 TABLE 4 Factors Associated With Ability to Identify at Least One Cigarette Brand Brazil Adjusted China Adjusted India Adjusted Nigeria Adjusted Pakistan Adjusted Russia Adjusted OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Gender Male 1.00 1.00 1.00 1.00 1.00 1.00 Female 1.55 (1.01, 2.38) 1.25 (0.67, 2.34) 1.21 (0.77, 1.92) 1.45 (0.95, 2.21) 0.46 (0.27, 0.81) 0.73 (0.49, 1.08) Age 5 years 1.00 1.00 1.00 1.00 1.00 1.00 6 years 1.37 (0.89, 2.13) 1.89 (1.00, 3.60) 0.75 (0.48, 1.18) 1.72 (1.12, 2.64) 2.01 (1.15, 3.5) 1.06 (0.70, 1.61) Location Urban 1.00 1.00 1.00 1.00 1.00 1.00 Rural 0.42 (0.27, 0.65) 2.39 (1.21, 4.72) 2.36 (1.49, 3.74) 1.36 (0.82, 2.24) 0.69 (0.36, 1.33) 0.76 (0.50, 1.14) Someone in the children’s 3.47 (1.83, 6.58) 1.63 (0.81, 3.03) 1.25 (0.69, 2.24) 3.26 (0.65, 6.24) 1.79 (1.02, 3.15) 1.8 (1.20, 2.70) household uses tobacco Knowledge of media characters 0.97 (0.83, 1.15) 1.64 (1.38, 1.95) 0.90 (0.79, 1.02) 0.86 (0.78, 0.94) 0.9 (0.76, 1.06) 1.12 (0.98, 1.28)

general access to health care and ed- logos and using plain packaging could should become involved in tobacco ucation.24 In this study, the chosen alter perceptions around smoking and control efforts in their jurisdictions countries all had high numbers of adult lessen attraction of target groups to and beyond, including advocating for smokers, but future research might specific cigarette brand logos.27,28 A stronger tobacco control policies want to examine locations with com- second way to limit promotion would such as comprehensive bans on the parable cultural, political, and envi- be to change the quantity, location, and advertising and promotion of tobacco ronmental variables. types of tobacco retailers, establishing products. minimum distances between these Despite relatively comprehensive bans, To our knowledge, this is the first points of purchase and places fre- at least in the countries considered in study to examine cigarette brand quented by young children.29 A third this study,15 young children are still awareness among young children way to better restrict exposure to cig- exposed to tobacco marketing. To- arette brands and smoking would be from several countries. Whereas bacco companies are using creative to change how onscreen prosmoking there were differences across sam- approaches to attract new smokers media messages reach youth. Numer- ples, we consistently found high brand and to retain existing smokers. For ous prosmoking messages reach awareness among children aged 5 example, in the United States, a large young children through current and and 6 years. Given the established percentage of advertising dollars now classic media and researchers have link between exposure to tobacco goes toward retailers and wholesalers found a dose-response relationship marketing and increased odds of so that they reduce prices and shift between such exposure and smoking.7 starting to smoke, these findings displays and merchandising of partic- A rating system that alerts parents and should be a clarion call to signifi- 25 ular brands. Of particular concern is guardians to this “mature content” cantly restrict tobacco advertising, the expected use of new technology could help reduce youth exposure.30 promotion, and sponsorship, espe- and the Internet to bypass country In addition to public health and policy cially in LMICs, consistent with the regulations and reach young people advocates, this study has implications requirements and recommendations of with protobacco content and sales.26 for pediatric health professionals. the FCTC. When the majority of 5 and 6 year olds First, it is important for practitioners from low- and middle-class populations to be aware that young children are can recognize domestic and inter- aware of cigarette logos and are likely ACKNOWLEDGMENTS national cigarette brands, not only is it to be susceptible to prosmoking mes- We acknowledge the hard work of our critical to have restrictions and bans in sages. Parents who smoke cigarettes international collaborators, including place but there also needs to be strict should be regularly advised to avoid the teams from Russia (led by Tatiana enforcement of such laws. This study’s using these products around their Voylokova of the Russian Public Opinion findings suggest that more rigorous young children. Pediatric patients ResearchCenter[VCIOM]),China(ledby approaches should be used to reduce should be counseled not to use, or Wu Junqing of Fudan University), India the reach of tobacco marketing to very start using, tobacco products. In addi- (led by Varun Kumar of Policy Innova- young children. For example, removing tion, pediatric health professionals tions), Nigeria (led by Adesegun Fatusi

e830 BORZEKOWSKI and COHEN Downloaded from www.aappublications.org/news by guest on September 28, 2021 ARTICLE of Obafemi Awolowo University), C. Ribas of the Federal University of MHS, for their work with preparing Pakistan (led by Atif Ikram Butt of the Rio de Janeiro). We also greatly appre- the instruments, securing institutional Pakistan Center for Communication ciate the assistance of Holly Henry, PhD, review board approval, and managing Programs), and Brazil (led by Rodolfo Jenny Chan, MSPH, and Jingyan Yang, the data.

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