Special communication Tob Control: first published as 10.1136/tobaccocontrol-2020-055722 on 23 September 2020. Downloaded from Boosting the Tobacco Control Vaccine: recognizing the role of the retail environment in addressing tobacco use and disparities Amanda Y. Kong ,1 Brian A. King2

1Department of Health Behavior, ABSTRACT the sales of combustible tobacco products.8 To date, Gillings School of Global Public Much of the progress in reducing cigarette smoking several countries have instituted varying smoking Health, University of North Carolina at Chapel Hill, Chapel and tobacco- related morbidity and mortality among prevalence endgame targets, including New Zealand Hill, North Carolina, USA youth and adults is attributable to population- level (5% smoking prevalence by 2025), Scotland (<5% 2Office on Smoking and Health, strategies previously described in the context of the by 2034) and Hong Kong (5% by 2022).7 Centers for Disease Control and Tobacco Control Vaccine. The retail environment is The USA has not set an endgame target, but Prevention, Atlanta, Georgia, used heavily by the tobacco industry to promote and two of the primary strategies discussed in recent USA advertise its products, and variations in exposure to and Surgeon General Reports include POS-related strat- characteristics of the retail environment exist across egies, including bans on the sales of some catego- Correspondence to 9 10 Amanda Y. Kong, Department demographic groups. It is therefore also an essential ries of tobacco products. As the tobacco control of Health Behavior, Gillings environment for further reducing smoking, as well as landscape has evolved in recent decades, the retail School of Global Public Health, ameliorating racial, ethnic and socioeconomic tobacco- sector has become an increasingly prominent place University of North Carolina at related disparities. This commentary provides an overview for tobacco product access and marketing. Accord- Chapel Hill, Chapel Hill, North Carolina, USA; of the importance of incorporating strategies focused ingly, retail-focused tobacco control strategies may akong2@ live.unc. edu on the tobacco retailer environment (availability; pricing be important levers for further reducing overall CDC Library. Protected by copyright. and promotion; advertising and display; age of sale; and cigarette smoking, and ameliorating observed Received 25 February 2020 retail licensure) as part of a comprehensive approach racial, ethnic and socioeconomic tobacco-related Revised 22 July 2020 Accepted 28 July 2020 to tobacco prevention and control. To reach tobacco disparities. endgame targets, such innovative strategies are a This commentary provides an overview of the complement to, but not a replacement for, long- standing importance of incorporating retail- focused strat- evidence- based components of the Tobacco Control egies as part of an integrated approach to help Vaccine. achieve the tobacco endgame. As the USA has just begun more robust discussions on retailer-focused endgame strategies, we use the USA as an under- lying framework, with the understanding that these BACKGROUND strategies may be applicable globally. Globally, substantial progress has been made in tobacco control, and much of this progress is a

result of the implementation of evidence- and FEDERAL REGULATORY CONTEXT http://tobaccocontrol.bmj.com/ population- based strategies, including those With the passage of regulations in the USA outlined in the WHO’s Framework Convention on addressing the manner in which tobacco products Tobacco Control (FCTC).1 2 The strategies that have can be advertised, including the 1998 Master Settle- been most impactful against the tobacco epidemic ment Agreement and the 2009 Prevent All Cigarette have recently been described in the context of the Trafficking Act, the tobacco industry has continued Tobacco Control Vaccine.3 The four components of to shift its advertising and promotion expenditures the Tobacco Control Vaccine include tobacco price towards less regulated areas, most notably the retail 11 12 increases, smoke- free policies, hard-hitting media environment. Tobacco industry documents and campaigns and access to cessation resources.3 interviews with tobacco retailers reveal the indus- However, while progress has been made in try’s use of contracts and retailer promotional incen-

combating the tobacco epidemic globally, calls tive programmes to secure prime POS display space on October 6, 2020 at Stephen B. Thacker have been made to explore additional strategies to encourage high sales volumes.11 12 In the USA to further reduce the burden of tobacco use.4 5 alone, the tobacco industry spent approximately These ‘endgame’ strategies are defined as ‘Initia- $9.4 billion13 on the marketing of cigarette and tives designed to change/eliminate permanently the smokeless tobacco products in 2017, $7.3 billion14 structural, political and social dynamics that sustain of which was for marketing and promotion in the © Author(s) (or their the tobacco epidemic, in order to end it within a retail environment. The 2009 Family Smoking employer(s)) 2020. No 6 commercial re- use. See rights specific time’. The importance of considering Prevention and Tobacco Control Act (FSPTCA) and permissions. Published aspects of place (both locally and globally) when granted the Food and Drug Administration (FDA) by BMJ. implementing endgame strategies has been noted, authority to regulate several aspects of the tobacco especially as local context and endgame strategies retail environment, including tobacco advertising, To cite: Kong AY, King BA. 7 15 Tob Control Epub ahead of may impact various social groups differentially. marketing, sales and distribution. Importantly, the print: [please include Day For example, potential endgame strategies include FSPTCA does not pre- empt, or prohibit, states and Month Year]. doi:10.1136/ several actions focused on the point of sale (POS), communities from enacting more stringent retailer- tobaccocontrol-2020-055722 including licensing of tobacco retailers and banning focused strategies.

Kong AY, King BA. Tob Control 2020;0:1–7. doi:10.1136/tobaccocontrol-2020-055722 1 Special communication Tob Control: first published as 10.1136/tobaccocontrol-2020-055722 on 23 September 2020. Downloaded from

TOBACCO RETAILER ENVIRONMENT Product availability It is estimated that there are 375 000 retailers that sell tobacco One way to decrease the presence of the tobacco industry in the products across the USA.16 Both adults and youth regularly retail environment is to prohibit sales of the product. While the interact with tobacco retailers, and the average US store has FDA cannot prohibit entire tobacco product classes, states and nearly 30 tobacco marketing materials (eg, branded signs; localities are not pre-empted from prohibiting their sales.9 In branded shelving, such as power walls; branded functional 2019, Beverly Hills, California, became the first USA jurisdiction items).17 In the USA, gas and convenience stores are the most to vote to prohibit the sales of all tobacco products, including common type of tobacco retailer and also have a higher prev- e- cigarettes, effective January 2021; however, cigar lounges and alence of tobacco advertising than other retailer types.17 The hotels are exempt.33 In 2020, Manhattan Beach, California, majority of US adult smokers purchase their cigarettes at gas became the second USA jurisdiction to approve a similar regula- and convenience stores,18 and nearly half of youth visit conve- tion without carve- outs.34 However, in both places, all retailers nience stores weekly.19 Additionally, variations in exposure are able to apply for hardship exemptions that would allow them to the retail environment exist across demographic groups; to continue selling tobacco products for a limited time.33 34 for example, Black youth living in rural areas and those with greater neighbourhood deprivation (eg, poverty level, educa- tion, unemployment) are more likely to report weekly conve- Flavoured tobacco products nience store visits.19 Numerous jurisdictions have also taken actions to limit the availability of specific tobacco product types, namely flavoured tobacco products. Flavoured combustible tobacco products, Inequities in the tobacco retail environment including mentholated products, reduce the harshness of smoke, Examination of historical tobacco industry documents reveals the making it easier to inhale.22 35 36 As such, flavoured products are tobacco industry’s focus on the retail environment as a venue for particularly appealing to novice smokers such as youth.37 38 In targeting their products to certain groups. In 1984, an RJ Reyn- 2015, Nova Scotia, Canada, became the first jurisdiction in the olds consumer report indicated that the Black population was an world to implement a ban on the sales of menthol cigarettes, and ‘important target group’ and outlined strategies for reaching this there has been no evidence of increased illicit cigarette sales.39 In population, including encouraging menthol cigarette brands, October 2017, a federal Canadian menthol tobacco product ban CDC Library. Protected by copyright. increasing the availability of promotions and placing promo- was implemented.40 Turkey was the first country to implement a tions in specific store types.20 21 Additionally, flavoured cigars menthol ban on cigarettes and hand- rolled tobacco in 2015, and were designed to appeal to new tobacco users and women, with this regulation was fully implemented in May 2020.41 Addition- menthol cigars specifically being targeted to young adult Black ally, the European Union fully implemented a ban on menthol smokers and neighbourhoods with higher proportions of Black cigarettes and roll- your- own tobacco in May 202041; however, individuals.22 These industry tactics likely continued to influ- menthol is not banned as an ingredient, and the industry has ence industry marketing over subsequent decades, and may also introduced ‘menthol- flavored accessories’.42 explain some of the continued disparities in tobacco product Under the FSPTCA, the USA prohibited the sales of flavoured availability, marketing and use. cigarettes, but exempted menthol.15 In early 2020, the FDA Numerous studies have documented higher tobacco retailer issued guidance to prohibit certain types of flavoured e-cig - availability in lower income neighbourhoods and in those with arettes; however, certain products are still permissible for a higher proportion of historically marginalised and minori- sale, including menthol and tobacco-flavoured e- cigarettes, 23 24 tized groups. A USA study found that neighbourhoods all flavoured cigars and non-cartridge- based flavoured e-ciga - http://tobaccocontrol.bmj.com/ with a greater proportion of Black residents and those living rettes.43 As of June 2020, over 270 US localities have prohibited below the poverty level had a greater number of retailers per the sale of flavoured tobacco products; at least 100 of these juris- 1000 people.23 In Ontario (Canada), the density of retailers dictions further restrict menthol cigarette sales.44 At the state per 1000 people was higher in areas with greater neighbour- level, Massachusetts is currently the only state to prohibit the hood deprivation; this was consistent in both urban and rural retail sales of all flavoured tobacco products, including menthol jurisdictions.24 cigarettes and e- cigarettes (effective June 2020).44 The inclu- This disparity in retailer availability also translates into ineq- sion of menthol is an important step towards reducing youth uities in POS tobacco marketing. A 2014 systematic review of consumption, as well as health disparities given that Black popu- 33 studies from the USA and 10 studies from other countries lations have markedly higher menthol smoking rates than other (Australia, Canada, Guatemala, Argentina, India, New Zealand, groups in the USA, partially attributable to tobacco industry 21 45 UK) indicated greater POS tobacco product marketing in neigh- targeting. on October 6, 2020 at Stephen B. Thacker bourhoods with greater socioeconomic disadvantage (eg, median household income, socioeconomic or deprivation indices).25 Furthermore, those neighbourhoods with a higher proportion of Minimum package sizes Black residents had more menthol marketing.25 This is of public Sales requirements on minimum package sizes could also help health concern because both greater retailer availability26–28 and deter the availability of inexpensively priced tobacco products. exposure to POS marketing29–32 are associated with increased Tobacco products packaged in smaller quantities can be sold at a smoking and decreased cessation. lower price, which may be more appealing to price-sensitive users, including youth or lower income individuals.46–48 While the FDA requires cigarettes to be sold in packages of 20, other tobacco TOBACCO RETAIL-FOCUSED STRATEGIES products do not have package size requirements. For example, To date, primary retailer-focused strategies have fallen under cigarillos are often sold in packages of two to five units49 and are the following five major categories: product availability; pricing more commonly used among males, younger adults, Black indi- and promotion; advertising and display; age of sale; and retail viduals, those with a General Educational Diploma/high school licensure. diploma and those with lower socioeconomic status.50–52 As of

2 Kong AY, King BA. Tob Control 2020;0:1–7. doi:10.1136/tobaccocontrol-2020-055722 Special communication Tob Control: first published as 10.1136/tobaccocontrol-2020-055722 on 23 September 2020. Downloaded from

2018, several jurisdictions in California require cigars to be sold product promotional discounts.71 Given that tobacco prod- in packages of at least five.53 ucts are less expensive, and promotions are more prevalent, in neighbourhoods with greater disadvantage and higher propor- 25 Pricing and price promotions tions of marginalised groups, retailer-focused strategies that Increasing the price of tobacco products is the single most increase the price of tobacco products may help ameliorate some effective strategy for reducing consumption, and is particularly tobacco- related disparities. impactful among price-sensitive users.47 48 Tobacco product excise taxes have been widely implemented and are the most Advertising and display 54 effective pricing strategy for reducing tobacco use. However, Exposure to POS advertising and marketing is associated with increased taxes on only some tobacco products may result in youth initiation, cravings, impulse purchases and decreased product switching to more affordable products, as was observed cessation.29 31 32 To date, no US jurisdictions have comprehen- 55 in Australia. Other pricing strategies in tandem with taxes sively prohibited POS marketing. Recently, New York state warrant consideration. implemented a law prohibiting the exterior display of tobacco products and advertisements within 1500 feet of a school (July 72 Minimum floor price 2020). 32 Minimum floor price (MFP) laws set a minimum price that a Several countries have comprehensive POS display bans. tobacco product may be sold for, and these strategies may help One study found that adult smokers had decreased exposure to reduce consumption by increasing prices above the market POS tobacco marketing and were less likely to make unplanned price.56 57 Furthermore, by setting an MFP, discount tobacco purchases for cigarettes after the implementation of POS bans 73 products, which appeal more to price-sensitive smokers, are in Australia and Canada. POS bans have also been found to 74 often eliminated from the market,57 and thus may help decrease decrease youth smoking behaviours in New Zealand and 75 tobacco use among these groups. Importantly, policies that Australia. However, the tobacco industry has responded to increase the price of tobacco products may result in price- display bans through the use of retailer incentives, such as price sensitive smokers paying a greater proportion of their income discounts, in exchange for retailer actions (eg, recommending on tobacco products,58 59 resulting in financial stress. However, brands, maintaining stock, listing specific brands on price CDC Library. Protected by copyright. 76 77 smokers who are exposed to greater POS marketing are more lists). Accordingly, continued surveillance of the retailer likely to impulsively purchase tobacco products,29 32 60 61 which environment is warranted, even in countries with POS display may also lead to increased financial stress.62 Additionally, many bans. price- sensitive groups have historically been targeted by the tobacco industry and experience a disproportionate burden of 63 Age of sale tobacco- related illness. Among adult daily smokers, 90% began smoking before they While MFP laws are a relatively new strategy, they have been turned 19 years old, and nearly all began before age 25.78 implemented by several US jurisdictions. Since 2012, at least Raising the minimum age of sale may make it more difficult for 151 Massachusetts municipalities have passed cigar-packaging youth to purchase and obtain tobacco products from older social regulations requiring single cigars to be sold for at least $2.50 sources.78 79 USA- based simulation studies estimate that raising and those packaged in greater quantities to be sold for at least 64 the age of tobacco sales to 21 would result in a 12% decrease $5.00. During 2014–2018, the average price of single cigars in smoking prevalence and a large reduction in smoking- related in places with the MFP increased from $2.24 to $2.41, and the 78

morbidity and mortality over time. http://tobaccocontrol.bmj.com/ availability of single cigars decreased from 28% to 14%.64 At 64 In December 2019, the USA federal minimum age of sale was the state level, youth cigar use decreased from 14.3% to 6.7%. increased from 18 to 21 years. The federal regulation does not Finally, in 2017, New York City raised the MFP for cigarettes exempt military populations, who have higher tobacco use prev- from $10.50 to $13, and set MFPs for cigars, smokeless tobacco, 80 65 alence than civilians. Prior to this federal action, 19 states and shisha and loose tobacco. 540 localities had increased the minimum age of sale for tobacco Early studies indicate that MFP laws have the potential 81 56 66 products, including e- cigarettes, to 21. One study found that to narrow income-based cigarette smoking disparities. during 2011–2016, individuals aged 18–20 years living in places However, the potential effectiveness of these strategies may be with local tobacco 21 policies had a 2.4–3.1 percentage point undermined by both a strong illicit market and too low MFPs, 82 67 reduction in the likelihood of being a current smoker. Further- as occurred in Malaysia. Finally, an unintended consequence more, an evaluation of California’s 2016 law found retailer of MFP laws is that the tobacco industry may profit off higher 57 violation rates of selling to a minor decreased 4.6% 7 months on October 6, 2020 at Stephen B. Thacker floor prices. An alternative endgame strategy entails capping after implementation.83 the pretax wholesale price, which would still allow for higher 8 68 In recent years, the tobacco industry, including e- cigarette prices, but increased revenue would benefit the government. manufacturers, has voiced public support for laws that increase the minimum age of sales to 21.84 85 In 2012, the US Surgeon Price promotions General noted that tobacco industry- supported youth access An important part of MFP laws is that price promotions, which bills have: included provisions that preempt stricter local laws; might lower the product price below the floor price, are prohib- placed responsibility for enforcement on agencies without ited.57 If tobacco product prices are increased through taxes or necessary capabilities; complicated prosecution of retailers for non- tax means, the use of price promotions may offset the bene- violations; and focused penalties on youth for tobacco product fits of increasing price.69 In 2013, Providence, Rhode Island, purchase, use or possession (PUP).37 Currently, 44 US states have began prohibiting multi- pack discounts and the redemption of PUP policies.78 However, concerns have been raised about such coupons that would lower tobacco product prices below the laws, including that they do not hold the tobacco industry or listed retail price.70 Several countries, including Brazil, Canada, retailers responsible for sales to minors, enforcement can be low India and the UK, have enacted comprehensive bans on tobacco or may be conducted inequitably (eg, African–American and

Kong AY, King BA. Tob Control 2020;0:1–7. doi:10.1136/tobaccocontrol-2020-055722 3 Special communication Tob Control: first published as 10.1136/tobaccocontrol-2020-055722 on 23 September 2020. Downloaded from

Hispanic youth were more likely to receive citations) and such have disproportionately experienced the burden of tobacco- laws are ineffective at reducing youth initiation and smoking related disease. Retailer-focused strategies are a complement prevalence.78 86 87 Therefore, it is important to closely monitor to, but not a replacement for, long-standing evidence- based provisions within industry- supported policies and assess their components of the Tobacco Control Vaccine and the FCTC. potential to undermine public health objectives. Furthermore, retail- focused strategies may be most impactful when combined together. For example, minimum packaging sizes could be paired with MFP laws, and prohibiting the sales of Retail licensure tobacco products or reducing the number of tobacco retailers in To implement and enforce any of the above tobacco retailer an area would also likely result in the elimination or reduction environmental strategies, it is essential for jurisdictions to know of POS advertising. which retailers are selling tobacco products. To date, 38 USA As with all tobacco control strategies, compliance is also states require retailers to have a licence to sell conventional critical to ensure efficacy and equity. For example, an analysis tobacco products.88 A 2014 California study found that youth of 2015 FDA under-age sales inspections found that retailers and young adults living in jurisdictions with strong local retail located in neighbourhoods with a greater proportion of Black licensing ordinances were less likely to use cigarettes.89 However, and Latino residents were more likely to sell tobacco products many tobacco retailer licensing lists are not valid, often making it to minors.99 If there is not strong compliance or enforcement is difficult to track and enforce policies. inequitable, population- level effects may not be fully realised.100 By knowing where tobacco retailers are located, a licensing Retailer- focused strategies should be implemented at multiple system lends itself to tobacco retailer reduction strategies. A type governmental levels, including local, state and national. Within of ‘cap and winnow’ approach has been proposed,90 where a cap the USA, tobacco control has traditionally percolated from the on the number of tobacco retailers in a jurisdiction is set and no bottom up, with local and state- level momentum eventually additional retailers may open until the total number of retailers spreading nationally as social norms shift and policy benefits is below this cap. Moreover, if retailers violate existing tobacco accrue.101 This was most recently evident with the USA federal control policies (eg, selling to a minor), they lose their licence to passage of a minimum age of sale law to 21 years, following sell tobacco, resulting in a natural reduction of tobacco retailers 90 considerable state and local momentum on this issue in the over time. After increasing tobacco licence fees by 15-fold in CDC Library. Protected by copyright. preceding 15 years. Within the USA, the tobacco industry has South Australia, the number of licences decreased by almost introduced state- level preemptive language to prevent local 24%.91 A similar decrease (10 000 licences to 7250) was observed jurisdictions from being able to enact some tobacco control in Finland after an increased fee.92 Other common retailer reduc- legislation in their communities.101 Given observed local-level tion strategies include prohibiting tobacco retailers near schools, disparities in tobacco retailer availability and marketing,25 102–108 within a certain distance of one another, and prohibiting certain the prohibition of local-level retailer-focused strategies may also retailer types (eg, pharmacies) from selling tobacco products.90 contribute to widening tobacco- related disparities. Theoretically, as the number of retailers decreases, exposure to The tobacco product landscape continues to diversify to POS marketing should decrease as well. include a variety of novel electronic, heated and smokeless prod- Various retailer reduction strategies, especially those focused ucts, further reinforcing the importance of integrating emerging on specific retailer types, may differentially impact overall retailer environment strategies in an effort to boost the Tobacco retailer availability, which may in turn disproportionally protect Control Vaccine. Retailer- focused strategies can serve as an some groups more than others. One of the first retailer reduction important complement to existing evidence-based strategies as policies focused on ameliorating disparities was implemented in

part of a comprehensive approach to reduce tobacco-related http://tobaccocontrol.bmj.com/ San Francisco, California, in 2015.93 After documenting stark disease and death, especially for those groups with the greatest racial, income and youth availability disparities in the number of burden of tobacco use and tobacco-related disease and death. tobacco retailers, this policy set a cap on the number of tobacco retailers to 45 per supervisorial district.93 Within the first 10 months of policy implementation, the total number of tobacco retailer licences decreased by 8%.93 In contrast, an examination What this paper adds of New York City’s tobacco-free pharmacy law found that while retailer density would decrease overall, this decline was greater Globally, substantial progress has been made in tobacco in neighbourhoods with higher income and greater proportions control, and much of this progress is a result of the of White residents.94 To address these disparities, New York City implementation of evidence- and population-based strategies. also implemented a cap, setting a maximum number of tobacco The four components of the Tobacco Control Vaccine (tobacco retailer licences to 50% of the total present in 2018.95 price increases, smoke- free policies, hard hitting media on October 6, 2020 at Stephen B. Thacker campaigns, access to cessation resources) have been most impactful against the tobacco epidemic. CONCLUSIONS The retail environment is used heavily by the tobacco industry The retail environment is used heavily by the tobacco industry to to promote and advertise its products and is therefore, an promote and advertise its products. It is therefore also an essen- essential environment for tobacco prevention and control tial environment for tobacco prevention and control strategies. strategies. Particularly as emerging research indicates that smokers are at a Primary retailer- focused tobacco control strategies have higher risk of severe complications due to COVID-19, renewed fallen under the following five major categories: product opportunities exist to reinforce the viability of retailer- focused availability; pricing and promotion; advertising and display; strategies to address tobacco use and achieve the endgame.96 97 age of sale; and retail licensure. While several countries have set endgame smoking prevalence Retail- focused tobacco control strategies may boost the targets to be at or less than 5%,7 98 novel and integrated strate- Tobacco Control Vaccine to further reduce tobacco use and to gies are becoming increasingly essential to ensure that tobacco- ameliorate tobacco- related health disparities. related disparities do not widen, especially for those groups that

4 Kong AY, King BA. Tob Control 2020;0:1–7. doi:10.1136/tobaccocontrol-2020-055722 Special communication Tob Control: first published as 10.1136/tobaccocontrol-2020-055722 on 23 September 2020. Downloaded from

Twitter Amanda Y. Kong @AmandaYKong 19 Sanders- Jackson A, Parikh NM, Schleicher NC, et al. Convenience store visits by US adolescents: rationale for healthier retail environments. Health Place 2015;34:63–6. Contributors AYK and BAK conceived the idea. AYK led the drafting of the article. 20 Consumer research report: Bates No. 501254820-4850. RJR, 1984. Available: http:// AYK and BAK critically revised and approved the final article. legacy.library. ucsf.edu/ tid/cit49d00 [Accessed 28 Apr 2017]. Funding AYK received funding from the National Cancer Institute of the National 21 Yerger VB, Przewoznik J, Malone RE. Racialized geography, corporate activity, and Institutes of Health under award number F31CA239331. health disparities: tobacco industry targeting of inner cities. J Health Care Poor Disclaimer The findings and conclusions in this report are those of the authors and Underserved 2007;18:10–38. do not necessarily reflect the official position of the US Centers for Disease Control 22 Kostygina G, Glantz SA, Ling PM. Tobacco industry use of flavours to recruit new and Prevention nor the National Institutes of Health. users of little cigars and cigarillos. Tob Control 2016;25:66–74. 23 Rodriguez D, Carlos HA, Adachi- Mejia AM, et al. Predictors of tobacco outlet density Competing interests None declared. nationwide: a geographic analysis. Tob Control 2013;22:349–55. Patient consent for publication Not required. 24 Chaiton MO, Mecredy GC, Cohen JE, et al. Tobacco retail outlets and vulnerable populations in Ontario, Canada. Int J Environ Res Public Health 2013;10:7299–309. Provenance and peer review Not commissioned; externally peer reviewed. 25 Lee JGL, Henriksen L, Rose SW, et al. 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