E-Cigarette Talking Points Dat6,----- ^ ~~ Submitted in /W.nfW^ Committee Council File No: I'K - M_ Trisha Roth, M.D., F.A.A.P. , £ nspnty: Acteor Rr i id—

® I am here as a Pediatrician, a Public Health and Tobacco Control Advocate. I am a member of the American Academy of Pediatrics. ® I am Chair of Substance Abuse for our local chapter which includes Los Angeles County. I am bringing documents from the American Academy of Pediatrics which I believe support your position. They support the amendments to the City’s Tobacco Retail Permit and Self-service display ordinances to include the definition of e-cigarettes.

• I believe this is an important and vital FIRST STEP that local cities and counties must take to regulate products such as E- cigarettes.

Pediatric Concerns

• Use of E-cigarettes by youth is on the rise: Results from the 2012 National Youth Tobacco Survey tells us that use of e- cigarettes for students in grades 6-12 was 6.8%. Current (last 30 days) e-cigarette use was 2.1% for the same age group and dual use of e-cigarettes and conventional cigarettes was 1.6%.

• E-cigarettes dangerously appeal to youth- e-cigarettes are available in a variety of flavors such as chocolate, cotton candy, peach schnapps, java jolt, and pina colada. These flavors have been banned in traditional cigarettes, but exist in e-cigarettes. o According to the statement issued this month by the American Academy of Pediatrics - “Due to lack of regulation in e-cigarette marketing, children, who are impressionable and model the behavior of adults, are at risk from viewing marketing aimed at adults.”

® This is also a concern due to the increased number of e-cigarette uses - these devices mimic conventional cigarette use and help to re-normalize smoking behaviors.

® Because e-cigarettes are offered in many child-friendly flavors, there is also a concern surrounding toxicity-the nicotine cartridges and refills pose a poison risk to children.

® Given the increased media attention and popularity of e-cigarettes, the public health community is faced with a daunting task of responding to the aggressive marketing of e-cigarettes and advocating for policies to restrict the sale to minors and amend local youth access laws. I applaud Council Member Paul Korretz and Council Member O’Farrell and all the members of this Committee for moving forward on these very important amendments today!

o Pediatricians (like myself) need to be aware of the dangers and concerns, and have informed conversations with patients and families about e-cigarettes.

Thank You for your time and for taking this important step. Los Angeles has been a leader in Tobacco Control for many years. I have a long history of supporting many of the tobacco control policies including the enactment of your Tobacco Enforcement Program. The City will be a national leader on this matter and we hope that the State of California can follow in the foot steps of the City. E=Cifprettas

What ARE these things?! Also called Electronic Nicotine Delivery Systems (ENDS) or personal vaporizers (PV), e-cigarettes are a new way for smokers to get their nicotine- quickly. These products are marketed heavily towards young adults, particularly through use of social media and at mall kiosks. These products are touted as a "safer" alternative to smoking, and a way to either quit smoking cigarettes, or to smoke in places cigarette smoking is not allowed. However, these products are not yet regulated by the US Food and Drug Administration (FDA), and no rigorous scientific studies have shown that they are safe for use.

Rechargeable vs. Disposable The device is battery-powered; some brands can be recharged via a USB port, others are disposable. A battery-powered e-cigarette is pictured below (photo courtesy of Legacy). The middle piece is called a vaporizer (or in some brands, an atomizer), which is the piece that heats the liquid stored in the cartridge (where the flavored nicotine is stored). Disposable e-cigarettes do not require charging, or changing batteries or cartridges. As of September 2013, the disposables, sold one at a time, were $7.99 in a pharmacy located within a major U.S. city. At the same store, a rechargeable 'starter kit' was $34.99. Overall, disposable e-cigarettes last for roughly the same amount of time as two packs of traditional cigarettes, and rechargeable e-cigarettes last as long as a pack and a half. These estimates vary by brand and by the smoker's usage patterns.

In both types of devices, nicotine vapor is exhaled from the end, mimicking the behavior of a regular cigarette. The flavor cartridge may contain up to 20mg of nicotine per cartridge1.

Rechargeable e-cigarette

Battery Vaporizer Cartridge

Indicator Light Mouthpiece

Disposable e-cigarette

Lack of E-cigarette Regulation As of July 2013, the World Health Organization reported that there are no rigorous, scientific studies that have been conducted to determine if electronic cigarettes are a useful method for helping people

American Academy oe Pediatrics Julius B. Richmond to stop smoking2. Because e-cigarettes are not currently regulated, there are no standards for product manufacturing or safety. The amount of nicotine in a cartridge can vary widely between brands because of this lack of regulation. The chemical compounds in an e-cigarette can also vary between brands. Until rigorous research is done on these products, their safety is unknown.

Despite these items not being regulated for use, many people still use them. Common reasons for use include: the perception that they are healthier/less toxic than traditional cigarettes, aid in tobacco craving/withdrawal symptoms, smoking cessation facilitator, and relapse avoidance3.

Dangerous Appeal to Youth E-cigarette cartridges are available in a variety of flavors. A quick Google search shows availability of flavors like peach schnapps, java jolt, pina colada, peppermint, and chocolate. These flavors have been banned in traditional cigarettes, but exist in e-cigarettes, and it's these flavors that have been shown to entice children4.

Use of e-cigarettes by youth is on the rise: Results from the 2012 National Youth Tobacco Survey tells us that ever use of e-cigarettes for students in grades 6-12 was 6.8%5. Current (last 30 days) e-cigarette use was 2.1% for the same age group and dual use of e-cigarettes and conventional cigarettes was 1.6%6.

Public Health Concerns E-cigarettes aid tobacco companies in circumventing smoke-free laws. While some smoke-free laws do not mention whether e-cigarettes are specifically prohibited there is an effort to add e-cigarettes to these laws and policies. Use of e-cigarettes is restricted on airplanes, as the US Department of Transportation has deemed that federal regulations prohibiting smoking on aircrafts applies to e- cigarettes as well7. As of August 2013, a few states (ND, NJ, UT) have enacted legislation to specifically prohibit e-cigarette use in 100% smoke-free venues8. Several others (AR, CO, DE, KS, MD, NH, OK, OR, SD) have passed laws regulating e-cigarette use in various venues such as correctional facilities, school properties, and commuter trains9. However, e-cigarettes continue to be marketed as a way to smoke in places you can't smoke. The desire to get around smoke-free laws has led to the creation of vaping lounges- similar to cigar bars and hookah lounges, these vaping lounges allow e-cigarette users to use their devices (or 'vape') in a confined, social setting.

Access to e-cigarettes by minors is also a concern: only a few states have passed laws prohibiting sales of these devices to minors (As of September 2013: AL*, AR, CA, CO, HI, ID, IL**, IN, KS, MD, MN, MS, NH, NJ*, NY, NC, SC, TN, UT*, VT, WA, Wl, WY)10.

Sales of e-cigarettes have grown rapidly in the United States, and after doubling every year since 2008, sales in 2013 are accelerating and projected to reach $1.7 billion11. Marketing of these items is also unregulated and currently booming through print, TV, radio, and other forms of advertising. In this year's Super Bowl broadcast, NJOY e-cigarettes purchased a 30-second television advertisement slot which reached at least 10 million viewers in certain markets and reportedly translated into a dramatic 30-40% increase in sales12.

American Academy of Pediatrics Julius B. Richmond These devices can also re-normalize smoking behaviors and cigarette use13. Children mimic what they see, and despite smoking rates decreasing over the last several years, rates of adolescent use may rise due to the uptick in adult e-cigarette use. There is also concern that e-cigarettes may cause a relapse for former smokers14.

Also worrisome is that e-cigarette manufacturers are offering incentives to purchase their product (blu e-cigarettes has a rewards program that gives discounts and free products from their rewards catalogue). Some manufacturers also offer recycling programs, where participants can earn free e- cigarettes by mailing back old, used products.

Tobacco companies that make conventional cigarettes have realized the potential of e-cigarettes, and have been releasing their own lines of e-cigarettes. Lorillard was the first, having bought the blu e- cigarette company in 2012, and the product is sold nationwide. RJ Reynolds released its e-cigarette Vuse in July 2013, and it's currently only sold in the Denver, CO area. Altria released MarkTen e-cigarettes in August 2013, and they are currently only sold in convenience stores across Indiana. British American Tobacco currently distributes its Vype e-cigarette only within the United Kingdom, and the product can easily be ordered online. Adoption of e-cigarettes by conventional cigarette makers seems to have inspired other manufacturers as well- electronic hookah pens15, e-Swishers16 (a type of cigar), and other products are now available in electronic form, but none as widely available as the e-cigarette.

These concerns have been voiced repeatedly by the health community- In September 2013, health organizations banded together to send President Obama a letter requesting that he urge the FDA to take action on regulation of e-cigarettes17. Less than a week later, forty state Attorneys General sent a joint letter to the FDA Commissioner Margaret Hamburg requesting regulations on e-cigarettes by the end of October 201318.

Pediatric Concerns Due to a lack of regulation in e-cigarette marketing, children, who are impressionable and model the behavior of adults, are at risk from viewing marketing aimed at adults. This is also a concern due to the increased number of e-cigarette users- these devices mimic conventional cigarette use and help to normalize smoking behaviors. Because e-cigarettes are offered in many child-friendly flavors, there is also a concern surrounding toxicity- the nicotine cartridges and refills pose a poison risk to children. Not all states have laws regulating purchase age for e-cigarettes, which means access to these devices is possible for minors.

Pediatricians should be aware of the dangers and concerns, and have informed conversations with patients and families about e-cigarettes.

*law applies to those under the age of 19 ♦♦Illinois passed a law barring sale of alternative nicotine products to minors that will take effect in January 2014.

American Academy of Pediatrics Julius B. Richmond CITATIONS 1) Cobb N, Abrams D. E-cigarette or Drug-Delivery Device? Regulating Novel Nicotine Products. N Engl J Med. 2011; 365(3): 193-195. 2) World Health Organization. Questions and answers on electronic cigarettes or electronic nicotine delivery systems (ENDS). July 9,2013. Available at http://www.who.int/tobacco/communications/ statements/eletronic_cigarettes/en/index.html. Accessed September 25,2013. 3) Etter J, Bullen C. Electronic Cigarette: User Profile, Utilization, Satisfaction and Perceived Efficacy. Addiction. 2011; 106(11): 2017-2028. 4) De Graaf C, Zandstra E. Sweetness Intensity and Pleasantness in Children, Adolescents, and Adults. Physiol Behav. 1999; 67(4): 513-520. 5) Centers for Disease Control and Prevention. Notes from the Field: Electronic Cigarette Use Among Middle and High School Students — United States, 2011-2012. September 6,2013. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm. Accessed September 25,2013. 6) Id. 7) ChangeLab Solutions: Are there any restrictions on how e-cigarettes are used or sold? Available at http://changelabsolutions.org/tobacco-control/questipn/are-there-any-restriction. Accessed October 9, 2013. 8) Americans for Nonsmokers’ Rights Foundation. U.S. State and Local Laws Regulating Use of Electronic Cigarettes. August 19,2013. Available at http://www.no-smoke.org/pdf/ecigslaws.pdf. Accessed September 25,2013. 9) Id. 10) Legal Resource Center for Maryland Public Health Law and Policy. State Electronic Smoking Device Legislation. September 2013. Available at http://www.publichealthlawcenter.org/sites/default/files/ resources/UofMaryland-fs-state-e-smokingdevice-legislation-9-2013.pdf. Accessed September 25,2013. 11) Elliot S. E-Cigarette Makers' Ads Echo Tobacco’s Heyday. New York Times. Aug. 29,2013. Available at http://www.nytimes.eom/2013/08/30/business/media/e-cigarette-makers-ads-echo-tobaccos- heyday.html. Accessed September 24,2013. 12) Wallace B. Smoke Without Fire. New York Magazine, April 28,2013, available at http://nymag.com/ news/features/e-cigarettes-2013-5/. Accessed September 24,2013. 13) Ayers J, Ribisl K, Brownstein J. Tracking the Rise in Popularity of Electronic Nicotine Delivery Systems (Electronic Cigarettes) Using Search Query Surveillance. Am J Prev Med.2011; 40(4): 448-453. 14) McMillen R, Maduka J, Winickoff J. Use of Emerging Tobacco Products in the United States. J Environ Public Health. 2012; Volume 2012, Article ID 989474,8 pages, doi:10.1155/2012/989474 15) U.S. Health Works. Hookah pen: The latest smoking craze. April 29,2013. Available at http://www.ushealthworks.eom/blog/index.php/2013/04/hookah-pen-the-latest-smoking-craze/.Accessed September 25, 2013. 16) Hawkins C. Swisher lights up with electronic cigarettes. February 8,2013. Jacksonville Business Journal. Available at http://www.bizjournals.com/jacksonville/print-edition/2013/02/08/swisher-lights-up-with- electronic.html?page=all. Accessed September 25,2013. 17) AAP Richmond Center. September 19,2013. Letter to President Available at http://www2.aap.org/ richmondcenter/pdfs/Sept20131etterECigs.pdf. Accessed September 25,2013. 18) National Association of Attorneys General. September 24,2013. Letter to Commissioner Hamburg. Available at http://www.mass.gov/ago/docs/press/2013/e-cigarette-letter.pdf. Accessed September 25, 2013.

American Academy or Pediatrics Julius B. Richmond E-cigarettes easy to buy, can hook kids on nicotine http://aapnews.aappublications.org/content/early/2013/10/04/aa .

AAP News______aapnews.aappublicalions.org

Published online October 4, 2013

(doi: 10.1542/aapnews.20131004-4) NEWS AND FEATURES

Copyright © 2013, The American Academy of Pediatrics E-cigarettes easy to buy, can hook kids on nicotine

Trisha Korioth, Staff Writer

Parents may try electronic cigarettes to help them quit smoking. Teens may try them because they think they're safer than regular cigarettes. One electronic cigarette, however, can have as much nicotine as a whole pack of cigarettes. In addition, the Food and Drug Administration (FDA) has found cancer-causing chemicals in electronic cigarettes.

Electronic cigarettes are advertised as a way to help smokers quit. Also known as e-cigarettes or e-dgs, they are sold in many colors, shapes, sizes and flavors, such as vanilla, chocolate and peach schnapps. The devices have a battery, vaporizer and cartridge that make a mist that is inhaled. Smoking e-cigarettes Is known as “vaping."

E-dg usage has doubled among middle and high school students. A survey by the Centers for Disease Control and Prevention found that about one in 10 high school students admitted using an e-cigarette.

E-cigs are not regulated or approved by the FDA and do not have to follow the same rules as other nicotine produds. This means that the amount of nicotine and other harmful ingredients in each cartridge is not always the same. In addition, it's easy for kids to buy e-dgs. More than half of states allow kids of any age to purchase e-dgarettes, and they're easy to get online and in mall booths.

The American Academy of Pediatrics (AAP) urges parents to talk with their kids about the dangers of e-dgarettes. Most cartridges have 20 milligrams of nicotine, and a dose of as little as 10 milligrams of nicotine can be fatal for a child. In addition, children can easily become hooked on the nicotine.

Parents who think their child may be using e-dgarettes should watch for signs of nicotine addiction, according to the AAP. This includes feeling nervous, craving e-dgarettes and not being able to quit. Parents who are trying to quit smoking should avoid using e-dgarettes and try other options that are approved by FDA, such as nicotine patches or gum.

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Pediatrics______pediatrics.aappublications.org

Published online September 30,2013 Pediatrics Vol. 132 No. 4 October 1, 2013 pp. 0825 -e831 (doi: 10.1542/peds.2013-1150) Article International Reach of Tobacco Marketing Among Young Children

Dina L.G. Borzekowski, EdD and Joanna E. Cohen, PhD

+ Author Affiliations

ABSTRACT

BACKGROUND: Prosmoklng messages, delivered through marketing and the media, can reach very young children and influence attitudes and behaviors around smoking. This study examined the reach of tobacco marketing to 5 and 6 year olds in 6 low- and middle-income countries.

METHODS: Researchers worked one-on-one with 5 and 6 year olds in Brazil, China, India, Nigeria, Pakistan, and Russia (W = 2423). The children were asked to match logos with pictures of products, Including 8 logos for cigarette brands. Analyses examined, overall and by country, whether gender, age, location, household use of tobacco, and knowledge of media characters were associated with awareness of cigarette brand logos. Additional analyses considered the relationship between cigarette brand logo awareness and intentions to smoke.

RESULTS: Overall, 68% of 5 and 6 year olds could identify at least 1 cigarette brand logo, ranging from 50% In Russia to 86% in China. Across countries, being slightly older and having someone in the household who used tobacco, were significantly 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.

Key Words: advertising smoking media cigarettes tobacco preschoolers Marlboro China Russia India Pakistan Nigeria Brazil • Abbreviations:

FCTC — Framework Convention on Tobacco Control LMIC — low- and middle-income country OR — odds ratio

What’s Known on This Subject:

Prosmoklng messages, delivered through marketing and the media, can reach very young children and influence attitudes and behaviors around smoking.

What this Study Adds:

Marketing of tobacco and cigarette brands has successfully reached young children in low- and middle-income countries. More effective measures are needed to restrict the reach of tobacco marketing.

Twenty-two years ago, a small study made a huge impact on the way tobacco is marketed in the United States. Fischer et al1 found that 6-year-old boys and girls recognized with similarly high rates logos of the Disney Channel’s Mickey Mouse and Camel cigarettes’ Old Joe Camel. This and similar studies revealed sophisticated and effective marketing practices that were deariy reaching young children.2-4 The upshot

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of these studies and the publicity they garnered was stricter regulations around tobacco advertising in the United States.5,6

Although many factors are associated with tobacco use, research shows that exposure to, interest in, and positive attitudes about protobacco marketing and media messages are associated with increased odds of youth liking smoking, early initiation, and increased use.7,8 This phenomenon seems to be global. Studies conducted around the world have found that youth with high exposure and awareness levels to protobacco messaging, whether through advertising, point-of-sale displays, depictions in movies, or promotional materials, are more likely to smoke.8-11

In 2003, the World Health Assembly responded to the global tobacco epidemic by adopting the Framework Convention on Tobacco Control (FCTC). Article 13 of the FCTC addresses tobacco advertising, promotion, and sponsorship, whereas Article 11 focuses on tobacco packaging and labeling; however, there is evidence and concern that there is still a long way to go to achieve full implementation of the recommended provisions.12 Tobacco use trends suggest that multinational tobacco companies have moved their promotional efforts from high-income, industrialized countries to low- and middle-income countries (LMICs).13 In many LMICs, weak tobacco control policies and/or poor enforcement of these policies, coupled with the strong presence of the tobacco industry, can contribute to an overall high level of protobacco influences.14,15

If children living in LMICs have a high awareness of tobacco brands, positive attitudes, and intentions to smoke, then stronger efforts need to be implemented to protect this vulnerable population. This 6-country study investigated young children's recognition of tobacco brands and is the first attempt to our knowledge to gather data on the reach of tobacco marketing among preschool-aged children In LMICs.

METHODS

Sample

The World Health Organization divides the world’s countries into 6 regions: Americas, Western Pacific, South-East Asia, Africa, the Eastern Mediterranean, and Europe. This study was conducted In the LMICs (based on the World Bank classifications) with the highest number of adult smokers.14,16 Information on number of smokers was obtained through the World Health Organization’s Global Tobacco Control Report.14 For this work, data collection occurred in Brazil, China, India, Nigeria, Pakistan, and the Russian Federation (hereafter referred to as Russia).

Working with in-country public health professionals, an area in each country was selected that would clearly represent an urban and a rural population. Table 1 lists by country the geographic areas from where the samples were drawn. Next, a cluster sample strategy was performed In which low- and middle-income regions were first identified and then neighborhoods for recruitment were randomly selected. In India, Nigeria, Pakistan, and Russia, researchers went on a specified path through selected neighborhoods and found households in which a 5- or 6-year-old child lived and there was an available parent or guardian to give consent. In Brazil and China, all schools with students in our specified age range from the selected low- and middle-income neighborhoods were identified. Schools from this list were randomly selected, and then recruitment occurred by asking all parents if they and their children would be willing to participate In a health survey. From among those willing to participate, researchers randomly selected subjects and came to the schools on consecutive mornings and afternoons to interview children and their parents/guardians. Data on eligible participants and refusals by country are available upon request.

TABLE 1 View this table: in this window In a new window Locations Where Data Collection Occurred

In each country, the study design and protocols were approved by official in-country review boards. Additionally, an overall review and approval were obtained through the Johns Hopkins Institutional Review Board. Active parental and participant consent was obtained.

Procedures

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In person, one of the authors trained local researchers, ensuring standardization but allowing for necessary variations across countries. Additionally, pilot testing occurred in each country to test the feasibility and cultural appropriateness of the protocols and the instruments. In China, India, Nigeria, Pakistan, and Russia, data were collected in the spring of 2012; Brazil's data collection was delayed until late fall of 2012 because of nationwide strikes stalling institutional review board review. Data collection lasted, on average, 30 minutes with the child and 8 minutes with the parent/guardian.

For both the child and parent/guardian participants, researchers went through the survey instruments, interviewing subjects one on one. Data collection was performed in the local language and dialect of the participants, in addition to demographic information and ownership of household items, parents/guardians provided information on household members and their use of tobacco products. For the children, the instruments were developmentally appropriate; most questions Involved showing pictures, and children’s answers could be offered through verbalizing a single word, manipulating cards, or pointing to a response. After several warm-up questions, researchers posed questions to assess the child's media exposure, familiarity with cigarette brand logos, and intentions to use tobacco.

Measures Familiarity With Tobacco Logos

Children played a matching game to show familiarity with logos with their respective objects. In this game (of which there were 24 different brand logos), there were 8 tobacco brands, 4 domestic and 4 international brands (except for Nigeria where we were unable to offer domestic brands). The logos were the most common ones, reflecting those a child would come across in his or her country. Several logos involved English letters and words, even though other languages and characters were used in these countries. The researcher laid out picture cards of 12 different objects, including items not represented by any brand logos. Children performed the physical manipulation of matching the cards. A 13th picture card of a question mark was available; this symbol was explained so that all participants understood that they should use this card when they did not know the brand logo (guessing was discouraged). Children received scores for their specific knowledge and overall familiarity with tobacco logos. We observed the overall Cronbach’s a for the 8 cigarette brand items to be 0.77 (ranging from 0.45 in India to 0.89 in China).

Intentions to Smoke Cigarettes

Researchers handed the children a Yes/No card and presented a series of 9 questions about who they might be and what they might do when they grew up and were "big people." To indicate their answers, children could point to “yes” or “no." Along with the questions “Do you think you will drive a car?" and “Do you think you will be in trouble with the police?” was the question “Do you think you will smoke cigarettes?" Children who responded “yes" had a positive score on intentions to smoke cigarettes.

Media Exposure

This study used an innovative approach to assess media exposure. This measure, which has been successfully used with preschool-aged children in other countries,17,18 involved children who provided characters’ exact names. Researchers presented participants with a picture card featuring 12 current and popular characters (5 domestic, 5 international, and 2 foils). Media exposure scores were based on the number of characters a child could correctly name. In contrast to asking self-report estimates of time spent with media, this measure reflects not only exposure but also receptivity, meaning how well a person may or may not recall media messages. Overall, the Cronbach's a for these 10 items (removing the foils) was 0.78 (ranging from 0.52 in Brazil to 0.83 in Nigeria).

Statistical Analyses

First we considered the internal consistency of our measures by calculating Cronbach's a scores (as reported in the previous section). Whereas average Cronbach's a scores were acceptable (>0.70), some in-country scores fell below the acceptable range, most likely because of the heterogeneous nature of the tested items.19 After preliminary exploration of the data, we used bivariate and multivariate analyses to explore factors (gender, age, location, household use of tobacco, and knowledge of media characters) associated with awareness of cigarette brand logos and intentions to smoke. Linear and

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logistic regression models were created for the overall data set (by using dummy variables for country) and for each individual country. Statistical significance was judged at the P < .05 level.

RESULTS

Information about the sample is shown in Table 2. Overall, two-thirds (67.9%) of the participating children could identify at least 1 cigarette brand logo, ranging from 50.1% In Russia to 85.9% in China (Table 3). More than a quarter (26.3%) could identify 2 to 3 brands, and 18.2% could identify £4 brands. In Brazil and India (both P < .001), on average, children could identify more domestic compared with international cigarette brand logos; in China, children were more aware of international cigarette brands (P < .001).

! TABLE 2 1 View this table: \ In this window In a new window j Description of the Sample, Demographics, and Awareness of Cigarette Brands

! TABLE 3 i View this table: i In this window In a new window 1 Factors Associated With Children's Ability to identify at Least One Cigarette Brand (W = 2423)

Factors associated with cigarette brand awareness varied by country. A child's gender was significantly associated with Identifying at least 1 cigarette brand in just 3 countries: in Brazil and Nigeria, being male was associated with lower odds of identifying at least 1 cigarette brand (Brazil: odds ratio [OR] = 0.5, P < .01; Nigeria: OR = 0.6, P< .05); in Pakistan, being male was associated with higher odds Identifying at least 1 cigarette brand (OR = 2.2, P < .01). Also, being 6 Instead of 5 years old was related to brand awareness in Brazil (OR = 1.5, P < .06), China (OR = 3.2, P < .001), Nigeria (OR = 1.5, P < .05), and Pakistan (OR = 2.0, P < .05). In both India and Nigeria, children in urban locations were less likely than those from rural locations to be able to identify at least 1 cigarette brand logo (OR = 0.4, P < .001, and OR = 0.5, P < .01, respectively). In contrast, rural children in Brazil were less likely than urban children to know at least 1 cigarette brand (OR = 0.4, P < .001). Having someone in one's household who used tobacco was significantly related to awareness of a cigarette brand in Brazil (OR = 3.6, P < .001), Pakistan (OR = 1.8, P c .05), and Russia (OR = 1.9, P < .01). In China, greater media exposure was significantly associated with the higher likelihood of being able to identify at least 1 cigarette brand (OR = 1.6, P < .001), whereas in Nigeria (OR = 0.8, P < .001), the reverse was true. There, greater media exposure predicted a lower likelihood of cigarette brand awareness.

The greatest intention to smoke was among the Indian children. Almost a third (30.2%) Indicated that they would smoke cigarettes when they were grown; interestingly, there were no significant differences between Indian boys and girts. Gender, however, was significantly associated with smoking intentions in China (OR =1.7, P < .05), Nigeria (OR = 2.2, P < .05), Pakistan (OR = 5.3, P < .01), and Russia (OR = 6.3, P < .05), where boys were more likely than girls to say that they would smoke later In life. Being 6 instead of 5 years old was significantly associated with a lower likelihood to report smoking intentions in Brazil (OR = 0.3, P < .001), China (OR = 0.6, P < .05), Nigeria (OR = 0.4, P < .01), and Pakistan (OR = 0.4, P < .05). Only in Russia was having someone in the household who used tobacco significantly related to greater intentions to smoke (OR = 4.6, P < .05). Higher media exposure was associated with lower smoking intentions in Nigeria (OR = 0.8, P < .01) and Russia (OR = 0.8, P < .01) but with higher intentions in China (OR = 1.2, P< .01).

By exploring multivariate models to predict the ability to name at least 1 cigarette brand logo, we observed in the overall models (as shown in Table 3) that children in China, India, and Pakistan were more likely to be aware of cigarette brands, compared with the reference of Brazil. Children in Nigeria and Russia were less likely to correctly identify a cigarette brand. Being slightly older, having someone in the household who used tobacco, and having greater media exposure were associated with greater odds of being able to identify at least 1 cigarette brand. Models for each country are presented

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in Table 4.

TABLE 4 View this table: In this window in a new window Factors Associated With Ability to Identify at Least One Cigarette Brand

Finally, considering the overall model examining intentions to smoke as an aduit, we observed that being male and younger are significant predictors. Location (rural versus urban), having someone in the household who smoked, knowledge of media characters, or identification of at least 1 cigarette brand were not significant predictors.

DISCUSSION

We found that among very young children from 6 LMICs, two-thirds can identify at least 1 cigarette brand logo. Whereas restrictions to tobacco marketing in high-income, industrialized countries have shown decreases in logo recognition and has been associated with smoking uptake by youth,20 this study suggests that stronger regulations need to be instituted and better enforced in LMICs, where tobacco companies have made great efforts to encourage uptake of their products.13 Of particular concern was the sample from China, where >28% of the population smokes (53% of men, 2% of women) and there is concern over whether there is sufficient adherence to the FCTC articles.21,22 In China, 86% of the sampled 5 and 6 year olds could identify at least 1 cigarette brand.

Claims are often made that parents and not governments or corporations should keep children away from harmful products such as tobacco. Interestingly, in 3 of the country samples (Brazil, Pakistan, and Russia), having someone in the household who smoked was associated with recognizing at least 1 cigarette brand. In contrast, this factor was not significant in China, India, and Nigeria. This finding suggests that, for some children, exposure to cigarettes may occur In the home, and for others, it can be through a variety of settings such as the neighborhood, print and electronic media, as well as other acquaintances. In this study, only in China was greater media exposure associated with higher odds of knowing a cigarette brand. This result suggests that the removal of cigarette commercials is having a positive impact on lessening children's awareness of brands. More work, though should be done to restrict the deliberate use of cigarette brands as props in television shows and movies 23

Although this study was conducted in several countries, the participants came from a single rural and urban area and may not reflect the national populations in each country. Possibly in other areas one might find different awareness and relationships with smoking intentions. In this study, however, efforts were made to measure "typical” children and not those from more wealthy, cosmopolitan communities (where awareness of tobacco marketing would presumably be higher).

A strength of this study is the mindfulness involved in assessing young children's awareness and intentions. Average reliability statistics were acceptable,19 confirming that the protocols and instruments used were developmentally and culturally appropriate, and reflected conventional knowledge about cigarettes and media. As expected, we observed variability across the countries. Not only do the selected countries differ in their smoking rates and public policies around tobacco advertising14 but they also vary tremendously in children’s general access to health care and education.24 In this study, the chosen countries all had high numbers of adult smokers, but future research might want to examine locations with comparable cultural, political, and environmental variables.

Despite relatively comprehensive bans, at least in the countries considered in this study,15 young children are still exposed to tobacco marketing. Tobacco companies are using creative approaches to attract new smokers and to retain existing smokers. For example, In the United States, a large percentage of advertising dollars now goes toward retailers and wholesalers so that they reduce prices and shift displays and merchandising of particular brands.25 Of particular concern is the expected use of new technology and the Internet to bypass country regulations and reach young people with protobacco content and sales.26

When the majority of 5 and 6 year olds from low- and middle-class populations can recognize domestic and international cigarette brands, not only is it critical to have

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restrictions and bans in place but there also needs to be strict enforcement of such laws. This study's findings suggest that more rigorous approaches should be used to reduce the reach of tobacco marketing to very young children. For example, removing logos and using plain packaging could alter perceptions around smoking and lessen attraction of target groups to specific cigarette brand logos.27,28 A second way to limit promotion would be to change the quantity, location, and types of tobacco retailers, establishing minimum distances between these points of purchase and places frequented by young children.29 A third way to better restrict exposure to cigarette brands and smoking would be to change how onscreen prosmoklng media messages reach youth. Numerous prosmoking messages reach young children through current and classic media and researchers have found a dose-response relationship between such exposure and smoking.7 A rating system that alerts parents and guardians to this "mature content” could help reduce youth exposure.30

In addition to public health and policy advocates, this study has implications for pediatric health professionals. First, it Is important for practitioners to be aware that young children are aware of cigarette logos and are likely to be susceptible to prosmoklng messages. Parents who smoke cigarettes should be regularly advised to avoid using these products around their young children. Pediatric patients should be counseled not to use, or start using, tobacco products. In addition, pediatric health professionals should become Involved In tobacco control efforts In their jurisdictions and beyond, including advocating for stronger tobacco control policies such as comprehensive bans on the advertising and promotion of tobacco products.

To our knowledge, this is the first study to examine cigarette brand awareness among young children from several countries. Whereas there were differences across samples, we consistently found high brand awareness among children aged 5 and 6 years. Given the established link between exposure to tobacco marketing and Increased odds of starting to smoke, these findings should be a clarion call to significantly restrict tobacco advertising, promotion, and sponsorship, especially in LMICs, consistent with the requirements and recommendations of the FCTC.

ACKNOWLEDGMENTS

We acknowledge the hard work of our international collaborators, including the teams from Russia (led by Tatiana Voylokova of the Russian Public Opinion Research Center [VCIOM]), China (led by Wu Junqing of Fudan University), India (led by Varan Kumar of Policy Innovations), Nigeria (led by Adesegun Fatusi of Obafemi Awolowo University), Pakistan (led by Atif Ikram Butt of the Pakistan Center for Communication Programs), and Brazil (led by Rodolfo C. Ribas of the Federal University of Rio de Janeiro). We also greatly appreciate the assistance of Holly Henry, PhD, Jenny Chan, MSPH, and Jingyan Yang, MHS, for their work with preparing the instruments, securing Institutional review board approval, and managing the data.

FOOTNOTES

Accepted July 25, 2013.

Address correspondence to Dina L.G. Borzekowski, EdD, Department of Behavioral and Community Health, School of Public Health, University of Maryland, College Park, MD 20742. E-mail: [email protected]

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 work, subcontracted and trained researchers in the 6 countries to conduct data collection and data entry, and analyzed the data and prepared the manuscript; and Dr Cohen helped secure funding for this work and assisted with protocol and instrument development, data analysis, and write-up of the findings.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to the article to disclose.

FUNDING: Supported by a grant from the Institute for Global Tobacco Control with funding from the Bloomberg Initiative to Reduce Tobacco Use.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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