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Global Evidence on the Effect of Point-Of-Sale Display Bans on Smoking Prevalence Yanyun He,1 Ce Shang,2 Jidong Huang,3 Kai-Wen Cheng,1,2 Frank J Chaloupka1,2

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Global Evidence on the Effect of Point-Of-Sale Display Bans on Smoking Prevalence Yanyun He,1 Ce Shang,2 Jidong Huang,3 Kai-Wen Cheng,1,2 Frank J Chaloupka1,2 Research paper Tob Control: first published as 10.1136/tobaccocontrol-2017-053996 on 13 January 2018. Downloaded from Global evidence on the effect of point-of-sale display bans on smoking prevalence Yanyun He,1 Ce Shang,2 Jidong Huang,3 Kai-Wen Cheng,1,2 Frank J Chaloupka1,2 1University of Illinois, Chicago, ABStract countries have implemented POS display bans, Illinois, USA Background Since Iceland became the first country to including Canada (Manitoba became the first prov- 2Institute for Health Research and Policy, University of Illinois, impose a ban on point-of-sale (POS) tobacco product ince to ban POS displays on January 2004, and as Chicago, Illinois, USA displays in 2001, 20 countries have implemented POS of January 2010, all provinces had followed suit), 3School of Public Health, display bans as of 2016. This study examined the effect Thailand (September 2005), Belarus (January 2008), Tobacco Center of Regulatory that POS display bans have on smoking prevalence. Ireland (July 2009), Australia (the first jurisdiction, Science, Georgia State Methods Data were sourced from Euromonitor the Australian Capital Territory, implemented in University, Atlanta, Georgia, USA International and the WHO MPOWER package for December 2009; and as of January 2012 all states 2007–2014 from 77 countries worldwide. generalised and territories had a ban) and Norway (January Correspondence to linear models with country and year fixed effects were 2010). In countries where POS display bans came Dr Ce Shang, Institute for Health estimated to analyse the effect of POS display bans on into force, cigarettes may not be displayed in-store Research and Policy, University smoking prevalence. and consequently consumers are not permitted to of Illinois, Chicago, IL 60002, Results Having a POS display ban reduced overall adult browse or examine the cigarette brands/products on USA; cshang@ uic. edu daily smoking, male smoking and female smoking by offer prior to purchase. Received 14 August 2017 about 7%, 6% and 9%, respectively. To date, 20 countries have implemented POS Revised 29 November 2017 Conclusions Having a POS display ban is likely to display bans (online supplementary appendix). Accepted 7 December 2017 reduce smoking prevalence and generate public health However, the limited number of studies exam- Published Online First 13 January 2018 benefits. ining the effect of POS display bans on smoking behaviours has provided mixed results. In Canada and Iceland where POS display bans have been implemented, a decrease in youth and adult 8 9 INTRODUCTION smoking prevalence was observed. The bans may copyright. The WHO Framework Convention on Tobacco have contributed to these reductions. However, Control (WHO FCTC), a treaty with 181 parties without assessing other changes in the tobacco worldwide, calls for comprehensive restrictions on control environment, such as the implementation tobacco marketing, promotion and sponsorship.1 of other tobacco control strategies, the two existing As countries have implemented regulations banning observational studies could not determine conclu- advertising and promotion of tobacco products sively whether POS display bans reduced smoking. in traditional media outlets such as television, Shang et al examined the association between POS radio and outdoor billboards, tobacco companies advertising restrictions and smoking behaviours http://tobaccocontrol.bmj.com/ increasingly market their products to customers at among youth using data from the Global Youth the point of sale (POS). POS displays (eg, product Tobacco Survey in 130 countries between 2007 and 10 11 placement, brand exhibition and price discounts) 2011. A POS advertising ban was significantly have become an important competitive marketing associated with reduced experimental smoking and strategy.2 In the USA, tobacco industry expendi- smoking participation among youth. tures on cigarette POS advertising and promotion Several studies examined the effect of POS increased from $76 million in 2011 to $238 million displays on purchasing behaviours or the effect of in 2014.3 4 In Chile, the tobacco industry invests in POS display bans on exposure to tobacco product making bigger and more attractive display cabinets marketing. Wakefield et al found that 31% of for their products to attract shoppers and prompt smokers thought removal of POS displays would 12 impulse purchases. For example, to support new help them quit. Carter et al and Clattenburg on 19 December 2018 by guest. Protected product launches and to better communicate with et al also found strong evidence that POS displays customers, small liquid-crystal display screens were prompted impulse buying of cigarettes and urges to installed in some stores.5 smoke and undermined quit attempts.7 13 Seeing tobacco products can stimulate the desire Li et al used longitudinal individual-level data to purchase and decrease thoughts about quitting. from the International Tobacco Control survey to POS displays are associated with greater odds compare the variability in POS marketing restric- of impulse purchasing and the urge to purchase tions in four Western countries: Australia and tobacco products.6 Another study found that a Canada, where POS display bans had been imple- small-to-moderate proportion of tobacco purchases mented, and the UK and the USA, where there were made on impulse, and approximately one-third were no such bans in place.14 They also examined of smokers agreed POS promotion made quitting the effect of POS marketing restrictions on adult smoking more difficult.7 smokers’ exposure to tobacco product marketing To cite: He Y, Shang C, Iceland became the first country to impose and their cigarette purchasing behaviours. In coun- Huang J, et al. Tob Control a ban on POS advertising and displays in 2001 tries where POS display bans were implemented, 2018;27:e98–e104. (online supplementary appendix). Since then, other smokers reported exposure to tobacco marketing e98 He Y, et al. Tob Control 2018;27:e98–e104. doi:10.1136/tobaccocontrol-2017-053996 Research paper Tob Control: first published as 10.1136/tobaccocontrol-2017-053996 on 13 January 2018. Downloaded from declined markedly. Smokers in countries without POS display 2015, the exposure measure was adjusted using the proportion bans were more likely to make unplanned purchases. A study in of cigarette sales in large stores among total sales revenues, Norway observed before and after implementation of the POS during the period when only large stores were subject to POS display ban in January 201015 found that compared with older display bans. The correlation between the provinces/states in people young people were more likely to be tempted by tobacco Australia and Canada who had the ban and the provinces/states products when seeing them in the shop, and therefore, found it who did not have the ban might affect the effect of the ban on more difficult to choose a brand or buy tobacco products after smoking participation. See online supplementary appendix for the ban was implemented. formula for the constructs of this exposure measure variable. In contrast, an Irish study found no significant short-term change in smoking prevalence among adults within the first year following the implementation of a POS display ban.16 Quinn Control variables for other policies et al examined the economic impact of the POS display ban on The WHO FCTC, one of the United Nations’ most widely cigarette sales in Ireland using aggregated actual sales data and embraced treaties, was adopted in May 2003 and came into found no statistically significant decline in cigarette pack sales force on February 2005. To support treaty implementation, following the implementation of the legislation.17 WHO developed the MPOWER package, focused on six effec- However, these existing studies either presented descriptive tive and cost-effective tobacco control measures: M (monitor statistics or estimated associations between POS display bans and tobacco use), P (protect people from smoke), O (offer help to quit), W (warn about the dangers of tobacco), E (enforce bans on smoking behaviours, and as a result, did not analyse the causal 19 20 impact of POS display bans on smoking. In addition, many coun- tobacco marketing) and R (raise taxes on tobacco). All WHO tries have implemented a comprehensive set of tobacco control member states were assessed based on their performance imple- policies, such as tax increases, smoke-free air laws and graphic menting each measure. The six MPOWER scores were catego- warning labels, as suggested by the WHO FCTC, which could be rised into four or five levels. For M, the score value ranges from potential confounders when estimating the effect of POS display 1 to 4: 1 represents no known data/no recent data/no national representative data, and 2–4 represent the weakest to the stron- bans on smoking. 21 POS display bans are likely to affect smoking behaviour by gest level of monitoring. For the other five policy dimensions cutting off an important communication channel with potential (POWER), the scores measure overall strength on a scale of 1–5: customers and providing a supportive environment for smokers 1 represents a lack of data (missing data), and 2–5 represent the to quit.18 However, to date, no studies in the peer-reviewed weakest to the strongest policies. Since the MPOWER scores literature have assessed the impact of POS display bans on adult were not reported, the scores in the prior years (2008, 2010 and 2012) were replaced using the scores in years 2009, 2011 smoking across multiple countries. Using aggregated coun- copyright. and 2013, assuming that no policy changes occurred. Following try-level longitudinal data from 77 countries in the world from 22 2007 to 2014, and a two-way fixed effects model, we analyse the previous literature, we constructed a composite score for each causal link between POS display bans and smoking prevalence, country and year by summing up each individual score and used accounting for the tobacco control environment and population it to account for tobacco control environment.
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