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OBJECTIVES: Describe tobacco companies' marketing strategies targeting low socioeconomic status (SES) females in the USA. METHODS: Analysis of previously secret tobacco industry documents. RESULTS: Tobacco companies focused marketing on low SES women starting in the late 1970s, including military wives, low-income inner-city minority women, 'discount-susceptible' older female smokers and less-educated young white women. Strategies included distributing discount coupons with food stamps to reach the very poor, discount offers at point-of-sale and via direct mail to keep cigarette prices low, developing new brands for low SES females and promoting luxury images to low SES African-American women. More recently, companies integrated promotional strategies targeting low-income women into marketing plans for established brands. CONCLUSIONS: Tobacco companies used numerous marketing strategies to reach low SES females in the USA for at least four decades. Strategies to counteract marketing to low SES women could include (1) counteracting price discounts and direct mail coupons that reduce the price of tobacco products, (2) instituting restrictions on point-of-sale advertising and retail display and (3) creating counteradvertising that builds resistance to psychosocial targeting of low SES women. To achieve health equity, tobacco control efforts are needed to counteract the influence of tobacco industry marketing to low-income women. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe relationships between tobacco-related environments and disparities in smoking by sexual orientation. METHODS: We examined three aspects of state-level tobacco environments, which were derived from the ImpacTeen State Level Tobacco Control Policy and Prevalence Database: (1) tobacco price and tax data and tobacco control funding; (2) tobacco control policies and (3) tobacco prevalence and norms data. This information was linked to individual-level data on sexual orientation, tobacco use and nicotine dependence in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N=34 653; 577 LGB respondents), a cross-sectional, nationally representative survey of adults in the USA. RESULTS: Lesbian, gay and bisexual (LGB) adults in states with more restrictive tobacco environments were less likely to have ever smoked (AOR=0.78, 95% CI 0.62 to 1.00) and to currently smoke (AOR=0.77, 95% CI 0.60 to 0.99) than LGB adults in more permissive tobacco environments. Further, sexual orientation disparities in past and current smoking, as well as in current nicotine dependence, were lower in states with the most restrictive tobacco environments. Results were robust to adjustment for confounders at the individual and state levels. CONCLUSIONS: Restrictive state-level tobacco environments are correlates of smoking behaviours among LGB adults in the USA; such environments could potentially reduce social inequalities in smoking based on sexual orientation. [ABSTRACT FROM AUTHOR]

Background The Tea Party, which gained prominence in the USA in 2009, advocates limited government and low taxes. Tea Party organisations, particularly Americans for Prosperity and FreedomWorks, oppose smoke-free laws and tobacco taxes. Methods We used the Legacy Tobacco Documents Library, the Wayback Machine, Google, LexisNexis, the Center for Media and Democracy and the Center for Responsive Politics (opensecrets.org) to examine the tobacco companies' connections to the Tea Party. Results Starting in the 1980s, tobacco companies worked to create the appearance of broad opposition to tobacco control policies by attempting to create a grassroots smokers' rights movement. Simultaneously, they funded and worked through third-party groups, such as Citizens for a Sound Economy, the predecessor of AFP and FreedomWorks, to accomplish their economic and political agenda. There has been continuity of some key players, strategies and messages from these groups to Tea Party organisations. As of 2012, the Tea Party was beginning to spread internationally. Conclusions Rather than being a purely grassroots movement that spontaneously developed in 2009, the Tea Party has developed over time, in part through decades of work by the tobacco industry and other corporate interests. It is important for tobacco control advocates in the USA and internationally, to anticipate and counter Tea Party opposition to tobacco control policies and ensure that policymakers, the media and the public understand the longstanding connection between the tobacco industry, the Tea Party and its associated organisations. [ABSTRACT FROM AUTHOR]

Background The estimated effect of cigarette graphic warning labels (GWL) on smoking rates is a key input to the Food and Drug Administration's (FDA) regulatory impact analysis (RIA), required by law as part of its rule-making process. However, evidence on the impact of GWLs on smoking prevalence is scarce. Objective The goal of this paper is to critically analyse FDA's approach to estimating the impact of GWLs on smoking rates in its RIA, and to suggest a path forward to estimating the impact of the adoption of GWLs in Canada on Canadian national adult smoking prevalence. Methods A quasi-experimental methodology was employed to examine the impact of adoption of GWLs in Canada in 2000, using the USA as a control. Findings We found a statistically significant reduction in smoking rates after the adoption of GWLs in Canada in comparison with the USA. Our analyses show that implementation of GWLs in Canada reduced smoking rates by 2.87-4.68 percentage points, a relative reduction of 12.1-19.6%; 33-53 times larger than FDA's estimates of a 0.088 percentage point reduction. We also demonstrated that FDA's estimate of the impact was flawed because it is highly sensitive to the changes in variable selection, model specification, and the time period analysed. Conclusions Adopting GWLs on cigarette packages reduces smoking prevalence. Applying our analysis of the Canadian GWLs, we estimate that if the USA had adopted GWLs in 2012, the number of adult smokers in the USA would have decreased by 5.3-8.6 million in 2013. Our analysis demonstrates that FDA's approach to estimating the impact of GWLs on smoking rates is flawed. Rectifying these problems before this approach becomes the norm is critical for FDA's effective regulation of tobacco products. [ABSTRACT FROM AUTHOR]

Background Cigarette butt litter is a potential target of tobacco control. In addition to its toxicity and non-biodegradability, it can justify environmental regulation and policies that raise the price of tobacco and further denormalise its use. This paper examines how the tobacco industry has managed the cigarette butt litter issue and how the issue has been covered in the media. Methods We searched the Legacy Tobacco Documents Library () using a snowball strategy. We analysed data from approximately 700 documents, dated 1959-2006, using an interpretive approach. We also searched two newspaper databases, Lexis/Nexis and Newsbank, and found 406 relevant articles, dated 1982-2009 which we analysed quantitatively and qualitatively. Results The tobacco industry monitored and developed strategies for dealing with the cigarette litter issue because it affected the social acceptability of smoking, created the potential for alliances between tobacco control and environmental advocates, and created a target for regulation. The industry developed anti-litter programs with Keep America Beautiful (KAB) and similar organisations. Media coverage focused on industry-acceptable solutions, such as volunteer clean-ups and installation of ashtrays; stories that mentioned KAB were also more frequently positive towards the tobacco industry. Among alternative approaches, clean outdoor air (COA) laws received the most media attention. Conclusions Cigarette litter, like secondhand smoke, is the result of smoker behaviour and affects nonsmokers. The tobacco industry has tried and failed to mitigate the impact of cigarette litter. Tobacco control advocates should explore alliances with environmental groups and propose policy options that hold the industry accountable for cigarette waste. [ABSTRACT FROM AUTHOR]

Objective The purpose of this paper was to examine trends in the use of premium and discount cigarette brands and determine correlates of type of brand used and brand switching. Methods Data from the International Tobacco Control (ITC) US adult smoker cohort survey were analysed. The total study sample included 6669 adult cigarette smokers recruited and followed from 2002 to 2011 over eight different survey waves. Each survey wave included an average of 1700 smokers per survey with replenishment of those lost to follow-up. Results Over the eight survey waves, a total of 260 different cigarette brands were reported by smokers, of which 17% were classified as premium and 83% as discount brands. Marlboro, Newport, and Camel were the most popular premium brands reported by smokers in our sample over all eight survey waves. The percentage of smokers using discount brands increased between 2002 and 2011, with a marked increase in brand switching from premium to discount cigarettes observed after 2009 corresponding to the $0.61 increase in the federal excise tax on cigarettes. Cigarette brand preferences varied by age group and income levels with younger, higher income smokers more likely to report smoking premium brand cigarettes, while older, middle and lower income, heavier smokers were more likely to report using discount brands. Conclusions Our data suggest that demographic and smoking trends favour the continued growth of low priced cigarette brands. From a tobacco control perspective, the findings from this study suggest that governments should consider enacting stronger minimum pricing laws in order to keep the base price of cigarettes high, since aggressive price marketing will likely continue to be used by manufacturers to compete for the shrinking pool of remaining smokers in the population. [ABSTRACT FROM AUTHOR]

Objective This paper considers the evidence on whether outdoor secondhand smoke (SHS) is present in hospitality venues at high levels enough to potentially pose health risks, particularly among employees. Data sources Searches in PubMed and Web of Science included combinations of environmental tobacco smoke, secondhand smoke, or passive smoke AND outdoor, yielding 217 and 5,199 results, respectively through June, 2012. Study selection Sixteen studies were selected that reported measuring any outdoor SHS exposures ( particulate matter (PM) or other SHS indicators). Data extraction The SHS measurement methods were assessed for inclusion of extraneous variables that may affect levels or the corroboration of measurements with known standards. Data synthesis The magnitude of SHS exposure (PM2.5) depends on the number of smokers present, measurement proximity, outdoor enclosures, and wind. Annual excess PM2.5 exposure of full-time waitstaff at outdoor smoking environments could average 4.0 to 12.2 µg/m3 under variable smoking conditions. Conclusions Although highly transitory, outdoor SHS exposures could occasionally exceed annual ambient air quality exposure guidelines. Personal monitoring studies of waitstaff are warranted to corroborate these modeled estimates. [ABSTRACT FROM AUTHOR]

Background Raising cigarette prices through taxation is an important policy approach to reduce smoking. Yet, cigarette price increases may not be equally effective in all subpopulations of smokers. Purpose To examine differing effects of state cigarette price changes with individual changes in smoking among smokers of different intensity levels. Methods Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of US adults originally interviewed in 2001-2002 (Wave 1) and re-interviewed in 2004-2005 (Wave 2): 34 653 were re-interviewed in Wave 2, and 7068 smokers defined at Wave 1 were included in our study. Mixed effects linear regression models were used to assess whether the effects of changes in state cigarette prices on changes in daily smoking behaviour differed by level of daily smoking. Results In the multivariable model, there was a significant interaction between change in price per pack of cigarettes from Wave 1 to Wave 2 and the number of cigarettes smoked per day (p=0.044). The more cigarettes smoked per day at baseline, the more responsive the smokers were to increases in price per pack of cigarettes (ie, number of cigarettes smoked per day was reduced in response to price increases). Conclusions Our findings that heavier smokers successfully and substantially reduced their cigarette smoking behaviours in response to state cigarette price increases provide fresh insight to the evidence on the effectiveness of higher cigarette prices in reducing smoking. [ABSTRACT FROM AUTHOR]

Objective To elucidate how demographics of US Census tracts are related to tobacco outlet density (TOD). Method The authors conducted a nationwide assessment of the association between socio-demographic US Census indicators and the density of tobacco outlets across all 64 909 census tracts in the continental USA. Retail tobacco outlet addresses were determined through North American Industry Classification System codes, and density per 1000 population was estimated for each census tract. Independent variables included urban/rural; proportion of the population that was black, Hispanic and women with low levels of education; proportion of families living in poverty and median household size. Results In a multivariate analysis, there was a higher TOD per 1000 population in urban than in rural locations. Furthermore, higher TOD was associated with larger proportions of blacks, Hispanics, women with low levels of education and with smaller household size. Urban--rural differences in the relation between demographics and TOD were found in all socio-demographic categories, with the exception of poverty, but were particularly striking for Hispanics, for whom the relation with TOD was 10 times larger in urban compared with rural census tracts. Conclusions The findings suggest that tobacco outlets are more concentrated in areas where people with higher risk for negative health outcomes reside. Future studies should examine the relation between TOD and smoking, smoking cessation, as well as disease rates. [ABSTRACT FROM AUTHOR]

Background Modification of tobacco curing methods and other changes in cigarette manufacturing techniques could substantially reduce the levels of tobacco-specific nitrosamines (TSNA), a group of potent carcinogens, in cigarette smoke. In 1999, two major US cigarette manufacturers stated their intent to move towards using tobaccos low in TSNA. There is no information available on current TSNA levels in tobacco of various cigarettes available in the US, particularly in the newer varieties introduced over the past decade. Methods Seventeen brands of cigarettes were purchased in April of 2010 from retail stores in Minnesota. TSNA levels were measured in the tobacco filler and smoke of these cigarettes. Results In all brands, the sum of two potent carcinogenic TSNA - 4-(methylnitrosamino)-1-(3-pyridyl)- 1-butanone and N'-nitrosonornicotine--in cigarette filler averaged 2.54 (±1.05) µg/g tobacco. This value is virtually identical to the sum of these two carcinogens reported for the tobacco of a US filtered cigarette in 1979. TSNA levels in smoke positively correlated with those in tobacco filler of the same cigarettes. Conclusion We found no indication that any meaningful attempt was made to reduce or at least control TSNA levels in the new varieties of the popular brands Marlboro and Camel introduced over the last decade. In light of the recently granted regulatory authority to the FDA over tobacco products, regulation of TSNA levels in cigarette tobacco should be strongly considered to reduce the levels of these potent carcinogens in cigarette smoke. [ABSTRACT FROM AUTHOR]

OBJECTIVES: As smoking among college students reached new highs in the 1990s, most interventions for college student smoking prevention focused on individual student knowledge, attitudes and beliefs. No published studies report on statewide movements to accelerate the adoption of tobacco-free policies on college campuses. The results of the first 4 years of the North Carolina Tobacco-Free Colleges Initiative are presented. METHODS: The North Carolina Health and Wellness Trust Fund developed a multilevel intervention to accelerate the diffusion of tobacco-free policies on college campuses, including funding campus coordinators and coalitions to tailor activities to the campus environment at 64 colleges. Evaluators tracked process and policy outcomes as well as the diffusion of policy adoption from January 2006–December 2009. RESULTS: Prior to the initiative, only one small, private college campus in North Carolina was tobacco-free. By 4 years into the initiative, 33 colleges and community colleges, representing more than 159 300 students, have adopted comprehensive tobacco-free policies to protect students, faculty, staff and visitors. Participating campuses also adopted 68 policies restricting smoking in certain areas and limiting industry activity. CONCLUSIONS: Tobacco-free policy adoption on college campuses can be accelerated with a multilevel statewide intervention. [ABSTRACT FROM AUTHOR]

Background Increases in tobacco taxes are effective in reducing tobacco consumption, but because of the addictive nature of cigarettes, smokers often seek out less expensive sources of cigarettes. The objective of this study is to estimate the prevalence of cigarette packs that are untaxed by the state in which the participant resides in a sample of US smokers at two time points. Methods Data for this study were taken from the 2009 and 2010 waves of the International Tobacco Control United States Survey. Members of this nationally representative cohort of smokers were invited to send us an unopened pack of their usual brand of cigarettes. Results In 2009, 318 packs were received from 401 eligible participants (79%). In 2010, 366 packs were received from 491 eligible participants (75%). In total, 20% of the packs in 2009 and 21% in 2010 were classified as untaxed by the participant's state of residence. The prevalence of untaxed cigarettes was higher in states with higher-excise taxes. Smokers who do not have a plan to quit were significantly more likely to have sent back a pack that was classified as untaxed by the participant's state of residence. Conclusions One in five packs were untaxed with rates higher in states with higher-excise taxes. It is unclear whether these estimates differ from the actual prevalence of cigarettes that are untaxed by a smoker's state of residence. Harmonisation of excise tax rates across all 50 US states might be one method of reducing or eliminating the incentive to avoid or evade these taxes. [ABSTRACT FROM AUTHOR]

Objective: To explore and understand key cultural contexts of tobacco use among South Asian communities in the USA. Design: Focus groups, with homogeneous compositions of gender, generational status and length of time in the USA, were conducted in two distinct South Asian ethnic enclaves. Focus group findings were triangulated with observational data regarding the availability of culturally specific tobacco from commercial ethnic outlets and cultural events. Subjects: Respondents included 88 men and women of South Asian descent, aged 18-65 years, immigrant and native born, representing diversity of religion, socioeconomic status and region of origin, with the use of at least one culturally specific tobacco product in previous 24 months. Results: A large number of culturally specific products were commonly used by community members. Knowledge of product-specific health risks was lacking or inaccurate. Many culturally specific tobacco products were considered to have beneficial properties. South Asian tobacco items were used to preserve cultural traditions and express ethnic identity in a new dominant culture. The social and cultural values ascribed to use helped distinguish community members from mainstream society and from other minority populations. Conclusions: Many cultural factors govern tobacco use among diverse global populations. Especially for migrants with a common regional origin, the role of ethnic identity may strongly influence culturally specific tobacco patterns. Qualitative inquiry helps elucidate such culturally framed behaviour in culturally diverse populations. These cultural contexts should be integrated into research and practice. Understanding multi-dimensional factors influencing non-traditional tobacco use is essential to ensure that comprehensive tobacco control strategies address tobacco-related disparities. [ABSTRACT FROM AUTHOR]