Memorandum by Cancer Research UK (H 05)

 

Introduction

 

Cancer Research UK is the world's largest independent organisation dedicated to cancer research. We funded £333 million of research in 2007/08 and our vision is that together we will beat cancer. We carry out world-class research to improve our understanding of cancer and to find out how to prevent, diagnose and treat different types of the disease. One of our absolute priorities is to reduce the number of people affected by cancer.

 

We welcome the opportunity to submit evidence to the Committee considering the Health Bill.

 

 Our position

 

 Cancer Research UK's 'Out of Sight, Out of Mind' campaign is calling for:

· The prohibition of point of sale displays for tobacco;

· The prohibition of tobacco vending machines; and

· The inclusion of a reserve power to introduce plain packaging for all tobacco products at a later date.

 

These measures should be implemented as part of a comprehensive tobacco control strategy that includes support for those seeking to quit and other measures.

 

Cancer Research UK strongly believes that removing displays of tobacco at the point of sale (PoS) is a necessary step to protect young people from tobacco marketing. What follows below is a summary of some of the recent evidence to support this. Also included is evidence to counter tobacco industry claims that a tobacco display ban has had an adverse effect on the Canadian retail sector.

 

Summary of evidence to support the removal of PoS displays

 

1.1 Literature Review by the Centre for Tobacco Control Research (CTCR), and included in their report, funded by Cancer Research UK (report provided):

 

· The CTCR's work and reputation is internationally recognised. In particular Professor Gerard Hastings, the Centre's Director has provided guidance to the Scottish, UK and European Parliaments and the World Health Organisation, across a variety of tobacco control issues, but particularly concerning the role and impact of tobacco marketing.

· The CTCR report examines other studies looking at the role of point of sale advertising and displays on young people's uptake and also analyses primary data from the Youth Tobacco Policy Survey. Some of the most significant studies from other countries are outlined below. Studies conducted in the USA, New Zealand, Australia and the UK, and discussed in the CTCR report, have found PoS awareness (both advertising and displays) to be associated with:

 

i. Likelihood of smoking (Schooler et al 1996; Henrikson et al 2004b; Slater et al 2007)

ii. Intention to smoke (MacFadyen et al 2001)

iii. Brand choice (Wakefield et al 2002b)

iv. Unaided recall of brands (Sparks 1999)

v. Positive brand imagery i.e. positive perceptions of brands, (Donovan et al 2002).

 

It should be noted that where tobacco advertising restrictions are weak, the effect of PoS advertising and displays may be diluted by 'noise' from other advertising, making the independent effect of PoS marketing difficult to discern.

 

1.2 Primary data analysis in the CTCR report:

 

· The primary data analysis presented is based on a long-term study known as the Youth Tobacco Policy Survey (YTPS), which examines the impact of tobacco advertising restrictions and other tobacco control policies on young people in the UK. A number of peer-reviewed papers have been published based on this work, and this report was an extension of previous papers.

· The survey has now taken place five times since 1999, covering the period before the tobacco advertising ban, and up to five and a half years after it. The report covers the four survey waves conducted with almost 4,500 young people in total from a variety of backgrounds, social groups and lifestyles aged between 11 and 16 years.

· A particular strength of the YTPS is its focus on tobacco marketing variables which other broader studies, such as Goddard (1990) have only been able to touch on. The YTPS has also controlled for important confounding factors (age, gender, social grade, sibling, peer and parental smoking) to ensure that any influence of marketing variables is considered after taking account of other known influences.

· The study examines 'susceptibility', a particularly useful measure for calibrating the extent to which young people, who have never smoked, intend to smoke in the future[i]^{,[ii],[iii],[iv]} It builds on intention to smoke, which is known to be a strong predictor of future smoking.[v]^{,[vi],[vii],[viii]} For example, the report by Goddard (1990) based on a longitudinal cohort of 12-14 year olds, found a significant association between intention to smoke and starting to smoke.

· The CTCR finds that PoS displays encourage product brand awareness among youth. When other risk factors are controlled for, including sibling, peer and parental smoking, young people's susceptibility to take up smoking (i.e. the degree to which young people who have never smoked intend to do so in the future) increases with greater awareness of brands and tobacco marketing. Furthermore, awareness of cigarette brands is also positively associated with awareness of PoS marketing, i.e. those who were aware of PoS marketing had higher brand awareness than those who were not aware.

· The study also finds that PoS displays are very prominent and are now the most important source of tobacco marketing for young people. In 2006, almost half (46%) of UK teens were aware of tobacco marketing at PoS. The authors note that such displays offer the perfect marketing opportunity in a restricted market, through promotional packs and branding and also through benefiting from a large retail distribution network.

· In the 2008 survey young people were asked (i) whether they had seen cigarettes displayed in shops in the last month (ii) how often they pay close attention to cigarette packets displayed in shops (never, rarely, sometimes, often or very often) and (iii) whether they agree or disagree that cigarettes should be put out of sight in shops (agree a lot, agree a little, neither agree nor disagree, disagree a little, disagree a lot). Findings revealed high awareness of cigarettes displayed in shops, with 82% of participants having seen cigarettes displayed in shops in the previous month; irrespective of age, gender or smoking status. Almost a third (32%) of regular smokers pay close attention to cigarette packets displayed in shops compared with 4% of never smokers. Almost two-thirds (64%) of 11-16 year olds agreed (a lot or a little) that cigarettes should be put out of sight in shops; mostly never smokers (72%).

· The YTPS demonstrates that awareness of PoS and the brands most prominently displayed at PoS remains high, which normalises tobacco products among young people and undermines the TAPA,[ix] which has otherwise successfully reduced awareness of various other forms of marketing.[x] The YTPS also reveals that the vast majority of young people favour the removal of tobacco displays, and separate qualitative research (see below) helps to reveal why.

 

1.3 UK qualitative research from young people:

 

· The CTCR has also recently conducted qualitative research with young people across the UK.[xi] This gives a snapshot of the genuine impact of these displays on young people. Young people commented that PoS tobacco displays were 'obvious' within shops due to the 'massive display', and such displays appeared to be attractive to both male and female smokers, being described as 'cool' and likely to encourage smoking or stimulate purchase. Even non-smokers could see the appeal of cigarette displays, stating that 'things like this attracts people to smoke'; which helps explain why so many youngsters in the YTPS favour their removal. See below for a sample of comments relating specifically to PoS tobacco displays:

 

'Have seen this type [shows pack of Mayfair] in shops on the shelves and with my friends in schools. Like, it's cool and fun to smoke'

(Male 12, C2DE, Smoker)

 

'Say you enter into the shop you see this massive display over the counter. In the shops things like this attracts people to smoke'

(Male, 11, ABC1, Non-smoker)

 

'Things like [cigarette] displays arouse me to buy. Looks cool'

(Female, 14, C2DE, Smoker)

 

1.4 Other supportive research:

 

· Other reports and guidelines have come to the same conclusion. They recognise that the evidence is strong even if causality in a strict epidemiological sense cannot be proved.

· A 2009 systematic review[xii] (provided) found that in seven out of eight observational studies a statistically significant association between exposure to tobacco promotion at PoS and smoking initiation or susceptibility to smoking was observed. Two experimental studies of children found statistically significant associations between exposure to PoS tobacco promotions and beliefs about ease of getting tobacco and smoking prevalence rates among their peers. The authors say that a moderately strong association between PoS and smoking susceptibility and uptake of smoking was evident from studies conducted in different time periods and settings and using a range of exposure and outcome measures.

· Questions have been raised regarding a) dose response and b) direction of causality in such studies. Dose response was not looked at because the exposure measures generally split subjects into only two groups. As most of the studies were cross-sectional, the direction of causality was often not discernable. However, increased susceptibility to smoking among never-smokers is less credibly a cause of increased exposure to PoS marketing, since such subjects are not yet buying tobacco products. Also, studies that examined susceptibility in never-smokers did find an association with exposure to PoS promotion after adjustment for other predictors of susceptibility to smoking (Feighery et al., 2006: Weiss et al., 2006, quoted in reference iv). The one cohort study (that could show direction of causality) showed that awareness of displays affect smoking behaviour rather than the other way round (Weiss et al, 2006).

· Research with 25,000 young people in New Zealand shows that those 15 year olds most exposed to PoS displays are almost three times more likely to try smoking and that exposure to PoS is a greater risk factor than even parental smoking.[xiii] New Zealand, like the UK, already has a ban on tobacco advertising.

· Recently agreed guidelines to the WHO Framework Convention on Tobacco Control (FCTC) define retail displays as a form of advertising and promotion and recommend that Parties to the FCTC, which include the UK, ban them.

 

1.5. PoS display bans support declines in youth smoking rates over time:

 

· Many different figures, time periods and measures of smoking have been quoted and provided by different sources. We believe the most reliable data have been provided by national health and public departments. In Canada display bans have been introduced as part of a range of tobacco control measures. By 2007 six provinces had introduced PoS display bans and these coincided with a fall in smoking prevalence rates amongst 15-19 year olds from 22% to 15% in 2007.[xiv] Survey evidence in Iceland has also shown that youth smoking rates fell significantly after a display ban was implemented in 2001. Smoking prevalence rates amongst Icelandic 10^th graders (aged 15-16) dropped from 18.6% in 1999 (two years prior to the display ban) to 13.6% in 2003 - twice the rate of decline compared to the previous four year period.[xv] The Public Health Institute of Iceland (a statutory Government body) has indicated that these results give the most accurate view of youth smoking prevalence in the country.

· Many factors affect susceptibility to smoke. Behaviour/prevalence is influenced by a range of policies making it difficult to disentangle the effects of specific policies. Policies take time to have an effect and may work firstly through their influence on psychosocial variables - proximal measures that are directly relevant to the policy e.g. noticing packs and awareness of brands and distal variables that are more distant from the policy and are influenced by other policies such as perceived prevalence, smoking norms, and perceived acceptability of smoking.  Changes in behaviour/prevalence may occur through these psychosocial variables. 

1.6 PoS displays have a strong influence on unplanned purchases:

 

· Recent research conducted in Australia[xvi] suggests that PoS displays have a strong influence on unplanned purchases, acting as a form of advertising even in the absence of advertising materials. In a series of interviews with daily smokers, questioned just after they had purchased cigarettes from a supermarket, PoS displays were found to influence nearly four times as many unplanned purchases as planned purchases. Removing tobacco products from sight is therefore highly likely to reduce the number of unplanned purchases. The research also found that 88% of the smokers questioned were supportive or at least ambivalent towards a complete ban on PoS displays.

 

1.7 PoS displays 'normalise' tobacco products and undermine the information about health risks:

 

· Research has shown that the degree to which young people overestimate smoking rates is a predictor of starting smoking.[xvii] The widespread availability of tobacco products and the prominence of tobacco displays at the PoS lead young people to believe that smoking is normal and socially acceptable behaviour and to overestimate smoking prevalence rates. The proximity of tobacco products to less harmful products such as sweets and chocolate also undermines the information relating to health risks.

 

1.8 Impact of Tobacco display bans on the Canadian retail sector:

 

· Several documents funded by the tobacco industry have suggested that the implementation of tobacco display bans in Canadian provinces have resulted in the closure of small convenience stores. One particularly alarmist brief prepared by the Tobacco Retailers Alliance (TRA) - a group wholly funded by the Tobacco Manufacturers' Association (itself funded by the UK's three largest tobacco companies) - made the unreferenced claim that the introduction of display bans have caused 12 stores to close per week in the province of Quebec and 23 stores to close per week in the province of Ontario (both provinces launched their display bans on June 1, 2008). Not only is this claim misleading since it ignores the impact of the global economic downturn that began to impact Canada during this same period, but the Canadian Convenience Store Association's own data indicate that the country's convenience retail sector remains quite sound (see below). Claims that the introduction of display bans would seriously harm the convenience retail sector are also undermined by the fact that other Canadian provinces have subsequently introduced their own PoS display bans.

· In February 2009, a study on the state of Canada's convenience retail sector was jointly produced by the Canadian Convenience Store Association, consulting firm PricewaterhouseCoopers, the University of Montreal's École des Hautes Études Commerciales, and Caisse Populaires Desjardins (Canada's largest credit union). [xviii] Overall, the report found that:

 

"Despite major changes in gasoline prices, the laws on the sale of tobacco and the cost of credit card transactions (credit and debit), convenience stores continue to succeed because of innovation, careful management of operations, and the expansion of their range of services."

 

· With regard to challenges facing the industry, the report does stress that tobacco smuggling has reduced the sales and footfall at Canada's convenience stores. However, the report does not link smuggling to the prohibition of PoS displays, nor does the Royal Canadian Mounted Police's 2008 Contraband Tobacco Enforcement Strategy, which instead cites pricing, organised crime, and illegal tobacco production on First Nations' reserves as the primary drivers of the current smuggling problem.[xix] Canadian Convenience Store Association President Dave Bryans has also indicated that PoS displays and smuggling are two fully separate issues, stating:

 

"Convenience stores won't go out of business because they've covered the tobacco walls, they'll go out of business because our regular customers are getting product 10 times cheaper than we can sell it to them.''[xx]

 

· In terms of the number of outlets, the report found that the total number of stores in operation had fallen by an average of 2% per year between 2004 and 2008. This figure translates to approximately one store closing each day over that period, or 7 per week, which is far less than the 23 per week in Ontario alone that had been claimed by the TRA. Moreover, the report was not alarmist about these store closures, instead describing the trend as one of "consolidation" and noting that "compression of profit margins and losses of revenue from tobacco smuggling can account for these closings, but so does the difficulty in finding people to take over from those who wish to sell." Moreover, the store closings may also indicate a change in the nature of Canada's convenience retail sector, with the report finding that the number of convenience stores co-located with gas stations actually grew over the period examined, while the number of standalone stores (i.e. those without gas stations) fell. Nevertheless, despite this shift the report still predicted that total sales at all standalone convenience stores in Canada would rise by 1.5% in fiscal 2008, even given the effects of the economic downturn.

· Given that the province of Saskatchewan introduced Canada's first PoS display ban in 2002, it is very unlikely that Canada's four most populous provinces (Ontario, Quebec, British Columbia and Alberta) would have implemented tobacco display bans in 2008 had Saskatchewan's retailers been negatively affected. Across Canada, 12 of the 13 provinces and territories have now implemented a PoS ban.[xxi]

· There is no systematic evidence demonstrating that convenience stores in Canada have closed following the prohibition of tobacco displays at the PoS. Instead, the convenience retail sector's own documents paint a picture on an industry that is going through transitions, but continuing to thrive. Moreover, arguments about the potential for store closures do not appear to have been accepted by provincial governments throughout Canada. However, the Canadian experience does clearly demonstrate the damaging effects of tobacco smuggling.

 

 

 

---

[i] Evans N, Farkas A, Gilpin EA, et al. Influence of tobacco marketing and exposure to smokers on adolescent susceptibility to smoking. Journal of the National Cancer Institute (1995) 87:1538-1545.

 

[ii] Kaufman NJ, Castrucci BC, Mowery PD, et al. Predictors of change on the smoking uptake continuum among adolescents. Archives of Pediatrics and Adolescent Medicine (2002) 156:581-587.

 

[iii] Pierce JP, Choi WS, Gilpin EA, et al. Tobacco industry promotion of cigarettes and adolescent smoking. Journal of the American Medical Association (1998) 279:511-515.

 

[iv] Jackson C. Cognitive susceptibility to smoking and initiation of smoking during childhood: A longitudinal study. Preventive Medicine (1998) 27:129-134.

 

[v] McNiel AD, Jarvis MJ, Stapleton JA, et al. Prospective study of factors predicting uptake of smoking in adolescents. Journal of Epidemiology and Community Health (1988) 43:72-78.

 

[vi] Kaplan CP, Napoles SA, Stewart SL, Perez-Stable EJ. Smoking acquisition among adolescents and young Latinas: The role of socio-environmental factors. Addictive Behaviour (2001) 26:531-550.

 

[vii] Morello P, Duggan A, Adger H, et al. Tobacco use among high school students in Buenos Aires, Argentina. American Journal of Public Health (2001) 91:2219-224.

 

[viii] Goddard E. Why children start smoking, Office of Population Census and Surveys. HMSO London.

 

[ix] Brown A & Moodie C. Adolescent perceptions of tobacco control measures in the UK. (Submitted to Addiction Research and Theory)

 

[x] Moodie C, MacKintosh A-M, Brown A, & Hastings GB. (2008). The effect of tobacco marketing awareness on youth smoking susceptibility and perceived prevalence, before and after the introduction of a tobacco advertising ban. European Journal of Public Health, 18, 484-490.

 

[xi] Brown A & Moodie C. Adolescent perceptions of tobacco control measures in the UK. (Submitted to Addiction Research and Theory)

 

[xii] Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: A systematic review. Nicotine and Tobacco Research, 11:1: 25-35. 2009.

 

[xiii] Paynter J, et al. Point of sale tobacco displays and smoking amongst 14-15 year olds in New Zealand: cross sectional study. Tobacco Control. Submitted. Presented March 2009 at the World Conference on Tobacco or Health

 

[xiv] Canadian Tobacco Use Monitoring Survey 2000-2007. http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/research-recherche/stat/ctums-esutc_2007-eng.php

 

[xv] The European School Survey Project on Alcohol and Other Drugs (ESPAD). www.espad.org/sa/node.asp?node=730

 

[xvi] Carter OBJ, Mills BW, Donovan RJ. (2009) The effect of retail cigarette pack displays on unplanned purchases: results from immediate post purchase interviews. Tobacco Control, 18, 218-221.

 

[xvii] Choi WS, Ahluwalia JS, Harris KJ, Okuyemi K. (2002) Progression to Established Smoking: The Influences of Tobacco Marketing. American Journal of Preventive Medicine, 22(4):228-32.

[xviii] Canadian Convenience Stores Association. (2009). Local Presence, National Strength - Convenience Stores in Canada: Industry Overview. http://www.conveniencestores.ca/images/stories/PDF/engacsafinal.pdf.

 

[xix] RCMP. 2008 Contraband Tobacco Enforcement Strategy. http://www.rcmp-grc.gc.ca/ce-da/tobacco-tabac-strat-2008-eng.pdf

 

[xx] The Canadian Press. (20 Apr. 2008). Ontario set to ban cigarette display cases.

http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20080420/ont_cigs_080420?s_name=&no_ads

 

[xxi] Ontario Tobacco Research Unit. (2008). Retail Display Of Tobacco Products: Monitoring Update. http://www.otru.org/pdf/14mr/14mr_no1_2.pdf

 

June 2009