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Memorandum by ASH (H 08) 1. Action on Smoking and Health (ASH) is a campaigning health charity set up in 1971 by the Royal College of Physicians to work towards eliminating the harm caused by tobacco. 2. This report, prepared for the Committee: l collates and analyses peer reviewed evidence on tobacco displays at the point of sale (POS) published in 2009 since the completion of the Health Bill Impact Assessment, l contributes previously unpublished data on English retailers and l reviews
evidence from the 3. New studies add to the evidence that manufacturers concentrate prominent POS displays in poor neighbourhoods and near schools, targeting disadvantaged communities. Retailers are largely powerless in the location, scale or nature of displays as these decisions are made by manufacturers. [1] [2] 4. The clear balance of international, peer reviewed research demonstrates that POS displays contribute significantly to youth smoking and undermine smokers' attempts to quit. According to a recently published systematic review by Paynter and Edwards, [3] the consistency of evidence already available in 2008 showed "ample justification exists for banning POS advertising and displays of smoked tobacco products" and the evidence has continued to grow rapidly since. 5. Taken together, these studies do not simply demonstrate a consistent correlation but also show the temporal relationship, causal process and dose response. [4] 6. It is not claimed that POS displays alone cause youth smoking nor that there is a simple "see cigarette - want cigarette - buy cigarette" model for youth smoking. Other factors are important and some may have an even greater effect. For example, Sargent (2009) [5] found that exposure to images of smoking in films has a greater effect in starting to smoke while exposure to POS displays played a greater role in embedding the behaviour. Beliefs about smoking prevalence among peers and the ease of availability of cigarettes are also important. 7. The tobacco industry assertion "that cause-and effect relationships have not been established in any way; that statistical data do not provide the answers; and that much more research is needed" [6] was first advocated, not in relation to the present Health Bill, but over 50 years ago in response to science linking smoking to lung cancer. However, it has been applied consistently since, notably in relation to smokefree places and recently to proposals to end POS displays. 8. A strategy to install Retail Vending Machines, already
successfully deployed in Introduction 9. Seven relevant studies published since January 2009 were
identified using "PubMed", the US National Library of Health on-line database
of research published in medical journals.
An eighth study (Hoek et al.) was revealed through an additional on-line
search. Each of these studies provided
further evidence linking POS displays to smoking behaviours and beliefs and the
authors of 7 of the 8 studies explicitly state that the results support the
case for action to restrict or prohibit such displays. No studies were
identified that disputed a link between POS display and increased smoking
behaviour. In addition ASH has contributed data on the New evidence from the UK and the Ireland 10. ASH
identified tobacco retailers located within a one mile diameter of a low income
neighbourhood in 11. The pattern of coercive contracts for displays reported to
us was similar to that described by John (2009) and by Cohen (2009) (see
paragraphs 22-26 and 32-35) and observed across 12. Manufacturers have used retailers in marketing strategies - as in political campaigns - as a human shield. One retailer told us he would not have such a large display if it were not funded by the tobacco company that provides it and insists that it be kept fully stocked with their product. He reported that meant that he had "£3,000 of dead cash" which he claimed increased the pressure he felt to sell to minors: "You just
want to shift the stock so if a kid comes in late at night 13. In Ireland the industry has had 5 years to prepare for Ireland's prohibition of POS displays which was included in the Public Health (Tobacco) (Amendment) Act 2004. They have used the time to make a considerable investment in RVMs, which are estimated to cost €10,000 each. The Irish Office of Tobacco Control reports that by 2008 68% of retailers were equipped with RVMs. More recent observations suggest that the proportion has risen substantially in advance of the regulations coming into force on July 1, 2009. [9] [10] [11] 14. At least one tobacco manufacturer has advised their Irish retailers that the RVM's advertising panel will be removed by tobacco company personnel prior to July 1st to ensure compliance with the regulations. 15. The installation of RVMs in the 16. The problem of excessive POS displays is of the industry's
own making, as is the solution. In Ireland RVMs are already ubiquitous and
in the Many studies show how POS displays increase smoking 17. Smee (1992) [13] found that lower levels of advertising controls and higher levels of tobacco advertising expenditure are associated with higher levels of tobacco consumption. The findings are not directly relevant to the Health Bill as his analysis applied principally to the relationship between general advertising and population smoking rates rather than POS displays and youth smoking rates. Even though the data he had access to was limited by today's standard he concluded: "In each case the banning of advertising was
followed by a fall in smoking 18. Payntor and Edwards (2009) reviewed the evidence published in the academic press that POS displays influence key smoking related behaviours and beliefs, increase susceptibility to smoking in youth, undermine smokers' quit attempts and promotes relapse among ex-smokers. 19. 'Susceptibility' is a particularly useful measure for calibrating the extent to which young people, who have never smoked, intend to smoke in the future. It builds on intention to smoke, which is known to be a strong predictor of future smoking. For example, the report by Goddard (1990)[14] , based on a cohort of 12-14 year olds, found "intention to smoke" was linked significantly to starting to smoke. 20. Twelve peer reviewed studies were identified, 11 of which found significant relationships between displays and smoking behaviour and beliefs. Seven out of 8 observational studies among children found a statistically significant link between exposure to POS displays and smoking uptake or susceptibility to smoking. Experimental studies with children found links between displays and children's beliefs about the ease of getting tobacco and beliefs about smoking prevalence among their peers (two important factors in experimenting with smoking). One study of adults found that even a picture of a cigarette packet could induce cravings among smokers and another found that displays triggered impulse purchases among 25% of smokers and urges to smoke among one in three ex-smokers. 21. Paynter and Edwards observe that more "prospective" studies are needed but that given "the consistency of the evidence... ample justification exists for banning POS advertising and displays of smoked tobacco products". Tobacco manufacturers use POS displays to target disadvantaged communities 22. In the 23. The research reveals that POS displays had "increased dramatically" following the introduction of restrictions on tobacco advertising. In common with previous studies they found "tobacco companies are targeting
people with the lowest income and education 24. Interviews with retailers revealed that tobacco industry representatives use display contracts and incentive schemes to dictate to retailers. Refusing a display contract means refusing discounts and incentives that would leave them unable to compete with other shops. "It's not an offer. Because of the contract they will tell you how it's going to be... it's a mandatory thing. It has to be the way they want it" "It's almost like it's not my store... I was overwhelmed, she [the tobacco company sales representative] walks in one day and throws some books on my counter and tells me 'I'll tell you what you are going to do.' I said 'Who the hell are you?' She said I'm ... from Philip Morris.' 'OK and what do you want?' She tells me where she's going to put her things and how she is going to arrange things. I tell [her] to 'pick up your s*** and get the f*** out. Leave the s*** alone." The retailer subsequently arranged a contract with a competing manufacturer. 25. The researchers conclude that the nature of these contracts render any voluntary codes ineffective as "It is tobacco companies that tailor tobacco advertisements to the characteristics of the neighbourhood and type of store... retailers are only free to refuse to participate... what the tobacco companies offer owners who are willing to participate is a competitive advantage that is extremely difficult to turn down". 26. The authors conclude that legislation is required to remove tobacco advertising and put tobacco products out of view. POS displays trigger unplanned purchases 27. In Carter's Australian study (2009) [15] 206 adult smokers were interviewed after purchasing cigarettes. One in five purchases (22%) had been unplanned. Unplanned purchases were more common among young smokers. Half of smokers (49%) supported a proposal to ban POS tobacco displays (four times as many as opposed such a law) and one in four (28%) believed that such a law would make it easier to quit. Such smokers commented, "it might help to stop impulse buys" and "whatever helps people quit is worthwhile". 28. The researchers conclude the data are "consistent with previous experimental data that younger people are particularly impressionable with regards to POS tobacco displays" and "provide the clearest evidence yet that POS tobacco displays have a strong influence on unplanned purchases - even if unaccompanied by advertising materials. Policies to remove tobacco displays from line of sight are highly likely to impact on unplanned purchase." POS displays undermine quit attempts 29. Hoek et al (2009) [16] note "industry documents suggest retail marketing is particularly important in a "dark market" [ie advertising is prohibited]". In depth interviews were conducted with 20 adults who had made quit attempts in the previous 6-8 months. The initial perception of most participants was that POS displays had not affected their quit attempts but their detailed accounts suggest otherwise. These include: "Oh yeah, they are right smack in front of you, so you can't miss them" "When I go up to the counter, the first thing that catches your eyes at the back of them [staff] is the cigarette counter...[they] are right in front of you" "I think I would agree with people that say that having them in your face, for those who are trying to give up, [that] it is harder for them." "It's in your face, isn't it. If something is not on display, then it's sending a clear message: Smoking Kills" 30. They report: "Several relapsed smokers noted that easy access to cigarettes had undermined their quit attempts. These comments are consistent with research into nicotine craving, which may be induced by environmental stimuli such as POS displays". They conclude "When combined with existing evidence, our results strengthen public health researchers' calls to ban POS". 31. Although the study is small and conducted in Increasingly prominent displays compromise public health messages 32. MacGregor (2008) found POS displays provided by tobacco
manufacturers to retailers in the 33. In jurisdictions where marketing restrictions have been introduced there has been a paradoxical increase in POS displays. In Ontario Canada Cohen et al examined the prevalence and scale of tobacco displays in 20 cities the year prior to a partial ban on such displays. 34. They found extensive tobacco displays in all cities; in addition tobacco promotions were more common in low income neighbourhoods and in shops near schools. The authors note other studies which found shelf space devoted to brands such as Marlboro and Camel were more common in areas where adolescents frequently shop compared to other shops in the community. This study found similar results with POS promotions at shops located close to an elementary or secondary school. 35. They also report "Additionally there was support for our hypothesis that cities with more comprehensive bylaws would have more promotions, perhaps to offset the social unacceptability of smoking brought by restricting where smoking can occur." Increased
POS displays since the 36. Brown and Moodie (2009)[17]
monitored the impact of the 37. The report analyses three waves of the Youth Tobacco Policy Study (each wave with a sample of over 1,100 young people). They observe "Evidence suggests that tobacco companies target youngsters with positive lifestyle images and covert messages" and found a relationship much more complex than "see cigarette - want cigarette - buy cigarette". Instead, promotional activity gives young people the impression of smoking as a social norm participated in and supported widely across society. Fortunately, "comprehensive tobacco control measures aimed at making non-smoking the norm at the collective level may filter down to the individual level, helping rectify adolescent's misperceptions of smoking prevalence". 38. The study concludes "Our findings affirm the need for a
comprehensive tobacco marketing ban, Young children experience promoting tobacco as promoting smoking 39. Research by Freeman et al (in press)[18] shows that children as young as 7 may begin to form lifestyle associations with smoking before reaching the age typically associated with smoking. Analyses of industry documents suggest that past practices included the intentional targeting of youth to encourage tobacco use and studies have shown exposure to tobacco promotion to be associated with tobacco use initiation by young people. 40. In the past the tobacco industry has been able to target young
people through the use of advertising[19]
and product placement in films made for children. [20]
Today in the 41. This 42. The researchers found: "Any given cigarette advertisement may affect perceptions of the particular brand it is intended to promote as well as general perceptions of the product category... to the extent that brand advertising builds general perceptions of cigarette smoking, then each exposure to a cigarette advertisement has much stronger potential to enhance the absolute attractiveness of smoking as a lifestyle choice". 43. They concluded that these findings suggest that the cumulative
result of exposure to cigarette advertising is a complex network of positive
associations 44. The children had also been asked questions to indicate susceptibility to smoking and this was found to be associated with a greater understanding of advertisements as promoting a particular brand. The researchers concluded "If youths initially tend to understand cigarette advertisements as promoting the product category, then each exposure to an advertisement should have a cumulative influence on their perceptions of the attractiveness of smoking. In general, in other words, initial exposures to cigarette advertising (and the positive portrayals of smoking contained therein) should increase youth's willingness to experiment with cigarette smoking (ie their susceptibility). Then once they become susceptible to smoking youths may begin to attend more readily to brand information. If so, then later exposures to cigarette advertising should affect decisions about which brands to experiment with and smoke regularly. Studies demonstrating a positive association between cigarette ad spending and market shares among adolescents and young adults are consistent with this proposition." 45. This study illustrates the relatively complex way which children's understandings of tobacco promotions develop, first as promoting smoking in general and then later as a brand specifically. How does exposure to POS displays compare with other factors in youth smoking uptake? 46. Sargent (2009) examines the range of factors that influence smoking among young people and highlights the importance of distinguishing between the different stages in smoking, specifically having a first cigarettes and continuing to smoke. Over 4,300 German adolescents aged 11-15 were interviewed and followed up one year later. Several factors were found to predict smoking uptake among those who were "never smokers" at first interview including exposure to images of smoking in films, "sensation seeking", friend, parental and sibling smoking and tobacco marketing. These factors were also found to predict embedding the practice among those who had already smoked. The researchers found that both exposure to smoking in films and tobacco marketing influenced young people both to start and to continue to smoke. 47. However, smoking in films had a considerably greater effect on starting to smoke than POS displays; POS displays had a slightly greater effect on increasing cigarette consumption once they started smoking. The study shows that in order to reduce youth smoking a range of factors needs to be addressed including on screen smoking and POS display with equal intensity.
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Sargent J and Hanewinkel R. Comparing the effects of entertainment media and
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Office of Tobacco [10] National
Tobacco Retail Audit 2008, Office of Tobacco Control [11] Personal communication from Prof Ann McNeill [12] The images can be found at http://www.smokefreeaction.org.uk/rvm.html [13] Smee
C (1992) Effect of Tobacco Advertising on Tobacco Consumption: A discussion
document reviewing the evidence. Department of Health. [14] Goddard E
(1990). Why children start smoking. An enquiry carried out by th Social Survey
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