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A Longitudinal Study of Exposure to Retail Cigarette Advertising
and Smoking Initiation
Lisa Henriksen, PhD, Nina C. Schleicher, PhD, Ellen C. Feighery, RN, MS, and Stephen P.
Fortmann, MD
Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto,
California
Abstract
OBJECTIVES—Accumulating evidence suggests that widespread advertising for cigarettes at
the point of sale encourages adolescents to smoke; however, no longitudinal study of exposure to
retail tobacco advertising and smoking behavior has been reported.
METHODS—A school-based survey included 1681 adolescents (aged 11–14 years) who had
never smoked. One measure of exposure assessed the frequency of visiting types of stores that
contain the most cigarette advertising. A more detailed measure combined data about visiting
stores near school with observations of cigarette advertisements and pack displays in those stores.
Follow-up surveys 12 and 30 months after baseline (retention rate: 81%) documented the
transition from never to ever smoking, even just a puff.
RESULTS—After 12 months, 18% of adolescents initiated smoking, but the incidence was 29%
among students who visited convenience, liquor, or small grocery stores at least twice per week
and 9% among those who reported the lowest visit frequency (less than twice per month).
Adjusting for multiple risk factors, the odds of initiation remained significantly higher (odds ratio:
1.64 [95% confidence interval: 1.06–2.55]) for adolescents who reported moderate visit frequency
(0.5–1.9 visits per week), and the odds of initiation more than doubled for those who visited ≥2
times per week (odds ratio: 2.58 [95% confidence interval: 1.68–3.97]). Similar associations were
observed for the more detailed exposure measure and persisted at 30 months.
CONCLUSIONS—Exposure to retail cigarette advertising is a risk factor for smoking initiation.
Policies and parenting practices that limit adolescents’ exposure to retail cigarette advertising
could improve smoking prevention efforts.
Keywords
adolescence; advertising; cohort studies; smoking
Tobacco use among adolescents has declined since 2000, but 21% of eighth-graders and
45% of high school seniors still report experimenting with smoking.1 Because this behavior
increases the risk for adult smoking,2,3 it is important for pediatricians to be aware of
environmental factors that promote smoking experimentation and initiation in childhood and
adolescence.
Address correspondence to Lisa Henriksen, PhD, Stanford University School of Medicine, Stanford Prevention Research Center, 1070
Arastradero Rd, Suite 353, Palo Alto, CA 94304-1334. lhenriksen@stanford.edu.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
NIH Public Access
Author Manuscript
Pediatrics. Author manuscript; available in PMC 2011 March 1.
Published in final edited form as:
Pediatrics
. 2010 August ; 126(2): 232–238. doi:10.1542/peds.2009-3021.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Point of sale has become the dominant channel for tobacco advertising in the United States,
representing 90% of the tobacco industry’s $12.5 billion marketing budget in 2006.4 The
quantity of cigarette ads in stores has increased over time,5,6 and tobacco companies provide
more ads and shelf space for cigarettes in stores where adolescents shop frequently.7 Not
surprising, 63.7% of US adolescents reported seeing ads for cigarettes all or most of the time
when they visit convenience stores, supermarkets, and gas stations.8
Two population-based surveys of adolescents examined the impact of retail tobacco
marketing on smoking initiation. A US study correlated data from the Monitoring the Future
school surveys with the prevalence of tobacco advertising in convenience stores near the
surveyed schools.9 Higher scores on a measure of retail tobacco advertising were correlated
with higher odds of “puffing” (only), but the study could not determine whether surveyed
adolescents visited any of those stores. A national survey of students (aged 14–15) in New
Zealand observed a graded, cross-sectional relationship between the frequency of visiting
stores that sell cigarettes and the odds of experimenting with smoking10; however, in New
Zealand, tobacco advertising is banned at the point of sale and pack displays are the only
form of retail promotion. Thus, previous studies were cross-sectional, and neither measured
exposure to retail tobacco advertising per se. A longitudinal survey of California adolescents
revealed that perceived exposure to cigarette advertising in stores and to actors who smoke
on television were associated with greater susceptibility to smoking at follow-up,11 but the
study did not examine the unique influence of retail cigarette advertising on smoking
behavior. To address these important gaps in the literature, this study examined whether
exposure to retail cigarette advertising is a risk factor for smoking initiation, by using
longitudinal data from a sample of adolescents for whom cross-sectional findings have been
reported.12,13 A secondary objective was to examine which of 3 exposure measures that
were correlated with trying smoking at baseline predict initiation at follow-up.
METHODS
The Survey of Teen Opinions about Retail Environments (STORE) combined data from a
longitudinal, school-based survey with observations of retail tobacco marketing in Tracy,
California (population 56 929), a Central Valley city with a similar ethnic/racial composition
to the state of California and a higher median household income. Active parental consent
and student assent were obtained by using a protocol that was approved by Stanford
University’s Administrative Panel on Human Subjects. The baseline survey was
administered at all 3 middle schools in grades 6 to 8 (February through April 2003) by using
a procedure described elsewhere (78% participation rate).12 Follow-up surveys were
administered ~12 months after baseline, when students were in grades 7 to 9, and ~30
months after baseline, when students were in grades 9 to 11.
Measures
Two items assessed adolescents’ smoking status at baseline and follow-ups: ever smoking,
even just a puff, and number of days smoked in the past month. The primary outcome was
smoking initiation, defined as the transition from never smoking to ever smoking at either
follow-up. This study did not examine current smoking as a separate outcome because the
incidence of smoking in the previous 30 days was quite low: 4.1% at 12 months and 7.9% at
30 months.
We compared 3 measures of exposure to retail cigarette advertising reported in a previous
cross-sectional study.13 A 3-item measure of shopping frequency asked students to report
how often they visited any convenience stores, small markets, and liquor stores, 3 types of
stores that typically contain the most cigarette advertising.14–16 A more detailed measure
combined information about where and how often students shopped in stores near school
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and assessed the quantity of advertising and shelf space (product facings) for cigarettes in
those stores. Specifically, we multiplied the frequency of visits to each store near school by
the number of cigarette-branded ads, functional items (eg, ash cans, clocks, counter mats),
and product facings in each store and then summed scores for each student to compute
cigarette brand impressions per week. A measure of perceived exposure, adapted from the
National Youth Tobacco Survey, was a single item that asked students to estimate how often
they see cigarette ads when they visit stores.8
Measurements of other baseline characteristics that could confound associations between
exposure to retail cigarette advertising and smoking initiation are described in more detail
elsewhere.12 Briefly, exposure to social influences to smoke was measured by asking about
current smoking by a parent or other household member, the number of 4 best friends who
smoke, and perceived exposure to people who smoke in movies or on television. Other
covariates were risk-taking propensity,17 unsupervised time after school (days per week),
self-reported grades in school, and demographics (gender, grade level, race, and ethnicity).
Analyses
Of the 2110 students who completed a baseline survey, 1681 reported never having tried
smoking, and 1356 of these provided data about smoking behavior at either or both follow-
ups (retention rate: 81%). Attrition analyses compared all covariates for this analysis sample
with the 325 who were lost to follow-up, by using χ2 and t tests.
Tests of the primary hypothesis about exposure to retail cigarette advertising and smoking
initiation used multilevel modeling to account for clustering of students within schools.
Although exposure to retail cigarette advertising varied significantly among schools, the
relationships between exposure and smoking initiation did not vary. In the final models, all
covariates were also treated as fixed effects, and the intercept randomly varied across
schools. Separate multilevel models examined smoking shopping frequency and cigarette
brand impressions per week with smoking initiation at 12-month and 30-month follow-ups.
Because these 2 exposure variables were quite skewed, we compared groups according to
tertiles. All models included perceived exposure as a covariate because it was not highly
correlated with other exposure measures at baseline,13 and a previous study observed
independent associations of perceived exposure and shopping frequency with adolescent
smoking.10 All models also adjusted for demographics, exposure to smoking by parents and
peers, risk-taking behavior, exposure to smoking on television or in movies, self-reported
grades in school, and unsupervised time after school. The last 2 variables were dichotomized
at the median value because the distributions were quite skewed. Race and ethnicity were
treated as separate variables. Race was coded to compare any minority with Hispanic and
non-Hispanic white students because the last 2 groups have the highest smoking rates among
California adolescents. Ethnicity was coded to compare any Hispanic with non-Hispanic
students regardless of race.
RESULTS
Attrition was ~30% between each assessment and was consistent across grades. No greater
attrition occurred during the transition to high school. The baseline never smokers who were
lost to follow-up were more likely than the analysis sample to be boys (56.0% vs 44.2%; P
< .001), to live with a smoker (47.2% vs 38.0%; P < .01), to earn mostly Bs or lower (58.3%
vs 38.8%; P < .001), and to score higher on risk-taking behavior (2.6 vs 2.4; P < .001).
Students who were lost to follow-up did not differ from the analysis sample on shopping
frequency (P = .27); however, students who were lost to follow-up were more likely than the
analysis sample to rank in the highest tertile of cigarette brand impressions per week (42.8%
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vs 31.1%; P < .001). No differences between the 2 groups were observed for other
covariates, including exposure to peer smoking and unsupervised time after school.
The analysis sample (aged 11–14 at baseline) included slightly more girls than boys (Table
1). The sample was both racially and ethnically diverse: 5.3% black, 14.9% Asian/Pacific
Islander, 23.0% multiracial, 53.4% white, and 3.5% other or unknown; 40.2% were
Hispanic.
At baseline, adolescents who had never smoked reported visiting convenience stores, liquor
stores, or small markets an average of 2.1 times per week (SD:2.8; maximum:18.0). Visits to
stores near school yielded an average of 325 cigarette brand impressions per week (SD: 501;
maximum: 5987). These cues were noticeable to never smokers: 82.1% of the sample
reported seeing cigarette ads in stores sometimes or often. As shown in Table 1, shopping
frequency was positively correlated with other measures of exposure to retail cigarette
advertising and with several risk factors for smoking initiation. Shopping frequency was
unrelated to gender, age (grade level), being a racial minority, and having at least 1 friend
who smokes.
The incidence of smoking initiation was 18% after 12 months and 27% after 30 months. The
unadjusted associations between store visits at baseline and the probability of smoking at 12-
and 30-month follow-ups illustrate a graded relationship (Fig 1). A significant quadratic
term indicates an accelerated probability of smoking with more frequent store visits. Table 2
summarizes the odds ratios and confidence intervals from the multilevel model, adjusted for
all covariates in the table. Compared with students who reported the lowest shopping
frequency (fewer than 0.5 visits per week), the odds of initiation after 12 months increased
64% for students who reported moderate visits (0.6–1.9 visits per week) and more than
doubled for those who reported ≥2 visits per week (see Table 2). This association persisted
at the 30-month follow-up: the odds of smoking increased 19% for moderate visits and 42%
for the most frequent visits. Although Hispanic adolescents were more likely than others to
report trying smoking at the 12-month follow-up, there was no significant interaction of
ethnicity with shopping frequency on smoking initiation (data not shown).
Perceived exposure predicted a small but significant increase in the odds of initiating, but
only at the 30-month follow-up (see Table 2). Tests of an interaction examined whether the
impact of shopping frequency on smoking initiation was greater for students who perceived
more exposure to cigarette ads in stores, but it was not significant (data not shown).
The most detailed measure of exposure, cigarette brand impressions per week, predicted
similar increases in the odds of smoking initiation at both follow-ups. After 12 months, the
odds of smoking were 2.36 times greater for students who ranked in the highest category of
exposure (≥260 brand impressions per week) than for students who ranked in the lowest
category of exposure(<60brandimpressionsper week); after 30 months, the odds of smoking
were 58% greater (Table 3). The difference between moderate and low tertiles of cigarette
brand impressions was not significant at either time point.
DISCUSSION
This is the first longitudinal study to provide evidence that adolescents’ exposure to
widespread cigarette advertising at the point of sale is a risk factor for smoking initiation.
Two measures of exposure were developed by (1) assessing self-reported frequency of visits
to the types of stores that contain the most cigarette advertising and (2) eliciting information
about where and how often adolescents shopped near school and observing the quantity of
ads and pack facings in those stores. Adjusting for multiple other risk factors, both measures
predicted significant increases in the odds of initiating smoking among adolescents who had
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never smoked at baseline. A graded relationship was also observed: the more store visits
adolescents reported at baseline, the greater their chances of initiating smoking at follow-up.
Contrary to expectation, the most detailed exposure measure, cigarette brand impressions
per week, was not a substantially better predictor of smoking initiation than the 3-item
measure of shopping frequency. Because the combination of in-store observations with
student survey data are costly and impractical for population-based surveys, we recommend
shopping frequency as an appropriate and useful indicator of exposure to retail tobacco
advertising.13 An alternative is to infer exposure from geographic area measures, such as the
density of stores that sell cigarettes in specified neighborhoods or the quantity of cigarette
ads that those stores contain. Imputing environmental data to individuals assumes that
exposure is constant for individuals in the same area, but this study observed substantial
individual differences in adolescents’ exposure to retail cigarette advertising within school
neighborhoods. This does not invalidate area measures of exposure but indicates that such
predictors will have limited power.
Perceived exposure (noticing cigarette ads) was not as strong a predictor of smoking
initiation as the other measures of exposure. This result is consistent with our cross-sectional
report and our conclusion that perceived exposure measures a different underlying construct.
13 Additional research is needed to examine whether perceived exposure measures a
cognitive bias for cigarette advertising and whether it predicts other aspects of adolescent
smoking. Such inquiry is important because perceived exposure is typically the only item
about the retail environment that appears on state and national surveys about adolescent
smoking.
Strengths of this study are its longitudinal design, the inclusion of multiple measures of
exposure to retail cigarette advertising, and the assessment of behavioral outcomes at 2
follow-ups. Surveying students in a single California community is the primary weakness of
this study and limits the ability to generalize findings to other adolescents and stores;
however, it seems unlikely that adolescents’ exposure to retail tobacco advertising and its
relationship with smoking behavior would be different for adolescents who live in other
areas where cigarette packs and advertising are displayed prominently at the point of sale.
California has the longest running anti-tobacco media campaign in the United States but
does not advertise anti-tobacco messages at the point of sale. Exposure to anti-tobacco
education in the media and in school might make California adolescents more resistant than
others to retail cigarette advertising, but that would make it more difficult to detect its effect
on smoking behavior in this sample.
The response and retention rates in this study are comparable to other school-based surveys
that use active parental consent18,19; however, students who were lost to follow-up reported
more frequent exposure to retail cigarette advertising at baseline. Consequently, this study
may underestimate its impact on smoking behavior at follow-up. By focusing exclusively on
exposure measured at baseline, this study cannot assess the impact of cumulative exposure
to retail cigarette advertising on smoking.
Previous research has shown that adolescents’ exposure to pack displays alone, in the
absence of cigarette advertising at the point of sale, is associated with increased intentions to
smoke.10,20 This study cannot disentangle the relative importance of advertising and pack
displays in encouraging youth smoking.
Shopping frequency may be a proxy for access to cigarettes or for other unmeasured
confounders; however, this study controlled for a large number of potential confounders,
including unsupervised time and risk-taking propensity. It is highly plausible that retail
cigarette advertising would influence smoking initiation because it is ubiquitous at the point
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of sale and salient to adolescents. Thus, it seems unlikely that an unmeasured risk factor
confounded our results. Moreover, because randomized trials of the influence of retail
cigarette advertising are not possible, longitudinal studies such as this one provide the
strongest guidance available to establish relevant policies.
In 2009, the Family Smoking Prevention and Tobacco Control Act granted the Food and
Drug Administration (FDA) authority to regulate the manufacturing, marketing, and sale of
tobacco products.21 Three provisions that could reduce the impact of pro-smoking cues at
the point of sale are restricting tobacco advertising to black-and-white, text-only
(“tombstone”) format, eliminating misleading terms such as “light” and “mild,” and
mandating stronger warning labels on advertising and packaging. Even with expanded
authority, the FDA’s restrictions must be consistent with the first amendment, a requirement
that tobacco companies are contesting in court.22 Indeed, a previous FDA ruling mandating
tombstone advertisements did not survivejudicialreview.23 Results of this study provide
empirical evidence for the argument that restricting advertising at the point of sale could
reduce adolescent smoking.
CONCLUSIONS
A growing body of evidence suggests that stores that are saturated with cigarette advertising
and product displays constitute a significant public health concern, particularly for youth.24
Results from this longitudinal study complement and extend previous findings from cross-
sectional surveys9,10 and experiments.20,25 Additional longitudinal studies are needed to
assess the impact of retail cigarette advertising on other behavioral outcomes, such as
established smoking and brand choice.26
The steady decline in smoking rates among US adolescents that has been observed since
2000 is unlikely to continue without addressing the proliferation of cigarette advertising at
the point of sale. Both US and international agencies identify regulations of retail
advertising and promotions as a priority for tobacco control.27,28 Smoking initiation by
children and adolescents remains significant, and health professionals need to maintain their
vigilance. Until and unless public health efforts to curtail tobacco advertising and promotion
further in retail settings succeed, those who care for adolescent patients should warn them
and their parents about the potential effects of exposure to such advertising. Widespread
adoption is needed for current clinical guidelines that call for medical care providers to
assess smoking status and provide support for cessation. Pediatricians and other health care
practitioners could also advocate for anti-tobacco education that addresses retail promotion.
Acknowledgments
This research was funded by the National Cancer Institute grant R01-CA67850.
ABBREVIATION
FDA Food and Drug Administration
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FIGURE 1.
Predicted probability of smoking initiation at follow-up on the basis of shopping frequency
(visits per week) measured at baseline.
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TABLE 1
Characteristics of Never Smokers at Baseline and Association With Exposure to Retail Tobacco Marketing
Characteristics at Baseline nValue Shopping Frequency, visits/wk P
Low Moderate High
Grade level, % 1356 .120
6 504 37.2 33.0 38.5 40.2
7 410 30.2 32.5 27.7 30.5
8 442 32.6 34.5 33.8 29.4
Male gender, % 1354 44.2 42.2 43.4 46.8 .355
Hispanic ethnicity, % 1342 40.2 30.6 38.5 51.1 <.001
Racial minority 1351 46.0 46.4 48.2 43.2 .317
Self-reported grades (mostly Bs or below), % 1351 38.8 31.3 37.9 46.9 <.001
Unsupervised after school (>2 d/wk), % 1342 50.2 42.3 55.0 53.8 <.001
Risk-taking propensity (4 = max), mean ± SD 1355 2.4 ± 0.9 2.3 ± 0.9 2.5 ± 0.8 2.6 ± 1.0 <.001
At least 1 parent/household smoker, % 1353 38.0 27.3 39.7 47.1 <.001
At least 1 friend smokes, % 1354 9.7 8.2 9.2 11.7 .180
Perceived exposure, mean ± SD
See smoking in movies/television (4 = often) 1352 2.8 ± 0.9 2.6 ± 0.9 2.9 ± 0.9 2.3 ± 1.0 <.001
See cigarette ads in stores (4 = often) 1354 3.2 ± 0.8 3.1 ± 0.8 3.3 ± 0.8 3.4 ± 0.8 <.001
Cigarette brand impressions/wk, mean ± SD 1354 324.7 ± 501.2 113.9 ± 266.8 226.9 ± 304.9 633.4 ± 663.6 <.001
P values derived from χ2 or analysis of variance. All proportions are column percentages unless otherwise noted. For example, 33% of students who reported low shopping frequency were sixth-graders.
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TABLE 2
Predictors of Smoking Initiation After 12 and 30 Months
Baseline Characteristics Smoking at 12 mo (n = 1182), OR (95%
CI) Smoking at 30 mo (n = 895), OR (95% CI)
Constant 0.02 (0.01–0.06) 0.03 (0.02–0.04)
Grade level
6 1.00 1.00
7 0.88 (0.58–1.32) 1.41 (1.19–1.67)
8 1.44 (0.99–2.10) 1.26 (1.07–1.49)
Male gender 0.94 (0.68–1.30) 0.86 (0.75–0.99)
Ethnicity (Hispanic vs all others) 1.59 (1.15–2.22) 1.43 (1.25–1.65)
Racial minority (any vs all others) 1.01 (0.73–1.40) 0.88 (0.77–1.01)
Self-reported grades (mostly Bs or below) 1.51 (1.10–2.09) 1.61 (1.40–1.86)
Unsupervised after school (>2 d/wk) 1.36 (0.98–1.88) 0.83 (0.73–0.96)
Risk-taking propensity (1–4) 1.51 (1.25–1.81) 1.41 (1.30–1.53)
At least 1 parent/household smoker 1.54 (1.12–2.12) 1.25 (1.09–1.44)
At least 1 friend smokes 1.67 (1.06–2.64) 1.91 (1.56–2.36)
Perceived exposure
See smoking in movies/television (4 = often) 1.10 (0.91–1.31) 1.26 (1.17–1.36)
See cigarette ads in stores (4 = often) 0.90 (0.74–1.10) 1.11 (1.02–1.22)
Shopping frequency (visits/wk)
Low (<0.5) 1.00 1.00
Moderate (0.5–1.9) 1.64 (1.06–2.55) 1.19 (1.00–1.41)
High (2.0–18.0) 2.58 (1.68–3.97) 1.42 (1.19–1.69)
Odds ratios (ORs) are adjusted for all other variables in the table. CI indicates confidence interval.
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TABLE 3
Cigarette Brand Impressions as Predictor of Smoking Initiation After 12 and 30 Months
Baseline Characteristics Smoking at 12 mo (n = 1182), OR (95%
CI) Smoking at 30 mo (n = 895), OR (95% CI)
Constant 0.03 (0.01–0.07) 0.03 (0.01–0.09)
Grade level
6 1.00 1.00
7 0.88 (0.58–1.32) 1.39 (0.94–2.07)
8 1.52 (1.04–2.22) 1.26 (0.85–1.86)
Male gender 0.94 (0.68–1.30) 0.87 (0.62–1.20)
Ethnicity (Hispanic vs all others) 1.56 (1.12–2.17) 1.38 (0.99–1.93)
Racial minority (any vs all others) 1.01 (0.73–1.39) 0.88 (0.63–1.22)
Self-reported grades (mostly Bs or below) 1.55 (1.13–2.14) 1.61 (1.15–2.25)
Unsupervised after school (>2 d/wk) 1.31 (0.95–1.82) 0.82 (0.59–1.13)
Risk-taking propensity (1–4) 1.50 (1.25–1.80) 1.40 (1.16–1.70)
At least 1 parent/household smoker 1.61 (1.17–2.21) 1.27 (0.91–1.76)
At least 1 friend smokes 1.61 (1.02–2.54) 1.88 (1.15–3.06)
Perceived exposure
See smoking in movies/television (4 = often) 1.08 (0.90–1.30) 1.26 (1.05–1.51)
See cigarette ads in stores (4 = often) 0.90 (0.73–1.10) 1.10 (0.89–1.36)
Cigarette brand impressions per week
Low (<60) 1.00 1.00
Moderate (60–259) 1.22 (0.79–1.89) 1.20 (0.81–1.79)
High (≥260) 2.36 (1.55–3.61) 1.58 (1.05–2.37)
Odds ratios (ORs) are adjusted for all other variables in the table. CI indicates confidence interval.
Pediatrics. Author manuscript; available in PMC 2011 March 1.
