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Contributors: The research was conceived and supervised by GH, who also provided direction for the paper. LM conducted the initial exploratory research, questionnaire design and piloting, data analysis, and report writing. AMM provided guidance and support for the questionnaire design and data analysis. Susan Anderson managed the fieldforce team and the data collection process. Dr Ray Lowry assisted with the sample generation and ethics approval. GH will act as guarantor.
To examine young people's awareness of and involvement with tobacco marketing and to determine the association, if any, between this and their smoking behaviour.
Cross sectional, quantitative survey, part interview and part self completion, administered in respondents' homes.
North east England.
Stratified random sample of 629 young people aged 15 and 16 years who had “opted in” to research through a postal consent procedure.
There was a high level of awareness of and involvement in tobacco marketing among the 15-16 year olds sampled in the study: around 95% were aware of advertising and all were aware of some method of point of sale marketing. Awareness of and involvement with tobacco marketing were both significantly associated with being a smoker: for example, 30% (55/185) of smokers had received free gifts through coupons in cigarette packs, compared with 11% (21/199) of non-smokers (P<0.001). When other factors known to be linked with teenage smoking were held constant, awareness of coupon schemes, brand stretching, and tobacco marketing in general were all independently associated with current smoking status.
Teenagers are aware of, and are participating in, many forms of tobacco marketing, and both awareness and participation are associated with current smoking status. This suggests that the current voluntary regulations designed to protect young people from smoking are not working, and that statutory regulations are required.
The role of mass media advertising in encouraging smoking is now well established. Econometric studies, which model the effects of advertising expenditure on aggregate consumption, generally show that prevalence increases as the amount of advertising increases and reduces when advertising is banned.1 Consumer studies show that young people who smoke are more likely to appreciate and to be aware of tobacco advertising,2–12 sponsorship,13–15 and merchandising.16–19 Furthermore, cohort studies have shown that awareness and involvement with these forms of marketing predicts future smoking behaviour among young people.20
However, less is known about young people's experiences of other marketing devices, such as point of sale promotion, coupon schemes, brand stretching (the attachment of tobacco brands to non-tobacco products), or the internet. This study presents data from a cross sectional study of young people's experiences with the full range of such devices. While it cannot prove causal effects, it does show the scope and reach of tobacco marketing and provides support for tight and comprehensive regulation.
This is particularly relevant at present, as the detailed provisions of the UK government's primary legislation to ban tobacco advertising and promotion are currently being reviewed.21
The research examined young people's awareness of and involvement with a broad range of tobacco marketing activities. In line with previous studies on tobacco advertising, sponsorship, and merchandising, we expected that young people would be aware of and involved in other forms of tobacco marketing, and that this awareness and involvement would be positively associated with smoking status.
A random sample of 15 year olds, stratified by sex and postcode sector, was drawn from the patient registration database of a health authority in the north of England. Ethics committee approval was granted but required that names and addresses be passed to the researchers only after potential respondents had consented. Initially, therefore, a sample of 2400 was invited to participate in the research, which it was hoped would yield at least 280 smokers. Via their parents, all were sent an information sheet, questionnaire (to establish smoking status), consent form to be countersigned by a guardian, and a freepost return envelope. Two reminders were sent.
A total of 1062 young people consented, a response rate of 48% after redundant addresses were discounted. Other studies have shown that around one in five 15 year olds smoke,22 and in our sample 214 (20%) were regular smokers; 825 (78%) were not regular smokers, and 23 (2%) did not state their smoking status. The consent process provided a more than adequate sample of young people who were not regular smokers so, to minimise costs, we used random numbers to reduce this portion of the sample by 373.
Ultimately 686 names and addresses were allocated to professional interviewers, who were briefed and instructed to make at least four attempts to contact and interview respondents. Interviewers were given no information concerning the smoking status of sample members. Parental permission was again obtained before the interview. Each respondent received a £5 gift voucher.
In all, 629 interviews were successfully completed. The time lapse between the initial sample selection and administering the survey meant that a third of respondents had reached age 16. Two respondents (ages 14 and 17) were excluded from the later analysis. Young women were overrepresented in the sample (table (table1).1).
Extensive exploratory research and qualitative piloting informed the development and refinement of a two part questionnaire. The first part was suitable for a face to face interview; the second sought information on smoking status and was completed by the respondent. Show cards and coded answering procedures were used to enable the young people to respond freely even if parents were present during the interview, as happened in 44% of cases. Analysis showed that parents' presence did not influence response.
The questionnaire examined awareness of and involvement with different types of tobacco marketing (box); smoking status; and other variables known to be related to adolescent smoking (including intentions for future smoking and education; smoking by peers, siblings, and parents; gender; and social class).
We used bivariate analysis, including the χ2 test for trend and Kruskal-Wallis tests, to examine variations, by smoking status, in awareness of and involvement with tobacco marketing. Two logistic regression models were constructed to examine whether or not any association existed between awareness of tobacco marketing and smoking status, independently of other variables known to influence smoking. The first model examined marketing techniques separately; the second assessed their cumulative impact.
Young people are very aware of tobacco marketing. Table Table22 shows “prompted” awareness of different marketing techniques—that is, respondents were asked whether they had come across specific, named types of marketing, such as advertisements in magazines or newspapers or special price offers for cigarettes.
Nearly all had seen cigarette advertising on billboards, and over half had come across it in the press. All had seen some form of advertising at point of sale, and around half were aware of coupon schemes and special price offers for cigarettes.
Other forms of promotion were less familiar. Around a fifth of the sample had come across brand stretching (clothing or other items with cigarette logos on), new pack designs or sizes, free gifts offered on packets, competitions, and famous people smoking in films and on television. There was also awareness, at a lower level, of free gifts from the shopkeeper, promotional mail from cigarette companies, internet sites, and the distribution of free cigarettes.
Young smokers were more aware of virtually all forms of tobacco marketing than were non-smokers or those who had tried smoking (table (table2).2). This trend was particularly noticeable for free gifts, special price offers, promotional mail, and pack design.
Involvement with tobacco marketing was broadly similar for both male and female respondents (table (table3).3). Many had actively participated in tobacco marketing—for example, by using coupon schemes or receiving direct mail. Over half of current smokers had participated in tobacco marketing of one form or another, compared with around a quarter of non-smokers and those who had tried smoking. Almost a third of smokers had received free gifts through coupon schemes, over a quarter had received special price offers for cigarettes and around a tenth had received free gifts at events or had been exposed to promotional mail.
Table Table44 shows the association between awareness of each tobacco marketing technique and current smoking status when other variables that are known to be linked with teenage smoking were controlled for. Awareness of coupon schemes and brand stretching were both associated with the greater probability of being a current smoker, as was having friends, siblings, or a mother who smoked. In this model, having friends who smoke was most strongly associated with being a current smoker.
The number of tobacco marketing techniques of which young people were aware was positively related to current smoking status (table (table5).5). Having friends, siblings, or a mother who smoked was associated with a greater probability of being a current smoker.
Young people aged 15-16 are aware of, and participating in, many forms of tobacco marketing, and this phenomenon is consistently associated with being a smoker. When other factors that are known to be linked with teenage smoking are held constant, awareness of coupon schemes and brand stretching, and tobacco marketing in general, are all independently associated with current smoking.
In some instances this may be explained by the greater exposure that young smokers are likely to have to certain forms of tobacco marketing (package design or price promotions, for example), but not in others (brand stretching and shop advertising). In any case, it is likely that young people, and especially young smokers, are getting some kind of benefit or reassurance from these different forms of tobacco marketing. Previous researchers have drawn a link between this type of reward and the reinforcement of smoking.20
This confirms the need for statutory controls on tobacco marketing; the current voluntary regulations designed to protect young people are clearly not working. It also suggests that the Tobacco Advertising and Promotion Bill should be comprehensive: it should outlaw not just the specific practices of couponing and brand stretching, but all forms of tobacco marketing.
Finally, flexibility is also likely to be important; there is a need to combat the marketing innovations that will undoubtedly emerge as the bill takes effect. The establishment of a Tobacco Regulatory Authority, as proposed by last year's Select Committee report,23 is the obvious way to achieve this.
Tobacco advertising, sponsorship, and merchandising encourage teenage smoking
The effect of other forms of tobacco marketing, such as brand stretching or coupon schemes, is unknown
15-16 year olds are aware of and participate in these other forms of tobacco marketing, and this phenomenon is consistently associated with being a smoker
When other factors known to be linked with teenage smoking are held constant, awareness of coupon schemes, brand stretching, and tobacco marketing in general are all independently associated with current smoking
This suggests that young people, and especially young smokers, are getting some kind of benefit or reward from tobacco marketing
We thank the respondents and acknowledge the support of the fieldforce team and Newcastle and North Tyneside Health Authority.
Funding: This study was largely funded by the Cancer Research Campaign, with additional support from the Department of Health.
Competing interests: None declared.