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1.  “Their Packaging Has Always Been Like a Power”: A Qualitative Study of U.S. Smokers’ Perceptions of Cigarette Pack Visual Design Features to Inform Product Regulation 
Cigarette packaging matters to consumer behavior. However, it is less clear which changes to packaging design would be salient for adult smokers. Such information is critically important to regulators in the United States who are charged with reviewing new tobacco products for their impact on population health. In this qualitative study, U.S. adult smokers (n = 33) participated in six telephone-based focus groups in March 2017. Separate groups were comprised of lesbian, gay, and bisexual (LGB) participants; participants with less than four years of post-secondary education; a mix of LGB and straight participants; and, the general population. All groups were purposely selected for diversity. Open thematic coding identified salient design elements used on cigarette packaging. Smokers articulated design elements’ use, meaning, and links with consumer behaviors. Three themes were identified: (1) the power of color, (2) supporting color with other design elements (e.g., logos/images, typography, the pack itself), and (3) the combined product brand experience of multiple design elements. Participants linked design elements to product characteristics and to consumer behavior (e.g., purchase). As the Food and Drug Administration is charged with regulating tobacco products, these findings suggest the importance of considering the cigarette pack part of the characteristics of a product.
PMCID: PMC5664735  PMID: 29039769
marketing; product packaging; smoking; United States Food and Drug Administration; tobacco products
2.  Raising the Legal Age of Tobacco Sales 
IOM has called for an increase in the minimum age of tobacco product sales. It is not clear what age increase would garner the greatest public support, or whether trust in the U.S. government predicts policy support.
The data for these analyses are from a nationally representative telephone sample of U.S. adults (N=4,880) conducted from September 2014 to May 2015. The authors assessed whether support varied by the proposed minimum age of tobacco sales using a survey experiment (i.e., random assignment to the 19-, 20-, or 21-year age minimum condition), and, in cross-sectional analyses, whether smoking status, individual demographics, state-level politics, and general trust in the government predicted policy support. Analyses were conducted from May to December 2015.
Odds of support for raising the minimum sales age to 21 years trended higher than support for raising to age 20 or 19 years (AOR=1.22, 95% CI=0.97, 1.53, p=0.09). There was majority support for raising the age of sales for cigarettes in all regions of the U.S. (66.3%, 95% CI=64.0, 68.6). Race, age, and trust in government were significant predictors of support.
Raising the age of tobacco sales is broadly supported by the public. An age 21 years tobacco sales policy trends toward garnering more support than a policy at age 19 or 20 years. Trust in government may be an important consideration in understanding policy support beyond demographics.
PMCID: PMC5116423  PMID: 27263054
3.  Identification of Vape Shops in Two North Carolina Counties: An Approach for States without Retailer Licensing 
Stores that sell electronic nicotine delivery systems (ENDS) as their primary product are a new phenomenon and often termed “vape shops”. While vape shops are now regulated by state and federal agencies, not all states maintain lists of vape shops in operation. Standard ways of identifying tobacco retailers through off-premise alcohol permits and business listing services may not identify vape shops. We used four online business listing services (i.e., Google Maps, ReferenceUSA,, Yelp) to identify vape shops in two counties in North Carolina (NC). In one county, we also assessed four vaping web sites. We drove primary and secondary roads to physically validate the identified stores and attempt to identify stores not listed online. To assess the accuracy of the online searches, we calculated sensitivity and positive predictive values (PPVs). This research was conducted in spring and summer 2016 and identified 28 vape shops online. We confirmed 16 vape shops (seven in Pitt County, NC, USA, and nine in Durham County, NC, USA). Online searches ranged in sensitivity, 62.5%–81.3%, and PPVs ranged from 73.3% to 92.3%. Because of the range of sensitivity found among the business listing services, state policymakers should consider uniform licensing requirements for vape and tobacco retailers to more easily track retailers and ensure compliance with regulations.
PMCID: PMC5129260  PMID: 27801793
tobacco products; commerce; retailers; vaping; e-cigarette
4.  Limited indications of tax stamp discordance and counterfeiting on cigarette packs purchased in tobacco retailers, 97 counties, USA, 2012 
Preventive Medicine Reports  2017;8:148-152.
Increasing the per-unit cost of tobacco products is one of the strongest interventions for tobacco control. In jurisdictions with higher taxes in the U.S., however, cigarette pack litter studies show a substantial proportion of littered packs lack the appropriate tax stamp. More limited but still present counterfeiting also exists. We sought to examine the role of tobacco retailers as a source for untaxed and counterfeit products. Data collectors purchased Newport Green (menthol) or Marlboro Red cigarette packs in a national probability-based sample of tobacco retailers (in 97 counties) from June–October 2012. They made no effort to buy counterfeit or untaxed cigarettes. In this cross-sectional study, we assessed the presence, tax authority, and type (low-tech thermal vs. encrypted) of cigarette pack tax stamps; concordance of tax stamps with where the pack was purchased; and, for Marlboro cigarettes, publicly available visible indicators of counterfeiting. We purchased 2147 packs of which 2033 had tax stamps. Packs missing stamps were in states that do not require them. We found very limited discordance between store location and tax stamp(s) (< 1%). However, a substantial minority of cigarette packs had damaged tax stamps (13%). This occurred entirely with low-tech tax stamps and was not identified with encrypted tax stamps. We found no clear evidence of counterfeit products. Almost all tax stamps matched the location of purchase. Litter studies may be picking up legal tax avoidance instead of illegal tax evasion or, alternatively, purchase of illicit products requires special request by the purchaser.
•This study purchased 2147 cigarette packs in 97 U.S. counties.•No clear indicators of cigarette counterfeiting were found.•Virtually all packs had the correct tax stamp affixed.•Inspection protocols for illicit cigarettes should consider real-world behaviors.
PMCID: PMC5635242
Taxes; Smoking; Tobacco products; Government regulation; Government
5.  Inequities in tobacco retailer sales to minors by neighborhood racial/ethnic composition, poverty, and segregation, USA, 2015 
Tobacco control  2016;25(E2):e142-e145.
Tobacco retailers are an important source of tobacco products for minors. Previous research shows racial discrimination in sales to minors, but no national study has examined neighborhood correlates of retailer underage sales.
We accessed publicly available results of 2015 FDA inspections of tobacco retailers (n=108,614). In this cross-sectional study, we used multilevel logistic regression to predict the likelihood of retailer sale to a minor based on tract characteristics. We assessed the proportion of residents identifying as American Indian, Asian, Black, Latino, and White; isolation index scores for each racial/ethnic group; the proportion of people less than age 65 living in poverty; and, the proportion of residents age 10–17 in relation to retailer inspection results.
The proportion of American Indian residents, Black residents, Latino residents, and residents less than age 65 under the poverty line in a neighborhood are independently, positively associated with the likelihood that a retailer in that neighborhood will fail an underage buy inspection. The proportion of White residents and residents age 10–17 are independently, negatively associated with the likelihood of sale of tobacco products to a minor. Isolation index scores show a similar pattern. In multivariable models holding neighborhood characteristics constant, higher proportions of Black (+), Latino (+), and age 10–17 (−) residents remained significant predictors of the likelihood of underage sale.
Regulatory agencies should consider oversampling retailers in areas with higher likelihood of sales to minors for inspection. Interventions with tobacco retailers to reduce inequities in youth access should be implemented.
PMCID: PMC5177468  PMID: 27609780
disparities; neighborhoods; youth access; Food and Drug Administration; compliance
6.  A National Study of Social Media, Television, Radio, and Internet Usage of Adults by Sexual Orientation and Smoking Status: Implications for Campaign Design 
Background: Smoking rates among lesbian, gay, and bisexual (LGB) people significantly exceed that of heterosexuals. Media interventions are an important part of tobacco control efforts, but limited information is available on LGB people’s media use. Methods: A nationally representative sample of 12,900 U.S. adults completed an online questionnaire assessing media use, smoking status, and demographic information. Multivariable logistic regression was used to assess relationships between media use with sexual orientation and smoking status. Results: A total of 590 (4.6%) respondents identified as LGB, of which 29% were smokers. Regardless of sexual orientation and smoking status, the Internet was the most popular media channel used, followed by television and radio. LGB respondents had significantly greater odds of having accounts on social media websites, accessing Facebook daily, and being a frequent Internet user, compared to heterosexual respondents. Similar media use was found between smokers and non-smokers, but smokers had greater odds of being frequent television viewers and frequent Internet users, compared to non-smokers. Conclusions: Compared to heterosexuals, LGB respondents reported greater use of the Internet, especially social media. Media campaigns targeting LGB populations can maximize reach by utilizing social media alongside traditional media channels.
PMCID: PMC5409650  PMID: 28430161
smoking; LGBT; media
7.  Is There a Relationship Between the Concentration of Same-Sex Couples and Tobacco Retailer Density? 
Nicotine & Tobacco Research  2015;18(2):147-155.
Tobacco use is markedly higher among lesbian, gay, and bisexual populations than heterosexuals. Higher density of tobacco retailers is found in neighborhoods with lower income and more racial/ethnic minorities. Same-sex couples tend to live in similar neighborhoods, but the association of this demographic with tobacco retailer density has not been examined.
For a national sample of 97 US counties, we calculated the number of tobacco retailers per 1000 persons and rates of same-sex couples per 1000 households in each census tract (n = 17 941). Using spatial regression, we examined the association of these variables in sex-stratified models, including neighborhood demographics and other environmental characteristics to examine confounding.
Results from spatial regression show that higher rates of both female and male same-sex couples were associated with a higher density of tobacco retailers. However the magnitude of this association was small. For female couples, the association was not significant after controlling for area-level characteristics, such as percent black, percent Hispanic, median household income, the presence of interstate highways, and urbanicity, which are neighborhood correlates of higher tobacco retailer density. For male couples, the association persisted after control for these characteristics.
Same-sex couples reside in areas with higher tobacco retailer density, and for men, this association was not explained by neighborhood confounders, such as racial/ethnic composition and income. While lesbian, gay, and bisexual disparities in tobacco use may be influenced by neighborhood environment, the magnitude of the association suggests other explanations of these disparities remain important areas of research.
PMCID: PMC4723672  PMID: 25744959
8.  Health Inequities among Lesbian, Gay, and Bisexual Adults in North Carolina, 2011–2014 
Inequalities in health have been identified for lesbian, gay, and bisexual (LGB) populations nationally. Policies in the U.S. South offer fewer protections for LGB people than in other regions, yet, limited data exist for this region. North Carolina (NC) BRFSS data from 2011 to 2014 were combined (LGB n = 604; heterosexual n = 33,170) and analyzed using SAS survey procedures to estimate health characteristics by sexual orientation within gender. Many examined indicators were not different by sexual orientation, however, other results were significant and consistent with findings from state population surveys in other regions of the country. Both genders showed inequities in mental health, having over twice the odds of five or more poor mental health days in the past month and of having ever been diagnosed with a depressive disorder. Sexual minority women had higher odds compared with heterosexual women for ever having smoked cigarettes, current smoking, exposure to secondhand smoke both in the workplace and at home, and both alcohol risk factors, binge and heavy drinking. Being part of the LGB population in NC is associated with worse health. The implementation of anti-LGB policies in the NC warrants ongoing monitoring of LGB health inequities in NC and in other southeastern states for potential effects on the health and well-being of sexual minorities.
PMCID: PMC5580539  PMID: 28757566
homosexuality; Behavioral Risk Factor Surveillance System; public health surveillance; North Carolina; sexual minority; health status disparities
9.  An Experiment Assessing Punitive versus Wellness Framing of a Tobacco-Free Campus Policy on Students’ Perceived Level of University Support 
The objective of this study was to examine how different ways of describing a hypothetical tobacco-free campus policy would impact college students’ perceived level of support from the college. In the spring of 2016, we randomized 1885 undergraduate students in a required course to three message conditions in an online survey: control (no message), wellness (emphasizing promoting health and quitting support), and punitive (emphasizing consequences for violating the policy). The dependent variable was perceived organizational support. We selected items previously shown to be relevant for college students (alpha = 0.92 in our data). Given significant non-normality, we used non-parametric Kruskal-Wallis tests with pairwise comparisons to examine differences in perceived organizational support across the three conditions. We examined results by smoking status and if the participant correctly reported the message they received. We found no significant difference in perceived organizational support among students exposed to different tobacco-free campus policy announcements (p = 0.75). We also found no significant difference among smokers (p = 0.66). However, among smokers who correctly reported the message they received, we found significantly lower perceived university support (p = 0.01). Messages about tobacco-free campus policies should focus on the role of policy in supporting a healthy environment instead of punitive enforcement. Campus administrators should use caution when using message frames focusing on consequences of violating newly adopted policies.
PMCID: PMC5580640  PMID: 28825650
universities; health policy; communication; smoke-free; organizational support
10.  A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing 
American journal of public health  2015;105(9):e8-e18.
Tobacco industry documents show systematic targeting by race, ethnicity, and income at the point of sale (POS). We sought to systematically review evidence of disparities in tobacco marketing at tobacco retailers by socio-demographic neighborhood characteristics.
We identified 43 relevant papers from 893 results of a systematic search in 10 databases updated on May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity). We conducted a narrative review and present results stratified by neighborhood characteristics and types of tobacco product marketing.
There are disparities in the marketing of tobacco products by neighborhood demographics. Socioeconomic disadvantage is associated with more tobacco marketing. Disparities in menthol marketing are starkly present, with targeting toward more urban neighborhoods and neighborhoods with more black residents. Smokeless tobacco products are targeted toward more rural neighborhoods and neighborhoods with more white residents. Differences in store type partially explain these disparities.
Geodemographic market targeting, a standard marketing practice across industries, represents an issue of social and environmental injustice for youth exposure to tobacco marketing and for smokers whose quit attempts may be stymied by disproportionate marketing in lower-income neighborhoods and neighborhoods with more black residents.
PMCID: PMC4529779  PMID: 26180986
tobacco industry; smoking; reproducibility of results; environments; health status disparities; marketing
11.  Neighborhood Inequalities in Retailers’ Compliance With the Family Smoking Prevention and Tobacco Control Act of 2009, January 2014–July 2014 
Retailer noncompliance with limited US tobacco regulations on advertising and labeling was historically patterned by neighborhood in ways that promote health disparities. In 2010, the US Food and Drug Administration (FDA) began enforcing stronger tobacco retailer regulations under the Family Smoking Prevention and Tobacco Control Act of 2009. However, recent research has found no differences in compliance by neighborhood characteristics for FDA advertising and labeling inspections. We sought to investigate the neighborhood characteristics associated with retailer noncompliance with specific FDA advertising and labeling inspections (ie, violations of bans on self-service displays, selling single cigarettes, false or mislabeled products, vending machines, flavored cigarettes, and free samples).
We coded FDA advertising and labeling warning letters (n = 718) for type of violations and geocoded advertising and labeling inspections from January 1 through July 31, 2014 (N = 33,543). Using multilevel models, we examined cross-sectional associations between types of violations and neighborhood characteristics previously associated with disparities (ie, percentage black, Latino, under the poverty line, and younger than 18 years).
Retailer advertising and labeling violations are patterned by who lives in the neighborhood; regulated tobacco products are more likely to be stored behind the counter as the percentage of black or Latino residents increases, and single cigarettes are more often available for purchase in neighborhoods as the percentage of black, poor, or young residents increases.
Contrary to previous null findings, noncompliance with FDA advertising and labeling regulations is patterned by neighborhood characteristics, sometimes in opposite directions. Given the low likelihood of self-service violations in the same neighborhoods that have high likelihood of single cigarette sales, we suggest targeted approaches to FDA retailer inspections and education campaigns.
PMCID: PMC4599057  PMID: 26447548
12.  Identifying Lesbian, Gay, Bisexual, and Transgender Search Terminology: A Systematic Review of Health Systematic Reviews 
PLoS ONE  2016;11(5):e0156210.
Research on the health of lesbian, gay, bisexual, and transgender (LGBT) populations can provide important information to address existing health inequalities. Finding existing research in LGBT health can prove challenging due to the plethora of terminology used. We sought to describe existing search strategies and to identify more comprehensive LGBT search terminology. We iteratively created a search string to identify systematic reviews and meta-analyses about LGBT health and implemented it in Embase, PubMed/MEDLINE, and PsycINFO databases on May 28–29, 2015. We hand-searched the journal LGBT Health. Inclusion criteria were: systematic reviews and meta-analyses that addressed LGBT health, used systematic searching, and used independent coders for inclusion. The published search terminology in each record and search strings provided by authors on request were cross-referenced with our original search to identify additional terminology. Our search process identified 19 systematic reviews meeting inclusion criteria. The number of search terms used to identify LGBT-related records ranged from 1 to 31. From the included studies, we identified 46 new search terms related to LGBT health. We removed five search terms as inappropriate and added five search terms used in the field. The resulting search string included 82 terms. There is room to improve the quality of searching and reporting in LGBT health systematic reviews. Future work should attempt to enhance the positive predictive value of LGBT health searches. Our findings can assist LGBT health reviewers in capturing the diversity of LGBT terminology when searching.
PMCID: PMC4878791  PMID: 27219460
13.  Up in Smoke: Vanishing Evidence of Tobacco Disparities in the Institute of Medicine's Report on Sexual and Gender Minority Health 
American journal of public health  2012;102(11):2041-2043.
The Institute of Medicine (IOM) released a groundbreaking report on lesbian, gay, bisexual, and transgender (LGBT) health in 2011, finding limited evidence of tobacco disparities. We examined IOM search terms and used 2 systematic reviews to identify 71 articles on LGBT tobacco use. The IOM omitted standard tobacco-related search terms. The report also omitted references to studies on LGBT tobacco use (n = 56), some with rigorous designs. The IOM report may underestimate LGBT tobacco use compared with general population use.
PMCID: PMC3477969  PMID: 22994185
14.  Single Cigarette Sales: State Differences in FDA Advertising and Labeling Violations, 2014, United States 
Nicotine & Tobacco Research  2015;18(2):221-226.
Single cigarettes, which are sold without warning labels and often evade taxes, can serve as a gateway for youth smoking. The Family Smoking Prevention and Tobacco Control Act of 2009 gives the US Food and Drug Administration (FDA) authority to regulate the manufacture, distribution, and marketing of tobacco products, including prohibiting the sale of single cigarettes. To enforce these regulations, the FDA conducted over 335 661 inspections between 2010 and September 30, 2014, and allocated over $115 million toward state inspections contracts.
To examine differences in single cigarette violations across states and determine if likely correlates of single cigarette sales predict single cigarette violations at the state level.
Cross-sectional study of publicly available FDA warning letters from January 1 to July 31, 2014.
All 50 states and the District of Columbia.
Tobacco retailer inspections conducted by FDA (n = 33 543).
Exposure(s) for Observational Studies:
State cigarette tax, youth smoking prevalence, poverty, and tobacco production.
Main Outcome(s) and Measure(s):
State proportion of FDA warning letters issued for single cigarette violations.
There are striking differences in the number of single cigarette violations found by state, with 38 states producing no warning letters for selling single cigarettes even as state policymakers developed legislation to address retailer sales of single cigarettes. The state proportion of warning letters issued for single cigarettes is not predicted by state cigarette tax, youth smoking, poverty, or tobacco production, P = .12.
Conclusions and Relevance:
Substantial, unexplained variation exists in violations of single cigarette sales among states. These data suggest the possibility of differences in implementation of FDA inspections and the need for stronger quality monitoring processes across states implementing FDA inspections.
PMCID: PMC4723674  PMID: 25744967
16.  "May I Buy a Pack of Marlboros, Please?" A Systematic Review of Evidence to Improve the Validity and Impact of Youth Undercover Buy Inspections 
PLoS ONE  2016;11(4):e0153152.
Most smokers become addicted to tobacco products before they are legally able to purchase these products. We systematically reviewed the literature on protocols to assess underage purchase and their ecological validity. We conducted a systematic search in May 2015 in PubMed and PsycINFO. We independently screened records for inclusion. We conducted a narrative review and examined implications of two types of legal authority for protocols that govern underage buy enforcement in the United States: criminal (state-level laws prohibiting sales to youth) and administrative (federal regulations prohibiting sales to youth). Ten studies experimentally assessed underage buy protocols and 44 studies assessed the association between youth characteristics and tobacco sales. Protocols that mimicked real-world youth behaviors were consistently associated with substantially greater likelihood of a sale to a youth. Many of the tested protocols appear to be designed for compliance with criminal law rather than administrative enforcement in ways that limited ecological validity. This may be due to concerns about entrapment. For administrative enforcement in particular, entrapment may be less of an issue than commonly thought. Commonly used underage buy protocols poorly represent the reality of youths' access to tobacco from retailers. Compliance check programs should allow youth to present themselves naturally and attempt to match the community’s demographic makeup.
PMCID: PMC4822877  PMID: 27050671
17.  Testing warning messages on smokers’ cigarette packages: A standardized protocol 
Tobacco control  2015;25(2):153-159.
Lab experiments on cigarette warnings typically use a brief one-time exposure that is not paired with the cigarette packs smokers use every day, leaving open the question of how repeated warning exposure over several weeks may affect smokers. This proof of principle study sought to develop a new protocol for testing cigarette warnings that better reflects real-world exposure by presenting them on cigarette smokers’ own packs.
We tested a cigarette pack labeling protocol with 76 US smokers ages 18 and older. We applied graphic warnings to the front and back of smokers’ cigarette packs.
Most smokers reported that at least 75% of the packs of cigarettes they smoked during the study had our warnings. Nearly all said they would participate in the study again. Using cigarette packs with the study warnings increased quit intentions (p<.05).
Our findings suggest a feasible pack labeling protocol with six steps: (1) schedule appointments at brief intervals; (2) determine typical cigarette consumption; (3) ask smokers to bring a supply of cigarette packs to study appointments; (4) apply labels to smokers’ cigarette packs; (5) provide participation incentives at the end of appointments; and (6) refer smokers to cessation services at end of the study. When used in randomized controlled trials in settings with real-world message exposure over time, this protocol may help identify the true impact of warnings and thus better inform tobacco product labeling policy.
PMCID: PMC4492886  PMID: 25564282
smoking; health communication; persuasive communication; government regulation; tobacco products
18.  Promoting Tobacco Use Cessation for Lesbian, Gay, Bisexual, and Transgender People 
Lesbian, gay, bisexual, and transgender (LGBT) people are at increased risk for the adverse effects of tobacco use given their high prevalence of use, especially smoking. Evidence regarding cessation is limited. To determine if efficacious interventions are available and to aid the development of interventions, a systematic review was conducted of gray and peer-reviewed literature describing clinical, community, and policy interventions as well as knowledge, attitudes, and behaviors regarding tobacco use cessation among LGBT people.
Evidence acquisition
Eight databases for articles from 1987 to April 23, 2014 were searched. In February–November 2013, authors and researchers were contacted to identify gray literature.
Evidence synthesis
The search identified 57 records, of which 51 were relevant and 22 were from the gray literature; these were abstracted into evidence tables, and a narrative synthesis was conducted in October–May 2014. Group cessation curricula tailored for LGBT populations were found feasible to implement and show evidence of effectiveness. Community interventions have been implemented by and for LGBT communities; although these interventions showed feasibility, no rigorous outcome evaluations exist. Clinical interventions show little difference between LGBT and heterosexual people. Focus groups suggest that care is needed in selecting messaging used in media campaigns.
LGBT-serving organizations should implement existing evidence-based tobacco dependence treatment and clinical systems to support treatment of tobacco use. A clear commitment from government and funders is needed to investigate whether sexual orientation and gender identity moderate the impacts of policy interventions, media campaigns, and clinical interventions.
PMCID: PMC4255587  PMID: 25455123
19.  Out smoking on the big screen: Tobacco use in LGBT movies, 2000–2011 
Tobacco control  2013;23(0):e156-e158.
Lesbian, gay, bisexual, and transgender (LGBT) people have significantly higher smoking prevalence than heterosexual people in the United States. The reasons for this disparity remain unclear. Tobacco use in movies has a substantial influence on tobacco use behaviours, particularly among youth. Yet, no research has examined tobacco use in movies for LGBT audiences or containing LGBT characters.
We identified 81 U.S. movies from 2000–2011 with a theatre release and with LGBT themes or characters. We then selected a random sample of these movies (n = 45) for quantitative content analysis to examine the proportion of movies with depictions of tobacco use and the number of occurrences of tobacco use.
Tobacco use was depicted in 87%(95% confidence interval [CI]: 80%–94%) of movies with an average of 4 occurrences of tobacco use per hour (95% CI: 3–5). Only 15% (95% CI: 8%–23%) of movies and 3% of all depictions of tobacco use conveyed any harms of tobacco use.
Viewers of movies with LGBT themes or characters are exposed, on average, to one depiction of tobacco use for every 15 minutes of movie run-time. As a major component of the entertainment media environment, movies may contribute to smoking among LGBT people.
PMCID: PMC4032800  PMID: 24277775
tobacco use dependence; smoking; motion pictures as topic; homosexuality; communications media
20.  Relationship Between Tobacco Retailers’ Point-of-Sale Marketing and the Density of Same-Sex Couples, 97 U.S. Counties, 2012 
The reasons for higher rates of smoking among lesbian, gay, and bisexual (LGB) people than among heterosexual people are not well known. Research on internal migration and neighborhood selection suggests that LGB people are more likely to live in neighborhoods where the tobacco industry has historically targeted their marketing efforts (lower income, more racial/ethnic diversity). We used multi-level models to assess the relationship between the rate of same-sex couples per 1000 coupled households and 2012 marketing characteristics of tobacco retailers (n = 2231) in 1696 census tracts in 97 U.S. counties. We found no evidence of tobacco marketing at retailers differing by same-sex couple rates in census tracts with the exception of three findings in the opposite direction of our hypotheses: a small, significant positive relationship for the rate of same-sex male couples and the price of Newport Green (mentholated) cigarettes. For male and female same-sex couples, we also found a small negative relationship between tobacco advertisements and same-sex household rate. Tobacco retailers’ tobacco marketing characteristics do not differ substantially by the rate of same-sex couples in their neighborhood in ways that would promote LGB health disparities. Further work is needed to determine if these patterns are similar for non-partnered LGB people.
PMCID: PMC4555248  PMID: 26225987
homosexuality; marketing; smoking; residence characteristics; commerce; health status disparities
21.  Health Inequalities Among Sexual Minority Adults 
Improving the health of lesbian, gay, and bisexual (LGB) individuals is a Healthy People 2020 goal; however, the IOM highlighted the paucity of information currently available about LGB populations.
To compare health indicators by gender and sexual orientation statuses.
Data are from Behavioral Risk Factor Surveillance System surveys conducted January–December of 2010 with population-based samples of non-institutionalized U.S. adults aged over 18 years (N=93,414) in ten states that asked about respondents’ sexual orientation (response rates=41.1%–65.6%). Analyses were stratified by gender and sexual orientation to compare indicators of mental health, physical health, risk behaviors, preventive health behaviors, screening tests, health care utilization, and medical diagnoses. Analyses were conducted in March 2013.
Overall, 2.4% (95% CI=2.2, 2.7) of the sample identified as LGB. All sexual minority groups were more likely to be current smokers than their heterosexual peers. Compared with heterosexual women, lesbian women had over 30% decreased odds of having an annual routine physical exam, and bisexual women had over 2.5 times the odds of not seeking medical care owing to cost. Compared with heterosexual men, gay men were less likely to be overweight or obese, and bisexual men were twice as likely to report a lifetime asthma diagnosis.
This study represents one of the largest samples of LGB adults and finds important health inequalities, including that bisexual women bear particularly high burdens of health disparities. Further work is needed to identify causes of and intervention for these disparities.
PMCID: PMC4102129  PMID: 24650836
22.  A Systematic Review of Store Audit Methods for Assessing Tobacco Marketing and Products at the Point of Sale 
Tobacco control  2013;23(2):98-106.
Over four-fifths of reported expenditures for marketing tobacco products occur at the retail point of sale (POS). To date, no systematic review has synthesized the methods used for surveillance of POS marketing. This review sought to describe the audit objectives, methods, and measures used to study retail tobacco environments.
We systematically searched 11 academic databases for papers indexed on or before March 14, 2012, identifying 2,906 papers. Two coders independently reviewed each abstract or fulltext to identify papers with the following criteria: (1) data collectors visited and assessed (2) retail environments using (3) a data collection instrument for (4) tobacco products or marketing. We excluded papers where limited measures of products and/or marketing were incidental. Two abstractors independently coded included papers for research aims, locale, methods, measures used, and measurement properties. We calculated descriptive statistics regarding the use of 4 P’s of marketing (product, price, placement, promotion) and for measures of study design, sampling strategy, and sample size.
We identified 88 store audit studies. Most studies focus on enumerating the number of signs or other promotions. Several strengths, particularly in sampling, are noted, but substantial improvements are indicated in the reporting of reliability, validity, and audit procedures.
Audits of POS tobacco marketing have made important contributions to understanding industry behaviour, the uses of marketing, and resulting health behaviours. Increased emphasis on standardization and the use of theory are needed in the field. We propose key components of audit methodology that should be routinely reported.
PMCID: PMC3849332  PMID: 23322313
questionnaires; tobacco industry; smoking; reproducibility of results; environments
23.  Physicians’ Attitudes and Use of E-Cigarettes as Cessation Devices, North Carolina, 2013 
PLoS ONE  2014;9(7):e103462.
Electronic cigarettes (e-cigarettes) are not currently approved or recommended by the Food and Drug Administration (FDA) or various medical organizations; yet, they appear to play a substantial role in tobacco users’ cessation attempts. This study reports on a physician survey that measured beliefs, attitudes, and behavior related to e-cigarettes and smoking cessation. To our knowledge this is the first study to measure attitudes toward e-cigarettes among physicians treating adult smokers.
Using a direct marketing company, a random sample of 787 North Carolina physicians were contacted in 2013 through email, with 413 opening the email and 128 responding (response rate = 31%). Physicians’ attitudes towards e-cigarettes were measured through a series of close-ended questions. Recommending e-cigarettes to patients served as the outcome variable for a logistic regression analysis.
Two thirds (67%) of the surveyed physicians indicated e-cigarettes are a helpful aid for smoking cessation, and 35% recommended them to their patients. Physicians were more likely to recommend e-cigarettes when their patients asked about them or when the physician believed e-cigarettes were safer than smoking standard cigarettes.
Many North Carolina physicians are having conversations about e-cigarettes with their patients, and some are recommending them. Future FDA regulation of e-cigarettes may help provide evidence-based guidance to physicians about e-cigarettes and will help ensure that patients receive evidence-based recommendations about the safety and efficacy of e-cigarettes in tobacco cessation.
PMCID: PMC4114778  PMID: 25072466
24.  “Real Men Don’t”: Constructions of Masculinity and Inadvertent Harm in Public Health Interventions 
American journal of public health  2014;104(6):1029-1035.
Research shows that constraining aspects of male gender norms negatively influence both women’s and men’s health. Messaging that draws upon norms of masculinity in health programming has been shown improve both women’s and men’s health, but some types of public health messaging (e.g., “Man Up!”) can reify harmful aspects of hegemonic masculinity that programs are working to change. We critically assess the deployment of hegemonic male norms in one particular STD campaign known as “Man Up.” We draw on ethical paradigms in public health to challenge programs that reinforce harmful aspects of gender norms and suggest the use of gender-transformative interventions that challenge constraining masculine norms and have been shown to have a positive effect on health behaviors.
PMCID: PMC4062033  PMID: 24825202
25.  A systematic review of the aetiology of tobacco disparities for sexual minorities 
Tobacco control  2011;22(2):66-73.
To conduct a systematic review of the literature examining risk factors/correlates of cigarette smoking among lesbian, gay and bisexual (ie, sexual minority) populations.
Sets of terms relevant to sexual minority populations and cigarette smoking were used in a simultaneous search of 10 databases through EBSCOhost. The search was limited to the peer-reviewed literature up to January 2011, using no geographic or language limits. For inclusion, the paper was required to: (1) have been written in English, (2) have sexual minorities (defined by either attraction, behaviour, or identity) included in the study population and (3) have examined some form of magnitude of association for risk factors/correlates of any definition of cigarette smoking. A total of 386 abstracts were reviewed independently, with 26 papers meeting all inclusion criteria. Abstracts were reviewed and coded independently by authors JB and JGLL using nine codes derived from the inclusion/exclusion criteria.
Studies used various measures of sexual orientation and of smoking. Risk factors that could be considered unique to sexual minorities included internalised homophobia and reactions to disclosure of sexual orientation. Some studies also indicated common smoking risk factors experienced at higher rates among sexual minorities, including stress, depression, alcohol use and victimisation.
This review identified risks that were associated with sexual minority status and common to the general population but experienced at potentially higher rates by sexual minorities. Government and foundation funds should be directed towards research on the origins of this disparity.
PMCID: PMC3779881  PMID: 22170335

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