Abstract
Background
Exposure to tobacco advertising and promotion increases the likelihood of smoking
amongst young people. While there is a universal ban on traditional or 'above-the-line'
advertising in Australia, the types and extent of exposure of young people to 'below-the-line'
tobacco advertising and promotion is largely unknown. In this study we aim to identify
levels of exposure of New South Wales (NSW) adolescents and young adults to tobacco
promotion at the point-of-sale (PoS), on the internet, in entertainment media and
at venues such as events or festivals and pubs, clubs, nightclubs, or bars; and to
identify those most at risk of exposure.
Methods
A telephone survey of 1000 NSW adolescents and young adults aged 12 to 24 years was
conducted. Self-reported exposure to tobacco promotions or advertising in the last
month were measured in four areas: (1) promotions or advertising at (a) events or
festivals and (b) pubs, clubs, nightclubs or bars, (2) on the internet, (3) people
smoking cigarettes in (a) movies, (b) TV shows, (c) video games and (d) on the internet,
and (4) displays of cigarette packs for sale at (a) large supermarkets, (b) grocery
stores or small supermarkets, (c) convenience stores, and (d) service or petrol stations.
Smoking status and susceptibility to smoking was also assessed.
Results
A substantial proportion of the young people surveyed reported seeing tobacco promotion
sometimes or often in the last month over most of the channels studied. The highest
levels of exposure were at the PoS (approx. two-thirds) and to people smoking cigarettes
in movies (77%). Lower levels of exposure to tobacco promotions and imagery were reported
on the internet (20%); at events or festivals (22.5%); in pubs, clubs, nightclubs
or bars (31%); and in video games (23%). However, the odds of exposure through video
games increased by 8% for every additional hour spent on the internet per day.
Conclusions
This study shows that adolescents and young adults in NSW are exposed to tobacco advertising
or promotion at the PoS, on the internet, in entertainment media and at venues such
as events or festivals and pubs, clubs, nightclubs or bars, despite the restrictions
on the marketing of tobacco in Australia.
Background
There is considerable evidence linking exposure to tobacco advertising and promotion
with an increased likelihood of smoking amongst young people.[1-4] As a result, an
increasing number of countries have implemented bans on tobacco advertising, marketing
and promotion.[5] Australia's Tobacco Advertising Prohibition Act 1992 and tobacco
control legislation in the states and territories has been implemented to prevent
most promotion or marketing of tobacco through traditional or 'above-the-line' forms
of media (print, radio, television, billboards, and other locations).[6,7]
In New South Wales (NSW), the most populous state of Australia, the Public Health
(Tobacco) Act of 2008 introduced new requirements relating to advertising of tobacco
products on retail premises, including how tobacco products may be displayed. The
new regulations state that tobacco products must be stored out of sight so that they
cannot be seen by the public from inside or outside the retail premises. Large retailers
(more than 50 employees) went out of sight 1 January 2010 (Phase 1), small retailers
(50 or fewer employees) followed from 1 July 2010 (Phase 2) and specialist tobacconists
must comply by 1 January 2013 (Phase 3).
Despite the ban on most traditional forms of tobacco advertising and promotion in
Australia, the tobacco industry has adapted by diverting resources to non-traditional
or 'below-the-line' means of promotion, such as point-of-sale (PoS) displays; portrayal
in films or movies; TV programs, magazines and electronic games; internet advertising
and events marketing.[7-10]
Large-scale population studies have shown that greater exposure to PoS tobacco displays
is associated with an increased likelihood of adolescent smoking.[11-17] A recent
study in the United Kingdom (UK), for instance, found that both noticing and being
attracted to PoS displays were associated with susceptibility to smoking amongst never
smokers aged 11 to 16 years.[18] Furthermore, experimental studies have shown that
youth exposed to images of tobacco-saturated PoS displays had stronger perceptions
relating to the availability and ease of tobacco purchase and of peer and adult smoking
as well as less support for tobacco control policies, compared to youth exposed to
images of PoS displays with no tobacco imagery.[19,20]
The appearance of tobacco brands or tobacco related products in cinema films has a
long history and is a pervasive form of tobacco promotion.[21] A recent study from
the UK showed that tobacco appeared in 70% of the most popular films from 1989 to
2008.[22] A number of studies have shown that greater exposure to smoking in films
is associated with an increased likelihood of smoking among adolescents and young
adults [23-29], and that this transcends different cultural contexts.[30] Evidence
as to the extent and effects of youth exposure to media portrayals of smoking has
previously come from countries such as the United States (US) and the UK, however,
with little research to date on the level and effect of exposure in Australian youth.
The internet may also influence youth tobacco use because it provides potential access
to tobacco products, as well as a venue that may stimulate demand through advertising
and promotional messages.[31] In 2005, almost one fifth of adult internet users in
the US recalled seeing tobacco products advertised online, with young adults being
the most likely group to recall such advertising.[32] Newly emerging forms of marketing
include viral marketing through social networking sites in which tobacco company names,
logos and images can be prominently displayed and rapidly disseminated amongst users
of the sites.[33] This type of marketing, though aimed primarily at young adults,
is also likely to influence younger teenagers.[6]
Research investigating online exposure to tobacco promotion has largely focused on
adults [32], with little or no research to date focusing on adolescent exposure, despite
the wide-spread use of the internet in this age group.[33]
It is important to assess exposure among adolescents and young adults to non-traditional
or below-the-line means of tobacco promotion, given this may be undermining tobacco
control efforts and diminishing the potential to further prevent uptake or reduce
smoking in this group of young people.
This study aims to identify (1) the degree to which NSW adolescents (12-17 years of
age) and young adults (18-24 years of age) have been exposed to tobacco promotion
at the PoS, on the internet, in entertainment media, and at entertainment venues;
and (2) to profile the characteristics of adolescents and young adults most at risk
of exposure to these types of tobacco promotion.
Methods
Design
The Cancer Institute NSW's Tobacco Promotion Impact Study (TPIS) is a telephone survey
of adolescents and young adults aged 12 to 24 years in New South Wales (NSW). It monitors
exposure to tobacco promotion at the PoS, on the internet and in entertainment media,
and smoking-related cognitions and behaviours. This paper presents findings from the
baseline survey conducted in NSW in June 2010.
Households were recruited using random digit dialling (landline telephone numbers
only) and participants within households were recruited using random selection (selecting
the nth oldest eligible person aged 12 to 24 years). Permission was obtained from
parents of 12 to 15 year olds before conducting each interview. Participants were
interviewed between 8 June and 30 June 2010 (n = 1,000). The questionnaire was piloted
with the survey population prior to the commencement of fieldwork. An overall response
rate of 45% (using the American Association for Public Opinion Research Response Rate
#3) was achieved for this period [34], comparable or superior to other similar studies.[35,36]
The TPIS was approved by the NSW Population Health Services Research Ethics Committee.
Measures
Individual characteristics
Demographic items capturing age, gender, region (Sydney vs. Rest of NSW), living arrangement,
language spoken at home, and disposable income were included in the study. Postcode
of residence was coded according to the Socio-Economic Indices for Areas SEIFA; [37],
an index of relative disadvantage, to indicate neighbourhood socio-economic status
(SES). Quintiles 4-5 were collapsed to indicate low SES, and quintiles 1-3 were collapsed
to indicate moderate to high SES. Age was operationalised for the bivariate and multiple
variable analyses as a binary variable grouping together participants aged 12-17 years
(adolescents), and those aged 18-24 years (young adults).
The amount of time spent on the internet and watching TV was reported as hours and
minutes per day and converted to hours per day (maximum of 10 h). Amount of disposable
income was measured by asking participants how much money they had available during
a normal week to spend on themselves (none, $50 or less, $50-$100, $100-$150, $150-$200,
over $200, don't know). The categories were collapsed to none, $50 or less, $50-$100,
$100+, unknown for analysis.
Smoking status
Current smokers were defined as those who had smoked cigarettes in the past month.
Ex-smokers were those who had ever smoked cigarettes, but not in the past month, and
had smoked 100 cigarettes or more in their lifetime. Experimenters had ever smoked
cigarettes, but not in the past month, and had smoked less than 100 cigarettes in
their lifetime. Non-smokers were categorised into one of two groups: susceptible non-smokers
and non-susceptible non-smokers.[38] To determine susceptibility to smoking, participants
who had never had a puff of a cigarette were asked "Do you think you will try cigarettes
sometime soon", "Do you think you will try cigarettes sometime in the next year" and
"If a friend offered you a cigarette, would you try it" (definitely no, probably no,
probably yes, definitely yes). Susceptible non-smokers were those whose response to
any one of the three smoking susceptibility items was anything other than 'definitely
no'. Non-susceptible non-smokers were those who answered 'definitely no' to all three
smoking susceptibility items. For the multiple variable analysis, a binary "ever smoked"
variable was used with those who answered "yes" to "have you ever smoked a cigarette,
even just a puff" coded as "ever smokers" and those who answered "no" or "don't know"
as "never smoked".
Smoking exposure
Exposure to smoking in the household and among friends was assessed by recording the
number of current smokers in a respondent's household and how many (if any) of the
participants' five closest friends smoked. As both of these variables had highly skewed
distributions, smoking in the household was operationalised as a three category variable
(none, one person, two or more people) and smoking among friends as a four category
variable (none, one friend, two friends, three or more friends).
Perceived exposure to tobacco promotion
Self-reported exposure to tobacco promotions or advertising in the last month were
measured in four areas: (1) promotions or advertising at (a) events or festivals and
(b) pubs, clubs, nightclubs or bars, (2) brands, company names or logos on the internet,
(3) people smoking cigarettes in (a) movies, (b) TV shows, (c) video games (platform
not specified) and (d) on the internet, and (4) displays of cigarette packs for sale
at (a) large supermarkets (defined for participants as having more than five cash
registers), (b) grocery stores or small supermarkets, (c) convenience stores, and
(d) service or petrol stations. Respondents aged 12-15 years (n = 334) were not asked
about exposure in pubs, clubs, nightclubs or bars due to the low likelihood they would
be attending these venues. Exposure to cigarette pack displays at PoS was measured
as, firstly, how often the respondent visited each store type (never, rarely, sometimes,
often). Those who had ever visited these stores were then asked how often they had
seen displays of cigarette packs for sale in each using the same response frame.
Statistical analyses
Outcome measures on exposure to tobacco promotion
For all tobacco promotion channels except cigarette pack displays, the response categories
of never/rarely and sometimes/often were collapsed to create binary exposure variables.
Respondents who reported that they didn't know whether they had seen such promotions
were coded "never/rarely" for exposure. Those who refused to answer a question were
coded as missing for that exposure channel (at maximum n = 2).
Exposure to cigarette pack displays in stores (large supermarkets, small supermarkets,
convenience stores and petrol stations) were combined measures reflecting both frequency
of visits to the store type and the frequency with which the respondent said they
saw cigarette pack displays at that store. For both visit frequency and frequency
of seeing pack displays, the coding ranged from 0 (never) to 3 (often). For each store
type, the two frequency variables were multiplied to create a combined numeric cigarette
pack display exposure score which was subsequently categorised as follows: Low exposure:
participants who reported they either never visited that store type or never saw cigarette
pack displays (irrespective of store visit frequency) or rarely visited and rarely
saw pack displays (score 0 or 1); High exposure: combinations of visit frequency and
seeing cigarette pack display frequency of either often and sometimes, or often and
often (score 6 or 9); and Medium exposure: all other combinations of store visit and
frequency of seeing pack displays (score 2 to 4). For the multiple variable analysis,
the outcome variable for exposure to cigarette pack displays in stores was a single
binary variable coded high exposure (versus not high) for the exposure score (as calculated
above) aggregated over all store types. High exposure was defined as being in the
top quartile of the total exposure score.
Analytic techniques
Descriptive statistics were generated for the tobacco promotion channels by gender
and age group (12-17 and 18-24 years). Bivariate comparisons of level of exposure
over all promotion channels across gender and age were examined using chi-square.
Multiple logistic regression models estimated the adjusted odds of participants reporting
seeing each of the different types of tobacco promotion sometimes or often. Each model
included as predictors: age group (12-17 years, 18-24 years), gender, SES (advantaged,
disadvantaged), disposable income, ever smoked, household smokers, and friends smoking.
For outcome variables examining tobacco promotion on the internet and in video games,
hours per day spent on the internet was also included in the model, and the model
examining depiction of people smoking in TV shows also included time spent watching
TV (in hours per day). Contrasts with the reference category for multiple category
predictor variables were Bonferroni adjusted.
The data were weighted to the NSW population for known age (12-15 years, 16-19 years,
20-24 years), sex (female, male) and region (Sydney, Rest of state) distributions
for 12-24 year olds within NSW from the 2006 Australian Bureau of Statistics (ABS)
Census data [39] using post-stratification weights. All analyses were conducted using
Stata v11.1 [40] and used a threshold of alpha at 0.05 for statistical significance.
Results
Description of sample
Table 1 shows the (unweighted) socio-demographic characteristics of the sample of
participants from NSW (n = 1000), by age group.
Table 1
Socio-demographic characteristics NSW sample (n = 1000) by age group
CHARACTERISTIC
12-17 yearsn =518
18-24 yearsn =482
Total
GENDER
n
%
n
%
%
Male
258
49.8
240
49.8
49.8
REGION
Sydney
298
57.5
343
71.2
64.1
Rest of NSW
220
42.5
139
28.8
35.9
NEIGHBOURHOOD SES
Low
163
31.5
148
30.7
31.1
Mod-High
355
68.5
334
69.3
68.9
LIVING ARRANGEMENT
Live with parent(s)/guardians/family
511
98.8
402
83.8
91.6
Live with a, or am sole parent/share with
6
1.2
78
16.25
8.4
others/spouse/live alone
LANGUAGE AT HOME
English
435
84.0
348
72.2
78.3
SMOKING STATUS
Current smoker
44
8.5
125
25.9
16.9
Non-susceptible non-smoker
322
62.2
155
32.2
47.7
Susceptible non-smoker
84
16.2
23
4.8
10.7
Ex-smoker
1
0.2
23
4.8
2.4
Experimenter
67
12.9
156
32.4
22.3
FRIENDS SMOKING†
None
331
63.9
149
30.9
48.0
1 friend
73
14.1
101
21.0
17.4
2 friends
55
10.6
81
16.8
13.6
3+ friends
59
11.4
151
31.3
21.0
HOUSEHOLD SMOKING
No one
380
73.4
285
59.1
66.5
1 person
96
18.5
133
27.6
22.9
2+ people
42
8.1
64
13.3
10.6
DISPOSABLE INCOME
None
51
9.9
9
1.9
6
<=$50
332
64.1
76
15.8
40.8
$50-$100
68
13.1
70
14.5
13.8
$100+
48
9.3
310
64.3
35.8
Unknown
19
3. 7
17
3.5
3.6
INTERNET USE* (n = 991)
median
mean
median
mean
Mean
(minutes per day)
120
120.5
120
171.8
148.1
TV USE*
(minutes per day)
90
108.8
90
103.6
106.0
TV USE*
(minutes per day)
90
108.8
90
103.6
106.0
* Internet and TV mean use in minutes weighted to state population by age and gender.Values
exceeding 600 min (10 h, <1% of sample) recoded to 600.
† How many of five closest friends smoke.
Just under half the sample were male and were aged 18-24 years. Almost one-third lived
in areas categorised as disadvantaged by SEIFA index. The majority of participants
lived with their parents or guardians, although one-sixth of young adults (18-24 years)
lived away from their parents. Most participants were not currently smoking (83%),
and reported that no one in their household (67%) smoked, however just over half had
friends who smoked. Just under two-thirds of participants aged 12-17 years had less
than $50 in disposable income per week, while the same proportion of young adults
had $100 or more for discretionary spending. Median internet use and time spent watching
TV was two hours and 1.5 h per day respectively and was the same for both the adolescents
and young adults.
Bivariate analyses of tobacco promotion
The proportion of participants reporting having seen tobacco promotion in the past
month and results of the bivariate comparisons of tobacco promotion exposure across
age group and gender are shown in Table 2.
Table 2
Proportions in NSW exposed to forms of tobacco promotion by gender and age (n = 1000)
EXPOSURE
Male %
Female %
p
12-18 years %
18-24 years %
Total p
PROMOTIONS OR ADVERTISING
Events/festivals
NS
=.001
Never/rarely
79.7
75.2
72.8
81.6
77.5
Sometimes/often
20.3
27.8
27.2
18.4
22.5
Pubs/clubs/nightclubs/bars*
NS
=.033
Never/rarely
71.4
67.2
75.9
67.3
69.2
Sometimes/often
28.9
32.8
24.1
33.7
30.8
BRANDS, COMPANY NAMES OR LOGOS
Internet
NS
<.001
Never/rarely
81.9
78.2
73.9
85.5
80.1
Sometimes/often
18.1
21.8
26.1
14.5
19.9
PEOPLE SMOKING CIGARETTES
Movies
NS
NS
Never/rarely
24.1
21.5
22.6
23.0
22.8
Sometimes/often
75.9
78.5
77.4
77.0
77.2
TV shows
NS
NS
Never/rarely
34.6
29.3
29.2
34.4
32.0
Sometimes/often
65.4
70.7
70.8
65.6
68.0
Video games
<.001
NS
Never/rarely
66.7
87.2
76.5
77.0
76.8
Sometimes/often
33.3
12.8
23.6
23.0
23.3
On the internet
NS
NS
Never/rarely
75.3
73.5
74.1
74.7
74.4
Sometimes/often
24.7
26.5
25.9
25.3
25.6
CIGARETTE PACK DISPLAYS†
Large supermarkets
=.018
<.001
Low
35.6
30.2
23.9
40.8
32.9
Med
33.5
30.3
36.8
27.8
31.9
High
30.9
39.5
39.3
31.5
35.1
Small supermarkets
<.001
<.001
Low
39.2
28.1
25.6
40.8
33.7
Med
36.4
32.4
37.7
31.6
34.4
High
24.4
39.6
36.7
27.6
31.8
Convenience stores
=.001
NS
Low
41.1
31.7
34.5
38.2
36.5
Med
38.7
39.4
40.9
37.4
39.0
High
20.3
28.9
24.6
24.4
24.5
Petrol stations
NS
=.014
Low
30.4
30.3
28.0
32.4
30.4
Med
33.7
32.9
38.1
29.2
33.3
High
35.9
36.8
34.0
38.4
36.3
† Level of exposure determined by combination of frequency visiting site and frequency
seeing pack displays.
* Respondents aged 12-15 years excluded (n = 334) as not asked this question - younger
age group 16-17 year-olds only.
Overall, a substantial proportion of the young people surveyed reported seeing tobacco
promotion sometimes or often in the last month over most of the channels. The highest
rate was for seeing people smoking in movies (77%) and the lowest was for seeing tobacco
brands, company names or logos on the internet (20%). Around one-third each reported
seeing cigarette pack displays in low, medium, or high frequency and this distribution
was similar across the different store types (large and small supermarkets, convenience
stores and petrol stations).
Bivariate analyses of reported tobacco promotion exposure for the different channels
by gender showed few differences except more male participants saw people smoking
sometimes/often in video games (33% vs. 13%, p < 0.001) than females, while female
participants reported seeing cigarette pack displays at high frequency in large supermarkets,
small supermarkets and convenience stores more often than males.
Comparisons of exposure to tobacco promotion by age showed adolescents were more likely
than the young adults to report seeing brands, company names or logos on the internet,
promotions/advertising at events/festivals, and cigarette pack displays in large and
small supermarkets, but had lower exposure to promotions/advertising at pubs/clubs/nightclubs/bars
(16-17 year olds only). Young adults reported higher levels of exposure to cigarette
pack displays in petrol stations. No differences by age were observed for seeing people
smoking cigarettes in movies, on TV shows, in video games or on the internet.
Multiple variable analyses of tobacco promotion
Table 3 shows results of the significant adjusted models of exposure to tobacco promotion
at events/festivals, on the internet, in video games and cigarette pack displays in
all stores combined.
Table 3
Adjusted odds ratios with 95% percent confidence intervals1 for participants reporting
seeing forms of tobacco promotion sometimes/often in the last month
Events/festivals
Brands/companynames/logos on internet
People smoking in video games
Cigarette pack displays exposure all stores
Predictor(reference category)
OR
95%CI
p
3
OR
95%CI
p
3
OR
95%CI
p
3
OR
95%CI
p
2
Age 18-24 years (12-17)
0.68
(0.46,1.01)
0.055
0.46
(0.30,0.70)
0.000
0.90
(0.59,1.38)
0.626
0.61
(0.40,0.91)
0.016
Sex (Male)
1.32
(0.97,1.80)
0.078
1.23
(0.88,1.70)
0.219
0.28
(0.20,0.39)
<.001
1.58
(1.17,2.13)
0.003
SES (not disadvantaged)
0.95
(0.68,1.32)
0.748
1.31
(0.92,1.85)
0.134
1.01
(0.71,1.44)
0.943
1.13
(0.82,1.56)
0.437
Disposable income (none)
0.354
0.298
0.976
0.947
<=$50
1.52
(0.79,2.91)
0.825
1.90
(0.87,4.11)
0.420
0.82
(0.43,1.56)
1.00
0.98
(0.5,1.90)
1.00
$50-$100
1.10
(0.52,2.33)
1.00
2.34
(1.01,5.42)
0.188
0.80
(0.38,1.68)
1.00
1.64
(0.78,3.45)
1.00
$100+
1.05
(0.50,2.20)
1.00
1.72
(0.73,4.03)
0.848
0.80
(0.39,1.64)
1.00
1.60
(0.75,3.40)
1.00
Unknown
0.94
(0.32,2.75)
1.00
1.26
(0.37,4.32)
1.00
0.75
(0.23,2.46)
1.00
1.06
(0.38,2.99)
1.00
Ever smoked (never smoked)
0.85
(0.58,1.27)
0.435
0.64
(0.43,0.95)
0.027
0.83
(0.55,1.23)
0.345
1.27
(0.86,1.87)
0.232
Household smoking (none)
0.457
0.701
0.646
0.303
1 person
1.26
(0.86,1.85)
0.461
1.18
(0.8,1.75)
0.818
0.84
(0.55,1.26)
0.775
0.86
(0.59,1.25)
0.474
2+ people
0.99
(0.57,1.75)
1.00
1.01
(0.55,1.85)
1.00
0.85
(0.50,1.45)
1.00
0.66
(0.38,1.15)
1.00
Friends smoking (none)
0.015
0.079
0.055
0.161
1 friend
1.98
(1.28,3.04)
0.006
1.70
(1.09,2.66)
0.059
1.18
(0.74,1.88)
1.00
1.29
(0.85,1.97)
0.403
2 friends
1.04
(0.63,1.74)
1.00
1.50
(0.91,2.48)
0.340
1.90
(1.16,3.11)
0.031
1.26
(0.79,2.01)
0.459
3+ friends
1.28
(0.79,2.08)
0.953
1.52
(0.92,2.49)
0.302
1.58
(0.98,2.55)
0.187
0.95
(0.59,1.52)
0.101
Internet use (hours/day)
-
-
1.06
(0.99,1.15)
0.11
1.08
(1.01,1.17)
0.030
-
-
-
1 Full results shown only for models that reached statistical significance. Analyses
also included seeing promotions or advertisements in pubs/clubs/nightclubs or bars,
seeing people smoking in movies, in TV shows and on the internet, but the overall
models did not reach statistical significance (>.05)
2
High exposure for seeing cigarette pack displays defined as top quartile of scores
for summed frequency of visit by frequency of seeing cigarette pack display across
all store types
3 Significance values for overall test shown for multicategory variables (e.g., disposable
income), and multiple contrasts reported with Bonferroni adjustment
Overall models for exposure to promotion/advertising in pubs/clubs/nightclubs/bars,
seeing people smoking cigarettes in movies, in TV shows or on the internet did not
reach statistical significance and therefore are not further described.
For tobacco promotion/advertising at events/festivals, only the number of friends
who smoked was significantly related to seeing this type of promotion once adjusted
for all other variables. Those with one smoking friend compared with no friends who
smoked had almost twice the odds of reporting seeing this type of promotion sometimes
or often.
The odds of seeing cigarette brands, tobacco company names or logos on the internet
were more than halved among participants aged 18-24 years compared with adolescents,
and those who had ever smoked had odds of reporting seeing this type of promotion
around one-third lower than those who had never smoked.
The odds of reporting seeing people smoking cigarettes in video games sometimes or
often were over 70% lower for female participants. Odds of exposure through video
games also increased by 8% for every additional hour spent on the internet per day.
High exposure to cigarette pack displays was more likely for female compared with
male participants (Adjusted Odds Ratio (AOR) =1.58, p = .003), but less likely for
participants aged 18-24 years than those aged 12-17 years (AOR = .61, p = .016).
Discussion
This study shows that adolescents and young adults in NSW are exposed to relatively
high levels of tobacco advertising or promotion at the PoS, on the internet, in entertainment
media and at venues such as events or festivals and pubs, clubs, nightclubs or bars,
despite the restrictions on the marketing of tobacco in Australia. The high levels
of exposure particularly at the PoS and to people smoking cigarettes in movies and
on TV found in this study highlight that the retail environment and entertainment
media are important avenues for the industry to market tobacco and tobacco products.
Most adolescents and young adults were exposed to cigarette pack displays in stores
in NSW, which provides further justification for the introduction of the PoS display
ban. It is interesting to note, however, that despite the first phase of the PoS display
ban in NSW being implemented six months prior, most adolescents and young adults still
report being exposed to cigarette pack displays in these stores. This raises the question
of whether participants actually saw the displays, indicating non-compliance with
legislation, or if they assumed that they had seen them because they had grown used
to seeing the displays prior to Phase 1.
Perceived exposure to people smoking cigarettes in movies and on TV was also found
to be relatively high in this study and efforts to reduce exposure warrants attention
in Australia. Although no association was found between exposure and smoking, other
studies have shown how portrayals of smoking in films or movies can increase susceptibility
to smoking [23].
Exposure to people smoking cigarettes in video games; tobacco brands, company names
and logos on the internet; and promotions or advertising for cigarettes or other tobacco
products at events or festivals, or in pubs, clubs, nightclubs or bars, while comparatively
low, was still reasonably common. In particular, almost one-quarter of participants
were using the internet for three or more hours each day, making the potential for
exposure via this medium quite high. Whilst no studies to the authors' knowledge have
assessed the impact of these forms of exposure on smoking-related cognitions and behaviours
among adolescents and young adults, it is possible that exposure to smoking through
these mediums may be undermining efforts to denormalise smoking.
This study demonstrates that adolescents in particular were at highest risk of exposure
to 'below-the-line' means of tobacco advertising or promotion, and that tobacco industry
marketing through the mediums studied are reaching this vulnerable population.
Strengths and limitations
Strengths of the TPIS are the large sample size, the representativeness of the sample,
the inclusion of a large number socio-demographic measures and that fact that it is
the only known study of its type in Australia monitoring exposure to tobacco promotion
in 'below-the-line' channels (at the PoS, on the internet and in entertainment media)
among adolescents and young adults.
There are, however, some limitations. Firstly, the study relies on self-reported exposure
not actual exposure to tobacco promotion. The measure of exposure to tobacco promotion
across a variety of channels relied on retrospective recall, possibly resulting in
some imprecision in measurement. Similarly, while the distinction between small and
large chain grocery stores in the Australian context is generally very obvious, this
may also have resulted in some imprecision in measurement. Secondly, the use of RDD
sampling frame will have resulted in systematic exclusion of mobile phone-only households.
However, this should not have overtly influenced the results as the proportion of
mobile-phone only households in Australia is relatively small [41,42]. Finally, the
results from this study may not be generalisable to adolescents and young adults from
other jurisdictions given the potential differences in tobacco control legislation
regarding promotion or marketing of tobacco.
Conclusions
Findings from this study highlight that 'below-the-line' means of tobacco promotion
are being noticed by young people in NSW, with high levels of exposure at the PoS
through cigarette pack displays and to portrayals of smoking in films or movies and
TV shows.
Exposure to tobacco promotion through video games, the internet and events is also
evident and of particular concern are the higher levels of exposure among adolescents
aged 12-17 years. Public health authorities need to not only monitor these trends,
but to address tobacco promotion in these forms through policy and practice.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
DAP conceived of the study, participated in its design and coordination, oversaw the
statistical analysis and drafted the manuscript. ACG conceived and performed the statistical
analysis, led the interpretation of results and helped to draft the manuscript. CR
advised on the statistical analysis, aided in the interpretation of results and helped
to draft the manuscript. JK participated in the design of the study and helped to
draft the manuscript. TC participated in the design of the study and helped to draft
the manuscript. SD participated in the design of the study, advised on the statistical
analysis and critically reviewed the manuscript. AB advised on the statistical analysis,
aided in the interpretation of results and critically reviewed the manuscript. All
authors read and approved the final manuscript.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2458/12/429/prepub