A recent prospective cohort study examined the relationship between self-reported exposure to marketing for tobacco products and initiation of tobacco use. Participants (N = 2,097) were 11^th and 12^th grade students drawn from 12 communities that were part of the Southern California Children’s Health Study. Participants completed a baseline survey while they were in high school, as well as follow-up survey about 16 months later (n = 1,553; 74.1% follow-up rate). Measures on both surveys included lifetime use of cigarettes, e-cigarettes, hookah, cigars or little cigars, smokeless tobacco, and pipe tobacco. Age of first use and frequency of past-month use were assessed for each product participants reported they had used. Based on these responses, participants were classified as never users (those who reported no use at baseline and follow-up) or initiators (those who reported no use at baseline, but use at follow-up). At baseline, exposure to promotion of the aforementioned six tobacco products was assessed across five marketing channels (internet, print media, point-of-sale advertising, outdoor advertising, and film advertising) via self-report. Responses to exposure levels were condensed into high and low exposure; responses in the middle were eliminated from analyses. Survey results indicated 58.7% of participants saw ads for cigarettes in stores most or all of the time, compared to 43.1% for e-cigarettes and 25.3% for hookah. Exposure to outdoor advertisements (i.e., billboards) was most frequently reported for cigarettes (18.1%). Participants reported being exposed to internet marketing more frequently for e-cigarettes (10.1%) than for other tobacco products. The authors employed mixed effects logistic regression models to evaluate the association between perceived exposure to tobacco product marketing at baseline and tobacco use initiation status at follow-up. Separate models were used to investigate exposure to marketing for a particular type of product and subsequent initiation of that product and the six types of tobacco products combined, as well as exposure through a particular marketing channel and initiation outcomes. Results of these analyses indicated participants who had never used cigarettes at baseline were more likely to report using them by the follow-up survey if they had been exposed to online cigarette marketing (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.56 – 5.66) or in stores (OR: 2.83; 95% CI: 1.23 – 6.50). Participants were more likely to initiate e-cigarette use following exposure to e-cigarette marketing online, inside stores, and outdoors. Participants who reported frequent exposure to online tobacco product advertising were three to four times more likely to begin using cigarettes and e-cigarettes as young adults, compared to youth with no exposure (cigarette OR: 3.05; 95% CI: 1.10 – 8.40; e-cigarette OR: 4.52; 95% CI: 1.81 – 11.29). Finally, among participants who reported frequent exposure to marketing for non-cigarette tobacco products in stores, the odds of cigarette use initiation at follow-up were two to three times higher, compared to their peers who did not report frequent marketing exposure at baseline. Exposure to online non-cigarette product marketing was also associated with subsequent cigarette use initiation.

Take away: This prospective cohort study documented that adolescents who reported frequent exposure to marketing for a specific tobacco product in high school were significantly more likely to initiate use of that product one and a half years later. Additionally, frequent exposure to marketing for non-cigarette tobacco products was associated with greater likelihood of cigarette use at follow-up.

Boley Cruz, T., McConnell, R., Wagman Low, B., Unger, J.B., Pentz, M.A., Urman, R., Berhane, K., Chou, C.P., Liu, F. & Barrington-Trimis, J. (2018). Tobacco marketing and subsequent use of cigarettes, e-cigarettes and hookah in adolescents. Nicotine & Tobacco Research [published online ahead of print May 28, 2018] doi: 10.1093/ntr/nty107