Title: Determining the Impact of Smoking Point of Sale Legislation Among Youth (DISPLAY) Study
Funder: Chief Scientist Office, Scotland

Abstract: Aim: The aim of the study is to assess the impact of the TPMS (Scotland) Act 2010 (that bans of point of sale (POS) advertising) on young people’s exposure to tobacco advertising, their attitudes towards smoking and their smoking behaviour. Design & Setting: We propose a before and after study of four communities with data collection at baseline before implementation of legislation in April 2013 and longitudinal follow-up for four years. Data collected in early 2015 will also provide baseline data to assess the impact of full implementation in all retail outlets. Community is defined as the catchment areas of schools selected for study. Schools will be purposively selected to reflect two levels of urbanisation (urban vs. small town) and two levels of social deprivation (high vs. medium, low). There are four main components to the study. In each community there will be: 1. An annual mapping study of tobacco retail outlets: Data for all outlets selling tobacco in each of the study communities will be extracted annually from the Register of Tobacco Retailers established under the Tobacco and Primary Medical Services (Scotland) Act. In Geographical Information Systems (GIS), the geo-coded outlet data will be combined with data from the marketing audit study (see below) and then analysed to provide an assessment of changes in tobacco vending and advertising over the study period. Further, tobacco retailing exposure measures will be constructed for each of the study participants at each time point. 2. An annual tobacco advertising and marketing audit of: i) A Panel of tobacco retailers (overt): A panel of 7 retailers per community will be recruited to monitor point of sale displays and related marketing activity. Data collected will include: visibility/placement of tobacco products; external and internal promotions; variety of/most prominent brands and pack sizes available; visibility of pricing information and price of key brands: tobacco control signage. Photographs of the interior will be taken and depth interviews will be conducted with retail managers/owners. ii) Tobacco retail outlets most used by young people (covert): All outlets identified in the mapping exercise will be visited by interviewers trained in covert observation. Data will be collected using an abbreviated version of the form used with the retailer panel. There will be additional data collection for both i) and ii), in May 2013 to assess compliance in supermarkets, and in May 2015 to assess compliance in all retail outlets 3. An annual school survey: This will have repeat cross-sectional design, in two phases. In phase 1 (2013-14), data will be collected from a sample of S2 and S4 pupils to explore the impact of partial implementation in supermarkets alone on awareness and attitudes. In phase 2 (2015-17), the survey will be repeated with a whole school sample (S1-S6), which will be of sufficient size to explore the impact of a complete ban in all retail outlets on both intermediate outcomes and longer term smoking behaviour outcomes. 4. Annual Focus groups: These will be conducted with school survey participants, purposively selected to include young people who are most at risk of becoming adult smokers. The topic guide will cover: local smoking behaviours and cultures; access to tobacco products including direct, indirect/proxy and black-market; awareness of and views on tobacco promotion including point of sale, other direct marketing methods, packaging, branding; awareness and perceptions of the impact of the legislation; views about preventing youth smoking. Outcomes: Using available evidence we have developed a logic model, which classifies outcomes according to the time-frame within which we expect them to occur. Short-term outcomes (within 6 months) include: Prevalence and density of POS advertising in tobacco retail outlets (mapping and audit studies). Intermediate outcomes (within 1 year) include: Awareness of point of sale advertising; Cigarette brand awareness; Perceived ease of access to cigarettes; Attempts to purchase cigarettes; Perceived youth smoking prevalence; Pro-tobacco attitudes (from the school surveys). Long-term outcomes (within 3 years) include: Incidence and prevalence of smoking (from the school surveys). Qualitative data will be collected via focus group interviews. Additionally the study will assess any unintended or adverse consequences associated with the legislation including: increase in purchases from black market sources or proxy purchases; and introduction of new strategies by retailers or tobacco industry to circumvent the regulations. Planned Analyses: Data from study components 1 to 3 will be integrated into 1 dataset. The primary analyses around implementation in supermarkets will focus on estimating the change in POS advertising between baseline (T0) and T1b and its relationship with intermediate attitudinal outcomes. In addition to the above, the primary analyses around implementation in small shops will also examine the impact of full implementation on behavioural outcomes. Specifically, we will: i) Examine change in exposure to tobacco advertising, access to tobacco products and attitudes towards smoking between T2 (baseline) and T3a-c for total sample – with sub-group analyses; ii) Examine change in incidence of regular smoking and smoking prevalence between baseline at T2 and T3b and T3c ; and iii) Assess if there is a of a dose-response relationship between changes in POS advertising or changes in availability of cigarettes and other study outcomes. Qualitative data will provide contextual data within which to interpret quantitative data and enable us to understand the mechanisms by which the legislation works. Using GIS we will develop methods of depicting data from across the study components using spacial analytical techniques. Figure 1 in attached pdf provides an overview of the study design, flow of study participants and timetable, together with a logic model, power calculation and project milestones.

Lay abstract: Smoking is the single most preventable cause of ill health, death and health inequalities in Scotland. Every year around 15,000 young people start smoking and many go on to become regular smokers. Tobacco advertising and marketing activity is an important factor in this and has been shown to influence adolescent smoking intentions, perceived smoking prevalence and the uptake of smoking. By 2005 most tobacco advertising and sponsorship had been banned in Scotland and the rest of the UK, but point of sale (POS) tobacco displays, which have become increasingly elaborate and prominent in recent years, is one of the few remaining ways by which the tobacco industry can legitimately promote their products. New legislation will come into force in Scotland in April 2013 that bans POS tobacco advertising in supermarkets. The ban will be extended to all retail outlets in April 2015. A recent systematic review found that, in children, POS displays increased: susceptibility to smoking; experimentation; and initiation into smoking. We therefore, believe that the legislation has the potential to have a major impact on young people’s attitudes to smoking and smoking behaviour and in the longer term reduce health inequalities. The aims of the study are to assess the impact of measures in The Tobacco and Primary Medical Services (Scotland) Act 2010 that ban of point of sale (POS) tobacco displays and advertising on young people’s exposure to tobacco advertising, their attitudes towards smoking and their smoking behaviour. We propose a before and after study of four purposively selected communities with data collection at baseline in early 2013 with longitudinal follow-up for four years. For the purposes of the study, community is defined as the catchment areas of schools selected for study. Schools will be selected to reflect two levels of urbanisation (urban vs. small town) and two levels of social deprivation (high vs. medium, low). There are four main components to the study. In each of the four communities there will be: 1) An annual mapping study of tobacco retail outlets; 2) An annual tobacco advertising and marketing audit of i) all tobacco retail outlets most used by young people and ii) a panel of tobacco retailers, (with additional follow ups immediately post-legislation implementation in May 2013 in supermarkets and May 2015 in all retail outlets to assess compliance); 3) An annual cross-sectional school survey of school children; 4) Annual focus group interviews with purposive samples of school children. In the analyses, we will explore the relationship between changes in the prevalence and density of POS tobacco advertising (from the mapping and tobacco advertising and marketing audit studies) and awareness of point of sale advertising; cigarette brand awareness; perceived ease of access to cigarettes; attempts to purchase cigarettes; perceived youth smoking prevalence; pro-tobacco attitudes and the uptake and prevalence of smoking (from the school surveys). Qualitative data on all the intermediate outcomes will be collected in the focus group interviews will allow us to interpret findings from the quantitative studies. The assembled multi-disciplinary research team has considerable expertise in: the conduct of complex evaluations; smoking in young people; the conduct of school surveys; tobacco marketing strategies; and geographical mapping. The Lead Applicant also previously led a multi-disciplinary research team in a complex evaluation of Scotland's smoke-free legislation. Three of the current applicants were involved in this internationally influential evaluation. This unique study is of considerable interest to both policy maker from Scotland and other jurisdictions considering similar legislation, which justifies the funding requested.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;RESPIRATORY;STROKE