Exposure to point-of-sale tobacco advertising and children’s observed and reported interest in tobacco advertising: a cross-sectional study in Japan

Abstract

Introduction

Despite being a party to the WHO Framework Convention on Tobacco Control, Japan continues to rely largely on voluntary self-regulation of point-of-sale (POS) tobacco advertising. We examined the prevalence of exposure to POS tobacco advertising and children’s observed and reported interest in such advertising in Japan.

Methods

We analysed data from 6921 adults aged ≥18 years who lived with at least one child aged ≤12 years and participated in the 2023 Japan Society and New Tobacco Internet Survey. Weighted prevalence estimates were calculated using inverse probability weighting. Analyses were conducted stratified by adult participants’ tobacco product use status and sex.

Results

Overall, 17.8% (95% CI 16.7% to 19.0%) of adults reported exposure to POS tobacco advertising in the previous 6 months, and 3.1% (95% CI 2.6% to 3.7%) reported observing interest in such advertising among children with whom they lived. Children’s observed interest was more frequently reported among current users of conventional cigarettes or heated tobacco products (6.4%, 95% CI 4.6% to 8.8%) than among those who had never used either product (2.0%, 95% CI 1.5% to 2.7%).

Conclusions

POS tobacco advertising exposure remains common in Japan, and young children are still exposed to tobacco marketing. Mandatory regulation of POS tobacco advertising should be implemented to protect children from early exposure to tobacco marketing.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Point-of-sale (POS) advertising is a major channel of tobacco marketing and has been associated with youth exposure and tobacco-related outcomes in multiple countries. In Japan, POS advertising is regulated on a voluntary basis under guidelines issued by the Ministry of Finance and remains common in retail settings such as convenience stores, where children may be exposed to tobacco marketing materials.

WHAT THIS STUDY ADDS

• In a nationwide survey in Japan, approximately 3% of adult participants reported observing interest in POS tobacco advertising among children aged ≤12 years with whom they lived. Such interest was reported across categories of adult participants’ tobacco product use status.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• These findings support consideration of mandatory regulation of POS tobacco advertising to protect children in retail environments and better align Japan’s tobacco control policies with the objectives of the WHO Framework Convention on Tobacco Control.

Introduction

Tobacco advertising, promotion and sponsorship (TAPS) are well-established determinants of tobacco initiation and continued use, particularly when exposure occurs early in life.¹ Accordingly, Article 13 of the WHO Framework Convention on Tobacco Control (WHO FCTC) obligates Parties to implement comprehensive bans on all forms of TAPS or, where constitutional constraints exist, to impose effective restrictions.^2,3 As of 2023, only 66 of 195 countries worldwide have implemented comprehensive TAPS bans consistent with Article 13.⁴

Despite being a party to the WHO FCTC, Japan has not achieved the level of TAPS regulation envisioned by the Convention. Tobacco advertising in Japan is regulated on a voluntary basis by the Guidelines for Advertising on Manufactured Tobacco Products issued by the Ministry of Finance. The Guidelines recommend restrictions on displayed tobacco advertisements, such as posters and signs, to tobacco sales locations, smoking areas or places used only by people aged ≥20 years, and restrict the distribution of tobacco samples and promotional materials to people aged ≥20 years. However, tobacco advertising at points of sale remains permitted.⁵ Reflecting this regulatory gap, the WHO has rated Japan’s implementation of TAPS policies at the lowest level among four categories.⁴ Tobacco product use remains common in Japan. The WHO estimated that the age-standardised prevalence of current tobacco use among people aged ≥15 years in high-income countries was 22.2% in 2022.⁶ In Japan, the prevalence of current use in 2023 was 18.9% for conventional cigarettes and 12.4% for heated tobacco products (HTPs).⁷

Among the various forms of TAPS, point-of-sale (POS) advertising represents a major component of tobacco industry marketing expenditures⁸ and has been consistently shown to be associated with tobacco experimentation and initiation among youth.¹ By 2022, POS advertising had been banned in 114 countries,⁴ and evidence from multiple settings indicates that comprehensive POS bans are associated with reduced tobacco uptake.^1,3

In comparison with the abovementioned countries, POS tobacco advertising remains highly visible in Japan. The 2018 International Tobacco Control Japan Survey showed that store windows or the interiors of stores selling tobacco products were the most commonly reported channels of exposure to cigarette and HTP advertising in Japan.⁹ These retail environments raise concerns not only about adults’ exposure to POS advertising but also about children’s awareness of and interest in such marketing.

Population-based evidence regarding children’s interest in POS tobacco advertising in Japan, particularly in relation to adult participants’ tobacco product use status, remains limited. We aimed to examine the prevalence of adult participants’ exposure to POS tobacco advertising and children observed and reported interest in such advertising among households with children.

Methods

Study design and data source

This study used data from the Japan ‘Society and New Tobacco’ Internet Survey (JASTIS), an annual questionnaire-based internet survey that has been conducted since 2015.¹⁰ JASTIS recruits participants from a large nationwide online panel managed by Rakuten Insight, a major internet research company in Japan, and collects information on tobacco product use, exposure to tobacco marketing and sociodemographic characteristics. Details of the nationwide sampling and recruitment procedures have been described previously.¹⁰ For the present analysis, we used data from the 2023 survey wave. The response rate among previous JASTIS or Japan COVID-19 and Society Internet Survey (JACSIS) participants invited to the 2023 follow-up survey was 63.6%. JASTIS and JACSIS are supported by public research grants, including Health Labour Sciences Research Grants and JSPS KAKENHI.

Study population

For the present study, we restricted the analytic sample to respondents aged ≥18 years who reported living with at least one child aged ≤12 years at the time of the survey. Participants with missing information on key variables were excluded from the relevant analyses. The survey did not ascertain the relationship between the adult respondent and the child; therefore, respondents may have included not only parents but also other adult household members, such as grandparents or older siblings. Accordingly, we refer to respondents as ‘adult participants’ or ‘survey participants’ rather than as parents or guardians throughout this manuscript.

Measures

Exposure to POS tobacco advertising among adult participants

Adult participants’ exposure to POS tobacco advertising was assessed using the following question: ‘In the past 6 months, have you seen tobacco promotional displays or samples placed near cash registers in retail outlets (eg, convenience stores)?’ Participants who answered ‘yes’ were classified as having been exposed to POS tobacco advertising.

Children’s interest in POS tobacco advertising, as observed and reported by adults

Children’s interest in POS tobacco advertising was assessed based on reports from adult participants using the following question: ‘Has your child ever touched or shown interest in tobacco promotional displays or samples placed near cash registers in retail outlets (eg, convenience stores)?’ Response options included ‘Yes, within the past 1 year’, ‘Yes, more than 1 year ago’, ‘Never’ and ‘Don’t know’. Participants who answered ‘Yes, within the past 1 year’ were asked to report the child’s age at the time the interest was observed. For the present analysis, children’s observed and reported interest was defined as a report of interest within the past 1 year when the child was aged ≤12 years. Participants who did not meet these criteria were classified as not having reported such interest for the present analysis. If more than one child or more than one instance was applicable, participants were instructed to report the youngest age at which the interest was observed. No visual examples or photographs of POS tobacco advertising were provided in the questionnaire; therefore, participants’ assessments were based solely on textual descriptions. The questionnaire did not distinguish whether the tobacco promotional displays or samples were for conventional cigarettes, HTPs or other tobacco products.

Tobacco product use status

Respondents’ tobacco product use status was categorised as never, former use or current use based on self-reported use of conventional cigarettes and HTPs. For each product, respondents who reported never having used the product or having tried it but never used it regularly were classified as never users; those who reported having previously used it regularly but having quit were classified as former users; and those who reported using it occasionally or almost every day were classified as current users. Participants were then classified as current users if they currently used either conventional cigarettes or HTPs, former users if they were former users of either product and currently used neither product, and never users if they were classified as never users for both products.

Statistical analysis

We calculated unweighted and weighted proportions of respondents’ exposure to POS tobacco advertising and children’s observed and reported interest in POS tobacco advertising. To account for differences between the internet survey sample and the Japanese general population, inverse probability weighting was applied using data from the Comprehensive Survey of Living Conditions.^11,12 Weighted prevalence estimates and corresponding 95% CIs were calculated overall and stratified according to adult participants’ tobacco product use status and sex.

To describe the age distribution of children with observed and reported interest in POS tobacco advertising, we estimated survey-weighted age-specific percentages with 95% CIs, visualised using bar charts. All analyses were descriptive in nature and were conducted using Stata SE V.18.0 (StataCorp LLC).

Patient and public involvement

Patients and members of the public were not involved in the development of the research question, study design, recruitment, conduct or dissemination plans for this study.

Results

Respondents’ characteristics

Table 1 shows the characteristics of participants aged ≥18 years living with children aged ≤12 years (n=6921). Overall, 17.8% of participants reported exposure to POS tobacco advertising in the past 6 months and 82.2% reported no exposure. The age distribution was concentrated in the 25–44 year range, with 30.4% of respondents aged 25–34 years and 48.6% aged 35–44 years. Participants aged 55 years or older accounted for a small proportion of the sample (2.4%). Women comprised 54.5% of the weighted sample. Regarding educational attainment, 43.4% had completed high school, 23.8% had a vocational school or junior college education and 32.1% had an undergraduate or postgraduate education. In terms of household income, 43.8% reported an annual income of ≥6 000 000 JPY and 33.0% reported incomes of 3 000 000–6 000 000 JPY. Most participants were married (91.6%). Regarding tobacco use, 12.6% were current conventional cigarette users and 23.5% were former users. For HTPs, 14.0% were current users and 6.8% were former users.

Table 1. Characteristics of survey participants cohabiting with children aged ≤12 years (2023 Japan Society and New Tobacco Internet Survey).

	Cohabitation with children aged ≤12 years, n=6921
	Unweighted		Weighted
	n	%	n	%
Exposure to POS tobacco advertising
Yes	1158	16.7	1235	17.8
No	5763	83.3	5697	82.2
Age (years)
18–24	245	3.5	266	3.8
25–34	2290	33.1	2107	30.4
35–44	3294	47.6	3369	48.6
45–54	955	13.8	1027	14.8
55–64	75	1.1	81	1.2
64+	62	0.9	82	1.2
Sex
Male	2970	42.9	3155	45.5
Female	3951	57.1	3777	54.5
Level of education
High school	1324	19.1	3006	43.4
Vocational school, Junior college	1597	23.1	1652	23.8
Undergraduate, postgraduate	3963	57.3	2227	32.1
Other	37	0.5	47	0.7
Income (JPY)
<3 000 000	513	7.4	569	8.2
3 000 000–6 000 000	2032	29.4	2228	33.0
>6 000 000	3361	47.6	3033	43.8
Not stated	1015	14.7	1042	13.8
Marital status
Married	6382	92.2	6394	91.6
Unmarried	539	7.8	582	8.4
Conventional cigarettes
Never	4887	70.6	4428	63.9
Former	1341	19.4	1630	23.5
Current	693	10.0	874	12.6
HTP
Never	5713	82.6	5494	79.3
Former	399	5.8	469	6.8
Current	809	11.7	969	14.0
Tobacco product use status
Never	4749	68.6	4282	61.8
Former	988	14.3	1148	16.6
Current (CC or HTP)	1184	17.1	1502	21.7

Population of adults aged ≥18 years living with at least one child aged ≤12 years.

Former users were defined as participants who were former users of either conventional cigarettes or HTPs and currently used neither product.

CC, conventional cigarettes; HTP, heated tobacco product; POS, point of sale.

Children’s observed and reported interest in POS tobacco advertising and adult participants’ exposure

Online supplemental table 1 presents the prevalence of children’s observed and reported interest in POS tobacco advertising and adult participants’ exposure to POS tobacco advertising according to participant characteristics. Overall, 3.1% (95% CI 2.6% to 3.7%) of participants reported that their children showed interest in POS tobacco advertising, whereas 17.8% (95% CI 16.7% to 19.0%) of adult participants’ reported exposure to POS tobacco advertising. Children’s observed and reported interest in POS tobacco advertising was more frequently reported among participants who were current conventional cigarette smokers (6.5%, 95% CI 4.1% to 10.0%) and current HTP users (8.1%, 95% CI 5.8% to 11.3%), as compared with never users.

Adult participants’ exposure to POS tobacco advertising was higher among male participants (22.1%, 95% CI 20.1% to 24.2%) than among female participants (14.3%, 95% CI 12.7% to 16.1%). Higher exposure prevalence was also observed among current conventional cigarette smokers (33.0%, 95% CI 28.3% to 38.6%) and current HTP users (39.7%, 95% CI 35.1% to 44.5%), as compared with never users. Across socioeconomic characteristics, adult participants’ POS exposure ranged from 16.8% to 19.9% across income categories, with lower prevalence observed among participants who did not report their income (11.6%, 95% CI 9.0% to 14.9%). Figure 1 shows the age distribution of children aged ≤12 years for whom interest in POS tobacco advertising within the past year was observed and reported by adult participants.

Figure 1. Survey-weighted age distribution of children aged ≤12 years for whom interest in point-of-sale tobacco advertising within the past year was observed and reported by adult participants. Bars represent survey-weighted percentages at each age, and error bars indicate 95% CIs.

Estimated prevalence by adult participants’ tobacco product use and sex

Figure 2 shows the estimated prevalence of children’s observed and reported interest in POS tobacco advertising according to adult participants’ tobacco product use status and sex. In the total sample, the estimated prevalence of children’s observed and reported interest was 2.0% (95% CI 1.5% to 2.7%) among adult participants who were never users, 2.8% (95% CI 1.9% to 4.1%) among adult participants who were former users and 6.4% (95% CI 4.6% to 8.8%) among adult participants who were current users of conventional cigarettes or HTPs.

Figure 2. Estimated prevalence of children’s observed and reported interest in point-of-sale tobacco advertising, by tobacco product use status and adult participants’ sex. Panels show (a) tobacco product use (conventional cigarettes or heated tobacco products), (b) heated tobacco product use and (c) conventional cigarette use. Participants were adults aged ≥18 years living with at least one child aged ≤12 years. Bars indicate survey-weighted prevalence estimates, and error bars represent 95% CIs. Current use was defined as self-reported current use of the specified tobacco product at the time of the survey. HTP, heated tobacco product.

When stratified by tobacco product type, a similar gradient was observed. Among current HTP users, the prevalence of children’s observed and reported interest was 8.1% (95% CI 5.8% to 11.3%), compared with 2.2% (95% CI 1.7% to 2.8%) among never users. Among current conventional cigarette users, the corresponding prevalence was 6.5% (95% CI 4.2% to 10.0%), compared with 2.2% (95% CI 1.6% to 2.8%) among never users. Stratified analyses by adult participants’ sex showed comparable prevalence patterns among male and female participants.

Discussion

This study provides evidence on exposure to POS tobacco advertising among adults and children in Japan, using a nationwide survey. We found that 17.8% of adults reported exposure to POS tobacco advertising in everyday retail settings, and 3.1% of adult participants reported that young children with whom they lived had touched or shown interest in such advertising. Children’s observed and reported interest in POS advertising was reported across households regardless of adult participants’ tobacco product use status, but the proportion being higher among current users of conventional cigarettes and HTPs than those who had never used either product. The age distribution further showed that observed and reported interest in POS tobacco advertising was reported even among young children.

These findings are broadly consistent with those of previous studies from other countries demonstrating that POS tobacco advertising remains a key source of marketing exposure for children in retail environments.^9,13 Studies conducted in settings with limited POS regulation have similarly reported substantial exposure among families with young children whereas jurisdictions that have implemented comprehensive POS advertising bans have observed marked reductions in youth exposure.¹⁴

The present findings are noteworthy in light of Japan’s current regulatory framework for tobacco advertising. Although the Tobacco Business Act and its associated Guidelines emphasise the prevention of smoking among persons under 20 years of age and call for avoidance of excessive advertising, POS tobacco advertising remains highly visible in retail environments that are routinely accessed by children.^5,9 The observed and reported interest in POS tobacco advertising among children in the present study suggests that existing voluntary self-regulatory measures may be insufficient to prevent children’s exposure to POS tobacco advertising in practice. This falls short of the comprehensive approach to TAPS required under Article 13 of the WHO FCTC.^2,3 This is of public health concern because previous research has shown that POS tobacco advertising is associated with increased purchasing among people who currently smoke and with tobacco experimentation and initiation among youth.^9,13,15

Repeated exposure to tobacco marketing in routine settings such as convenience stores may contribute to the normalisation of tobacco products and reduce perceptions of harm.¹⁶ Although we did not assess causal relationships in our study, the reported exposure observed in the present study underscores the potential public health implications of continued POS advertising in settings frequented by children. Taken together, these findings highlight a gap between Japan’s stated policy objectives under the WHO FCTC and the realities of tobacco marketing exposure at the POS.⁴ Mandatory regulatory measures targeting POS tobacco advertising should be implemented to better protect children from exposure to tobacco marketing, with tobacco control Non-governmental organizations and other civil society groups playing an important role in raising awareness, disseminating evidence, and advocating for stronger protections.

Limitations

Several limitations should be considered when interpreting the present findings. First, children’s observed and reported interest in POS tobacco advertising was assessed based on reports by adult participants. In households with multiple children, interest was reported at the household level, and the number of individual children who showed interest could not be determined. As a result, the prevalence estimates may underestimate the total number of children who showed interest. In addition, the survey did not assess whether adult participants visited retail outlets together with the children with whom they lived. Therefore, differences in opportunities for children to encounter POS tobacco advertising may have influenced the estimates.

Second, exposure to POS tobacco advertising was assessed using questionnaire items based on textual descriptions of promotional displays and samples placed near cash registers, without providing visual examples or photographs. Respondents’ interpretations of what constituted POS tobacco advertising may therefore have varied across retail settings, potentially leading to misclassification and underestimation of exposure, particularly in environments where promotional materials are less salient to adults but still visible or accessible to children. In a future survey, we are considering incorporating visual examples, such as photographs of common POS advertising.

Third, the use of an internet-based survey may limit generalisability. However, previous JASTIS studies have demonstrated that applying inverse probability weighting based on national census data can partially mitigate selection bias and improve comparability with nationally representative samples.¹¹

Finally, because exposure to POS tobacco advertising and children’s observed and reported interest were assessed at a single point in time, the temporal sequence between exposure and interest could not be established. Accordingly, our findings should be interpreted as descriptive and hypothesis-generating rather than causal.

Conclusions

POS tobacco advertising exposure remains common in Japan, and a measurable proportion of adult participants reported that young children with whom they lived had touched or shown interest in POS tobacco advertising in everyday retail environments. Mandatory regulation of POS tobacco advertising should be implemented to protect children from exposure to tobacco marketing.

Where authors are identified as personnel of the International Agency for Research on Cancer/World Health Organization, the authors alone are responsible for the views expressed in this article. These do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer/World Health Organization.

Data availability statement

Data are available upon reasonable request.