Frequency and Characteristics Associated With Exposure to Tobacco Direct Mail Marketing and Its Prospective Effect on Smoking Behaviors Among Young Adults From the US Midwest

Abstract

Objectives. We examined the exposure to tobacco direct mail marketing and its effect on subsequent smoking behaviors in a US Midwest regional cohort of young adults.

Methods. Data were collected from 2622 young adults (mean age = 24 years) in 2010 to 2011 (baseline) and 2011 to 2012 (follow-up). We collected information on demographics, tobacco use, and exposure to tobacco direct mail materials in the previous 6 months at baseline. Smoking behaviors were reassessed at follow-up. We investigated the characteristics associated with receiving these materials at baseline, and the associations between receiving cigarette coupons in the mail at baseline and smoking behaviors at follow-up.

Results. Thirteen percent of participants reported receiving tobacco direct mail materials in the previous 6 months. Receipt of these materials was associated with age, education, and tobacco use (P < .05). Among those who received these materials, 77% and 56% reported receiving coupons for cigarettes and other tobacco products, respectively. Among baseline nonsmokers and ex-smokers, receiving coupons was associated with becoming current smokers at follow-up (P < .05). Among baseline current smokers, receiving coupons was associated with lower likelihood of smoking cessation at follow-up (P < .05).

Conclusions. Tobacco direct mail marketing promoted and sustained smoking behaviors among US Midwest young adults. Regulating this marketing strategy might reduce the prevalence of smoking in this population.

It has been 50 years since the first Surgeon General’s report on smoking and health released in 1964. Since then, more than 20 million people in the United States have died because of smoking.¹ Smoking remains an important public health problem today. Currently, more than 480 000 deaths in the United States annually are attributed to smoking.¹ Smoking is particularly prevalent among young adults: 31.8% of young adults (aged 18–25 years) were current smokers in 2012, compared with 22.0% in the overall adult population (aged ≥ 18 years).¹ Additionally, more than 50% of those who ever smoked daily reported starting daily smoking between the ages of 18 and 30 years.¹ This indicates that these 12 years represent a critical period for developing smoking behaviors, and understanding factors that promote smoking behavior during this period might inform interventions to reduce the prevalence of smoking in the population.

Tobacco marketing is one of the factors that promote smoking, particularly among youths.^2–4 However, few studies have examined exposure to tobacco direct mail marketing and its effects on smoking behaviors among young adults. One study reported data from the New Jersey Adult Tobacco Survey 2001 (participants aged ≥ 18 years), which found that 11% of never or former smokers, 22% of recent quitters, and 35% of current smokers reported receiving direct mail materials from a tobacco companies in the previous 6 months.⁵ However, the cross-sectional design of the survey did not allow investigation of the effect of receiving these materials on subsequent smoking behaviors. We previously published the first longitudinal study in the United States examining the exposure to tobacco direct mail marketing in a cohort of adolescents and young adults from the US Midwest region.⁶ We found that 11% of 18- to 23-year-old participants (6% of nonsmokers and 24% of current smokers) reported receiving tobacco direct mail materials in 2006 to 2007 and that receipt of these materials was positively associated with smoking behaviors 6 months later in the overall adolescent and young adult sample. However, our previous analysis had limitations. First, the analysis pooled adolescents (who could not legally purchase tobacco products) with young adults, which might underestimate the effect of receiving these materials on subsequent smoking behaviors. Second, we did not assess the types of direct mail materials received. The effect of tobacco direct mail materials might differ by type of direct mail materials, particularly when some of these materials are coupons that offer discounts for tobacco products and others are simply advertisements.

In this study, we analyzed the data from the Minnesota Adolescent Community Cohort (MACC) Study collected when the participants were between the ages of 20 to 28 years. We assessed the prevalence and frequency of, and characteristics associated with receiving tobacco direct mail materials in this young adult sample. We also examined the type of materials received, and characteristics associated with receiving coupons for tobacco products in the mail. Finally, we assessed the effects of receiving cigarette coupons in the mail on subsequent smoking behaviors in this young adult sample. Findings from this study will provide evidence concerning regulation of tobacco direct mail marketing.

METHODS

The details of the design of the MACC study can be found elsewhere.⁷ Briefly, participants in the MACC study were selected in 2000 to 2001 through cluster random sampling of household phone numbers. Sixty geopolitical units (GPUs) in Minnesota (out of 126) were randomly selected. Five GPUs from 4 comparison states (North and South Dakota, Michigan, and Kansas) were chosen because of their similarity to Minnesota. We used modified random digit dialing and a combination of probability and quota sampling methods to obtain an even distribution of youths from ages 12 to 16 years.

Of the eligible households, 3636 participants in Minnesota and 605 participants in comparison states were recruited (recruitment rates of 58.5% and 58.3% respectively). An additional cohort of 585 twelve-year-old youths from the 60 Minnesota GPUs was recruited by using the same modified random digit dialing method during 2001 to 2002 (a recruitment rate of 63.6%), resulting in an overall sample of 4826. Participants were surveyed every 6 months through 2007 to 2008, and then annually between 2008 and 2013 through computer-assisted telephone interviews by using phone numbers provided by the participants (including mobile phone numbers). Recruitment and interviews were conducted by Clearwater Research, Inc. (Boise, ID). Participants (mean age = 24 years) who participated in the 2010 to 2011 data collection (baseline for this analysis, conducted between October 2010 and March 2011) were included in the analysis (n = 2622). Of those, 2186 (83.4%) participated in the 2011 to 2012 data collection (follow-up for this analysis, conducted between October 2011 and March 2012). Participants who had lower education and were heavier smokers were more likely to drop out from the study between baseline and follow-up (P < .05).

We collected demographics (age, gender, race/ethnicity, education) at baseline. Participants were classified into non-Hispanic White versus other because of the small number of participants in the other racial/ethnic groups (Black, Hispanic, Asian, Native American, and other), reflective of the racial/ethnic composition in the US Midwest region. Participants were asked at baseline to report if they had at least 1 close friend who smokes. To assess tobacco use behaviors at baseline, we asked participants about the number of cigarettes smoked in their lifetime and number of days smoked in the past 30 days. Responses to these items were used to categorize participants into nonsmokers (smoked < 100 cigarettes in a lifetime and did not smoke in the past 30 days), ex-smokers (smoked ≥ 100 cigarettes in a lifetime but did not smoke in the past 30 days), and current smokers (smoked ≥ 100 cigarettes in a lifetime and in the past 30 days; further categorized into smoking > 20 days in the past 30 days or not). Participants also reported ever and past-30-day use of snus and chewing tobacco, and were classified into never users, ever users (tried but did not use in the past 30 days), and current users (used in the past 30 days). Current smokers were asked to report whether they intended to quit smoking in the next year (yes or no).

Exposure to tobacco direct mail marketing was assessed at baseline by the item, “have you received an advertisement, gift or coupons in the mail from a tobacco company in the past six months?” Participants who had received these materials in the mail were then asked the number of times they received these materials and whether they had received the following categories of direct mail materials: coupons for cigarettes, coupons for tobacco products other than cigarettes, advertisements for cigarettes, advertisements for tobacco products other than cigarettes, and free merchandise. Those who received coupons for tobacco products were asked if they had redeemed the coupons, had given them to someone, or had thrown them away. At follow-up, we assessed whether the participants smoked in the past 30 days. Baseline nonsmokers and ex-smokers who reported smoking in the past 30 day at follow-up were classified as becoming current smokers, and baseline current smokers who stopped smoking in the past 30 days were classified as having quit smoking. Baseline current smokers were also asked if they had attempted to quit smoking in the past 12 months.

Statistical Analysis

Descriptive statistics were presented for exposure to tobacco direct mail marketing. We used logistic regression models to assess baseline characteristics associated with receipt of any tobacco direct mail materials (including coupons and advertisements for cigarettes and other tobacco products, and free merchandise), receipt of coupons for cigarettes in the mail, and receipt of coupons for other tobacco products in the mail. Two sets of models were employed in these analyses. The first set of models included only demographics, and the second set of models additionally included peer smoking and tobacco use behaviors at baseline. When assessing the associations between receiving cigarette coupons in the mail at baseline and smoking behaviors at follow-up, we stratified the analysis by baseline smoking status. Among baseline nonsmokers and ex-smokers, we assessed the association between receiving cigarette coupons in the mail at baseline and becoming a current smoker at follow-up, adjusting for demographics and peer smoking in a logistic regression model. Among baseline current smokers, we assessed the effect of receiving cigarette coupons at baseline on attempts to quit smoking in the past 12 months and smoking cessation in 2 separate logistic regression models, both adjusted for demographics, peer smoking, and intention to quit smoking at baseline. Including GPU as a random effect controlled for clustering by design. We performed all analyses in PC-SAS version 9.2⁸ using PROC GLIMMIX.

RESULTS

Of 2622 participants, 12.8% (n = 336) reported receiving tobacco direct mail materials in the previous 6 months. Although 70.4% of those who received these materials reported receiving them 1 to 3 times in the previous 6 months, 18.5% reported receiving them 6 or more times during the same period of time. Characteristics of the sample are reported in Table 1. Age, having at least 1 friend who smokes, tobacco use (cigarettes, snus, and chewing tobacco) were positively associated with receiving tobacco direct mail materials (P < .05), while education was negatively associated with receiving these materials in the previous 6 months (P < .05).

TABLE 1—

Characteristics Associated With Receipt of Any Tobacco Direct Mail (DM), Coupons for Cigarettes, and Coupons for Other Tobacco Products (OTP) Among Young Adults (n = 2622): Minnesota Adolescent Community Cohort (MACC) Study, 2010–2011

		Received DM		Received Cigarette Coupons		Received OTP Coupons
Characteristics	No.	%	AOR (95% CI)	%	AOR (95% CI)	%	AOR (95% CI)
Age (mean = 24.0 y; SD = 1.7 y)	. . .	. . .	1.09* (1.02, 1.17)	. . .	1.17* (1.08, 1.27)	. . .	1.11* (1.01, 1.21)
Gender
Male	1240	13.9	1.12 (0.89, 1.42)	9.4	0.84 (0.64, 1.11)	9.1	1.70 (1.24, 2.32)
Female	1382	11.9	1.00 (Ref)	10.1	1.00 (Ref)	5.4	1.00 (Ref)
Race/ethnicity
Other	277	14.1	1.01 (0.70, 1.47)	10.5	0.95 (0.62, 1.46)	7.6	1.00 (0.62, 1.62)
Non-Hispanic White	2345	12.7	1.00 (Ref)	9.7	1.00 (Ref)	7.1	1.00 (Ref)
Education
4-y college	1555	7.5	0.29* (0.21, 0.39)	4.9	0.22* (0.16, 0.32)	3.9	0.33* (0.22, 0.49)
2-y college	654	19.6	0.86 (0.63, 1.17)	16.1	0.53 (0.59, 1.15)	11.9	1.09 (0.74, 1.61)
≤ high school	409	22.3	1.00 (Ref)	18.3	1.00 (Ref)	11.4	1.00 (Ref)
≥ 1 friend who smokes
Yes	1387	19.5	2.04* (1.47, 2.82)	15.6	2.13* (1.43, 3.18)	11.0	1.69* (1.08, 2.63)
No	1233	5.4	1.00 (Ref)	3.2	1.00 (Ref)	2.8	1.00 (Ref)
Cigarette smokinga
Current, > 20 d in the past 30 d	344	39.0	4.77* (3.34, 6.80)	35.8	8.04* (5.31, 12.18)	25.3	7.38* (4.55, 11.96)
Current, ≤ 20 d in the past 30 d	288	17.4	1.91* (1.28, 2.86)	12.5	2.71* (1.68, 4.39)	10.1	2.54* (1.47, 4.41)
Ex-smokers	316	15.8	1.85* (1.25, 2.74)	12.7	2.59* (1.64, 4.08)	10.1	3.00* (1.79, 5.04)
Nonsmokers	1670	6.1	1.00 (Ref)	3.4	1.00 (Ref)	2.3	1.00 (Ref)
Snus use
Current	84	36.9	2.89* (1.55, 5.38)	22.6	2.27* (1.09, 4.73)	28.6	3.87* (1.93, 7.74)
Ever but not current	299	23.8	1.51* (1.00, 2.29)	17.1	1.13 (0.81, 2.10)	17.1	2.09* (1.27, 3.43)
Never	2239	10.5	1.00 (Ref)	8.3	1.00 (Ref)	5.0	1.00 (Ref)
Smokeless tobacco use (chew)
Current	155	31.0	1.92* (1.13, 3.27)	16.8	1.15 (0.60, 2.18)	25.2	1.98* (1.09, 3.61)
Ever but not current	335	17.6	1.08 (0.71, 1.64)	14.3	1.14 (0.71, 1.83)	9.9	0.76 (0.45, 1.30)
Never	2132	10.7	1.00 (Ref)	8.5	1.00 (Ref)	5.4	1.00 (Ref)

Note. AOR = Adjusted odds ratio; CI = confidence interval. Estimates for demographic variables were adjusted for each other only, and estimates for other variables were adjusted for all variables in the table.

^aCigarette smoking was categorized as current smokers (smoked ≥ 100 cigarettes in a lifetime and in the past 30 days; further categorized into smoking > 20 days in the past 30 days or not), nonsmokers (smoked < 100 cigarettes in a lifetime and did not smoke in the past 30 days), ex-smokers (smoked ≥ 100 cigarettes in a lifetime but did not smoke in the past 30 days).

*P < .05.

Among those who received these materials in the previous 6 months, 59.5% reported receiving materials under the brand name Camel, and 36.6% under the brand name Marlboro. Additionally, 76.2% received coupons for cigarettes, 65.2% received advertisements for cigarettes, 60.7% received advertisements for other tobacco products, 55.7% received coupons for other tobacco products, and 25.9% received free merchandize. Characteristics associated with receiving coupons for cigarettes and for other tobacco products in the mail were similar to those associated with receiving tobacco direct mail materials in general (Table 1). However, participants who currently used snus were more likely than those who had never used snus to receive coupons for cigarettes in the mail (P < .05). Participants who were current or former smokers were more likely than nonsmokers to receive coupons for other tobacco products (P < .05).

Among participants who received coupons for cigarettes in the mail (n = 254), 35.8% redeemed them to purchase cigarettes, 27.6% gave them to someone else, and 32.3% discarded them. Among those who received coupons for other tobacco products in the mail (n = 185), 14.6% redeemed them to purchase cigarettes, 23.8% gave them to someone else, and 60.0% discarded them. Baseline nonsmokers and ex-smokers who received cigarette coupons in the mail were more likely than those who did not receive cigarette coupons in the mail to become current smokers at follow-up, after adjusting for demographics and peer smoking (P < .05; Table 2). Baseline current smokers who received cigarette coupons in the mail were less likely than those who did not receive cigarette coupons in the mail to have attempted to quit smoking and have quit smoking at follow-up, after adjusting for demographics, peer smoking, and intention to quit smoking at baseline (P < .05; Table 2).

TABLE 2—

Association Between Receipt of Cigarette Coupons in the Mail in 2010–2011 and Smoking Behaviors in 2011–2012: Minnesota Adolescent Community Cohort (MACC) Study

Smoking Behaviors	Received Cigarette Coupons in 2010–2011, No. (%)	Did Not Receive Cigarette Coupons in 2010–2011, No. (%)	AOR (95% CI)
Nonsmokers in 2010–2011 who became current smokers in 2011–2012	10 (13.0)	89 (5.5)	2.29* (1.11, 4.75)
Smokers in 2010–2011 who attempted to quit smoking in the past 12 mo in 2011–2012	60 (58.8)	224 (75.2)	0.53* (0.32, 0.89)
Smokers in 2010–2011 who quit smoking in 2011–2012	13 (11.1)	96 (25.9)	0.51* (0.26, 0.99)

Note. AOR = Adjusted odds ratio; CI = confidence interval. Nonsmoker model was adjusted for age, gender, race/ethnicity (White/non-White), education, and peer smoking measured in 2010–2011. Smoker models were adjusted for age, gender, race/ethnicity (White/non-White), education, peer smoking, and intention to quit smoking in a year measured in 2010–2011.

*P < .05.

DISCUSSION

Few studies have examined the prevalence of tobacco direct mail marketing and its effect on smoking behaviors. The lack of research in this area represents a missed opportunity for tobacco control because tobacco companies spend more money on direct mail marketing and providing coupons than advertising in magazines, in newspapers, on the Internet, and at point of sale combined.⁹ Direct mail marketing is a specific means that tobacco companies use to distribute coupons. We found that, among a cohort of young adults originally from the US Midwest, more than 1 out of 10 had received direct mail materials from the tobacco companies in the previous 6 months, and among those who received these materials, 18% received them at least once a month on average, 76% received coupons for cigarettes, and 56% received coupons for other tobacco products. These findings suggest that tobacco companies are successful in using direct mail marketing to reach young adults, a population still developing their smoking behaviors. Future studies need to examine the prevalence of receiving coupons for tobacco products from all sources to better gauge the magnitude of the issue.

As expected, tobacco use was associated with exposure to tobacco direct marketing in our sample: heavier smokers were more likely to have received tobacco direct mail materials in general and coupons for cigarettes specifically, and current snus and chewing tobacco users were more likely to have received coupons for tobacco products other than cigarettes. However, we also observed that current and ex-smokers were also more likely than nonsmokers in our sample to have received coupons for tobacco products other than cigarettes, and current snus users were more likely than nonusers to have received coupons for cigarettes in the mail. This may indicate that tobacco companies are promoting polytobacco use through their direct mail marketing strategy. Snus users may experiment with cigarettes because of the price discounts offered by these coupons, and subsequently use both snus and cigarettes. Smokers who do not use other tobacco products may take advantage of price discounts (sometimes even free samples) offered by coupons for other tobacco products and experiment with other tobacco products and become polytobacco users.¹⁰ This would allow them to obtain nicotine at places where they cannot smoke, and hinder smoking cessation. Given that polytobacco use is more prevalent among young adults aged 18 to 25 years,¹ additional studies are needed to examine the effect of tobacco marketing on polytobacco use in this population.

We observed that young adults with lower education in our sample were more likely to have received tobacco direct mail materials in general, and coupons for cigarettes and other tobacco products specifically. Because receipt of tobacco direct mail and redemption of coupons were associated with subsequent smoking behaviors among youths and adults,^6,11 this differential exposure to tobacco direct mail marketing might in part explain the tobacco use disparities by socioeconomic status among young adults.^1,12,13

Our findings indicated that cigarette coupons, when delivered through the mail, were associated with becoming a current smoker among young adult nonsmokers and ex-smokers in our sample. The effect did not differ between nonsmokers and former smokers in a stratified analysis, although the estimates did not reach statistical significance because of reduced sample sizes. This suggests that discount coupons for cigarettes can promote smoking among nonsmokers and relapse among ex-smokers. Additionally, smokers who received these coupons were less likely than those who did not to subsequently attempt to and quit smoking. This concurs with a previous study showing that adult smokers who redeemed cigarette coupons from all sources were less likely than those who did not receive cigarette coupons to subsequently quit smoking.¹¹ These findings suggest that regulating tobacco coupons (and other price discounting strategies) may help reduce the prevalence of tobacco use in the young adult population. Recently, Providence, Rhode Island, and New York City, New York, adopted regulations to either prohibit redemption of tobacco coupons or any tobacco price discounting practice (including coupons and in-store promotions). National prospective studies are needed to investigate the impact of these tobacco-marketing strategies on smoking behaviors and to inform policy interventions at the state and federal levels.

Given our sample originally was from the US Midwest, and most of the participants were non-Hispanic White, our findings might not be generalizable to regions that have a higher racial/ethnic diversity. Our young adult sample (aged 20–28 years) also limited the generalizability of our findings to other age groups. Attrition over the duration of the study may bias our findings. Specifically, heavier smokers were more likely than lighter smokers and nonsmokers to drop out from the study. It is not clear if the prevalence of receiving tobacco direct mail among smokers who were lost to follow-up was the same as those who remained in the study. However, because we observed that heavier smokers were more likely to have received tobacco direct mail, we believe the differential attrition would lead to underestimation of the prevalence of receiving tobacco direct mail materials as smokers (who were more likely to receive these materials) were more likely than nonsmokers to drop-out from the study. Nonetheless, because we controlled for the characteristics associated with attrition (including smoking status), our estimates on the associations between receiving cigarette coupons in the mail and subsequent smoking behaviors should not be severely biased. Despite these limitations, findings from the current study suggest that tobacco companies are reaching young adults through direct mail marketing, and exposure to cigarette coupons delivered through the mail promotes smoking and discourages cessation among young adults. Regulating tobacco direct mail marketing and coupons might reduce the prevalence of smoking particularly in young adults in whom smoking is the most prevalent.