Abstract
Objective
To examine young adult smokers' receipt of tobacco industry direct mail and use of coupons to purchase cigarettes.
Method
A total of 699 young adults from a 2011 national survey who reported smoking every day/some days provided self-report data on past-six month receipt of direct mail and past-six month use of coupons to purchase cigarettes. Multivariable logistic regression models were used to calculate adjusted odds of direct mail receipt and coupon use.
Results
Overall, 25.1% of young adult smokers reported receiving direct mail from a tobacco company and 24.2% had used a coupon to buy cigarettes in the past 6 months. Direct mail receipt and coupon use to purchase cigarettes were significantly higher among females, daily smokers, and whites. Nearly 70% of smokers who received direct mail had also used a coupon to purchase cigarettes in the preceding 6 months. Brand websites were the most commonly reported means of joining a direct mailing list.
Conclusion
This study adds to limited research showing receipt of direct mail and use of price reducing coupons by young adults. Also, higher rates of direct mail receipt and coupon use among females suggest these strategies may be especially effective in encouraging smoking in females.
Introduction
Young adults are a population of interest for both the tobacco industry and tobacco control. Despite a general decline in smoking among adults, prevalence remains high for young adults, (1, 2) this age group poses challenges to tobacco control, as it includes young adults who are just beginning to smoke, occasional or someday smokers, smokers transitioning from someday to daily smoking, and daily smokers. Although smoking typically begins before age 18, over 10% of current smokers start smoking between ages 18 and 26. (1, 2) Consumption also increases in young adulthood, with one-third of occasional smokers transitioning to daily smoking between the ages of 18 and 26. (1, 2)
Tobacco industry marketing to young adults aims to encourage initiation as well as progression to established smoking. (3) While considerable research effort has focused on tobacco industry marketing in general, little attention has been given to tobacco industry direct mail, a form of direct marketing that transmits brand messages and distributes incentives (e.g., coupons, promotional gifts) directly to those on the industry's extensive databases. (4) Distribution of coupons through direct mail is particularly common, as studies report 69% (5) to 87% (6) of direct mail carrying coupons.
Data regarding the receipt and influence of tobacco industry direct mail and coupons are limited. The earliest finding, from 2001, shows one in three adult smokers in New Jersey having received direct mail. (7) More recent research documents direct mail and coupon receipt by both youth and young adults (including non-smokers) and an association with initiation and continued or even increased consumption. (8-10) As such, this study examines young adult (ages 18-34) smokers' receipt of tobacco industry direct mail as well as their use of coupons to purchase cigarettes.
Methods
We examined data from the 2011 National Young Adult Health Survey (NYAHS). The NYAHS sampling methodology are reported elsewhere. (11) In brief, the NYAHS is a random-digit dial cell phone survey of 18 to 34 year olds about health behavioral risk factors, including tobacco use, attitudes, susceptibility, and experiences.
While the 2011 NYAHS included 2871 participants, our 2014 analysis utilized data from 699 young adults who reported smoking every day or some days. Primary outcomes were past-6 month receipt of direct mail (“In the last 6 months, have you received mail addressed to you from a tobacco company such as coupons, sweepstakes promotions or gift offers?”) and past-6 month use of coupons to purchase cigarettes (“In the last 6 months, have you used coupons to buy cigarettes, smokeless tobacco, or other types of tobacco?”). We examined differences in responses to each outcome by gender, race/ethnicity, age, cigarettes per day, past-year quit attempt, and intention to quit using adjusted chi-square tests. Characteristics that were significantly associated with either outcome were entered into 2 multivariable logistic regression models to calculate adjusted odds of (1) direct mail receipt and (2) coupon use. Statistical significance was indicated by a p-value of less than 0.05 (Wald-F Chi-Square). A series of Yes/No question assessed ever receipt of direct e-mail from a tobacco company and ever visiting a brand website, as well as the most common ways to join a direct mailing list (e.g., “Have you ever signed up for mailings at a brand website?”). Sampling weights adjusted for nonresponse and the varying probabilities of selection to yield nationally representative estimates, and SUDAAN statistical software was used to account for the complex sample design.
Results
Overall, 25.1% of young adult smokers reported receiving direct mail from a tobacco company and 24.2% had used a coupon to buy cigarettes in the past 6 months (Table 1). Nearly 70% of smokers who received direct mail had also used a coupon to purchase cigarettes in the preceding 6 months, as compared to 9% who had not received direct mail (Wald-F Chi-Square, p<0.0001). The odds of receiving direct mail were significantly greater for females relative to males, 25 to 29 year-olds and 30 to 34 year-olds relative to 18 to 20 year-olds, and white non-Hispanics relative to non-whites and Hispanics. Odds of coupon use to purchase cigarettes were significantly greater for females relative to males, white non-Hispanics relative to non-whites and Hispanics, and daily smokers relative to some-day smokers.
Table 1. Prevalence of Direct Mail Receipt and Cigarette Coupon Use among Current Smokers - 2011 National Young Adult Health Survey.
| Received Direct Mail in Past 6 Months | Used Coupon to Buy Cigarettes in Past 6 Months | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| % | CI | P-Valuea | AOR | (95% CI) | p-valuea | % | CI | P-Valuea | AOR | (95% CI) | p-valuea | |
| Overall | 25.1 | 20.7, 30.2 | - | 24.2 | 19.7, 29.4 | - | ||||||
| Gender | 0.0013 | 0.0027 | 0.0134 | 0.0251 | ||||||||
| Male | 17.9 | 13.5, 23.4 | 1.00 | --- | 18.6 | 13.6, 25.0 | 1.00 | --- | ||||
| Female | 34.2 | 26.5, 42.9 | 2.21 | (1.32, 3.71) | 31.3 | 23.9, 39.9 | 1.87 | (1.08, 3.24) | ||||
| Age Group | 0.0001 | 0.0004 | 0.2664 | 0.2846 | ||||||||
| 18 to 20 Years | 10.3 | 5.8, 17.8 | 1.00 | --- | 16.2 | 7.3, 32.3 | 1.00 | --- | ||||
| 21 to 24 Years | 17.1 | 10.9, 25.8 | 1.71 | (0.75, 3.90) | 23.3 | 16.0, 32.7 | 1.38 | (0.46, 4.11) | ||||
| 25 to 29 Years | 37.8 | 29.0, 47.4 | 4.56 | (2.11, 9.83) | 30.7 | 22.5, 40.3 | 2.05 | (0.36, 6.05) | ||||
| 30 to 34 Years | 24.8 | 16.6, 35.5 | 2.43 | (1.02, 5.79) | 21.5 | 13.3, 32.8 | 1.07 | (0.33, 3.53) | ||||
| Race/Ethnicity | 0.0017 | 0.0395 | 0.0005 | 0.0155 | ||||||||
| White, Non-Hispanic | 31.9 | 25.4, 39.2 | 1.00 | --- | 32.0 | 25.5, 39.4 | 1.00 | --- | ||||
| Non-white or Hispanic | 16.9 | 11.9, 23.4 | 0.57 | (0.33, 0.97) | 15.0 | 9.9, 22.2 | 0.48 | (0.26, 0.87) | ||||
| Current Smoking Status | 0.0231 | 0.1535 | <0.0001 | 0.004 | ||||||||
| Daily | 29.1 | 23.3, 35.7 | 1.58 | (0.84, 2.96) | 32.1 | 25.9, 39.0 | 2.97 | (1.41, 6.24) | ||||
| Some Days | 18.1 | 11.9, 26.5 | 1.00 | --- | 10.3 | 5.7, 17.9 | 1.00 | --- | ||||
| Cigarettes per Dayb | 0.3284 | 0.5779 | 0.0728 | 0.3061 | ||||||||
| < 20 | 24.5 | 19.3, 30.6 | 1.00 | --- | 35.3 | 24.5, 47.7 | 1.00 | --- | ||||
| 20 + | 30.1 | 21.2, 40.8 | 1.21 | (0.62, 2.37) | 23.0 | 17.9, 29.1 | 1.47 | (0.70, 3.07) | ||||
| Past-year Quit Attemptc | 0.5546 | 0.8773 | ||||||||||
| Yes | 26.4 | 20.3, 33.5 | 24.1 | 18.0, 31.4 | ||||||||
| No | 23.6 | 17.6, 30.7 | 24.9 | 18.5, 32.5 | ||||||||
| Intention to Quitc | 0.3208 | 0.4343 | ||||||||||
| Next 6 Months | 27.3 | 21.4, 34.2 | 23.0 | 17.2, 30.0 | ||||||||
| No Intention to Quit | 22.3 | 15.6, 30.7 | 27.2 | 19.6, 36.5 | ||||||||
Wald-F Chi Square Test
For someday smokers, number smoked on smoking days;
Excluded from multivariable regression models due to non-significnat association with outcomes
AOR, Adjusted Odds Ratio (gender, age group, race/ethnicity, current smoking status, and cigarettes/day)
The most commonly reported means of potentially joining a direct mailing list was signing up for mailings on a brand website (Table 2). Of those receiving direct mail, about 58% reported ever visiting a tobacco brand website and 49% had received email from a tobacco company.
Prevalence of Select Direct Marketing Featuers and Strategies among Direct Mail Recipients - 2011 National Young Adult Health Survey.
| % | CI | ||
|---|---|---|---|
| Potential Means of Joining Direct Mailing List | |||
| Redeemed Coupon with Name and Address | 43.1 | 32.8 | 54.0 |
| Ever Entered a Cigarette Brand Sweepstakes | 33.2 | 23.7 | 44.2 |
| Shared Contact Info with Rep at Bar/Club | 34.4 | 24.8 | 45.4 |
| Signed up for Mailings at Brand Website | 60.3 | 49.5 | 70.1 |
| Ever Received Email from Tobacco Company | 48.8 | 37.9 | 59.9 |
| Ever Visited Tobacco Brand Website | 58.4 | 47.7 | 68.4 |
Discussion
Our study found that about a quarter of young adult smokers in the US, ages 18-34, reported receiving tobacco industry direct mail and a similar proportion used coupons to purchase cigarettes within the past 6 months. Additionally, these outcomes were highly associated, with coupon use being 7 times more prevalent among direct mail receivers than non-receivers. Consistent with previous studies, prevalence of direct mail receipt was higher among older young adults (8), females (8,10), more frequent smokers (8), and whites (8).
Our findings point to the need for further research on the extent to which direct mail and price reducing coupons reach and influence young adult smoking behavior, including initiation, consumption and transition from infrequent to regular smoking. By reducing the cost of cigarettes, coupons likely encourage smoking initiation and almost certainly facilitate continued and even increased smoking by easing the financial transition to daily and continued smoking. Data showing higher rates of receipt of direct mail and use of coupons by females is particularly concerning and suggest that these strategies may be especially effective in encouraging smoking in women.
Not surprisingly, given the presence of coupons in direct mailings, nearly 70% of those who received direct mail had also used a coupon to purchase cigarettes in the preceding 6 months. However, because direct mail is not the only potential source of coupons and our study did not establish how coupons were acquired we cannot determine the extent to which redeemed coupons were obtained through direct mail. Future research should address this.
Study findings also highlight the connection between direct mail and other forms of direct marketing. Almost half of those who received direct mail also reported receiving industry email in the past 6 months and over half had visited a tobacco brand website. Brand website registration was the most common way of signing up for direct mail, suggesting these websites not only provide the industry with a means of ongoing promotion with consumers, but also generate a significant number of young adult names for industry databases.
This study is subject to several limitations commonly found in survey research. Analyses were generally limited to data from 699 current smokers; this relatively small sample size may have limited the power to detect associations between covariates and direct mail receipt and coupon use. Additionally, this study assessed self-reported direct mail receipt and coupon use in the previous six months only, and inferences beyond this time frame are not possible. Finally, the cross-sectional nature of this study does not allow assessment of causal relationships.
Conclusion
Young adulthood is a time of both smoking initiation and progression to established smoking. As such, it is particularly concerning that young adult smokers report receiving direct mail and using coupons, two largely unregulated industry tactics that have been associated with initiation and continued smoking. (8-10) Future efforts should explore these tactics and their impact on young adult smoking. Moreover, research is needed to determine what policy and/or educational strategies could effectively counter their influence.
Acknowledgments
This work was supported by the National Institutes of Health (R01CA149705). The views expressed in the article do not necessarily represent the views of the National Institutes of Health or Rutgers, The State University of New Jersey. The authors wish to thank Mary Hrywna for her assistance with the preparation of this manuscript.
Footnotes
Conflict of interest statement: The authors declare that there are no conflicts of interests
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Contributor Information
M. Jane Lewis, Email: lewismj@sph.rutgers.edu.
Michelle T. Bover-Manderski, Email: bovermi@sph.rutgers.edu.
Cristine D. Delnevo, Email: delnevo@sph.rutgers.edu.
References
- 1.U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. Printed with corrections, January 2014. [PubMed] [Google Scholar]
- 2.Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. [Google Scholar]
- 3.Ling PM, Glantz SA. Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. American journal of public health. 2002 Jun;92(6):908–16. doi: 10.2105/ajph.92.6.908. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lewis MJ, Yulis SG, Delnevo C, Hrywna M. Tobacco industry direct marketing after the Master Settlement Agreement. Health promotion practice. 2004 Jul;5(3 Suppl):75S–83S. doi: 10.1177/1524839904264596. [DOI] [PubMed] [Google Scholar]
- 5.Wackowski OA, Lewis MJ. Tobacco brand coupons – enticing promotions mailed directly to smokers. Presentation at the National Conference on Tobacco or Health; Phoenix, AZ. June, 2009. [Google Scholar]
- 6.Brock B, Schillo BA, Moilanen M. Tobacco industry marketing: an analysis of direct mail coupons and giveaways. Tobacco control. 2014 Jul 22; doi: 10.1136/tobaccocontrol-2014-051602. [DOI] [PubMed] [Google Scholar]
- 7.Lewis MJ, Delnevo CD, Slade J. Tobacco industry direct mail marketing and participation by New Jersey adults. American journal of public health. 2004 Feb;94(2):257–9. doi: 10.2105/ajph.94.2.257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Choi K, Forster J. Tobacco direct mail marketing and smoking behaviors in a cohort of adolescents and young adults from the U.S. upper Midwest: a prospective analysis. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2014 Jun;16(6):886–9. doi: 10.1093/ntr/ntu013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Soneji S, Ambrose BK, Lee W, Sargent J, Tanski S. Direct-to-consumer tobacco marketing and its association with tobacco use among adolescents and young adults. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2014 Aug;55(2):209–15. doi: 10.1016/j.jadohealth.2014.01.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Choi K, Hennrikus DJ, Forster JL, Moilanen M. Receipt and redemption of cigarette coupons, perceptions of cigarette companies and smoking cessation. Tobacco control. 2013 Nov;22(6):418–22. doi: 10.1136/tobaccocontrol-2012-050539. [DOI] [PubMed] [Google Scholar]
- 11.Gundersen DA, ZuWallack RS, Dayton J, Echeverria SE, Delnevo CD. Assessing the feasibility and sample quality of a national random-digit dialing cellular phone survey of young adults. American journal of epidemiology. 2014 Jan 1;179(1):39–47. doi: 10.1093/aje/kwt226. [DOI] [PMC free article] [PubMed] [Google Scholar]