Oklahoma Retailers’ Perspectives on Mutual Benefit Exchange to Limit Point-of-Sale Tobacco Advertisements

Abstract

Businesses changing their practices in ways that support tobacco control efforts recently have gained interest, as demonstrated by CVS Health’s voluntary policy to end tobacco sales. Point of sale (POS) advertisements are associated with youth smoking initiation, increased tobacco consumption, and reduced quit attempts among smokers. There is interest in encouraging retailers to limit tobacco POS advertisements voluntarily. This qualitative exploratory study describes Oklahoma tobacco retailers’ perspectives on a mutual benefit exchange approach, and preferred message and messenger qualities that would entice them to take voluntary action to limit tobacco POS advertisements. This study found mutual benefit exchange could be a viable option along with education and law as strategies to create behavior change among tobacco retailers. Many retailers stated that they would be willing to remove non-contractual POS advertisements for a six-month commitment period when presented with mutual exchange benefit, tailored message, and appropriate messenger. Mutual benefit exchange, as a behavior change strategy to encourage voluntary removal of POS tobacco advertisements, was acceptable to retailers, could enhance local tobacco control in states with preemption, and may contribute to setting the foundation for broader legislative efforts.

Tobacco advertisements at retail stores, known as point-of-sale (POS) advertisements, are associated with increased youth smoking initiation (Donovan, Jancey, & Jones, 2002; Henriksen, Freighery, Wang, & Fortmann, 2004; Wakefield, Germain, Durkin, & Henriksen, 2006), increased cigarette use among smokers (Lavack & Toth, 2006; Pollay, 2007), and fewer quit attempts (Carter, Mills, & Donovan, 2009; Kirchner, Cantrell, Anesetti-Rothermel, Ganz, Vallone, & Abrams, 2013). Retailers and businesses adopting voluntary policies that support tobacco control efforts have gained positive attention (McDaniel and Malone 2011, 2012, 2014), as recently illustrated by the decision of CVS Health, the second largest pharmacy chain in the United States, to stop selling tobacco products (Kennedy, 2014). This action increased calls for other retailers to adopt voluntary policies that support tobacco control efforts (“28 Leading Health Groups Call on Drug Stores and Other Retailers”, 2014; “Open Letters to America’s Retailers”, 2014; Polan 2014).

Changing retailer polices around POS advertisements is complicated. Tobacco companies provide financial inducements to retailers through incentive programs to ensure prime locations within stores to display tobacco products, advertise price promotions, and maximize their products’ availability (Bloom, 2001, Feighery, Ribisl, Clark, & Haladjian, 2003; Ribisl, 2007). Tobacco companies offer retailers higher incentives to display more POS advertisements. Many retailers are attracted to these incentives. One study found about 67% of retailers participated in at least one type of incentive program and some received financial incentives up to $3,000 per quarter from tobacco companies (Feighery, Ribisl, Scleicher, & Clark, 2004). Even after receiving education on the negative impacts of POS advertisements, retailers expressed fear (John, Cheney, & Azad, 2009) and reluctance (Stay Displays Coalition, 2008) to remove POS advertisements. Sixty percent of retailers approached by local tobacco control advocates in California refused to participate in a POS advertisement voluntary reduction program for 18 months (Walters & Muir, 2000). Retailers’ concerns included losing profits and potentially violating their tobacco company contracts (Cooper Roberts Research, Inc., 2001; John et al., 2009). Retailers perceived that POS advertisements increased the sales of the products advertised and other products in the store (Cooper Roberts Research, Inc., 2001). Some retailers stated that it was their right to advertise and sell a legal product (Stay Displays Coalition, 2008). Although a legislative approach could overcome these barriers, 18 states, including Oklahoma, have preemptive language within their state laws that prohibit local governments from regulating tobacco advertising, including POS advertisements (Centers for Disease Control and Prevention, 2011).

We explored another strategy for behavior change. Rothschild (1999) suggested that depending on the motivation, opportunity, and ability of target audiences to perform a desired behavior, different approaches such as education, marketing, and law are needed to affect public health and social change. Marketing, a mutual benefit exchange approach, is most effective when the target audience needs to receive benefits as motivation and needs to be provided with support to perform the desired behavior. This exploratory study aimed to answer four questions: (1) Could a mutual benefit exchange approach address POS advertisements? (2) Would retailers express interest in limiting POS advertisements in exchange for business benefits? (3) If interest is expressed, which business benefit is perceived as most appealing? (4) What message and messenger qualities would entice them to take action? To the best of our knowledge, this qualitative exploratory study is the first to explore how retailers view an approach that exchanges business benefits for immediate action to limit POS advertisements. This approach could enable local tobacco control to take action in states with preemption and may have implications for states without preemption, but with opposition to implementing POS legislation.

Exploratory Study

We explored with retailers the voluntary removal of non-contractual POS advertisements for a six-month commitment period in exchange for one of three business benefits: (1) A certificate or door sticker endorsement to establish positive image of the store; (2) A two to three hours of store cleaning by youth in the community to create a pleasant store environment; or (3) An article featuring the store in the local newspaper to establish positive image and increase awareness of the store and/or products sold through either earned media or paid advertisements. The removal of non-contractual advertisements would allow retailers to remove POS advertisements without violating tobacco company contracts. The modest six-month commitment would allow retailers to experience the benefits resulting from this voluntary action with limited risk.

In July and August 2008, 22 Oklahoma retailers who owned or managed convenience stores that sold tobacco products participated in interviews conducted by a strategic planner with the Oklahoma Tobacco Control Program. A blend of convenience and snowball sampling methods was used to achieve a sample of retailers with diverse perspectives on tobacco POS advertisements. Retailers were referred by local tobacco control coalitions, by the interviewer’s personal social network, and by other retailers who were interviewed. Additionally, some retailers who were not part of the aforementioned networks received unsolicited visits to increase sample diversity. Only locally-owned convenience store retailers were included in the sample since decisions to remove POS advertisements can be made locally and convenience stores have a higher number of tobacco advertisements compared to other retail groups (Centers for Disease Control and Prevention, 2002; Pierce & Dillon, 2008). The recruitment process was terminated once no new findings were obtained from additional interviews, indicating that data saturation was reached (Krueger & Casey, 2000).

In-person interviews were conducted at retailers’ stores (n=18) and at a different worksite (n=1). Phone call interviews (n=3) were conducted when retailers were not available in-person. Interviews lasted for an average of 25 minutes. In-person interviews were audiotaped. Notes were hand-taken during phone interviews and during one in-person interview because the retailer requested to not be audio-recorded. The interviewer’s introduction contained a brief statement about the negative impact of POS advertisements on youth (Table 1), the purpose of the interview, and anonymity assurance. Each retailer’s verbal consent was secured before the interview began. Retailers were asked a set of semi-structured questions to explore their perspectives on a mutual benefit exchange program, including the appropriate message and messenger qualities that would entice them to take action (Table 1). The interviewer used her knowledge of the tobacco companies’ incentive programs and business practices to engage retailers in conversation, enhance her credibility, and define non-contractual tobacco POS advertisements. The extent of POS advertisements in each store was noted either before or after the interviews using the Operation Storefront observational tool instruction (Oklahoma Tobacco Control Program, 2008) as a guide.

Table 1.

Interview Purpose Statement and Key Questions

A recent study found that tobacco advertisements at retail stores are associated with youth initiate smoking, where tobacco advertisements create positive imagery for youth. That’s why tobacco companies are so particular about where they want their advertisements and shelves to be set up in convenience stores, as noted in their contracts with store owners. When youth are at the age when they try to make a statement about themselves, such as being independent, smart, macho, cool, and so forth, that’s when the idea of smoking comes to their minds. We care about youth in this community and we would like to prevent youth from smoking. However, we understand that convenience store owner/manager like you, are in business. You are trying to make a living to support your family and you have obligations to comply as written in the tobacco companies’ contracts. We would like to seek your opinions on how we could work with convenience store owners/managers in this community, like you, to reduce tobacco advertisements at retail stores. What do you think of these ideas to persuade convenience store owners/managers, like yourself, to remove all non-contractual tobacco advertisements for a six-month period? A good reputation sticker/certificate to establish positive image of your store. A free store cleaning by youth in the community to beautify your store. An article in local newspaper to promote your store’s visibility and positive image (earned media articles, press releases, or paid advertisements). What should the message be so that it would sound appealing to you and that you would participate in program like this? Who should be coming into the convenience store and talking to you regarding a program like this (adult or youth)?

All interview recordings were transcribed verbatim by the interviewer. Two analysts, including the interviewer, who were trained in qualitative data analysis, independently examined the transcripts and notes to identify main themes. Using the long table approach (Krueger & Casey, 2000), transcripts were dissected in which retailers’ quotes were hand-cut and clustered into categories to identify the main themes found across the interviews. The emerging themes, major findings, and clustered comments with verbatim anonymous retailers’ quotes were reviewed, discussed, arranged (to compare and contrast), coded, and agreed upon among the analysts.

Results

The interviewed retailers sold tobacco as well as various types of food and beverage products. Most of the retailers also sold gasoline. Table 2 provides more information on these retailers.

Table 2.

Characteristics of Retailers Interviewed

Retailer	Geographica	Roleb	Contracted with Tobacco Companies	Extent of POS Tobacco Adsc
1	Rural	Owner	Yes	Low
2	Rural	Owner	Yes	Low
3	Rural	Owner	Yes	Low
4	Rural	Owner	Yes	Low
5	Rural	Owner	Yes	Medium
6	Rural	Owner	Yes	Low
7	Rural	Manager	Yes	Low
8	Rural	Manager	Yes	Low
9	Rural	Manager	Yes	Low
10	Rural	Manager	Yes	Medium
11	Rural	Manager	Yes	Medium
12	Urban	Owner	No	Low
13	Urban	Owner	Yes	Low
14	Urban	Owner	Yes	High
15	Urban	Owner	Yes	Medium
16	Urban	Owner	Yes	Medium
17	Urban	Owner	Yes	High
18	Urban	Owner	Yes	High
19	Urban	Manager	Yes	Medium
20	Urban	Manager	Yes	Medium
21	Urban	Manager	Yes	High
22	Urban	Manager	Yes	High

^aRural = Counties with less than 20,000 population; Urban = Counties with 250,000 or more population (Economic Research Service, U.S. Department of Agriculture, 2013)

^bOwner = Possesses legal ownership of the convenience store; Manager = An employee and possesses no legal ownership of the convenience store

^cLow = 6 or less POS advertisements; Medium = 7 to 12 POS advertisements; High = 13 or more POS advertisements

Retailers Who Were Interested in Mutual Benefit Exchange

A large majority of retailers (n=17/22) indicated they would be willing to remove non-contractual POS advertisements for a six-month commitment period in exchange for business benefits.

That’s excellent. I would be interested in the article…that would be a real benefit…because we can’t really afford that kind of exposure in local newspapers. (Retailer 12, urban)

For me it is good. I can go for this one… This is really good thing. You are helping us with the business (Retailer 21, urban)

Among the benefits presented, these retailers preferred positive media publicity, promoting their stores in the local newspaper. A few retailers (n=3) provided ideas for additional business benefits, including: sponsorship at schools events, tax credit, local celebrity acknowledgement, or strategies to increase sales of products other than tobacco.

I can see a promotion at the school…anti-tobacco type promotion at schools sponsored by me… Get my name out there… get my store’s name out there. (Retailer 4, rural)

If you got them [retailers] a tax credit,… taxes for every dollar increase in sales other than tobacco or something so they would be more in tune to push for those kind of sales. (Retailer 5, rural)

You might be able to get influential people…local celebrities to say nice things about a store… (Retailer 12, urban)

Just over half of these retailers (n=9/17) had not taken any action to limit POS advertisements. Their stores were in rural and urban areas with most having a medium to high number of POS advertisements. Slightly less than half of the retailers (n=8/17) who were interested in the mutual benefit exchange approach had already taken steps to limit tobacco POS advertisements. Most of them believed that smoking was bad for youth and their stores were located in rural areas. These retailers had the least amount of POS advertisements compared to other retailers.

I personally would [participate in mutual benefit exchange] because I’ve already taken steps to implement that [to limit POS advertisements] in my store… I don’t want my kids to smoke. I don’t want my nieces and nephew... I don’t want my kids in the community to start smoking. (Retailer 1, rural)

Retailers Who Were Not Interested in Mutual Benefit Exchange

Some retailers (n=5/22) expressed no interested in limiting POS advertisements in exchange for business benefits. A couple of retailers indicated they would be willing to remove all non-contractual POS advertisements without any benefits or incentives. However, the retailers wanted to review their tobacco contracts to ensure that they would not violate their agreements.

I think this is a pretty good idea. But first you got to go and check out contract… You don’t want to violate the contract… You want to help the kids not to smoke. You don’t have to offer anything. (Retailer 18, urban)

A few retailers (n=3/5) indicated that they would not be willing to limit any POS advertisements regardless of the benefit presented. They were not interested in expanding their current business or building a positive image. One retailer mentioned that her store was located in a disadvantaged neighborhood and that a positive business image was not a priority. These retailers believed that POS advertisements were an important communication tool for the sales of the tobacco products. One mentioned that it was his right to advertise. These stores had the highest number of POS advertisements, with the exception of one retailer. All of the retailers with this perspective were from urban areas.

I’m going to tell you this right now that you go to any convenience stores, they will tell you no right at your face…because cigarettes are one of the main things in convenience stores and they have to display (Retailer 22, urban)

I will not budge no matter what you offer me… I can advertise the way I feel. It’s, ah, what do you call… my right (Retailer 13, urban)

Message

Eighteen retailers offered insight on messaging. Nearly half of the retailers (n=8/18) suggested the use of business-oriented messages, including the negative impact of POS advertisements on youth as an introduction. A large majority of these retailers (n=6/8) had not taken actions to limit POS advertisements.

All the convenience store owners…they want to make money. It’s a business. That’s what they want to do. Whatever you can do to help them with their business, they are happy with that. (Retailer 21, urban)

Your message should say a research found that tobacco company advertising lead to image input among young kids… For businessmen, the most attractive thing to them is cost. What is the cost that comes with it? Then you can say … we can…with minimum loss, we somehow will bring in traffic to your store by writing an article for you, probably give you a certificate… (Retailer 15, urban)

Slightly more than half of the retailers (n=10/18) suggested messages that focused on protecting youth from smoking initiation and promoting community health.

Kids, promote no smoking. (Retailer 6, rural)

I think it’s about Oklahoma’s health. (Retailer 5, rural)

However, a majority (n=6/10) of those had already taken action to limit POS advertisements.

Messenger

Ten retailers provided insight on the messenger. Retailers (n=5) who suggested business-oriented messages specified an adult as the preferred messenger. The reasoning behind the preference was that adults could understand sales and tobacco company contracts.

…An adult…has to be someone who understands sales. You have to understand that you are selling a product even though it doesn’t feel like it. (Retailer 12, urban)

Of the five retailers who suggested youth and health messages, four indicated no messenger preference.

I don’t care. It doesn’t matter. (Retailer 3, rural)

Discussion

We found that a large majority of the retailers interviewed would be willing to remove non-contractual POS advertisements for a six-month commitment period in exchange for a business benefit. The establishment of a positive business image through local media as the exchange benefit was preferred by a vast majority of the retailers in this study. This finding is consistent with other studies which suggested positive media publicity would bolster change efforts to ending tobacco sales among retailers (McDaniel & Malone, 2011, 2014). Providing a benefit that enhances the retailers’ business is the key to engaging those who have not taken action to limit POS advertisements. Retailers’ preference of an adult messenger to deliver a business-oriented message is an indicator that a tailored strategy is needed.

Although this is an exploratory study of a mutual benefit exchange approach, our findings are consistent with Rothschild’s framework that education, marketing (mutual benefit exchange), and law strategies are needed to change behavior. The retailers in our study could be categorized as: those receptive to change with some already having reduced POS advertisements; those who would be willing to change in exchange for a benefit; and those who would not change voluntarily. Table 3 reflects the practice implications to address POS advertisements using Rothschild’s framework based on our findings: (1) education informs retailers who are prone to change and encourages them to take action voluntarily; (2) marketing creates opportunity and exchange benefits with retailers who could be motivated to make immediate attempts, encourages repetitive behavior, and builds momentum for legislative efforts to limit POS advertisements; and (3) legislated policy mandates all retailers to remove POS advertisements, including those who are resistant to change, and creates a social norm where POS advertisements are not acceptable.

Table 3.

Practice Implications from Applying Rothschild’s Framework to Study Findings

Retailers’ Perspectives	Rothschild’s Framework	Practice Implications
Interested, but action already taken	Education for those prone to change	For retailers who are health-oriented, educate about POS advertisements’ negative impacts to encourage voluntary policy adoption and build support for legislation efforts to limit POS advertisements
Interested and would take action	Marketing (mutual benefit exchange) to those who could be motivated	For retailers were who could be motivated, not for health reasons, offer a mutual benefit exchange to encourage actions to limit POS advertisements with modest commitment and build relationships with non-traditional partners to reduce potential opposition to legislation efforts
Not interested and would not take action	Law to address those who are resistant to change	For retailers who resist change, legislate policy to impact all retailers within the jurisdiction to create a social norm where POS advertisements are not acceptable and to create equitable sales environment for all retailers

While a mutual benefit exchange approach could be another strategy to address POS advertisements, it may require a paradigm shift within the tobacco control community. Unlike traditional education and legislated policy, this approach focuses on working with the target audience to identify benefits that the audience wants, and offering exchanges that may differ from preconceived outcomes defined by the tobacco control program. In addition, working with and rewarding retailers who sell tobacco products may contradict some tobacco control values and practices. Other concerns may include the longevity of media publicity, the cost of maintaining a mutual benefit exchange program, and unintentional consequences such as exposing more people to POS advertisements as a result media publicity for the retailers. The Oklahoma program did not adopt a mutual benefit exchange approach; in fact, the program substantially reduced its effort to limit POS advertisements. However, the New York State tobacco control program incorporated a mutual benefit exchange approach in their earlier efforts and learned that working with retailers enabled them to strengthen relationships and communicate continuously on the importance to address tobacco industry marketing at retail stores. Retailers’ voluntary policies were used as success stories to raise awareness of local policy needs and build momentum for legislation (Phelps & Anker, New York State Department of Health, personal communication, 2014).

McDaniel and Malone (2012) commented that it is crucial that tobacco control programs have strong relationships with businesses and support voluntary policy adoption. The businesses would no longer perceive their interests as aligned with the tobacco industry, thus weakening the relationship between the tobacco industry and businesses. This could reduce opposition, build momentum, and strengthen support for broader tobacco control legislative efforts. The Road Crew program in Wisconsin involved government agencies, bar owners, bar patrons, and a brewer in a controversial partnership; however, this program reduced alcohol-impaired driving accidents by 17% in one year (Rothschild, Martin, & Miller, 2006). Engagement with controversial partners warrants further exploration to enhance POS advertisement control efforts.

Our study has some limitations. We interviewed retailers with existing relationships with tobacco control programs and social networks, which may have influenced the study findings and its generalizability. Additionally, the findings may have been influenced by the interviewer being a health department employee and an introduction that contained a statement about the negative impact of POS advertisements on youth. While the retailers expressed interest, it is not known if they would actually participate in a program or would extend their commitment past six months, as theorized. Although Oklahoma's laws did not change in the six years since the study, it is possible that the retailers' perspectives might have shifted.

Future studies can validate the effect of a mutual benefit approach to limit POS advertisements, particularly in states with preemption. The extent of relationships between tobacco control community and retailers, other business benefits as suggested by retailers in this study, community connectedness, and business competition affecting retailers’ willingness to limit all POS advertisements could be further explored. Strategies on how a mutual benefit exchange approach in conjunction with education could lead to adoption of legislated policies to limit POS advertisements are also worth investigating. Lastly, it is essential to understand the tobacco control community’s perspectives, concerns, and potential strategies to overcome barriers of using a mutual benefit exchange approach to enhance current POS advertisement control efforts.

In conclusion, offering a mutual benefit exchange for voluntary action to limit POS advertisements is acceptable among many retailers. Positive experiences with voluntary removal of POS advertising in local communities may be used to support broader tobacco control legislative efforts. While there are concerns and uncertainties, we believe that the mutual benefit exchange approach, as an additional strategy alongside education and legislation to address POS advertisements warrants further exploration and discussion.