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. 2015 Dec 1;93(12):851–861G. doi: 10.2471/BLT.15.155846

The environmental profile of a community’s health: a cross-sectional study on tobacco marketing in 16 countries

Profil environnemental de la santé d'une communauté: étude transversale sur le marketing du tabac dans 16 pays

El perfil ambiental de la salud de una comunidad: un estudio transversal sobre la publicidad del tabaco en 16 países

موجز بيئي عن صحة المجتمع المحلي: دراسة تشمل قطاعات متعددة تتناول تسويق التبغ في 16 دولة

社区卫生的环境概况：一项针对 16 个国家烟草营销情况的横断面调查

Зависимость состояния здоровья в общинах от экологической обстановки: одномоментное поперечное исследование маркетинга табака в 16 странах

Emily Savell a, Anna B Gilmore a, Michelle Sims a, Prem K Mony b, Teo Koon c, Khalid Yusoff d, Scott A Lear e, Pamela Seron f, Noorhassim Ismail g, K Burcu Tumerdem Calik h, Annika Rosengren i, Ahmad Bahonar j, Rajesh Kumar k, Krishnapillai Vijayakumar l, Annamarie Kruger m, Hany Swidan n, Rajeev Gupta o, Ehimario Igumbor p, Asad Afridi q, Omar Rahman r, Jephat Chifamba s, Katarzyna Zatonska t, V Mohan u, Deepa Mohan u, Patricio Lopez-Jaramillo v, Alvaro Avezum w, Paul Poirier x, Andres Orlandini y, Wei Li z, Martin McKee aa, Sumathy Rangarajan c, Salim Yusuf c, Clara K Chow bb,✉
PMCID: PMC4669733  PMID: 26668437

Abstract

Objective

To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing.

Methods

Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders.

Findings

Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15–1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17–5.67 and IRR: 2.52; CI: 1.23–5.17, respectively). Of the 11 842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24–76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities.

Conclusion

Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.

Introduction

Tobacco is a leading cause of morbidity and mortality, responsible for an estimated 18%, 11% and 4% of deaths in high-, middle- and low-income countries, respectively.1 Since the prevalence of smoking is falling in high-income countries but increasing in many middle- and low-income countries, the global burden of disease caused by tobacco use is expected to shift increasingly from high-income countries to countries with lower incomes.

As marketing by the tobacco industry plays a substantial role in smoking initiation,2–4 complete bans on such marketing can be an effective means of reducing tobacco use.5,6 In 2005, the World Health Organization’s (WHO’s) Framework Convention on Tobacco Control (FCTC) called for a comprehensive ban on all tobacco marketing.7 However, the lack of relevant capacity and/or political will in many countries and the insidious influence of the tobacco industry have meant that the implementation of some of the FCTC’s recommendations has been slow.8

In this paper, we assess the global tobacco marketing environment by examining and comparing the extent and nature of tobacco marketing in 462 communities spread across 16 low-, middle- and high-income countries.

Methods

Data source

All of the data we analysed were collected as part of the Environmental Profile of a Community’s Health study, which has already been described in detail.9–11 This study is a component of the Prospective Urban Rural Epidemiology study – a large cohort study that is designed to examine the relationship between lifestyle factors and cardiovascular disease in adults aged 35–70 years.10,11 The Environmental Profile of a Community’s Health study includes an objective environmental audit in which trained investigators walk a predefined kilometre-long route within a study community. During each such walk, the investigators visit stores and systematically record physical aspects of the environment – e.g. the number of tobacco advertisements that they see. The second part of the Environmental Profile of a Community’s Health study involves an interviewer-administered questionnaire that captures individuals’ perceptions of their community – including whether the interviewees recall seeing certain types of tobacco marketing within the previous six months.9 This questionnaire was administered to a subsample of the participants of the Prospective Urban Rural Epidemiology study.

We investigated data collected, between 2009 and 2012, in 16 countries. According to the World Bank’s 2006 classification,11 three of the countries – Canada, Sweden and the United Arab Emirates – were high-income, seven – Argentina, Brazil, Chile, Malaysia, Poland, South Africa and Turkey – were upper-middle-income, three – China, Colombia and the Islamic Republic of Iran – were lower-middle-income – and three – India, Pakistan and Zimbabwe – were low-income. Although Bangladesh is included in the Prospective Urban Rural Epidemiology study,10 we excluded Bangladeshi data on tobacco marketing from our analyses because they were relatively incomplete.

Measures of marketing

The Environmental Profile of a Community’s Health study records both push and pull marketing. Push marketing, which aims to increase product availability,12,13 was measured by trained researchers who recorded the number of tobacco outlets – e.g. vendors, street stands and general stores – seen during the audit walk and whether a tobacco-selling store visited during the walk sold single cigarettes. Pull marketing, which encourages customers to seek out a product through advertising and promotion,12,13 was measured using both direct observation – i.e. the number of tobacco advertisements counted during the audit walk and whether the tobacco-selling store visited during the walk had point-of-sale tobacco advertising – and via self-report in interviews – i.e. whether an interviewee recalled seeing various forms of tobacco advertising in the previous six months. Almost all of the tobacco marketing measures that we examined reflected those covered by the FCTC7 or the associated implementation guidelines.14 However, we also assessed tobacco outlet density as this has been shown to play an important role in smoking prevalence among adults and adolescents.15,16

Observed data

For each country and country income group, the mean numbers of tobacco outlets and advertisements observed per community, the percentage of visited stores that sold single cigarettes and the percentage of visited stores that had point-of-sale tobacco advertising, were calculated – separately for the urban and rural communities.

As statistical tests showed that our outcome data were highly overdispersed, we used negative binomial multilevel regression models to examine differences in the number of observed tobacco outlets and tobacco advertisements between urban and rural communities and between country income groups. In these models, the number of outlets or advertisements was used as the outcome variable. Country income group and community type – i.e. rural or urban – were used as the categorical explanatory variables, and a random effect was included for the country. Incidence rate ratios (IRRs) were obtained by exponentiation of the regression coefficient and reported with the corresponding 95% confidence intervals (CIs). As data on the sale of single cigarettes and point-of-sale advertising were based on only one tobacco-selling store per community – and it is not possible to know whether the selected store was representative of all tobacco-selling stores within the community – such data were not included in the regression analyses.

Self-reported data

To examine differences in self-reported marketing levels between community types and across country income groups, we considered 13 binary outcome variables. These included whether or not individuals reported seeing tobacco marketing of any of six traditional types of media – i.e. posters, signage, television, radio, print and cinema – and five non-traditional types – i.e. sponsorship, marketing on other products, marketing on the internet, free samples and vouchers. We also combined all the traditional types and all the non-traditional types of marketing into two separate binary variables.

We applied a logistic multilevel regression model to each of the binary outcome measures and again included categorical explanatory variables for country income group and community type. We also included random effects for country and community. Each model was adjusted for potential confounders – i.e. sex, age, education, smoking status, having close friends who smoke, access to the internet, television ownership and radio ownership.2,17–19 The resulting odds ratios (ORs) are reported with corresponding 95% CIs.

All of the models were fitted using the glmmadmb and glmer functions from the glmmADMB and lme4 packages of R version 3.0.2 (R Foundation, Vienna, Austria).

Results

We analysed data from 235 urban and 227 rural communities, across 16 countries (Table 1). Overall, 11 842 individuals who resided in the observed communities – i.e. 5809 in the urban and 6033 in the rural communities – were interviewed and included in the final analyses.

Table 1. Sample sizes for a tobacco marketing study in 462 communities, 16 countries, 2009–2012.

Countrya No. of study communities
 No. of interviewees
Total Urban Rural Total Urban Rural
All 462 235 227 11 842 5809 6033
High-income
Canada 46 31 15 1145 807 338
Sweden 23 20 3 580 496 84
United Arab Emirates 3 1 2 89 26 63
Total 72 52 20 1814 1329 485
Upper-middle-income
Argentina 20 6 14 544 171 373
Brazil 14 7 7 387 202 185
Chile 5 2 3 127 51 76
Malaysia 33 18 15 1168 591 577
Poland 4 1 3 89 26 63
South Africa 6 3 3 194 99 95
Turkey 38 25 13 1207 795 412
Total 120 62 58 3716 1935 1781
Lower-middle-income
China 101 39 62 3131 1224 1907
Colombia 54 31 23 278 151 127
Iran (Islamic Republic of) 20 11 9 593 321 272
Total 175 81 94 4002 1696 2306
Low-income
India 88 37 51 2118 766 1352
Pakistan 4 2 2 111 57 54
Zimbabwe 3 1 2 81 26 55
Total 95 40 55 2310 849 1461
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a Countries were categorized according to the World Bank’s 2006 classification.11

Observed data

Push marketing

There were marked differences in outlet type and density between countries and country income group (Fig. 1 and Table 2 available at: http://www.who.int/bulletin/volumes/93/12/15-155846). The mean number of tobacco-selling outlets observed in each community increased with decreasing country income, from 1.7 in the high-income countries to 3.4 in the upper-middle-income countries and over 5.0 in the lower-middle-income and low-income countries. This trend was driven largely by the relatively high numbers of vendors and street stands observed – a mean of almost two per community – in low-income countries. No such outlets were observed in high-income countries and, on average, only 0.2 and 0.7 were observed per community in the upper-middle-income and lower-middle-income countries, respectively. The mean number of general stores observed per community did not follow the same pattern – 1.7, 3.2, 4.6 and 3.4 in the high-, upper-middle-, lower-middle- and low-income countries, respectively.

Fig. 1.

Tobacco-selling outlets in urban or rural study community, 16 countries, 2009–2012

HIC: high-income country; LIC: low-income country; LMIC: lower-middle-income country; UMIC: upper-middle-income country.

Notes: Countries were categorized according to the World Bank’s 2006 classification.11 Outlets were counted during a kilometre-long audit walk in each study community.

Fig. 1

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Table 2. Observed push and pull tobacco marketing, 16 countries, 2009–2012.
Countrya Push marketing
 Pull marketing
Outlets selling cigarettes/tobacco
 No. of selected tobacco stores selling single cigarettes, (%) Mean no. of cigarette or tobacco adverts No. of selected tobacco stores with POS advertising, (%)
Mean no. of outletsb Mean no. of vendors or street stands Mean no. of general stores
All countries
All communities (n = 462) 4.2 0.7 3.5 145/461 (31.5) 1.3 139/458 (30.4)
  Urban (n = 235) 4.6 0.9 3.7 74/235 (31.5) 1.7 96/235 (40.9)
  Rural (n = 227) 3.8 0.5 3.3 71/226 (31.4) 0.9 43/223 (19.3)
High-income countries
Canada
  Urban (n = 31) 1.5 0.0 1.5 0/31 (0.0) 0.0 3/31 (9.7)
  Rural (n = 15) 1.1 0.0 1.1 0/15 (0.0) 0.0 0/15 (0.0)
Sweden
  Urban (n = 20) 2.1 0.0 2.1 0/20 (0.0) 0.8 10/20 (50.0)
  Rural (n = 3) 1.0 0.0 1.0 0/3 (0.0) 0.0 0/3 (0.0)
United Arab Emirates
  Urban (n = 1) 6.0 0.0 6.0 1/1 (100.0) 0.0 0/1 (0.0)
  Rural (n = 2) 4.5 0.0 4.5 1/2 (50.0) 0.0 0/2 (0.0)
Total
  All communities (n = 72) 1.7 0.0 1.7 2/72 (2.8) 0.2 13/72 (18.1)
  Urban (n = 52) 1.8 0.0 1.8 1/52 (1.9) 0.3 13/52 (25.0)
  Rural (n = 20) 1.5 0.0 1.5 1/20 (5.0) 0.0 0/20 (0.0)
Upper-middle-income countries
Argentina
  Urban (n = 6) 2.0 0.0 2.0 2/6 (33.3) 0.5 1/6 (16.7)
  Rural (n = 14) 0.8 0.0 0.8 3/14 (21.4) 0.5 1/14 (7.1)
Brazil
  Urban (n = 7) 1.0 0.3 0.7 0/7 (0.0) 10.4 7/7 (100.0)
  Rural (n = 7) 2.0 0.0 2.0 0/7 (0.0) 6.0 7/7 (100.0)
Chile
  Urban (n = 2) 3.0 1.0 2.0 0/2 (0.0) 0.5 1/2 (50.0)
  Rural (n = 3) 1.3 0.3 1.0 2/3 (66.7) 1.0 3/3 (100.0)
Malaysia
  Urban (n = 18) 5.8 0.2 5.6 0/18 (0.0) 0.1 9/18 (50.0)
  Rural (n = 15) 7.2 0.7 6.5 4/15 (26.7) 0.1 7/15 (46.7)
Poland
  Urban (n = 1) 8.0 0.0 8.0 0/1 (0.0) 0.0 0/1 (0.0)
  Rural (n = 3) 1.3 0.0 1.3 0/3 (0.0) 0.0 0/3 (0.0)
South Africa
  Urban (n = 3) 3.3 1.0 2.3 1/3 (33.3) 0.0 1/3 (33.3)
  Rural (n = 3) 1.3 0.0 1.3 1/3 (33.3) 0.0 1/3 (33.3)
Turkey
  Urban (n = 25) 4.0 0.0 4.0 0/25 (0.0) 0.1 9/25 (36.0)
  Rural (n = 13) 1.2 0.0 1.2 0/13 (0.0) 0.1 1/13 (7.7)
Total
  All communities (n = 120) 3.4 0.2 3.2 13/120 (10.8) 1.1 48/120 (40.0)
  Urban (n = 62) 4.0 0.2 3.8 3/62 (4.8) 1.3 28/62 (45.2)
  Rural (n = 58) 2.8 0.2 2.6 10/58 (17.2) 0.9 20/58 (34.5)
Lower-middle-income countries
China
  Urban (n = 39) 6.7 0.4 6.3 0/39 (0.0) 0.5 8/39 (20.5)
  Rural (n = 62) 3.0 0.0 2.9 0/61 (0.0) 0.0 0/58 (0.0)
Colombia
  Urban (n = 31) 7.7 2.4 5.3 31/31 (100.0) 3.3 17/31 (54.8)
  Rural (n = 23) 7.3 1.2 6.2 23/23 (100.0) 2.1 10/23 (43.5)
Iran (Islamic Republic of)
  Urban (n = 11) 3.0 0.0 3.0 7/11 (63.6) 0.0 0/11 (0.0)
  Rural (n = 9) 3.9 0.0 3.9 8/9 (88.9) 0.1 1/9 (11.1)
Total
All communities (n = 175) 5.3 0.7 4.6 69/174 (39.7) 1.0 36/171 (21.1)
  Urban (n = 81) 6.6 1.1 5.5 38/81 (46.9) 1.5 25/81 (30.9)
  Rural (n = 94) 4.1 0.3 3.8 31/93 (33.3) 0.6 11/90 (12.2)
Low-income countries
India
  Urban (n = 37) 5.4 2.8 2.6 32/37 (86.5) 4.5 28/37 (75.7)
  Rural (n = 51) 5.2 1.3 3.9 29/51 (56.9) 1.3 9/51 (17.7)
Pakistan
  Urban (n = 2) 4.0 0.0 4.0 0/2 (0.0) 3.0 1/2 (50.0)
  Rural (n = 2) 3.0 0.0 3.0 0/2 (0.0) 8.0 1/2 (50.0)
Zimbabwe
  Urban (n = 1) 1.0 0.0 1.0 0/1 (0.0) 0.0 1/1 (100.0)
  Rural (n = 2) 7.5 4.0 3.5 0/2 (0.0) 8.5 2/2 (100.0)
Total
  All communities (n = 95) 5.2 1.9 3.4 61/95 (64.2) 2.8 42/95 (44.2)
  Urban (n = 40) 5.3 2.6 2.7 32/40 (80.0) 4.3 30/40 (75.0)
  Rural (n = 55) 5.2 1.4 3.9 29/55 (52.7) 1.8 12/55 (21.8)
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POS: point-of-sale.

a Countries were categorized according to the World Bank’s 2006 classification.11

b Includes vendors, street stands and general stores.

Note: Observed numbers by trained investigators during a kilometre-long walk in each community.

Combining data from all 16 countries, more vendors and/or street stands were observed in the urban communities than in the rural – means of 0.9 and 0.5 per community, respectively – and the urban communities also had a higher mean number of general stores selling tobacco – 3.7, compared with 3.3 per rural community. However, these urban/rural differences were not consistent across all four country income groups (Fig. 1 and Table 2).

After controlling for community type and country income group, the upper-middle-income countries had similar numbers of tobacco outlets (IRR: 1.29; 95% CI: 0.67–2.49) compared with high-income countries, but lower-middle-income countries (IRR: 2.52; 95% CI: 1.23–5.17) and low-income countries (IRR: 2.58; 95% CI: 1.17–5.67) had significantly more (Table 3). Across all countries, the mean number of tobacco outlets observed per community was significantly lower in rural than in urban communities (IRR: 0.73; 95% CI: 0.63–0.85; Table 3).

Table 3. Incidence rate ratios for push and pull observed marketing of tobacco, 16 countries, 2009–2012.
Group IRR (95% CI)a
Tobacco outletsb Tobacco advertisementsb
Community type
Urban 1 1
Rural 0.73 (0.63–0.85) 0.40 (0.26–0.60)
Country income groupc
High 1 1
Upper-middle 1.29 (0.67–2.49) 3.96 (0.30–52.88)
Lower-middle 2.52 (1.23–5.17) 4.68 (0.26–85.00)
Low 2.58 (1.17–5.67) 80.98 (4.15–1578.42)
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CI: confidence interval; IRR: incidence rate ratio.

a Derived from negative binomial multilevel regression models.

b Based on the mean numbers of outlets and advertisements observed during a kilometre-long audit walk in each community.

c Countries were categorized according to the World Bank’s 2006 classification.11

The sale of single cigarettes was not observed in any of the communities in eight of the countries (Table 2). However, overall, outlets selling single cigarettes became increasingly common with declining country income (Fig. 2 and Table 2). Although the urban/rural differences in the sale of single cigarettes varied by country income group, the sale of single cigarettes was more common in urban than rural communities in both lower-middle- and low-income countries.

Fig. 2.

Proportion of tobacco-selling stores selling single cigarettes, 16 countries, 2009–2012

HIC: high-income country; LIC: low-income country; LMIC: lower-middle-income country; UMIC: upper-middle-income country.

Note: Countries were categorized according to the World Bank’s 2006 classification.11

Fig. 2

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Pull marketing

Tobacco advertisements were much more common in low-income countries than in the other countries. Very few tobacco advertisements were seen in high-income countries. In middle- and low-income countries, means of approximately 1 and 3 observed advertisements per community were recorded, respectively (Fig. 3 and Table 2). Combining data from all countries, tobacco advertisements were more common in the urban than rural communities, with means of 1.7 and 0.9 observed per community, respectively.

Fig. 3.

Tobacco advertisements in urban or rural study community, 16 countries, 2009–2012

HIC: high-income country; LIC: low-income country; LMIC: lower-middle-income country; UMIC: upper-middle-income country.

Notes: Countries were categorized according to the World Bank’s 2006 classification.11 Advertisements were counted during a kilometre-long audit walk in each study community.

Fig. 3

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After controlling for community type and country income group, the middle-income countries had similar numbers of tobacco advertisements (upper-middle-income IRR: 3.96; 95% CI: 0.30–52.88 and lower-middle-income IRR: 4.68; 95% CI: 0.26–85.00) as the high-income countries, whereas low-income countries had many more (IRR: 80.98; 95% CI: 4.15–1578.42). Overall, the mean number of tobacco advertisements observed per community was much lower in rural communities than in urban communities (IRR: 0.40; 95% CI: 0.26–0.60; Table 3).

The percentage of tobacco-selling stores visited that had point-of-sale tobacco advertising did not appear to differ clearly by country income group: 18% (13/72) in high-income, 40% (48/120) in upper-middle-income, 21% (36/171) in lower-middle-income and 44% (42/95) in low-income countries (Fig. 4 and Table 2). However the percentages across all countries were generally higher in the urban communities (41%; 96/235) than in the rural communities (19%; 43/223).

Fig. 4.

Proportion of tobacco-selling stores that had point-of-sale tobacco advertising, 16 countries, 2009–2012

HIC: high-income country; LIC: low-income country; LMIC: lower-middle-income country; UMIC: upper-middle-income country.

Note: Countries were categorized according to the World Bank’s 2006 classification.11

Fig. 4

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Self-reported data

Of the 11 842 interviewees, 5349 (45%; range: 4–100%) reported exposure to at least one type of tobacco marketing over the previous six months and 1184 (10%; range: 0–56%) reported exposure to at least five types of marketing over the same period (available from the corresponding author).

Pull marketing

Traditional

Interviewees in high-income countries were least likely to report exposure to all forms of traditional marketing except print media, although differences between other country income groups varied by the type of marketing (Fig. 5; further details available from corresponding author). Overall, television marketing – seen by 3501 (30%) of interviewees in the previous six months – was the most common form of traditional marketing, followed by posters (2334; 20%), print media (1949; 16%), signage (1934; 16%), radio (1465; 12%) and cinema marketing (567; 5%). All forms of traditional marketing except television marketing – and exposure to at least one form of traditional marketing – were less common in rural communities than urban ones (Table 4 available at: http://www.who.int/bulletin/volumes/93/12/15-155846).

Fig. 5.

Proportion of urban or rural interviewees who reported seeing at least one traditional type of tobacco marketing in the previous six months, 16 countries, 2009–2012

HIC: high-income country; LIC: low-income country; LMIC: lower-middle-income country; UMIC: upper-middle-income country.

Notes: Countries were categorized according to the World Bank’s 2006 classification.11 Traditional types of marketing were posters, signage, television, radio, print and cinema.

Fig. 5

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Table 4. Individuals who reported seeing tobacco marketing within the previous six months, 16 countries, 2009–2011.
Countrya No. of individuals reporting seeing marketing/individuals interviewed (%)
Traditional marketing
 Non-traditional marketing
Postersb Signagec Television Radio Print mediad Cinema Seen at least one type Sponsorshipe On other productsf Internet Free samples Vouchersg Seen at least one type
All countries
All communities 2335/11819 (19.8) 1934/11813 (16.4) 3501/11815 (29.6) 1465/11811 (12.4) 1949/11815 (16.5) 567/11813 (4.8) 5012/11820 (42.4) 1060/11818 (9.0) 1468/11818 (12.4) 938/11817 (7.9) 491/11816 (4.2) 491/11818 (4.2) 2139/11823 (18.1)
  Urban 1332/5800 (23.0) 1164/5795 (20.1) 1625/5797 (28.0) 763/5793 (13.2) 1234/5796 (21.3) 351/5795 (6.1) 2538/5800 (43.8) 712/5799 (12.3) 950/5799 (16.4) 630/5799 (10.9) 293/5798 (5.1) 312/5799 (5.4) 1391/5804 (24.0)
  Rural 1002/6019 (16.7) 770/6018 (12.8) 1876/6018 (31.2) 702/6018 (11.7) 715/6019 (11.9) 216/6018 (3.6) 2474/6020 (41.1) 348/6019 (5.8) 518/6019 (8.6) 308/6018 (5.1) 198/6018 (3.3) 179/6019 (3.0) 748/6019 (12.4)
High-income countries
Canada
  Urban 59/807 (7.3) 67/807 (8.3) 68/807 (8.4) 17/807 (2.1) 162/807 (20.1) 18/807 (2.2) 244/807 (30.2) 108/807 (13.4) 54/807 (6.7) 39/807 (4.8) 4/807 (0.5) 7/807 (0.9) 165/807 (20.5)
  Rural 27/338 (8.0) 23/338 (6.8) 29/338 (8.6) 9/338 (2.7) 62/338 (18.3) 12/338 (3.6) 95/338 (28.1) 35/338 (10.4) 15/338 (4.4) 14/338 (4.1) 0/338 (0.0) 3/338 (0.9) 55/338 (16.3)
Sweden
  Urban 66/495 (13.3) 97/491 (19.8) 48/492 (9.8) 4/490 (0.8) 194/492 (39.4) 19/491 (3.9) 237/495 (47.9) 44/493 (8.9) 125/493 (25.4) 81/491 (16.5) 4/492 (0.8) 7/493 (1.4) 182/495 (36.8)
  Rural 2/84 (2.4) 6/84 (7.1) 6/84 (7.1) 0/84 (0.0) 36/84 (42.9) 2/84 (2.4) 40/84 (47.6) 5/84 (6.0) 15/84 (17.9) 9/84 (10.7) 3/84 (3.6) 0/84 (0.0) 22/84 (26.2)
United Arab Emirates
  Urban 2/26 (7.7) 2/26 (7.7) 1/26 (3.9) 1/26 (3.9) 1/26 (3.9) 2/26 (7.7) 2/26 (7.7) 1/26 (3.9) 1/26 (3.9) 2/26 (7.7) 0/26 (0.0) 0/26 (0.0) 2/26 (7.7)
  Rural 5/63 (7.9) 1/63 (1.6) 4/63 (6.4) 1/63 (1.6) 4/63 (6.4) 0/63 (0.0) 9/63 (14.3) 0/63 (0.0) 1/63 (1.6) 1/63 (1.6) 0/63 (0.0) 0/63 (0.0) 1/63 (1.6)
Total
  All communities 161/1813 (8.9) 196/1809 (10.8) 156/1810 (8.6) 32/1808 (1.8) 459/1810 (25.4) 53/1809 (2.9) 627/1813 (34.6) 193/1811 (10.7) 211/1811 (11.7) 146/1809 (8.1) 11/1810 (0.6) 17/1811 (0.9) 427/1813 (23.6)
  Urban 127/1328 (9.6) 166/1324 (12.5) 117/1325 (8.8) 22/1323 (1.7) 357/1325 (26.9) 39/1324 (3.0) 483/1328 (36.4) 153/1326 (11.5) 180/1326 (13.7) 122/1324 (9.2) 8/1325 (0.6) 14/1326 (1.1) 349/1328 (26.3)
  Rural 34/485 (7.0) 30/485 (6.2) 39/485 (8.0) 10/485 (2.1) 102/485 (21.0) 14/485 (2.9) 144/485 (29.7) 40/485 (8.3) 31/485 (6.4) 24/485 (5.0) 3/485 (0.6) 3/485 (0.6) 78/485 (16.1)
Upper-middle-income countries
Argentina
  Urban 16/171 (9.4) 16/171 (9.4) 36/171 (21.1) 0/171 (0.0) 15/171 (8.8) 0/171 (0.0) 49/171 (28.7) 4/171 (2.3) 1/171 (0.6) 1/171 (0.6) 0/171 (0.0) 0/171 (0.0) 6/171 (3.5)
  Rural 6/373 (1.6) 7/373 (1.9) 86/373 (23.1) 2/373 (0.5) 24/373 (6.4) 0/373 (0.0) 103/373 (27.6) 6/373 (1.6) 0/373 (0.0) 2/373 (0.5) 0/373 (0.0) 0/373 (0.0) 8/373 (2.1)
Brazil
  Urban 15/202 (7.4) 8/202 (4.0) 37/202 (18.3) 8/202 (4.0) 23/202 (11.4) 3/202 (1.5) 56/202 (27.7) 6/202 (3.0) 2/202 (1.0) 7/202 (3.5) 1/202 (0.5) 1/202 (0.5) 13/202 (6.4)
  Rural 32/185 (17.3) 1/185 (0.5) 34/185 (18.4) 2/185 (1.1) 5/185 (2.7) 0/185 (0.0) 64/185 (34.6) 0/185 (0.0) 0/185 (0.0) 0/185 (0.0) 0/185 (0.0) 0/185 (0.0) 0/185 (0.0)
Chile
  Urban 35/51 (68.6) 18/51 (35.3) 51/51 (100.0) 37/51 (72.6) 24/51 (47.1) 0/51 (0.0) 51/51 (100.0) 2/51 (3.9) 39/51 (76.5) 9/51 (17.7) 0/51 (0.0) 0/51 (0.0) 39/51 (76.5)
  Rural 3/76 (4.0) 1/76 (1.3) 12/76 (15.8) 4/76 (5.3) 3/76 (4.0) 0/76 (0.0) 14/76 (18.4) 0/76 (0.0) 2/76 (2.6) 0/76 (0.0) 0/76 (0.0) 0/76 (0.0) 2/76 (2.6)
Malaysia
  Urban 260/591 (44.0) 194/591 (32.8) 271/591 (45.9) 223/591 (37.7) 251/591 (42.5) 67/591 (11.3) 300/591 (50.8) 191/591 (32.3) 191/591 (32.3) 230/591 (38.9) 80/591 (13.5) 101/591 (17.1) 262/591 (44.3)
  Rural 202/577 (35.0) 163/577 (28.3) 216/577 (37.4) 173/577 (30.0) 181/577 (31.4) 41/577 (7.1) 227/577 (39.3) 123/577 (21.3) 146/577 (25.3) 161/577 (27.9) 72/577 (12.5) 66/577 (11.4) 178/577 (30.9)
Poland
  Urban 6/26 (23.1) 5/26 (19.2) 4/26 (15.4) 1/26 (3.9) 6/26 (23.1) 1/26 (3.9) 12/26 (46.2) 2/26 (7.7) 3/26 (11.5) 4/26 (15.4) 4/26 (15.4) 2/26 (7.7) 11/26 (42.3)
  Rural 10/63 (15.9) 9/63 (14.3) 7/63 (11.1) 1/63 (1.6) 8/63 (12.7) 1/63 (1.6) 23/63 (36.5) 1/63 (1.6) 5/63 (7.9) 3/63 (4.8) 1/63 (1.6) 0/63 (0.0) 8/63 (12.7)
South Africa
  Urban 48/98 (49.0) 44/98 (44.9) 54/98 (55.1) 45/98 (45.9) 53/98 (54.1) 21/98 (21.4) 80/98 (81.6) 30/99 (30.3) 29/99 (29.3) 17/99 (17.2) 30/99 (30.3) 34/99 (34.3) 50/99 (50.5)
  Rural 38/95 (40.0) 33/95 (34.7) 34/95 (35.8) 46/95 (48.4) 29/95 (30.5) 3/94 (3.2) 65/95 (68.4) 16/95 (16.8) 17/95 (17.9) 5/94 (5.3) 16/94 (17.0) 10/95 (10.5) 25/95 (26.3)
Turkey
  Urban 124/795 (15.6) 127/795 (16.0) 170/795 (21.4) 45/795 (5.7) 89/795 (11.2) 12/795 (1.5) 252/795 (31.7) 43/795 (5.4) 87/795 (10.9) 21/795 (2.6) 6/795 (0.8) 4/795 (0.5) 110/795 (13.8)
  Rural 30/412 (7.3) 40/412 (9.7) 85/412 (20.6) 19/412 (4.6) 31/412 (7.5) 6/412 (1.5) 113/412 (27.4) 14/412 (3.4) 39/412 (9.5) 11/412 (2.7) 3/412 (0.7) 0/412 (0.0) 56/412 (13.6)
Total
  All communities 825/3715 (22.2) 666/3715 (17.9) 1097/3715 (29.5) 606/3715 (16.3) 742/3715 (20.0) 155/3714 (4.2) 1409/3715 (37.9) 438/3716 (11.8) 561/3716 (15.1) 471/3715 (12.7) 213/3715 (5.7) 218/3716 (5.9) 768/3716 (20.7)
  Urban 504/1934 (26.1) 412/1934 (21.3) 623/1934 (32.2) 359/1934 (18.6) 461/1934 (23.8) 104/1934 (5.4) 800/1934 (41.4) 278/1935 (14.4) 352/1935 (18.2) 289/1935 (14.9) 121/1935 (6.3) 142/1935 (7.3) 491/1935 (25.4)
  Rural 321/1781 (18.0) 254/1781 (14.3) 474/1781 (26.6) 247/1781 (13.9) 281/1781 (15.8) 51/1780 (2.9) 609/1781 (34.2) 160/1781 (9.0) 209/1781 (11.7) 182/1780 (10.2) 92/1780 (5.2) 76/1781 (4.3) 277/1781 (15.6)
Lower-middle-income countries
China
  Urban 329/1217 (27.0) 223/1216 (18.3) 527/1217 (43.3) 225/1215 (18.5) 158/1893 (18.4) 102/1216 (8.4) 636/1217 (52.3) 141/1217 (11.6) 263/1217 (21.6) 188/1219 (15.4) 81/1217 (6.7) 73/1217 (6.0) 372/1220 (30.5)
  Rural 234/1893 (12.4) 135/1892 (7.1) 833/1892 (44.0) 265/1892 (14.0) 224/1216 (8.4) 52/1893 (2.8) 946/1894 (50.0) 44/1893 (2.3) 171/1893 (9.0) 83/1893 (4.4) 35/1893 (1.9) 34/1893 (1.8) 261/1893 (13.8)
Colombia
  Urban 89/151 (58.9) 67/151 (44.4) 88/151 (58.3) 68/151 (45.0) 53/151 (35.1) 9/151 (6.0) 115/151 (76.2) 58/151 (38.4) 60/151 (39.7) 11/151 (7.3) 53/151 (35.1) 54/151 (35.8) 64/151 (42.4)
  Rural 96/127 (75.6) 79/127 (62.2) 89/127 (70.1) 72/127 (56.7) 55/127 (43.3) 9/127 (7.1) 108/127 (85.0) 66/127 (52.0) 67/127 (52.8) 17/127 (13.4) 62/127 (48.8) 64/127 (50.4) 70/127 (55.1)
Iran (Islamic Republic of)
  Urban 17/321 (5.3) 50/321 (15.6) 11/321 (3.4) 0/321 (0.0) 9/321 (2.8) 22/321 (6.9) 76/321 (23.7) 3/321 (0.9) 7/321 (2.1) 1/321 (0.3) 0/321 (0.0) 1/321 (0.3) 12/321 (3.7)
  Rural 1/272 (0.4) 5/272 (1.8) 2/272 (0.7) 2/272 (0.7) 2/272 (0.7) 4/272 (1.5) 11/272 (4.0) 1/272 (0.4) 1/272 (0.4) 1/272 (0.4) 0/272 (0.0) 0/272 (0.0) 1/272 (0.4)
Total
  All communities 766/3981 (19.2) 559/3979 (14.1) 1550/3980 (38.9) 632/3978 (15.9) 501/3980 (12.6) 198/3980 (5.0) 1892/3982 (47.5) 313/3981 (7.9) 569/3981 (14.3) 301/3983 (7.6) 231/3981 (5.8) 226/3981 (5.7) 780/3984 (19.6)
  Urban 435/1689 (25.8) 340/1688 (20.1) 626/1689 (37.1) 293/1687 (17.4) 286/1688 (16.9) 133/1688 (7.9) 827/1689 (49.0) 202/1689 (12.0) 330/1689 (19.5) 200/1691 (11.8) 134/1689 (7.9) 128/1689 (7.6) 448/1692 (26.5)
  Rural 331/2292 (14.4) 219/2291 (9.6) 924/2291 (40.3) 339/2291 (14.8) 215/2292 (9.4) 65/2292 (2.8) 1065/2293 (46.5) 111/2292 (4.8) 239/2291 (10.4) 101/2291 (4.4) 97/2292 (4.2) 98/2292 (4.3) 332/2292 (14.5)
Low-income countries
India
  Urban 211/766 (27.6) 187/766 (24.4) 201/766 (26.2) 57/766 (7.4) 94/766 (12.3) 63/766 (8.2) 353/766 (46.1) 47/766 (6.1) 57/766 (7.4) 3/766 (0.4) 19/766 (2.5) 22/766 (2.9) 62/766 (8.1)
  Rural 254/1352 (18.8) 189/1352 (14.0) 396/1352 (29.3) 53/1352 (3.9) 76/1352 (5.6) 83/1352 (6.1) 561/1352 (41.5) 14/1352 (1.0) 17/1352 (1.3) 0/1352 (0.0) 2/1352 (0.2) 1/1352 (0.1) 29/1352 (2.1)
Pakistan
  Urban 33/57 (57.9) 44/57 (77.2) 36/57 (63.2) 26/57 (45.6) 23/57 (40.4) 9/57 (15.8) 50/57 (87.7) 19/57 (33.3) 14/57 (24.6) 16/57 (28.1) 9/57 (15.8) 5/57 (8.8) 23/57 (40.4)
  Rural 23/54 (42.6) 35/54 (64.8) 26/54 (48.2) 10/54 (18.5) 10/54 (18.5) 1/54 (1.9) 42/54 (77.8) 3/54 (5.6) 1/54 (1.9) 0/54 (0.0) 2/54 (3.7) 1/54 (1.9) 5/54 (9.3)
Zimbabwe
  Urban 22/26 (84.6) 15/26 (57.7) 22/26 (84.6) 6/26 (23.1) 13/26 (50.0) 3/26 (11.5) 25/26 (96.2) 13/26 (50.0) 17/26 (65.4) 0/26 (0.0) 2/26 (7.7) 1/26 (3.9) 18/26 (69.2)
  Rural 39/55 (70.9) 43/55 (78.2) 17/55 (30.9) 43/55 (78.2) 31/55 (56.4) 2/55 (3.6) 53/55 (96.4) 20/55 (36.4) 21/55 (38.2) 1/55 (1.8) 2/55 (3.6) 0/55 (0.0) 27/55 (49.1)
Total
  All communities 582/2310 (25.2) 513/2310 (22.2) 698/2310 (30.2) 195/2310 (8.4) 247/2310 (10.7) 161/2310 (7.0) 1084/2310 (46.9) 116/2310 (5.0) 127/2310 (5.5) 20/2310 (0.9) 36/2310 (1.6) 30/2310 (1.3) 164/2310 (7.1)
  Urban 266/849 (31.3) 246/849 (29.0) 259/849 (30.5) 89/849 (10.5) 130/849 (15.3) 75/849 (8.8) 428/849 (50.4) 79/849 (9.3) 88/849 (10.4) 19/849 (2.2) 30/849 (3.5) 28/849 (3.3) 103/849 (12.1)
  Rural 316/1461 (21.6) 267/1461 (18.3) 439/1461 (30.1) 106/1461 (7.3) 117/1461 (8.0) 86/1461 (5.9) 656/1461 (44.9) 37/1461 (2.5) 39/1461 (2.7) 1/1461 (0.1) 6/1461 (0.4) 2/1461 (0.1) 61/1461 (4.2)
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a Countries were categorized according to the World Bank’s 2006 classification.11

b For example billboards, pasted on walls, visible on the sides of taxis and buses.

c Permanently sponsored signage on shops or other buildings.

d For example newspapers and magazines.

e Sponsorship of sporting, music or other events.

f On products such as umbrellas, ashtrays, shopping bags, clothing or any other products.

g Promotional vouchers that allow discounts.

The likelihood that interviewees from low-income countries reported exposure to at least one form of traditional marketing was almost 10 times higher (OR: 9.77; 95% CI: 1.24–76.77) than in high-income countries. Specifically, the likelihood of exposure to radio (OR: 46.05; 95% CI: 1.29–1642.57), signage (OR: 11.02; 95% CI: 1.07–113.60), television (OR: 9.42; 95% CI: 1.21–73.20) and cinema marketing of tobacco (OR: 3.08; 95% CI: 1.46–6.49) were significantly higher in low-income than in high-income countries (Table 5). Compared with the interviewees from urban communities, the likelihood that interviewees from rural communities reported exposure to traditional marketing was either significantly lower – posters, signage, print and cinema marketing – or not significantly different – television and radio marketing (Table 5).

Table 5. The likelihood that interviewees reported seeing traditional types of tobacco marketing within the previous six months, 16 countries, 2009–2012.
Group OR (95% CI)a
Posters Signage Television Radio Print media Cinema Any type
Community type
Urban 1 1 1 1 1 1 1
Rural 0.41 (0.28–0.59) 0.34 (0.24–0.48) 0.86 (0.62–1.21) 0.64 (0.40–1.02) 0.54 (0.39–0.75) 0.49 (0.30–0.78) 0.72 (0.53–0.98)
Country income groupb
High 1 1 1 1 1 1 1
Upper-middle 2.19 (0.28–16.87) 1.29 (0.18–9.03) 4.19 (0.77–22.84) 9.50 (0.46–195.60) 0.75 (0.12–4.53) 0.70 (0.33–1.50) 1.57 (0.29–8.49)
Lower-middle 2.37 (0.22–24.86) 2.16 (0.23–20.09) 3.73 (0.54–26.00) 13.89 (0.42–454.42) 0.43 (0.05–3.45) 1.63 (0.81–3.27) 2.19 (0.32–15.17)
Low 11.05 (0.94–129.43) 11.02 (1.07–113.60) 9.42 (1.21–73.20) 46.05 (1.29–1642.57) 1.29 (0.15–11.22) 3.08 (1.46–6.49) 9.77 (1.24–76.77)
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CI: confidence interval; OR: odds ratio.

a Derived from logistic multilevel regression models.

b Countries were categorized according to the World Bank’s 2006 classification.11

Non-traditional

Non-traditional marketing was reported less frequently than traditional marketing (Table 4). Although tobacco marketing on other products – e.g. umbrellas – was the most commonly reported form of non-traditional marketing, only 1468 (12%) of the interviewees reported seeing such marketing in the previous six months (Fig. 6 and Table 4). Country income group appeared to have little impact on exposure to non-traditional marketing but overall exposure and exposure to each form of non-traditional marketing appeared more common in the urban communities than in the rural.

Fig. 6.

Proportion of urban or rural interviewees who reported seeing at least one non-traditional type of tobacco marketing in the previous six months, 16 countries, 2009–2012

HIC: high-income country; LIC: low-income country; LMIC: lower-middle-income country; UMIC: upper-middle-income country.

Notes: Countries were categorized according to the World Bank’s 2006 classification.11 Non-traditional types of marketing were sponsorship, tobacco marketing on other products, on the internet, free samples and vouchers.

Fig. 6

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After controlling for confounders, the likelihood of exposure to non-traditional tobacco marketing in the low- and middle-income countries appeared similar to that in the high-income countries (Table 6). However, compared with their urban counterparts, the likelihood that rural interviewees reported exposure to one or more forms of non-traditional marketing was significantly lower (OR: 0.38; 95% CI: 0.25–0.59) – including the odds of exposure to sponsorship (OR: 0.35; 95% CI: 0.22–0.56), marketing on other products (OR: 0.32; 95% CI: 0.20–0.54), internet marketing (even after controlling for internet access; OR: 0.45; 95% CI: 0.26–0.78), free samples (OR: 0.37; 95% CI: 0.21–0.66) and vouchers (OR: 0.28; 95% CI: 0.16–0.51).

Table 6. The likelihood that interviewees reported seeing non-traditional types of tobacco marketing within the previous six months, 16 countries, 2009–2012.
Group OR (95% CI)a
Sponsorship On other products Internet Free samples Vouchers Any type
Community type
Urban 1 1 1 1 1 1
Rural 0.35 (0.22–0.56) 0.32 (0.20–0.54) 0.45 (0.26–0.78) 0.37 (0.21–0.66) 0.28 (0.16–0.51) 0.38 (0.25–0.59)
Country income groupb
High 1 1 1 1 1 1
Upper-middle 0.57 (0.04–7.71) 0.59 (0.03–12.56) 0.75 (0.06–8.66) 4.03 (0.07–224.84) 1.94 (0.04–88.53) 0.82 (0.07–10.03)
Lower-middle 0.91 (0.05–18.13) 1.26 (0.04–42.87) 0.46 (0.03–7.76) 10.20 (0.11–987.76) 10.73 (0.15–774.21) 0.96 (0.05–17.18)
Low 1.32 (0.06–29.21) 1.10 (0.03–42.45) 0.06 (0.00–1.47) 10.95 (0.11–1086.21) 1.19 (0.01–120.60) 1.03 (0.05–20.59)
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CI: confidence interval; OR: odds ratio.

a Derived from logistic multilevel regression models.

b Countries were categorized according to the World Bank’s 2006 classification.11

Discussion

Our study has three important findings in relation to tobacco marketing. First, we identified high levels of ongoing exposure to tobacco marketing – despite 14 of the study countries having ratified the FCTC at the time the data were collected; by December 2014, Argentina had signed but not ratified the FCTC and Zimbabwe had only acceded to it. Although ratification requires countries to implement comprehensive marketing bans, 10% of the interviewees reported seeing at least five types of tobacco marketing in the six months before interview and 45% reported seeing at least one type of tobacco marketing over the same period. Second, we detected substantially higher levels of tobacco marketing in the lower-income countries we investigated than in the higher-income. This result is consistent with the tobacco industry specifically targeting low- and middle-income countries,20,21 which could be due to large youth populations in lower-income countries and to high-income countries having more established policies on tobacco control.22 Third, for 13 of 15 marketing measures, exposure was significantly lower in the rural communities than in the urban ones.

High levels of tobacco marketing may reflect failure to enact legislation and/or to enforce compliance.23 Yet many of our interviewees – even those from countries with highly regarded tobacco control measures such as Brazil, Canada and Sweden24–26 – reported substantial exposure to tobacco marketing. This indicates that the tobacco industry may still be finding ways to market its products. Given that we recorded 10 times greater exposure to traditional marketing in the low-income countries than in the high-income countries – but similar levels of exposure to non-traditional marketing across all country income groups – it appears that legislation may have been relatively successful in controlling traditional marketing in high-income countries. This success may have resulted in the tobacco industry using newer, less regulated forms of marketing. Therefore, enforcement may need to be stronger and legislation continuously adapted to the changing marketing practices of the tobacco industry. Data on the tobacco industry’s marketing expenditure would also be useful, but such data are available for very few countries27 and not for any of our study countries.

Our observation of more intense tobacco marketing in urban communities than in rural communities is consistent with evidence that the tobacco industry focuses its marketing and distribution on areas with the greatest potential impact – i.e. areas with dense populations28,29 that can be easily reached at relatively low cost.30

Our study had several limitations. First, although diverse,11 the countries studied are not necessarily representative of low-, middle- and high-income countries globally and the communities investigated within each country are not necessarily representative of all communities.10 Although this means that the results cannot reliably be extrapolated to all communities within a country, the demographic characteristics of our interviewees do appear to match those of adults in the corresponding national populations.11 We also note that the main tobacco company in two of the three lower-middle-income countries – i.e. China and the Islamic Republic of Iran – is state-owned.31 Countries with state-owned monopolies traditionally do not market their products aggressively because the lack of competition renders this unnecessary.32 Our findings, especially those on self-reported marketing, indicate that the tobacco marketing environment may well be affected by state ownership of the local tobacco industry. In the Islamic Republic of Iran, for example, exposure to most forms of marketing appeared to be less intense than in other lower-middle-income countries. Our results appear to be consistent with data from WHO’s Global Adult Tobacco Survey33 that was conducted in 16 countries, including six of our study countries – Brazil, China, India, Pakistan, Poland and Turkey. Although the WHO’s survey did not include statistical comparisons, it did show relatively high self-reported exposure to tobacco marketing in lower-income countries – with the exception of the Russian Federation – and in urban communities.33 Our findings also seem similar to those from the International Tobacco Control Policy Evaluation Project,34 which has collected data from 22 countries, including five of our study countries – Brazil, Canada, China, India and Malaysia.

Second, the sample size varied markedly by country – both for the number of communities and number of interviewees. We would expect more uncertainty in an estimate for a country in which only a few communities are sampled. Additionally, the number of countries per country income group and the small number of communities surveyed in two of the three low-income countries may explain the wide CIs seen in some significant comparisons between low- and high-income countries. Third, although the methods used have been shown to be reliable,9 only one tobacco-selling store was visited per community during the walk – and it is not possible to know whether the selected store was representative of all stores within the community. Fourth, our study was limited by difficulties in estimating the tobacco industry’s marketing expenditure in each study country and by exposure of many individuals to cross-border marketing – including internet marketing. Finally, the study used data collected between 2009 and 2012 and some of the countries have since taken further steps to strengthen their tobacco marketing regulations.

Our study also has strengths. The Environmental Profile of a Community’s Health study takes a comprehensive approach to data collection, using both direct observation and self-reported data to assess the level and nature of diverse forms of tobacco marketing at both community and individual level; an approach shown to be reliable.9 The countries included in our analysis are very diverse in terms of both economics and culture. Additionally, although differences in self-reported exposure to marketing will reflect access to certain types of media, we were able to control for internet access and television and radio ownership in the individual-level models.

This study indicates that tobacco marketing remains ubiquitous even in countries that have ratified the FCTC. Given the strength of the link between marketing by the tobacco industry and the prevalence of smoking,2–4 there is an urgent need for countries either to implement comprehensive controls on tobacco marketing or to enforce such controls more effectively.

Acknowledgements

ES, ABG and MS have a dual appointment with the United Kingdom Centre for Tobacco and Alcohol Studies, England. KY has a dual appointment with UCSI University, Kuala Lumpur, Malaysia.

Funding:

The data collection and analyses were supported by a grant from the Canadian Institute of Health Research (application 1843490). ES is supported by the Economic and Social Research Council (grant ES/I900284/1). The UK Centre for Tobacco and Alcohol Studies is supported by the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council and the National Institute of Health Research, under the auspices of the UK Clinical Research Collaboration. SY is supported by the Heart and Stroke Foundation Mary Burke Chair for cardiovascular research. CKC is supported by a National Health and Medical Research Council Career Development Award (APP1033478) co-funded by the Heart Foundation and a Sydney Medical Foundation Chapmen Fellowship.

Competing interests:

None declared.

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