BACKGROUND
California was the second US state to adopt a law to end the sale of most flavored tobacco products (including menthol) in August 2020.1 However, a tobacco industry front group submitted more than 625,000 validated signatures to challenge the law on a ballot referendum in November 2022. One hundred local laws that restrict sales of flavored tobacco protected 22.1% of California’s population as of February 2021,2,3 and the state aims to increase this coverage. In addition, stronger support for the statewide law is anticipated where local laws exist.4 Prior evidence of more advertising and lower prices for menthol cigarettes at stores in neighborhoods with a greater proportion of Black residents in California and in the US suggests a history of predatory marketing.5–7 This secondary analysis tests whether these patterns persist in California. This research is important because California’s law is more comprehensive than the anticipated federal ban on menthol cigarettes and flavored cigars, and the state law would be enacted sooner.
METHODS
Trained professionals recorded the presence of interior or exterior advertising for menthol and non-menthol cigarettes and the single pack price for Newport (menthol) and Marlboro red (non-menthol) in a random sample of 1,199 licensed tobacco retailers from April-September, 2018 (94.4% completion rate). The analysis sample of stores that sold cigarettes (n=1,115) was 49.9% convenience stores, 14.3% liquor stores, 8.2% tobacco/head shops, 9.3% supermarkets, 8.2% small markets, 5.1% pharmacies, and 5.0% discount/other stores.
Store neighborhoods were defined by half-mile, store-centered roadway buffers and linked to census tract estimates from the American Community Survey (2012–2016). Logistic regressions for presence of advertising and ordinary least squares regressions for price included covariates: percent Non-Hispanic Black, Asian/Pacific Islander, Hispanic, American Indian, Alaskan Native and other/multiracial); percent school age (5 to 17 years) and young adult (18 to 24); percent of population with income <185% of the federal poverty level. All models also controlled for store type.
RESULTS
Menthol cigarettes were advertised in 66.1% and non-menthol in 70.8% of 1,115 stores that sold cigarettes. Stores in neighborhoods with greater proportions of Black residents were significantly more likely to advertise menthol cigarettes than stores in neighborhoods with the lowest proportion of Black residents: Quartile 3: AOR=1.51, 95% CI = 1.00, 2.28; Quartile 4: AOR= 1.86, 95% CI = 1.20, 2.87 (see Table). Average single-pack prices were $8.66 (SD=0.94) for Newport menthol and $8.50 (SD=0.81) for Marlboro red. Compared to stores in neighborhoods with the lowest proportion of Black residents, Newport cost an estimated $0.22 and $0.25 less in neighborhoods with higher proportions of Black residents, equivalent to approximately 0.25 SD (see Table).
Table:
Neighborhood correlates of the presence of menthol/non-menthol cigarette advertising and price: California, 2018
| Menthol cigarettes advertised, among stores that sold cigarettes (n=1115) | Non-menthol cigarettes advertised, among stores that sold cigarettes (n=1115) | Newport menthol price (n=944) |
Marlboro non-menthol price (n=1083) |
|||||
|---|---|---|---|---|---|---|---|---|
| AOR | 95% CI | AOR | 95% CI | Coef | 95% CI | Coef | 95% CI | |
| Constant | 0.89 | 2.00 | 8.86 | 8.77 | ||||
| Store type | ||||||||
| Convenience storea | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. | Ref. |
| Liquor store | 0.38 | (0.26, 0.56) | 0.65 | (0.43, 0.98) | 0.28 | (0.12, 0.44) | 0.26 | (0.12, 0.40) |
| Pharmacy | 2.92 | (1.20, 7.09) | 0.38 | (0.21, 0.68) | 0.00 | (−0.23, 0.24) | −0.35 | (−0.57, −0.14) |
| Small market | 0.17 | (0.10, 0.28) | 0.25 | (0.16, 0.40) | 0.58 | (0.36, 0.79) | 0.34 | (0.16, 0.52) |
| Supermarket | 0.59 | (0.37, 0.93) | 0.24 | (0.16, 0.38) | 1.36 | (1.17, 1.56) | 0.19 | (0.02, 0.35) |
| Tobacco/head shops | 1.16 | (0.67, 2.02) | 1.54 | (0.81, 2.92) | 0.02 | (−0.18, 0.22) | −0.24 | (−0.42,−0.07) |
| Discount/other | 0.28 | (0.15, 0.50) | 0.20 | (0.11, 0.35) | 0.24 | (−0.06, 0.53) | 0.41 | (0.19, 0.64) |
| Race/ethnicity, %, Quartile 1 is the referent category | ||||||||
| Black | ||||||||
| Quartile 2 (1.09% - 2.77%) | 1.03 | (0.70, 1.52) | 0.93 | (0.62, 1.40) | −0.11 | (−0.27, 0.06) | −0.12 | (−0.26, 0.02) |
| Quartile 3 (2.78% - 6.47%) | 1.51 | (1.00, 2.28) | 1.47 | (0.95, 2.26) | −0.22 | (−0.39, −0.06) | −0.09 | (−0.23, 0.05) |
| Quartile 4 (6.48% - 74.88%) | 1.86 | (1.20, 2.87) | 0.98 | (0.64, 1.52) | −0.25 | (−0.42, −0.08) | −0.07 | (−0.22, 0.08) |
| Asian/Pacific Islander | ||||||||
| Quartile 2 (3.10% - 7.56%) | 1.23 | (0.82, 1.84) | 0.87 | (0.57, 1.31) | 0.09 | (−0.07, 0.25) | 0.10 | (−0.04, 0.24) |
| Quartile 3 (7.57% - 15.37%) | 1.03 | (0.67, 1.57) | 0.89 | (0.57, 1.37) | 0.18 | (0.01, 0.35) | 0.11 | (−0.04, 0.25) |
| Quartile 4 (15.38% - 79.80%) | 0.97 | (0.63, 1.49) | 0.79 | (0.51, 1.24) | 0.11 | (−0.06, 0.29) | 0.19 | (0.04, 0.34) |
| Other/AIAN/Multi-racial | ||||||||
| Quartile 2 (1.83% - 3.14%) | 1.29 | (0.83, 2.01) | 1.25 | (0.79, 1.97) | −0.08 | (−0.25, 0.10) | 0.00 | (−0.15, 0.15) |
| Quartile 3 (3.15% - 4.55%) | 1.08 | (0.67, 1.75) | 1.19 | (0.72, 1.96) | 0.04 | (−0.15, 0.23) | 0.01 | (−0.16, 0.17) |
| Quartile 4 (4.56% - 25.51%) | 0.99 | (0.59, 1.65) | 1.01 | (0.60, 1.70) | −0.04 | (−0.25, 0.16) | 0.00 | (−0.18, 0.17) |
| Hispanic | ||||||||
| Quartile 2 (19.44% - 35.34%) | 1.05 | (0.69, 1.60) | 1.02 | (0.66, 1.57) | −0.07 | (−0.24, 0.10) | −0.15 | (−0.29, 0.00) |
| Quartile 3 (35.35% - 58.86%) | 0.75 | (0.45, 1.25) | 0.78 | (0.46, 1.31) | −0.04 | (−0.24, 0.16) | −0.11 | (−0.29, 0.06) |
| Quartile 4 (58.87% - 98.52%) | 0.56 | (0.29, 1.08) | 0.66 | (0.34, 1.30) | −0.14 | (−0.40, 0.12) | −0.11 | (−0.33, 0.12) |
| Age, %, Quartile 1 is the referent category | ||||||||
| School-age youth, 5–17 years | ||||||||
| Quartile 2 (14.07% - 16.90%) | 2.47 | (1.65, 3.71) | 1.77 | (1.17, 2.66) | −0.21 | (−0.37, −0.05) | −0.16 | (−0.30, −0.02) |
| Quartile 3 (16.91% - 20.15%) | 2.06 | (1.35, 3.12) | 1.81 | (1.18, 2.78) | −0.20 | (−0.37, −0.04) | −0.23 | (−0.38, −0.09) |
| Quartile 4 (20.16% - 30.04%) | 3.06 | (1.88, 4.99) | 2.60 | (1.58, 4.27) | −0.13 | (−0.31, 0.06) | −0.15 | (−0.31, 0.02) |
| Young adult, 18–24 years | ||||||||
| Quartile 2 (7.85% - 9.93%) | 1.62 | (1.08, 2.44) | 1.49 | (0.99, 2.25) | −0.14 | (−0.30, 0.02) | −0.09 | (−0.23, 0.05) |
| Quartile 3 (9.94% - 11.78%) | 1.82 | (1.14, 2.89) | 1.96 | (1.22, 3.16) | −0.15 | (−0.33, 0.04) | −0.19 | (−0.35, −0.03) |
| Quartile 4 (11.79% - 67.44%) | 1.82 | (1.13, 2.93) | 2.01 | (1.23, 3.27) | −0.20 | (−0.39, −0.01) | −0.13 | (−0.30, 0.03) |
| Poverty, <185% FPL, %, Quartile 1 is the referent category | ||||||||
| Quartile 2 (22.62% - 35.31%) | 1.32 | (0.85, 2.04) | 1.17 | (0.75, 1.82) | −0.03 | (−0.20, 0.14) | −0.06 | (−0.21, 0.08) |
| Quartile 3 (35.32% - 48.70%) | 0.93 | (0.58, 1.49) | 0.79 | (0.49, 1.28) | −0.05 | (−0.24, 0.13) | −0.03 | (−0.19, 0.13) |
| Quartile 4 (48.71% - 83.69%) | 0.62 | (0.37, 1.06) | 0.59 | (0.35, 1.00) | 0.02 | (−0.19, 0.24) | −0.01 | (−0.20, 0.17) |
AOR=Adjusted odds ratio; 95% CI=Confidence Interval; FPL=Federal poverty level. AIAN=American Indian Alaskan Native. Race categories are non-Hispanic. Census measures quartiled based on entire study sample, n=1,199. Price per single pack purchase, excluding sales tax. Inter-rater reliability ranged from kappa=0.46 and 0.63 for menthol and non-menthol advertising, and the intraclass correlations for prices were 0.76 for Newport and 0.80 for Marlboro.
Convenience stores do not sell uncooked meat (other than bacon). Small markets sell uncooked meat and/or produce and have fewer than three cash registers.
DISCUSSION
Controlling for store type, neighborhood poverty and other covariates, California tobacco retailers were more likely to advertise menthol cigarettes and charged less for the most popular brand, Newport, in neighborhoods with greater proportions of Black residents. These patterns were not observed for non-menthol cigarette ads or Marlboro price; they were unique to menthol. The findings are consistent with systematic reviews about area-level disparities in cigarette advertising and menthol prices.8,9
California’s sales restriction on flavored tobacco is expected to alleviate concerns about predatory marketing of menthol cigarettes, as well as promote smoking cessation and reduce initiation.10,11 As in the US, the prevalence of smoking menthol cigarettes in California is highest (68%) among Black adult smokers,12 which suggests that the state law could reduce racial inequalities in smoking prevalence and smoking-attributable deaths.13 Continued state and local efforts to restrict sales of menthol and other flavored tobacco are necessary to fill the years-long gap between the US Food and Drug Administration’s intention to ban menthol and its regulatory action.
Acknowledgements:
The authors are grateful to Amna Ali and Trent Johnson for assistance with manuscript preparation and to Ewald & Wasserman, LLC for data collection.
Funding: This research was supported by a grant from the National Institutes of Health/National Cancer Institute, #5R01-CA067850 and the California Department of Public Health, contract #17–10041.
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