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Background: Tobacco marketing has been established as the main motivator for tobacco use among youth. A proliferation of tobacco promotional activities in retail stores has been observed yet little is known about its impact on adolescent smoking behaviours. The purpose of this study is to use secondary data to describe the prevalence of retail tobacco point-of-purchase (PoP) activities, examine its associations with adolescent smoking behaviours, and determine what ecological factors moderate the relationship between PoP activities and student smoking behaviours in British Columbia. Methods: This cross-sectional study surveyed grade 10-11 students from 22 randomly-selected schools in BC on student smoking behaviour and conducted observations in 57 retail stores on tobacco PoP activities located within a 1 km radius of these schools. Descriptive analysis was conducted on retail tobacco PoP variables. Individual data on smoking behaviour and school level data on retailers were linked to analyse the association between retail tobacco PoP activities and student smoking behaviour using logistic regression. Moderating effects of contextual factors were also examined. GIS maps were generated to illustrate study findings. Result: A moderate to strong presence of tobacco PoP activities was observed in all tobacco retail stores located in BC school neighbourhoods. Nearly all stores displayed cigarette products in a visible manner (98.25%) and posted tobacco control signage (94.74%). In this model, proportion of stores in the school neighbourhood with presence of tobacco advertising increased the odds of a student being a smoker (OR = 1.28-3.27). Proportion of stores in the school neighbourhood with presence of tobacco control signage decreased the odds of a student being a smoker (OR = 0.11-0.66). The odds of a student being a smoker increased if they resided on the island compared to living in the lower mainland (OR = 1.11-1.75). Discussion: Convenience stores exhibited more tobacco PoP activities than other store types. Retailers in the school neighbourhood that had tobacco advertisements and tobacco control signage exhibited both detrimental and protective effects on student smoking. This provides supportive evidence to ban tobacco advertising in retail stores and increase efforts for creating an anti-tobacco environment in neighbourhood retail stores. Maps generated served descriptive and hypothesis generating purposes.

Background. Inuit experience some of the highest rates of tobacco use and of tobacco-related diseases in Canada. Communication strategies, such as health warnings on tobacco products, are seen as a necessary means of informing the public of tobacco-related health risk and motivating smokers to want to quit smoking. However, there is little evidence to suggest how such strategies might be working among Inuit nor is there evidence to suggest how best to communicate tobacco-related health risk to and promote smoking cessation among Inuit smokers. Objectives. (1) To systematically examine the effects of textual message frame (i.e., loss- vs. gain-framed), graphic type (i.e., gruesome vs. personal suffering), and narrative style (i.e., testimonial vs. didactic) on measures of message acceptance (i.e., personal relevance and perceived credibility), affective response, and potential message effectiveness. (2) To examine fear as a potential mediator of the relation between textual message frame and measures of potential message effectiveness, as well as of the relation between graphic type and measures of potential message effectiveness. (3) To examine the potential impact of the message spokesperson (i.e., Caucasian, middle-aged male/female vs. Inuit middle-aged male/female vs. Inuit Elder male/female) on measures of message acceptance and potential message effectiveness. Experimental design. A repeated measures (i.e., within-subject) 2 x 2 x 2 factorial design was used to examine the effects of textual message frame, graphic type and narrative style. A separate ranking task assessed the potential impact of the message spokesperson. Methods. Eligible participants (Inuit, aged 18 years of age or older, having smoked at least one cigarette in the previous 30 days and smoked over 100 cigarettes in their lifetime) were recruited in October 2012 from two communities in Nunavut (Iqaluit and Rankin Inlet). Participants completed a survey, an experimental procedure (i.e., a health warning rating task) and a health warning ranking task on a hand-held electronic device with a trained research assistant. With data from the health warning rating task, a series of multinomial regression models using the Generalized Estimating Equation (GEE) method were fitted to examine the effects of three message characteristics on each of the outcome measures, controlling for known covariates. Outcome measures were categorized into 3-levels: (1) extremely, (2) somewhat, and (3) not really. The “not really” category was used as the comparison category for multinomial regression models. Multinomial regression was also used to examine the potential mediating effects of fear as it related to each of the measures of potential message effectiveness. With data from the health warning ranking task, frequencies of participant choices as related to the message spokesperson were examined. 129 participants were included in the analyses. Results. Participants were, on average, 37.3 years of age (STD = 12.7) and smoked 13.0 cigarettes per day (STD = 8.9). Just over half were female (56.6%) and most had less than a high school education (72.7%). Messages with gruesome images were more likely than those with images of personal suffering to be rated as extremely relevant (OR = 2.23, CI: 1.56-3.20), credible (OR = 2.46, CI: 1.67-3.62), emotionally arousing (OR = 3.40, CI: 2.27-5.08), and potentially effective (OR = 2.56, CI: 1.69-3.86). Loss-framed messages were more likely than gain-framed messages to be rated as extremely emotionally arousing (OR = 1.71, CI: 1.23-2.37), but no more likely to be rated as extremely relevant (OR = 1.03, CI: 0.61-1.74), credible (OR = 1.06, CI: 0.81-1.39), or potentially effective (OR = 1.24, CI: 0.98-1.58). Testimonial messages were no more likely than didactic messages to be rated as extremely relevant (OR = 0.90, CI: 0.60-1.35), credible (OR = 0.97, CI: 0.70-1.34), emotionally arousing (OR = 1.22, CI: 0.90-1.67), or potentially effective (OR = 1.08, CI: 0.85-1.37). Fear appeared to partially mediate the relation between textual message frame and all three indicators of potential message effectiveness suggesting loss-framed messages elicited greater feelings of fear, thereby enhancing the potential effectiveness of the message. There was also some evidence that fear partially mediated the relation between graphic type and some indicators of potential message effectiveness suggesting messages with gruesome images elicited greater feelings of fear, thereby enhancing the potential effectiveness of the messages. Finally, greater proportions of participants indicated health warnings with an Inuit Elder were most personally relevant (44.2%) and most credible (35.9%) compared to health warnings with middle-aged Inuit or Caucasian spokespersons. However, participants’ choice of which health warning was potentially most effective was split relatively evenly between all options. Conclusions. Findings from this study suggest health warnings accompanied by gruesome images are potentially more effective at communicating tobacco-related health risk and motivating cessation among Inuit compared to those with images of personal suffering. This provides some initial evidence that current communication strategies that use gruesome imagery, like some tobacco product health warnings in Canada, may be effective among Inuit populations. However, when a spokesperson is used in a communication campaign, Inuit Elders tend to be preferred. Together these findings suggest that an integrated communication strategy that includes complementary, targeted materials working synergistically alongside population-level approaches (like tobacco product warning labels) may work best among Inuit.

Cigarette packaging is the most prominent form of tobacco promotion in Canada. Tobacco companies are increasingly selling cigarettes in innovative packaging, including the use of slim and super-slim “lipstick” sizes that are primarily marketed towards females. Australia is currently the only country that regulates the shape and size of cigarette packaging. The current study examined the relative importance of five cigarette packaging attributes—pack shape (e.g., “slims”) , brand, plain packaging, warning label size, and price—on perceptions of product taste, harm, and interest in trying, among young women in Canada. A discrete choice experiment was conducted online with smoking (n=211) and non-smoking (n=292) females, aged 16 to 24, recruited from a commercial sample. Respondents were shown 8 choice sets, each containing four packs displaying different combinations of the attributes: pack structure (slim, lipstick, booklet, standard); brand ( ‘Vogue’, ‘du Maurier’); branding (branded, plain); warning label size (50%, 75%); and price ($8.45, $10.45). For each choice set, respondents chose the brand that they: 1) would rather try, 2) would taste better, 3) would be less harmful, or “none”. For each outcome, the attributes’ impact on choices was analyzed using a multinomial logit model, and the relative importance (RI) of each attribute was calculated. The results showed that pack structure significantly influenced interest in trying (RI = 16%) and perceptions of taste (RI = 8%), whereas perceptions of harm were driven by pack structure (RI = 46%). Branding was the most important contributor to trial intent decisions (RI = 39%) and perceptions of taste (RI = 48%). Interest in trying among females significantly increased for booklet (p < 0.0001) packs compared to the traditional design. As well, females were significantly more interested in trying branded packs, female oriented ‘Vogue’ brand, and a 75% warning label size (p < 0.0001, for all). In terms of taste related perceptions, females believed that slim (p=0.02) and booklet packs (p=0.006) were significantly better tasting than traditional designs. Similarly, branded packs (p < 0.0001), ‘Vogue’ brand (p < 0.0001), 75% warning (p < 0.0001), and higher priced packs (p=0.04) significantly increased perceptions of taste among females. Among young females, booklet (p=0.03), lipstick (p < 0.0001) and slim (p < 0.0001) pack sizes were perceived as significantly less harmful compared to traditional designs. As well, women believed branded packs, ‘Vogue’ brand, and more expensive brands would be significantly less harmful (p < 0.0001, for all). Given that the discrete choice design did not include all pack profiles that could be generated with attribute-level combinations of branding, brand, and warning labels, and in particular, due to the absence of “branded Vogue packs with smaller warnings”, the findings on warning label size should be interpreted with caution. Overall, the findings suggest that “plain” packaging and prohibiting variations in pack shape and size may decrease interest in trying and reduce false perceptions of reduced product harm among young females.

Plain packaging can arguably reduce the appeal of cigarette packages and deter people from smoking. In this study, a 1 (brand type) X 4 (levels of plain packages) betweensubject design was utilized. The method used was an internet survey. 220 adult smokers and non-smokers from Halifax Regional Municipality (HRM) rated packages in terms of their brand imagery characteristics and answered a single multiple choice question to test their recall of the health warning on their package. According to the results of a MANOVA test and a bivariate logistic regression test of perception attributes, the association between plainer packages and the participants’ ratings for some attributes were significant, and ranged from slightly moderate to moderate strength levels of associations. Health warnings recall and plainer packages were also significantly and moderately associated. These associations provide a compelling argument for the need for plain packaging policies as a deterrent for smoking.