Tobacco messages encountered in real-time among low socio-economic position groups: a descriptive study

Individuals in low socio-economic position (SEP) groups use tobacco products at a higher rate [1] and suffer significantly more from tobacco-related diseases [2] than their higher socio-economic position peers. Tobacco marketing targeted specifically at low SEP groups can be one significant factor contributing to these disparities [3], while anti-tobacco messaging may be helpful in combatting tobacco use [4]. The U.S. Food and Drug Administration (FDA) has made health disparities a research priority area [5]. However, little is known about how many pro-tobacco and anti-tobacco messages low SEP groups encounter in the real world. This knowledge gap is partly because most research relies on self-reported recall of message exposure [6]. This self-reported recall can be contaminated with biases that span from respondent mood at the time of exposure [7] to how long ago they were exposed to the message [7, 8] to distance between exposure to the message and time when recall is measured. Therefore, collecting message exposure data in real-time is worthy of study [9].

Tobacco companies spend more than $9 billion per year on tobacco advertising [10, 11]. For decades, tobacco companies have disproportionately targeted low SEP groups [12], those with lower education [13], racial and ethnic minorities [14], and “blue-collar” workers [14, 15]. Communication inequality theory [16] explains this phenomenon in that there are disparities “in the generation, manipulation, and distribution of information at the group level and differences in access to and ability to take advantage of information at the individual level.” [16, 17] In other words, low SEP groups may be over-exposed to pro-tobacco messages and underexposed to anti-tobacco messages, creating disparities.

Past research has examined what types of messages low SEP groups may encounter, but most has been centered on self-report data [3], which can be contaminated with recall bias, or have been descriptive of the retail environment [12, 18‐20]. These studies show that tobacco advertising is frequently found at point-of-sale locations such as gas stations and convenience stores [18‐21], especially in low SEP neighborhoods [3, 20]. In addition, low SEP groups are more likely to recall tobacco advertising and report that it plays a role in whether they use the products [3], making it even more imperative to collect data about their encounters in real-time to avoid issues with time between exposure and recall. While past studies are informative, they still lack the component of what types of tobacco messaging low SEP groups are encountering in real-time.

Anti-tobacco public health campaigns have been associated with avoidance of or quitting of tobacco when undertaken in conjunction with other tobacco control policies [22, 23]. However, research shows that the actual effectiveness of public health campaigns promoting cessation among low SEP groups are rarely more effective [24]. In fact, researchers have frequently found mixed results about campaigns targeted at low SEP groups due to a myriad of factors, including possible differences in exposure to the campaigns and few campaigns targeting this population [24]. In order to be effective, campaigns must be funded and sustained and adequately funded [25].

The current study examines what low SEP individuals encounter in real-time in terms of pro- and anti-tobacco messaging, as well as the characteristics and themes of those messages to critically understand the current tobacco message environment to which they are exposed. Typical ad exposure measures can be weak due to the measures’ deep investment in time spent exposed to the message and lack of investment in specific message theme measures [26]. In the current study, using a mobile health application on a smartphone, participants reported and submitted photographs of tobacco messages that they encountered in real-time. The method of uploading the actual tobacco message has been shown to improve ad exposure measures, but has only ever been used in one other known study where participants reported tobacco ad exposure [9]. In the current study, the images were evaluated for frequency of pro- and anti-tobacco message encounters as well as the characteristics and themes of the messages. This study provides further information not only on how tobacco ads are encountered but also how anti-tobacco messages are encountered, giving tobacco regulators and public health officials a more complete picture of the tobacco messaging environment for low SEP groups.

The current study utilized a content analysis of real-time uploaded tobacco messages by low SEP groups. Results showed that an overwhelming majority of the messages were pro-tobacco and were mostly encountered inside and outside convenience stores and gas stations. These results coincide with previous studies [18‐20] and provide more information about real-time exposure to tobacco messages. This study also offers information about how little low SEP groups encounter anti-tobacco messaging.

In the current study’s sample of low SEP groups, results showed that conventional themes (e.g., price) were encountered most frequently. Policy regulations that take into consideration vulnerable groups’ high exposure of these marketing tactics may consider requiring anti-tobacco messaging at these locations to counteract these tactics. Regulations, such prohibiting advertising price reductions or banning point-of-sale advertising, could greatly impact this alluring advertising tactic’s ability to persuade low SEP groups to use tobacco products.

Most interesting of the findings in this study are the infrequent exposures to anti-tobacco messages, and the almost equal exposure to signage prohibiting smoking in a certain space. While exposure to signage prohibiting smoking contributes to the discouragement of use in the social context, it is not enough. Ideally, regulators and public health professionals would want to reach audiences with comprehensive messaging about the risks of smoking and about stopping or avoiding the use of tobacco products and give the tools to do so within the messaging (e.g., quitline information) [24]. In addition, these messages should be part of well-funded and sustained public health campaigns that target all sectors of the community, particularly low SEP groups. Instead, this study showed heavy exposure to signs simply prohibiting smoking.

While this study provided important information, it has its limitations. First, the study was conducted with a small sample of individuals susceptible to selection bias in only two major cities in the U.S. Future studies should expand the sample size and the location of individuals. In addition, some individuals may not have been able to upload every message they saw; such missed images could not be analyzed for theme or content. Therefore, this may not be a complete picture of what tobacco messages individuals in the sample were encountering in their day-to-day life. However, it still does give a more complete picture than requiring participants to recall messages they saw in the past because these data were collected in real-time. Finally, this was from a short period of time. Studies examining exposure over the course of a longer period may provide more extensive information about the tobacco messages encountered. Nonetheless, this study does show that 1) real-time reporting of tobacco messaging exposure can be realized, 2) low SEP groups are encountering a large number of pro-tobacco ads and fewer anti-tobacco messages, and 3) ads were encountered at point-of-sale locations with price reduction tactics. In all, this provides important evidence for regulators of tobacco advertising and public health professionals interested in providing ample and location appropriate anti-tobacco messaging.

Low SEP groups in this study encountered more pro-tobacco than anti-tobacco messages at places that were point-of-sale. Advertisers frequently use conventional themes, including price promotions to appeal to this group. Future research may consider examining whether anti-tobacco messages at point-of-sale may help combat the advertisements encountered there, especially for price-sensitive, low SEP groups.

This study offers important preliminary evidence for tobacco regulators. It illustrates that low SEP groups are encountering more pro-tobacco messages than anti-tobacco messages. These pro-tobacco messages use tactics focused on price, among a group that may be price sensitive. In addition, this study provides preliminary evidence that low SEP groups, at least in this sample, are not encountering anti-tobacco campaigns at a high rate and may consider more communication programs to help resolve tobacco use disparities. Based on this study, regulators also may consider placing anti-tobacco messaging in locations where pro-tobacco messaging is so prevalent, such as convenience stores and gas stations.