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Objective: To determine whether tobacco retailer density and cigarette prices differ between low and high socioeconomic status suburbs in South-East Queensland.
Methods: A survey of retail outlets selling cigarettes was conducted in selected suburbs over a two-day period. The suburbs were identified by geographical cluster sampling based on their Index of Relative Socio-economic Advantage and Disadvantage score and size of retail complex within the suburb. All retail outlets within the suburb were visited and the retail prices for the highest ranking Australian brands were recorded at each outlet.
Results: A significant relationship was found between Index of Relative Socioeconomic Advantage and Disadvantage score (in deciles) and the number of tobacco retail outlets (r=0.93, p=0.003), with the most disadvantaged suburbs having a greater number of tobacco retailers. Results also demonstrate that cigarettes were sold in a broader range of outlets in suburbs of low SES. The average price of the packs studied was significantly lower in the most disadvantaged suburbs compared to the most advantaged. While cigarettes were still generally cheaper in the most disadvantaged suburbs, the difference was no longer statistically significant when the average price of cigarette packs was compared according to outlet type (supermarket, newsagent, etc).
Conclusions: In South-East Queensland, cigarettes are more widely available in the most disadvantaged suburbs and at lower prices than in the most advantaged suburbs.
In Australia, tobacco use causes about 15,500 deaths each year.1 It is the greatest preventable contributor to the country's burden of disease through years of life lost from premature death, ill health and disability.1 Despite these alarming statistics, a substantial number of Australians continue to smoke, with 15.1% of those aged 14 years and older being daily smokers in 2010.2
Smoking prevalence is highest among people who are disadvantaged in terms of employment type, education and income level, with the most disadvantaged being more likely to smoke and to smoke more cigarettes per day.3,4 In addition, a clear social gradient of tobacco-related disease also exists, with the most disadvantaged experiencing poorer health and a shorter life expectancy.5 This suggests that current interventions have not been sufficient to substantially reduce smoking rates amongst the most socioeconomically disadvantaged, and that more targeted interventions are required.
Despite recent advances in the regulation of tobacco retailing in Queensland, there is still considerable room for improvement. In Queensland, the retail display of cigarette packs and smoking-related products is now banned, however there are still no restrictions on where cigarettes can be sold, and there is no requirement for tobacco retailers to be licensed. With the exception of Victoria, this conflicts with all other state and territory jurisdictions where tobacco retailers require a licence. It is also in stark contrast to a number of other products and services considered potentially harmful to health, safety or social principles including food preparation and sales or the commercial sex industry.6 In addition, it conflicts with the substantial regulatory requirements that govern the sale of Australian pharmaceutical products, even though these are designed to restore or enhance health.6 Despite these obvious differences, relatively little attention has been paid to the potential impact that tobacco retailing regulation (such as restrictions on the number of retailers or minimum floor prices for tobacco products) could have on smoking prevalence in Australia, particularly in areas of socioeconomic disadvantage.
Recent international studies have examined issues concerned with tobacco retailer density, attaining contrasting results. A number of North American-based studies examining the relationship between socioeconomic status (SES) and tobacco retailer density have established that lower median household income is inversely associated with increased tobacco retailer density.7–11 Similarly, a North American study exploring the relationship between youth smoking prevalence and tobacco retailer density determined that increased tobacco retailer density is associated with low SES.12 Two recent Australian studies in New South Wales found conflicting results. Paul et al.13 found no significant relationship between SES and density of tobacco outlets at both postcode and census collection district level in the Hunter region. However, a recent study by Kite et al.14 using tobacco retail licence data for the entire state reported a significant relationship between tobacco outlet density, SES and remoteness, independent of smoking prevalence. These differences could be partly dependent on variation in retail geography between the studies, with Paul et al.'s study13 containing both rural areas with very low population densities, and urban areas with high commercialism and relatively low residential populations.
Evidence from studies of other products, including alcohol and fast food, support the view that increased retailer density is associated with increased sales and can lead to adverse health outcomes.15–17 This evidence corresponds with traditional market theories which argue that the increased availability of consumer goods results in greater consumer awareness, presents more purchasing opportunities and leads to higher sales.18 Consequently, it can be reasoned that greater tobacco retailer density has the potential to encourage higher consumption and higher smoking prevalence. However, unlike the fast food industry, additional factors, such as nicotine dependence, could influence cigarette purchasing patterns.
A high tobacco retailer density can potentially reduce cigarette prices through price competition. The price of tobacco products is one of the most influential factors affecting smoking behaviour in Australia. Research demonstrates that an increase in the price of cigarettes results in a reduction in both consumption and smoking prevalence,19–21 and that people of low SES are particularly sensitive to price increases in tobacco products.20,21 However, despite this evidence, there is limited or no research that examines whether the purchase price of cigarettes differs according to the SES of an area.
The objective of this study was to determine if tobacco retailer density and cigarette prices differ between low-SES and high-SES suburbs in Southeast Queensland.
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Our finding of a greater tobacco retailer density in the most socioeconomically disadvantaged suburbs compared to the most advantaged suburbs is consistent with research in North America7–11 and Australia,14 but differs from another recent Australian study.13 That study, based in the NSW Hunter Region, used databases of tobacco retail outlets that are updated on a two to three yearly basis. In contrast, our study used an in-person check of all retail outlets within a one kilometre radius to identify retailers that sell cigarettes. We found that in the most disadvantaged suburbs, a greater proportion and a wider range of retailers sell cigarettes, including Asian grocers and a clothing store. Reliance on databases could miss retailers such as these. Differences in retail geography between the two studies may also partly account for the difference in results. For example, whether a significant retail area (i.e. a shopping centre) is located within a suburb is likely to be a greater determinant of tobacco retailer density than SES. We attempted to account for this by sampling only suburbs that contained a medium-sized shopping centre to ensure comparability.
Our study also found that access to cigarettes in terms of store opening hours is high regardless of the SES of a suburb. All suburbs we surveyed had supermarkets (the main point of cigarette purchase) that were open seven days a week. In addition, three of the four suburbs had tobacco retail outlets that were open 24 hours a day. This demonstrates that in the current market, smokers in South-East Queensland are able to access cigarettes easily, regardless of the day of the week or time of day. This has the potential to influence recent quitters to relapse as they can readily access cigarettes when experiencing a craving.
We found that cigarette pack prices are lower in low-SES suburbs compared to high-SES suburbs. In addition, we determined that the average price of the four packs studied was lower than the recommended retail price in low-SES suburbs. However, when comparing the mean price of cigarette packs according to outlet type, we determined that while pack prices were generally lower in low-SES suburbs, the difference was not statistically significant. Whether smokers in low-SES suburbs benefit from these lower prices depends on their purchasing behaviour. As most smokers purchase their cigarettes from supermarkets,28 which had only small price differences between high and low-SES suburbs, it is unlikely that most smokers in low-SES suburbs would purchase cigarettes for much less than smokers in high-SES suburbs, despite having access to a wider variety of outlets that supply cheap cigarettes.
However, it is possible that certain sub-populations in low-SES suburbs benefit from these lower prices. Our study results suggest that other area demographics (such as ethnicity) have the potential to influence the number and type of retail outlets selling cigarettes. This was evident in the low-SES suburbs where the large Vietnamese population has resulted in a greater number of Asian grocery stores and as a result, has potentially influenced the greater number of tobacco retailers in these suburbs. The relationship between tobacco retailer density and demographics other than SES is relatively unexplored in Australia and these results suggest that future research is warranted.
The finding that low-SES suburbs have greater tobacco retailer density and overall lower prices is consistent with traditional market theories which suggest that greater competition results in lower prices. It is also likely to produce greater consumer awareness, present more frequent opportunities for purchase and consequently lead to higher sales.18 Given what is known about the purchasing patterns of smokers, it is probable that an increase in tobacco retailer density would result in an increase in the number of spontaneous cigarette purchases, normalise smoking for children, and influence recent quitters to relapse. To date, only one published study has examined the impact of tobacco retailer density on smoking cessation success. This study observed an association between quit success and proximity of the quitter's home to a tobacco retailer, but not with retailer density.31 Further research on the influence of retailer density around homes and workplaces on relapse is needed.
Our results suggest a number of tobacco control strategies. First, compulsory licensing for tobacco retailers should be a priority to enable effective and efficient monitoring of tobacco sales. As no licensing system exists in Queensland, the only way to accurately identify all tobacco retailers was to conduct personal visits. This is impractical for ongoing monitoring of tobacco sales. Our finding that cigarettes were sold from a wide variety of outlets, including a clothing store, suggests relying on traditional categories of tobacco retailers may miss some outlets. In Australia, there are currently no zoning restrictions or ordinances that limit the number, concentration or placement of tobacco retailers. Reducing the density of tobacco retailers through limiting the number of tobacco retail licences issued per suburb may reduce cigarette discounting in addition to reducing the convenience of purchasing cigarettes.
Comparison of average pack prices in high-SES and low-SES suburbs stratified by type of retailer suggests that the biggest impact on cigarette prices is likely to be achieved by removing cigarette sales from supermarkets and/or by introducing a legislated minimum floor price for tobacco products. As demonstrated in this study, cigarette prices are heavily discounted in supermarkets, so removing cigarettes from their shelves would therefore decrease price competition, resulting in an overall increase in price.
A number of limitations of this study need to be considered when interpreting the results. The chosen sample areas may not have captured all tobacco retail outlets within the selected suburbs. However, it is anticipated that using the supermarket as the central point would have allowed the survey to capture the majority of retail outlets, and restricting the area to a 1 km radius ensured a similar geographic area was assessed in each suburb. The suburbs selected do not necessarily reflect all suburbs in Queensland. For example, due to demographic and environmental differences, it is questionable whether results from this study would be repeated in regional and remote areas or Indigenous communities. Despite these limitations, our study provides a clear picture of the relationship between tobacco retailer density, SES and cigarette prices in Australia.
Increases in the price of tobacco products have proven to be the most effective means of decreasing smoking prevalence.19,20 Tobacco companies recognise this, and have been introducing a number of sub-value brands to the market in response to the most recent increase in tobacco excise. Our study only monitored four major brands and pack sizes of cigarettes. Future research should examine the impact of sub-value brands and heavily discounted imported cigarettes on cigarette purchasing in low SES areas, especially in light of the recent Australian legislation requiring plain packaging on tobacco products.
Finally, while this study examined cigarette price and availability, it by no means reflects where smokers buy their cigarettes or smoking prevalence. For example, buying habits may also be influenced by the location of where a smoker works or socialises, and there are additional sources through which smokers can procure cigarettes that have not been captured in this survey, i.e. internet purchases and contraband cigarettes. Future Australian studies would benefit from exploring the relationships between cigarette price and availability, SES, purchasing behaviour and smoking prevalence. Our results suggest that interventions to restrict the number of retail outlets could be usefully employed by governments as further disincentives to tobacco use.