JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 59, NO.

College Students Exposure to Tobacco Marketing in Nightclubs and Bars

S. Lee Ridner, PhD; John A. Myers, PhD; Ellen J. Hahn, PhD; Tiffany N. Ciszewski, BSS

Abstract. Objective: To examine whether a college students exposure to tobacco marketing in nightclubs and bars was affected by the presence of a smoke-free law. Participants: A random sample (N = 478) of students participated in the survey (no smoke-free law, n = 240; smoke-free law, n = 238). The analysis was limited to students who reported being in nightclubs and bars (n = 171). Methods: A nonexperimental, cross-sectional, 2-group design was used. Results: Students in the smoke-free law city were more likely to be approached by tobacco marketers (34.7% versus 20.2%, p = .02), offered free gifts (41.7% versus 24.2%, p = .02), and take free gifts for themselves (34.7% versus 19.2%, p = .02). They were more likely to be exposed to direct marketing strategies (1.83 versus 1.12, p = .02). There was no difference on indirect tobacco marketing by site. Conclusions: Tobacco marketing is pervasive in nightclubs and bars. Smoke-free laws may protect against exposure to secondhand smoke but not the pro smoking messages students encounter. Keywords: marketing, policy, student, tobacco

moking is the leading cause of preventable death in the United States. The Centers for Disease Control and Prevention1 estimates that among adults over 443,000 lives were lost annually between 2000 and 2004, which resulted in $96.8 billion in productivity losses. Despite the societal costs in both lives and dollars, 1 in 5 American adults continue to smoke.2 Young people, adolescents and young adults, are at the greatest risk of smoking, which puts them at risk for a lifetime of nicotine addiction and tobacco-related diseases. Although higher education is associated with lower smoking rates, a nationwide study of college students showed 22% reported smoking at least once in the past 30 days.3
Dr Ridner is with the School of Nursing at the University of Louisville in Louisville, Kentucky. Dr Hahn is with the College of Nursing at the University of Kentucky in Lexington, Kentucky. Dr Myers and Ms Ciszewski are with the School of Public Health and Information Sciences at the University of Louisville in Louisville, Kentucky. Copyright 2010 Taylor & Francis Group, LLC 159

Americans are covered by a patchwork of statewide and local laws regulating smoking.46 Some communities have laws that prohibit smoking in all workplaces and buildings open to the public (100% smoke-free); some communities have laws that prohibit smoking in restaurants but not bars (partially smoke-free); some communities have no laws in place at all. Studies show that in public and private workplaces where smoking is restricted, both smoking prevalence and average daily cigarette consumption among smokers is reduced.713 In addition, smoke-free environments are associated with an increase in cessation attempts.14,15 A recent study of Massachusetts youth reported that youth living in towns with strong smoke-free regulations were less likely to become established smokers compared to those from towns with weak regulations.16 In efforts to maintain current customers and win new ones, tobacco companies spend over $13 billion annually to market their products in the United States.17 Among adolescents, the marketing activities are responsible for up to 34% of all smoking experimentation.18 The relationship between marketing activities and smoking behaviors was constant even when controlling for other social inuences (eg, family and peer smoking) associated with smoking.12,19 In addition, studies have shown that marketing activities are likely to facilitate the progression from smoking experimentation to established smoking.20,21 Furthermore, a meta-analysis has shown that exposure to marketing and media more than doubles the odds of becoming a tobacco user.22 In 1998 tobacco companies agreed to stop marketing to children as part of the Master Settlement Agreement with states Attorneys General.23 As a result, young adults became the new target of marketing activities.24 Nightclubs and bars offer tobacco companies a unique opportunity to market their products to adults only. These venues are a logical choice for advertisements, promotional items, contests, and free trials of cigarettes given the high numbers of young adult patrons.25,26 A study of internal tobacco industry

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documents revealed that the companies were interested in moving young adults along the smoking continuum or promoting relapse by designing particular cigarettes specic to young adult smokers.26 This is especially important because young adults (ages 18 to 30) who smoke are more likely to be occasional rather than daily smokers, smoke 10 or fewer cigarettes per day,27 and are more likely to try and be successful with quitting smoking.26 For college students, exposure to free trials of cigarettes in nightclubs, bars, or other campus events is associated with increased smoking.28 This was particularly true for late initiators or students who did not smoke regularly before age 19. A national study of college students conducted by the American College Health Association3 showed that 68% of college students reported drinking at least once in the past 30 days. Although data on the number of students who frequent bars and nightclubs are not readily available, young adults are more likely to frequent bars than older adults,27 which may put this population at greater risk of exposure to the direct marketing practices of tobacco companies. One study found that over one quarter of young adult smokers who frequent entertainment venues which allow smoking would quit smoking if the venue were smoke-free.29 Data from an exploratory pilot study of college students living and attending school in a city with a comprehensive smoke-free ordinance extending to nightclubs and bars suggested that direct marketing practices declined once a smoke-free law covering bars was implemented.30 The purpose of the study was to examine whether or not a college students exposure to tobacco marketing in nightclubs and bars was affected by the smoke-free law (or lack thereof) in the city in which their college campus is located. To achieve this objective we rst explored if there was a difference in the proportion of students exposed to each tobacco marketing strategy studied, stratied by whether the students campus was located in a city with or without a smoke-free law. In addition, we tested for differences in the overall amount of tobacco marketing each college student was exposed to based on campus location. Then we investigated if the differing tobacco marketing strategies could be combined into more overarching approaches taken by tobacco companies (eg, direct tobacco marketing, indirect tobacco marketing) and if college students were exposed to these approaches differently based on the location of their college campus. METHODS A nonexperimental, cross-sectional, 2-group design was used to study associations between the variables. The sample was drawn from 2 regional universities located in 2 different communities in the same state. One of the universities was located in the city that had no law limiting smoking in public buildings. The second university was located in a city that had a 100% smoke-free ordinance that prohibits smoking in all workplaces, including nightclubs and bars. The university located in the community with no law limiting smoking had an enrollment of nearly 20,000 students. The university located in the city with 100% smoke-free law had just over
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16,000 students enrolled. The universities were similar in age (no law = 23 years, law = 24 years), gender (female = 60% at both), in-state residency (no law = 83%, law = 86%), and both had 25% of students living on campus. The no-law community was approximately 49,000 people, 81% Caucasian, 27% held bachelor degrees or higher, and a median income of $29,000. The community with the law was somewhat smaller (population 27,000), less diverse (88% Caucasian), less educated (24% bachelor degrees or higher), and the median income was $25,500. The unit of analysis was college students nested within communities with different levels of smoke-free legislation. The data were obtained using an electronic survey. The procedures were reviewed and approved by institutional review boards at each university. A waiver of documentation of written informed consent was obtained (a preamble to the questionnaire was used). The registrars ofce at each university supplied the research team with a random sample of 750 student e-mail addresses of students 18 to 30 years of age. The students received an initial e-mail explaining the purpose of the study and inviting them to participate. Data were collected over a 6-week period. Nonrespondents received periodic reminder e-mails. If they agreed to participate, an embedded link directed them to a secure server used for data collection. Students who completed the online survey received a $5 electronic gift certicate. Measures Level of Tobacco Marketing Exposure The measure consists of 10 questions that determined the number and types of exposures to direct marketing and advertising. A 4-point Likert-type scale was used to measure the exposure. Responses included never = 0, rarely = 1, sometimes = 2, and frequently = 3. The participants reported the frequency with which they see tobacco marketers in nightclubs and bars in their local city. Next, they reported how many times they were approached by tobacco marketers. They also reported whether or not they had been offered free gifts, and/or obtained a gift for themselves and friends from tobacco marketers. Participants also reported how many times they had seen cigarette advertisements while at nightclubs and bars on the walls, napkins, coasters, the bar, and other, using items from Gilpin, White, and Pierce31 and the California Tobacco Survey. The responses were sum scored with a possible range from 0 to 30. Higher scores were associated with greater tobacco marketing exposure. Types of Tobacco Marketing Exposure In addition, marketing strategies were dichotomized into either direct or indirect marketing. Direct marketing strategies are represented by strategies that involved highengagement activities (approached by a marketer or seen, offered, or took free gifts from marketers), whereas indirect marketing were represented by low-engagement strategies (print advertising on walls, napkins, coasters, and
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the bar itself). These variables were established as outcome variables for analysis. The internal consistency was high for both constructs (Cronbachs alpha = .86 and .93, respectively). Number of Strategies Exposed by Students In addition to the level of marketing to which an individual was exposed, we investigated if the city in which an individual attends school signicantly predicts the number of direct and indirect tobacco marketing strategies to which they were exposed. For each of the 10 exposure questions discussed above, the data were dichotomized (0 = not exposed, all other response [1,2,3] = exposed). Questions 1 to 5 represented the number of direct marketing strategies to which an individual was exposed, while questions 6 to 10 represented the number of indirect marketing strategies an individual was exposed to in the city in which they attended school. Nightclub and Bar Exposure Using a 4-point Likert scale, from never = 0 to frequently = 3, participants were asked, During the past month, how many days have you been out to a nightclub or bar? The questions stem was modied for each site to make reference to the local community name. Smoking Status Smoking status was determined by a series of questions. Participants reported the age when they smoked a whole cigarette, whether they had smoked at least 100 cigarettes, and whether they had smoked any cigarettes in the past 30 days. Demographic Variables Demographics included age, gender, marital status, current residence, sorority or fraternity membership, and mothers and fathers educational level. Statistical Analysis College students who had not visited a nightclub or bar were excluded from all analyses. Differences in demographics (eg, gender, marital status, whether they lived on campus, member of a fraternity or sorority, current drinker, etc) by group were tested by using traditional chi-square techniques for categorical variables and independent-samples t test techniques for continuous variables (eg, age). Differences in the reported frequency of various tobacco marketing strategies by group were tested using traditional chi-square techniques and unadjusted odds ratios reported. Independent-samples t test techniques were performed to test for differences in direct and indirect marketing between the 2 cities; Mann-Whitney techniques were also used to assess whether results held consistent when normality was not assumed. Next, indirect and direct marketing became independent outcome variables and were (individually) made a function of (1) city of residence, (2) current smoking status,
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(3) age, (4) gender, (5) current drinking status, (6) member of fraternity or sorority, and (7) marital status by using linear regression techniques. Two separate linear regression models were developed for the 2 outcome variables assessed: one model investigated which variables signicantly predict exposure to direct tobacco marketing strategies and the second model investigated which variables signicantly predict exposure to indirect tobacco marketing strategies. The stepwise procedure was utilized to indicate the most parsimonious model for each outcome. RESULTS Descriptive Analysis The overall sample (N = 478) consisted of a relatively equal number of students from each of the sites (no-law site n = 240; site with a law, n = 238). The response rate was 31.9% for the survey. Since the primary goal was to explore differences in exposure to tobacco marketing in nightclubs and bars, the analysis was limited to students who reported being in those venues (n = 171). A higher proportion of students living in the city with no smoke-free law (41%) reported going to nightclubs and bars compared to the city with a law (30%, p = .02). Participants were mostly female (no-law site = 62.6%, site with a law = 64.3%), Caucasian (no-law site = 97.1%, site with a law = 88.9%), and unmarried (no-law site = 85.9%, site with a law 81.4%). There were no differences in parents marital status or education. Students in the city with no law were more likely to live with a roommate/friend than students in the city with a law (66.7% versus 52.2%, p = .03). There were no other demographic differences by group. Responses on the tobacco marketing scale ranged from 0 to 30 (M = 6.78, SD = 6.40). Students in the city with a smoke-free law were more likely to be approached by marketers (34.7% versus 20.2%, p = .02), offered free gifts (41.7% versus 24.2%, p = .02), and take free gifts for themselves (34.7% versus 19.2%, p = .02), compared to college students in the city with no law (see Table 1). There were no other differences in tobacco marketing by location. College students in the site with a law were exposed to signicantly more direct tobacco marketing strategies when compared to students in the no law site (1.83 versus 1.12, p = .02); there was no difference in the number of indirect tobacco marketing strategies an individual was exposed to based on city of residence (2.75 versus 2.96, p = .51). Results held consistent when using Mann-Whitney techniques (p = .03 and p = 0.53, respectively). The only signicant predictor of the number of direct tobacco marketing strategies an individual was exposed to (surviving the stepwise procedure) was city of residence (B = .679, p = .03). No predictors examined signicantly inuence the number of indirect tobacco marketing strategies to which an individual was exposed. Interestingly, smoking and nonsmoking students reported similar experiences in exposure to tobacco marketing. The only difference in exposure to tobacco marketing by smoking status is exposure
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TABLE 1. Tobacco Marketing Strategies Stratied by Smoke-Free Law Status Variable Current smoker Seen free items given away in town Approached by marketers Offered free gift Taken free gifts for self Taken free gifts for friend Advertising on walls Advertising on napkins Advertising on coasters Advertising on bar Advertising other

Smoke-free law (n = 72) 42.1% 40.3% 34.7% 41.7% 34.7% 31.9% 69.4% 44.4% 44.4% 40.2% 59.7%

No law (n = 99) 42.0% 26.3% 20.2% 24.2% 19.2% 12.5% 74.8% 46.5% 48.5% 59.8% 64.6%

OR 1.001 1.894 2.101 2.232 2.237 1.642 0.768 0.922 0.850 0.824 0.811

95% CI 0.9221.018 0.9893.623 1.0544.184 1.1574.310 1.1164.505 0.8283.257 0.3901.511 0.5011.700 0.4621.563 0.4441.529 0.4341.515

p < .05.

to tobacco advertising on coasters; nonsmokers report seeing advertising on coasters more (55.6% versus 34.7%, p < .01). COMMENT This study demonstrates differences in college students exposure to direct tobacco marketing in nightclubs and bars depending on whether or not the city where the campus is located has a smoke-free law. Students in the community with a smoke-free law were more likely to be approached, offered, and take free items from tobacco marketers than those in the community without such a law. Although it was not signicantly different, students in the smoke-free community tended to see more free items given away compared to the students in the no-law community. The greater direct marketing in the smoke-free community is contradictory to experiences reported in a focus group study with college students in communities with varying strengths of smoke-free law.30 Although students in both communities were often exposed to indirect marketing (ie, advertising on napkins, walls, and coasters), reported exposure to this type of marketing did not differ by smoke-free law status. Differences in reports of direct tobacco marketing by college students in cities with smoke-free laws may reect more aggressive marketing strategies aimed at young adults to offset the decline in smoking associated with smoke-free laws.32 Although students in the community without a law were more likely to frequent a nightclub or bar, they reported less exposure to direct marketing. Unlike the study by Rigotti and colleagues,28 our study did not nd differences in tobacco marketing exposures by college students smoking status. Rigotti found that students were more likely to be smokers if they were in environments where free cigarettes were given away. This was particularly true for students initiating smoking at 19 years of age or older. Our study used the broader measure of free gift instead of specically assessing free cigarettes given away,
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which may account for us not nding a difference by smoking status. In addition, over 10,000 students participated in the Rigotti study compared to our much smaller sample. Data from the exploratory pilot study indicated that local students were offered a number of gifts ranging from lighters to free cigarette samples.30 Similar to Gilpin and colleagues,31 our study showed that a high proportion of students who visited nightclubs and bars reported being exposed to tobacco marketing. The Gilpin study was conducted in California, where all bars were smoke-free at the time of the study. The current study was conducted in a state with a patchwork of smoke-free laws that are enacted at the local level. One very interesting nding is that nearly one-third of the nonsmokers were offered a free gift. While data were not available on the type of gift offered to the students, free cigarettes have been reported as free gifts in other studies.30 Another interesting nding is that students obtained gifts for themselves and their friends. Obtaining these gifts routinely involves providing personal information to the marketers. That personal information becomes part of a database for mailing and marketing activities long after the night out at the local nightclub or bar.33

Limitations There were a number of limitations to this study. Foremost, this is a preliminary study of tobacco marketing in 2 communities located in a tobacco-producing state. Whether or not these results are consistent with other communities will need to be established by replication. The data are cross-sectional and we could only examine the associations between variables and not causation. In addition, we relied on self-report data and must assume participants were truthful in their responses. The population sampled was a limitation because the sample was comprised mostly of Caucasian women with a response rate of 31.9%. Therefore, some care must be taken in generalizing these results.
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Conclusions College students are exposed to a number of tobacco marketing activities in nightclubs and bars. Students in the city with the smoke-free law were more likely to report direct marketing than those in the city without such a law. Although these laws are designed to protect the public and limit exposure to secondhand smoke, pro smoking messages are pervasive in nightclubs and bars. These messages may put college students at risk for adopting smoking, relapsing, or not successfully quitting. Perhaps, one unintended consequence of smoke-free laws may be more aggressive tobacco company marketing to college students in bars and nightclubs located in smoke-free communities. It is important for health care providers and program planners to develop interventions to counter the direct and indirect marketing and messages students receive while in bars and nightclubs.
ACKNOWLEDGMENTS

This work was supported by Impact of Smoke-free Laws on Tobacco Marketing Among College Students, 116589RSGHP-09099-01-CPHPS, from the American Cancer Society. NOTE For comments and further information, address correspondence to S. Lee Ridner, PhD, ARNP, University of Louisville, School of Nursing, 555 S. Floyd Street, K-Building, Louisville, KY 40292, USA (e-mail: slridn01@louisville.edu).
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