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      Denormalising tobacco at a Danish music festival

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          INTRODUCTION Music festivals and similar arenas are used worldwide by the tobacco industry to promote tobacco to youth and to shape brand image and generate brand recognition 1,2 . The industry uses subtle tobacco promotion described as ‘below-the-line promotion’, such as handing out free cigarette samples or engaging in tobacco sponsorships 3,4 . Given the enormous impact of music on youth lifestyle and identity formation, music events are considered efficient arenas for tobacco promotion and marketing 1,2 . In Denmark, the tobacco advertising ban from 2008 is subject to various exemptions, among others allowing for a ‘neutral placement of tobacco’ at point-of-sale 5 . This exemption is utilised by the tobacco industry to market and promote tobacco. In spite of the ban on sponsorship, the industry provides festivals with funding and free cigarettes for resale, in exchange for exclusive agreements and promotion of tobacco products. A 2010 study of tobacco use at the largest Danish music festival, Roskilde Festival, found that 9% of never-smokers had consumed tobacco for the first time during the festival while 24% of those who had quit smoking, within the past year, relapsed into tobacco use during the festival 6 . The festival environment thus presents a great risk for youth smoking initiation and relapse. This article describes the adoption and implementation of tobacco-free initiatives to end tobacco promotion and to denormalise tobacco use at the Danish music festival Strøm. THE CASE Strøm is an electronic music organization based in Denmark. Strøm aims to stimulate and develop the electronic music scene both in Denmark and internationally through music events, educational activities, workshops and mainly targets children, adolescents and young adults. The largest event is the yearly Strøm Festival in the Copenhagen area. Each year, Strøm activities attract more than 15000 people, mainly adolescents and young adults aged 18–30 years (Christensen MS, Schjørring MK, unpublished data, 2015). A 2015 survey of Strøm Festival found that 47% (n=602) of the festival audience had smoked a cigarette on the day or the day before going to the festival, indicating that tobacco played an important role for many of the festival participants (Christensen MS, Schjørring MK, unpublished data, 2015). From its establishment in 2007, smoking and tobacco have been an integral part of the visual identity of Strøm. Tobacco products were consistently visible and thus indirectly promoted in social media posts and visual communication material related to the festival. However, in 2014 Strøm decided to cease the indirect promotion and the sale of tobacco products. The decision was based on the role of Strøm as an important facilitator of educational activities for children and youth, which was not ethically compatible with promotion and sale of tobacco. Nonetheless, this was a difficult decision, considering the loss of funding from tobacco sponsorships and concerns about negative feedback from the audience. To consolidate the decision to cease promotion and sale of tobacco among Danish stakeholders, Strøm initiated a partnership with the Danish Cancer Society, the National Institute of Public Health, and The Health and Care Administration of the Municipality of Copenhagen. The aim of the partnership was to denormalise tobacco use and to inspire reflections about the presence of the tobacco industry in the music scene. To reach this goal the partnership focused on three key activities: 1) To create awareness among Strøm staff of the presence of tobacco and their role in indirectly promoting tobacco in the music scene, 2) To end exposure to tobacco marketing and to eliminate tobacco sponsorship in Strøm, and 3) To inspire a wider range of stakeholders in the music industry to reflect upon the relationship between tobacco and music with the hope to expand tobacco-free activities to other music organisations. The initiatives were funded by the Municipality of Copenhagen, while the other partners contributed with specialist knowledge to qualify and share knowledge, since this was the first initiative of its kind. Strøm led the formation and implementation of the initiatives. Qualitative interviews with Strøm staff The first initiative of the tobacco-free strategy consisted of qualitative interviews with employees and volunteers within the Strøm organisation (n=17). Most Strøm staff members also work in other positions in the Danish music scene. In the interviews, examples of direct and indirect tobacco promotion were shown to the respondents and debated subsequently. Using the potential of the interview as an intervention, they aimed to create awareness among the employees and volunteers of the presence of tobacco and smoking in the music scene and to make them reflect on their own experience, attitudes and behaviour to smoking. Several of the Strøm staff members interviewed considered smoking to be a socially accepted and integral part of the music scene and associated it with positive social situations. Interviewees mentioned that they had experienced tobacco marketing at music festivals and at cultural events in general. ‘I volunteered in the backstage area at a danish music festival one year, and BAT [British American Tobacco] sponsored all of the area. A few girls were to stand in a bar made of an old minivan and told to smoke or pretend to smoke. We were told that it almost didn’t matter whether we knew the bar menu or not, the pivotal thing was to know everything about their cigarettes and put them on the counter in a certain way when people bought a drink, small subtle triggers like that.’ (Strøm worker) Staff members expressed a clear understanding of the financial dependency on the tobacco industry for music organisations. ‘It is no secret that I have received tobacco sponsorships and still receive and sell tobacco at a nightclub that I co-own and at another music event, which I arrange. I also play at music venues, which sell tobacco. Tobacco is a natural part of the food chain; it is not something you think about, it is something you budget for.’ (Strøm worker) A few interviewees noted that the smoking behaviour of performing artists and role models in general is an important factor in the smoking initiation and smoking behaviour of young people. ‘When artists smoke while they perform, then I feel like smoking. I take it almost as an invitation to smoke. I attended a concert at [Danish concert-venue] and everyone smoked. It seemed like the security guards gave up trying to stop it.’ (Strøm worker) Most interviewees, however, found that role models from the music scene do not influence their own smoking behaviour or that of young people. They also did not consider their own smoking to have an influence on young people. ‘It’s a safe space when you are on the stage and then I smoke if I want to. I don’t give a shit if you are not allowed to smoke. It’s a part of going out and the first thing I think about when I drink a beer.’ (Strøm worker) End exposure of tobacco products and eliminate tobacco industry sponsorship in all Strøm events The partnership developed an official code of conduct to end exposure to tobacco at all Strøm events: There will be no exposure of tobacco products, smoking or any kind of symbol relative to smoking in the press, promotion and communication material developed and distributed by Strøm; Strøm staff members should avoid appearing in Strøm related contexts while smoking; Strøm will not receive any kind of sponsorships from the tobacco industry or tobacco related organisations and; There will be no sale of tobacco products or e-cigarettes at Strøm events. The code was published on the Strøm website and displayed in print at Strøm’s office. After implementing the code, smoking and tobacco products were no longer included in the visual material related to Strøm. Through the Strøm partnership and the various tobacco-free initiatives implemented at Strøm events, the visibility of smoking has significantly decreased in the context of the festival. Through the interviews, it was clear that the Strøm code of conduct has increased awareness among Strøm employees of the potential influence of their smoking behaviour on adolescents. The partnership entailed financial support to develop and run the initiatives. Eliminating the sale of tobacco did not pose a financial constraint to Strøm, which might be due to the festival being less dependent on revenue from tobacco sales as many Strøm events are located in urban spaces where tobacco is available from nearby convenience stores and supermarkets. Official press photos of the audience at Strøm Festival 2014 (before implementation of code) Official press photos of the audience at Strøm Festival 2015 (after implementation of the code) Survey among external network The third initiative consisted of a survey among stakeholders in the Danish music industry. Stakeholders included bookers, artists, journalists, stakeholders from record companies, industry associations and festivals. In all, 316 persons were contacted and 161 persons (51%) responded to the survey. The aim of the survey was not to gain a fully representative data set but rather to outline the main trends and the potential for adopting further tobacco-free initiatives in the music environment. A secondary objective was to inspire reflection among stakeholders on the relationship between tobacco and music events, while building awareness of the possibility to change existing practices. The survey results suggest positive attitudes towards adopting tobacco-free initiatives to change the norms of tobacco involvement in the music industry. However, the main challenges related to financial sustainability without tobacco industry funding remain substantial. Interviewees reflected on the close links between tobacco and music industry and some questioned the morality of these relations. The stakeholders displayed considerable variation in their will to initiate similar initiatives to those of Strøm. Some would like to continue the initiatives in other parts of the music business, while others found them too radical. Several respondents considered tobacco industry funding a normal and essential part of their business strategies and pointed to the financial challenges associated with leaving behind tobacco industry funding and the concern for a decrease in the alcohol sale following restrictions in the sale of tobacco. Many respondents were, however, very positive or positive (81%) towards the Strøm code of conduct and the initiatives taken to limit exposure of tobacco and smoking. Twenty-four respondents to the survey represent organizations and venues, which could potentially implement tobacco-free initiatives similar to those of Strøm. Of the 24 respondents, 51% expressed that they were very interested or interested to some extent in implementing similar tobacco-free initiatives. The sale of tobacco products and the acceptance of tobacco sponsorships at musical events seemed to be motivated mainly by financial incentives. The respondents feared both financial insecurity without tobacco funding and negative response from the audience following increased focus on tobacco control. On the other hand, the high level of support from music organisations to take on tobacco-free initiatives (51%) points to a potential for expanding the tobacco-free initiatives. Expansion to other organisations would, however, require alternate sources of financing to replace tobacco related income. conclusions The Danish music scene is a valued arena for the tobacco industry’s promotion of smoking to young people. In general, there is low awareness among stakeholders in the music industry both of the powerful role of the tobacco industry in its promotion strategies and of their own role in the indirect tobacco promotion to young people. In order to denormalise tobacco in the music scene, a vital first step is to create awareness among the stakeholders. In the Danish musical festival Strøm, a code of conduct to cease indirect tobacco promotion and tobacco sponsorships was a feasible measure towards this goal. To further disseminate the code and denormalise the presence of tobacco in the music scene, it is important to counter both the financial incentives for festivals to promote tobacco and the fear of negative audience response. We have provided an example of how to initiate the denormalisation of tobacco at the music scene and highlighted the importance of raising awareness among artists and other stakeholders from the music scene and the potential for changing the perception of tobacco as an integral part of music culture.

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          Finding the Kool Mixx: how Brown & Williamson used music marketing to sell cigarettes.

          To describe the history of Kool's music-themed promotions and analyse the role that music played in the promotion of the brand. Analysis of previously secret tobacco industry documents, legal documents, and promotional materials. Brown & Williamson started Kool sponsorship of musical events in 1975 with Kool Jazz concerts. Music was considered to be an effective marketing tool because: (1) music helped consumers make emotional connections with the brand; (2) music concerts were effective for targeted marketing; (3) music tied together an integrated marketing campaign; and (4) music had potential to appeal widely to a young audience. Brown & Williamson's first music campaigns successfully targeted young African-American male audiences. Subsequent campaigns were less effective, exploring different types of music to achieve a broader young adult appeal. This case study suggests Brown & Williamson used music most successfully for targeted marketing, but they failed to develop a wider audience using music because their attempts lacked consistency with the Kool brand's established identity. The 2004 "Kool Mixx" campaign both returned to Brown & Williamson's historic practice targeting young African-American males, and also exploited a musical genre with much more potential to bring Kool more universal appeal, as hip-hop music is increasingly popular among diverse audiences. Tobacco control efforts led by African-American community activists to oppose these marketing strategies should continue; expanding these coalitions to include the hip-hop community may further increase their effectiveness.
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            Tobacco promotion 'below-the-line': Exposure among adolescents and young adults in NSW, Australia

            Abstract Background Exposure to tobacco advertising and promotion increases the likelihood of smoking amongst young people. While there is a universal ban on traditional or 'above-the-line' advertising in Australia, the types and extent of exposure of young people to 'below-the-line' tobacco advertising and promotion is largely unknown. In this study we aim to identify levels of exposure of New South Wales (NSW) adolescents and young adults to tobacco promotion at the point-of-sale (PoS), on the internet, in entertainment media and at venues such as events or festivals and pubs, clubs, nightclubs, or bars; and to identify those most at risk of exposure. Methods A telephone survey of 1000 NSW adolescents and young adults aged 12 to 24 years was conducted. Self-reported exposure to tobacco promotions or advertising in the last month were measured in four areas: (1) promotions or advertising at (a) events or festivals and (b) pubs, clubs, nightclubs or bars, (2) on the internet, (3) people smoking cigarettes in (a) movies, (b) TV shows, (c) video games and (d) on the internet, and (4) displays of cigarette packs for sale at (a) large supermarkets, (b) grocery stores or small supermarkets, (c) convenience stores, and (d) service or petrol stations. Smoking status and susceptibility to smoking was also assessed. Results A substantial proportion of the young people surveyed reported seeing tobacco promotion sometimes or often in the last month over most of the channels studied. The highest levels of exposure were at the PoS (approx. two-thirds) and to people smoking cigarettes in movies (77%). Lower levels of exposure to tobacco promotions and imagery were reported on the internet (20%); at events or festivals (22.5%); in pubs, clubs, nightclubs or bars (31%); and in video games (23%). However, the odds of exposure through video games increased by 8% for every additional hour spent on the internet per day. Conclusions This study shows that adolescents and young adults in NSW are exposed to tobacco advertising or promotion at the PoS, on the internet, in entertainment media and at venues such as events or festivals and pubs, clubs, nightclubs or bars, despite the restrictions on the marketing of tobacco in Australia. Background There is considerable evidence linking exposure to tobacco advertising and promotion with an increased likelihood of smoking amongst young people.[1-4] As a result, an increasing number of countries have implemented bans on tobacco advertising, marketing and promotion.[5] Australia's Tobacco Advertising Prohibition Act 1992 and tobacco control legislation in the states and territories has been implemented to prevent most promotion or marketing of tobacco through traditional or 'above-the-line' forms of media (print, radio, television, billboards, and other locations).[6,7] In New South Wales (NSW), the most populous state of Australia, the Public Health (Tobacco) Act of 2008 introduced new requirements relating to advertising of tobacco products on retail premises, including how tobacco products may be displayed. The new regulations state that tobacco products must be stored out of sight so that they cannot be seen by the public from inside or outside the retail premises. Large retailers (more than 50 employees) went out of sight 1 January 2010 (Phase 1), small retailers (50 or fewer employees) followed from 1 July 2010 (Phase 2) and specialist tobacconists must comply by 1 January 2013 (Phase 3). Despite the ban on most traditional forms of tobacco advertising and promotion in Australia, the tobacco industry has adapted by diverting resources to non-traditional or 'below-the-line' means of promotion, such as point-of-sale (PoS) displays; portrayal in films or movies; TV programs, magazines and electronic games; internet advertising and events marketing.[7-10] Large-scale population studies have shown that greater exposure to PoS tobacco displays is associated with an increased likelihood of adolescent smoking.[11-17] A recent study in the United Kingdom (UK), for instance, found that both noticing and being attracted to PoS displays were associated with susceptibility to smoking amongst never smokers aged 11 to 16 years.[18] Furthermore, experimental studies have shown that youth exposed to images of tobacco-saturated PoS displays had stronger perceptions relating to the availability and ease of tobacco purchase and of peer and adult smoking as well as less support for tobacco control policies, compared to youth exposed to images of PoS displays with no tobacco imagery.[19,20] The appearance of tobacco brands or tobacco related products in cinema films has a long history and is a pervasive form of tobacco promotion.[21] A recent study from the UK showed that tobacco appeared in 70% of the most popular films from 1989 to 2008.[22] A number of studies have shown that greater exposure to smoking in films is associated with an increased likelihood of smoking among adolescents and young adults [23-29], and that this transcends different cultural contexts.[30] Evidence as to the extent and effects of youth exposure to media portrayals of smoking has previously come from countries such as the United States (US) and the UK, however, with little research to date on the level and effect of exposure in Australian youth. The internet may also influence youth tobacco use because it provides potential access to tobacco products, as well as a venue that may stimulate demand through advertising and promotional messages.[31] In 2005, almost one fifth of adult internet users in the US recalled seeing tobacco products advertised online, with young adults being the most likely group to recall such advertising.[32] Newly emerging forms of marketing include viral marketing through social networking sites in which tobacco company names, logos and images can be prominently displayed and rapidly disseminated amongst users of the sites.[33] This type of marketing, though aimed primarily at young adults, is also likely to influence younger teenagers.[6] Research investigating online exposure to tobacco promotion has largely focused on adults [32], with little or no research to date focusing on adolescent exposure, despite the wide-spread use of the internet in this age group.[33] It is important to assess exposure among adolescents and young adults to non-traditional or below-the-line means of tobacco promotion, given this may be undermining tobacco control efforts and diminishing the potential to further prevent uptake or reduce smoking in this group of young people. This study aims to identify (1) the degree to which NSW adolescents (12-17 years of age) and young adults (18-24 years of age) have been exposed to tobacco promotion at the PoS, on the internet, in entertainment media, and at entertainment venues; and (2) to profile the characteristics of adolescents and young adults most at risk of exposure to these types of tobacco promotion. Methods Design The Cancer Institute NSW's Tobacco Promotion Impact Study (TPIS) is a telephone survey of adolescents and young adults aged 12 to 24 years in New South Wales (NSW). It monitors exposure to tobacco promotion at the PoS, on the internet and in entertainment media, and smoking-related cognitions and behaviours. This paper presents findings from the baseline survey conducted in NSW in June 2010. Households were recruited using random digit dialling (landline telephone numbers only) and participants within households were recruited using random selection (selecting the nth oldest eligible person aged 12 to 24 years). Permission was obtained from parents of 12 to 15 year olds before conducting each interview. Participants were interviewed between 8 June and 30 June 2010 (n = 1,000). The questionnaire was piloted with the survey population prior to the commencement of fieldwork. An overall response rate of 45% (using the American Association for Public Opinion Research Response Rate #3) was achieved for this period [34], comparable or superior to other similar studies.[35,36] The TPIS was approved by the NSW Population Health Services Research Ethics Committee. Measures Individual characteristics Demographic items capturing age, gender, region (Sydney vs. Rest of NSW), living arrangement, language spoken at home, and disposable income were included in the study. Postcode of residence was coded according to the Socio-Economic Indices for Areas SEIFA; [37], an index of relative disadvantage, to indicate neighbourhood socio-economic status (SES). Quintiles 4-5 were collapsed to indicate low SES, and quintiles 1-3 were collapsed to indicate moderate to high SES. Age was operationalised for the bivariate and multiple variable analyses as a binary variable grouping together participants aged 12-17 years (adolescents), and those aged 18-24 years (young adults). The amount of time spent on the internet and watching TV was reported as hours and minutes per day and converted to hours per day (maximum of 10 h). Amount of disposable income was measured by asking participants how much money they had available during a normal week to spend on themselves (none, $50 or less, $50-$100, $100-$150, $150-$200, over $200, don't know). The categories were collapsed to none, $50 or less, $50-$100, $100+, unknown for analysis. Smoking status Current smokers were defined as those who had smoked cigarettes in the past month. Ex-smokers were those who had ever smoked cigarettes, but not in the past month, and had smoked 100 cigarettes or more in their lifetime. Experimenters had ever smoked cigarettes, but not in the past month, and had smoked less than 100 cigarettes in their lifetime. Non-smokers were categorised into one of two groups: susceptible non-smokers and non-susceptible non-smokers.[38] To determine susceptibility to smoking, participants who had never had a puff of a cigarette were asked "Do you think you will try cigarettes sometime soon", "Do you think you will try cigarettes sometime in the next year" and "If a friend offered you a cigarette, would you try it" (definitely no, probably no, probably yes, definitely yes). Susceptible non-smokers were those whose response to any one of the three smoking susceptibility items was anything other than 'definitely no'. Non-susceptible non-smokers were those who answered 'definitely no' to all three smoking susceptibility items. For the multiple variable analysis, a binary "ever smoked" variable was used with those who answered "yes" to "have you ever smoked a cigarette, even just a puff" coded as "ever smokers" and those who answered "no" or "don't know" as "never smoked". Smoking exposure Exposure to smoking in the household and among friends was assessed by recording the number of current smokers in a respondent's household and how many (if any) of the participants' five closest friends smoked. As both of these variables had highly skewed distributions, smoking in the household was operationalised as a three category variable (none, one person, two or more people) and smoking among friends as a four category variable (none, one friend, two friends, three or more friends). Perceived exposure to tobacco promotion Self-reported exposure to tobacco promotions or advertising in the last month were measured in four areas: (1) promotions or advertising at (a) events or festivals and (b) pubs, clubs, nightclubs or bars, (2) brands, company names or logos on the internet, (3) people smoking cigarettes in (a) movies, (b) TV shows, (c) video games (platform not specified) and (d) on the internet, and (4) displays of cigarette packs for sale at (a) large supermarkets (defined for participants as having more than five cash registers), (b) grocery stores or small supermarkets, (c) convenience stores, and (d) service or petrol stations. Respondents aged 12-15 years (n = 334) were not asked about exposure in pubs, clubs, nightclubs or bars due to the low likelihood they would be attending these venues. Exposure to cigarette pack displays at PoS was measured as, firstly, how often the respondent visited each store type (never, rarely, sometimes, often). Those who had ever visited these stores were then asked how often they had seen displays of cigarette packs for sale in each using the same response frame. Statistical analyses Outcome measures on exposure to tobacco promotion For all tobacco promotion channels except cigarette pack displays, the response categories of never/rarely and sometimes/often were collapsed to create binary exposure variables. Respondents who reported that they didn't know whether they had seen such promotions were coded "never/rarely" for exposure. Those who refused to answer a question were coded as missing for that exposure channel (at maximum n = 2). Exposure to cigarette pack displays in stores (large supermarkets, small supermarkets, convenience stores and petrol stations) were combined measures reflecting both frequency of visits to the store type and the frequency with which the respondent said they saw cigarette pack displays at that store. For both visit frequency and frequency of seeing pack displays, the coding ranged from 0 (never) to 3 (often). For each store type, the two frequency variables were multiplied to create a combined numeric cigarette pack display exposure score which was subsequently categorised as follows: Low exposure: participants who reported they either never visited that store type or never saw cigarette pack displays (irrespective of store visit frequency) or rarely visited and rarely saw pack displays (score 0 or 1); High exposure: combinations of visit frequency and seeing cigarette pack display frequency of either often and sometimes, or often and often (score 6 or 9); and Medium exposure: all other combinations of store visit and frequency of seeing pack displays (score 2 to 4). For the multiple variable analysis, the outcome variable for exposure to cigarette pack displays in stores was a single binary variable coded high exposure (versus not high) for the exposure score (as calculated above) aggregated over all store types. High exposure was defined as being in the top quartile of the total exposure score. Analytic techniques Descriptive statistics were generated for the tobacco promotion channels by gender and age group (12-17 and 18-24 years). Bivariate comparisons of level of exposure over all promotion channels across gender and age were examined using chi-square. Multiple logistic regression models estimated the adjusted odds of participants reporting seeing each of the different types of tobacco promotion sometimes or often. Each model included as predictors: age group (12-17 years, 18-24 years), gender, SES (advantaged, disadvantaged), disposable income, ever smoked, household smokers, and friends smoking. For outcome variables examining tobacco promotion on the internet and in video games, hours per day spent on the internet was also included in the model, and the model examining depiction of people smoking in TV shows also included time spent watching TV (in hours per day). Contrasts with the reference category for multiple category predictor variables were Bonferroni adjusted. The data were weighted to the NSW population for known age (12-15 years, 16-19 years, 20-24 years), sex (female, male) and region (Sydney, Rest of state) distributions for 12-24 year olds within NSW from the 2006 Australian Bureau of Statistics (ABS) Census data [39] using post-stratification weights. All analyses were conducted using Stata v11.1 [40] and used a threshold of alpha at 0.05 for statistical significance. Results Description of sample Table 1 shows the (unweighted) socio-demographic characteristics of the sample of participants from NSW (n = 1000), by age group. Table 1 Socio-demographic characteristics NSW sample (n = 1000) by age group CHARACTERISTIC 12-17 yearsn =518 18-24 yearsn =482 Total GENDER n % n % % Male 258 49.8 240 49.8 49.8 REGION Sydney 298 57.5 343 71.2 64.1 Rest of NSW 220 42.5 139 28.8 35.9 NEIGHBOURHOOD SES Low 163 31.5 148 30.7 31.1 Mod-High 355 68.5 334 69.3 68.9 LIVING ARRANGEMENT Live with parent(s)/guardians/family 511 98.8 402 83.8 91.6 Live with a, or am sole parent/share with 6 1.2 78 16.25 8.4 others/spouse/live alone LANGUAGE AT HOME English 435 84.0 348 72.2 78.3 SMOKING STATUS Current smoker 44 8.5 125 25.9 16.9 Non-susceptible non-smoker 322 62.2 155 32.2 47.7 Susceptible non-smoker 84 16.2 23 4.8 10.7 Ex-smoker 1 0.2 23 4.8 2.4 Experimenter 67 12.9 156 32.4 22.3 FRIENDS SMOKING† None 331 63.9 149 30.9 48.0 1 friend 73 14.1 101 21.0 17.4 2 friends 55 10.6 81 16.8 13.6 3+ friends 59 11.4 151 31.3 21.0 HOUSEHOLD SMOKING No one 380 73.4 285 59.1 66.5 1 person 96 18.5 133 27.6 22.9 2+ people 42 8.1 64 13.3 10.6 DISPOSABLE INCOME None 51 9.9 9 1.9 6 .05) 2 High exposure for seeing cigarette pack displays defined as top quartile of scores for summed frequency of visit by frequency of seeing cigarette pack display across all store types 3 Significance values for overall test shown for multicategory variables (e.g., disposable income), and multiple contrasts reported with Bonferroni adjustment Overall models for exposure to promotion/advertising in pubs/clubs/nightclubs/bars, seeing people smoking cigarettes in movies, in TV shows or on the internet did not reach statistical significance and therefore are not further described. For tobacco promotion/advertising at events/festivals, only the number of friends who smoked was significantly related to seeing this type of promotion once adjusted for all other variables. Those with one smoking friend compared with no friends who smoked had almost twice the odds of reporting seeing this type of promotion sometimes or often. The odds of seeing cigarette brands, tobacco company names or logos on the internet were more than halved among participants aged 18-24 years compared with adolescents, and those who had ever smoked had odds of reporting seeing this type of promotion around one-third lower than those who had never smoked. The odds of reporting seeing people smoking cigarettes in video games sometimes or often were over 70% lower for female participants. Odds of exposure through video games also increased by 8% for every additional hour spent on the internet per day. High exposure to cigarette pack displays was more likely for female compared with male participants (Adjusted Odds Ratio (AOR) =1.58, p = .003), but less likely for participants aged 18-24 years than those aged 12-17 years (AOR = .61, p = .016). Discussion This study shows that adolescents and young adults in NSW are exposed to relatively high levels of tobacco advertising or promotion at the PoS, on the internet, in entertainment media and at venues such as events or festivals and pubs, clubs, nightclubs or bars, despite the restrictions on the marketing of tobacco in Australia. The high levels of exposure particularly at the PoS and to people smoking cigarettes in movies and on TV found in this study highlight that the retail environment and entertainment media are important avenues for the industry to market tobacco and tobacco products. Most adolescents and young adults were exposed to cigarette pack displays in stores in NSW, which provides further justification for the introduction of the PoS display ban. It is interesting to note, however, that despite the first phase of the PoS display ban in NSW being implemented six months prior, most adolescents and young adults still report being exposed to cigarette pack displays in these stores. This raises the question of whether participants actually saw the displays, indicating non-compliance with legislation, or if they assumed that they had seen them because they had grown used to seeing the displays prior to Phase 1. Perceived exposure to people smoking cigarettes in movies and on TV was also found to be relatively high in this study and efforts to reduce exposure warrants attention in Australia. Although no association was found between exposure and smoking, other studies have shown how portrayals of smoking in films or movies can increase susceptibility to smoking [23]. Exposure to people smoking cigarettes in video games; tobacco brands, company names and logos on the internet; and promotions or advertising for cigarettes or other tobacco products at events or festivals, or in pubs, clubs, nightclubs or bars, while comparatively low, was still reasonably common. In particular, almost one-quarter of participants were using the internet for three or more hours each day, making the potential for exposure via this medium quite high. Whilst no studies to the authors' knowledge have assessed the impact of these forms of exposure on smoking-related cognitions and behaviours among adolescents and young adults, it is possible that exposure to smoking through these mediums may be undermining efforts to denormalise smoking. This study demonstrates that adolescents in particular were at highest risk of exposure to 'below-the-line' means of tobacco advertising or promotion, and that tobacco industry marketing through the mediums studied are reaching this vulnerable population. Strengths and limitations Strengths of the TPIS are the large sample size, the representativeness of the sample, the inclusion of a large number socio-demographic measures and that fact that it is the only known study of its type in Australia monitoring exposure to tobacco promotion in 'below-the-line' channels (at the PoS, on the internet and in entertainment media) among adolescents and young adults. There are, however, some limitations. Firstly, the study relies on self-reported exposure not actual exposure to tobacco promotion. The measure of exposure to tobacco promotion across a variety of channels relied on retrospective recall, possibly resulting in some imprecision in measurement. Similarly, while the distinction between small and large chain grocery stores in the Australian context is generally very obvious, this may also have resulted in some imprecision in measurement. Secondly, the use of RDD sampling frame will have resulted in systematic exclusion of mobile phone-only households. However, this should not have overtly influenced the results as the proportion of mobile-phone only households in Australia is relatively small [41,42]. Finally, the results from this study may not be generalisable to adolescents and young adults from other jurisdictions given the potential differences in tobacco control legislation regarding promotion or marketing of tobacco. Conclusions Findings from this study highlight that 'below-the-line' means of tobacco promotion are being noticed by young people in NSW, with high levels of exposure at the PoS through cigarette pack displays and to portrayals of smoking in films or movies and TV shows. Exposure to tobacco promotion through video games, the internet and events is also evident and of particular concern are the higher levels of exposure among adolescents aged 12-17 years. Public health authorities need to not only monitor these trends, but to address tobacco promotion in these forms through policy and practice. Competing interests The authors declare that they have no competing interests. Authors' contributions DAP conceived of the study, participated in its design and coordination, oversaw the statistical analysis and drafted the manuscript. ACG conceived and performed the statistical analysis, led the interpretation of results and helped to draft the manuscript. CR advised on the statistical analysis, aided in the interpretation of results and helped to draft the manuscript. JK participated in the design of the study and helped to draft the manuscript. TC participated in the design of the study and helped to draft the manuscript. SD participated in the design of the study, advised on the statistical analysis and critically reviewed the manuscript. AB advised on the statistical analysis, aided in the interpretation of results and critically reviewed the manuscript. All authors read and approved the final manuscript. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/12/429/prepub
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              The use of tobacco and cannabis at an international music festival.

              Music festivals are known to attract a high proportion of drug users. Using a survey of 1,772 visitors at the Roskilde Festival in Denmark, we assessed substance use at the festival, the incidence of use of substances among never-users and the incidence of use among lifetime users who had not used a substance in the past 12 months. New onset of tobacco use was reported by 9.2% of never-smokers, and new onset of cannabis use was reported by 9.3% of never-smokers of cannabis. Resumption of tobacco use was reported by 24% of past year abstainers, and resumption of cannabis use was reported by 30% of past year abstainers. New onset of other types of substances was reported by less than 0.5% of subjects, but among past year abstainers, 5-10% reported resumption of amphetamine, ketamine, MDMA and cocaine use. New onset smokers of cannabis were significantly younger than never-smokers. Music festivals such as the Roskilde Festival may be important arenas for the prevention of onset of tobacco and cannabis use and for a return to substance use. Copyright © 2010 S. Karger AG, Basel.
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                Author and article information

                Journal
                Tob Prev Cessat
                Tob Prev Cessat
                TPC
                Tobacco Prevention & Cessation
                European Publishing on behalf of the European Network for Smoking and Tobacco Prevention (ENSP)
                2459-3087
                21 October 2019
                2019
                : 5
                : 35
                Affiliations
                [1 ]National Institute of Public Health, Copenhagen University, Copenhagen, Denmark
                [2 ]The Danish Cancer Society, Copenhagen, Denmark
                Author notes
                CORRESPONDENCE TO Maja Kring Schjørring. National Institute of Public Health, Copenhagen University, Studiestræde 6, 1455 København, Copenhagen, Denmark. E-mail: mksc@ 123456sdu.dk
                Article
                35
                10.18332/tpc/112672
                7205085
                8d7c394a-51da-4b70-b808-70653c3602c4
                © 2019 Schjørring M. K

                This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License.

                History
                : 16 August 2019
                : 28 September 2019
                Categories
                Tobacco Industry monitoring letters

                tobacco industry,advocacy,denormalising,advertising and promotion,youth

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