The environmental profile of a community’s health: A cross-sectional study on tobacco marketing in 16 countries

Objective: Tobacco industry marketing is a major determinant of smoking prevalence. The Framework Convention on Tobacco Control requires Parties to implement a “comprehensive ban” on tobacco marketing. This paper examines tobacco marketing in 16 high, upper-middle, lower-middle, and low income countries (HIC, UMIC, LMIC, LIC).

Methods: The Environmental Profile of a Community’s Health study provided cross-sectional data on tobacco marketing collected between 2009-2012. This included direct observations during a 1km walk in 462 communities across 16 countries, and self-reported exposure to 11 forms of marketing among almost 12,000 individuals. Multilevel regression models were used to examine differences in marketing between urban/rural communities and country income groups, controlling for potential confounders.

Findings: 10% of individuals reported seeing five or more types of tobacco marketing in the last six months. Multilevel regression analysis showed that compared with HICs the observed number of advertisements per community was 81 times higher in LICs (p=0.004), the number of tobacco outlets 2.5 times higher in both LICs (p=0.019) and LMICs (p=0.012), while the odds of self-reported exposure to at least one form of traditional marketing (television, radio, posters, signage, print, cinema) were almost 10 times higher in LICs (p=0.030). For 13 of 15 measures, marketing exposure was significantly lower in rural than urban communities.

Conclusion: Despite global legislation, tobacco marketing is ubiquitous and varies substantially by country income and community type; it is greatest in low income countries and in urban communities. Urgent efforts must be made to restrict tobacco marketing particularly in lower income countries.