Outlet density: a new frontier for tobacco control

The current model of selling cigarettes in Canada and elsewhere was instituted before the health effects of smoking were well known. An anachronism much in need of reform, this model makes cigarettes readily available in the retail environment so that they can be bought with minimal expenditure of time or effort. Such a state of affairs is inadvisable for an addictive and lethal substance. This editorial argues for a fundamental reconfiguration of the tobacco retail environment, particularly regarding outlet density. In the USA, the Institute of Medicine has recently made bold recommendations, calling for the development, implementation and evaluation of legal mechanisms for restructuring tobacco retail sales and restricting the number of tobacco outlets [1]. The connection between outlet density and public health can be garnered from alcohol policy [1,2]. Literature demonstrates that increased availability leads to increased consumption which leads in turn to increased problem rates [3]. For this reason, public health has advocated for the suppression of availability for disproportionately harmful things such as firearms [4–7] and enhancement of availability for disproportionately beneficial things such as fresh vegetables [8,9]. In some jurisdictions, alcohol availability theory has given rise to a population-level approach whereby taxes are high, outlet density is restricted and minimum age is enforced. Tobacco control already uses taxes and minimum age. The neglect of outlet density is not justified. There is inconsistency in public health messaging that combines warnings about the danger of smoking with tolerance of a retail environment that practically spews cigarettes out of every crevice. Public support exists for restricting the sale of tobacco. A 2006 representative survey (n = 976) showed that 30% of adults in Ontario, Canada did not want tobacco to be sold at all and 28% thought it should be sold in government-run stores in the way that alcohol is sold in Ontario [10]. In a national survey (n = 4048), one-third of Canadian smokers—especially young smokers—said if they had to travel further to buy cigarettes they would smoke less [11]. Studies on tobacco outlet density are not conclusive, but some show an association between greater density and higher smoking prevalence, economically disadvantaged neighborhoods [12–14] and increased youth smoking [15]. One study found that a greater number of tobacco outlets near schools was associated with an increased likelihood that underage smokers would buy their own cigarettes [16]. More research is needed to determine whether these associations are causal and, if so, in what direction. The relationship between outlet density and tobacco-related disease and death also requires further examination. Given the inconsistency in public health messages that discourage smoking but tolerate high outlet density, how can the number of outlets be reduced? One option is to require businesses to buy a license to sell tobacco and curtail the categories of store permitted to apply for the license. (In Canada and elsewhere, some jurisdictions currently require licenses for tobacco outlets; however, the licensing systems do not typically entail controls on availability.) Pharmacies are already not allowed to sell tobacco products in many Canadian provinces [10]. Licensing conditions could include a limit on hours and days of sale. Ideally licenses would be expensive, causing some retailers to abandon tobacco sales. Retailers failing to comply with regulations would lose their license. The impact would be stronger if there was a moratorium on new licenses until a target had been reached, e.g. 10 licenses per 20 square miles. Thus the stage would be set for reduced density by attrition. The upside of this gradual approach would be minor disruption and time to adjust for untoward effects. The downside would be delayed health benefits. Governments could also use zoning laws to ban tobacco outlets within a given distance of places where children congregate. Tobacco outlets might be deemed inappropriate near a place of worship, residential area or government office. Zoning laws could dictate a required distance between outlets to avoid clustering. New outlets would be allowed only in designated locations such as industrial use areas. The upside of zoning laws would be faster achievement of desired outcomes. The downside would be potential backlash from vested interests. The French model giving exclusive rights to sell tobacco in a specified area to licensed retailers, and requiring a licensee to be a real person as opposed to a corporation and not to operate more than one outlet [17], could be upgraded to include a public health component. For example, tobacco retailers might have to provide cessation information with every cigarette purchase. In addition to the ‘stick’ approach, ‘carrots’ could be used to encourage retailers not to sell tobacco. What about a rewards program for choosing not to sell cigarettes? Interestingly, a US grocery chain announced recently that it will stop selling tobacco because of the harmful effects of smoking [18]. Reducing the number of tobacco retail outlets is a challenge for tobacco control in the 21st century [19]. Unintended consequences are one possible hurdle. The goal is to discourage people from buying tobacco products at all, not to cause a shift in allegiance from one source to another. A detailed policy analysis can help to determine the overall net benefit of the options presented above. Research has a valuable role to play in mapping the location of tobacco outlets, determining their density in different areas and comparing these data to trends in tobacco-related disease and death. Tobacco control professionals need to be united to tackle the new frontier of reduced outlet density. The authors thank Rob Cunningham for helpful comments on an earlier draft. Diane van Abbe assisted with literature searches and retrieval. Both authors are employed by the Ontario Tobacco Research Unit, which is funded by the Ontario Ministry of Health Promotion. None.

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