Symposium Presentation for the Society for Research on Nicotine and Tobacco: Understanding How Tobacco Outlets and Marketing Affect Thoughts and Behaviors in Real-Time: A New Generation of Ecological Momentary Assessment. Boston, MA 2013.

1. The Influence of
Tobacco Retail Outlets
on Real-Time Smoking
Urges During a Quit
Attempt
Kellie L. Watkins, MS
Ph.D. Student, Department of Epidemiology
University of Texas, School of Public Health
Department of Health Disparities Research
University of Texas, MD Anderson Cancer Center

2. Tobacco Retail Outlets & Smoking
• Density of outlets is linked to higher smoking rates
among adults (Chuang, Cubbin, Ahn, & Winkleby, 2005)
• Proximity of outlets to the home is related to smoking
relapse (Reitzel et al., 2011)
Laboratory Studies: tobacco cues increase craving to
smoke in acute withdrawal (Carter & Tiffany, 1999; Shiffman et al., 2012)
What about in real life? Outlets may represent an
environmental cue to smoke, provoking cravings/urges:
• Prominent product placement
• Offering increased access to tobacco products
• Concentrated marketing

3. New Directions
Most previous tobacco outlet research has focused on
participant’s neighborhood outlets
• But real exposure is much more far-reaching than
neighborhoods
Ecological Momentary Assessment (EMA) allows
assessments in real-time, real-life settings
• Important for cue-driven, time-limited, fluctuating
mechanisms like smoking cravings/urges
EMA can be combined with GPS and GIS information
• Know where people are when they take assessments, link
this with potential environmental cues, like tobacco outlets

4. Our Focus
CRAVINGS

5. Study Aims
Aim 1: Does the density of tobacco outlets around
participants affect cravings in real-time during a specific quit
attempt?
Greater density = Stronger smoking urges
Aim 2: Does participants’ proximity to tobacco outlets affect
cravings in real-time during a specific quit attempt?
Closer proximity = Stronger smoking urges
For Aims 1 & 2: Do these relations vary based on
participants’ nearness to home (i.e., in versus outside of
neighborhood)?

6. Parent Project (PREVAIL):
Participants and Methods
Participants were racially/ethnically diverse, low
socioeconomic status smokers enrolled in a smoking
cessation program at the Parkland Hospital System in
Dallas, Texas (N=102)
Followed smokers from quit day to 1 week post-quit
Sociodemographic information and tobacco
dependence (Heaviness of Smoking) were collected
at baseline
Smoking status was collected daily via EMA diary

7. Dependent Variable: EMA urge data, collected via
smartphone; <4 random assessments per day
Independent Variables: Participant’s relation to tobacco
outlets density & proximity in real-time, multi-step
process:
• Participant location data with each random assessment
• Tobacco retail outlet locations were extracted from the
Texas Comptroller of Public Accounts for the sixteen
Dallas-Ft. Worth Counties (N=6770)
• Tobacco retail outlet location and participant’s
addresses were geocoded
Our Study

8. IV #1: Density Calculation
Tobacco retail
outlet
Participant Home
Person
completing EMA
1 mile
density
buffer
1 mile residential
buffer
Density of tobacco outlets within 1 mile buffer. Density = # outlets / buffer area

9. IV #2: Proximity Calculation
Proximity to
closesttobacco
outlet
Participant Home
Tobacco retail
outlet
Proximity = distance to the closest outlet
Person
completing EMA
1 mile residential
buffer

10. Linear mixed model regressions examined relations of
density/proximity of tobacco retail outlets and smoking
urges (p<0.05)
An interaction term for both models was used to
assess whether relations varied when a participant
was within or outside of their neighborhood (p<0.10)
• Assessment occurred <1 mile of home versus >1 mile of home
Covariates: sociodemographic variables (age, gender,
employment, race, partner status, education),
heaviness of smoking, treatment group, and daily
smoking status
Data Analysis

11. included excluded
• Excluded participants were more dependent on tobacco
than included participants (HSI=2.9 versus 3.4). No other
differences.
• EMA compliance was 84.3% for included participants.
• 30.2% of included participants’ assessments had valid
geo-location data.
• 1109 total assessments with valid EMA and geo-location
data.
Study Sample
102
47 55

12. Participant Characteristics (N=47)

13. • Relations between tobacco outlet density and real-
time smoking urges were non-significant (p=.51)
• The interaction between tobacco outlet density and
nearness to home was also non-significant (p=.99)
Aim 1: Outlet Density & Smoking Urges
Sub-aim: Do these relations vary based on
participants’ nearness to home (i.e., in versus
outside of neighborhood)?
Aim 1: Does the density of tobacco outlets around
participants affect cravings in real-time during a
specific quit attempt?

14. • Relations between tobacco outlet proximity and real-
time smoking urges were non-significant (p=.16)
• The interaction between tobacco outlet proximity and
nearness to home was significant (p=.056)
Aim 2: Outlet Proximity & Smoking Urges
Sub-aim: Do these relations vary based on
participants’ nearness to home (i.e., in versus
outside of neighborhood)?
Aim 2: Does participants’ proximity to tobacco
outlets affect cravings in real-time during a specific
quit attempt?

15. Where Does Proximity Matter?
For assessments taken within a mile of home, closer
proximity to tobacco outlet was associated with a greater
reported urge to smoke (β = -1.83, SE = .54, p = .001)
[Insert figure here]

16. Density was not-significant:
• A single proximal tobacco outlet is a more salient
cue for craving than multiple surrounding outlets
Proximity was significant, but only when
participants were close to home:
• Neighborhood outlets are particularly salient
cues for craving
- Participant familiarity within these locations?
- Increased exposure to tobacco marketing?
Conclusions

17. Implications
Potential Interventions:
– Limiting the sale and/or marketing of tobacco
products in close proximity of residential
neighborhoods
– Advising smokers to avoid patronizing
neighborhood tobacco outlets during a quit attempt
Family Smoking Prevention and Tobacco Control
Act; 22 June 2009
– FDA granted power to regulate tobacco industry
– Potential limits on licensing and advertising

18. Limitations:
– Missing geo-location data
– Included participants were less dependent on
tobacco
– EMA data was not collected > 1 week post-quit
Continuing Research: the link between exposure
to tobacco marketing and smoking urges in real-
time, real-world environments
– Single data collection instrument
Limitations and Future Directions

19. UT MD Anderson Cancer Center, Department of Health
Disparities Research
– Lorraine R. Reitzel PhD, Seann D. Regan MA, Nga
Nyugen MS, Yumei Cao MS, Adolfo G. Cuevas MA, &
Cho Lam Ph.D.
UT Heath Science Center, School of Public Health
– Michael Businelle PhD, Darla Kendzor PhD
UT Southwestern Medical Center
– Insiya B. Poonawalla MS, Erica Cuate MPH, Anshula
Kesh BA
Parkland Health and Hospital System
– David Balis MD
Collaborators and Supporting
Institutions

20. Supporting grants:
– American Cancer Society )MRSGT-10-104-01-CPHPS; PI:
Kendzor)
– American Cancer Society (MRSGT-12-114-01-CPPB; PI:
Businelle)
– National Cancer Institute R25E CA56452 (PI: Chang, to
KLW)
– MD Anderson Cancer Center Support Grant (CA016672)
– MD Anderson Startup Funds (Reitzel)
Authors have no competing interests pertaining to this
research.
No industry funding disclosures or off label medication
usage.
Funding and Disclosures

21. Carter, B. L., & Tiffany, S. T. (1999). Meta-analysis of cue-reactivity in addiction research.
Addiction, 94(3), 327-340.
Chuang, Y. C., Cubbin, C., Ahn, D., & Winkleby, M. A. (2005). Effects of neighbourhood
socioeconomic status and convenience store concentration on individual level smoking.
Journal of Epidemiology & Community Health, 59(7), 568-573. doi: 10.1136/jech.2004.029041
Conklin, C. A., Robin, N., Perkins, K. A., Salkeld, R. P., & McClernon, F. J. (2008). Proximal
versus distal cues to smoke: the effects of environments on smokers' cue-reactivity.
Experimental and Clinical Psychopharmacology, 16(3), 207-214. doi: 10.1037/1064-
1297.16.3.207
Reitzel, L. R., Cromley, E. K., Li, Y., Cao, Y., Dela Mater, R., Mazas, C. A., et al. (2011). The
effect of tobacco outlet density and proximity on smoking cessation. American Journal of Public
Health, 101(2), 315-320. doi:10.2105/AJPH.2010.191676
Shiffman, S., Dunbar, M., Kirchner, T., Li, X., Tindle, H., Anderson, S., et al. (2012). Smoker
reactivity to cues: effects on craving and on smoking behavior. Journal of Abnormal
Psychology. Advance Online Publication. doi:10.1037/a0028339
Shiffman, S., Engberg, J. B., Paty, J. A., Perz, W. G., Gnys, M., Kassel, J. D., et al. (1997). A
day at a time: predicting smoking lapse from daily urge. Journal of Abnormal Psychology,
106(1), 104-116. doi: 10.1037/0021-843X.106.1.104
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Ecological momentary assessment. Annual
Review of Clinical Psychology, 4, 1-32. doi:10.1146/annurev.clinpsy.3.022806.091415
References