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more ground for expecting effects from a reduction of tobacco outlet density, although the evidence base with high quality studies for alcohol is also limited.

In conclusion

The main question discussed in this chapter is whether a reduction in density and/or proximity of tobacco points of sale is likely to lead to a reduction in smoking behaviour in the population. This study showed that there are various mechanisms that make such an effect likely, and comparisons with research on alcohol outlet density support a confirmative conclusion, although the evidence in this field is not strong regarding a reduction of outlets. Moreover, there are indications from cross- sectional studies suggesting associations between tobacco outlet density/proximity in the

neighbourhood of schools and smoking experimentation or incidence. So far, in the absence of evidence from studies among youth or adults in which changes in proximity or density of tobacco points of sale are investigated in relation to smoking behaviour (or any other design evaluating the impact of restrictions), the overall evidence supporting a reduction in POS is indicative rather than conclusive.

Taking these limitations into account, the results suggest that the greatest influence of the density/proximity of tobacco POS may be on adolescents who are not yet addicted but are willing to smoke opportunistically. The present results also suggest that for youth, density may be more relevant than proximity. This may imply that it is not the mere presence of a tobacco retailer near a school that influences students to experiment with smoking but rather the number of tobacco retailers (McCarthy et al., 2009). In addition to increasing access, this higher density may increase the level of exposure to smoking cues and possibly thereby promote smoking initiation. It is also suggested that a higher density of retailers around the school increases youth exposure to smoking models (i.e., those purchasing cigarettes, people smoking on the route to school), thus increasing their perceptions of tobacco’s acceptability (Adams et al., 2013). Finally, a greater number of outlets might influence impulse buying by adolescents, possibly influenced by exposure to advertising in the tobacco POS around the school (Adams et al., 2013). Future studies should examine the effect of changes in outlet density over time to better understand these relationships. In addition, there are indications that smoking cessation-related outcomes are associated with density/proximity. Whether these findings also imply that a reduction of outlets positively affects these behaviours remains to be seen, as no study thus far had addressed this research question. There remain further questions regarding to what extent outlet density should be reduced before intended and unintended effects are ‘best balanced’ and whether reductions in certain types of outlets are more effective compared to others. For example, the market share of tobacco sales through vending machines is fairly small, so the impact on the availability of tobacco products induced by banning vending machines is minimal. However, their wide distribution and visibility may have effects on ‘normalising’ tobacco use.

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Whether tobacco outlet density should be restricted may thus also depend on other aspects, for example, whether the wide availability of a substance that is seen as very harmful is compatible with health messages.

To create a stronger evidence base for changes in policies regarding the density and/or proximity of points of sale, more studies are required, preferably those that link changes in outlet density to smoking behaviour. For example, by using an interrupted time series design (or experiments) to examine the effects of changes in outlet density and proximity on smoking behaviour, the temporal relationship between density and/or proximity of points of sale could be clarified. However, these studies may be difficult to realise. The case of Hungary would have been an ideal situation for evaluating the impact of a rather large reduction in the number of points of sale. However, the other tobacco control measures implemented within the same time period make isolation of the effects of a reduction of POS on smoking behaviour a challenging endeavour.

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Chapter 4 Facilitators and barriers to implementing policies

restricting tobacco points of sale

Various factors may facilitate or hamper the implementation of policies aimed at a reduction of tobacco points of sale. We will address the following issues: public opinion and support for limiting tobacco sales (§4.1), unintended consequences for purchasing behaviour and the market (§4.2) and expected economic consequences (§4.3). Note that data on the actual (unintended)

consequences of limiting tobacco retail outlet density are scarce due to a lack of research in this field.

4.1 Public opinion and support

Studies abroad and in the Netherlands show that there is (increasing) public support for restricting sales of tobacco, although there are differences according to the type of location and smoking status (e.g., Farley et al., 2014; Hayes et al., 2014; TNS NIPO/KWF, 2014).

In the Netherlands, opinions on tobacco control measures among members of the general population have been surveyed annually since 2009, except for 2010 (TNS NIPO/KWF, 2014).

 Table 4.1 shows that most support is found for a ban on the sale of tobacco at sports locations (71%) and in drug stores (63%), which may seem logical given the incompatible ‘health messages’ at these locations and smoking. The proportions of adults in favour of these measures increased between 2009 and 2014.

 Over four out of ten adults (44%) report being in favour of a ban in pubs, bars and restaurants.

 Only one in five adults support a ban on the sale of tobacco products in convenience stores.

 For all locations, the proportion of current smokers in favour of a sales ban was appreciably lower compared to both ex-smokers and never smokers. For example, for grocery stores, the respective proportions were 40% (ex-smokers), 36% (never smokers) and 11% (current smokers).

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Table 4.1: Proportion of the general population (≥ 18 years) in the Netherlands in favour of prohibiting the sale of tobacco products (by location)

2009 2011 2012 2013 2014

Grocery stores 25% 29% 28% 32% 31%

Cafeteria at sports locations 60% 61% 65% 68% 71%

Drug store 53% 53% 58% 61% 63%

Convenience stores 16% 19% 17% 21% 19%

Gas stations 19% 21% 20% 24% 24%

Music festivals 35% 38%

Pubs/bars/restaurants 40% 39% 42% 44%

Source: THS NIPO 2014 (commissioned by the National Cancer Foundation/KWF)

Table 4.2 shows that banning tobacco sales altogether is supported by only 14% of adults, but this proportion has significantly increased since 2009 (8%).

 Almost half the population would support a ban on selling tobacco products within 250 metres from primary and secondary schools.

 A ban on tobacco vending machines is supported by approximately one-third of the

respondents, and this proportion has increased. Nonetheless, as shown in §2.5.1, according to the EC Special Eurobarometer survey in 2012, public support for this measure in the Dutch population is lowest among all EU countries.

Table 4.2: Proportion of the general population (≥ 18 years) in the Netherlands agreeing with specific measures related to the sale of tobacco products

2009 2011 2012 2013 2014

POS >250 metres from primary school

43% 44% 45% 46% 47%

POS >250 metres from secondary school

42% 44% 45% 45% 47%

Sale only by tobacconist 36% 40% 44% 46% 46%

Ban on vending machines 21% 27% 29% 32% 32%

Total ban on sale 8% 11% 11% 14% 14%

Source: THS NIPO 2014 (commissioned by the National Cancer Foundation/KWF)

In their study on public support for limiting tobacco retail in New Zealand, Whyte et al. (2014) conclude that “Tobacco’s wide availability supports its status as a ubiquitous and normalised product and is inconsistent with public opinion, which strongly supports additional restrictions on tobacco retail marketing. Policy makers have a clear mandate to introduce new measures that

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