Urban-rural differences in tobacco product availability in food retailers, United States, 2017

Purpose: Tobacco use prevalence is higher in rural compared to urban settings, possibly due to differences in tobacco availability, including the option to purchase food and other essential items in stores that do not sell tobacco (tobacco-free food retailers). The goal of this research is to determine whether tobacco-free food retailer availability varies by urbanicity/rurality. Methods: Using the 2017 National Establishment Time-Series database, we identified food retailers across all census tracts containing food retailers in the United States (n = 66,053). We used multivariable logistic and linear regression models to test whether tobacco-free food retailer availability varied across 4-levels of census tract urbanicity/rurality (urban, suburban, large town, and small town/rural) for 2 outcomes: (1) the presence of at least 1 tobacco-free food retailer and (2) the percent of all food retailers that were tobacco-free. Findings: Compared to urban core census tracts, suburban census tracts had a lower odds (aOR = 0.77, 95% CI = 0.73, 0.81) of having at least 1 tobacco-free food retailer, while small town/rural census tracts had greater odds (aOR = 1.23, 95% CI = 1.15, 1.32). Suburban census tracts (B = –2.29, P <.001) and large town census tracts (B = –1.90, P <.001) also had a lower percentage of tobacco-free food retailers compared to urban census tracts. Conclusions: Compared to urban cores, tobacco-free food retailers were less prevalent in suburban and large town areas, though similarly or slightly more available in rural areas. Future research should assess whether these differences depend on varying store types

Hurricane flooding and acute gastrointestinal illness in North Carolina

Hurricanes often flood homes and industries, spreading pathogens. Contact with pathogen-contaminated water can result in diarrhea, vomiting, and/or nausea, known collectively as acute gastrointestinal illness (AGI). Hurricanes Matthew and Florence caused record-breaking flooding in North Carolina (NC) in October 2016 and September 2018, respectively. To examine the relationship between hurricane flooding and AGI in NC, we first calculated the percent of each ZIP code flooded after Hurricanes Matthew and Florence. Rates of all-cause AGI emergency department (ED) visits were calculated from NC's ED surveillance system data. Using controlled interrupted time series, we compared AGI ED visit rates during the three weeks after each hurricane in ZIP codes with a third or more of their area flooded to the predicted rates had these hurricanes not occurred, based on AGI 2016–2019 ED trends, and controlling for AGI ED visit rates in unflooded areas. We examined alternative case definitions (bacterial AGI) and effect measure modification by race and age. We observed an 11% increase (rate ratio (RR): 1.11, 95% CI: 1.00, 1.23) in AGI ED visit rates after Hurricanes Matthew and Florence. This effect was particularly strong among American Indian patients and patients aged 65 years and older after Florence and elevated among Black patients for both hurricanes. Florence's effect was more consistent than Matthew's effect, possibly because little rain preceded Florence and heavy rain preceded Matthew. When restricted to bacterial AGI, we found an 85% (RR: 1.85, 95% CI: 1.37, 2.34) increase in AGI ED visit rate after Florence, but no increase after Matthew. Hurricane flooding is associated with an increase in AGI ED visit rate, although the strength of effect may depend on total storm rainfall or antecedent rainfall. American Indians and Black people—historically pushed to less desirable, flood-prone land—may be at higher risk for AGI after storms

Associations of County Tobacco Retailer Availability With U.S. Adult Smoking Behaviors, 2014–2015

Introduction: Greater availability of tobacco product retailers in an area may be associated with smoking behaviors, and the majority of people who smoke purchase their cigarettes at gas stations and convenience stores. This cross-sectional study investigates the associations of overall tobacco retailer density and gas/convenience density with adult smoking behaviors. Methods: This study built a list of tobacco retailers in 2014 and calculated the county-level number of retailers per 1,000 people. Individual-level smoking behavior data were drawn from the 2014–2015 Tobacco Use Supplement for a sample of adults (n=88,850) residing in metropolitan counties across the U.S. General estimating equation models were fit to investigate the associations between retailer density and cigarette smoking behaviors (smoking status, quit attempt, quit length). Analyses were conducted in 2020. Results: A greater number of tobacco retailers (AOR=1.63, 95% CI=1.35, 1.96) and gas stations and convenience stores (AOR=3.29, 95% CI=2.39, 4.52) per 1,000 people were each associated with a higher odds of a respondent smoking every day than the odds of a respondent not smoking. In addition, both measures were associated with a higher odds of a respondent being an every-day than being a some-day smoker. Associations for gas/convenience density were similar in models that additionally controlled for other tobacco retailers (excluding gas/convenience). Study results did not support associations between retailer density and cessation. Conclusions: Tobacco retailer density, especially gas/convenience density, is correlated with daily smoking, the most harmful tobacco use behavior. Calculating tobacco retailer density using gas/convenience stores may be a feasible proxy for overall tobacco retailer density

Associations of tobacco retailer availability with chronic obstructive pulmonary disease related hospital outcomes, United States, 2014

There are associations between tobacco retailer density and smoking behaviors, but little is known about whether places with more tobacco retailers have more smoking-related health problems. Using cross-sectional data from 2014, we investigated the relationships between tobacco retailer density and chronic obstructive pulmonary disease (COPD) related outcomes in a sample of 1510 counties across the United States. Higher retailer density was associated with a 19% (IRR, 1.19; 95% CI, 1.12–1.27) higher COPD-related hospital discharge rate and 30% (IRR, 1.30; 95% CI 1.21–1.39) higher total COPD-related hospital costs per population. The tobacco retailer environment may be an important target for reducing smoking-related health burdens and costs

Sociodemographic inequities in tobacco retailer density: Do neighboring places matter?

We apply a spatial perspective to measure the extent to which the 2018 U.S. racial, ethnic, and socioeconomic composition of census tracts were each associated with tobacco retailer density within a tract and in its neighboring tracts (n = 71,409). A 10-percentage point increase in the Black population was associated with 0.07 (p < 0.05) more retailers per square mile within a focal tract and 0.35 (p < 0.001) more retailers per square mile in its neighbors on average. A greater percent of Hispanic/Latino residents was associated with more retailers per square mile, both within a focal tract (b = 0.95, p < 0.001) and in its neighbors 0.39 (p < 0.001). Inverse associations were observed for percent white. We also observed inequities by socioeconomic status. The overall magnitude of inequities may be underestimated if the spatial dependence between focal tracts and their neighbors are not taken into consideration. Policymakers should prioritize interconnected geographic areas experiencing high racialized and socioeconomic segregation when designing and implementing policies to reduce retail tobacco product availability

Patterns of Children’s Blood Lead Screening and Blood Lead Levels in North Carolina, 2011–2018—Who Is Tested, Who Is Missed?

BACKGROUND: No safe level of lead in blood has been identified. Blood lead testing is required for children on Medicaid, but it is at the discretion of providers and parents for others. Elevated blood lead levels (EBLLs) cannot be identified in children who are not tested. OBJECTIVES: The aims of this research were to identify determinants of lead testing and EBLLs among North Carolina children and estimate the number of additional children with EBLLs among those not tested. METHODS: We linked geocoded North Carolina birth certificates from 2011–2016 to 2010 U.S. Census data and North Carolina blood lead test results from 2011–2018. We estimated the probability of being screened for lead and created inverse probability (IP) of testing weights. We evaluated the risk of an EBLL of ≥3 lg=dL at <30 months of age, conditional on characteristics at birth, using generalized linear models and then applied IP weights to account for missing blood lead results among unscreened children. We estimated the number of additional children with EBLLs of all North Carolina children using the IP-weighted population and bootstrapping to produce 95% credible intervals (CrI). RESULTS: Mothers of the 63.5% of children (402,002 of 633,159) linked to a blood lead test result were disproportionately young, Hispanic, Black, American Indian, or on Medicaid. In full models, maternal age ≤20 y [risk ratio ðRRÞ = 1:10; 95% confidence interval (CI): 1.13, 1.20] or smoking (RR = 1.14; 95% CI: 1.12, 1.17); proximity to a major roadway (RR = 1.10; 95% CI: 1.05, 1.15); proximity to a lead-releasing Toxics Release Inventory site (RR = 1.08; 95% CI: 1.03, 1.14) or a National Emissions Inventory site (RR = 1.11; 95% CI: 1.07, 1.14); and living in neighborhoods with more housing built before 1950 (RR = 1.10; 95% CI: 1.05, 1.14) or before 1940 (RR = 1.18; 95% CI: 1.11, 1.25) or more vacant housing (RR = 1.14; 95% CI: 1.11, 1.17) were associated with an increased risk of EBLL, whereas overlap with a public water service system was associated with a decreased risk of EBLL (RR = 0.85; 95% CI: 0.83, 0.87). Children of Black mothers were no more likely than children of White mothers to have EBLLs (RR = 0.98; 95% CI: 0.96, 1.01). Complete blood lead screening in 2011–2018 may have identified an additional 17,543 (95% CrI: 17,462, 17,650) children with EBLLs ≥3 lg=dL. DISCUSSION: Our results indicate that current North Carolina lead screening strategies fail to identify over 30% (17,543 of 57,398) of children with subclinical lead poisoning and that accounting for characteristics at birth alters the conclusions about racial disparities in children’s EBLLs

Neighborhood Inequities in Tobacco Retailer Density and the Presence of Tobacco-Selling Pharmacies and Tobacco Shops

Studies document inequitable tobacco retailer density by neighborhood sociodemographics, but these findings may not be robust to different density measures. Policies to reduce density may be less equitable depending on how the presence of store types differs by neighborhood characteristics. We built a 2018 list of probable tobacco retailers in the United States and calculated four measures of density for all census tracts (N = 71,495), including total count, and number of retailers per 1,000 people, square mile, and kilometers of roadway. We fit multivariable regression models testing associations between each density measure and tract-level sociodemographics. We fit logistic regression models testing associations between sociodemographics and the presence of a tobacco-selling pharmacy or tobacco shop. Across all measures, tracts with a greater percentage of residents living below 150% of the federal poverty level (FPL) had higher density. A higher percentage of Black residents, Hispanic or Latino residents, and vacant housing was inconsistently associated with density across measures. Neighborhoods with a greater percentage of Black residents had a lower odds of having a pharmacy (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI; 0.95, 0.97]) and tobacco shop (aOR = 0.87, CI [0.86, 0.89]), while those with a greater percentage of residents living below 150% FPL had greater odds of having a tobacco shop (aOR = 1.18, CI [1.16, 1.20]). Researchers and policymakers should consider how various measures of retailer density may capture different aspects of the environment. Furthermore, there may be an inequitable impact of retailer-specific policies on tobacco availability

Trends in the Number and Type of Tobacco Product Retailers, United States, 2000-2017

Introduction: Tobacco product retailers provide access to tobacco products and exposure to tobacco marketing. Without a national tobacco retailer licensing system in the United States, there are no estimates of national trends in tobacco retailer numbers and store type over time. Methods: We developed a protocol to identify likely tobacco retailers across the United States between 2000 and 2017 using industry codes and retailer names in the annual National Establishment Time Series (NETS) database. We calculated annual counts of tobacco retailers in seven store-type categories and annual numbers of tobacco retailers that opened and closed. Results: We estimate that there were 317 492 tobacco product retailers in 2000; the number grew to 412 536 in 2009 before falling to 356 074 in 2017, for a net 12% increase overall. Gas/convenience stores and grocery stores accounted for more than two thirds of all retailers. On average, new openings accounted for 8.0% of the total retailers, whereas 7.3% of retailers closed or stopped selling tobacco each year, with stronger market volatility following the Great Recession. Since 2011, there was a disproportionate reduction in tobacco-selling pharmacies and an increase in both tobacco-specialty shops and tobacco-selling discount stores. Conclusions: During two decades when smoking declined, tobacco retailer availability increased in the United States. The economic climate, corporate and public policies, and new tobacco products may all contribute to trends in tobacco retailer availability. State and local jurisdictions considering tobacco retailer policies may find retailer trend information useful for forecasting or evaluating potential policy impacts. Implications: This study provides historic data tracking tobacco retailers in the United States between 2000 and 2017, documenting trends that unfolded as the general economic market contracted and grew, with greater regulation of the tobacco retailer environment. These data provide a context for better understanding future changes in the tobacco retailer market. In addition, the protocol established in this study could be applied in any US-based location without tobacco retailer licensing to allow identification of stores and tracking of trends