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TC Online First, published on November 6, 2012 as 10.1136/tobaccocontrol-2012-050518 Brief report

Changes in tobacco industry advertising around high schools in Greece following an outdoor advertising ban: a follow-up study
Constantine I Vardavas,13 Charis Girvalaki,1,3 Lambros Lazuras,4 Danai Triantafylli,4 Christos Lionis,1 Gregory N Connolly,2 Panagiotis Behrakis2,3
1 Department of Social Medicine, Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece 2 Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts, USA 3 Smoking and Lung Cancer Research Center, Hellenic Cancer Society, Athens, Greece 4 South-East European Research Centre (SEERC), Thessaloniki, Greece

Correspondence to Dr Constantine I Vardavas, Center for Global Tobacco Control, Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA 02215, USA; vardavas@hsph.harvard.edu Received 6 March 2012 Accepted 19 October 2012

ABSTRACT Background As tobacco advertising bans are enacted in accordance with the Framework Convention on Tobacco Control, it is essential to assess enforcement and how the industry may circumvent such measures. Objective design During this longitudinal study, we compared the characteristics of points-of-sale (POS) advertising within 300 m of all high schools in Heraklion, Greece before (n=101 POS and 44 billboards in 2007) and after (n=106 POS in 2011) an outdoor advertising ban was implemented in 2009. Cigarette advertisements in all retailers near all high schools were assessed. Results Following the ban, tobacco industry billboards around schools were eradicated (from 44 to 0). The proportion of POS that had external advertisements dropped from 98% to 66% ( p<0.001), more so in regulated convenience stores (from 97% to 35%, p<0.001) than in kiosks (98% to 92%, p=0.192), which were exempt from the ban. The proportion of convenience stores that had advertisements on the door (79.5% to 20.4%, p<0.001), ads that could be seen from the street (92.3% to 22.4%, p<0.001) or illuminated exterior ads (46.2% to 10.2%, p<0.001) was also signicantly reduced. Overall, the average number of exterior advertisements per POS fell from 7.4 to 3.9 (p<0.05). This reduction was noted in regulated convenience stores (4.83.0 vs 0.92.1, p<0.001) and in unregulated kiosks (9.06.7 vs 6.54.5, p=0.019). Conclusions The outdoor advertising restriction in Greece has led to a reduced number of tobacco advertisements per POS, and the eradication of billboard advertising. Nevertheless, there is a need to regulate kiosks, which were identied as a key vector for tobacco advertising, and to increase compliance among regulated convenience stores.

in outdoor areas of POS (convenience stores and kiosks). However, after strong political debate, covered areas of kiosks were classied as interior areas. Therefore, although advertising was banned on the roofs of kiosks, they were exempt from all other restrictions, a factor we hypothesised would affect the legislations success. The objective of this study was twofold: to assess how the advertising ban impacted on tobacco advertising in close proximity to all high schools in Heraklion, Greece; and how kiosks, which were exempt from the legislation, affected the success of the ban.

METHODS
This longitudinal study took place in the city of Heraklion, Greece over 4 years. It compared the number of advertisements per POS and the descriptive characteristics of POS advertising within 300 m of all 13 high schools in Heraklion before (pre ban, in 2007) and after (post ban, in 2011) the implementation of the 2009 outdoor advertising restriction. Using a previously published protocol, we located and evaluated all tobacco industry advertising at POS or on billboards within a 300 m Euclidian radius of each high school in Heraklion (n=10).10 Researchers then travelled by foot along every road within each high schools radius and assessed all POS or industry billboards during the pre-ban and post-ban survey. Only convenience stores and kiosks were found to sell tobacco products around schools in the study area and thus POS were classied as either convenience stores or kiosks (freestanding small venues that sell cigarettes, newspapers, candy). Visibility from the school was recorded if the POS could be seen from the school gate. After identifying all POS, the advertising within each POS was evaluated. The number of advertisements, visibility from the street (whether the ads were large enough to be seen from the road when walking or driving past), and characteristics (whether they were lit up or had moving parts that would catch the eye) were noted. Even though interior advertising was not regulated with the change in the legislation, we also counted each interior advertisement and assessed their placement in relation to a childs height (if positioned below 1.2 m). No children or adults were engaged as research participants, but ethics approval was obtained from the University Hospital of Crete.

INTRODUCTION
Tobacco advertising through points of sale (POS) plays a key role in reinforcing brand imagery.1 2 Concrete evidence exists on the association between tobacco advertising and smoking,35 with the temptation to buy cigarettes6 and with complications in cessation attempts.7 In Greece, where the prevalence of adult smoking is one of the highest globally, adolescent smoking remains around the European average, which implies late-onset smoking8 In Greece over the past 4 years there has been a movement to adopt tobacco control policies, a component of which was the ban of outdoor tobacco advertising in 2009.9 The proposed legislation banned outdoor tobacco advertisements (billboards) and advertising
Tobacco Control 2012;00:13. doi:10.1136/tobaccocontrol-2012-050518 Copyright Article author (or their employer)

Statistical tests
All analyses were based on two-sided tests, with statistical signicance noted at p<0.05. 2 tests
1

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Brief report
(2) for categorical variables and t tests for continuous variables were performed. Continuous variables are presented as meansSD. The statistical analysis was performed using the statistical package PASW V .19.0. post ban), attributable to the legislation which restricted advertising on the roof of kiosks. The average number of exterior advertisements per POS after the ban fell from 7.45.9 to 3.94.5 ( p<0.05). This reduction was noted in regulated convenience stores (4.83.0 vs 0.92.1, p<0.001) and in unregulated kiosks (9.06.7 vs 6.54.5, p=0.019). Surprisingly, following the outdoor advertising ban, the absolute number of interior advertisements per POS also reduced slightly (5.74.1 pre ban vs 4.43.9 post ban, p=0.119).

RESULTS
The total number of tobacco billboards within the study area decreased from 44 to 0, indicating total compliance with the advertising ban for billboards. Out of the 106 POS assessed post ban, 56 were convenience stores and 50 were kiosks. There were a similar number of POS in 2011 (n=106) and in 2007 (n=101). As seen in table 1, the percentage of POS that had external advertisements dropped from 98% to 66% ( p<0.001) due to the reduction in external advertisements in regulated convenience stores (which fell from 98% to 35%, p<0.001), rather than the reduction in kiosks which were exempt (98% pre ban vs 93% post ban, p=0.192). The percentage of kiosks that were visible from each schools front gate reduced from 42.6% pre ban to 22.8% post ban ( p=0.031). Following the legislation, the percentage of convenience stores that had advertisements on the door (79.5% to 20.4%, p<0.001), ads that could be seen from the street (92.3% vs 22.4%, p<0.001) or illuminated exterior ads (46.2% pre ban vs 10.2% post ban, p<0.001) was signicantly reduced. A reduction was also observed in the percentage of convenience stores with internal advertisements below a childs height (79.5% pre ban vs 34.7% post ban, p<0.001). For kiosks, the percentage with external illuminated ads (37.1% vs 33.3%, p=0.704) did not change, while a reduction in the percentage with ads visible from the street was noticed (96.8% pre ban vs 73.7%

DISCUSSION
Our results indicate a signicant reduction in the number and the characteristics of outdoor advertisements around high schools in Greece after the implementation of the outdoor advertising restriction. There was an eradication of billboards and a reduction in external promotions in regulated convenience stores and unregulated kiosks. However, compliance was not complete as one in three regulated convenience stores did not comply. Interestingly, internal advertising was also found to decrease, indicating that an outdoor advertising ban may have an impact on internal advertising around high schools as seen in our study. This study indicated that unregulated kiosks still act as the main vector for promoting tobacco products in Greece. Taking into account that these unregulated kiosks account for more than half of the POS near high schools, one can conclude that regulating kiosks would be an imperative next step in tobacco control on a national level. The tobacco industry acknowledges this fact and has stressed the need for kiosks to be exempt from relevant EU legislation.11 Moreover, following the partial

Table 1 Comparison of point-of-sale (POS) advertising around all high schools in Heraklion, Greece before and after the implementation of the outdoor advertising ban (2007 vs 2011)
All POS Pre ban (2007), N=101 Type of POS School visible from POS Any external ads? Any external ads seen from the street Any external ads on the door? Any external ads illuminated? Any interior ads? Any internal ads illuminated? Any internal ads mechanical? Any internal ads at childs eye level? No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes 69.4 (68) 30.6 (30) 2.0 (2) 98.0 (99) 5.0 (5) 95.0 (96) 52.0 (51) 48.0 (47) 59.4 (60) 40.6 (41) 5.1 (2) 94.9 (37) 69.2 (27) 30.8 (12) 92.3 (36) 7.7 (3) 20.5 (8) 79.5 (31) Post ban (2011), N=106 83.0 (88) 17.0 (18) 34.0 (36) 66.0 (70) 50.0 (53) 50.0 (53) 89.6 (95) 10.4 (11) 77.4 (82) 22.6 (24) 14.3 (7) 85.7 (42) 67.3 (33) 32.7 (16) 91.8 (45) 8.2 (4) 65.3 (32) 34.7 (17) Convenience stores Pre ban Post ban (2007), N=39 (2011), N=49 38.6 (39) 89.2 (33) 89.8 (44) 2.6 (1) 97.4 (38) 7.7 (3) 92.3 (36) 20.5 (8) 79.5 (31) 53.8 (21) 46.2 (18) 5.1 (2) 94.9 (37) 69.2 (27) 30.8 (12) 92.3 (36) 7.7 (3) 20.5 (8) 79.5 (31) 46.2 10.8 10.2 65.3 34.7 77.6 (49) (4) (5) (32) (17) (38) Kiosks Pre ban (2007), N=62 61.4 (62) 57.4 (35) 42.6 (26) 1.6 (1) 98.4 (61) 3.2 (2) 96.8 (60) n/a n/a 62.9 (39) 37.1 (23) n/a n/a n/a n/a n/a n/a n/a n/a Post ban (2011), N=57 53.8 (57) 77.2 (44) 22.8 (13) 7.0 (4) 93.0 (53) 26.3 (15) 73.7 (42) n/a n/a 66.7 (38) 33.3 (19) n/a n/a n/a n/a n/a n/a n/a n/a

p Value 0.031 <0.001 <0.001

p Value 1.00 <0.001 <0.001

p Value 0.031 0.192 <0.001

<0.001

22.4 (11) 79.6 (39) 20.4 (10) 89.8 (44) 10.2 14.3 85.7 67.3 (5) (7) (42) (33)

<0.001

0.007

<0.001

0.704

0.288 1.00

0.288 1.00

1.00

32.7 (16) 91.8 (45) 8.2 (4) 65.3 (32) 34.7 (17)

1.00

<0.001

<0.001

Data are presented as % (N). *2 tests. All analyses are based on two-sided tests, with statistical significance noted at p<0.05. Interior advertising was only assessed in convenience stores as kiosks have no interior.

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Brief report
tobacco advertising ban of the EU directive 2003/33/EC, the tobacco industry shifted towards heavy advertising at POS, an initiative that can be counterbalanced by prohibiting indoor and outdoor tobacco advertising.12 Adopting a comprehensive approach against the display of tobacco products within POS (including kiosks in the case of Greece) could lead to reductions in recall of tobacco advertisements and weaker pro-smoking beliefs among the youth. Most importantly, it may also help in the de-normalisation of tobacco use among the Greek youth, as seen among the youth in Ireland following the advertising ban.13 Research performed in New Zealand following POS display legislation indicated that 64% of stores surveyed had at least one breach of the legislation; within our study 35% of regulated convenience stores were non-compliant.14 We must note that although kiosks seemed to move further away from high schools following the ban, we are unable to explain why, as the distance from the school was not part of the regulations. Prior to the ban it was common for two or three kiosks or convenience stores to be at the front gates of each school; now this is rare. Further research is needed to assess the potential social and economic factors that may inuence tobacco industry advertising. The results from the fourth largest city in Greece indicate that the implementation of an outdoor advertising ban eliminated tobacco billboards near high schools and signicantly reduced cigarette advertising, but more so in regulated convenience stores than in unregulated kiosks. The reduction noted in indoor advertising within convenience stores is positive; however, this might indicate that the tobacco industry in Greece is now focusing on non-regulated kiosks. Despite this progress, there is a loophole in the existing legislation concerning outdoor advertising within kiosks that needs to be addressed. Stricter implementation of the law is needed and the classication of the covered areas of kiosks as external areas is warranted to eliminate pro-smoking cues and help de-normalise tobacco use in the country.
Contributors CIV had the main role in data analysis, data interpretation and manuscript preparation and collected the pre-ban data. CG, DT and LL participated in data collection, data cleansing, result interpretation and manuscript preparation, while GNC, CL and PB participated in study design, result interpretation and manuscript preparation. All authors read and approved the nal manuscript. Funding Funding was provided by the George D. Behrakis Foundation to the Center for Global Tobacco Control, Harvard School of Public Health through the HEART project (Hellenic Action for Research Against Tobacco). Competing interests None. Ethics approval University Hospital of Crete, Institutional Review Board. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Complete data available on request.

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What this study adds

Children and adolescents exposed to tobacco promotion are more likely to form positive attitudes and normative beliefs towards smoking, which in turn increases the likelihood of smoking uptake. Outdoor advertising in close proximity to high schools in Greece through billboards and points of sale (POS) were extensive in Greece over previous years, while an advertising restriction was put in place in 2009. The implementation of a nationwide outdoor tobacco advertising ban led to the eradication of industry advertising billboards around high schools. Following the outdoor advertising ban, the number of external and internal ads was found to reduce; however only the number of external ads per POS was found to reduce statistically signicantly. Kiosks, which were exempt from the current legislation, are the main vector for tobacco advertising, while regulated convenience stores now play a smaller role in comparison to before the advertising ban.

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Tobacco Control 2012;00:13. doi:10.1136/tobaccocontrol-2012-050518

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Changes in tobacco industry advertising around high schools in Greece following an outdoor advertising ban: a follow-up study
Constantine I Vardavas, Charis Girvalaki, Lambros Lazuras, et al. Tob Control published online November 6, 2012

doi: 10.1136/tobaccocontrol-2012-050518

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