Point-of-sale tobacco advertising in Beirut, Lebanon following a national advertising ban

Ramzi G Salloum 0 3 4 Rima T Nakkash 2 3 Allison E Myers 1 3 Kathryn A Wood 3 6 Kurt M Ribisl 3 5 0 Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , 1102F McGavran-Greenberg, 135 Dauer Drive, Chapel Hill, NC 27599 , USA 1 Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , Chapel Hill, NC , USA 2 Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut , Beirut , Lebanon 3 Dauer Drive , Chapel Hill, NC 27599 , USA 4 Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill , 1102F McGavran-Greenberg, 135 5 Health Behavior, Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill , Chapel Hill, NC , USA 6 Duke University School of Nursing , Durham, NC , USA Background: The objective of this study was to conduct an audit of point-of-sale (POS) tobacco advertising and assess compliance with an advertising ban in a large district of Beirut, Lebanon. Methods: The audit was conducted 3 months following the ban on tobacco advertising. Trained students observed all tobacco retail outlets (n = 100) and entered data into a web-based form using iPad technology. Presence of tobacco advertisements was assessed to determine compliance with the national advertising ban. Results: Among the 100 tobacco retail outlets, 62% had tobacco advertisements, including 7% with a tobacco brand logo as part of the main exterior store sign. Conclusions: POS tobacco advertising is widespread in Beirut despite the national advertising ban. These findings point to an urgent need for the enforcement of the advertisement ban with tobacco retail outlets in Lebanon. - Background For decades, the multinational tobacco industry has enjoyed free and unrestricted tobacco product advertising, marketing, and sponsorship in Lebanon [1-3]. Analysis of tobacco industry documents has revealed that this laxness in regulation has been the outcome of a deliberate tobacco industry strategy to delay adoption and implementation and weaken the content of proposed regulation [4]. Smoking prevalence in Lebanon is estimated at 42.9% among adult males and 26.3% among adult females [5]; this is among the highest rates for females in the Middle East region. Among 13-15 year olds, 8.3% are current smokers (12.1% of boys and 5.6% of girls) [6] and there is an increase in evidence of tobacco advertising targeted to the Lebanese youth [1-4]. Lebanon ratified the Framework Convention on Tobacco Control (FCTC) in 2005 but it was not until 2011 that it adopted the first comprehensive tobacco control legislation. The law banned smoking in all indoor public places, effective September 2011. The ban became effective for the hospitality sector in September 2012. The legislation also banned all forms of advertising and sponsorship of tobacco products effective March 2012, and larger textual or pictorial warnings were dictated through the issuance of a ministerial decree. Thus, for the first time in the countrys history, all forms of advertising and sponsorship of tobacco products became illegal. The Lebanese Ministry of Public Health, Ministry of Tourism, Ministry of Interior, and Ministry of Economy and Trade have been charged with enforcing the provisions of the new law [7]. In matters related to advertising, the Agency for Consumer Protection within the Ministry of Economy and Trade is responsible for enforcement. Violators of the advertising ban can face large fines of up to 40 million Lebanese Pounds (approximately $27,000 USD). A follow up Ministerial Decree No. 7437, issued in January 2012 [7], allowed retailers to display one sign inside their stores stating that tobacco products are sold on the premises, but places the following restrictions: (1) the sign can be no more than A5 in size (14.8 cm 21 cm); (2) the text of the sign shall only read Tobacco products are sold here; and (3) no other logo and/or trademark is allowed except for that of the Lebanese Rgie, the government authority with exclusive rights to import and export local tobacco products and issue licenses to tobacco growers. To date, no studies have documented the prevalence of point-of-sale (POS) tobacco advertising in Lebanon or the Middle East region. Findings from a recent systematic review of store audit methods to capture tobacco products and marketing at POS [8] indicate only twelve studies to date that have assessed retailer compliance with a national regulation: these were in India [9,10], Mexico [11,12], the United Kingdom and Ireland [13-15], and the United States [16-20]. In general, these studies found lower compliance rates in developing countries (India and Mexico) and higher compliance rates in developed countries (example up to 97% compliance immediately following implementing a law to remove POS tobacco displays in Ireland) [14]. The primary aim of our study was to assess compliance of tobacco retail outlets with a national ban on interior and exterior tobacco advertising in the Ras Beirut district of the Lebanese capital city. A secondary aim of the study was to document the number of exterior and interior tobacco advertisements and to survey tobacco product placement within stores. The store audits were performed 3 months after the law took effect. Methods Sample The store audits were conducted in Ras Beirut, a diverse mixed-use district that occupies the northwestern quarter of the city and is home to the American University of Beirut. The research area comprises 10 city sectors, the majority of which have high urban density; printed maps of each sector were generated using Google Maps. The store audits were completed by 5 undergraduate students who received a half-day training session on how to create a census of the tobacco retail outlets and on how to complete the store audits. The training session included 10 mock audits of stores outside of our sampling area. The students canvassed the entire district with predetermined routes, marking the location of each store and assigning it a unique identification number, and thus creating a census of all tobacco retail outlets (N = 103) in the Ras Beirut district. With the exception of supermarkets, the students were able to identify the small tobacco retail outlets from the street because tobacco advertising and/or products were visible through the storefronts. We made the assumption that all supermarkets in the region sold tobacco products and thus the students were instructed to include them in their census of tobacco retail outlets. Next, the students conducted the interior and exterior audits and electronically recorded their observations. Prior to completing each interior audit, the students obtained permission from the store owner or clerk. Tobacco retail outlets observed were all stores that sold cigar (...truncated)