摘要：Objectives. We tested the impact of banning tobacco displays and posting graphic health warning signs at the point of sale (POS). Methods. We designed 3 variations of the tobacco product display (open, enclosed [not visible], enclosed with pro-tobacco ads) and 2 variations of the warning sign (present vs absent) with virtual store software. In December 2011 and January 2012, we randomized a national convenience sample of 1216 adult smokers and recent quitters to 1 of 6 store conditions and gave them a shopping task. We tested for the main effects of the enclosed display, the sign, and their interaction on urge to smoke and tobacco purchase attempts. Results. The enclosed display significantly lowered current smokers’ (B = −7.05; 95% confidence interval [CI] = −13.20, −0.91; P < . 05) and recent quitters’ (Β = −6.00, 95% CI = −11.00, −1.00; P < . 01) urge to smoke and current smokers’ purchase attempts (adjusted odds ratio = 0.06; 95% CI = 0.03, 0.11; P < . 01). The warning sign had no significant main effect on study outcomes or interaction with enclosed display. Conclusions. These data show that POS tobacco displays influence purchase behavior. Banning them may reduce cues to smoke and unplanned tobacco purchases. Smoking is the leading cause of preventable mortality in the United States, accounting for approximately 443 000 deaths each year. 1 Currently, 19.3% of US adults smoke cigarettes, and nearly half attempt to quit smoking each year. 2 However, approximately 90% of smokers who attempt to quit relapse within 6 months, 3–6 and relapses may occur years after quitting. 7 The tobacco industry aggressively markets its products to consumers, spending nearly 90% of its $8 billion marketing budget on promotional allowances to retailers and advertising and price promotions at the point of sale (POS), making retail stores the most important advertising channel for the industry. 8 Retail cigarette advertising and promotions have increased over time, 9,10 and cigarette products are prominently placed on shelves behind checkout counters, exposing all store customers to tobacco products, including youths and adults who do not smoke or have recently quit. Tobacco ads and displays may act as cues to smoke, 11–13 stimulate purchases among customers who did not intend to buy cigarettes, 14,15 and influence relapse among recent quitters by stimulating cravings for cigarettes. 16 In a telephone survey of Australian adults, Wakefield et al. found that 55.3% noticed POS displays often or always and 25.2% bought cigarettes as a result of seeing displays when shopping for something other than cigarettes. 15 Among respondents who had attempted to quit smoking in the past 12 months, 37.7% reported that seeing the tobacco displays increased their urge to purchase cigarettes and 60.9% bought cigarettes even though they were trying to quit. Carter et al. conducted intercept surveys with shoppers outside supermarkets to examine the influence of tobacco displays at the time of purchase and found similar patterns: approximately 22% reported unplanned cigarette purchases, with nearly half (47%) influenced by tobacco displays. 14 In a cohort study, Germain et al. found that smokers with moderate or high sensitivity to tobacco displays at baseline were significantly less likely to quit smoking at follow-up than were those with low sensitivity (moderate, odds ratio [OR] = 0.32; 95% confidence interval [CI] = 0.14, 0.74; P = .007; high, OR = 0.27; 95% CI = 0.08, 0.91; P = .035). 16 Laboratory-based cue reactivity studies show that drug-dependent individuals react strongly to cues associated with past or current drug use, including nicotine; viewing images such as cigarette packs or other people smoking can elicit subjective cigarette craving and psychophysiological arousal (e.g., increased heart rate). 17,18 The federal Family Smoking Prevention and Tobacco Control Act of 2009 19 gives state and local governments legal authority to regulate the time, place, and manner of tobacco advertising. To date, state and local governments have attempted to ban tobacco displays and mandate graphic health warning signs at the POS. Tobacco product displays have been banned in Ireland, Canada, and Australia, but not in the United States. Studies show that graphic antismoking advertising can elicit strong emotional responses from smokers and influence them to quit. 20 However, these studies have largely focused on media campaign advertising and cigarette pack warning labels, and it is unclear whether posting similar messages at the POS will have the same impact. In 2009, New York City required licensed tobacco retailers to post graphic warning signs at the POS. Coady et al. conducted street intercept surveys with adult smokers and recent quitters before and after policy implementation and found that signs increased awareness about the health risks of smoking and thoughts about quitting smoking but did not deter smokers from purchasing cigarettes. 21 However, street intercept interviews are subject to social response bias and cannot adequately control for potential confounders. To test the potential impact of these policies on US adults, we designed a virtual store experiment. Virtual reality applications simulate real-world environments and are useful for studying behavioral responses to environmental cues that may be difficult to assess in a real-life setting. 22–24 Virtual environments have been used to examine the impact of banning POS tobacco displays and ads on youths, 25 consumer food-purchasing decisions, 26 and the effects of smoking cues on cigarette cravings among adults. 27,28 Virtual reality studies examining cravings in smokers suggest that these techniques may be more effective and have stronger ecological validity than traditional methods (e.g., photos) for triggering and assessing craving. 28–32 We randomized adult smokers and recent quitters to virtual store conditions and had them conduct a shopping task to assess whether exposure to an enclosed tobacco product display and a graphic health warning sign decreased urges to smoke and tobacco purchase attempts.
