Examining tobacco regulation opinions and policy acceptance among key opinion leaders and tobacco retailers in low socioeconomic status African American, Hispanic, and non-Hispanic White communities

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Content Examining Tobacco Regulation Opinions and Policy Acceptance among Key Opinion
Leaders and Tobacco Retailers in Low Socioeconomic Status African American, Hispanic,
and Non-Hispanic White Communities

By
Robert Garcia, MPH

A Dissertation Presented to the
Faculty of the Graduate School
University of Southern California
In partial fulfillment of the
Requirements for the degree
Doctor of Philosophy
Health Behavior Research
Department of Preventive Medicine
University of Southern California
August, 2018

2
Dedication
This dissertation is dedicated to my amazing wife, Dr. Sara Castro-Olivo, who provided the
unconditional support, guidance, and love to achieve this milestone. Her persistence and hard
work have been the ultimate example of resilience. I know that I am much better person and
scholar because of her. Without Sara, I would not have even considered embarking on this
journey. She was my inspiration and also provided the fire to keep me going. The dissertation is
also dedicated to my intelligent and fearless daughter, Alejandra Sofía, who was only a few
months old when I started my doctoral studies. Seeing her stand her ground and be confident in
what she knows, gave me encouragement and joy as I navigated my doctoral studies. She is truly
as her name means a “defender of wisdom”. I also dedicate this dissertation to my parents, Raúl
and María García, who when they came to the U.S. only dreamed of providing their future
children an opportunity that they were not able to have themselves. Over the years their
sacrifices and hard work were motivators for me to continue striving for more. While they were
not able to provide me with many gifts they gave me their virtue of determination and drive to do
more for others and hope to carry on this legacy.
3
Acknowledgements
The support and guidance of my advisor Dr. Lourdes Baezconde-Garbanati, allowed me
to complete this dissertation. Throughout my doctoral studies Dr. Baezconde-Garbanati has been
an advocate and facilitator of my growth as a researcher and leader in our field. There were
several times where she provided me an opportunity that I might have not felt ready for; but with
her guidance I was able to achieve. She has also provided me with a great example of what is to
be an exceptional scientist who is dedicated to improving the health of the community. Dr.
Baezconde-Garbanati is a clear of example of what it means to be a mentor and community
based scientist. I would also like to thank my dissertation committee members: Drs. Jennifer
Unger, Steve Sussman, Chih-Ping Chou, and Larry Palinkas. They provided an enormous
amount of knowledge throughout this process. They were an excellent example of a dissertation
committee that is dedicated to enabling their student’s success. I only hope to be able to provide
such mentorship to my own students and colleagues in the future. I would also like to
acknowledge Dr. Jonathan Samet, Dr. Mary Ann Pentz, and the staff of the USC Tobacco Center
of Regulatory Science who provided support and opportunities that made this dissertation
possible.

4
TABLE OF CONTENTS

DEDICATION................................................................................................................... 2
ACKNOWLEDGEMENTS ............................................................................................. 3
LIST OF FIGURES .......................................................................................................... 5
LIST OF TABLES ............................................................................................................ 6
ABSTRACT ....................................................................................................................... 7
CHAPTER 1: INTRODUCTION TO THE STUDIES ................................................. 8
OVERVIEW OF THE DISSERTATION STUDIES ....................................................................... 9
COMPLIANCE RESEARCH ................................................................................................ 13
BACKGROUND & SIGNIFICANCE ..................................................................................... 14
Tobacco Use Disparities ............................................................................................ 14
Tobacco Product Marketing In Vulnerable Communities………………………………15
Current Research on Tobacco Retailer Compliance ................................................. 17
Theoretical Framework for Dissertation Theories .................................................... 19
OVERALL DESIGN AND METHODS .................................................................................. 22
CHAPTER 2: STUDY 1- Exploring attitudes and awareness of
Key Opinion Leaders towards the FDA and tobacco regulatory policy...……………...23
BACKGROUND AND SIGNIFICANCE ................................................................................. 23
METHODS ....................................................................................................................... 24
Analysis ...................................................................................................................... 28
RESULTS ......................................................................................................................... 30
DISCUSSION .................................................................................................................... 43
CHAPTER 3: STUDY 2-Factors that lead to independent tobacco retailers’
compliance with tobacco regulatory policy in vulnerable communities…................… 48
BACKGROUND AND SIGNIFICANCE ................................................................................. 48
METHODS ....................................................................................................................... 52
Analysis ...................................................................................................................... 60
RESULTS ......................................................................................................................... 64
DISCUSSION .................................................................................................................... 75
CHAPTER 4: CONCLUSIONS. ................................................................................... 83
REFERENCES. ............................................................................................................... 89
APPENDIX: SURVEY INSTRUMENTS. .................................................................. 101
TCORS PROJECT 2-FOCUS GROUP ANCHORING SURVEY ............................................ 102
TCORS PROJECT 2- FOCUS GROUP GUIDE ................................................................... 119
TCORS PROJECT 2-RETAILERS’ SURVEY ..................................................................... 127
TCORS PROJECT 2-RETAILERS’ SHOP OBSERVATION FORM ....................................... 146

5
LIST OF FIGURES

FIGURE 1: THEORETICAL CONCEPTUAL MODEL ........................................... 21
FIGURE 2: STUDY 2 CONCEPTUAL MODEL ........................................................ 62
FIGURE 3: FINAL THEORETICAL MODEL .......................................................... 82

6
LIST OF TABLES

TABLE 1: KEY OPINION LEADER DEMOGRAPHICS ........................................ 31
TABLE 2: KOL COMMUNITY PERCEPTIONS-ANCHORING SURVEY .......... 33
TABLE 3: KOL FOCUS GROUP THEMES ............................................................... 35
TABLE 4: SAMPLING STRATEGY FOR STUDY 2 ............................................... 54
TABLE 5: VARIABLES INCLUDED IN THE ANALYSIS ...................................... 63
TABLE 6: RETAILER DEMOGRAPHICS ................................................................ 65
TABLE 7: RETAILER LITERACY ............................................................................. 66
TABLE 8: RETAILERS’ PERCEPTIONS OF TOBACCO SALES ........................ 68
TABLE 9: RETAILER KNOWLEDGE AND ATTITUDES OF THE FDA ............ 69
TABLE 10: STORE CHARACTERISTICS ................................................................ 71
TABLE 11: TOBACCO PRODUCT PROMOTION AND PLACEMENT .............. 72
TABLE 12: ADJUSTED LOGISTIC REGRESSION ................................................ 74

7
ABSTRACT
Background: The overall smoking rates in the U.S. have continued to decrease in recent years
but disparities still exist among racial ethnic communities. The retail environment has been
identified as an area that largely contributes to these disparities. The FDA has regulatory
authority over tobacco products and how they are sold and promoted. Independent retailers in
racial/ethnic communities have been understudied in how they comply with and understand
tobacco regulations.
Methods: The current dissertation used community-based approaches to investigate tobacco
retailer knowledge, attitudes and compliance of tobacco regulations. Study 1 conducted focus
groups with 57 Key Opinion Leaders (KOL’s) from African-American (AA), Hispanic/Latino
(HL), and Non-Hispanic White (NHW) communities. They completed an anchoring survey and a
90-minutes focus group on their knowledge, awareness and attitudes of the FDA and tobacco
regulatory policy. Study 2 used community health workers to recruit 576 independent tobacco
retailers from the same communities. The participating retailers were interviewed and the
CHW’s also conducted store observations. The retailer interview addressed their knowledge of
the FDA and tobacco policies, attitudes towards the FDA, and their perceived benefits of selling
tobacco products. The observation addressed product availability, product placement, and
presence of promotions, exterior ads, and regulatory materials.
Results: For all communities over half of the KOL’s were aware of the FDA’s role in regulating
tobacco products. Less than half believed that retailers in their community would be aware of
this role. Focus group data revealed differences in the level of distrust, with AA KOL’s
expressing a higher level of distrust compared to the other communities. All communities
expressed the desire to collaborate with the FDA in their regulatory efforts. Less than half of the
AA and HL retailers were aware of the FDA’s role in tobacco regulation. Retailers in the AA
communities had higher odds of being non-compliant.
Conclusions: The retail environment contributes to continued disparities in tobacco use. These
data identified that there are disparities in independent tobacco retailers’ compliance. Regulatory
and public health agencies should include both KOL’s and retailers in their outreach and
educational efforts. Messages to retailers need to be delivered in a culturally relevant manner.
Further, more outreach with racial/ethnic communities will be essential to increase retailers’ and
community buy-in to work towards reducing the burden of tobacco use disparities in diverse and
vulnerable communities.

8
CHAPTER 1: INTRODUCTION TO THE STUDIES
Despite efforts to reduce inequities in tobacco use among ethnic minorities, many
disparities continue to exist in tobacco use and exposure. Research shows that the burden of
tobacco related disease is higher for vulnerable communities as compared to non-Hispanic
Whites (Spruijt-Metz, Cook, Wen, Garcia, O’Reilly, Hsu, Unger, Nguyen-Rodriguez, 2014).
This is so critically important, that the Food and Drug Administration (FDA) has included
racial/ethnic communities in its research priorities to address tobacco regulation. A key vehicle
identified by the FDA to ensure proper regulation and compliance with tobacco regulation is the
retail environment. The retail environment can contribute to tobacco disparities by participating
in illegal sales to minors, providing accessibility to tobacco products, and as the main site for
industry products promotional activities (Lee, Baker, Ranney, & Goldstein, 2015; Rose, Myers,
D’Angelo, & Ribisl, 2013). In particular, compliance in these studies is defined as the display of
state and local tobacco retailer licenses, the display of the State of California’s AskID signage,
asking customers who look younger than 27 years old for id to purchase tobacco products, not
selling single cigarettes, not having self-service tobacco product displays, the lack of products
displayed within twelve inches of child related items, and the lack of tobacco product ads within
three feet of the ground.
The Family Smoking Prevention and Tobacco Control Act (FSPTCA/The Act) expanded
the role of the FDA to include retail environments. This resulted in a need for more research on
independent retailers. Although retailers are usually perceived as a “vector” or facilitator of
tobacco industry tactics in the retail environment, in reality, many retailers are actually a
vulnerable population as well. Since the implementation of the Master Settlement Agreement
(MSA), which curtailed tobacco industry promotion and advertising, retailers became among the
9
most vulnerable due to the direct industry targeting of the retail environment in their respective
ethnic communities. Since the MSA the industry turned its marketing and promotional budgets
towards the retail environments, making retailers, not just a vector for the promotion of products,
but also a vulnerable population, in and of themselves due to the severe pressures from the
tobacco industry (Guthrie, Hoek, Darroch, & Wood, 2015; Jaine, Russell, Edwards, & Thomson,
2014; Li et al., 2016). It is estimated that the major tobacco companies spend 84% of their
marketing budgets in the retail environment (Robertson, McGee, Marsh, & Hoek, 2015).
Overview of the dissertation studies
This dissertation is part of a larger study, Maximizing Retailers’ Responsiveness to FDA
Regulations in Vulnerable Communities (Project 2) (Baezconde-Garbanati, Project Leader), of
the USC Tobacco Center for Regulatory Sciences (TCORS) in Vulnerable Populations (Pentz &
Samet, Center PIs). The USC TCORS is composed of three different but complementary
research projects in vulnerable populations. Project 2 in particular explores how to address
tobacco retailers’ compliance by examining their preferred communication channels, perceptions
of FDA credibility, knowledge, and intentions (Baezconde-Garbanati et al., 2017).
I have been involved in this study since its inception, working on survey development and
instrumentation, conducting focus groups, analyzing data and disseminating findings. This
dissertation builds upon the parent project, which focuses on optimal communication with the
FDA, by examining the individual level factors among key opinion leaders (KOL) and retailers
that may impact tobacco regulatory policies, including compliance. It uniquely expands the work
of the parent project by directly associating the results of Key Opinion Leader focus groups to
those of retailers’ interviews and shop observations. The studies in this dissertation also differed
from the parent project in that they did not aim to examine communication channels and what
10
affects retailer receptivity to communication from/with regulatory agencies; a main aim of the
parent study. Instead, these studies examine tobacco regulation opinions and policy acceptance
among KOL and tobacco retailers in three distinct ethnic communities, African Americans,
Hispanic/Latinos and Non-Hispanic Whites. The studies also examine what factors lead to
tobacco retailer compliance and how they differ among the three communities: African-
American (AA), Hispanic/Latino (H/L), and Non-Hispanic Whites (NHW). Although data is
being compiled for other groups (American Indians and Koreans), these are uniquely different
communities; and the data were not yet available from the parent study for examination.
The first study presented here (Study 1) Exploring attitudes and awareness of Key
Opinion Leaders towards the FDA and tobacco regulatory policy) is an exploratory qualitative
study to examine Key Opinion Leaders’ awareness and attitudes towards the FDA and other
tobacco regulations. This study explores and identifies themes from Key Opinion Leaders focus
groups in the Hispanic, African American and Non-Hispanic White communities. Study 1 builds
on the current body of research by addressing limitations presented in the literature such as the
lack of tobacco related data from Key Opinion Leaders in vulnerable populations. This study
also helps inform the second study, which focuses on the tobacco retail environment. It informed
the development of the instrument for assessing retailers’ knowledge, attitudes and behaviors and
tying the focus results to what is occurring on the ground in the retail environment. This research
closely follows guidelines in Backinger et al. (2016) on the data of relevance to the FDA
(Backinger et al., 2016). The data presented here address FDA research priorities related to
communication and the influences of tobacco product marketing influences. This information
will be useful for the FDA and other regulatory agencies (California Department of Public
Health, Tobacco Control Program, and to over 68 county health departments and local lead
11
agencies in California that implement tobacco regulatory efforts) in helping them target their
outreach to these priority populations. Already the State of California has conducted two waves
of retailers store observations (Henriksen et al, 2017). Our store observations however differ
from those, as ours are done with retailers being aware that their stores are under observation,
and interviews are conducted directly with retailers themselves. The State of California’s
observations however, includes a host of other variables, such as sales of alcohol and fast food
sales. The observations conducted by the State of California primarily focused on the availability
of healthy foods to address the needs of communities in food desserts. The data collected
regarding tobacco products was not a primary outcome (California Department of Public Health,
2014; Henriksen et al., 2017).
In addition, to our knowledge, this is one of few studies to interview the retailers directly,
and one of the first to have had community health workers (CHWs) from the communities
themselves engaged in conducting the interviews in low socioeconomic racial/ethnic
communities. Further, these studies combine qualitative and quantitative data from surveys,
focus groups and store observations with community workers, with consent of the retailers
(Baezconde-Garbanati et al., 2017).
Research (Holliday, Audrey, Campbell, & Moore, 2016; S. Howard, Dryden, & Johnson,
2010; Schuster et al., 2006; Valente, 2017; Valente & Pumpuang, 2007) on Key Opinion Leaders
has shown the critical role they can play in the buy-in of their communities on tobacco control,
on tobacco regulation, and other community-relevant tobacco prevention activities. By
examining Key Opinion Leader focus groups data, we gain a clearer understanding of prevention
strategies needed to address tobacco regulation and control in priority populations.
12
Study 2 of this dissertation (Factors that lead to independent tobacco retailer compliance
with tobacco regulatory policy in vulnerable communities) examined variables that influence a
retailer’s compliance with tobacco regulatory policy. This second study in particular determined
how a retailer’s attitudes towards the FDA and tobacco regulatory policy, perceived retail benefit
of selling tobacco products, the display of tobacco promotional materials in their store, and of
other signage, knowledge of the FDA and tobacco regulatory policy, impact compliance with
tobacco regulatory policies. We also examined how retailers’ own tobacco product use may
impact the display of pro-tobacco promotional materials, and how these in turn may predict
compliance by retailers with tobacco regulatory policies.
This study makes an important contribution to the scientific literature by examining how
attitudes towards the FDA and tobacco regulatory policy, predict retailer compliance with
tobacco regulation. Further, study 2 examined how this relationship was impacted by
racial/ethnic community (African American and Hispanic/Latino) key opinion leaders’
perception of regulatory authority. Although materials are available in the FDA retailers’ website
in Spanish and language services are available in fifteen languages, individualized tailored
messages are not always available to retailers from the FDA. Examining these relationships
helped to better understand if, when, and for what, there might be a need for tailoring (based on
ethnicity, levels of education, language proficiency, literacy and numeracy levels) of educational
materials on tobacco regulation provided for the retail environment; and on the FDA website
(https://www.fda.gov/TobaccoProducts/GuidanceComplianceRegulatoryInformation/Retail/defa
ult.htm); and how this might be dependent on the community’s ethnicity and socioeconomic
status.
13
The current literature is focused on retailers’ attitudes towards policies on sales
restrictions (Jaine et al., 2014) This study will add to this limited research by providing a broader
understanding of how retailers’ attitudes towards a regulatory agency (like the FDA) could affect
their business practices. Examining this could provide data that may indicate a need for a
different outreach approach by the FDA and other regulatory bodies for retailers, who may hold
negative attitudes towards regulation of tobacco in general or of the FDA in particular.
Compliance research
There is limited research on FDA compliance in vulnerable communities. The current
research has shown relatively low non-compliance rates, 1-2%, among retailers based on FDA
data (Lee, Baker, et al., 2015; Ribisl et al., 2017). One study (Rose et al., 2013) found non-
compliance rates to be approximately 15%. Independent retailers however, have been shown to
be more likely to be non-compliant (Lee, Baker, et al., 2015; Silver, Macinko, Giorgio, Bae, &
Jimenez, 2015). Currently, there is little data on independent tobacco retailers in racial/ethnic
communities. So, it is important we gain a clearer understanding of what can influence retailers’
levels of compliance with tobacco regulatory policy. Given that communities with high
proportions of culturally and linguistically diverse populations are more likely to have
independent retailers selling in their neighborhoods, it is imperative that we develop a more
comprehensive picture as a means to reduce tobacco related disparities.
In their totality the two studies contribute to the scientific literature by providing a more
comprehensive understanding for the FDA and other regulatory agencies regarding compliance
in small independent retailers in three diverse and priority communities (Hispanics, African
American, and Non-Hispanic Whites). This in turn can provide strategies that can assist
14
regulatory bodies with decision making related to retailer oriented educational campaigns. Given
the critical importance of targeted tobacco marketing and promotion by the industry in
vulnerable communities, by informing both the regulatory actions and educational campaigns for
independent retailers; these studies move us closer to reducing tobacco initiation, progression to
nicotine addiction and may ease the burden of tobacco related diseases in selected vulnerable
populations. These studies help show how personal, environmental, and behavioral factors can
influence each other in predicting tobacco retailers’ compliance.
These studies provide data that can contribute to a more culturally and language
responsive approach by the FDA and other regulatory agencies; when working with independent
retailers in addressing tobacco regulatory policies in vulnerable communities.
Background & Significance
Tobacco Use Disparities
The leading cause of preventable death in the United States for several decades has been
smoking, which also accounts for over $75 billion in health costs annually.(Centers for Disease
Control and Prevention, 2012; Federal Trade Commision cigarette report for 2009 and 2010>,
2012; John, Cheney, & Azad, 2009) Although these advances are remarkable we have hit a
plateau and the rates have not decreased significantly in recent years, especially among
vulnerable populations(Centers for Disease Control and Prevention, 2014). In some groups,
tobacco use prevalence rate declines have not been as prominent as in other ethnic/cultural and
racial groups, or have stalled.
Large disparities in smoking and tobacco use remain for racial and ethnic minorities
(Centers for Disease Control and Prevention, 2012; Jamal et al., 2016; U.S. Department of
15
Health and Human Services, Public Health Service, 2014). While the differences in prevalence
rates might be lower for most groups, racial and ethnic minorities, especially African Americans,
carry most of the burden of tobacco related diseases, (Haskins, 2017; Lisa Henriksen et al., 2008)
including lung cancer, (Cantrell et al., 2013)

other tobacco-related cancers, and cardiovascular
disease. African American males have shown a higher incidence of lung cancer (122.8 per
100,000) compared to non-Hispanic Whites (81.5 per 100,000) (Cantrell et al., 2013). African
Americans are more likely to die from tobacco related disease even though they tend to report
smoking less cigarettes and commence smoking at an older age (Giovino & Gardiner, 2016).
Although incidence varies across diseases and racial/ethnic groups, the burden is considered
higher for minorities because they are less likely to have access to high-quality healthcare
services to diagnose and treat tobacco-related diseases (Cantrell et al., 2013; Widome, Brock,
Noble, & Forster, 2013).
Tobacco Product Marketing and Promotion in Vulnerable Communities
It is estimated that 90% of tobacco marketing expenditures occur at retail and
convenience stores (Henriksen, Feighery, Schleicher, Haladjian, & Fortmann, 2004; John et al.,
2009)(Cantrell et al., 2013). When examining the marketing methods of the tobacco industry
throughout history we are able to see similar methods. Tobacco companies have long segmented
the population in order to increase sales and product reach (Proctor, 2011). One example is how
the tobacco industry used the Suffrage Movement to increase smoking rates among women
(Proctor, 2011). They created marketing materials that depicted smoking as an equalizer for
women since at that time it was a social taboo for women to smoke (Brandt, 2007; Proctor,
2011). The imagery of smoking as an equalizer is a well-tested strategy in tobacco marketing
from the suffrage movement to youth attempting to be more grown up (Proctor, 2011). This
16
image of tobacco companies being on the side of those who were being oppressed or limited by
society eventually would aid in their tactics against the growing science indicating the risk of
disease through the use of tobacco products (Brandt, 2007; Proctor, 2011).
From the first report on smoking from the Surgeon General in 1964 to the most recent
50
th
anniversary report(U.S. Department of Health and Human Services, Public Health Service,
2014), and the implementation of the Master Settlement Agreement (MSA) between attorneys
general of the United States, there have been many changes in the practices of tobacco
companies over the years. What has not changed however, is the specific marketing of their
products in vulnerable communities. When the first Surgeon General report was published the
tobacco companies widely promoted their products and many different type of mediums (Brandt,
2007). There was also a lot of marketing targeted towards youth with the use of cartoon
characters and tobacco related paraphernalia that attracted children (i.e. cigarette candies)
(Brandt, 2007). After over three decades since the 1964 report, tobacco companies were finally
limited in their marketing methods (Brandt, 2007; Proctor, 2011; Wakefield et al., 2002).
The MSA, which limited the tobacco industry’s marketing approaches, took effect in
1998. The agreement was between most of the states and the tobacco industry in response to a
lawsuit seeking recovery of state Medicaid costs associated to the treatment of tobacco induced
diseases. No longer allowed under the MSA was the promotion of tobacco products on
television, the use of cartoon characters, billboard advertisements, product giveaways, and public
transit ads (“About the Master Settlement Agreement" - American Legacy Foundation retrieved
November 5, 2014).
17
While the bans from the MSA limited most outdoor advertising there were little to no
restrictions on point of sale (PoS) marketing (Wakefield et al., 2002; Widome et al., 2013).
Previous research has shown that limited marketing bans only allow tobacco companies to
redirect their resources to other mechanisms, which is the case with the current state of PoS
marketing (Wakefield et al., 2002). Many gains have been achieved since the MSA but there is
still more work to be done especially in regards to tobacco promotion in racial/ethnic
communities.
Research has shown that the prevalence of tobacco advertisements vary widely
depending on the racial and ethnic makeup of the neighborhood (Chen, Cruz, Schuster, Unger, &
Johnson, 2002; John et al., 2009). For example, Henriksen et al (2012), found a disparity in
menthol advertisements based on community demographics in that for each 10% increase in
African-American populations in the area, there was a 5.9% increase in menthol ads.
The passage of the Family Smoking Prevention and Tobacco Control Act and the new
regulatory authority of the Food and Drug Administration (FDA), allows for further regulation of
tobacco industry advertising. It is thus imperative that the FDA be well informed of the current
state of tobacco PoS marketing efforts and their effects in vulnerable communities.
Current Research on Tobacco Retailer Compliance
The passage of the Family Smoking Prevention and Tobacco Control Act (FSPTCA/The
ACT) provided new regulatory authority to the Food and Drug Administration (FDA), which
allowed for the first time for strict federal level regulation of the tobacco industry, this included
limits in the retail arena. Current research on tobacco retailers shows a low incidence of FSPTCA
(The Act) violations, usually in the single digits. But many limitations in publicly available data
18
do not allow for a thorough examination of the differences by type of retailer and the factors that
could influence compliance. Rose (Rose et al., 2015) and colleagues for example, found that
only 1% of stores nationally received at least a warning letter from the FDA, but their own
research (Rose et al., 2013) found 15% of North Carolina stores were in violation. The FDA or
their contracted agents provide retailers a warning letter after their first violation during an
undercover retail inspection. The retailers are given fifteen days to respond to the warning letter
and address the issues raised in the letter. If the retailer fails to respond they could face financial
penalties and the loss in their ability to sell tobacco products.
Another study (Lee, Baker, et al., 2015) found that there were few warning letters in
regards to self-service displays issued to stores in neighborhoods with higher concentrations of
racial/ethnic minorities and lower income families. The same study however, found that these
neighborhoods were more likely to have noncompliance in regards to selling single cigarettes. In
the first finding the authors hypothesize that the lack availability of self-service displays is likely
due to retailer fears of theft. In regards to the second finding, it has been documented that single
cigarettes are typically more likely to be available in these areas due to price sensitive consumers
(Henriksen, 2012; Henriksen et al., 2008).
Providing data on compliance rates and factors affecting compliance (i.e. personal,
environmental and behavioral) would not only help inform the FDA but also help to minimize
the influence (Rose et al., 2013) of the retail environment in tobacco disparities. This is
especially true given that many of the tobacco retailers in these communities tend to be
independent and small stores (Lee, Baker, et al., 2015; Morland, Wing, Diez Roux, & Poole,
2002) also known as “bodegas” in Hispanic/Latino communities or “corner stores” among
African Americas. The research presented here is the first to focus solely on independent
19
retailers in small retail stores (bodegas and corner stores, 7/11 types, independent convenience
stores). Furthermore, the dissertation studies will also be one of the first to examine retailers’
compliance differences among different vulnerable and at high-risk ethnic communities.
Theoretical Framework for the Dissertation Studies
The overall theoretical foundation for the dissertation studies is based on Urie
Bronfenbrenner’s Ecological Systems Theory (Bronfenbrenner, 1992). The theoretical model for
the dissertation is presented in Figure 1. This model brings into view the various influences on a
retailer’s business practices. Ecological approaches to tobacco control have been shown to be
effective by employing interventions that combine different layers of influences on behavior
(Sallis, Owen, & Fisher, 2008). A key notion of ecological models is that there are different
systems that can influence a person’s behavior that can be intrapersonal, interpersonal,
community, organizational, or cultural (Onwuegbuzie, 2013; Sallis et al., 2008).
Bronfenbrenner (1979) proposed levels that each can influence a person’s development
differently; the micro system, mesosystem, and exosystem. The microsystem includes a person’s
immediate environment which is constantly interacted with such as their home or place of
employment (Bronfenbrenner, 1992; Onwuegbuzie, 2013). The mesosystem relates to how the
environments of the microsystems connect with each other. The individual must actively
participate in two or more environments (i.e. home, work, or school) that interrelate for it to be
part of the mesosystem. The exosystem is the level where the individual is not an active
participant but occurrences in this level can affect their behavior (Bronfenbrenner, 1992;
Leonard, 2011; Onwuegbuzie, 2013).
20
Though the tobacco retailers were the individuals of focus for study 2, we included
KOL’s in the model, as it will help to reflect the sentiments of the community on the tobacco
regulatory and retail environment. Assessing key opinion leaders from different sectors of
society is also crucial as policy implementation and adoption occurs in an ecological manner
instead of at an individual level (K. A. Howard et al., 2000). Each level of the model plays a role
in a tobacco retailer’s compliance with tobacco regulatory policy. It is necessary however, to
determine the level of influence of each system in order to better inform future efforts of the
FDA and other regulatory agencies to increase implementation and compliance with tobacco
regulatory policy.
In study 2 the theory shows how different levels of a retailer’s environment can
influence their behavior. For the microsystem the measurement of a tobacco retailer’s knowledge
of tobacco regulatory policy and the FDA along with their use of tobacco products will help
assess how individual level influences can determine if the retailer is in compliance.
Furthermore, a tobacco retailer’s attitudes towards the FDA and tobacco regulatory policy will
also influence their compliance. The mesosystem variables for this study include the display of
promotional materials, the perceived retail benefits of selling tobacco products and the receipt of
information from the FDA. The exosystem will include store revenue, the top selling product and
the attitudes and knowledge of the Key Opinion Leaders.
21
Figure 1: Dissertation Theoretical Framework
ExoSystem Factors
Store
Revenue
Top Selling
Product
KOL
Attitudes
toward
FDA/Policy
KOL
Knowledge
of
FDA/Policy
MesoSystem Factors
Display of
Promotional
Materials
Perceived
Retail Benefits
of Selling
Tobacco
Microsystem & Individual Retailer
Factors
Knowledge of
FDA/Tobacco
Policy
Attitudes
towards
FDA/Tobacco
Policy
Tobacco
Product Use
Retailer
Compliance with
Tobacco
Regulation
OUTCOME
22
Overall Design and Methods
This research draws upon data collected from a broader study on tobacco retailers
conducted in the Greater Los Angeles Area. Further detail on the parent study can be found in
Baezconde-Garbanati et al. (2017). The project is a part of the Tobacco Center of Regulatory
Sciences for Vulnerable Populations at the University of Southern California (Samet, Pentz). The
parent project titled, Maximizing Retailers’ Responsiveness to FDA Regulations in Vulnerable
Communities, contains three main methods for data collection: key opinion leader focus groups
combined with anchoring demographic surveys, one-on-one tobacco retailer interviews in
language, and tobacco retail shop observations (audits). The parent project aims to examine the
most effective messages and communication channels to relay regulatory information to
independent retailers (in bodegas and corner stores). The parent project is recruiting retailers and
key opinion leaders from five communities: 800 retailers in the African American, American
Indian, Hispanic/Latinos, Korean American, and non-Hispanic White communities. In regards to
the key opinion leaders focus groups the same communities were assessed with a goal of
between twelve-twenty participants per community. Data from only three groups were available
at the time of this dissertation.
23
CHAPTER 2: Study 1
Exploring attitudes and awareness of Key Opinion Leaders towards the FDA and tobacco
regulatory policy
Background and Significance
Assessing tobacco regulatory agency and policy awareness among community key
opinion leaders, KOL’s is key to ensuring compliance and preventing the burden of tobacco in
vulnerable populations. The current research on key opinion leaders and tobacco regulatory
policy has focused on how KOLs adopt tobacco regulatory activities or how they are involved in
passing tobacco regulations (K. A. Howard et al., 2000; Joseph, Hennrikus, Thoele, Krueger, &
Hatsukami, 2004; Schuster et al., 2006). Only two studies were found that examined key opinion
leaders from diverse occupational backgrounds. However, key opinion leaders can play a crucial
role in tobacco regulation by influencing attitudes and beliefs of their community members.
There is a long history in using KOL’s to advance public health initiatives (Buller, Young,
Fisher, & Maloy, 2007; K. A. Howard et al., 2000; Schuster et al., 2006; Valente & Pumpuang,
2007). KOLs are potentially central in addressing the effects of the tobacco retail environment as
they are aware of their strengths, needs, and vulnerabilities.
KOL’s are a key environmental factor that can influence the buy-in of retailers and
therefore contribute to the potential increase of compliance and decrease in the burden of tobacco
related disparities. While it is important to understand the patterns of compliance it is equally
important to examine the mechanisms that lead to compliance, such as policy awareness in key
opinion leaders. KOL’s are in a unique position to influence their communities but also become
a partners to the FDA so it is important to have an understanding to their attitudes and awareness
to the FDA and tobacco regulatory policies (K. A. Howard et al., 2000). KOL’s can serve in
different capacities in regards to tobacco regulation such as, messengers of tobacco policy
24
information, role models for change, legitimizing behavior change, and as empowered agents of
change that can lead intervention efforts with their respective communities (Holliday et al., 2016;
Valente, 2017; Valente, Fujimoto, Palmer, & Tanjasiri, 2010; Valente & Pumpuang, 2007).
KOL’s can be partners who can remove barriers to compliance and behavior change in retailers
(Valente & Pumpuang, 2007).
Study 1 in this dissertation aimed to increase the current understanding of policy and
FDA awareness among key opinion leaders. Study 1 also explored KOL attitudes towards
tobacco policy and the FDA. This study also examined how KOL perceive their communities’
level of awareness of tobacco policy and the FDA. This study focused on African American,
Hispanic/Latino, and Non-Hispanic White communities in the Greater Los Angeles area. These
communities were the focus because of their high risk tobacco use profiles and documented high
burden of tobacco related diseases, and specific targeting by the tobacco industry (American
Legacy Foundation; Sussman et al., 2014). This is one of the first studies to focus on KOL’s
from diverse occupational and ethnic backgrounds combined. Study 1 has the potential to benefit
the tobacco retailers, the communities they serve for tobacco reduction, and regulatory agencies.
Methods
Identification of Key Opinion Leaders
Key opinion leaders were recruited from three ethnic communities and six different
occupational backgrounds including, health, education, business, religious, media and
government. For recruitment into the study, we utilized a snow ball sample, reaching out to our
various community partners and community-based organizations in each of the various
racial/ethnic communities, who assisted us in identifying key opinion leaders. For some
categories, i.e. media, religious, government, we conducted Internet searches to identify KOL’s
25
who were prominent in their respective communities and then confirmed they were seen as true
leaders in their community, with our Advisory Committee for the project. For some categories,
i.e. education, health, business, we identified KOLs from prominent organizations and asked for
a representative to participate in the focus groups. We also visited the communities of interest to
identify KOL’s by attending community meetings, church related activities, civic engagement
activities, community activities, and school related activities. Once identified the potential
participants were first contacted by email in which we explained the study purpose and why they
were being recruited. If the potential participant did not respond to the email, project staff called
them by phone, and provided the same information. Once a potential KOL agreed to participate
they were provided more details on the study and asked if they identified with one of the
communities of interest. We also asked them to verify their occupation. It was also made clear
to the potential KOL’s that they did not need a background in tobacco control/regulation in order
to participate. For the H/L community approximately one-third of potential KOL’s contacted
agreed to participate. A little over half of the potential KOL’s from the AA and NHW
communities agreed to participate.
During recruitment, project staff confirmed that they were a member of one of the
communities of interest; and worked in one of the above listed occupational categories, hence
meeting our inclusion criteria for the study on KOL.
Data Collectors
Research project staff, faculty from specific communities, and PhD level associated
graduate students (including myself) conducted data collection for the KOL focus groups in
language, as needed. Data collectors were also responsible for the administration of the
anchoring survey, consent of the participants, note taking during the focus groups and the audio
26
recording of the focus groups. As facilitators for the focus groups, the data collectors also had
extensive experience in leading focus groups for culturally and linguistically diverse
communities. Prior to the focus groups the facilitators were trained with the focus group guide to
ensure proper time and participant management during the interview. The facilitators and other
project staff were involved with the planning and conceptualization of the focus group project.
Facilitators for the KOL focus groups also represented the racial/ethnic identity of each of the
communities (i.e. Hispanic/Latino facilitator for Hispanic/Latino KOL focus groups) in order to
provide familiarity and increase active participation from the KOL’s.
Data Collection
All IRB protocols concerning protection of Human Subjects were followed. Participants
were assured of confidentiality in their participation and told they could withdraw at any time or
refuse to answer any questions they did not wish to answer.
The focus groups were hosted in large conference rooms in the community to allow for
ease of communication from the participants. The focus group staff included a facilitator, two
note-takers and a project staff member to assist in welcoming and consenting the participants.
Two digital recorders were used to provide an audio recording of the focus group interview to be
used for development of transcripts and future qualitative analysis.
Anchoring Survey: Prior to the beginning of the focus group the KOL’s were provided an
anchoring survey to complete. The anchoring survey was a pen and paper instrument. The
anchoring survey took fifteen to twenty minutes to complete. The anchoring survey was used to
gather demographic information from the KOL’s along with their perceptions and knowledge of
the FDA and tobacco regulatory policy.
27
Focus Groups: The focus groups lasted approximately ninety minutes to complete in
order to not over-burden the KOL’s. All of the focus group instruments (guide and anchoring
survey) were made available in English and Spanish. The use of the focus group guide in a
different language was dependent on the linguistic needs and preferences of the KOL’s. The
focus group was conducted in any of these languages as necessary. Two focus group sessions
were conducted for each community and only one community was represented in each session.
The KOL’s received a compensation of a $75 gift card for their time at the completion of the
focus group.
KOL Anchoring Survey
The anchoring survey asked the KOL’s to indicate their demographics including; age,
gender, ethnicity, country of origin, language preferences, English proficiency, along with city of
residence and employment. The anchoring survey also asked the KOL’s to report their level of
knowledge in regard to their community as very knowledgeable, moderately knowledgeable,
somewhat knowledgeable, not at all knowledgeable or don’t know. The KOL’s were asked about
their perceptions of retailers’ awareness and compliance regarding tobacco regulations with
responses ranging from very to not at all informed or compliant. The KOL’s were presented with
the FDA logo and asked if they recognize the logo and to indicate the name of the organization.
After this the KOL’s were asked if they have ever heard of the FDA, are aware of the FDA’s
ability to regulate tobacco products, and if they see the FDA as a credible source of information.
The KOL’s were also asked to provide their perception of retailer awareness of the FDA and if
they believed retailers in their community can distinguish between FDA and local regulatory
campaigns. The KOL’s anchoring survey also asked if their community perceives the FDA as a
credible source of information. (See appendix A for copy of anchoring survey).
28
KOL Focus Group Guide
The focus group guide began with an explanation of the study and a verbal consent to
participate. After an explanation of the focus group ground rules and procedures the main body
of the interview began. The first questions of the focus group concentrated on the community
perceptions of the FDA. First the KOL’s were asked what they know about the FDA. The KOL’s
were asked: do you view the FDA as a credible source of information? After this question, the
participants were provided a brief description of the FSPTCA and the new regulatory role of the
FDA regarding tobacco products. The facilitator then asked the KOL’s if they were aware of
this role for FDA (Were you aware of this new role for FDA?) and if they believe that
community members are aware of this role (Do you think community members like yourself
understand the FDA’s role in tobacco regulation?). The KOL’s were also asked to describe any
positive or negative feelings they had in regard to the FDA (Please describe any positive or
negative feelings you have about the FDA).
Analysis
Descriptive statistics, Chi-Square and ANOVA are presented for the KOL anchoring
survey results. Chi-square and ANOVA tested for significant differences between racial/ethnic
communities and occupational backgrounds. The verbatim focus group transcripts were analyzed
using Atlas.ti software. Overarching themes were identified with framework analysis through
reading the data to become familiarized, this approach has been used before for policy related
qualitative research (Srivastava & Thomson, 2009). Then the identified themes were mapped to
specific quotes. The data were coded and categorized by the associated themes and subthemes.
There were some themes that were identified a-priori while others through the analysis. The
overarching themes were prioritized in the analysis. Overarching themes were those that were
29
found to be repetitive and prevalent across the focus group transcripts. The themes that emerged
from this analysis were then tied to the results of the anchoring survey and help inform the
retailers’ survey. This study used open-ended questions to allow participants to provide their
perceptions of various processes and situations occurring in their community.
The focus group transcripts were ordered chronologically for analysis. During the review
of the focus group transcripts, coding categories were created based on recurring themes. Initial
coding categories were reflective of the aims of the study. These initial coding categories
included: 1) positive attitudes towards the FDA and tobacco regulatory policy, 2) negative
attitudes towards the FDA and tobacco regulatory policy, 3) knowledge of the FDA and tobacco
regulatory policies, 4) perceived community attitudes towards the FDA and tobacco regulatory
policy and 5) perceived community knowledge of the FDA and tobacco regulatory policy. After
this initial coding, we refined the codes by merging codes, eliminating codes, and subdividing
codes. This was based on the identification of larger or repetitive themes. Analyzing the results
of this coding led to the identification of patterns of responses from KOL’s. It identified if
KOL’s from different communities provide the same insights. The results from the KOL focus
groups also help to inform Study 2 of the dissertation. The emerging themes were used to help
identify the variables to explore in Study 2. For instance, preliminary analysis has indicated that
there are differences between African American, Hispanic/Latino, and Non-Hispanic White
KOL’s in regard to their attitudes towards the FDA. We could expect based on the strong
assertions made by some of the KOL’s that we will find similar differences regarding attitudes
towards the FDA and tobacco policy among the retailers in Study 2.

30
Results
Focus Group Participants
A total of 57 individuals participated in the focus groups, and all responded to the
anchoring survey. These were 23 from AA, 16 from H/L and 18 NHW. Two focus groups were
conducted in each community. Data presented below is based on a combined analysis of 57 focus
group participants that participated in focus groups in 2016. KOL demographic information is
presented in Table 1.
Over half of the Key Opinion Leaders (KOL), who participated in the focus groups
represented African American (59%) communities and 41% represented Hispanic communities.
The mean age of the KOL’s was 43.8 years (sd=11.1) and 64% were female. Approximately a
quarter of the KOL’s were born outside of the U. S. but all of them reported speaking English at
home. The KOL’s represented diverse occupational backgrounds with 33% from health or
advocacy occupations followed by government, 15%, education, 15%, business, 13%, religious,
5%, and service, 5%. The majority, 59%, of the KOL’s have lived in the community they served
for over 10 years, while less than a third, 28%, and had worked in tobacco control. Most of the
participants involved with tobacco control were from local government or health advocacy
fields. Those who worked in government primarily represented agencies that were responsible
for tobacco regulation or enforcement. While those who worked in health and advocacy
represented agencies that were focused on youth and community development. Some were also
involved in tobacco prevention. Other occupations did not have participants who were involved
with tobacco prevention, control, or regulation. Only 15% of the KOL’s reported being a current
smoker.

31
Table 1: KOL Demographics

Anchoring Survey
Frequency data on the KOL’s perceptions of their community are presented in Table 2. A
higher amount of Hispanic KOL’s (81%), reported visiting tobacco retail shops in their
community compared to African-American KOL’s (65%). When asked about how they felt
about the number of tobacco shops in their communities approximately a quarter of African-
American (26%) and of Hispanic KOL’s (25%) indicates that there were too many. There were
differences in how the KOL’s perceived how informed retailers were in regards to tobacco laws
with 46% of African-Americans saying they were well-informed compared to 25% of Hispanics.
There was however, a higher percentage of African-Americans (32%) compared to Hispanics
(n=57) N (%)
Female 34 (60)
Mean age 42.6 yrs (±11.5)
Community
African American (n=23) 23 (40)
Hispanic/Latino (n=16) 16 (28)
Non-Hispanic White (n=18) 18 (32)
Occupation
Business 8 (14)
Education 8 (14)
Government 7 (12)
Health & Advocacy 16 (28)
Media 11 (18)
Religious 3 (5)
Service 4 (6)
Years lived in the community they Serve
3 yrs or less 17 (30)
4 to 9 yrs 12 (21)
10 yrs or more 28 (49)

Currently Smoke 6 (11)
Work in tobacco control 12 (21)
32
(19%) who felt that retailers were not well informed about tobacco laws. Nearly half of the
African-American KOL’s (47%) perceived that retailers in their community were aware of the
FDA’s regulator authority over tobacco products compared to 25% of Hispanic KOL’s.
KOL Knowledge of tobacco regulations
Half of the KOL’s from African-American communities had little to no knowledge of
city, 52%, county, 57%, or state, 52% tobacco laws. Hispanic KOL’s reported lower levels of
little to no knowledge of city, 19%, county 25%, and state, 19% tobacco laws. When asked if
they thought that retailers in their communities could distinguish between different agencies
(FDA, state, and county) that regulate tobacco, none of the Hispanic KOL’s responded yes while
38% responded that they did not know. 28% of African-American KOL’s responded yes to the
same question while another 41% responded that they did not know. There was a significant
difference between the two groups’ responses (Fishers, p<0.05). Most of the KOL’s (77%)
believed that retailers in their communities were at least moderately compliant with tobacco
regulations.
When presented with an image of the FDA logo almost all of the KOL’s (92%) indicated
that they had seen it before and 72% were able to correctly list the name of the agency. All of
the KOL’s indicated that they had heard of the FDA and approximately two-thirds were aware of
their ability to regulate tobacco products. Slightly over two-thirds (69%) of the KOL’s reported
viewing the FDA as a reliable source of information regarding tobacco regulation. However, less
than half (43%) of the KOL’s thought that their community viewed the FDA as a credible source
of information and 35% thought that their community was not aware of the FDA. When broken
down by ethnic community over half (53%) of the Hispanic KOL’s believed that their
community was not aware of the FDA compared to 23% of the African-American KOL’s.
33
Table 2: Key Opinion Leaders’ Community Perceptions-Anchoring Survey
* X
2
p<0.05

Focus Groups

The KOL focus groups provided in-depth qualitative data on the KOL’s attitudes towards
the FDA, their knowledge of the FDA and tobacco regulation. The focus groups also provided
data on the KOL’s perceptions of their community’s attitudes towards the FDA and their
Overall
N (%)
African
American
N (%)
Hispanic
N (%)
Non-
Hispanic
White N (%)
Visit tobacco retail shops in your
community
18 (75) 15 (65) 13 (81) 15 (83)
Perception on number of tobacco
shops in your community*

Far Too Many 15 (26) 10 (44) 3 (19) 2 (11)
Too Many 21 (37) 7 (30) 9 (56) 5 (28)
About Right 21 (37) 6 (26) 4 (25) 11 (61)
Retailers in your community informed
about tobacco laws

Well informed 22 (39) 10 (45) 4 (25) 8 (44)
Moderately informed 22 (39) 5 (23) 9 (56) 8 (44)
Not well or at all informed 12 (22) 7 (32) 3 (19) 2 (11)
Retailers in your community compliant
with tobacco laws

Compliant 13 (24) 5 (22) 4 (27) 4 (24)
Moderately Compliant 29 (53) 12 (52) 9 (60) 8 (47)
Non-Compliant 1 (2) 1 (4) 0 0
Don’t Know 12 (22) 5 (22) 2 (13) 5 (29)
KOL recognized FDA Logo 51 (90) 21 (91) 15 (94) 15 (83)
KOL’s aware of FDA tobacco
authority
34 (61) 14 (64) 11 (69) 9 (50)
Retailers aware of FDA tobacco
authority
20 (36) 9 (43) 4 (25) 7 (39)
Retailers able to distinguish between
FDA, state or county campaigns*

Yes 8 (14) 6 (27) 0 2 (11)
Don’t Know 19 (34) 9 (41) 6 (38) 4 (22)
Does community view FDA as
credible source of information

Yes 24 (44) 10 (45) 6 (40) 8 (47)
No 14 (26) 7 (32) 1 (7) 6 (35)
They are not aware of the FDA 16 (30) 5 (23) 8 (53) 3 (18)
34
knowledge of the FDA and tobacco regulation. Table 3 provides a summary of these themes. The
table also indicates how often the theme emerged for each community. The themes are recorded
as appearing frequently, sometimes, or rarely, which has been done in previous research
(Baezconde-Garbanati, Murphy, Moran, & Cortessis, 2013). For this study themes that appeared
more than ten times were recorded as frequently, themes that appeared five to ten times were
recorded as sometimes, and those less than five were recorded as appearing rarely.
The analysis revealed fifteen themes from the focus groups. These themes could be
placed in four categories: 1) attitudes towards the FDA, knowledge of the FDA and tobacco
regulation, 2) perceived community attitudes of the FDA, and 3) perceived community
knowledge of the FDA and 4) tobacco regulation. Within the thematic category of attitudes
towards the FDA, we explored subthemes of distrust, lack of transparency, past job performance,
and ability to regulate. In the thematic category of knowledge of the FDA and tobacco
regulation, the subthemes of uncertainty regarding the role of the FDA, uncertainty and lack of
knowledge regarding tobacco regulation prior to The Act, and knowledge of the FDA’s role in
tobacco regulation were explored. Within the thematic category of perceived community
attitudes towards the FDA, the subthemes of collaboration with the community, distant authority
with no local presence, enforcement of regulations, and perceived lack of diversity were
explored. In the thematic category of perceived community knowledge of FDA/tobacco
regulation we explored the following subthemes: lack of clarity in the community about the role
of the FDA, how community is informed, and the presence of non-compliant retailers in
community.

35
Table 3: Key Opinion Leaders’ Focus Group Themes
African-
American
Hispanic Non-Hispanic
White
Attitudes of FDA
Lack of Transparency Frequently Rarely Sometimes
Past job performance Frequently Rarely Rarely
Unable to regulate Frequently Sometimes Rarely
Distrust of FDA Frequently Sometimes Rarely
Knowledge of FDA/Tobacco
Regulation

Uncertainty regarding the
role of the FDA
Frequently Sometimes Sometimes
Understanding of their role
in the drug approval
process
Frequently Frequently Frequently
Uncertainty and lack of
knowledge regarding
tobacco regulation prior to
The Act
Frequently Frequently Frequently
Knowledge of the FDA’s
role in tobacco regulation
Sometimes Rarely Sometimes
Perceived Community Attitudes
towards FDA

Collaboration with
community
Frequently Frequently Sometimes
Distant authority with no
local presence
Frequently Sometimes

Frequently
Lack of clarity of how the
regulations will be enforced
Sometimes Frequently Frequently
Perceived lack of diversity Sometimes Sometimes Rarely
Perceived Community Knowledge
of FDA/Tobacco Regulation

Lack of clarity in the
community about the role
of the FDA
Frequently Frequently Frequently
Lack of clarity of how
community is informed
Sometimes Sometimes Frequently
Presence of non-compliant
retailers in community
Frequently Sometimes Rarely
Retail environment changes Rarely Sometimes Rarely
Perceptions as an agency
that only responds to crises
Sometimes Sometimes Rarely
36
Attitudes towards the FDA
Distrust of the FDA. The most prevalent attitude towards the FDA was that of distrust,
especially among the African-American KOL’s. Many KOL’s described past issues with the
FDA that has led to their distrust. Such past issues included the amount of previously approved
drugs being recalled. The respondents felt that the FDA did not have the community’s best
interests in mind. The KOL’s also expressed a lack of belief in the agency.
“I just don’t believe in the agency, I just don’t trust them.” (AA KOL)
The lack of trust in the FDA came up frequently in the African-American KOL focus group. The
issue of trust was also raised in the Hispanic KOL focus groups but was not as prevalent. Some
the Hispanic KOL’s expressed having some trust in the FDA but were not sure if they would
trust them to do their job fully.
“I actually do trust the FDA, not 100%...I think that there is a capacity issue…I think that
there could be areas of improvement.” (H/L KOL)
Non-Hispanic White KOL rarely expressed distrust of the FDA and indicated a higher level of
trust. Most discussion regarding trust of the FDA in the NHW KOL focus groups revolved
around past performance of the FDA or giving them the benefit of the doubt.
“The FDA regulates umm who has access to tobacco, where they have access to tobacco
at like where they can purchase it…the age that you can access tobacco.” (NHW KOL)
Authority to regulate tobacco. KOL also expressed doubt in the FDA’s authority to
regulate tobacco products. Again, the KOL’s recalled previous errors by the agency influencing
their belief that the FDA could not effectively regulate tobacco products. The discussion of the
FDA’s inability to regulate tobacco products occurred frequently in the African American KOL
focus groups compared to sometimes in the Hispanic/Latino and rarely in the non-Hispanic
37
White focus groups. When discussed in the non-Hispanic White focus groups the KOL’s saw the
FDA as a slow moving bureaucratic institution that could not respond quickly to a situation. In
the Hispanic/Latino focus groups some participants discussed more the abilities of the tobacco
industry more so than the inability of the FDA.
“The tobacco industry knows how to sell, the FDA does not. You know it doesn't ever get
to the public effectively anyways.” (H/L KOL)
When asked about the FDA’s ability to regulate tobacco products the African American
KOL’s discussed witnessing tobacco retailers engaging in non-compliant behavior such as
selling single cigarettes or to minors. The statement of one African American KOL was one of
many mentioned during the focus group:
“But the regulation part, I don't think so because just as an example... My neighborhood
store, sells single cigarettes, okay. They are expensive. If you buy a single cigarette it
costs you almost $5 a pack. If you bought it like that. But they sell single cigarettes, they
can't regulate. I don't think they can regulate it.” (AA KOL)
Past job performance. There was a clear theme in the focus groups regarding the
FDA’s past performance in conducting their job. The attitudes towards the FDA’s job past
performance were frequently discussed before expressing thoughts on trust and beliefs in the
FDA’ abilities. Interesting however, was that many times the examples provided were related to
roles not under the FDA’s purview, such as the regulation of agricultural products, which the
responsibility of the United States Department of Agriculture. A common example raised was
the frequency of poultry related outbreaks.
38
“They are under resourced and under staffed. In the sense that there’s always some kind
of chicken virus or beef virus. Most of the time they probably don’t have an opportunity
to get to all these factories across the country that produce meats.” (HL KOL)
“You know something else the FDA could do is be more visible, and not just come out
when there is a crisis or pandemic, an allergic pandemic and all that.” (AA KOL)
Knowledge of the FDA and/or Tobacco Regulation
Uncertainty regarding the role of the FDA. While at least half of each ethnic
community’s KOL’s reported being aware of the FDA there was a lot of uncertainty during the
focus groups regarding their role. In all focus groups participants discussed roles that do not fall
under the FDA’s regulatory mandate. One of the most common misconceptions was regarding
the handling of food borne disease outbreaks or with meat inspections. These misconceptions
occurred frequently in the African-American KOL focus groups compared to sometimes in the
Hispanic/Latino and Non-Hispanic White KOL focus groups.
“With Foster Farms…When they went in and inspected, and then you heard about the
FDA because there were problems at the meat processing plant…that’s the only time we
really do hear about them.” (AA KOL)
“And for me too, like the FDA's involvement in organic vs. non-organic farming. And the
FDA's approval of GMOs; the FDA's assertion that all vitamins and supplements are
basically useless. This makes a lot of people who are interested in organic and non-GMO
products not trust the FDA so much.” (NHW KOL)
Knowledge of the FDA’s role in tobacco regulation. In none of the groups did the
discussion of the FDA’s role in Tobacco Regulation occur frequently but most discussion
regarding this topic was correct.
39
“What I'm familiar with is something about like how it's marketed, like that, things
cannot be at eye-level, like children's eye-level. There are certain rules about where there
do advertisements. That's the extent I've heard it, so I know that certain signage.” (HL
KOL)
“ FDA regulates - who has access to tobacco, where they have access to tobacco at like
where they can purchase it. The age that you can access tobacco - the type of messages in
terms of what tobacco ... tobacco can impact you in terms of your health- what the
message is - where it can be displayed.” (AA KOL)
“As it was mentioned earlier alcohol tobacco and firearms which basically was looking
at whether the stamp was on the package. The tax stamp that was the scope of the
regulation and then when you get the FDA if you are talking about does the company
[increase] the tobacco with extra nicotine to make it especially addictive. That would be
something for FDA to really regulate…”(NHW KOL)
When statements like this were made, most other participants would agree, and the moderator
would carry on to the next item in the focus group guide.
KOL Perceived Community Attitudes Towards the FDA
Lack of clarity with how regulations will be enforced. When the focus group
discussions turned to the KOL’s perceptions of their communities there was a common theme of
not understanding how the FDA will enforce tobacco related regulations across communities.
“Yeah. Regulations are great but how are we going to enforce it? What is the mechanism
put in place to watch how it's going to be done?” (AA KOL)
“I don’t even know how it would get regulated. The footwork involved and overseeing
that.” (NHW KOL)
40
“I am still a little confused if they are thinking about regulating it or is it more of a
concern about…is it more of educating the public about the effects.” (HL KOL)
This lack of clarity the KOL’s felt influenced the attitudes of their community members towards
the FDA and their regulatory authority.
“I feel like the FDA is great for information but they're not really great for
enforcement…if I was fined $500, I would be like "alright, listen, let me put that away"
and I wouldn't do that again. And so the consequences are not really adding up for the
business owners or the community.” (AA KOL)
Most of the lack of clarity was also attributed to many levels of regulation that exists for the
tobacco retail environment.
“There’s confusion just in the community because you have state law, you have local
tobacco control laws, and now you have FDA. I think that it is a lot of information for
retailers.”(H/L KOL)
The KOL’s expressed that the tobacco companies were getting their message across
while the FDA was behind the curve which, allowed one side to drive the narrative regarding
tobacco regulation.
Community Collaborations. Another common theme regarding community attitudes
towards the FDA is that in order them increase their credibility the FDA needs to collaborate
with local government and community organizations. The need for similar statements
highlighted this mentioned in the previous section that there were too many levels of regulation
that retailers were confused on whom to follow. The discussion of the FDA collaborating with
local organizations occurred frequently in both the AA and H/L KOL focus groups. In the AA
41
focus groups the KOL’s expressed that given the history with regulatory or enforcement agencies
that there was a need for community collaboration and oversight.
“They might need to be policed, someone will need to police the FDA, and they will need
to be held accountable.” (AA KOL)
The need for the FDA to collaborate with local agencies was highlighted by the fact that many
KOL’s saw them as a distant authority with no local presence, which was viewed as an
impediment to their regulatory ability. This was another theme found across the ethnic
communities represented in the focus groups.
“My neighborhood store, sells single cigarettes, okay… I don't think they can regulate
it… It's hard to regulate because it depends on the individual store. And the FDA is way
in DC, they have no clue.” (AA KOL)
The KOL’s felt that many would not understand whom the FDA is or why they are involved with
tobacco regulation since they are not seen out in the community.
KOL Perceptions of Community Knowledge of FDA/Tobacco Regulation
Lack of clarity in community about the role of the FDA. Prevalent in all the KOL
focus groups was the perception that community members were not clearly aware the role the
FDA plays in tobacco regulation. Many expressed that the general population in their
communities would not be aware that there was a specific regulatory authority over tobacco
products. One H/L KOL stated:
“I am not sure if it is a question of trust because most people really don’t know what their
function and whether they are a legitimate group or honest.” (H/L KOL)
Further, some of the KOL’s stated that their community likely assumed there was a
federal regulatory authority prior to the passage of The Act in 2009. When it came to retailers in
42
their community the KOL’s expressed that most were likely aware of tobacco regulations but not
the source of those regulations. A NHW stated:
“It doesn’t really matter to most people where regulations come from. Like we can't sell
tobacco to minors or advertise on TV and radio, but I guess the "who" is in charge
probably isn’t as important to people than the actual "what" is not allowed.” (KOL,
NHW)
These sentiments were expressed frequently across all community focus groups.
Lack of clarity on how the community is informed. When asked about community
knowledge about tobacco regulations the KOL’s expressed that they were not sure how the
community was being informed. This theme emerged most from the NHW KOL’s compared to
those representing the AA and H/L communities. A common sentiment from the NHW focus
groups is reflected well by the following statement:
“As far as I know it hasn't really been communicated and I haven't seen their presence
represented around enforcement…and they certainly aren't communicating to
communities at least at the community level. [In] respect to tobacco products.” (NHW,
KOL)
While many felt that community members in general would not be aware of tobacco regulations
some expressed that those born outside the U.S. were at a greater disadvantage. One AA KOL
stated:
“In some neighborhoods there is a lot of foreign born owners and maybe they are not
aware of the FDA and what they are supposed to do…So is there any kind of mandatory
training for retailers or something online or in person.” (AA KOL)
43
Some of the KOL’s did state that the existence of non-compliant retailers in their community
were due to them and their customers not being fully informed of tobacco regulations. This
theme only occurred frequently in the AA focus groups.
The main differences between communities regarding themes were found in distrust of
the FDA and knowledge of the FDA. The theme of distrust was more prevalent in the AA
communities compared to HL and NHW communities. Further, the HL KOL’s were more
ambiguous with their distrust of the FDA by saying they had some trust in the FDA. In the
NHW focus groups they did not see so much as a question of trust but rather of awareness. The
NHW KOL’s also seemed to have the highest knowledge of the FDA and tobacco regulations
compared to the other groups.
Discussion
The current study presents information that is beneficial to the FDA and other regulatory
agencies on areas that could assist in increasing compliance with tobacco regulations. To the
best of our knowledge this is one of the first studies to assess Key Opinion Leaders’ knowledge
and attitudes regarding the FDA and their new regulatory authority over tobacco products.
KOL’s have been shown to be influential in tobacco policy adoption among community
members (K. A. Howard et al., 2000; Schuster et al., 2006; Valente & Pumpuang, 2007). Their
views and opinions on the current state of tobacco regulation is important to helping regulatory
agencies achieving their mission at the local community level. In Figure 1, the KOL’s are
included as part of the exo-system. Their views and actions can influence the system and larger
environment in which the tobacco retailers exist.
Related to the tobacco retailers’ exo-system is the FDA’s role in tobacco regulation and
how KOL’s can assist them in that role. A key finding from this study is that across all
44
communities the KOL’s expressed a strong desire to collaborate with the FDA to regulate the
tobacco retail environment. This theme was even prevalent in the AA focus groups, which also
displayed higher levels of distrust towards the FDA. The goals of collaboration however, were
different for each community with AA KOL’s wanting it to be more of an oversight role while
H/L and NHW KOL’s viewed it as an opportunity to increase the effectiveness of the new
federal tobacco regulations. Moving forward it will be important for regulatory agencies to reach
out to different communities to understand their unique needs and how to best approach tobacco
regulation.
An interesting finding of this study was the level of distrust expressed in the AA KOL
focus group occurred more frequently compared to the H/L and NHW focus groups, this also
comes in at exo-level for tobacco retailers’ compliance. While the KOL’s representing the H/L
and NHW communities felt that the FDA had room for improvement the lack of trust in AA
focus groups dominated the conversation. The overall sentiment in the AA focus groups was
that the FDA did not have their community’s best interest in mind. Rather, the AA KOL’s felt
the FDA was under the influence of corporate lobbies and needed to be monitored by citizens.
When discussing trust of the FDA the H/L KOL’s tended to be more ambiguous while the NHW
KOL’s were more willing to cautiously express trust. This finding could likely be explained by
examining the historical burden the AA community has with tobacco related diseases. Several
studies have found large disparities of tobacco advertising in African-American communities
(Dauphinee, Doxey, Schleicher, Fortmann, & Henriksen, 2013; Lisa Henriksen, Schleicher,
Dauphinee, & Fortmann, 2012; Lisa Henriksen, Schleicher, Feighery, & Fortmann, 2010; Lee,
Baker, et al., 2015; Lee, Henriksen, Rose, Moreland-Russell, & Ribisl, 2015; Milam et al.,
2013). Further, it has been shown that African-American bear higher burden of tobacco related
45
disease compared to other ethnicities as they are less likely to have access to quality healthcare
(Centers for Disease Control and Prevention, 2014; Fu et al., 2008; R.Trinidad, J.Pérez-Stable,
M.White, L.Emery, & Karen Messer, 2011). As the FDA continues to reach out to different
ethnic minority communities it will be important they consider how they are viewed by these
communities and why these views exist.
Many of the KOL’s felt that their communities were not aware of the FDA or tobacco
regulations. For several of the KOL’s they expressed that it was hard to assess to community
trust of the FDA since they were not sure if their communities were aware of the FDA. A
common statement from the KOL’s across communities was that, “it is not a matter of trust since
they don’t know who they are.” In fact, many KOL’s themselves were confused as to the role of
the FDA. In all the communities, many KOL’s confused the role of the FDA with that of the
USDA (meat inspections) or of the CDC (disease outbreaks). The KOL’s also expressed in the
anchoring survey and focus groups that they and the retailers in their community could not
distinguish between federal, state, and local agency tobacco regulations. They received materials
from all of these organizations and the environment seemed too crowded. This could lead to
lower levels of compliance among retailers, as they might not be aware of the FDA’s ability to
enforce these regulations. Not being able to understand the differences between the levels of
regulation can also lead to confusion among retailers. This confusion could cause retailers to
only follow one set of regulations but still be at risk for punitive actions from other regulatory
agencies. There is a potential for retailers to see regulatory agencies as allies if these agencies
take time to clearly educate retailers on the different levels of regulation.
Moving forward it will be important for the FDA to communicate their role in the health
of the U.S. population. This could also help address the lack of trust in some of the communities
46
represented in the current study. Several of the issues raised regarding distrust of the FDA
revolved around issues that do not fall under their regulatory purview.
Further investigation that examines differences in awareness and how they relate to the
KOLs’ linguistic and cultural background could be beneficial to inform regulatory agencies.
These differences might highlight the need for culturally appropriate materials in a language that
will encourage buy-in from KOL’s, which can lead to potential increases in retailer compliance
with tobacco regulatory policies. KOL’s possess great knowledge and can provide a window into
the communities they serve and how regulatory agencies can meet their unique needs. The
information gained from these different channels (KOL’s and retailers) in turn creates a stronger
foundation for future tobacco regulatory messages and educational campaigns that are likely to
be received well in ethnically diverse populations.
Limitations
The current study has some limitations. First, this study is cross sectional in design
limiting the ability to assess the differences in awareness over time. Since 2009, the FDA and
other regulatory agencies have been making efforts to reach retailers. There have also been
many changes in the retail environment with new products coming to the shelves. The lack of
longitudinal data in this study will not allow us to assess the effects of these changes on the
awareness of KOL’s in regard to tobacco policy. Another limitation in this study is that it only
provides data for KOL’s from the Los Angeles Area. This limitation will not allow account for
regional differences that likely exist. The tobacco regulatory climate in California is more active
than most other states so the results here might not apply to other states with much lower
regulatory efforts, which was also noted by the KOL’s.

47
Implications for tobacco product regulation and future research
The findings from this study provide for direct implications in the emerging field of
tobacco regulatory science. With the retail environment changing at a fast pace with the advent
of new types of products and with regulatory agencies racing to keep up it is important to
provide data that will aid in the dissemination of regulatory messaging. This study also informs
regulatory agencies on the gaps of tobacco policy awareness in KOL’s, who are potential
partners for the FDA in their regulatory efforts. This information helps to create effective
messaging that will be well received by the independent retailers (bodegas and corner stores). It
is important the FDA run educational programs that will inform KOL’s about their regulatory
efforts in order to increase buy-in from the retailers in their respective communities.
This study also highlights the potential for the FDA to reach out more to community-
based organizations and local agencies that can serve as partners. Given that the KOL’s indicated
a willingness to collaborate with the FDA future work should examine the capacity of
community organizations. There are more implications for the FDA to further examine distrust
expressed during the focus groups. With high levels of distrust, it will be challenging for the
FDA to accomplish its mandate of regulating tobacco products. Not being able to make progress
on this mandate will have implications for vulnerable populations where there are higher levels
of distrust, as the burden of tobacco use disparities will continue. The FDA and other regulatory
agencies will also need to educate the retailers and public about their roles in tobacco regulation.
This research also highlights the use of community experts to gain knowledge of an underserved
population. Gaining this perspective can allow for the better implementation of regulatory
efforts. It will be important that the FDA and local collaborators both identify methods in how
they can work together to achieve a mutual goal of preventing use of tobacco.
48
CHAPTER 3: Study 2
Factors that lead to independent tobacco retailers’ compliance with tobacco regulatory
policy in vulnerable communities.
Background and Significance
Retailer compliance with the FSPTCA and other tobacco policies is a key element in
reducing tobacco related disparities in racial ethnic communities. Understanding how the
different ecological systems influence a retailers’ non-compliance is necessary to have a
successful policy implementation process (Lee, Baker, et al., 2015). Given the variability and
complexity of tobacco regulatory it can be expected that independent retailers are not fully
knowledgeable of the FSPTCA or of the new regulatory role of the FDA (Rose et al., 2015). In
states with a high regulatory environment such as California, there can be many levels (city,
county, state and federal) of regulation for tobacco retailer. In the end this leaves retailers
confused and not fully knowledgeable of tobacco regulatory policy.
The limited current research indicates that among retailers there is moderate knowledge
of current federal tobacco policy and of the FDA (Rose et al., 2015). Other research focused on
local tobacco regulatory laws posit that lack of awareness among independent retailers (in
bodegas in the Latino community and corner stores in African American neighborhoods) plays a
role in compliance (Li et al., 2016; Silver et al., 2015). In a study examining retailer compliance
after passage of minimum age of sale policies in New York found that independent retailers were
most likely to be non-compliant with the new laws (Silver et al., 2015). Previous research
suggests that compliance can be difficult to achieve if there is a lag between policy adoption and
enforcement (Sabatier & Mazmanian, 1980). This is due to how the media creates attention
towards the new policy. When a new policy is passed there can be a lot of media attention which
49
will begin to lag as they move on to a new issue or event (Rose et al., 2015; Sabatier &
Mazmanian, 1980). Given that the passage of the FSPTCA occurred in 2009, it is possible that
independent retailers may not be aware of all of the implemented policies and the new role of the
FDA.
For over 20 years the majority of tobacco marketing expenditures have focused on the
retail environment (Federal Trade Commision cigarette report for 2009 and 2010, 2012). There
is an emphasis by the major tobacco companies on retail outlets. It is estimated that 90% of
tobacco marketing expenditures occur at retail and convenience stores (Cantrell et al., 2013; L
Henriksen et al., 2004; John et al., 2009). Tobacco retail marketing has been well documented as
a risk factor in youth and young adult smoking initiation, unsuccessful quit attempts, and relapse
for those who no longer smoke (Cantrell et al., 2013; Lisa Henriksen, 2012; Lee et al., 2017;
Ribisl et al., 2017; White, White, Freeman, Gilpin, & Pierce, 2006).
With the large amount of effort tobacco companies place in the retail environment, it is
important to understand how retailers themselves view the benefits of selling tobacco. The
research in regards to this is very limited. Searches of tobacco industry documents have shown
that incentives are paid to retailers to display products and advertisements in prominent areas
(Henriksen et al., 2004; John et al., 2009). These incentives could play a role in tobacco retailers
deciding to display promotional materials but is important to examine other personal factors that
could influence this behavior. Some of the current literature in regards to tobacco retailer
perceptions about tobacco products and regulation comes from New Zealand. In recent years the
country of New Zealand has made it a goal to become smoke free by 2025 (Jaine et al., 2014).
The tobacco industry has insisted on the damage this ambition could have on retailers and the
communities they serve (Guthrie et al., 2015; Jaine et al., 2014). The research however, is
50
showing that retailers are in large not concerned with the loss of revenue or show ambivalence
towards the topic (Guthrie et al., 2015; Jaine et al., 2014; Robertson, Marsh, Hoek, McGee, &
Egan, 2015). Jaine and colleagues (2014) found that most of the retailers in their qualitative
study agreed with the new tobacco regulations and in reducing access (Jaine et al., 2014).
Furthermore, they found that independent retailers felt a sense of responsibility to their
communities and needed to put their well-being ahead of selling tobacco products (Jaine et al.,
2014).
A qualitative study on why California retailers stop selling tobacco products found that
retailers felt the costs out compliance outweighed the economic gain (McDaniel & Malone,
2011). The same study (McDaniel & Malone, 2011) also found that all but one of the retailers in
their sample reported revenue from tobacco products as the primary reason for ceasing to offer
tobacco products. It must be noted that most of the retailers in the California study were
pharmacies or grocery chains (McDaniel & Malone, 2011). While this information is useful by
informing the current research it is important to investigate the perceived benefits of selling
tobacco products among independent retailers. Independent retailers will have a higher presence
in communities with diverse communities that also have a low socioeconomic status compared to
grocery chains and pharmacies. These outlets are can also be respected and valued members of
the communities they serve so they play a vital role in addressing tobacco regulation among
vulnerable populations.
The current available literature on tobacco retailer attitudes related to tobacco policy is
primarily international research and not focused on the United States. In a recent New Zealand
study, Guthrie (2015) and colleagues found that retailers are reluctant parties in the distribution
of tobacco products due to the health consequences of smoking. Another New Zealand study
51
found that retailers in their sample supported a restriction on selling tobacco near schools as they
felt the children should not have access to an addictive product (Guthrie et al., 2015). This
evidence suggests that retailers could be potential partners in tobacco regulation but more
research is needed to understand how their attitudes towards tobacco policies relates to their
business tobacco practices and compliance with tobacco regulation policies. Further
investigation on the attitudes of tobacco retailers towards tobacco regulation is needed to inform
regulatory agencies how to approach them.
Study 2 provides a better understanding on the relationship between retailer tobacco
policy awareness, product promotion and retailer attitudes and use of tobacco products than what
has been found to date in the literature. This study builds upon the foundation of earlier studies
(Study 1) by determining how compliance is predicted by perceived benefits of selling tobacco
products, display of promotional materials, ads on the exterior of the store, retailer tobacco
product use and retailer demographics. For this study compliance is defined as the display of
state and local tobacco retailer licenses, the display of the State of California’s AskID signage,
asking customers who look younger than 27 years old for id to purchase tobacco products, not
selling single cigarettes, not having self-service tobacco product displays, the lack of products
displayed within twelve inches of child related items, and the lack of tobacco product ads within
three feet of the ground. The study also examined how retailer use of tobacco products can
influence compliance with tobacco regulatory policies. There is however, limited research
examining how tobacco product use among retailers is can influence compliance with tobacco
regulatory policies. It is therefore, an exploratory component of this research. One study among
Vape Shop retailers (Allem, Unger, Garcia, Baezconde-Garbanati, & Sussman, 2015), examined
vape shop employee e-cigarette use and their attitudes towards potential regulation and electronic
52
cigarettes. The study found that the retailer’s use of their products influenced how they promoted
them in their stores. While this study is not focused on e-cigarettes it is possible that tobacco
retailers would also promote tobacco products more favorably if they themselves were also
consumers. This study aims to determine the level of association between a retailer’s perceptions
on the effect of tobacco products on their business and the practice of displaying promotional
materials. Retailers who perceive that tobacco products are beneficial to their business could be
likely to have more promotional materials for tobacco products. The type of relationship between
the amounts of promotional materials along with the perception of tobacco products effect on
retailers’ compliance with tobacco regulatory policy is also unknown. It is important to begin
research on how retailer variables, such as tobacco product attitudes and use, influences their
tobacco policy awareness and practices in displaying promotional materials.
Hypothesis 1: Retailers that perceive tobacco products have a positive effect on their business
will have more tobacco product promotional items displayed in their stores.
Hypothesis 2: Retailers that use tobacco products themselves will have a larger number of
promotional tobacco materials displayed as compared to those who do use tobacco products.
Hypothesis 3: Retailers that use tobacco products and/or display promotional materials for
tobacco products, have negative attitudes of the FDA and negative attitudes towards tobacco
policies, will be more likely to be in non-compliance.
Methods
We focused our data collection on retailers in African American, Hispanic/Latino, and
Non-Hispanic White communities specifically. A total of 573 retailers (200 for AA and H/L and
173 for NHW) were recruited to conduct a retailer interview and shop observation. The data
were collected from October 2015 until April 2017. Greater details on these data can be found
elsewhere (Baezconde-Garbanati et al., 2017).

53
Sample Selection and Randomization of Tobacco Retail Shops
The retailers participating in this study were interviewed in person, in language (Spanish
or English), as needed, and asked to allow that their shop be observed for approximately 20
minutes. Retailers were identified through the publicly available tobacco retailer listings of the
California Board of Equalization (BOE) (PSTD-STF-PPABDataRequests@boe.ca.gov). The
BOE listings included over 38, 000 licensed tobacco retailers. In order to be included in this
study the retailers have to be independent and not associated with a national or major chain.
Stores to be selected for this study are those that did not sell gasoline, gasoline only stations,
liquor stores, corner stores, and small markets.
The data were collected from communities that are either predominantly African
American, Hispanic/Latino, or Non-Hispanic White. The communities of interest were identified
through publicly available data from the US Census. This data is used to identify the proportion
of the racial/ethnic groups of interest for this study in all of the zip codes in the greater Los
Angeles area. The threshold proportions for inclusion were different for each racial/ethnic
community. The thresholds were based on the percent population of each racial/ethnic
community in Los Angeles and their respective median household incomes. Table 4 below
provides more detailed information on thresholds for each racial/ethnic community.

54
Table 4: Sampling Strategy for Study 2
*A range of 30-80% or above of an ethnic group in the census tract is used for determining ethnic representation
in the population

Retailer Interview and Shop Observation
The data collectors for the retailer study were trained community health workers
(CHW’s) and promotores de salud that represented the communities of interest. The use of
community health workers aids data collection as they have won the trust of the communities
they represent, and provide a familiarity to the shop employees, to the geographic area and
understand the issues that may impact the logistics of the implementation of the research in each
community. The CHW’s were identified by our Advisory Committee and local agencies, which
served as community partners in the study. They were compensated through their respective
agency.
The training for the CHW’s lasted three days and covered the FDA, the FSPTCA, the
retail environment and the parent research project. The CHW’s were also trained in data
collections procedures such as approaching and consenting participants, using electronic tablets
for data recording, use of the paper and pencil instrument, and providing retailers compensation
for their participation. During training the CHW’s were required to thoroughly review the study
measures and review terms related to tobacco products (i.e. flavors, types of products,
Los Angeles County Thresholds
Total % Median
Household
Income ($)
% Above
Ethnicity
Median
Household
Income ($)
Median
Household
Income ($)
1 Standard
Deviation
Entire
Population
9, 818, 605 - 55, 909 - - -
African
American
856, 874 8.73 42, 071 30.0<* 42, 000 17, 588
Hispanic 4, 687, 889 47.74 44, 989 80.0 <* 45, 000 11, 189
Non-Hispanic
White
2, 728, 321 27.79 71, 768 50.0 <* 72, 000 26, 868
55
advertisements). The CHW’s practiced the data collection procedure during the training and
went through a live practice run at an actual retail outlet with project staff.
While out in field project staff through field notes and daily meetings, closely monitored
the CHW’s, reports from the CHW’s. They also conducted periodic quality checks and observed
the CHW’s during data collection. To test for reliability a project staff member accompanied the
CHW’s on data collection to half of the shops. Twenty five percent of all surveys were subjected
to reliability checks. The project staff debriefed the CHW’s at the end of each day of data
collection to address any questions or issues. If the project staff became aware of any issues they
immediately addressed the issue and if necessary provided additional training to all the CHW’s.
The CHW’s were also required to complete daily field notes that summarized events that
occurred during data collection. There were also periodic booster training sessions to maintain
data collection protocol fidelity.
The CHW’s were matched to the cultural and linguistic needs of the communities they
visited to conduct data collection. There were some cases where the ethnicity of the CHW did
not match the ethnicity of the community due to the linguistic needs of the retailer. This was
done to increase the likelihood of retailer participation by providing the opportunity to conduct
the survey in a language they are comfortable speaking given the technicality of the subject
matter. We found that often retailers were not necessarily from the same community they work
in. Each store was visited by two CHW’s so that one could conduct the interview while the other
began the shop observation.

56
Data Collection
Retailer Interview and Shop Observation
Trained community health workers in teams of two, approached identified stores based
on our sampling scheme to conduct the interview and shop observation. The CHW’s were
trained to attempt to interview an owner or manager but sometimes a clerk was interviewed
because of availability. The participating retailers received a $75 gift card for the interview
portion and another $50 if they allowed the CHW’s to conduct a shop observation. Two CHW’s
visited each shop to conduct the data collection. The interview took approximately twenty
minutes to complete in order to not burden the retailers. The CHW’s attempted to conduct the
store interview and observation during the morning or at times when there were fewer customers.
Along with the incentive for their participation the retailers were provided with a leave
behind packet that included information on tobacco regulations and the FDA consumer tobacco
fact sheets. The data for these studies were collected from October 2015 until April 2017. All
the data were captured using a tablet to record the participants’ responses and the shop
observations. The CHW’s also carried a paper and pencil version of the measurements in case of
technical issues or participant preference for a paper survey. Pictures were also taken with a
digital camera to capture the level of signage and products available in the store. The interview
was conducted in English, Spanish or Korean depending on the language needs of the
participant.
Measures
Interview: The interview portion of the data collection asked participants about their
demographics including; age, gender, ethnicity, country of origin, length of time in the U.S.,
57
languages, English proficiency, and education level. The participants were also asked about their
annual household income and their retail shop’s annual profit.
The participants were also asked about their knowledge of the FDA. The participants
were first asked if they recognized the FDA logo and if they could list the name correctly. After
this the participants were provided with a brief statement explaining the FDA and their role in
tobacco regulation. The participants were then asked if they have heard of the FDA prior to the
day of interview. We also asked the participants if they know who regulates tobacco products
and are provided the choices of the FDA, State government, city government, other, or don’t
know. We also asked if they feel that other retailers in their area are aware of the FDA’s role in
regulating tobacco.
There were also two questions regarding the participants’ attitudes towards the FDA. One
question is if the retailer believes the FDA has the right to regulate tobacco products. The other
question asks if they view the FDA as a trustworthy source of information. The participants were
asked if they are aware of a state campaign called Healthy Stores and Healthy Community.
The participants were then asked about information they have received or sought in
regard to specific FDA regulations. We asked the participants if they have received any tobacco
regulatory information directly from the FDA in the previous year. A similar question was also
asked but it addressed if the participants received such information from other sources (i.e. news
sources, internet sources, television, radio, trainings, tobacco industry sources, other retailers,
social media, and regular mail). Participants were asked to identify their language of preference
for tobacco regulatory information. (Survey is attached in the appendix section of the
dissertation).
58
During the employee interview, we asked the retailers about their perceptions of tobacco
products as they relate to their business. The employees were first asked to identify their
business’ main source of revenue. The responses for this question include; alcohol, tobacco,
food, non-alcoholic beverages, other, and don’t know. The employees were then presented with a
table that asks them to identify the effect specific tobacco products have on their business
revenue. The tobacco products include; cigarettes, cigarillos, e-cigarettes, vape pens, hookah, e-
hookah, smokeless tobacco and other. For each product, the participants could identify the level
of effect on revenue through a five level Likert scale that ranges from helps make a lot of money
to makes my business lose money. The participants were also provided the choices of don’t know
and do not sell product. The participants were also asked to indicate their retail outlet’s annual
profit with choices ranging from <$25, 000 to >$200, 000. Along with store profits the retailers
were also asked to identify their business’ main source of revenue by selecting on the following
choices: Alcohol, Tobacco, Food, Non-Alcoholic Beverages, Other, or don’t know.
One of the measures to assess tobacco product use among retailers asked the participants
to indicate if they have smoked at least 100 cigarettes in their lifetime. We then asked the
participant if they currently smoked cigarettes every day, some days or not at all. The
participants were asked if they smoked during the past 30 days and if so, how many days they
smoked. We also asked the retailers to indicate the number of cigarettes they currently smoke per
day. Finally, we asked if they used any tobacco products in the past 30 days.
Tobacco Retailer Shop Observation: The CHW’s asked the retailers if they would allow
them to conduct a store observation. The observation measure is the Standardized Tobacco
Assessment for Retail Settings, STARS. (State and Community Tobacco Control Research,
2014) This instrument was created through a collaboration of researchers, opinion leaders, the
59
CDC, universities, state health departments, and the Tobacco Legal Consortium. This instrument
allows for the documentation of the pricing and promotion of tobacco products in the retail
environment. The STARS measure is designed for use by youth or adults trained in data
collection. An independent translation company translated the STARS measure in Spanish for
our study.
For this study, the CHW’s notated the type of store (convenience, liquor, grocery,
discount, tobacco shop, or other) and how many cash registers are available in the retail shop. In
the shop observation the CHW’s notated if promotional materials are on display on the interior
or exterior of the store. The observation form also asked what type of tobacco products
(cigarettes, mentholated cigarettes, cigarillos, chew, or e-cigarettes) are advertised on the exterior
of the shop. The posting of a price was recorded on the shop observation form. The CHW’s also
indicated if there are promotional materials on display in certain locations inside the shop and if
they included a price or cross-product promotions.
The presence of age of sale signage on the exterior or interior of the shop was also
recorded on the shop observation form. The age of sale signage includes; We Card, 1-800-
5ASK4ID, or other. The shop observation form also asked if the shop has their California and
city tobacco retailer license posted. Posting of materials from the FDA’s Retailers Break the
Chain campaign was notated on the observation form.
Compliance was measured by the responses the CHW’s notated on the observation form.
We used these responses as they related to required materials to be displayed (licenses), actions
to be completed (ask for id), or not displaying items in certain areas (in the eyesight of children).
Compliance related items addressed in the observation measure included if free samples or single
cigarettes were available, self-service displays, non-compliant product placement (i.e. within 3
60
feet of the floor), non-compliant placement of tobacco ads, and if identification was required for
purchase. The display of a retailer’s California and Los Angeles tobacco retailer license along
with a Proposition 65 nicotine warning sign was also used to assess compliance. The display age
of sale warning signs was also used to assess compliance but it had to be the State of California’s
1-800-ASKID signage to be compliant. The display of the We Card signage did not account for
compliance as this is provided by the tobacco industry and not a regulatory agency. If one of the
measures for compliance mentioned in the previous section is coded as yes, then the retailer will
be found to be in non-compliance.
Analysis
A variety of statistics were utilized to analyze the data in this study. Descriptive statistics
are first presented to characterize the overall sample and variables of interest. Items to be used
for each of the predictor variables are outlined in Table 5 below. Second, to assess the reliability
of the variables used in this study we used Cronbach’s alpha, and all of the variables had an
alpha higher than 0.7 indicating acceptable reliability. Pearson Chi Square and independent t-
tests were used to test hypotheses 1 & 2. This test was used to determine the relationship
between categorical variables (perceived retail benefits of selling tobacco, display of promotional
materials, tobacco product use). The chi square tests also helped to determine if any of the
hypothesized differences are due to chance alone.
Third, a multivariate logistic regression was conducted to determine the level of influence
the predictor variables (perceived retail benefits of selling tobacco products, attitudes towards
FDA and tobacco policy, knowledge of the FDA and tobacco regulatory policy, retailer tobacco
use, and the display of promotional materials) have on the outcome, a retailer’s compliance with
61
tobacco regulatory policy. Logistic regression is the analysis selected for the current study; as
the outcome variable is dichotomous (compliant vs. non-compliant).
We utilized a forward stepwise approach to build the logistic model in order to build the
model and determine the amount of variance a predictor contributes to the model. This approach
was used to address hypothesis 3 and to determine the level of influence on compliance of the
other predictor variables. We also wanted to ensure that only those variables that contribute to
the model are included. After first running a model with only the outcome and constant we added
variables. For comparing communities, the retailers in NHW communities were set as the
reference group. When comparing different types of tobacco retailers, convenience stores were
the reference group.
The order the variables are added to the model was based on our assumptions of which
variables will contribute the most to the model. This order is based in part on the results from the
KOL focus groups. The first variable to be added to the model was the retailer’s attitudes
towards the FDA and tobacco regulatory policy followed by knowledge of the FDA and tobacco
regulatory policies, perceived retail of effects of selling tobacco products, the display of
promotional materials and finally the retailers’ tobacco product use. The conceptual model for
the logistic regression is presented in Figure 2.

62
Figure 2: Study 2 Conceptual Model

After conducting the multivariate logistic regression with the five predictors we took the
coefficients presented in the results and exponentiated them in order to obtain the odd ratios.
These odds ratios will help in the assessment of the level of influence each predictor variable has
on a retailer’s compliance with tobacco regulatory policy. The use of odds ratios helps to better
understand the relationship between each predictor and the outcome. In order to test the effect of
community on the relationship between the attitudes towards the FDA and tobacco policy on
compliance we first created a dichotomous dummy variable for each community (African
American, Hispanic, and Non-Hispanic White).
We then ran two separate models that include one of the dummy variables and the
attitudes variable along with the outcome of compliance. After running the two separate models
Compliance
FDA/Policy
Positive
Attitudes
Knowledge
Promotional or
Regulatory
Display
Tobacco Use
Effect on
Business
63
for each racial/ethnic community we compared the obtained odds ratios. If there is a difference
between the three odds ratios for each community, we then add an interaction term
(community*attitudes) to stepwise approach described above. The level significance of the
interaction term was used to determine if racial/ethnic community moderates the relationship
between attitudes towards the FDA and tobacco policy and retailer compliance with tobacco
regulatory policy.
Table 5: Variables included in the analysis
Variable Instrument Measures Used
Attitudes Retailer
Interview
Does FDA have right to regulate?
Is FDA a trustworthy source of information?
Retail
Benefits
Retailer
Interview
What effect do tobacco products have on this business?
Knowledge Retailer
Interview
Have you seen this logo?
Name of organization?
Who regulates tobacco products?
Heard of FDA before today?
Tobacco Use Retailer
Interview
Smoked 100 cigarettes, lifetime?
Smoke cigarettes every day?
How many cigarettes, past 30 days?
Ever use of other tobacco products?
Other tobacco product use past 30 days?
Promotional
Display
Store
Observation
Cigarette price promotions?
Menthol cigarette price promotions?
Orbs price promotions?
Cross product promotions?
Advertisements outside?
Compliance Store
Observation
California tobacco retailer license?
Los Angeles tobacco retailer license?
Prop 65 health warning regarding tobacco products?
Age of sale signage? (interior and exterior)
Any Break the Chain materials (FDA) displayed?
Single cigarettes for sell?
Self-service tobacco product displays available?
Tobacco products within 3 feet of ground?
Tobacco product ads within 3 feet of ground?
Tobacco products or ads near the display of candies?

64
Results
Description of the sample
Retailer demographics are presented in Table 6 for the total sample (n=576). Although
the communities of interest for this study (AA, HL, NHW) are equally represented the race of the
retailers interviewed are more varied. Retailers who identified as Hispanics represented the
largest proportion of retailers followed by those who identified as Asian or Non-Hispanic White.
Over half (54.7%) of the retailers identified as a different racial/ethnic background compared to
the community they served. Stores in AA communities (74.0%) had a significantly higher
amount of retailers identifying as a different race compared to the H/L (35.0%) and NHW
(55.1%) communities (X
2
=61.4 (2), p<0.01). The sample also had equal representation of the
different employee positions (owner, manager, and clerk). Most interviewed retailers were male
and had been in the U.S. for at least 20 years. The mean age for the sample was 42.5 yrs (±13.7
yrs). Nearly half of the NHW retailers reported smoking at least 100 cigarettes in their lifetime
but current use was less prevalent with 31.2% reporting being current smokers. Less than 20% of
HL and AA retailers reported being current smokers.

65
Table 6: Retailer Demographics
(n=576) N (%)
Male 362 (62.9)
Mean age 42.5 yrs (±13.7)
Community Ethnicity
African American 200 (34.7)
Hispanic/Latino 200 (34.7)
Non-Hispanic White 176 (30.6)
Store Position
Owner 174 (30.2)
Manager 189 (32.8)
Clerk 204 (35.4)
Born in the U.S. 138 (24.0)
Retailer Race
African or African-American 65 (11.3)
Asian 132 (22.9)
American Indian 1 (<1.0)
Hispanic/Latino 251 (43.6)
Non-Hispanic White 99 (17.2)
Mixed Race 6 (1.0)
Pacific Islander 4 (<1.0)
Time lived in U.S.
10 years or less 96 (16.7)
11 to 19 years 126 (21.9)
20 years or more 340 (59.1)
Education
Less than HS 93 (16.2)
GED or HS Diploma 149 (25.9)
Some College 130 (22.6)
College Grad or Higher 198 34.4
Household Income
$40, 000 or less 255 (44.3)
$40, 001 to $60, 000 79 (13.7)
$60, 001 or more 69 (12.0)
Don’t Know 67 (11.6)
Refused to Answer 104 (18.1)

Retailers’ Literacy
Table 7 shows frequencies of measures that assessed retailers’ literacy levels. As shown
in the table retailers in NHW communities were more likely to be educated in the U.S. and speak
English at home compared to retailers in AA and HL communities (p<0.01). Retailers in HL
66
communities consistently reported lower rates of literacy compared to retailers in NHW and AA
communities. Less than one-third of HL retailers reported being extremely confident in filling
out any form or medical forms in English and excellent in their reading ability in English. Nearly
two thirds of the retailers in HL communities identified as Hispanics and 51.5% reported being
in the U.S. for over 20 years. However, retailers in HL communities were also more likely to
report receiving their highest level of education outside of the U.S. compared to retailers in the
NHW and AA communities (p<0.01).
Table 7: Retailer Literacy
* X2 p<0.01

Overall

N (%)
African
American

N (%)
Hispanic
N (%)
Non-
Hispanic
White
N (%)
Educated in U.S* 258 (44.8) 88 (44.0) 67 (33.5) 103 (58.5)
English Use at Home* 258 (44.8) 86 (43.0) 57 (28.5) 115 (65.3)
Confidence filling out forms in
English*

Extremely 270 (46.8) 107 (53.5) 61 (30.5) 102 (58.0)
Quite a bit 136 (23.6) 35 (17.5) 63 (31.5) 38 (21.6)
Somewhat 97 (16.8) 34 (17.0) 41 (20.5) 22 (12.5)
A little 56 (9.7) 18 (9.0) 26 (13.0) 12 (6.8)
Not at all 13 (2.3) 5 (2.5) 7 (3.5) 1 (0.6)
Perceived Level of English Reading
Ability*

Excellent 206 (35.8) 78 (39.0) 39 (19.5) 89 (50.1)
Very Good 83 (14.4) 20 (10.0) 28 (14.0) 35 (20.0)
Good 98 (17.0) 32 (16.0) 32 (16.0) 34 (19.3)
Ok 128 (22.2) 51 (25.5) 62 (31.0) 15 (8.5)
Poor 57 (9.9) 18 (9.0) 37 (18.5) 2 (1.1)
Confidence filling out medical
forms*

Extremely 215 (37.3) 95 (47.5) 46 (23.0) 74 (42.1)
Quite a bit 149 (25.9) 31 (15.5) 71 (35.5) 47 (26.7)
Somewhat 109 (18.9) 42 (21.0) 34 (17.0) 33 (18.8)
A little 78 (13.5) 21 (10.5) 41 (20.5) 16 (9.1)
Not at all 21 (3.7) 9 (4.5) 7 (3.5) 5 (2.8)
67
Retailer perceived benefits of selling tobacco products
Table 8 shows frequencies of how the retailers perceived tobacco products. Few retailers
in the HL (5%) communities regarded tobacco as their main source of revenue compared to AA
(11.5%) and NHW retailers (21.6%). Marlboro was the most commonly sold brand for the
majority of NHW (86.5%) and HL (90.5%) retailers, while a significantly lower amount of AA
(24.5%) retailers reported it as the best seller (p<0.01). Less than half HL retailers reported that
cigarettes and cigarillos made at least a little money for their store. Over two-thirds of retailers in
each the NHW and AA communities however, reported that the two products made at least a
little money for their stores. Retailers who displayed promotions (1.98 ±1.11) on the interior of
their store had a significantly higher mean score (t=-10.14, p<0.01) for the perceived benefits
scale compared to those who did not (1.16, ±0.84).

68
Table 8: Retailers’ perceptions of tobacco sales
Overall
N (%)
African
American
N (%)
Hispanic
N (%)
Non-
Hispanic
White
N (%)
Business’ main revenue source*
Alcohol 139 (24.1) 49 (24.5) 56 (28.0) 34 (19.3)
Tobacco 71 (12.3) 23 (11.5) 10 (5.0) 38 (21.6)
Mix of Alcohol & Tobacco 5 (0.9) 3 (1.5) 0 (0.0) 2 (1.1)
Food 205 (35.6) 78 (39.0) 79 (39.5) 48 (27.3)
Non-alcoholic beverages 46 (8.0) 12 (6.0) 22 (11.0) 12 (6.8)
Gas 68 (11.8) 21 (10.5) 20 (10.0) 27 (15.3)
General Merchandise 29 (5.0) 11 (5.5) 10 (5.0) 8 (4.5)
Perceived retail benefit of cigarettes*
Makes a lot of money 80 (13.9) 33 (16.5) 12 (6.0) 35 (19.9)
Makes a little money 292 (50.8) 101 (50.5) 87 (43.5) 104 (59.1)
Revenue neutral 137 (23.8) 51 (25.5) 65 (32.5) 21 (11.9)
Loses money 36 (6.26) 10 (5.0) 18 (9.0) 8 (4.5)
Don’t’ sell 12 (2.1) 3 (1.5) 5 (2.5) 4 (2.3)
Perceived retail benefit of cigarillos*
Makes a lot of money 102 (17.8) 61 (30.5) 14 (7.0) 27 (15.3)
Makes a little money 271 (47.4) 92 (46.0) 82 (41.2) 97 (55.1)
Revenue neutral 77 (13.5) 22 (11.0) 38 (19.1) 17 (9.7)
Loses money 34 (6.0) 10 (5.0) 20 (10.1) 4 (2.3)
Don’t sell 79 (13.8) 13 (6.5) 37 (18.6) 29 (16.6)
Perceived retail benefit of e-cigarettes*
Makes a lot of money 26 (4.7) 6 (3.0) 2 (1.0) 18 (10.2)
Makes a little money 98 (17.6) 20 (10.0) 12 (6.0) 66 (38.6)
Revenue neutral 64 (11.5) 17 (8.5) 15 (7.5) 32 (18.2)
Loses money 33 (5.9) 22 (11.0) 9 (4.5) 2 (1.1)
Don’t sell 329 (59.1) 128 (64.0) 150
(75.0)
51 (29.0)
Noticed rise in sales of e-ecigs* 62 (10.8) 13 (6.5) 10 (5.0) 39 (22.2)
Most commonly sold tobacco brand*
Kool 22 (3.8) 21 (10.5) 1 (0.5) 0 (0.0)
Marlboro 382 (66.3) 49 (24.5) 181
(90.5)
152 (86.4)
Newport 126 (21.9) 115 (57.5) 11 (5.5) 0 (0.0)
* X2 test p<0.01
Retailers’ Knowledge and Attitudes of the FDA
Table 9 presents data on the retailers’ knowledge and attitudes of the FDA. Most of the
retailers were aware of the FDA and could correctly identify its logo. However, less than half of
69
retailers in AA and HL knew that the FDA regulated tobacco products. Less than half (39.2%) of
all the retailers believed that other retailers would be aware that the FDA regulates tobacco
products. Most retailers had positive attitudes towards the FDA with two-thirds of those retailers
who responded saying that the FDA had the right to regulate tobacco products and 58.6%
reporting that they were trustworthy. Between communities the proportions were similar for
those finding the FDA trustworthy (NHW: 62.6%, HL: 57.4%, AA: 56.3%) and agreeing that
they had the right to regulate (NHW: 71.6%, HL: 66.3%, AA: 69.0%).
Table 9: Retailers’ Knowledge and Attitudes of the FDA
Overall
N (%)
African
American
N (%)
Hispanic
N (%)
Non-
Hispanic
White
N (%)
Seen FDA logo 396 (69.8) 142 (71.4) 120 (61.9) 134 (77.0)
Correctly named FDA* 164 (28.5) 62 (31.0) 35 (17.5) 67 (38.1)
Heard of FDA before 425 (74.6) 153 (76.5) 125 (63.8) 147 (84.5)
Does FDA regulate tobacco products* 296 (51.4) 89 (44.5) 95 (47.5) 112 (63.6)
FDA has right to regulate tobacco
products
385 (68.9) 136 (69.0) 128 (66.3) 121 (71.6)
Is FDA trustworthy for tobacco rules
info*

Yes 334 (58.6) 112 (56.3) 113 (57.4) 109 (62.6)
Do other retailers know FDA regulates
tobacco products

Yes 222 (39.2) 85 (42.7) 73 (37.6) 64 (36.8)
No 103 (18.2) 35 (17.6) 39 (20.1) 29 (16.7)
Don’t know 242 (42.7) 79 (39.7) 82 (42.3) 81 (46.6)
How do you find out about banned
products

FDA 87 (15.1) 20 (10.0) 34 (17.0) 33 (18.8)
Tobacco Companies 87 (15.1) 26 (13.0) 32 (16.0) 29 (16.5)
Tobacco Distributors 70 (12.2) 18 (9.0) 30 (15.0) 22 (12.5)
Not aware of banned products 150 (26.0) 60 (30.0) 54 (27.0) 36 (20.5)
Received regulatory info directly from
FDA

Yes 172 (29.9) 39 (19.5) 65 (32.5) 68 (38.6)
No 253 (43.9) 111 (55.5) 76 (38.0) 66 (37.5)
Don’t Know 146 (25.4) 48 (24.0) 57 (28.5) 41 (23.3)
* X2 test p<0.01
70
Store Characteristics
Overall a third of the tobacco retail outlets were identified as convenience stores, 27.3%
as a grocery store and 13.9% as a liquor store. Only 9% of the shops were identified by the
CHW’s as tobacco shop. HL communities had the lowest proportion of tobacco shops (2.1%)
and highest proportion of grocery stores (40.2%) while NHW had the highest proportions of
tobacco shops (18.4%) and the lowest proportions of grocery stores (14.2%). Approximately half
of all retailers sold alcohol in their stores. AA retailers had the lowest proportion of stores
selling alcohol compared to at least half of NHW and HL retailers. Just under half of the retailers
(45.0%) displayed both their California and Los Angeles tobacco license in their store but only
9.1% displayed the Prop 65 warning signs about the health effects of tobacco. Table 10 further
details frequencies of these store characteristics broken down by the different communities.

71
Table 10: Store Characteristics
Overall
N (%)
African
American
N (%)
Hispanic
N (%)
Non-Hispanic
White
N (%)
Store Type
Convenience 212 (36.8) 74 (37.6) 63 (33.3) 75 (41.6)
Liquor 80 (13.9) 25 (12.9) 24 (12.0) 31 (17.6)
Grocery 157 (27.3) 57 (29.4) 75 (37.5) 25 (14.2)
Discount 36 (6.3) 17 (8.5) 17 (8.5) 2 (1.1)
Tobacco 52 (9.0) 17 (8.5) 4 (2.0) 31 (17.6)
Alcohol sold here 279 (50.1) 117 (60.3) 77 (41.2) 85 (49.4)
California tobacco license posted 349 (63.3) 134 (69.1) 110 (59.4) 105 (62.4)
L.A city tobacco licensed posted* 276 (49.9) 117 (60.3) 73 (38.8) 86 (50.0)
Prop 65 warning sign 50 (9.1) 16 (8.4) 15 (8.6) 19 (11.1)
Posted Age of Sale signs posted
inside

Tobacco Industry: We Card* 178 (32.1) 49 (25.8) 53 (28.8) 76 (44.3)
State of CA: 1-800-5Ask ID* 388 (70.3) 139 (72.1) 132 (71.0) 117 (67.4)
Posted Age of Sale signs posted
outside

Tobacco Industry: We Card* 144 (26.1) 139 (18.6) 37 (20.3) 71 (41.6)
State of CA: 1-800-5Ask ID* 101 (18.3) 30 (15.5) 26 (14.4) 45 (23.3)
Retailer asked for ID to purchase
tobacco

No tobacco customers 320 (58.3) 98 (51.3) 128 (68.6) 94 (54.0)
Yes 40 (7.3) 13 (6.8) 11 (5.9) 16 (9.0)
No 68 (12.4) 47 (24.1) 14 (7.5) 7 (4.2)
Customer appeared over 27 112 (20.4) 29 (15.2) 30 (16.0) 53 (31.2)
* X2 test p<0.01
Tobacco product placement and promotion
Less than 5% of all retailers had open packs of cigarettes (3.6%), packs with less than 20
cigarettes (1.6%), or samples of cigarettes available (0.4%). 15.6% of all retailers had a display
for cigarettes within twelve inches of child related items. There was a significantly (p<0.001)
higher proportion of retailers in AA communities that had cigarettes (23.7%) and cigarillos
(40.7%) displayed within twelve inches of child related items compared to HL (11.7% & 22.8%)
and NHW (14.7% & 6.3%) retailers. Less than half (42.4%) of the retailers had at least one
exterior ad for a tobacco product.
72
Table 11 provides further details on the differences between communities on tobacco
product placement and promotion. HL communities had the lowest proportions of retailers that
displayed exterior ads for tobacco products (e.g., cigarettes, menthol cigarettes, cigarillos, and e-
cigarettes) compared to AA and NHW retailers. In regards to the second hypothesis, there were
no significant associations found between the retailer’s tobacco use and the display tobacco
product promotions or ads. The mean cigarette pack price was $4.87 (±$1.13) for all stores
observed and the mean price for a pack of menthols was $4.98 (±$1.14).
Table 11: Tobacco Product Promotion and Placement
Overall
N (%)
African
American
N (%)
Hispanic
N (%)
Non-Hispanic
White
N (%)
Products within 12” of child related items
Cigarettes (all types) * 86 (15.6) 46 (23.7) 22 (11.7) 18 (10.6)
Cigarillos* 148 (26.7) 79 (40.7) 43 (22.8) 26 (15.1)
E-cigarettes* 41 (7.4) 12 (6.2) 3 (1.6) 26 (15.8)
Ads within 3’ of the ground
Cigarettes (all types) * 104 (18.9) 49 (25.3) 17 (9.1) 38 (21.7)
Cigarillos* 63 (11.4) 39 (20.1) 15 (8.0) 9 (6.3)
E-cigarettes* 39 (7.0) 16 (8.3) 5 (2.7) 18 (10.5)
Products advertised on the exterior
Cigarettes (non-menthol)* 193 (35.0) 79 (40.7) 40 (21.3) 74 (43.1)
Cigarettes (menthol)* 168 (30.4) 82 (42.5) 29 (15.3) 57 (31.6)
Cigarillos** 94 (17.0) 63 (32.5) 16 (8.5) 15 (9.0)
E-cigarettes* 67 (12.2) 28 (14.5) 12 (6.5) 27 (14.8)
Price promotions
Cigarettes* 202 (36.6) 76 (39.2) 43 (22.9) 83 (47.1)
Menthol Cigarettes* 180 (32.6) 66 (34.0) 38 (20.3) 76 (44.2)
Multipacks 54 (9.8) 10 (5.2) 21 (11.2) 23 (13.4)
Cigarillos* 106 (19.2) 33 (17.0) 22 (11.6) 51 (29.1)
E-cigarettes 28 (5.1) 9 (.7) 9 (4.8) 10 (5.9)
Lowest priced product (Mean)
Cigarettes 4.87
(±1.13)
4.58
(±0.98)
5.05
(±1.23)
5.01
(±1.11)
Newport Menthol 6.39
(±0.79)
6.18
(±0.79)
6.55
(±0.71)
6.50
(±0.82)
Menthol Cigarettes 4.99
(±1.14)
4.67
(±0.99)
5.15
(±1.23)
5.18
(±1.13)
E-cigarettes 8.65
(±2.95)
9.08
(±3.81)
7.92
(±2.03)
8.63
(±2.56)
* X
2
test p<0.01

73
Logistic Regression Analysis

Unadjusted logistic regression showed that perceived benefits of selling tobacco, having
promotional materials displayed, having exterior ads for tobacco products, and store type were
all significantly associated with tobacco policy compliance. The results of the adjusted logistic
regression are presented in Table 12. The final model included perceived benefits of selling
tobacco, having promotional materials displayed, having exterior ads for tobacco products, and
store type as predictors. Gender, age, level of education, and length in the U.S. were also
included as covariates in the model. Goodness of fit statistics revealed that the model did not
deviate (Pearson X
2
=449.4, p>0.05; Hosmer-Lemeshow X
2
=4.3, p>0.05). The odds of being
non-compliant with tobacco policy for those with promotional materials were 1.86 (95% CI:
1.41, 2.96) times those without promotional materials displayed when holding all other variables
constant. Retailers who had exterior ads for tobacco products had 2.20 (95% CI: 1.11, 4.34)
higher odds of being non-compliant compared to those without exterior ads. The only store type
that had a significant association with tobacco policy compliance was discount stores that had
64% (lower odds of being non-compliant compared to the other store types. When placed into
the model perceived retail benefits of selling tobacco products no longer had a significant
association with tobacco policy compliance.

74
Table 12: Adjusted Logistic Regression
OR (95% CI)
Perceived benefits of tobacco products 1.06 (0.76, 1.49)
Display of promotional materials 1.92 (1.30, 2.82)
Display of exterior ads 1.98 (1.03, 4.01)
Community
NHW 1.00
AA 2.57 (1.17, 5.67)
H/L 1.39 (0.66, 2.92)
Store Type
Convenience 1.00
Liquor 0.98 (0.36, 2.66)
Grocery 0.55 (0.27, 1.14)
Discount 0.36 (0.13, 0.98)
Tobacco 0.44 (0.14, 1.39)
Age 1.01 (0.98, 1.03)
Education 1.16 (0.92, 1.48)
Length of time in the U.S. 0.87 (0.67, 1.12)
Gender 1.10 (0.64, 1.88)
Bold font indicates significance (p<0.05)
Community Differences in Compliance
Unadjusted analysis for each community showed that retailers in AA and HL
communities had a significant association with being non-compliant but NHW retailers did not
have a significant association. In the adjusted model, the retailers in AA communities maintained
significant association with non-compliance. The stores in AA communities had approximately
two and half times the odds (95% CI: 1.17, 5.67) of being non-compliant compared to stores in
the NHW communities. Stores that had discordance between the racial identities of the
community and the retailer did not have a significant association with non-compliance. There
were 44.1% of stores who had a retailer of a different racial identity from the community they
served but only 15.8% of those stores were not in compliance.
Role of store position on the relationship with compliance
Understanding that clerks are less likely to have a role in deciding the practices of a
tobacco retail outlet we examined how the associations with compliance changed when only
75
excluding them from the analysis. The odds of non-compliance increased for stores in AA
communities by 60% to 3.21 (1.24, 8.26) compared to the odds of non-compliance in NHW
communities. The odds of being non-compliant decreased for by approximately 40% for stores
who displayed price promotions to 1.52 (95% CI: 1.02, 2.30). The odds of being non-compliant
for stores who have exterior ads increased by 34% to 2.32 ( 95% CI: 1.03, 5.43). The significant
association between non-compliance and being a discount store was no longer present. All of the
other variables in the model remained non-significant. There was also no significant relationship
between owners/managers that identified as a different race than the community they serve.
Discussion
This study documented the level of compliance among independent retailers in three
communities and variables that are associated with tobacco policy compliance. Variation in
compliance between racial/ethnic communities is of concern as it contributes to the existing
tobacco use disparities (Haskins, 2017; Lee, Baker, et al., 2015; Ribisl et al., 2017). While
smoking rates have continued to decrease the rates for those living in communities that are
predominantly low SES and have a high proportion of racial/ethnic minorities continue to be
considerably higher (Haskins, 2017). These disparities if allowed to persist are further
concerning since the populations affects face higher burdens of tobacco related disease (Fagan,
Moolchan, Lawrence, Fernander, & Ponder, 2007; U.S. Department of Health and Human
Services, Public Health Service, 2014). Research has continued to show that the retail
environment plays large role in the continuance of these disparities, but little research has been
investigated what contributes to a retailer’s compliance with tobacco policy. The examination of
compliance at different ecological levels (micro, meso, and exo) as presented in this research is
76
beneficial to the regulation of tobacco given the complexities of the retail environment. Figure 3
shows the resulting theoretical model from this study.
While the analyses and resulting model indicate that micro level variables (attitudes
towards the FDA, knowledge of the FDA, and tobacco product use) do not have a significant
association with tobacco retailer non-compliance further study is warranted based on other
findings from this study. For instance we also examined the role of discordance in the
racial/ethnic identity of the retailer and the community they serve. The results showed that there
was no significant association with non-compliance based on this discordance. Interestingly
however, AA communities were more likely to have a retailer of different race/ethnicity. Given
that this community had higher odds of having non-compliant retailers it will be necessary to
further investigate other factors that could influence this association. For instance it could be that
materials from regulatory agencies for these retailers are sent in culturally relevant manners for
the community they serve but not for the retailer. This study also found low levels of literacy for
certain communities so it will also be important that regulatory agencies create materials that
depend more on graphics rather than text to deliver the messages.
Another micro level variable of interest was store position. The odds of non-compliance
changed for some of our variables of interest when we excluded clerks from the analysis. The
odds of non-compliance increased for AA communities. In all communities each store position
was represented by approximately 30% of the sample so it would not be that AA stores were
over-represented by one type of position. It is likely that the owners or managers at these stores
are the ones likely making decisions on product placement and promotion that contributes to
non-compliance. In examining the only action a clerk would be responsible for, asking customers
for their id to purchase tobacco, there were no significant differences between store positions.
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This could also indicate the increased involvement of the tobacco industry with stores in AA
communities. Future research will have to attempt to decipher why this increased odds occurred
for AA communities and examine the amount of communication these retailers have with
tobacco industry representatives and distributors. Again it will be important for the FDA and
other regulatory agencies to create messages that are culturally appropriate for the retailer but
reflect the relevant issues for the community they serve.
Also at the micro level is the role of literacy versus language usage among the retailer.
The majority of retailers in this study indicated that they primarily used English at home but
when asked about their comfort filling out forms in English very few indicated high levels of
confidence. This will be important for the FDA to consider as they design educational materials
and campaigns explaining policy to the retailers. It might be necessary to depend more on
infographic types of materials that can be easier to understand for different levels of literacy.
This will be important for all types of communications from the FDA including Internet based
websites and social media. The FDA and other regulatory agencies will have to also keep this in
mind when also working with NHW communities. In our sample there were a large proportion of
NHW retailers who did indicate high levels of English language literacy levels. Further, nearly
40% of the NHW retailers were not educated in the U.S. so it cannot be assumed that they can
easily understand regulatory messages presented in English. Our study also found that currently
e-cigarettes were sold more in NHW communities. Therefore it will be important moving
forward that the FDA communicates effectively with these retailers as they continue to increase
regulation on e-cigarettes.
At meso level the perceived benefits of selling tobacco products will need further
investigation, as this was significant in the unadjusted model but not the adjusted model. This is
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also important for the FDA as many retailers might see tobacco products as beneficial since they
are not fully aware of the regulations or the consequences of non-compliance. This was
expressed in the focus groups presented in Study 1. The KOL’s felt that many retailers engaged
in non-compliant behaviors since they were not fully aware of the consequences and felt the risk
was worth it due to the low profit margins of independent retailers. The display of price
promotions was significantly associated with non-compliance, which could also indicate the
involvement of the tobacco industry. Moving forward the public health researchers will have to
help better inform the FDA and other regulatory agencies on how the retailers are deciding to
offer and display price promotions. This information will help the FDA better regulate stores as
they conduct their inspections.
While there have been some studies on tobacco retailer compliance with tobacco
regulatory policies there has been no research done on this subject matter with independent
retailers. Previous research has shown that lower SES and racial/ethnic dominant communities
tend to have a higher prevalence of independent retailers (Silver et al., 2015). In assessing the
perceptions of the retail effects of tobacco products among independent retailers (in bodegas and
corner stores), these findings can help create educational campaigns and other interventions.
Addressing these perceptions could also increase compliance among retailers. Understanding the
relationship between these perceptions and the presence of promotional and regulatory materials
will help regulatory agencies target their messaging for independent retailers in ethnically
diverse communities. It could also help regulators determine the amount of licensure and other
regulatory costs that could make retailers reassess the perceived retail benefits of tobacco
products.
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This study did not find significant associations between retailers’ related exo-level
variables and non-compliance. Future research will need to investigate how other exo-level
variables play a role in retailer compliance. Variables such as the demographic profile of the
neighborhood. Other studies have shown that neighborhoods with higher amounts of youth and
low SES members have higher amounts of tobacco ads and prevalence of consumption (L
Henriksen et al., 2004; Lee et al., 2017). Variables that could be regulated such as proximity to
schools and other youth oriented locations should also be examined as there is evidence of high
prevalence of tobacco promotion at the point of sale in stores closer to schools (Cantrell et al.,
2013; Lee, Henriksen, et al., 2015; Widome, Brock, Klein, & Forster, 2012). Given that youth
tend to be more price conscious it will also be important to investigate if the sell single cigarettes
are more prevalent in these areas. Further there is indication that the FDA might further regulate
cigars and cigarillos. These products are sometimes sold individually and in our study were
shown to be displayed near child related items so future research investigating their prevalence in
communities with high amounts of youth can also help inform future FDA regulatory actions.
Limitations
The present study has some limitations that should be noted. First, this study is cross
sectional in design limiting the ability to assess the differences in awareness over time. Since
2009, the FDA and other regulatory agencies have been making efforts to reach retailers. New
regulations have also been implemented in the past three years including the FDA’s deeming rule
on electronic cigarettes and the State California raising the minimum tobacco purchase age from
eighteen to twenty-one. There have also been many changes in the retail environment with new
products coming to the shelves. The lack of longitudinal data in this study will not allow us to
assess the effects of these changes on the awareness of tobacco retailers in regards to tobacco
80
policy. Another limitation in this study is that it only provides data for independent retailers in
the Los Angeles Area. This limitation will not allow account for regional differences in the
tobacco retail environment. The tobacco regulatory climate in California is more active than
most other states so the results here might not apply to other states with much lower regulatory
efforts.
The lack of more detailed information on the promotional materials does not allow us to
determine if different messages are provided to the different communities in our sample. There
is documented evidence (Dauphinee et al., 2013; Lee, Henriksen, et al., 2015; Ribisl et al., 2017;
Widome et al., 2013) that this occurs so this should also be assessed among independent
retailers. In regards to the effect of tobacco products on business revenue, it is not possible to
completely assess the perceptions without knowing the profits gained from tobacco sales among
the retailers in our sample. This information is implied with the current questioning but data on
actual sales among independent retailers will help mitigate these perceptions and their effect on
the presence of promotional and regulatory messages. Information is also needed on the retailer’s
sources of promotional materials and what instructions they have received on how to display
these materials. There is also a lack of measurement regarding retailer attitudes towards tobacco
products. Measuring retailer attitudes towards tobacco products would assist in creating a clearer
understanding on the effects of the personal influences on retailer practices and compliance. It
would also help to capture how those who do not use tobacco products view them and if this
would affect their practices or compliance.
Conclusions
The results from this study help present factors that influence independent tobacco
retailers’ compliance with tobacco regulation. By presenting a model with personal,
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environmental, and behavioral influences; regulatory agencies and public health professionals
gain a new insight onto how to increase compliance. The results also inform regulators of
differences between communities in regards to tobacco policy compliance. Beyond presenting
data from multi-ecological levels and using community based approaches this study is unique.
These two approaches allowed the data to present a complete picture into the communities and
thus aid the FDA, other regulatory agencies, and other public health stakeholders and best
approaches on addressing tobacco regulation and disparities in vulnerable communities. This
information will help to highlight the need for culturally and language responsive and
appropriate, policy and behavior interventions for retailers. The study helps inform interventions
that would occur at the exo-level but need to be delivered with consideration of meso and micro
level variables.

82
Figure 3: Final Ecological Model
(Shaded areas indicate non-significant associations)

ExoSystem Factors
Store
Revenue
Top Selling
Product
KOL
Attitudes
toward
FDA/Policy
KOL
Knowledge
of
FDA/Policy
MesoSystem Factors
Display of
Promotional
Materials
Perceived
Retail Benefits
of Selling
Tobacco
Microsystem & Individual Retailer Factors
Knowledge of
FDA/Tobacco
Policy
Attitudes
towards
FDA/Tobacco
Policy
Tobacco
Product Use
Retailer
Compliance with
Tobacco
Regulation
OUTCOME
83
CHAPTER 4: Conclusions
Overall
Take together these studies provide useful data for regulatory agencies as they approach
independent retailers located in racial/ethnic communities. Study 1 found that the levels of
distrust towards the FDA are a satiated theme in African-American communities. The KOL’s
however, expressed an interest in collaborating with the FDA in its mission to regulate tobacco
products in the retail environment. The studies also found that most retailers had knowledge of
the FDA but only NHW’s had a majority that knew of their role in regulating tobacco products
similar to the findings from the KOL focus groups. As the FDA continues their attempts to
further regulate tobacco products much work will fall onto state and local agencies. The data
presented here will also be informative to them as they have the most direct contact to local
independent retailers. The KOL’s expressed the need for more local intervention with tobacco
retailers. Recently there have been some national studies on the tobacco retail environment and
they show that issues regarding tobacco product advertising and retailer practices vary by region
and community (Lee et al., 2017; Ribisl et al., 2017). It will then be important for the FDA to
partner with local agencies so that any approach with retailers is relevant to their situation, which
can lead to higher compliance rates.
A key finding of these studies was the disparity in the odds of non-compliance between
the represented racial/ethnic communities. In line with current and past research African-
American communities remain at the highest risk for exposure to tobacco products (Dauphinee et
al., 2013; Henriksen et al., 2017; Lee et al., 2017; Ribisl et al., 2017; Widome et al., 2013).
Interesting though in our study was that most of the retailers in African-American communities
were of a different racial/ethnic background. Further investigation into whether this discordance
84
in racial/ethnic background could play a role in retailer practices is warranted. Approximately
one-fifth of the retailers from AA communities indicated that they received regulatory
information from the FDA. Further outreach is needed towards retailers in these communities as
they face a higher burden of tobacco use disparities.
The need for materials to be presented in culturally and linguistically relevant manner
was also identified through these studies. In the KOL focus groups they were identified how
many retailers in their communities were foreign born and might not understand how to comply
with tobacco regulations or be able to understand messages communicated to them by regulatory
agencies. Our data from the retailers showed that while many said they could read in English
well there were also several who did not speak English at home. The retailers in our study also
varied in their educational attainment but over half completed their highest level of education
outside of the U.S. This highlights the need for regulatory messaging to be delivered in a manner
that is easy to understand and not presented in an overwhelming manner (e.g., a page full of text
in small font). Cultural adaptations have been shown to be effective for other types of
interventions and educational campaigns (Castro, Barrera, & Holleran Steiker, 2010; Gonzales,
2017; Wallace, Fulwood, & Alvarado, 2008) so they could be used in the context of tobacco
regulatory efforts. By doing these adaptations the FDA and other regulatory agencies would
demonstrate that they are invested in ensuring retailers are in compliance.
Community-based approaches to tobacco regulation
Unique to these studies was the use of community-based approaches in tobacco
regulation research. Further, utilizing both CHW’s and KOL’s allowed the researchers a clearer
window into the tobacco retail environment in vulnerable communities. The use of CHW’s
provided a more detailed and nuanced view of the communities in where data was collected. The
85
CHW’s increased participation by providing research staff with viability of recruiting from
certain neighborhoods. For instance, during data collection the CHW’s advised the research staff
that one area might not be welcoming to the study since they were experiencing tensions
regarding race relations. The KOL’s provided a wide view of their communities that allow
researchers to understand overarching themes. While the use of KOL’s has been documented
(Schuster et al., 2006; Valente, 2017) in tobacco control and tobacco use intervention research
there was limited research in their role in tobacco regulation. Understanding their views
regarding tobacco regulation aids in the development in outreach programs by regulatory
agencies as they have the interests of the entire community in mind. Further, the use of KOL’s in
this study identified potential partners for the FDA and other agencies as they move forward to
regulate tobacco products.
Moving forward the use of similar and other community-based approaches can be another
tool in public health and regulatory agencies mission to reduce tobacco use disparities. There is
well-documented use of CHW’s in health promotion activities (Balcázar et al., 2010; Johnson,
Sharkey, Dean, St John, & Castillo, 2013; Manzo, Rangel, Flores, & de la Torre, 2017; Medina,
Balcázar, Hollen, Nkhoma, & Mas, 2007) but there is limited research on their use in data
collection and more research roles. Study 2 demonstrated the successful use of training and
monitoring practices in the use of CHW’s while adhering to strong research protocols. Though
not assessed in the current studies it is possible that the inclusion of CHW’s also aids in their
awareness of tobacco regulatory issues. This awareness could lead in their engagement to aid
regulatory agencies in their efforts regarding tobacco products, therefore leading to greater
community buy-in.

86
Future Directions
It will be important for public health and regulatory agencies to identify new approaches
to address tobacco use disparities among racial/ethnic minorities. Recent research continues to
document the disparities in tobacco products’ advertising, price promotions, and retailer density
(Henriksen et al., 2017; Lee et al., 2017; Primack, Bost, Land, & Fine, 2016; Ribisl et al., 2017).
Further regulation on advertising is likely to be hard to implement based on past court cases but
there are some successful examples of limiting price promotions in other municipalities and
should be explored further at the federal level (Henriksen et al., 2017). Lee and colleagues also
found that areas with lower tobacco retailer density also had a lower amount of price promotions
across racial/ethnic communities (Lee et al., 2017). This finding warrants further investigation of
how policies regulating tobacco sales in proximity to schools and other sensitive locations can be
used to decrease retailer density.
Since the enactment of the FSPTCA there have been several efforts to understand how
tobacco products can be better regulated. The FDA has provided several avenues for research
funding and much has been learned about tobacco products and their promotion and sale.
However, there is a need more intervention research to be conducted with vulnerable
communities, particularly independent retailers. They are a group that a unique need in
complying with tobacco regulations but also in maintain a business that can sustain their
families.
It will be important to engage tobacco retailers in future research, public health
campaigns, and regulatory educational programs. The KOL’s in our study indicated that retailers
were likely more concerned with their bottom line rather than making sure they were in
compliance. Educating retailers on the consequences of non-compliance could also help ensure
87
they are not putting their store at risk. Retailers should also be engaged so they can understand
the impact that tobacco products have on their community. Any program with retailers should
aim to motivate retailers to limit tobacco product access to youth as most smokers begin before
the age of 18 (Centers for Disease Control and Prevention, 2012). It will be necessary though for
public health professionals to understand how independent retailers operate to ensure that they
can maintain a viable business. Including retailers in community advisory boards to help inform
any research or intervention aimed towards them could expand the community-based approaches
used in this study. The inclusion of retailers would not only increase buy-in to regulatory actions
and programs but also empower them to identify new ways they can help to address tobacco use
disparities.
The tobacco product environment continues to evolve with electronic nicotine delivery
devices and other innovations. Altria Phillip Morris for instance recently applied to the FDA’s
Tobacco Product Scientific Advisory Committee, TPSAC, for their new product, IQOS, which
they are calling a smoke free, heated tobacco product. Though this product’s application was not
recommended for approval for by the TPSAC, Altria Phillip Morris has begun to announce that
they are moving away from cigarettes. It will be important for all those with an interest in
reducing tobacco use and related disparities to stay vigilant in order to respond promptly to new
tobacco industry products and tactics.
Challenges in regulating tobacco products and addressing tobacco use disparities will
persist but addressing these should not fall solely to the FDA. While they will play a key role in
regulation they will be limited by their mandate in the FSPTCA and continued use of legal action
by the tobacco industries. It will also fall to local agencies and public health professionals to
work in collaboration with retailers and other stakeholders. The smoking rates have continued to
88
drop overall but progress has not been equally achieved. Many disparities persist and addressing
retail environment has been documented as a key avenue to achieve equity in tobacco prevention
and control (Henriksen et al., 2017; Lee et al., 2017; Ribisl et al., 2016, 2017). Public health
professionals will have to continue to monitor the retail environment in order to keep up with
changes in products and practices. The identification independent retailers as vulnerable
population and the use of community-based approaches when working with them has the
potential to generate the changes necessary to reduce tobacco use disparities. These changes will
allow for the youth in the affected communities to develop in a healthier manner by limiting their
burden of tobacco-induced disease.

89
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APPENDIX: SURVEY INSTRUMENTS

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TCORS PROJECT 2 - Focus Group
Anchoring Survey

Instruction
Thank you for taking the time to complete this survey. The survey should take about 10 minutes
to complete. If there are any questions you do not feel comfortable answering, you can skip those
questions. You can also stop at any time. Please DO NOT write your name on this survey. The
answers you provide will be kept completely confidential. There are no right or wrong answers.

1) What is your gender?
❑ Male
❑ Female
❑ Other (Please specify) __________________

2) What is your age? ___________

3) In what country were you born?
❑ Africa (Please specify) __________________
❑ Korea
❑ Latin America (Please choose one)
❑ Mexico
❑ Central America
❑ South America
❑ United States of America or United States (U.S.)
❑ Other (Please specify) __________________

4) If not born in the U.S., how long have you been in the U.S.?
❑ 5 years or less
❑ 6 years to 10 years
❑ 11 years to 20 years
❑ 20 years or more
❑ I don’t know

5) What language do you mainly speak at home? (Pick one)
❑ English
❑ Korean
❑ Spanish
❑ Other (Please specify) ______________________
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5a) What other languages do you speak at home? (Check all that apply)
❑ English
❑ Korean
❑ Spanish
❑ Other (Please specify) ______________________

6) How well do you speak English?
❑ Very well
❑ Well
❑ Not well
❑ Not at all

7) What is your race? (Check all that apply)
❑ African American or Black
❑ African
❑ American Indian or Alaska Native
❑ What is your tribe(s)? :_______________________
❑ Asian
❑ Asian Indian
❑ Chinese
❑ Filipino
❑ Japanese
❑ Korean
❑ Vietnamese
❑ Other Asian: (Please specify) ______________________
❑ Hispanic/Latino
❑ Native Hawaiian and/or Other Pacific Islander
❑ White

8) In what city do you currently live?
City: ______________________________
Zip code: ____________
9) Do you live on a reservation/Rancheria/tribal land?
❑ Yes
❑ No
9a) If “Yes,” please specify the name of the reservation/Rancheria/tribal land where you live:
_________________________________________________
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10) In what city do you currently work?
City: ______________________________
Zip code: ____________

11) Would you say the neighborhood you live in is predominantly...(Check all that apply)
❑ African American
❑ American Indian
❑ Hispanic/Latino
❑ Korean
❑ White – European American
❑ Mixed race (Please specify) ____________
❑ Other (Please specify) ____________

12) What is your current job? (Check all that apply)
❑ Business (For example: business owner, entrepreneur, accountant, sales man)
❑ Education (For example: school board member, teacher, principal, school aid)
❑ Government (For example: city council member, city clerk, politician)
❑ Health (For example: nurse, doctor, health educator, social worker)
❑ Media (For example: news anchor, journalist, blogger, reporter)
❑ Religious (For example: priest, pastor, chaplain, rabbis, monk, nun)
❑ Service (For example: waiter, clerk, bank teller)
❑ Other (Please specify) ____________ (For example: carpenter, student)

13) How long have you lived in your current community?
❑ Less than a year
❑ 1 to 3 years
❑ 4 to 6 years
❑ 7 to 9 years
❑ 10 to 12 years
❑ 13 to 14 years
❑ 15 years or more
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14) How knowledgeable do you feel about your community?
❑ Very knowledgeable
❑ Moderate knowledgeable
❑ Somewhat knowledgeable
❑ Not at all knowledgeable
❑ Don’t know
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15) In the community you work with, do you work mostly with: (Check all that apply)
❑ African Americans
❑ Hispanic/Latino
❑ Asian American
❑ Pacific Islander
❑ American Indian
❑ Caucasian (White)
❑ Lesbian, Gay, Bisexual, and Transgender
❑ Low Income
❑ Labor
❑ Rural
❑ Mental Health
❑ Other (Please specify) _______________

We are almost done, but want to ask you several questions regarding tobacco products and your use.
There are no right or wrong answers. Please complete to the best of your ability.

16) Do you currently smoke cigarettes?
❑ Yes
❑ No

17) Do you currently “vape” ” or use any kind of electronic cigarette and/or electronic hookah?
❑ Yes
❑ No

For the next set of questions, please think about the community you live in when responding.

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18) Do you visit retail shops in your community that sell tobacco?
❑ Yes
❑ No

19) What do you think about the number of tobacco retail shops in your community? Would you
say there are:
❑ Far Too Many
❑ Too Many
❑ About Right
❑ Too Little
❑ Far too Little

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20) What do you think are the effects of the following products on people in your community?

Very
Harmful
Harmful Neutral Beneficial
Very
Beneficial
Don’t know/
Not sure
Cigarettes

❑

❑ ❑ ❑ ❑ ❑
Cigarillos or Little
Cigars

❑

❑ ❑ ❑ ❑ ❑
Cigars

❑

❑ ❑ ❑ ❑ ❑
Electronic
Cigarettes/Vape
Pens

❑

❑ ❑ ❑ ❑ ❑
Smokeless
Tobacco

❑

❑ ❑ ❑ ❑ ❑

109

Yes Somewhat A Little No
21) Are you aware of the
different tobacco control
laws in place within your
local community?

❑

❑ ❑ ❑
22) Are you aware of the
different tobacco control
laws in place within your
city?

❑

❑ ❑ ❑
23) Are you aware of the
different tobacco control
laws in place within your
county?

❑

❑ ❑ ❑
24) Are you aware of the
different tobacco control
laws in place within your
state?

❑

❑ ❑ ❑

25) How well informed do you think tobacco retailers in your community are regarding tobacco
control laws and regulations?
❑ Very well informed
❑ Well informed
❑ Moderately informed
❑ Not well informed
❑ Not informed at all

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26) How compliant would you say are tobacco retailers in your community with tobacco control
laws and regulations?
❑ Highly compliant
❑ Compliant
❑ Moderately compliant
❑ Somewhat compliant
❑ Non-compliant
❑ Don’t know

27) In your community, are you seeing individuals using electronic cigarettes and/or vape pens as
a quitting device?
❑ Yes
❑ No
❑ Don’t know

Please continue on to the next page you are
almost done!!!

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28) How often do you use any of the following to send/receive information?

Very
Frequently
Frequently Sometimes Rarely I Don’t Use
Facebook

❑

❑ ❑ ❑ ❑
Google+

❑

❑ ❑ ❑ ❑
Instagram

❑

❑ ❑ ❑ ❑
Twitter

❑

❑ ❑ ❑ ❑
Email

❑

❑ ❑ ❑ ❑
Regular Mail

❑

❑ ❑ ❑ ❑
In Person (Face to Face)

❑

❑ ❑ ❑ ❑
Mobile Phone

❑
❑ ❑ ❑ ❑
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Mobile Smart phone App

❑

❑ ❑ ❑ ❑
Text Messages

❑

❑

❑

❑

❑
Forums/Message Boards

❑

❑ ❑ ❑ ❑
Skype

❑

❑ ❑ ❑ ❑
Other (Please specify)
______________________

❑

❑ ❑ ❑ ❑

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29) In the past 30 days, how often did you see tobacco products being advertised or promoted on
any of the following communication services?

Never

Rarely Sometimes Often
Very
often

I Don’t
Use
Facebook

❑

❑ ❑ ❑ ❑ ❑
Google+

❑

❑ ❑ ❑ ❑ ❑
Instagram

❑

❑ ❑ ❑ ❑ ❑
Twitter

❑

❑ ❑ ❑ ❑ ❑
Mobile phone

❑

❑ ❑ ❑ ❑ ❑
Mobile Smart
phone App

❑

❑ ❑ ❑ ❑ ❑
Text messages

❑

❑ ❑ ❑ ❑ ❑
Radio

❑

❑ ❑ ❑ ❑ ❑
TV

❑

❑ ❑ ❑ ❑ ❑
Print Media
(newspapers,
magazines,
newsletters)

❑

❑ ❑ ❑ ❑ ❑
Other (Please
specify)
_____________

❑

❑ ❑ ❑ ❑ ❑

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30) In the past 30 days, how often did you see e-cigarettes products being advertised or promoted
on any of the following communication services?

Never

Rarely Sometimes Often Very often

I Don’t Use
Facebook

❑

❑ ❑ ❑ ❑ ❑
Google+

❑

❑ ❑ ❑ ❑ ❑
Instagram

❑

❑ ❑ ❑ ❑ ❑
Twitter

❑

❑ ❑ ❑ ❑ ❑
Mobile
phone

❑

❑ ❑ ❑ ❑ ❑
Smart
phone App

❑

❑ ❑ ❑ ❑ ❑
Text
messages

❑

❑ ❑ ❑ ❑ ❑
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Radio

❑

❑ ❑ ❑ ❑ ❑
TV

❑

❑ ❑ ❑ ❑ ❑
Print Media
(newspapers,
magazines,
newsletters)

❑

❑ ❑ ❑ ❑ ❑
Other
(specify)
__________

❑

❑ ❑ ❑ ❑ ❑

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31) Do you work in tobacco control?
❑ Yes → Continue to Question 31a
❑ No → Continue to Question 32
❑ Don’t know → Continue to Question 32

31a) If “Yes,” how long have you been involved in tobacco control?
❑ 5 years or less
❑ 6 to 10 years
❑ 11 to 20 years
❑ 21 years or more

31b) In what specific ways are you involved in tobacco control?
❑ Local Lead Agency
❑ Competitive Grantee
❑ Statewide Grantee
❑ Tobacco Control Coalition Member
❑ Prop 99 funded program
❑ Subcontractor of Prop 99 funded program
❑ Tobacco control research
❑ I am not involved in tobacco control
❑ Other (Please specify) _______________________________

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32. Have you ever seen this logo above?
❑ Yes
❑ No
❑ Not Sure

33. What is the name of this organization?

118

34. Have you ever heard of the US Food and Drug Administration also known as the FDA?
❑ Yes
❑ No

35. Are you aware that the FDA now has the ability to regulate tobacco products?
❑ Yes
❑ No

36. Do you think tobacco retailers in your neighborhood are aware that the FDA has the
authority to regulate tobacco products?
❑ Yes
❑ No

37. Do you think tobacco retailers in your community can distinguish the difference between
campaigns originated by the FDA versus the California Department of Health Services or
your local county Department of Public Health?
❑ Yes
❑ No
❑ Don’t know

38. Would you like to receive information from the FDA regarding tobacco control regulation?
❑ Yes
❑ No

39. Do you think the FDA is a reliable source of information on tobacco regulation?
❑ Yes
❑ No

40. Do you think members of your community consider the FDA a credible source of tobacco
information?
❑ Yes
❑ No
❑ People in my community do not know the FDA

Thank you for taking the time to complete this survey!

119
TCORS Project 2
Focus Group Guide

Welcome & Explanation of Study (1 min)
Moderator tells the group: Welcome! Thank you for joining us today. My name is
XXXX and I am your group leader. (Present other staff by names) will also be helping
me today. We all work for the University of Southern California, Department of
Preventive Medicine and the Institute for Health Promotion and Disease Prevention. Each
of you has been identified as a leader or key person in your community. We have invited
you to this focus group to hear your opinions about how to best communicate information
about tobacco laws and regulations to your community. Our goal is to use the information
you provide to help make tobacco control messages more effective with retail
storeowners, policy makers, and your community. Our meeting will take about an hour
and a half. There are no right or wrong answers, just your honest opinions. We'd like to
hear from each of you about these questions.

Consenting Focus Group Participants (3-5 minutes)

Instruction: Focus group assistant will place a consent form in front each seating area
prior to starting the focus group meeting. Moderator will explain and ask participants
to review and sign consent form before starting focus group discussion. Afterwards, the
focus group assistant will collect signed consent forms and review for completion. If
any form is not properly completed, the focus group assistant will ask the person to
complete.

Moderator tells group: In front of your seat, you’ll find a consent form. Please take
some time to review and complete the consent form before we get started with our focus
group discussion. Once completed, please give your consent form to the focus group
assistant. He/She will come around to collect these. Feel free to ask any questions about
the form you are completing.

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Self-Administered Anchoring surveys (10-15 minutes)

Instruction: Focus group assistant will place an anchoring survey in front each
seating area prior to starting the focus group meeting. Moderator will explain and ask
participants to review and complete the anchoring survey after signing their individual
consent form and before the start of the focus group discussion. Afterwards, the focus
group assistant will collect completed surveys and review for completion. If any survey
is not properly completed, the focus group assistant will ask the person to complete.

Moderator tells group: In front of your seat you will also find a brief questionnaire. It
will take approximately 10 minutes to complete. I would like to ask you to review and
complete the questionnaire after you have completed your consent form and prior to us
starting our focus group discussion. Once completed, please give your questionnaire to
the focus group assistant. Feel free to ask any questions about the questionnaire you are
completing.

Self-Introductions (5 min)
Instruction: Focus group participants will check-in with focus group assistant. During
this process prior to starting the meeting, the focus group assistant will distribute table
cards and ask participants to write their name age on their individual cards. Focus
group participant will also ask participants to display in front of their seating area.

Moderator tells group: We now want to ask that each of you introduce yourself using
your first name and age.

Focus Group Ground Rules (5 min)
Instruction: The moderator will cover all the rules about participation.

Moderator tells group: Before we begin, I would like to cover some ground rules about
your participation in this focus group.
121
1) This meeting will be like participating in a survey except that it is a talking circle,
not one-on-one; it’s an informal discussion.
2) Please relax and be comfortable.
3) Please know that you don’t have to answer a question if you prefer not to. When
we come to you, if you prefer not to answer, just say, “I pass.” However, we hope
that you will participate fully.
4) Please let us know if you agree or disagree with what others say; there are no right
or wrong answers.
5) Please speak one at a time. We are recording the focus group and the focus group
assistant is taking notes. The recording will be used for our research study
purposes so we can write out the information fully and do not lose any aspect of
what you tell us. Please share your comments with everyone in the meeting.
6) Once the focus group has been completed, we will review the recording and write
a report on what we have learned. All of your responses will be kept confidential.
For reporting purposes, we might use your age and your first name.
7) From time to time, I might have to move the discussion forward when there is still
more to say about the topic we are on so that we can stay on track. I hope you’ll
understand.
8) If you have a cell phone, please make sure to turn it off or put it on mute. We
would like to reduce the number of distractions during this meeting.
Are there any questions?

Main Body of Interview
Instruction: Focus group participants will view educational material used by the FDA
when asked questions 8-10

Moderator tells group: First, I would like to ask you some questions about how you
view the Food and Drug Administration (FDA), how you think your community views
the FDA, and the best way to communicate FDA information to retailers and others in
your community. We would also like to show you some educational materials developed
by the FDA and obtain your opinions on what works best for your community.
122

Community Perception of FDA
1) What do you know about the US Food and Drug Administration also known as the FDA?
(1-3 minutes)
a. Probe (What do you think this agency is supposed to do?)

Moderator tells group: In June of 2009, President Barack Obama signed into law The
Family Smoking Prevention and Tobacco Control Act. This Act established the US Food
and Drug Administration (FDA) as the “primary Federal regulatory authority with respect
to the manufacture, marketing, and distribution of tobacco products.” This means that one
thing the FDA will do is to better inform youth, young adults and adults who use any
tobacco products about the health risks of those products. Specifically, FDA will require
tobacco manufacturers to list ingredients, report levels of harmful constituents in smoking
products, and require health warnings on labels. In addition, the FDA has also obtained
the authority to directly regulate distribution, sales, and marketing of tobacco products
within the United States at the distributor and retailer level. This means that retailers are
unable to set their own prices or promotions when selling tobacco and must follow
standards set by the FDA.

2) Were you aware of this new role for FDA? (1-3 minutes)
a. Probe (If no one knows about this role, ask if they have any questions about what
you just described. You can also describe some of the new FDA responsibilities
such as inspecting retail stores to make sure tobacco advertisements are not
giving free samples, no single cigarette sales are occurring, and FDA is in charge
of disclosing the ingredients of cigarettes to the public.)
b. Do you think people in your community are aware of this new role of the FDA as
a regulatory authority on tobacco?

3) Do you think community members like yourself understand the FDA’s role in tobacco
regulation? (1-3 minutes)
a. Probe (Why or why not?)
123

4) What are your thoughts about trusting the FDA to give accurate tobacco information
about tobacco regulation? (3-5 minutes)
a. Probe (How can that trust be improved?)

5) How do you think people in your community would trust the information coming from
the FDA on tobacco regulation? (3-5 minutes)
a. Probe (Why or why not?)
b. American Indian Population Only: Probe (How would the local tribes perceive
the FDA providing information about tobacco regulation?)

6) How do you think retailers in your community would trust the information coming from
the FDA on tobacco regulation? (3-5 minutes)
a. Probe (Why or why not?)
b. American Indian Population Only: Probe (Would retailers who are Native
receive messages differently than non-Native owned business on tribal lands, why
or why not?)

7) Please describe any positive or negative feelings you have about the FDA. (5-10 minutes)
a. Probe (Do they do a good job? Are they reflected positively in the media? Are
they experts in their field?)
b. Probe (Among community people like yourself, who do you consider a respected
source of health information about federal government rules or regulation about
tobacco)
c. Probe (Is there any other agency/organization that you believe would be better
than the FDA?)

FDA Educational Material Perception
Instruction: Focus group moderator will show the educational material used by the FDA
to ask the next questions. Please have them raise their hand to count how many people
have seen the material.
124
8) Have you seen this educational material before? (1-3 minutes)
a. Probe (If yes, where you have you seen this material before?)

9) What are your first impressions of this material? (3-5 minutes)
a. Probe (What kind of information do these tobacco related material give?)

10) What is the material’s main message? (3-5 minutes)
a. Probe (What is the materials trying to convey?)
b. Probe (How believable do you think the message in the FDA material are?)
c. Probe (Are there any others who do not understand the material?)

Messages to Minority Communities that are Understandable
11) How could the FDA make tobacco related materials appropriate and effective for tobacco
retailers in your community? (5-10 minutes)
a. Probe (How do you think community members like yourselves view these
materials?)
b. Probe (What are ways that the FDA can make these materials more attractive and
easier to understand?)
c. Probe (What edits would motivate/attract someone in your community to read
these materials?)

Communication Channels for information and Communication about Tobacco and Health
Issues
12) What do you think are the two best methods of communication to reach community
members like yourself regarding information about tobacco regulation? (1-3 minutes)

13) What are some reasons that currently hinder or prevent the delivery of FDA regulation
information on tobacco? (1-3 minutes)

125

American Indian Population Only:
14) What kinds of tobacco regulations exist for stores in tribal lands? (5-10 minutes)
a. Probe- (Do they follow the state, local/county laws, youth access, sales to
minors, tobacco products in hands reach, sold near candy, etc?)
b. What are some ways that tribes can make sure the stores on tribal lands are in
compliance with FDA regulations?

15) What are ways the tribe can be involved to help tobacco retailers on tribal land are in
compliance with FDA regulations? (3-5 minutes)

16) What are some things that can improve the delivery of FDA regulatory information on
tobacco? (3-5 minutes)
a. Probe (Why or why not?)
b. Probe (How can we optimize the delivery of FDA regulatory information on
tobacco in your community? Are there any communication channels or vehicles
we have not mentioned, that would optimize the delivery, dissemination, and use
of FDA information about tobacco in your community?)

17) As a community leader how can you influence or support compliance of FDA regulation
in the retail environment? (3-5 minutes)
a. Probe (What can you do to help influence the retail environment? What can you
do to support compliance in the retail environment?)
b. Probe (What are resources that would help you with this effort?)

E-cigarette Pilot Questions
18) What is your opinion about the safety of e-cigarettes? (1-3 minutes)
a. Probe (Do you know what e-cigarettes are?)
b. Probe (Why are they safe or why are they not safe?)

126
19) What is your opinion about the popularity of e-cigarettes? (1-3 minutes)
a. Probe (Are they popular amongst community members like yourselves?)
b. Probe (Are they popular amongst young people?)

Acknowledgements and Conclusion (5-10 min)

Instruction: Focus group moderator will thank participants for their time and
participation. Moderator will also ask if there are any questions from anyone
participating and answer any questions. The focus group assistant will hand out
reimbursement forms and confirm that participants receive their incentive.

Moderator tells group: Thank you all for your time and help in answering these
questions, we greatly appreciate it. We are now handing out a form, so you can all
receive a small gift for your time. Please sign this form (show the form) and take it to the
focus group assistant who will hand you a $75 gift card as a thank you for your time and
participation once you give him/her your signed form and materials.

Does anyone have any questions at this time?

We are officially done. We want to thank you for your help and feedback. If you have
any questions about the study, please do not hesitate to contact Dr. Baezconde-Garbanati,
the Principal Investigator on the study at baezcond@hsc.usc.edu or at (323) 442-8231.

Adjourn the talking circle/focus group.

127
TCORS PROJECT 2-Retailers’ Survey

Store ID: __________________________
Computer Number: _____ Zip Code: ___________
❑ 1 Paper Survey _________ Store Address: ______________
Date of Interview: __________________ ❑ 1 Actual address matches assigned
address.
Interviewer Name: _________________

Introduction:
Thank you for taking the time to complete this survey. The survey will take about 20 minutes to
complete. This survey is about your opinions related to tobacco. There are no right or wrong
answers, just your opinions. If there are any questions you do not feel comfortable answering,
you can skip the questions. You can also stop the survey at any time. We will NOT write your
name on this survey. The answers you provide will be kept private.

If you have any questions about the survey, please contact Dr. Lourdes Baezconde-Garbanati,
who is the Director of this program, at baezcond@hsc.usc.edu or you can call her at (323) 442-
7366.

Part I: About You

1) What is your gender?
❑ 1 Male
❑ 2 Female
❑ 3 Other (Please specify)_____________________________________
❑ 4 Refuse to answer

2) What is your position at the store?
❑ 1 Owner
❑ 2 Manager
❑ 3 Clerk
❑ 4 Other (Please specify): _____________
❑ 5 Refuse to answer

3) What is your age? ___________

4) In what country were you born?
❑ 1 Africa (Please specify which country) __________________
❑ 2 Asia (Please specify which country) __________________
❑ 3 Latin America (Please specify which country) __________________
❑ 4 United States of America or United States (U.S.)
❑ 5 Other (Please specify what country) _________________
128
5) If not born in the U.S., how long have you been in the U.S.?
❑ 1 5 years or less
❑ 2 6 years to 10 years
❑ 3 11 years to 19 years
❑ 4 20 years or more
❑ 5 I don’t know
❑ 6 Refuse to answer

6) What is your race or ethnicity? (Select all that apply)
❑ 1 African American or Black
❑ 1 African (Please specify) _________________________
❑ 1 American Indian or Alaska Native
❑ 1 What is your tribe(s)? (Please specify) _______________________
❑ 1 Asian (Please specify) __________________
❑ 1 Hispanic/Latino (Please specify) _________________________
❑ 1 Native Hawaiian and/or Other Pacific Islander
❑ 1 White (Please specify) ______________________
❑ 1 Other (Please specify) ______________________
❑ 1 Refuse to answer

7) What languages do you speak at home? (Check all that apply)
❑ 1 English
❑ 1 Korean
❑ 1 Spanish
❑ 1 Armenian
❑ 1 Arabic
❑ 1 Russian
❑ 1 Native/Tribal Language (Please specify) ________________
❑ 1 Other (Please specify) ______________________
❑ 1 Refuse to answer
8) What is the highest grade or level of school you have completed?
❑ 1 Some Elementary School
❑ 2 Completed elementary School
❑ 3 Some Middle School
❑ 4 Completed middle School/Junior High
❑ 5 Some High School, No Diploma
❑ 6 High School Graduate
❑ 7 GED
❑ 8 Some College, No Degree
❑ 9 College Graduate
❑ 10 Some Graduate School
❑ 11 Completed Graduate School
129
❑ 12 Other (Please specify) ______________________
❑ 13 Don’t know
❑ 14 Refuse to answer
9) In what country did you complete your highest grade or level of schooling?
❑ 1 USA
❑ 2 Other (Please specify) __________________________
❑ 3 Refuse to answer

10) How confident are you filling out forms by yourself in English?
❑ 1 Extremely
❑ 2 Quite a bit
❑ 3 Somewhat
❑ 4 A little bit
❑ 5 Not at all
❑ 6 Refuse to answer

10a) How confident are you filling out medical forms by yourself?
❑ 1 Extremely
❑ 2 Quite a bit
❑ 3 Somewhat
❑ 4 A little bit
❑ 5 Not at all
❑ 6 Refuse to answer

11) How would you rate your ability to read in English?
❑ 1 Excellent
❑ 2 Very good
❑ 3 Good
❑ 4 Okay
❑ 5 Poor
❑ 6 Very poor
❑ 7 Refuse to answer

Part II: Opinions on Tobacco

We are now going to ask you several questions regarding your opinion about tobacco
products. There are no right or wrong answers, just your opinions.

12) What is this business’ main source of revenue?
❑ 1 Alcohol
130
❑ 2 Tobacco
❑ 3 Food
❑ 4 Non-Alcoholic Beverages
❑ 5 Other (Please specify) _____________
❑ 6 Don’t know
❑ 7 Refuse to answer

13) What effect do the following tobacco products have on this business’ revenue?

14) Have you noticed a rise in sales of e-cigarettes in this store in the last year?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Do not sell e-cigarettes
❑ 5 Refuse to answer

14a) Have your customers asked you to sell e-cigarettes or additional types of e-cigarette
products?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Refuse to answer

Helps it
make a
lot of
money
Helps it
make a
little bit of
money
Doesn’t
make or lose
money
(breakeven)
Makes it
lose a
little bit
of money
Makes it
lose a lot
of
money
Don’t
know
Do not
sell
produc
t
Cigarettes
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
Cigarillos
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
E-cigarettes
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
Vape Pens/
Vaporizers
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
Hookah
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
E-Hookah
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
Smokeless Tobacco
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
Other (Please specify)
_____________
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑
131

15) Have you noticed a rise in sales of vape pens/vaporizers in this store in the last year?
❑ 1 Yes
❑ 2 No
❑ 3 Not sure
❑ 4 Do not sell vape pens/vaporizers
❑ 5 Refuse to answer

15a) Have your customers asked you to sell vape pens/vaporizer products or additional
types
of vapes/vaporizer products?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Refuse to answer

Part III: Opinions on Healthy Stores for a Healthy Community Campaign

INSTRUCTIONS TO INTERVIEWER: Below is a definition of the campaign. Please
read this definition if respondent says they do not know what the campaign is.
*Campaign Defined: The State of California’s “Healthy Stores for a Healthy Community”
campaign focuses on improving the health of Californians by making changes in retail stores
that will promote community health and protect youth. It will integrate nutrition, alcohol, and
tobacco approaches.

16) Have you heard about California’s campaign called “Healthy Stores for a Healthy
Community?”
❑ 1 Yes
❑ 2 No
❑ 3 Not sure
❑ 4 Refuse to answer

17) Have you taken part in any campaign or project related to improving your retail store?
❑ 1 Yes (please specify what campaign__________________________)
❑ 2 No→ Continue to Question 18
❑ 3 Don’t know → Continue to Question 18
❑ 4 Refuse to answer→ Continue to Question 18

132
17a) If “Yes,” how helpful was that campaign or project to your business?
❑ 1 Very helpful
❑ 2 Helpful
❑ 3 Somewhat helpful
❑ 4 Not helpful
❑ 5 Don’t know
❑ 6 Refuse to answer

18) Do you think your store would participate in a tobacco education program for consumers?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Refuse to answer

Part IV: Knowledge and Beliefs about FDA

19) Have you ever seen this logo?
❑ 1 Yes
❑ 2 No → Continue to Question 21
❑ 3 Don’t know → Continue to Question 21

20) What is the name of this organization? _______________________

---------- PAGE BREAK ON ACCESS FILE AND HARDCOPY ----------

133
INSTRUCTIONS TO INTERVIEWER: Below is a definition of the FDA. Please read
this definition if respondent says they do not know what is FDA or if they give
you a wrong answer or are not sure.

*FDA Defined: FDA is the “Food and Drug Administration” of the federal government. It sets up
rules for making, selling and marketing tobacco. They set up these rules to protect public
health.

21) Before today, had you ever heard of the US Food and Drug Administration also known as
the FDA?
❑ 1 Yes
❑ 2 No

22) Who do you think regulates tobacco products? (Check all that apply)
❑ 1 Food and Drug Administration (FDA)
❑ 1 State Government
❑ 1 City Government
❑ 1 Other (please specify): _____________________
❑ 1 Don’t know

23) Do you believe that the FDA has the right to regulate the sales of tobacco products in this
store?
❑ 1 Yes
❑ 2 No

24) Do you think other retailers that sell tobacco products in your area know that the FDA has
the ability to regulate tobacco products?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know

25) Do you think the FDA is a trustworthy source of information on tobacco rules?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know

134
26) How trustworthy are the following organizations as a source of information on tobacco?

Part V: Communication

We are now going to ask you several questions about communication and how you receive
information.

27) How do you first find out about tobacco products that the FDA has asked you to remove
from this stores shelf?
❑ 1 FDA
❑ 2 Other Retailers
❑ 3 Customers
❑ 4 Tobacco Companies
❑ 5 Tobacco Distributors
❑ 6 Other (Please specify)_____________________________
❑ 7 I don’t know of any tobacco products that need to be removed from this stores shelf
❑ 8 Refuse to answer

28) Thinking about all the ways you communicate (such as phone, social media, texting,
email, face-to-face), list the 3 most frequent ways you learn about things for your
business (such as items to purchase for store, sales items, licenses, customers)?
1: __________________
2: __________________
3: __________________

29) Do you (or the owners of this store) look for information about tobacco rules from the
following:

Trust them
completely
Trust them
a lot
Trust them
more or less
Trust them
a little
Do not
trust
them at
all
Tobacco Distributor 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
Tobacco Companies 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
Wholesalers 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
National Association of Tobacco Outlets (NATO) 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
Smoke-free Alternatives Trade Associations
(SFATA)
1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
Other Retailers 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
Other (Please specify) _____________ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑
135
Federal Government ❑ 1 Yes ❑ 2 No
State Government ❑ 1 Yes ❑ 2 No
City Government ❑ 1 Yes ❑ 2 No
National Association of Tobacco Outlets (NATO) ❑ 1 Yes ❑ 2 No
Convenience Store News ❑ 1 Yes ❑ 2 No
Chambers of Commerce ❑ 1 Yes ❑ 2 No
Business Associations (Please specify) _______ ❑ 1 Yes ❑ 2 No
Other Retail Store Owners ❑ 1 Yes ❑ 2 No
Customers ❑ 1 Yes ❑ 2 No
Tobacco Companies ❑ 1 Yes ❑ 2 No
Tobacco Distributers ❑ 1 Yes ❑ 2 No
Wholesalers ❑ 1 Yes ❑ 2 No
E-cigarette Distributors ❑ 1 Yes ❑ 2 No
Other (Please specify) ____________________ ❑ 1 Yes ❑ 2 No

INTRO SCRIPT FOR QUESTION #30: Since 2009, the FDA has had the authority to regulate
tobacco products.

30) In the past year, have you (or the owners of the store) received any information directly
from the FDA/Federal Government related to tobacco rules for this store?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Refuse to answer

31) In the past year, have you received any information explaining FDA/ Federal Government
tobacco rules from any other sources?
❑ 1 Yes → Continue to Question 31a
❑ 2 No → Continue to Question 31b
❑ 3 Don’t know→ Continue to Question 31b
❑ 4 Refuse to answer→ Continue to Question 31b

136

31a) [only ask this
question if YES to Q31]
In the PAST YEAR, from
which of these sources
did you receive
information about the
FDA (check all that
apply)?
31b) [Ask all participants]

In the FUTURE, would you like to
receive information explaining
FDA tobacco rules from any of
these sources?
Newspapers & News Magazines ❑ 1 Yes ❑ 1 Yes
Trade/Business Magazines ❑ 1 Yes ❑ 1 Yes
Conventions ❑ 1 Yes ❑ 1 Yes
Internet ❑ 1 Yes ❑ 1 Yes
Forums/Message Boards
❑ 1 Yes ❑ 1 Yes
Flyers ❑ 1 Yes ❑ 1 Yes
TV ❑ 1 Yes ❑ 1 Yes
Radio ❑ 1 Yes ❑ 1 Yes
Webinar/Training ❑ 1 Yes ❑ 1 Yes
FDA Website ❑ 1 Yes ❑ 1 Yes
Tobacco Companies ❑ 1 Yes ❑ 1 Yes
Tobacco Distributors ❑ 1 Yes ❑ 1 Yes
Wholesalers ❑ 1 Yes ❑ 1 Yes
Other Retail Store Owners ❑ 1 Yes ❑ 1 Yes
Customers ❑ 1 Yes ❑ 1 Yes
Face to Face (Talking in Person) ❑ 1 Yes ❑ 1 Yes
Landline Phone ❑ 1 Yes ❑ 1 Yes
Cell Phone/Mobile ❑ 1 Yes ❑ 1 Yes
Text Messages ❑ 1 Yes ❑ 1 Yes
137

31a) [only ask this
question if YES to Q31]
In the PAST YEAR, from
which of these sources
did you receive
information about the
FDA (check all that
apply)?
31b) [Ask all participants]

In the FUTURE, would you like to
receive information explaining
FDA tobacco rules from any of
these sources?
Smartphone Apps (ex.
WhatsApp, Viber)
❑ 1 Yes ❑ 1 Yes
Mail ❑ 1 Yes ❑ 1 Yes
Email ❑ 1 Yes ❑ 1 Yes
Facebook ❑ 1 Yes ❑ 1 Yes
Twitter ❑ 1 Yes ❑ 1 Yes
Instagram ❑ 1 Yes ❑ 1 Yes
YouTube ❑ 1 Yes ❑ 1 Yes
Any Other Source (Please
specify) _______
❑ 1 Yes ❑ 1 Yes

31c) In what language would you prefer to receive this information?
❑ 1 English
❑ 2 Korean
❑ 3 Spanish
❑ 4 Armenian
❑ 5 Arabic
❑ 6 Russian
❑ 7 Native/Tribal Language (Please specify) ________________
❑ 8 Other (Please specify) ______________________
❑ 9 Refuse to answer

32) Thinking about all the different ways you communicate for this business (such as phone,
social media, texting, email, face-to-face), what are the top 3 ways you trust the most?
1: __________________
2: __________________
3: __________________
138
33) In the past 6 months, have you actively searched for any information about tobacco
products?
❑ 1 Yes → Continue to Question 33a
❑ 2 No→ Continue to Question 34
❑ 3 Don’t know → Continue to Question 34
❑ 4 Refuse to answer→ Continue to Question 34

33a) Where did you search for this information? (Check all that apply)
❑ 1 Internet (Please specify) _____________
❑ 1 Magazine (Please specify) _____________
❑ 1 Interpersonal communication (Person to person)
❑ 1 Other (Please specify) _____________
❑ 1 Don’t know
❑ 1 Refuse to answer

34) In the past 6 months, have you actively searched for any information about e-cigarettes?
❑ 1 Yes
❑ 2 No→ Continue to Question 35
❑ 3 Don’t know→ Continue to Question 35
❑ 4 Refuse to answer→ Continue to Question 35

34a) Where did you search for this information? (Check all that apply)
❑ 1 Internet (Please specify) _____________
❑ 1 Magazine (Please specify) _____________
❑ 1 Interpersonal communication (Person to person)
❑ 1 Other (Please specify) _____________
❑ 1 Don’t know
❑ 1 Refuse to answer

35) What can make it hard for you to follow FDA/Federal government tobacco rules? (Check
all that apply)
❑ 1 I have no access to educational materials.
❑ 1 I have customers who want me to sell singles or get free samples.
❑ 1 I don’t know the rules.
❑ 1 I don’t understand the rules.
❑ 1 I receive pressure from tobacco distributors that come to my store.
❑ 1 Tobacco companies encourage me not to follow the FDA rules.
❑ 1 I receive too much information from different sources that confuse me.
❑ 1 Information is not offered in the language I understand the best.
❑ 1 Other (Please specify): _________________________________________
❑ 1 None of the above
❑ 1 Refuse to answer

139
36) Which of the following could help you or others follow FDA tobacco rules? (Check all that
apply)
❑ 1 Education Materials (Please specify): _______________________________
❑ 1 Trainings / Webinars
❑ 1 Enforcement of the Rules
❑ 1 Learning more about what happens if I do not follow the rules
❑ 1 Checklists or Posters with the Rules by the Checkout Counter
❑ 1 Other (Please specify): _______
❑ 1 None of the above

37) Where do you (or the owners of this store) get tobacco products for this store? (Check all
that apply)
❑ 1 Wholesalers
❑ 1 Warehouse
❑ 1 Costco
❑ 1 Tobacco Company Distributors
❑ 1 Online
❑ 1 Stores in Tribal Land
❑ 1 Don’t know
❑ 1 Other (Please specify): _________________________________________
❑ 1 Refuse to answer

Part VI: Tobacco Industry Relationship
38) Are you or the storeowner required by a tobacco company to do any of the following…?
(Check all that apply)
❑ 1 Place shelves and displays of tobacco products in store in a certain place
❑ 1 Stock tobacco company products in easy to see places near the counter
❑ 1 Place tobacco company products in easy to see places on shelves
❑ 1 Show ads for tobacco company products
❑ 1 Other (Please specify:____________)
❑ 1 None of the above
❑ 1 I do not have a tobacco contract
❑ 1 Don’t know
❑ 1 Refuse to answer

39) What is the most common tobacco brand sold in this store?
❑ 1 Camel
❑ 2 Kool
❑ 3 Marlboro
❑ 4 Newport
❑ 5 Pall Mall
❑ 6 Parliament
❑ 7 Other (Please specify) _______________
❑ 8 Don’t know
140
❑ 9 Refuse to answer

39a) Which tobacco brand brings in the most money for this store?
❑ 1 (Please specify) ________________________________
❑ 2 Don’t know

40) What is the most frequently sold tobacco product in this store?
❑ 1 (Please specify) ________________________________
❑ 2 Don’t know

40a) What tobacco product brings in the most money for this store?
❑ 1 (Please specify) ________________________________
❑ 2 Don’t know

41) What are the most important issues that you are facing in the community that may be
impacting your business? (check all that apply)
❑ 1 Crime
❑ 1 Gang Violence
❑ 1 Business Property Taxes
❑ 1 Energy Costs
❑ 1 Drug Abuse
❑ 1 Homelessness
❑ 1 Other (Please specify) ___________
❑ 1 No problems
❑ 1 Don’t know
❑ 1 Refuse to answer

VII. Personal Tobacco Use & Opinions
Now I am going to ask you a few questions about your own use of tobacco products.

42) Have you smoked at least 100 cigarettes or 5 packs of cigarettes in your entire life?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Refuse to answer

43) Do you now smoke cigarettes every day, some days or not at all?
❑ 1 Every day→ Continue to Question 45
❑ 2 Some days → Continue to Question 44
❑ 3 Not at all → Continue to Question 46
❑ 4 Don’t know
❑ 5 Refuse to answer
141

44) During the past 30 days, on how many days did you smoke cigarettes?
❑ 1 None
❑ 2 Response: Enter number of days ____ [RANGE: 1 – 30]
❑ 3 Don’t know
❑ 4 Refuse to answer

45) On average, about how many cigarettes do you now smoke each day?
❑ 1 Response: Enter number of cigarettes per day ____ [RANGE: 1 – 99]
❑ 2 Don’t know
❑ 3 Refuse to answer

INSTRUCTIONS TO INTERVIEWER: Read this introduction before asking the
following questions.

The next questions are about electronic cigarettes, often called e‐cigarettes. E‐cigarettes look
like regular cigarettes, but are battery powered and produce vapor instead of smoke. There
are many types of e‐cigarettes. Some common brands include NJOY®, Blu™, and Smoking
Everywhere.

46) Have you ever used an e-cigarette even one time?
❑ 1 Yes
❑ 2 No → Continue to Question 49
❑ 3 Don’t know
❑ 4 Refuse to answer

47) Do you now use e-cigarettes….
❑ 1 Every day→ Continue to Question 49
❑ 2 Some days → Continue to Question 48
❑ 3 Not at all → Continue to Question 49
❑ 4 Don’t know
❑ 5 Refuse to answer

48) During the past 30 days, how many days did you use an e-cigarette?
❑ 1 None
❑ 2 Response: Enter number of days ____ [RANGE: 1 – 30]
❑ 3 Don’t know
❑ 4 Refuse to answer

49) Have you ever used a vape pen or vaporizer even one time?
❑ 1 Yes
142
❑ 2 No → Continue to Question 52
❑ 3 Don’t know
❑ 4 Refuse to answer

50) Do you now use a vape pen or vaporizer….
❑ 1 Every day→ Continue to Question 52
❑ 2 Some days → Continue to Question 51
❑ 3 Not at all → Continue to Question 52
❑ 4 Don’t know
❑ 5 Refuse to answer

51) During the past 30 days, how many days did you use a vape pen or vaporizer?
❑ 1 None
❑ 2 Response: Enter number of days ____ [RANGE: 1 – 30]
❑ 3 Don’t know
❑ 4 Refuse to answer

52) Did you cut down on cigarette smoking by using e-cigarettes or a vape pen?
❑ 1 Yes
❑ 2 No → Continue to Question 54
❑ 3 I do not use e-cigarettes or a vape pen → Continue to Question 55

53) Did you quit cigarette smoking by using e-cigarettes or a vape pen?
❑ 1 Yes
❑ 2 No

54) Currently, do you use both cigarettes and e-cigarettes (or a vape pen)?
❑ 1 Yes
❑ 2 No

55) Have you ever tried using tobacco products other than cigarettes?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know
❑ 4 Refuse to answer

56) Which of these tobacco products have you used in the last 30 days? (Check all that apply)
❑ 1 Chewing tobacco/ snuff/ smokeless tobacco/ dip
❑ 1 Bidis (flavored cigarettes from India with tobacco wrapped in a leaf and tied with thread)
❑ 1 Clove cigarettes/ kreteks
❑ 1 Commercial tobacco in a pipe
❑ 1 Menthol cigarettes
❑ 1 Cigars
❑ 1 Blunts
143
❑ 1 Cigarillos/little cigars
❑ 1 Hookah
❑ 1 Snus
❑ 1 Other: _______________________________
❑ 1 I haven’t used any of these tobacco products in the past 30 days.

57) What is your opinion about the safety of e-cigarettes? Would you say they are…
❑ 1 Completely safe
❑ 2 Safer than regular cigarettes
❑ 3 About as safe or dangerous as regular cigarettes
❑ 4 More dangerous than regular cigarettes
❑ 5 Don’t know
❑ 6 Refuse to answer

58) In your opinion, do e-cigarettes and other vaping products contribute to young people
becoming addicted to nicotine?
❑ 1 Yes
❑ 2 No
❑ 3 Don’t know/No opinion

Do you favor this proposal strongly, favor it somewhat, oppose it somewhat, or oppose it
strongly?
59) Pass a state law prohibiting the use of e-
cigarettes and vaping products in places
where smoking is not allowed, such as in
restaurants, bars and workplaces.
❑ 1 Favor strongly
❑ 2 Favor somewhat
❑ 3 Oppose somewhat
❑ 4 Oppose strongly
❑ 5 Don’t know/No opinion
❑ 6 Refuse to answer
60) Tax e-cigarettes and other vaping
products in California, and devote the
money for public education programs,
research and the enforcement of laws
relating to their use.
❑ 1 Favor strongly
❑ 2 Favor somewhat
❑ 3 Oppose somewhat
❑ 4 Oppose strongly
❑ 5 Don’t know/No opinion
❑ 6 Refuse to answer
61) Regulate and license shops that sell e-
cigarettes and other vaping products in
❑ 1 Favor strongly
❑ 2 Favor somewhat
INSTRUCTIONS TO INTERVIEWER: Read this introduction before asking the following
questions.
I am going to read some proposals that have been made about the use of electronic cigarettes,
also referred to as vaping or e-cigarettes. E-cigarettes are small, battery-powered devices that
enable users to smoke by inhaling a vapor of a liquid nicotine mixture, instead of burning a
cigarette. For each proposal, please tell me whether you favor or oppose it.

144
California in the same way as stores that
sell regular tobacco cigarettes
❑ 3 Oppose somewhat
❑ 4 Oppose strongly
❑ 5 Don’t know/No opinion
❑ 6 Refuse to answer
62) Pass a state law that restricts adding
flavors to e-cigarettes and other vaping
products to reduce their appeal to
young people
❑ 1 Favor strongly
❑ 2 Favor somewhat
❑ 3 Oppose somewhat
❑ 4 Oppose strongly
❑ 5 Don’t know/No opinion
❑ 6 Refuse to answer

145
VIII. Income

63) What is the range of your annual household income?
❑ 1 $0-$40,000
❑ 2 $40,001-$60,000
❑ 3 Greater than $60,001
❑ 4 Don’t know
❑ 5 Refuse to answer

64) What is this business’ annual profit? [Note to data collector: business annual profit =
revenue minus expenses & salary)
❑ 1 Under $25,000
❑ 2 $25,000-$49,999
❑ 3 $50,000-$74,449
❑ 4 $75,000-$99,999
❑ 5 $100,000-$149,999
❑ 6 $150,000-$200,000
❑ 7 Over $200,000
❑ 8 Don’t know
❑ 9 Refuse to answer

❑ 1 Give interview participant a leave behind packet

Would you be interested in being contacted again in the future for another study?
❑ 1 Yes → Instruct and show flyer from leave behind packet
❑ 2 No

Thank you so much for your participation in this survey.

146

TCORS Project 2-Retailers’ Shop Observation Form
147

Abstract (if available)

Abstract Background: The overall smoking rates in the U.S. have continued to decrease in recent years but disparities still exist among racial ethnic communities. The retail environment has been identified as an area that largely contributes to these disparities. The FDA has regulatory authority over tobacco products and how they are sold and promoted. Independent retailers in racial/ethnic communities have been understudied in how they comply with and understand tobacco regulations. ❧ Methods: The current dissertation used community-based approaches to investigate tobacco retailer knowledge, attitudes and compliance of tobacco regulations. Study 1 conducted focus groups with 57 Key Opinion Leaders (KOL’s) from African-American (AA), Hispanic/Latino (HL), and Non-Hispanic White (NHW) communities. They completed an anchoring survey and a 90-minutes focus group on their knowledge, awareness and attitudes of the FDA and tobacco regulatory policy. Study 2 used community health workers to recruit 576 independent tobacco retailers from the same communities. The participating retailers were interviewed and the CHW’s also conducted store observations. The retailer interview addressed their knowledge of the FDA and tobacco policies, attitudes towards the FDA, and their perceived benefits of selling tobacco products. The observation addressed product availability, product placement, and presence of promotions, exterior ads, and regulatory materials. ❧ Results: For all communities over half of the KOL’s were aware of the FDA’s role in regulating tobacco products. Less than half believed that retailers in their community would be aware of this role. Focus group data revealed differences in the level of distrust, with AA KOL’s expressing a higher level of distrust compared to the other communities. All communities expressed the desire to collaborate with the FDA in their regulatory efforts. Less than half of the AA and HL retailers were aware of the FDA’s role in tobacco regulation. Retailers in the AA communities had higher odds of being non-compliant. ❧ Conclusions: The retail environment contributes to continued disparities in tobacco use. These data identified that there are disparities in independent tobacco retailers’ compliance. Regulatory and public health agencies should include both KOL’s and retailers in their outreach and educational efforts. Messages to retailers need to be delivered in a culturally relevant manner. Further, more outreach with racial/ethnic communities will be essential to increase retailers’ and community buy-in to work towards reducing the burden of tobacco use disparities in diverse and vulnerable communities.

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Asset Metadata

Creator Garcia, Robert (author)

Core Title Examining tobacco regulation opinions and policy acceptance among key opinion leaders and tobacco retailers in low socioeconomic status African American, Hispanic, and non-Hispanic White communities

School Keck School of Medicine

Degree Doctor of Philosophy

Degree Program Preventive Medicine (Health Behavior Research)

Publication Date 06/28/2020

Defense Date 02/12/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag community health workers,key opinion leaders,OAI-PMH Harvest,tobacco disparities,tobacco regulation compliance,tobacco retailers,vulnerable populations

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Baezconde-Garbanati, Lourdes (committee chair), Chou, Chih-Ping (committee member), Palinkas, Lawrence A. (committee member), Sussman, Steven Yale (committee member), Unger, Jennifer Beth (committee member)

Creator Email garc617@usc.edu,rgarcia28@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-13100

Unique identifier UC11672278

Identifier etd-GarciaRobe-6355.pdf (filename),usctheses-c89-13100 (legacy record id)

Legacy Identifier etd-GarciaRobe-6355.pdf

Dmrecord 13100

Document Type Dissertation

Format application/pdf (imt)

Rights Garcia, Robert

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA