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J Adolesc Health. 2019 Nov 26. pii: S1054-139X(19)30447-1. doi: 10.1016/j.jadohealth.2019.09.004. [Epub ahead of print]

Tobacco Retail Density and Initiation of Alternative Tobacco Product Use Among Teens.

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Department of Epidemiology and Population Health, Stanford University, Palo Alto, California.
Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, California. Electronic address:
Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California.
Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California.
Stanford Prevention Research Center, Stanford University School of Medicine, Stanford University, Palo Alto, California.



The rise of noncigarette, alternative tobacco product (ATP) use among adolescents may be due in part to an increase in retail availability of ATPs. We examined whether proximity and density of tobacco retailers near students' homes are associated with a higher likelihood of initiating ATP use over time.


Using data from 728 adolescents (aged 13-19 years at baseline) residing in 191 different neighborhoods and attending 10 different California high schools, longitudinal multilevel and cross-classified random effect models evaluated individual-level, neighborhood-level, and school-level risk factors for ATP initiation after 1 year. Covariates were obtained from the American Community Survey and the California Department of Education.


The sample was predominantly female (63.5%) and was racially and ethnically diverse. Approximately one third of participants (32.5%) reported ever ATP use at baseline, with 106 (14.5%) initiating ATP use within 1 year. The mean number of tobacco retailers per square mile within a tract was 5.66 (standard deviation = 6.3), and the average distance from each participant's residence to the nearest tobacco retailer was .61 miles (standard deviation = .4). Living in neighborhoods with greater tobacco retailer density at baseline was associated with higher odds of ATP initiation (odds ratio = 1.22, 95% confidence interval = 1.07-2.12), controlling for individual and school factors.


Tobacco retailers clustered in students' home neighborhood may be an environmental influence on adolescents' ATP use. Policy efforts to reduce adolescent ATP use should aim to reduce the density of tobacco retailers and limit the proximity of tobacco retailers near adolescents' homes and schools.


Adolescents; Alternative tobacco products; E-cigarettes; Neighborhoods; Schools; Tobacco retail environment; Tobacco retailer; Young adults

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