Corporations and Health Watch

The More Things Change: Examining Alcohol Industry Issues Management Strategies

Posted on January 1, 2010 by Corporations and Health Watch

Every industry carefully plans how to advance its business agenda and counter threats to profitability. What makes industries change the strategies they use to respond to public pressure to modify health damaging practices? Do announced changes in practice reflect real change or are they simply old wine in new bottles? In this report, Corporations and Health Watchanalyzes changes in alcohol industry responses to criticisms of its marketing practices.

One source for such an analysis is the documents disclosed by the tobacco industry. One of the stipulations of the 1998 Master Settlement Agreement between the tobacco industry and the attorneys general of 46 states was that several million formerly confidential tobacco industry documents would be made publicly available.

¹ Many of these documents also pertained to the alcohol industry (AI), since the tobacco giant Philip Morris had owned Miller Brewing Company from 1970 to 2002 and was closely involved with the Beer Institute.² (Altria Group, Philip Morris’ parent corporation, continues to own 27% of the stock in the multinational alcohol company SABMiller.)

Earlier this year, researchers at the Curtin University of Technology in Australia sifted through the tobacco documents in order to identify alcohol industry themes, strategies, and tactics.² They identified the following industry strategies designed to forestall regulatory action: 1) Industry-run education programs; 2) Focusing blame on individuals and groups with a “problem”, including minorities ; 3) Promoting responsible drinking; and, 4) Denying any association between advertising and consumption.

Granting the validity of their analysis, a question that arises is: Have the alcohol industry’s issues management (IM) strategies changed substantially since 2002, the last year studied by Bond and colleagues?

Source of alcohol industry profits

To understand the goals and tactics of the AI requires an understanding of the source of their profits. While the majority of Americans either do not drink or drink very little alcohol, a considerable portion of U.S. alcohol sales can be attributed to pathological and underage drinking. Greenfield and Rogers found that the top 5% of drinkers consume about 42% of the alcohol sold in the U.S.³ Moreover, about 17.5% of total consumer alcohol purchases are drunk by youth under the legal drinking age, according to Foster and colleagues.⁴

With that in mind, one can speak of the AI’s goal for alcohol sales to be As High As Reasonably Achievable (AHARA). This is analogous to the environmental health concept of ALARA (As Low As Reasonably Achievable) for exposure to radiation and toxic chemicals.^{5 (pp260-261)} “Reasonably achievable” for the alcohol industry means avoiding a popular or political backlash which could drastically reduce sales.

As we shall see in examining the individual IM strategies, maintaining AHARA requires a risk analysis that is stable over the long term yet nimble with regard to details.

The Four Strategies

1) Industry-run education programs

Since even relatively well-designed education and persuasion interventions are largely ineffective in achieving sustained behavior change,^6,⁷ it is no surprise that they remain a favored AI intervention. In fact, industry-run education programs in particular could be said to have four benefits: 1) they do not appreciably affect consumption (and thus do not cut into industry sales); 2) they draw attention and resources away from more effective interventions; 3) they offer a branding opportunity; and, 4) they create a “halo effect”, making the industry look beneficent.⁸

Currently, many industry-created education efforts are directed at parents. Examples include Family Talk About Drinking(Anheuser-Busch); Let’s Keep Talking (MillerCoors); Parents, You’re Not Done Yet (Century Council); and, Are You Doing Your Part? (Century Council). These efforts seek to frame underage drinking as ultimately the responsibility of parents. While, certainly, parents are an important factor in underage drinking,⁹ a large body of research points to the role of alcohol availability in youth drinking, including alcohol prices,¹⁰ alcohol outlet density,¹¹ and enforcement of underage drinking laws.¹²

Thus, industry education programs consist primarily of amplification of half-truths in conjunction with omission of other (especially environmental) factors and minimization of the full range of risks to public health and public safety.¹³

2) Focusing blame on individuals with a “problem”

As Dan Beauchamp made clear in his seminal Beyond Alcoholism: Alcohol and Public Health Policy,¹⁴ the rise of the alcoholism paradigm redirected attention away from the substance of alcohol and onto the problem drinker. While this perspective did have many positive aspects,¹⁵ it also gave the alcohol industry a “free pass,” since alcohol control strategies were seen to be irrelevant, at best.^16,¹⁷

Whereas within the mainstream alcohol studies community the alcoholism paradigm has largely been superseded by the public health paradigm, the AI and its apologists continue to embrace the former because of its IM utility. A prime example of that paradigm’s focus on the “problem” individual is the so-called “hard-core drunk driver,” the favored target of the Century Council and the American Beverage Institute. The Century Council defines these individuals as

those who drive with a high BAC of 0.15 or above, who do so repeatedly as demonstrated by having more than one drunk driving arrest, and who are highly resistant to changing their behavior despite previous sanctions, treatment or education.¹⁹

Chamberlain and Solomon¹⁹ observe that a disproportionate focus on the hard-core drunk driver tends to obscure the fact that “social” drinkers who binge occasionally are responsible for about 60% of alcohol-impaired driving trips and “are at a much higher relative risk of crash per trip than frequent drinking drivers with the same BACs” (p. 274). And yet, by blaming hard core drinking drivers, proponents of these stereotypes allow mainstream “social drinkers” to separate themselves from the impaired driving issue, without ever having to critically assess their own drinking and driving habits. (p. 272)

3) Promoting responsible drinking

Even the most cursory examination of alcohol advertising today will reveal the ubiquity of the “drink responsibly” message. In fact, many brands have even incorporated the r-word into their brand identity. For example, Captain Morgan message on rum commands: “Drink Responsibly – Captain’s Orders!”.

What “responsible” drinking means exactly is left to the individual imagination, leading Smith and colleagues²⁰ to characterize the term as “strategically ambiguous” in that the messages engender a “high degree of diversity in meanings of message content” while serving to “subtly advance both industry sales and public relations interests” (p. 1). Other researchers have also raised questions about the true impact of alcohol industry’s promotion of responsible drinking.^21,²²

One of the more blatant AI attempts to take advantage of the murky nature of the “drink responsibly” meaning was a highly-publicized Anheuser-Busch telephone survey in which 94% of responding drinkers claimed that they drank “responsibly” and “in moderation”.²³ Again, “responsibly” and “moderation” were conveniently left undefined. Moreover, it is a well-known marketing research axiom that survey respondents will tend to give socially desirable answers, especially in regard to questions about potentially sensitive topics like alcohol consumption.²⁴

By contrast, if alcohol companies were sincere about promoting true responsibility, they could use their considerable marketing muscle to design campaigns similar to the 0-1-2 Domino Strategy from FACE, a national, non-profit organization that educates the public’s understanding about alcohol and its impact, or the 0013 campaign from the U.S. Air Force. While these campaigns may have their limitations, at least they are direct, specific, mnemonic, and use evidence-based guidelines.

4) Denying any association between advertising and consumption

A key element of the alcohol industry IM program—and, indeed, of any industry which knowingly harms human health—is the deliberate obfuscation of scientific knowledge.^25,²⁶ This practice has been variously termed manufactured doubt,²⁷denialism, and agnotology.²⁸

With regard to the relationship between alcohol advertising and consumption, it was once a relatively easy task to deny a link, since many econometric studies found little evidence, perhaps due to methodological shortcomings.^6,

The denialist task is now more difficult given the recent spate of well-designed longitudinal studies showing a significant effect of alcohol advertising and marketing on the alcohol consumption of adolescents, in particular.⁷

Despite this, the AI and its allies prefer to ignore the last decade of research, with industry talking points repeated by corporate-libertarian think tanks such as the Cato Institute,²⁹ the American Enterprise Institute,³⁰ and the Washington Legal Foundation,³⁰ as well as related front groups such as the Statistical Assessment Service.³¹

Conclusion

Clearly, the AI has maintained a continuity in its IM strategies since the late 1970s, about the time the American public health community began to identify the AI as a significant factor influencing patterns of alcohol consumption.

Three of the four IM strategies identified by Bond, et al.² (industry-run education programs; focusing blame on individuals and groups with a “problem”, including minorities ; and denying any association between advertising and consumption) tightly parallel strategies from other industries. For example, the automobile industry’s nut-behind-the-wheel defense identified by Ralph Nader in his 1965 book Unsafe At Any Speed³² was also an attempt to shift the blame to “problem” individuals.

The third strategy, to feature vague messages in advertising about responsibility, however, seems to be peculiar to the alcohol industry, although the “responsibility” meme has been increasingly adopted by the gambling industry (Griffiths, 2009).³³

Countering these IM strategies and their concomitant deleterious effects on health and safety requires that public health practitioners, advocates, and activists to master two key competencies: Familiarity with the ways that the AI and its partners operate, and the research base that points toward truly effective prevention. (See Box 1 below for resources) , and Capabilityto communicate those concepts in ways that citizens can comprehend and appreciate, combined with facility with media advocacy techniques in order to effect a new social movement for the prevention of alcohol-related problems.³⁴ See Box 2 below for resources.

BOX 1

Box 1: Resources on Alcohol Industry

American Medical Association (2004). Alcohol industry 101: Its structure & organization. Chicago: American Medical Association. Available at:http://www.alcoholpolicymd.com/pdf/AMA_Final_web_1.pdf

American Medical Association (2002) Partner or foe? The alcohol industry, youth alcohol problems, and alcohol policy strategies. Available at: http://www.alcoholpolicymd.com/pdf/foe_final.pdf

Jahiel, R. I., & Babor, T. F. (2007). Industrial epidemics, public health advocacy and the alcohol industry: lessons from other fields. Addiction, 102(9), 1335-1339.

Jernigan, D. H. (2009). The global alcohol industry: an overview. Addiction, 104(Supp 1), 6-12.

Marin Institute. http://www.marininstitute.org/site/

Stenius, K., & Babor, T. F. (2009). The alcohol industry and public interest science. Addiction, doi: 10.1111/j.1360-0443.2009.02688.x.

BOX 2

Resources on Media Advocacy

Dorfman, L., Wallack, L., & Woodruff, K. (2005). More than a message: framing public health advocacy to change corporate practices. Health Education & Behavior, 32(3), 320-336; discussion 355-362.

Freudenberg, N., Bradley, S. P., & Serrano, M. (2009). Public health campaigns to change industry practices that damage health: An analysis of 12 case studies. Health Education & Behavior, 36(2), 230-249.

Harwood, E. M., Witson, J. C., Fan, D. P., & Wagenaar, A. C. (2005). Media advocacy and underage drinking policies: A study of Louisiana news media from 1994 through 2003. Health Promotion Practice, 6(3), 246-257.

Mosher, J. F. (1999). Alcohol policy and the young adult: Establishing priorities, building partnerships, overcoming barriers. Addiction, 94(3), 357-369.

Wallack, L., & Dorfman, L. (1996). Media advocacy: a strategy for advancing policy and promoting health. Health Education Quarterly, 23(3), 293-317.

Wallack, L., Dorfman, L., Jernigan, D., & Themba, M. (19963). Media advocacy and public health: Power for prevention. Newbury Park, CA: Sage Publications.

Robert S. Pezzolesi, MPH is Founder and President of the Center for Alcohol Policy Solutions in Syracuse, New York and blogs at Upstreaming Alcohol Policy at http://alcoholpolicy.org

References

1 Healton, C. G., Haviland, M. L., & Vargyas, E. (2004). Will the master settlement agreement achieve a lasting legacy?Health Promotion & Practice, 5(3 Suppl), 12S-17S.

2 Bond, L., Daube, M., & Chikritzhs, T. (2009). Access to confidential alcohol industry documents: From ‘Big Tobacco’ to ‘Big Booze’. Australasian Medical Journal, 1(3), 1-26.

3 Greenfield, T. K., & Rogers, J. D. (1999). Who drinks most of the alcohol in the US? The policy implications. Journal of Studies on Alcohol, 60(1), 78-89.

4 Foster, S. E., Vaughan, R. D., Foster, W. H., & Califano, J. A. (2006). Estimate of the commercial value of underage drinking and adult abusive and dependent drinking to the alcohol industry. Archives of Pediatrics & Adolescent Medicine, 160(5), 473-478.

5 Michaels, D. (2008). Doubt is their product: How industry’s assault on science threatens your health. Oxford: Oxford University Press.

6 Babor, T.F., Caetano, R., Casswell, S., Edwards, G., Giesbrecht, N., Graham, K., et al. (2003). Alcohol: No ordinary commodity. Oxford: Oxford University Press.

7 Anderson, P., Chisholm, D., & Fuhr, D.C. (2009). Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet, 373(9682), 2173-2174.

8 Klein, J., & Dawar, N. (2004). Corporate social responsibility and consumers’ attributions and brand evaluations in a product–harm crisis. International Journal of Research in Marketing, 21(3), 203-217.

9 Van der Zwaluw, C. S., Scholte, R. H. J., Vermulst, A. A., Buitelaar, J. K., Verkes, R. J., & Engels, R. C. M. E. (2008). Parental problem drinking, parenting, and adolescent alcohol use. Journal of Behavioral Medicine, 31(3), 189-200.

10 Hollingworth, W., Ebel, B. E., McCarty, C. A., Garrison, M. M., Christakis, D. A., & Rivara, F. P. (2006). Prevention of deaths from harmful drinking in the United States: The potential effects of tax increases and advertising bans on young drinkers. Journal of Studies on Alcohol, 67(2), 300-308.

11 Truong, K. D., & Sturm, R. (2009). Alcohol environments and disparities in exposure associated with adolescent drinking in California. American Journal of Public Health, 99(2), 264-270.

12 MMWR (2004). Enhanced enforcement of laws to prevent alcohol sales to underage persons–New Hampshire, 1999-2004.Morbidity and Mortality Weekly Report, 53(21), 452-454.

13 Lindsay, G. B., Merrill, R. M., Owens, A., & Barleen, N. A. (2008). Parenting manuals on underage drinking: Differences between alcohol industry and non-industry publications. American Journal of Health Education, 39(3), 130-137.

14 Beauchamp, D. E. (1980). . Philadelphia: Temple University Press.

15 Roizen, R. (1991). The American discovery of alcoholism, 1933-1939 (Doctoral dissertation). Retrieved on November 20, 2009, from http://www.roizen.com/ron/disshome.htm.

16 Bacon, S. (1971) The role of law in meeting problems of alcohol and drug use and abuse. In: Kiloh, L.G. & Bell, D.S. (eds) 29th International Congress on Alcoholism and Drug Dependence, Sydney, Australia, February, 1970 (Australia, Butterworths), pp. 162–172.

17 Room, R. (2004). Alcohol and harm reduction, then and now. Critical Public Health, 14, 329-344.

18 Century Council (n.d.). Hardcore drunk driving sourcebook. Arlington, VA: Century Council. Retrieved on November 19, 2009, from http://www.centurycouncil.org/files/materials/hdd_sourcebook1.pdf

19 Chamberlain, E. & Solomon, R. (2001). The tooth fairy, Santa Claus, and the hard core drinking driver. Injury Prevention, 7, 272–275.

20 Smith, S. W., Atkin, C. K., & Roznowski, J. (2006). Are “drink responsibly” alcohol campaigns strategically ambiguous?Health Communication, 20(1), 1-11.

21 Barry, A. E., & Goodson, P. (2009). Use (and misuse) of the responsible drinking message in public health and alcohol advertising: A review. Health Education & Behavior. doi: 10.1177/1090198109342393

22 DeJong, W., Atkin, C. K., & Wallack, L. (1992). A critical analysis of “moderation” advertising sponsored by the beer industry: Are “responsible drinking” commercials done responsibly? The Milbank Quarterly, 70(4), 661-678.

23 Harris Interactive (2008, November 12). Anheuser-Busch responsible drinking survey. Retrieved on November 23, 2009, from http://www.alcoholstats.org/mm/docs/6741.pdf.

24 Mick, D.G. (1996). Are studies of dark side variables confounded by socially desirable reporting? The case of materialism.Journal of Consumer Research, 23(2), 106-119.

25 Freudenberg, N. (2005). Public health advocacy to change corporate practices: Implications for health education practice and research. Health Education & Behavior, 32(3), 298-319.

26 Freudenberg, N., & Galea, S. (2008). The impact of corporate practices on health: Implications for health policy. Journal of Public Health Policy, 29(1), 86-104.

27 Krimsky, S. (2003). Science in the private interest: Has the lure of profits corrupted biomedical research? Lanham, MD: Rowman and Littlefield.

28 Proctor, R., & Schiebinger, L. (2008). Agnotology: The making and unmaking of ignorance. Stanford, CA: Stanford University Press.

29 Basham, P. & Luik, J. (2009). Banning alcohol ads won’t cure alcoholism. Retrieved on November 18, 2009, from http://www.cato.org/pub_display.php?pub_id=10371.

30 Calfee, J.E. (2004). A critical look at the new litigation against alcoholic beverage advertising. Retrieved on November 18, 2009, from http://www.aei.org/speech/20558.

31 Szalavitz, M. (2005). Alcohol and advertising. Retrieved on November 18, 2009, from http://www.alcoholnews.org/advertising.html..

32 Nader, R. (1965). Unsafe at any speed: The designed-in dangers of the American automobile. New York: Grossman.

33 Griffiths, M. D. (2009). Minimizing harm from gambling: what is the gambling industry’s role? Addiction, 104(5), 696-697.

34 Wallack, L., Winett, L., & Nettekoven, L. (2003) Preventing alcohol-related problems: Prospects for a new social movement [PowerPoint presentation]. Alcohol Policy XIII Conference, Boston, MA, March, 14, 2003. Retrieved on November 23, 2009, from http://www2.edc.org/alcoholpolicy13/presentations/wallack.ppt.

Photo Credits:
1. championsdrinkresponsibly
2. aleutia
3. maistora

Activists in Review: The Yes Men—taking on corporations, one prank at a time

Posted on January 1, 2010 by Corporations and Health Watch

In their ongoing efforts to reform corporations, advocates have used diverse tactics to expose detrimental practices or push for reform. On the one hand, public health professionals can change business practices that harm health by conducting research that documents the health problems associated with a particular product or industry and then bring these findings to the attention of policy makers. Another approach is to use tactics that expose and ridicule these types of corporate practices in an attempt to provoke media and public attention.

The two leading members of “The Yes Men,” known as “Andy Bichlbaum” and “Mike Bonanno” pose as Exxon oil executives shortly after making the announcement of a human-flesh-derived fuel called “Vivoleum” at the Oil and Gas Expo (GO-Expo 2007) in Calgary, Alberta.

The Yes Men, performance artists and global justice activists who expose corporate wrong doing, have used this latter approach by carrying out pranks and stunts to attract media coverage of dangerous or immoral business practices. In this profile, Corporations and Health Watch describes The Yes Men and analyzes the success of their antics in bringing about corporate change.

The Yes Men Fix the World

Perhaps the best way to explain The Yes Men, founded by performance artists and activists Mike Bonnano (real name, Igor Vamos) and Andy Bichlbaum (real name, Jacques Servin), is to describe some of their stunts.

In 1999, The Yes Men created GATT.org, a sham version of the World Trade Organization’s website that displays documents and reports satirizing the WTO’s approach to business. For example, a new release was posted stating : “At a Wharton Business School conference on business in Africa that took place on Saturday, November 11, the WTO announced the creation of a new, much-improved form of slavery for the parts of Africa that have been hardest hit by the 500-year history of free trade there.” After being mistaken for the real website, The Yes Men were invited to speak on behalf of the WTO with television reporters, schools and in other public settings.

In 2002, posing as trade experts, The Yes Men gave a lecture at a university in upstate New York proposing new solutions to world hunger. After serving the 100 students attending the talk free Big Macs, the lecturer proposed a new system for recycling Big Macs from human waste and serving them again. He showed a cost-benefit formula that proved the profitability of the recycling scheme, showing benefits for up to ten re-servings. By the end of the lecture, students were booing and hissing, just the reaction The Yes Men hoped to elicit.

In 2004, on the 20th anniversary of the toxic chemical disaster that killed about 20,000 people and left thousands more with chronic illnesses in Bhopal, India, The Yes Men posed as public spokesmen from Dow Chemical, the company that bought the Bhopal plant from Union Carbide. In an interview with BBC World News, the “spokesman” apologized profusely for the accident and promised that $12 billion would be donated to help clean up the waste site and provide compensation to the many people who were injured. Shortly after airing the interview, BBC World News discovered that the interview was a prank, leading it to apologize to its viewers for failing to uncover the deception. Dow denounced the hoax and reiterated their position that they had no responsibility for further compensation. Many newspapers and TV outlets covered the fake apology and the Dow response.

In 2007, Yes Man Andy Bichlbaum posed as an ethicist to deliver a speech to more than 300 oilmen attending Canada’s largest oil conference, GO-EXPO. During the speech, The Yes Men reassured the audience that even if oil procedures continue to cause environmental and health problems, the industry could turn the bodies of human victims into fuel. After lighting a candle of Vivoleum, a fuel allegedly made from human bodies, Bichlbaum was escorted off the stage. Yes Man Mike Bonanno joined the event posing as an spokesperson for Exxon. Later he told reporters, “If our idea of energy security is to increase the chances of climate calamity, we have a very funny sense of what security really is. While ExxonMobil continues to post record profits, they use their money to persuade governments to do nothing about climate change. This is a crime against humanity.”

Expose the Guts, Embarrass the Powerful, Have Fun

Under the teaching section on their website, The Yes Men explain their pedagogical approach:

When trying to understand how a machine works, it helps to expose its guts. The same can be said of powerful people or corporations who work hard to make themselves richer—regardless of consequence for everyone else. By catching powerful entities off guard, you can momentarily expose them to public scrutiny. This way, everyone sees how they work and can figure out how to control them. We call this identity correction. In a Nutshell:

Find a target (some entity running amok) and think of something sure to annoy them—something that’s also lots of fun.

If you’re stumped, imagine the target losing control and acting stupidly. What would it take to make them do that?

Capitalize on the target’s reaction. Write a press release and e-mail it to hundreds of journalists. In 1967, Yippies threw a hundred one-dollar bills from a balcony onto the New York Stock Exchange floor. The journalists they’d brought along told the world how the brokers, consumed with greed, dropped their trading and scrambled around for the money.

Preparing the Press Release. Imagine an “objective” newspaper story about the event. How would it read? Be realistic. Then write that story. (Got qualms? This is just what corporations do every day to sell products or candidates.)

The easiest way to embarrass someone powerful is to show how petty they are. Learn to embrace legal threats and use them as evidence in the court of public opinion.

: After a screening of the Yes Men Fix the World at the Roxie, audience members and other members participated in a performance about Chevron.

Yes Men Impact

So what’s the impact of The Yes Men? First, they have been successful in attracting media coverage. The confusion and excitement that their events elicit have brought their message to millions of people not often reached by corporate reformers. In the process, the group has cast a shadow on the public images of several major corporations, including Dow Chemical, Halliburton, ExxonMobil, and McDonalds and business organizations like the Chamber of Commerce and the World Trade Organization.

Two films have been made about The Yes Men and their exploits, The Yes Men (2003) and The Yes Men Fix the World (2009), allowing their messages to reach a wider audience and to educate and raises consciousness among activists and reformers.

Some critics accuse The Yes Men of being insensitive—creating hoaxes that could raise false hopes or deceive victims. Others say they are sophomoric, simply ridiculing companies without leading people to meaningful action. In a review of, The Yes Men Fix the World, the New York Times movie critic Stephen Holden observes: “Whether their high jinks accomplish much beyond momentarily embarrassing the corporations and government agencies they misrepresent at business conferences and public forums is an open question. But it is great fun to watch them do their dirty work.”

To be effective, public health researchers, professionals and activists seeking to change harmful business practices need to use a range of tactics and strategies. The Yes Men suggest a model that warrants consideration.

Angela Donadic is a Masters of Public Health student and writes for Corporations and Health Watch.

The two leading members of “The Yes Men,”, known as “Andy Bichlbaum” and “Mike Bonanno” pose as Exxon oil executives shortly after making the announcement of a human-flesh-derived fuel called “Vivoleum” at the Oil and Gas Expo (GO-Expo 2007) in Calgary, Alberta.

Photo Credits:
1. itzafineday
2. joeathialy
3. ari
4. itzafineday

After criticism, food industry abandons Smart Choices Program

Posted on January 1, 2010 by Corporations and Health Watch

In August 2009, major U.S. food manufacturers—including Kellogg, Kraft, ConAgra, General Mills, Pepsico, Sun-Maid, and Unilever—implemented the “Smart Choices” nutrition labeling program. Spending more than $1.47 million in 2008 and 2009 to develop the system featuring a green check mark and logo on foods that meet certain nutritional standards, 14 processed foods giants developed the system to promote their own products as “healthy.” ¹ Two months later, on October 23rd, the Smart Choices program announced that it would “voluntarily postpone active operations and not encourage wider use of the logo at this time by either new or currently enrolled companies.” What happened?

While the idea of putting a label on the front of the package to guide consumers in making healthy choices holds much appeal, food researchers and media critics were outraged by the standards used. “Smart Choices Foods: Dumb as They Look?” asked a headline in Forbes magazine. When Kellogg gave its sugar-dense Froot Loops and Cocoa Krispies the Smart Choice check (because of the vitamins they added and the milk children poured in), Walter C. Willett, chairman of the nutrition department of the Harvard School of Public Health told the New York Times, “These are horrible choices.” Awarding checks to these products, he explained, is “a blatant failure of this system and it makes it, I’m afraid, not credible.”

While media and scientific criticism of the Smart Choices program may have made the food industry uncomfortable, it was two government agencies that sent the industry-funded architects of Smart Choices back to the drawing board. On October 15th Connecticut State Attorney General Richard Blumenthal announced an investigation into “a potentially misleading national food label program that deems mayonnaise, sugar-laden cereals and other nutritionally suspect foods ‘Smart Choices.’’’

Blumenthal noted that, “These so-called Smart Choices seem nutritionally suspect—and the label potentially misleading… Our investigation asks what objective scientific standards, research or factual evidence justify labeling such products as ’smart.’ … Busy moms and dads deserve truth in labeling—particularly when their children‘s health is at stake.”

About a week after Blumenthal’s announcement, the U.S. Food and Drug Agency released a letter warning that Smart Choices may actually do more harm than good. They noted that their research suggested that Smart Choices, as implemented, may mislead customers about the health benefits of certain foods and may make consumers less likely to read the detailed nutrition facts panel. FDA Commissioner Margaret Hamburg told reporters that “There are products that have gotten the Smart Choices check mark that are almost 50 percent sugar.” ² In the cautionary letter, the FDA affirmed its position that, “both the criteria and symbols used in front-of-package and shelf-labeling systems be nutritionally sound, well-designed to help consumers make informed and healthy food choices, and not be false or misleading.” ³ Two days later, Smart Choices’ suspended operations and declared it welcomed the “opportunity to collaborate on front-of-package labeling with the FDA.” ⁴

Do health advocates support a unified Front of Package (FOP) labeling systems?

While food advocates and government officials rejected the particulars of Smart Choices, many of these critics, most notably the Center for Science in the Public Interest (CSPI), have long argued for an easy-to-use symbol to supplement the nutrition facts panel. In fact, CSPI submitted a petition to the FDA in November 2006 arguing for a simplified uniform national program. In this petition, they describe the inconsistent, confusing and misleading systems have been implemented by various corporations to promote their own products. For example, the petition by CSPI notes that:

Pepsi Co’s “Smart Spot” symbol has been applied to their Munchies Kid Mix, a snack mix that includes Cap’n Crunch cereal and Cheetos and candy-coated chocolate
General Mills has a “Goodness Corner” symbol that has been applied to its Chocolate Lucky Charms
Kraft’s “Sensible Solution” program has been applied to several high-fat cheeses, salty hot dogs, and Nabisco Strawberry Newtons
Kellogg uses misleading “Best to You” banners to “draw attention to a product’s more healthful attributes” while overlooking less healthful characteristics. For example, one banner advertises that the product contains “iron” and “energy” while overlooking excessive sugar content
the dairy industry allows a “3-A-Day” symbol on its products regardless of fat content
the American Heart Association’s “heart check” does not consider trans fats or refined sugars
Unilever’s “Eat Smart” allows for its extremely salty products to earn this label

Next steps: a nutritionally sound Front of Package (FOP) labeling system

Had it been properly designed and implemented, the Smart Choices program could have created a more unified and less confusing system for consumers. Instead, the food industry paid for a rating system that would not force it to make changes that might jeopardize profitability. CSPI Director Michael Jacobson believed the corporations participating in Smart Choices were hoping to avoid federal regulation of Front-of-Package labeling by showing the FDA that they were capable of developing a system on their own. ^5,⁶ He told the New York Times, “It clearly blew up in their faces. And the ironic thing is, their device for pre-empting government involvement actually seems to have stimulated government involvement.” ⁶ In its October 21st letter, the FDA promises to devise rules for FOP labeling that American consumers can trust. ³

So what are the lessons from the temporary demise of Smart Choices? First, active public oversight and monitoring can yield action. The threat of investigations by the Connecticut Attorney General and perhaps other State Attorneys General and the FDA’s cautionary letter clearly got the attention of the food industry, which feared bad publicity or possible legal action that could damage their reputation in a very tough economy. Second, the rating system established by the industry-funded Smart Choices program clearly does not meet most reasonable professional nutrition standards—one more example of industry self-regulation failing to safeguard public health. (For more on this, see Voluntary Guidelines vs. Public Oversight: Finding the right strategies to reduce harmful corporate practices) Finally, the Smart Choices story shows that with a new administration in Washington, advocates and state officials can hope for at least some level of support for their efforts from federal regulators, a dramatic change from a year ago.

On the other hand, it may be easier to stop a bad program like Smart Choices than to start an effective front-of-package labeling system. The decisions the FDA makes in the coming months will show whether the agency is willing to lead the fight for a labeling system that in fact promotes health. As FDA Commissioner Peggy Hamburg told reporters, “There‘s a growing proliferation of forms and symbols, check marks, numerical ratings, stars, heart icons and the like… There‘s truly a cacophony of approaches, not unlike the tower of Babel.” Whether the FDA can quiet that cacophony by requiring the food industry to speak in a language that all Americans can understand and use to make healthier food choices remains to be seen.

Lauren Evans is a student in the Doctor of Public Health program at City University of New York.

References

1 Ruiz R. Smart Choices Foods: Dumb as They Look? Processed-foods giants spent more than $1 million to create nutritional guidelines for a labeling system that favors their own products. Forbes.com. September 17, 2009. Available at http://www.forbes.com/2009/09/17/smart-choices-labels-lifestyle-health-foods.html. Accessed November 22, 2009.

2 Foodprocessing.com. Maybe a not-so-smart choice. October 26, 2009. Available at http://www.foodprocessing.com/industrynews/2009/141.html. Accessed November 14, 2009.

3 Foodconsumer.org FDA concerned about Smart Choices. October 24, 2009.

4 FDA. Guidance for Industry: Letter Regarding Point of Purchase Food Labeling. October 2009. Available at http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/
GuidanceDocuments/FoodLabelingNutrition/ucm187208.htm. Accessed November 22, 2009.

5 Press Release from Smart Choices Program. Smart Choices Program™ Postpones Active Operations: Group Welcomes Opportunity to Collaborate on Front-of-package Labeling with the FDA. October 23, 2009. Available at http://www.smartchoicesprogram.com/pr_091023_operations.html. Accessed November 22, 2009.

6 Neuman W. Food label program to suspend operations. October 23, 2009. The New York Times.

Image Credits:
1. KayVee.INC
2. Mike Licht, NotionsCapital.com

Cash for Clunkers: who benefits?

Posted on September 30, 2009 by Corporations and Health Watch

The Car Allowance Rebate System, better known as “Cash for Clunkers,” is a federal program that gave car buyers a rebate of up to $ 4,500 on a new car if they trade in an older, less fuel efficient car. The program is meant to stimulate the ailing U.S. economy and reduce pollution caused by cars by committing U.S. tax dollars to the foundering auto industry. Late last month, the federal government ended the Cash for Clunkers program two weeks early because the three billion dollars budgeted for the program had been nearly exhausted. Although hundreds of thousands of Americans took advantage of the rebate opportunity to purchase a new car, and nearly the entire budget was spent, it isn’t clear that Americans (and America) will emerge both economically and environmentally healthier. In this profile, CHW examines the impact of the Cash for Clunkers program on our nation’s health and the environment.

Clash for Clunkers was dramatically more successful in engaging new car buyers than Congress or the White House had imagined: the initial one billion dollar budget intended to last through Labor Day was exhausted so quickly that after just 10 days, Congress funneled another two billion dollars into the program to keep up with demand.

President Obama has declared the program a “proven success” citing the “50% increase in fuel economy” and “$700 to $1000 in annual savings for consumers in reduced gas costs alone…”¹ The White House’s assessment of the Cash for Clunkers program has reported some large and impressive numbers to back up their declaration of resounding success: nearly 700,000 cars were sold, $2.9 billion spent,² and an estimated 42,000 jobs will be created or saved during the second half of the year as a result of the Cash for Clunkers program. Motor vehicle output added 0.20 percentage point to the second-quarter change in real GDP.³

Has Cash for Clunkers Met its Goals?

Although hundreds of thousands of Americans took advantage of the rebate opportunity to purchase a new car, some environmentalists question whether Americans (and America) will emerge both economically and environmentally healthier. They focus on two issues. First, buyers who took the rebate still had to buy a brand new car at costs coming in somewhere around $25,000 to $30,000. This might have simply shifted consumers spending from one place to another. So instead of spending additional money that they wouldn’t have, new car buyers might now be unable to spend on “appliances, clothes and other stuff that consumers will not buy…now that they have the burden of lease or loan payments for their new vehicles.” ⁴ If this effect is significant, Cash for Clunkers may end up being simply a government plan to favor the success of the auto industry over the many other industries whose goods American could consider consuming. It is also estimated that 60 percent of the cars purchased under Cash for Clunkers would have been purchased this year anyway, meaning that we might see a post-Clunkers lull in business.⁴

What about the impact on air pollution? The difference between the average miles per gallon of the trade-ins versus the new cars bought through Cash for Clunkers was about nine miles per gallon.⁵ According to Jack Hidary, an architect of the Clash for Clunkers program, $700 is the gas savings for driving a car that is 10 miles per gallon more efficient, so it is likely that many buyers will save money by getting a new more fuel-efficient car. The Cash for Clunkers program, however, allowed consumers to trade vehicles in for cars that were only slightly more fuel-efficient. In the case of passenger cars, consumers could use the rebate to purchase a new car with just four miles per gallon more efficient gas use. In the case of light-duty trucks, the rebate was good for new vehicle purchases that got just one or two additional miles per gallon, emphasizing that reducing emissions was a secondary priority for the program.⁶

But even if new cars purchased under the program were significantly more fuel efficient, it seems unlikely that the program’s impact will be big enough to improve air quality on its own. One columnist noted that if the new cars purchased under the rebate program get “ten miles per gallon more than the Clunkers they replace, the reduction in gasoline consumption will cut our oil consumption by 0.2 percent per year, or less than a single day’s gasoline use.” ⁴ Few interventions of any kind can contribute to significant, long-term change unilaterally, so it is not surprising that a program like Cash for Clunkers can’t single-handedly make drastic environmental improvements. Perhaps the only undoubted success of Cash for Clunkers has been its impact on the auto industy: Ford and General Motors saw ten and 21 percent increases in sales in August compared to July.⁷ Toyota posted even bigger gains.

Measuring Up a “Proven Success”

So was Cash for Clunkers good, bad, or a wash? It is worth remembering that public policies to improve the economy and environment are implemented because unemployment and pollution undermine the long- and short-term health and well-being of human, not because the government or civil society has an interest in the physical environment or job markets in and of themselves. Therefore, measuring the success of the Clash for Clunkers program must compare the opportunities provided and lost to improve public health.

Several news articles have mentioned the safety benefits of Cash for Clunkers: newer cars have better and more safety features, therefore the program will put safer cars on the road. As Consumer Reports mentions:

“…450,778 SUVs and other light trucks that likely lacked electronic stability control and other modern safety equipment [were taken off the road through Cash for Clunker]. The National Highway Traffic Safety Administration has estimated that making ESC standard on new cars would save as many as 10,000 lives a year. This program has taken a significant step toward that goal.”⁵

This is great news, but thinking about vehicle safety also begs the question: why should the federal government spend three billion tax dollars on bailing out an industry whose products kills and injures so many Americans? In 2008, there were 37, 261 people killed in motor vehicle crashes (a record low) and nearly 2.35 million injured. By those figures alone, the morbidity and mortality caused each year by motor vehicles dwarfs the potential safety gains from Cash for Clunkers. In 2007, a total of 288 people were killed on mass transit of any kind, a number less than 1% of those killed by passenger vehicles.⁸ In 2006 there were 19, 238 people injured on all forms of mass transit, 122 times fewer injuries than the more than two million caused by motor vehicles.⁹ Yes, these are absolute numbers- so how do these numbers compare when looking at rates? Motor vehicles kill five times as many people per passenger mile than mass transit.¹⁰

Public transportation systems, especially light and heavy rails systems, also create less fuel emissions than motor vehicle, and therefore provide a much longer-term investment in environmental health than Cash for Clunkers can achieve. What if Congress had instead given the auto industry $3 billion to invest in developing new capacities for making mass transit vehicles?

The Cash for Clunkers program also represents a lost opportunity to improve public health in other ways. The nearly three billion dollars spent to boost the auto industy did very little for a key piece of our economic crisis: inequality. The proportion of wealth and earnings by the richest 10% of our communities has steadily risen in the past 30 years. This growing inequality was intimately connected to the underlying causes of the current economic crisis: predatory lending and banking practices that promised to earn executives and their brokers exorbitant amounts of money. Inequality has been documented in public health research as a causal factor in social and health outcomes as diverse as teen birth and mortality. The Cash for Clunkers program, however did little to provide a way for low-income folks to benefit from the government commitment to stimulate the economy. For example, despite the claimed objective to get “clunkers” off the road, cars older than 25 years could not be traded in for the rebate, even though they are the most-polluting, and least fuel efficient and safety advanced vehicles. Also, all cars that were traded in, even if they were fairly new and running well, had to be destroyed under the program’s rules, bringing up the questions of what to do with 700,000 newly junked cars. Will lower-income families who cannot afford a brand new car now have more trouble finding a used (but less than 25 year old) car at all, since trade-ins have to be legally destroyed? Will the destroyed cars pose another set of environmental problems?

As one columnist argued: “…By mandating the destruction of trade-ins, Congress removed 700,000 cars from the used-car market, inevitably driving up prices of the cars that lower-income consumers tend to buy.”⁴

While no data have come out showing this prediction to be true, it seems that the Cash for Clunkers program did not take advantage of what we know about public health: policy approaches to reduce inequality have economic and health benefits. These same policy approaches, however, also require abandoning the government’s monetary, legislative, and otherwise political support of corporations that harm health. From the subsidizing of harmful industries like the auto industy to the extreme financial deregulation of a decade ago, these pro-corporate polices may appear to be bids for a strong economy, but the impacts are much different. For example, financial deregulation led to the lending practices that disproportionately preyed upon low-income communities and communities of color, and led to the current economic recession.

How About Cash for Buses and Subways?

Why, then, should the federal government’s stimulus efforts ensure that the auto industry survives, as opposed to investing in any other businesses or industries in the United States? An alternative to bailing out a failing industry is to invest in an industry that has seen sharp growth in the past year: mass transit. Currently, mass transit systems across the country are experiencing tremendous cuts to their already inadequate budgets. For example, in July alone the New York City Metro Transit Authority announced 360 jobs cuts, despite having experienced a significant uptick in ridership since the U.S. economy took a downturn. Although mass transit systems are efficient and affordable for riders, urban municipalities that currently maintain such systems do not have sufficient funds to maintain and upgrade them, and fare revenues cover only from 20 to 50% of the costs of maintaining the transit systems.¹¹

src=”uploads/images/old_archives/img/mass_transit_promotion.png” alt=”mass transit promotion by Metro Library and Archive” hspace=”10″ vspace=”5″ width=”250″ height=”250″ align=”right” />A stimulus package that invests in the research, business planning, and workforce to upgrade and create effective mass transit systems has multiple benefits. Cash for Clunkers may have caused an uptick in the employment and earning of auto industry workers, but as many have pointed out, nearly 60% of the sales made under Clash for Clunkers would have happened in the next year anyway, leaving auto workers to brace for another severe dip in demand. Investing in mass transit infrastructure, on the other hand, will lay the groundwork for strong job markets in a variety of fields (from engineering to sanitation) required to support smart, efficient public transportation. The recession has caused a surged in mass transit use across the country, causing its use to reach a 50-year high11,¹² and therefore providing a key opportunity to shift transportation trends in the U.S. towards the long-term, permanent growth of these infrastructures. In fact, the Obama Administration’s stimulus package did commit just over eight billion dollars to capital improvements in mass transit systems, including high speed rail lines.12,¹³ Hopefully this infusion of funds represents more than a temporary stimulus, but a longer-term investment in health promoting industries than can provide sustainable employment, and provide for safe, effective transportation for many times more Americans than just those who can afford a new car.

The gains to the health of U.S. economy and environment as a result of the Cash for Clunkers program can be considered modest at best, and at worst, the U.S. government’s political investment in supporting an industry whose products, cars and trucks, directly contributes to poor health in several ways. The need for government to spur spending, and therefore job growth, could have dovetailed with environmental and public health goals much more effectively. Public policies that foster investments in public transportation is just one of those alternatives. Strengthening mass transit will stimulate job growth and retention in an industry that can be counted on to continue to experience thriving market demand, reduce American consumers’ impact on the environment, and promote public health.

References

1 Hedgpeth D; Bacon P.With Senate Vote, Congress Refuels ‘Clunkers’ Program. The Washington Post August 7, 2009. Available at: http://www.washingtonpost.com/wp-dyn/content/article/2009/08/06/AR2009080601656.html. Accessed August 16, 2009.

2 Puzzanghera J; Zimmerman M. ‘Cash for clunkers’ final tally: nearly 700,000 cars sold. Los Angeles Times. Available at:http://www.latimes.com/business/la-fi-clunkers27-2009aug27,0,2161518.story?page=2 Accessed August 31, 2009.

3 Bureau of Economic Analysis. Available at: http://www.bea.gov/newsreleases/national/gdp/gdpnewsrelease.htm. Accessed September 1, 2009.

4 Stelzer I. Seven lessons of Cash for Clunkers’ failure The San Francisco Examiner. August 28, 2009. Available at:http://www.sfexaminer.com/opinion/columns/Irwin_Stelzer/Seven-lessons-of-Cash-for-Clunkers-failure-55595162.html. Accessed September 1, 2009.

5 Evarts E. Consumer Reports. August 27, 2009. Available at: http://blogs.consumerreports.org/cars/cash-for-clunkers/index.html. Accessed September 1, 2009.

6 Fact Sheet: Cash for Clunkers Committee on Energy and Commerce. June 8, 2009. Available at:http://energycommerce.house.gov/Press_111/20090505/
cashforclunkers.pdf. Accessed August 2, 2009.

7 Barth L. September 2, 2009. Available at: http://blogs.consumerreports.org/cars/cash-for-clunkers/index.html. Accessed September 2, 2009.

8 United States Department of Transportation Federal Transit Administration. Available at: http://transit-safety.volpe.dot.gov/Data/samis/default.asp?ReportID=2. Accessed September 1, 2009.

9 Bureau of Transportation Statistics. Table 2-33c: Table 2-33a: Transit Safety Data by Modea for All Reported Incidents. Available at: http://www.bts.gov/publications/national_transportation_
statistics/html/table_02_33a.html. Accessed August 25, 2009.

10 Morris EA.The Danger of Safety. Freakonomics Blog from The New York Times.July 2, 2009. Available at:http://freakonomics.blogs.nytimes.com/2009/07/02/the-danger-of-safety/?apage=2. Accessed September 1, 2009.

11 Public Transit Faces New Pressures. March 10th, 2009. Available at:http://www.pbs.org/wnet/blueprintamerica/reports/transit-in-trouble/video-public-transit-faces-new-pressures-part-one/485/. Accessed September 1, 2009.

12 Epstein, D. For Ailing Transit Systems, Stimulus Windfall Is a Mixed Blessing. June 21, 2009. Available at:http://www.propublica.org/ion/stimulus/item/for-ailing-transit-systems-stimulus-windfall-is-a-mixed-blessing-621. Accessed September 2, 2009.

13 Hochberg A. A Hitch For Rail Riders: Getting To Final Destination. September 2, 2009. Available at:http://www.npr.org/templates/story/story.php?storyId=112467963. Accessed September 2, 2009.

Photo Credits:

1. billselak
2. metrolibraryarchive

The health impact of retail practices: towards a research agenda

Posted on September 30, 2009 by Corporations and Health Watch

Every day, owners and managers of hundreds of thousands of retail establishments across the United States make decisions that influence the health of the American people. They decide what to sell, which products to promote, where to display goods and how much to charge for them, and where to locate new outlets. Their decisions shape the choices consumers face in the market and make it easier or harder for people to buy tobacco, alcohol, food and beverages, medicines, firearms, automobiles or many other products associated with current patterns of health and disease. In this review, Corporations and Health Watch provides an overview of the impact of retail practices on health and suggests some directions for future research that can guide policies to encourage health-promoting and discourage health-harming retail practices.

Retail practices are the decisions that owners and managers of retail establishments make about how, where and when to sell what to whom. These practices, listed below, are shaped by corporate policies, the state of the economy, government regulations, customer behavior and many other factors. Other business practices such as product design, pricing and advertising influence and are influenced by decisions about retailing, making it difficult to isolate the unique impact of decisions about retail operations.

While public health officials and advocates have sometimes looked at specific retail practices such as the sales of tobacco products to minors or food safety procedures in restaurants, few public health agencies or researchers have systematically considered retail practices as an important influence on health or considered alternative approaches to encouraging healthier retail business practices.

Selected Retail Practices

Point of purchase advertising
Local advertising
Internet merchandising
Location and density of stores
Product placement within stores and on shelves
Shelf space dedicated to various products
Sales and pricing
Labeling and warning signs
Verification of customer eligibility (e.g. tobacco, alcohol and guns)

As we shall see, growing evidence makes a compelling case for studying the health impact of retail practices more carefully and of developing new approaches to preventing their adverse consequences. First, retail outlets are everywhere, as shown below. No community and few neighborhoods are without several convenience stores, fast food establishments, tobacco and alcohol outlets and drug stores. Most Americans can buy a gun or an automobile within a few miles of their home. On any given day, up to 100 million Americans visit a convenience store.¹ Thus retail outlets are a ubiquitous part of our social environment that play a major role in determining patterns of the sale and consumption of healthy and less healthy products.

Prevalence of Selected Retail Outlets in US

19,700 new car and truck dealers ²

30,000 beer, wine and liquor stores ³

35,394 supermarkets with $2 million or more in annual sales⁴

54,000 federally licensed gun dealers⁵

56,000 retail pharmacies⁶

80,000 casual-dining restaurants⁷

144,875 convenience stores⁸

195,000 fast-food establishment⁷

Second, data suggest that number of retail outlets or their size is growing, at least in some categories. Between 1970 and 2001, for example, the number of fast food restaurants in the United States increased more than seven-fold, from 30,000 to 222,000.⁹ While the overall number of super markets appears to have declined, the number of very large stores has increased significantly. Wal-Mart, for example, the world’s largest public corporation, operated 125 stores in the United States in 1975 and 3,800 by 2005.¹⁰ The vastly expanded shelf space available in Wal-Mart superstores puts many more products, some healthy and many unhealthy, at the fingertips of consumers across the United States, profoundly influencing the diet of millions of Americans. Similarly, the growth of pharmacy retail chains puts many drug, food and other products within easy reach.

Third, a growing body of research evidence shows that the characteristics of retail establishments influence health and health behavior. For example, local gun retail availability is significantly associated with increased risk of firearm injury and homicide,¹¹ and alcohol outlet density is associated with self-reported driving after drinking and drinking frequency.¹²Patients living in areas with fewer pharmacies are less likely to fill prescriptions for medications.¹³ Exposure to point-of-purchase tobacco advertising is associated with higher tobacco use.¹⁴ These and dozens of other studies show that retail practices influence health, making a summary and synthesis of these diverse studies an important priority. For a selected bibliography on the health impact of retail practices in the alcohol, automobile, firearm, food and beverage, pharmaceutical and tobacco industries, click here.

In addition, differences in retail practices in different types of communities may contribute to socioeconomic and racial disparities in health. For example, the differing retail face of the alcohol, tobacco and food industries in better off and poor neighborhoods and in Black, Latino and white areas may explain some of the differences in cancer prevalence among these communities. ¹⁵ In some studies, differences in the density of supermarkets and fast food outlets in neighborhoods with different socioeconomic and racial/ethnic characteristics have been associated with differences in rates of obesity.¹⁶ ¹⁷

Convenience stores illustrate well how retail outlets can become amplifiers of ill health. Often sited at gasoline stations, convenience stores sell candy, ice-cream, soft drinks, and processed food as well as other products and perhaps some groceries. They are often located along busy highways, in densely-populated urban neighborhoods, or near transportation hubs. Some are open 24 hours a day. In 1994, there were 98,200 convenience stores in the US, today the count is 144,875, an increase of almost 50%.⁸ In 2008, as shown below, convenience stores sales of cigarettes and other tobacco products accounted for 36.6 % of in-store sales; packaged beverages, mostly sweetened sodas, accounted for 14.1 %; food service, often high fat, sugar and salt cooked products, accounted for 13.9% and beer for 10.2 %.¹⁸ This product mix makes these outlets convenient places to purchase the products associated with the nation’s most serious health problems including heart disease, diabetes, stroke, cancer and alcohol-related motor vehicle accidents.

Percentage of Products Sold at Convenience Stores, 2008

Convenience stores sell the products associated with the nation’s most serious health problems including heart disease, diabetes, stroke, cancer and alcohol-related motor vehicle accidents.

Changing Retail Practices to Improve Health

Fortunately, there are several domains of experience in modifying the health impact of retail practices that provide evidence that can guide policy and practice. As shown below, local, state and federal governments, consumers, corporations and retail owners themselves can each take action to change harmful practices. To date, most of these approaches have been tried somewhere but few studies provide evidence about which strategies or mix of strategies are most effective in promoting health and under what circumstances.

Strategies for Changing Retail Practices to Promote Health and Prevent Disease

Changes initiated by government

Regulation of products (what is sold, price (via taxes or subsidies), quality; customers (age, sobriety, mental status, criminal record); store environment (safety, hygiene, etc.)
Requirements for posting of labels or warning signs
Requirements on density of outlets, distance from schools or churches
Regulations on hours of operations

Changes initiated by consumers

Community organizing to encourage police or regulatory action
Boycotts of stores or products

Changes initiated by corporations

Slotting fees to support healthier products
Development and promotion to retailers of healthier products

Changes initialed by retailers

Voluntary posting of health information
Strict enforcement of rules on sales to minors
Discounts on healthier products

To illustrate with tobacco, perhaps the industry with the best studied retail practices, change can come about through:

Restrictions on sales to minors
Requirements for warning labels in stores
Zoning laws limiting density of tobacco outlets
Requirements for placement of displays of tobacco products
Consumer boycotts of merchants who continue to sell to minors
Ending tobacco industry payments and incentives to merchants who sell their products
Voluntary retailer agreement to stop selling or displaying tobacco products

A review of the evidence on retail practices provides some grounds for optimism that changes in these practices can contribute to healthier environments, behaviors and health outcomes. For example, the decision by a single gun store owner in Milwaukee to stop selling cheap Saturday night special hand guns was associated with a 96% decrease in recently sold, small, inexpensive handguns use in crime in Milwaukee, a 73% decrease in crime guns recently sold by this dealer, and a 44% decrease in the flow of all new, trafficked guns to criminals in Milwaukee.¹⁹ In 2007, New York City required restaurant chains to post prominently the caloric content of the food they sold, a policy subsequently adopted by many other municipalities and states. Preliminary evidence suggests that calorie posting may be associated with changes in consumer behavior and in the products that restaurants offer but more research is needed.²⁰ ²¹ ²² ²³ Synthesizing findings such as these from policy, programmatic, voluntary and mandatory efforts to change retail practices across industries and jurisdictions may contribute to new approaches to primary prevention.

Research Questions on Retail Practices and Health

Available evidence suggests that retail practices influence health, that intentional changes in these practices can promote health, and that some jurisdictions have successfully implemented such changes. Thus, the development of a systematic body of knowledge to guide elected and public health officials and advocates may help to accelerate these changes, thus reducing the prevalence and inequities in chronic diseases, accidents and injuries and other health problems. What are some research priorities for a better understanding of the impact of retail practices on health?

How do retail practices change over time and place?

In the last few decades, the density and size of many retail outlets has increased significantly. Some sectors have become increasingly vertically integrated—think Wal-Mart –giving them far greater influence in the economy and in communities. How do macro-economic forces change retail practices? The current recession seems to be favoring retailers who offer bargains and hurting more high-end outlets. What are the health consequences of these changes? Does the recession present any opportunities for more effective oversight of harmful retail practices? What are the best metrics for studying changes in retail practices? For example, a recent study found that that the cumulative shelf-space allocated to energy-dense snack foods was positively but modestly associated with BMI²⁴, suggesting that the imaginative selection of indicators such as shelf-space may help to assess the impact of changes in retail practices.

What’s the role of retailers in the supply chain and what decisions do they make?

From the time a product is manufactured until it reaches the consumer’s hands, it passes through many other hands, including growers, factory workers, packagers, wholesalers, distributors, and truckers. What is the influence of each of these stages on the health impact of retail practices? What are the opportunities for intervention at each stage? In addition, retailers vary in the degree of vertical integration and autonomy granted to local managers.²⁵ How do the health-related retail practices of a vertically integrated company like Wal-Mart,¹⁰ which provides detailed real-time data on purchases to store managers, differ from those of chains that give franchisees more autonomy, such as the Subway fast food chain or independent retailers?

To change retail practices will require identifying who makes what decisions. At McDonald’s, for example, managers have little control over what products to offer, suggesting that campaigns to modify product mix will need to target the national corporate level. Bodegas and grocery stores, on the other hand, could decide to display alcohol and tobacco products less prominently, perhaps in exchange for support from health officials for displaying healthier products. Some chain stores set retail prices nationally, while others give local managers discretion. Mapping decision-making across industries and levels (e.g., global and national corporate, regional and local) might help health officials decide on appropriate levels for intervention to achieve a specified change in practice.

What’s the impact of retail practices on disparities in health?

As noted previously, differences in retail practices in communities with different socioeconomic and racial/ethnic characteristics appear to contribute to health inequities.¹⁵ What is the fraction of inequities in obesity, diabetes or heart disease that can be attributed to such differences? What are the windows of opportunity for changing disparity-enhancing retail practices such as higher density of alcohol outlets in poor communities or more lax enforcement of tobacco regulations? Does the human rights perspective or civil rights law offer a way of re-framing these issues? For example, some community groups have charged that higher densities of fast food outlets in Black or Latino neighborhoods constitutes a form of racial profiling that widen disparities in health.

On another front, health advocates need to ensure that health-promoting changes in retail practices do not end up exacerbating health inequities. For example, if a supermarket offers healthier food at a higher price, only better off customers may benefit, widening existing socioeconomic disparities in obesity or other food-related health conditions.

What incentives can health officials use to encourage health-promoting changes in retail practices?

For retailers to change practices voluntarily, the costs of change and the adverse impact on their bottom lines need to be low and the promise of a better reputation and increased sales volume and profits needs to be high. A pharmacist may be willing to offer discounts on some prescription medicine to attract customers or a fast food outlet may add salads or fruits to their menus to entice health-conscious mothers and their children. When do these changes lead to real improvement in health and when are they merely public relations window dressing? Health officials and advocates with a firm grasp of how retailers make decisions might be better able to negotiate meaningful changes than those who have to rely on retailers’ good will. For example, a study of how fast food owners made decisions about their menus found that obstacles to healthier menus included the belief that the demand for healthier foods is low and that healthier menu items have a short shelf life and take more time and money to prepare.²⁶ Finding ways to help managers overcome these obstacles may lead to change.

What advocacy strategies are most effective in changing retail practices?

Only a few studies have compared advocacy strategies across industries²⁷ ²⁸, and none appear to have focused specifically on campaigns to change retail practices. Developing evidence-based guidelines for selecting the most effective activities to change practices such as location of retail outlets, point-of-purchase marketing or store-based labeling can help health officials and advocates to make more informed strategic decisions.

From a community organizing perspective, one asset for mobilizing for changes in retail practices is that retail outlets have a visible presence in most communities, making them an attractive target. On another level, small business owners often identify with their communities, making them perhaps more open to moral appeals for changing harmful practices and also less likely to leave for other jurisdictions in response to demands for change.

For retail outlets that are closely controlled by a single corporation – McDonalds, Wal-Mart, Walgreens or CVS Pharmacies — shareholder actions by national consumer groups or corporate campaigns using internet or other new communications media might be an option. For global companies whose brand names and logos are their most valuable asset, the threat of a campaign that could engage customers in boycotts or brand shifting at local outlets around the country or world remains a powerful fear.²⁹

Aggregating and analyzing advocacy and health department experiences from diverse efforts to change retail practices can help to develop a framework for selecting effective and efficient strategies.

How can advocates integrate local and global efforts to reduce the harm of retail practices?

Activists seeking to change corporate practices that harm health have learned that successes in one place can lead to defeats in others. In tobacco control, for example, success in changing the practices of the tobacco industry in the United States and other developed nations has led to more aggressive marketing and public relations campaigns in Africa, Asia and Latin America. Forcing harmful practices to migrate to another region or country can unintentionally maintain or exacerbate developed and developing nation disparities. How can public health officials and advocates avoid this outcome as they seek to change retail practices? One strategy that some corporate reform groups have used is to establish global websites and networks, providing a forum for activists working across issues, industries and continents to share information and debate strategy. Some of these focus more on labor and environmental issues than on the retail consumer practices described here. The box below shows some sources on monitoring retail practices.

Selected resources and organizations on monitoring of retail practices

Corporate Accountability International Value the Meal

Cruz TB. Monitoring the tobacco use epidemic IV. The vector: Tobacco industry data sources and recommendations for research and evaluation. Prev Med. 2009;48(1 Suppl):S24-34.

McSpotlight

Slater S, Giovino G, Chaloupka F. Surveillance of tobacco industry retail marketing activities of reduced harm products. Nicotine Tob Res. 2008;10(1):187-93.

Sprawl-Busters

Wagner MM, Robinson JM, Tsui FC, Espino JU, Hogan WR. Design of a national retail data monitor for public health surveillance. J Am Med Inform Assoc. 2003;10(5):409-18.

Wagner MM, Tsui FC, Espino J, et al. National Retail Data Monitor for public health surveillance. MMWR Morb Mortal Wkly Rep. 2004 Sep 24;53 Suppl:40-2

Wal-Mart Watch

Towards a public health agenda on retail practices
In sum, retail outlets constitute a critical intermediary between the producers and consumers of products that influence health. A better understanding of the forces that shape retail environments and practices may help to inform new approaches to primary prevention of our most serious health problems in these settings. By defining research, advocacy and policy agendas to enhance health- promoting and discourage health-damaging or disparity-widening retail practices, health professionals can contribute to improved population health.

By Nicholas Freudenberg, Distinguished Professor of Public Health at Hunter College, City University of New York and the founder and director of Corporations and Health Watch.

References

1 Aruvian Research. Convenience Stores in United States – Porter’s Five Forces Strategy Analysis. March 2009. Available at:http://www.researchandmarkets.com/reportinfo.asp?cat_id=0&report_id=585702&q=convenience%20stores%20
in%20United%20States&p=1.

2 About the National Automobile Dealers Association. No date. Available at: http://www.nada.org/AboutNADA/.

3 Hoovers. Beer, Wine and Liquor Stores Industry Overview. No date. Available at: http://www.hoovers.com/beer,-wine,-and-liquor-stores/–ID__200–/free-ind-fr-profile-basic.xhtml.

4 Food Marketing Institute. Industry Overview 2008. Available at: http://www.fmi.org/facts_figs/?fuseaction=superfact.

5 Vernick JS, Webster DW, Bulzacchelli MT, Mair JS. Regulation of firearm dealers in the United States: an analysis of state law and opportunities for improvement. J Law Med Ethics. 2006;34(4):765-75.

6 Brooks JM, Doucette WR, Wan S, Klepser DG. Retail pharmacy market structure and performance. Inquiry. 2008;45(1):75-88.

7 Fitzgerald M. Making fast food even faster. October 27, 2007. New York Times. Available at:http://www.nytimes.com/2007/10/28/technology/28proto.html.

8 National Association of Convenience Stores. About NACS. No date. Available at:http://www.nacsonline.com/NACS/About_NACS/Pages/default.aspx.

9 Paerataku S, Ferdinan D, Champagne C, Ryan D, Bray G. Fast food consumption and dietary intake profiles – Fast Food. Nutrition Research Newsletter, Nov, 2003. Available at: http://findarticles.com/p/articles/mi_m0887/is_11_22/
ai_111023412/.

10 Lichtenstein. N The retail revolution How Wal-Mart created a brave new world of business.; New York: Metropolitan Books, 2009.

11 Miller M, Azrael D, Hemenway D. Firearm availability and suicide, homicide, and unintentional firearm deaths among women. J Urban Health. 2002 ;79(1):26-38.

12 Gruenewald PJ, Johnson FW, Treno AJ. Outlets, drinking and driving: a multilevel analysis of availability. J Stud Alcohol. 2002;63(4):460-8.

13 Brooks JM, Doucette WR, Wan S, Klepser DG. Retail pharmacy market structure and performance. Inquiry. 2008 Spring;45(1):75-88.

14 Pollay RW. More than meets the eye: on the importance of retail cigarette merchandising. Tob Control. 2007 Aug;16(4):270-4.

15 Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved. 2008 Feb;19(1):26-40.

16 Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74-81.

17 Morland KB, Evenson KR. Obesity prevalence and the local food environment. Health Place. 2009;15(2):491-5.

18 Reuters. Convenience Store Sales, Profits Showed Gains in 2008, According to NACS. April 7, 2009. Available at:http://www.reuters.com/article/pressRelease/idUS150522+07-Apr-2009+PRN20090407.

19 Webster DW, Vernick JS, Bulzacchelli MT. Effects of a gun dealer’s change in sales practices on the supply of guns to criminals. J Urban Health. 2006;83(5):778-87.

20 Harnack LJ, French SA. Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: A review of the literature. Int J Behav Nutr Phys Act. 2008 ;5:51.

21 Ludwig DS, Brownell KD. Public health action amid scientific uncertainty: the case of restaurant calorie labeling regulations. JAMA. 2009;302(4):434-5.

22 Kuo T, Jarosz CJ, Simon P, Fielding JE. Menu labeling as a potential strategy for combating the obesity epidemic: a health impact assessment. Am J Public Health. 2009;99(9):1680-6.

23 Gerend MA. Does calorie information promote lower calorie fast food choices among college students? J Adolesc Health. 2009;44(1):84-6.

24 Rose D, Hutchinson PL, Bodor JN, Swalm CM, Farley TA, Cohen DA, Rice JC. Neighborhood food environments and Body Mass Index: the importance of in-store contents. Am J Prev Med. 2009;37(3):214-9.

25 Paik Y, Choik DY. Control, autonomy and collaboration in the fast food industry. International Small Business Journal 2007; 25(5):539-562.

26 Glanz K, Resnicow K, Seymour J, Hoy K, Stewart H, Lyons M, Goldberg J. How major restaurant chains plan their menus: the role of profit, demand, and health. Am J Prev Med. 2007;32(5):383-8.

27 Nathanson CA. Social movements as catalysts for policy change: the case of smoking and guns. J Health Polit Policy Law. 1999;24(3):421-88.

28 Freudenberg N, Bradley SP, Serrano M. Public health campaigns to change industry practices that damage health: an analysis of 12 case studies. Health Educ Behav. 2009;36(2):230-49.

29 Jones P, Comfort d., Hillier d. Anti-corporate retailer campaigns on the internet. International Journal of Retail Distribution Management 2006;34(12): 882-891.

Photo Credits:
1. roadsidepictures
2. k-ideas
3. glasgows
4. loneprimate
5. walmartmovie

Healthy Skepticism: Countering misleading drug promotion advertising and promoting healthy skepticism about pharmaceutical marketing practices

Posted on September 30, 2009 by Corporations and Health Watch

Healthy Skepticism is an international non-profit organization with headquarters in Adelaide, Australia. Its website http://www.healthyskepticism.org offers a collection of journal articles focusing mainly on the problems that arise when pharmaceutical companies advertise directly to physicians and publishes a monthly newsletter for its member subscribers.

Healthy Skepticism is an international non-profit organization with headquarters in Adelaide, Australia. Its website, www.healthyskepticism.org, offers a collection of journal articles focusing mainly on the problems that arise when pharmaceutical companies advertise directly to physicians. Other articles deal with problems arising from Direct to Consumer (DTC) advertising, misleading and unethical advertisements, and issues such as government policies on pharmaceuticals. In a fact sheet, the organization offers seven reasons why we should all be concerned about the harmful effects of drug promotion.

This extensive collection includes references for over 16,000 articles and is updated regularly. In addition, the organization publishes a monthly newsletter for its member subscribers, most of whom are physicians and pharmacists. You may become a free subscriber by using this link http://www.healthyskepticism.org/lists/?p=subscribe.

Dangerous levels of salt in chain restaurant meals prompts action by public health departments and a lawsuit against Denny’s Corporation

Posted on September 30, 2009 by Corporations and Health Watch

Food manufacturers and chain restaurants continue to increase the amount of sodium in their foods to dangerously high levels. Growing concern about the salt in processed and restaurant foods and the lack of industry concern over the health of the American people has led advocates to consider new ways to encourage the food industry to lower the salt in processed food. In this report, CHW describes two distinct efforts: a national initiative started by the New York City Department of Health in April 2009 and a class action lawsuit filed in July 2009 against Denny’s by the Center for Science in the Public Interest (CSPI), an organization with a long history of advocating for stronger policies involving salt content in processed foods. We also describe the recent voluntary action taken by Campbell Soup Co. in July 2009 to lower the sodium content of one of its best-selling products, tomato soup, so that it meets recommended guidelines.

More than 25 years ago, the Food and Drug Administration’s Dietary Sodium Initiative called on the food industry to voluntarily reduce sodium levels in processed foods. However, since that time, food manufacturers and chain restaurants have continued to increase the amount of sodium in their foods to dangerously high levels. Indeed, at some of the nation’s largest chain restaurants, the amount of salt in a single meal is often more than two to three times higher than the recommended daily allowance for sodium. For most Americans, this means an increased risk of high blood pressure, heart attack, and stroke in the long-term, all leading causes of death among U.S. adults. For some, particularly the elderly, consuming several days’ worth of salt in a single meal may be enough to trigger congestive heart failure.¹ In a recent news story, pediatric urologists and nephrologists also attribute the sharp rise in kidney stones in children to increased salt intake, particularly from highly processed, high-salt, high-fat foods.

Growing concern about the salt content in processed and restaurant foods and the lack of industry concern over the health of the American people has led advocates to consider new ways to encourage the food industry to lower the salt in processed food. In this report, Corporations and Health Watch describes two distinct efforts: a national initiative started by the New York City Department of Health in April 2009 and a class action lawsuit filed in July 2009 against Denny’s by the Center for Science in the Public Interest (CSPI), an organization with a long history of advocating for stronger policies involving salt content in processed foods. We also describe the recent voluntary action taken by Campbell Soup Co. in July 2009 to lower the sodium content of one of its best-selling products, tomato soup, so that it meets recommended guidelines.

How much sodium is safe to consume? For most adults, no more than 1,500mg daily

According to the Institute of Medicine, children aged 4-8 should consume no more than 1,200 mg of sodium per day. Guidelines issued by the Centers for Disease Control and Prevention, suggest that 69% of the adult population – those over age 40, African Americans, and those with high blood pressure – should consume no more than 1,500 mg daily. And for the third of American adults who do not fit into those high-risk categories, the upper limit of sodium intake is around 2,300 mg. More than three-quarters of the sodium that Americans consume comes from processed and restaurant foods; approximately 12% is naturally occurring in foods such as dairy products; about 5% is added during preparation at home; and only about 6% is added at the table.

Exactly how much sodium is present in chain restaurant foods?

Not only do many restaurant chains add dangerous levels of salt to their products, they often do their best to hide the amount of sodium that is present. This information is hidden on websites to which many customers lack access, and despite the best efforts of consumer advocates, these restaurants have repeatedly refused to disclose this information voluntarily to customers on menus. In other cases, the tables used to determine sodium and caloric content are difficult for the average customer to interpret. A sample of popular items for adults and children, taken from a recent press release by CSPI reveals the high amounts of salt that is typical in today’s chain restaurants:

Chili’s Honey-Chipotle Ribs with Mashed Potatoes with Gravy, Seasonal Vegetables, and a Dr. Pepper soda has 6,440 mg, or 429% of the advised daily limit for most U.S. adults
Olive Garden Chicken Parmigiana with a Breadstick, Garden Fresh Salad with House Dressing, and Raspberry Lemonade has 5,735 mg, or 382% of the advised daily limit for most U.S. adults
Children’s menu at KFC: Popcorn Chicken with Macaroni and Cheese, Teddy Grahams, and 2% milk has 2,005 mg, or 167% the advised daily limit for children
Children’s menu at Red Lobster: Chicken Fingers, Biscuit, Fries, Raspberry Lemonade has 2,430 mg, or 203% of the advised daily limit for children

What can be done to encourage the food industry to reduce the amount of salt and disclose the amount of salt to their customers?

Three recent examples illustrate the range of strategies for that are being used to reduce salt in processed food.

NYC Department of Health launches nationwide public health campaign to cut the salt in restaurants and processed foods

Some public health departments have begun campaigns to encourage chain restaurants to reduce the amount of sodium in their foods and to disclose the amount of sodium in their products to consumers. The New York City Department of Health’s Cardiovascular Disease Prevention division launched a national campaign in April of this year with the support of numerous public health departments across the country and organizations such as the American Medical Association, the American Public Health Association, the American College of Epidemiology, and the American College of Cardiology. According to a campaign press release, “The initiative calls on food industry leaders to help develop, and then adhere to, sodium targets for all products, using categories such as breads, breakfast cereals and prepared entrees. The goal is to achieve substantial, gradual reductions in salt levels across a wide range of foods.” In New York City alone, more than 750,000 people are at increased risk of heart attack and stroke because of uncontrolled high blood pressure. Nationwide, it is estimated that a 50% reduction in salt in processed and restaurant foods could prevent 150,000 premature deaths each year. In a fact sheet, the campaign describes in greater detail the strategy of “Working with the food industry to set salt reduction targets that are substantial, achievable, gradual, and measurable.” In addition, the campaign seeks to educate consumers about the dangers of salt and hypertension in publications such as “Cut the Salt! And lower your blood pressure and risk of heart attack and stroke” [pdf].

Campbell Soup Co. adopts a new strategic priority: the reduction in sodium in hundreds of its products

In late July 2009, approximately three months after the start of the national health campaign described above, Campbell Soup Co. announced that it would voluntarily reduce the amount of sodium in one of its best-selling products, tomato soup, which it has been producing for 62 years. The new formulation meets federal nutritional guidelines for sodium because it contains 480 mg or less of sodium per serving. Instead of relying on excessive amounts of sodium to enhance the flavor of its tomato soup, the company says that it is experimenting with different varieties of tomatoes and other flavorings.²

According to executives in the company, cutting sodium across hundreds of its products is now a top strategic priority.² Denise Morrison, president of Campbell Soup North America, has said “We hope it’s the biggest change you never notice.” ² The company says that it has test-marketed the newer formulation of its soup in all 50 states, and most people say they do not miss the salt or that they like the new formulation better.² This is precisely the type of positive action by the private sector that the national campaign started by the New York City Health Department seeks to achieve.

A class action lawsuit is filed against Denny’s by CSPI

In July 2009, the Center for Science in the Public Interest filed a class action complaint in New Jersey against Denny’s Corporation. Denny’s is a corporation that in 2008 had more than $648 million in company restaurant sales in its more than 1,500 restaurants across the country. The goal of the suit is to compel the restaurant corporation to disclose the amount of sodium in its meals, and to provide customers with a warning concerning the safety of high-sodium food. CSPI met with Denny’s Corporation lawyers initially in an effort to convince Denny’s to lower sodium content in their meals. It became clear, however, that the corporation was not willing to cooperate with this request.³ According to a Public Citizen blog entry, “We chose to contact Denny’s as the first (but not, we suspect, the last) restaurant chain to face a lawsuit for it’s wrongdoing because, as best we could tell, Denny’s is Public Health Enemy Number One when it comes to sodium. Denny’s admitted, when we first met with its lawyers, that it knew that excess sodium was a problem for Americans, and that its meals contained astronomically high levels of sodium. This is a classic consumer protection lawsuit, no different from a suit against a used car dealer who sells a car with 200,000 miles, but with the odometer disconnected. What we seek is simple – a court order forcing Denny’s to do what it should already be doing: Warning of the risks of high-sodium meals and telling its customer’s just how much sodium they get when they eat at Denny’s. That way, folks can decide whether or not to risk their lives by eating Denny’s meals.”

The complaint highlights the fact that “at least 75 percent of Denny’s meals contain more than the maximum amount of sodium most Americans should consume in an entire day.” Below are some menu items CSPI listed in its complaint against Denny’s.

A: Moons Over My Hammy: A ham and scrambled egg sandwich with Swiss and American cheese on grilled sourdough served with hash browns has 3,230 mg sodium, or 215 percent of the advised daily limit.

B: The Super Bird: A turkey breast sandwich with melted Swiss cheese, bacon strips and tomato on grilled sourdough served with French fries has 2,610 mg sodium, or 174 percent of the advised daily limit.

C: Double Cheeseburger: Two beef patties and four slices of American cheese with lettuce, tomato, pickles, and red onion served with French fries has 4,130 mg sodium, or 275 percent the daily limit.

D. Spicy Buffalo Chicken Melt: A fried chicken breast covered in a buffalo sauce with lettuce, tomato, and Swiss cheese on ciabatta bread with a garlic spread served with French fries has 4,120 mg sodium, or 275 percent of the advised daily limit.

E. Super Grand Slam Slamwich: Two scrambled eggs, sausage, crispy bacon, shaved ham, mayonnaise, and American cheese on potato bread grilled with a maple spice spread served with hash browns, and two pancakes has 5,690 mg sodium, or 379 percent of the advised daily limit.

On July 23, 2009 Denny’s responded to investors regarding the class action complaint in a press release. in which the company reassures investors that it will fight CSPI’s lawsuit aggressively in court, claiming the suit is “without merit.” The company points to a new menu for health-conscious consumers Better for You introduced in June 2009.

However, CSPI defends its legal action. Said Michael F. Jacobsen, CSPI’s Executive Director, “Who knows how many Americans have been pushed prematurely into their graves thanks to sodium levels found in Olive Garden, Chili’s, and Red Lobster? These chains are sabotaging the food supply.” ⁴

Future directions

The new national campaign begun by the New York City Department of Health shows that reducing the amount of salt that people consume requires action by individuals, governments, and the private sector. Individuals can learn about how to monitor and reduce their salt intake, but chain restaurants such as Denny’s that serve customers dangerously high levels of sodium and fail to properly disclose salt content to customers make this task much more difficult.

By their recent action, the New York City Department of Health and the Center for Science in the Public Interest demonstrate two complementary and reinforcing strategies to encourage the food industry to make it easier for their customers to avoid dangerously high levels of salt. Campbell Soup Company’s decision to hold the salt in its tomato soup shows that the processed food manufacturers can find innovative ways to reduce the salt content of its products so that they meet federal guidelines, without necessarily sacrificing taste. By pursuing multiple strategies to lower salt in processed food, health advocates can help lower the burden of salt-related chronic diseases.

By Lauren Evans, doctoral student in public health at City University of New York.

References

1 CSPI press release dated 7/23/09. Unsafe sodium levels at Denny’s prompt class action lawsuit. http://www.cspinet.org/new/200907231.html. Accessed September 3, 2009.

2 Downing J. Campbell takes a gamble, cuts salt in tomato soup. The Sacramento Bee. August 20, 2009. http://www.sacbee.com/161/story/2124138.html?storylink=lingospot_related_articles. Accessed September 3, 2009.

3 Activist group sues Denny’s over sodium levels. July 23, 2009. http://www.reuters.com/article/healthNews/idUSTRE56M4J320090723. Accessed September 3, 2009.

4 CSPI press release dated May 11, 2009. “Heart Attack Entrees with Side Orders of Stroke”
src=”uploads/images/old_archives/img/clip_image005_0000.gif” border=”0″ alt=”blank2″ width=”1″ height=”5″ />Overly Salty Restaurant Meals Present Long-Term Health Risks for All, and Immediate Danger for Some. http://www.cspinet.org/new/200905111.html. Accessed September 3, 2009.

Photo Credits:
1. premshree
2. the_sampler
3. grenfrog00

News: New York City considers point-of-sale warning signs for tobacco products in convenience stores

Posted on September 30, 2009 by Corporations and Health Watch

In June 2009 Congress approved and President Obama signed legislation giving the U.S. Food and Drug Administration (FDA) the authority to regulate tobacco products. The FDA will also be allowed to restrict tobacco marketing to youth and require larger warnings on packages. The federal law also preserves state and local authority to adopt other tobacco control measures that they deem appropriate. So far, it appears that New York City is the first local jurisdiction in the United States to consider mandating point-of-sale warning signs since the passage of the federal legislation.
In June 2009 Congress approved and President Obama signed legislation giving the U.S. Food and Drug Administration (FDA) the authority to regulate tobacco products. (a video of the press conference on the signing of this legislation by President Obama is available here.)

Tobacco-industry critics had long argued that tobacco should not be exempt from important consumer protections such as ingredient disclosure, product testing, and restrictions on advertising to children. Advocacy groups such as the Campaign for Tobacco-Free Kids, argued that in the United States, where products such as lipstick and macaroni-and-cheese are regulated to protect consumers, it did not make sense for the most deadly and addictive legal product in America to enjoy a special exemption (see a report by Campaign for Tobacco-Free Kids titled Big Tobacco’s Guinea Pigs: How an Unregulated Industry Experiments on America’s Kids and Consumers [pdf]).

Under the new law, tobacco companies will be required to disclose all ingredients in their products to the FDA, including nicotine and the toxic constituents in cigarette smoke. The FDA will also be allowed to restrict tobacco marketing to youth and require larger warnings on packages. The federal law also preserves state and local authority to adopt other tobacco control measures that they deem appropriate. So far, it appears that New York City is the first local jurisdiction in the United States to consider mandating point-of-sale warning signs since the passage of the federal legislation (3).

Details about the proposed health code amendment in New York City

On June 24th 2009, the City Board of Health voted to solicit public comment on a health code amendment that would require all New York City tobacco retailers to display prominent point-of-sale warnings and cessation messages (3,8). The proposed signs would include a graphic that shows the heath risk associated with smoking and information about how to get help quitting. The proposed point-of-sale warnings would affect the city’s approximately 12,000 tobacco retailers. Not surprisingly, the posters are opposed by groups such as the New York Association of Convenience Stores (9) and the International Premium Cigar & Pipe Retailers Association (10). The Health Department said that although the tobacco industry or retailers may challenge the rule in court, the proposal would likely survive such a challenge because requiring the communication of factual information is constitutional. In a fact sheet [pdf], the New York City Health Department stated, “These warnings will provide factual health information about tobacco, while also providing useful information about how to avoid or overcome addiction to it. The goal is not to hurt retailers but to protect consumers. Retailers don’t have to sell tobacco. Those who choose to sell such a dangerous product have an obligation to warn people about the hazards.” The Health Department would provide the posters free of charge, and they would be available in multiple languages.

Scientific research supports such signage as a strategy to reduce the burden of tobacco use

Researchers believe that tobacco advertising has recently increased in retail stores and that these in store promotions are very effective in reaching children and teens (5). Studies indicate that 75 percent of teens shop in convenience stores at least once a week, and that they are more likely than adults to be influenced by advertisements (5). Despite laws against selling to minors, approximately 30% of youth smokers in New York City buy tobacco products in retail stores (7). And in New York City, approximately two-thirds of smokers would like to quit, but they need help in order to be successful (11).

Dr. Thomas Farley, the New York City Health Commissioner, noted that “Smoking continues to be the leading case of preventable death in New York City. While the tobacco industry spends billions to glamorize smoking, we will show New Yorkers the harsh realities. These warning signs will help persuade smokers to quit and show children why they shouldn’t start to smoke” (3).

The evidence underlying point-of-sale warnings is strong and persuasive. Interested readers can review the Health Department’s Notice to the Public [pdf] that provides an overview of this evidence and specific details of the proposal (12). If the New York City Board of Health votes to introduce such signs in retail outlets, advocates hope to see reductions in tobacco sales to young people as well as an increase in the use of smoking cessation services for those seeking to quit.

References

1. Campaign for Tobacco-Free Kids Fact Sheet “Toll of Tobacco in the United States.” http://www.tobaccofreekids.org/research/factsheets/pdf/0072.pdf. Accessed August 21, 2009.

2. Centers for Disease Control and Prevention (CDC). Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Cost – United States, 1995-1999. MMWR 2002;51(14):300-303.

3. New York City Department of Health. Press Release dated June 24, 2009. “Board of Health votes to invite public comment on a health code amendment requiring New York City Tobacco Retailers to Post Health Warning Signs.” http://www.nyc.gov/html/doh/html/pr2009/pr045-09.shtml. Accessed August 21, 2009.

4. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Deparmtnet of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention ad Health Promotion, Office on Smoking and Health, 2004.

5. Press Release dated June 4, 2009. Schumer Reveals: Almost 100,000 NYS children will try their first tobacco product this year. Targeted News Service. http://schumer.senate.gov/new_website/record.cfm?id=313941. Accessed August 21, 2009.

6. Presentation by Anne Pearson, Senior Legal Council for Policy. Bureau of Tobacco Control, New York City Department of Health and Mental Hygiene. June 24, 2009. http://www.nyc.gov/html/doh/downloads/pdf/notice/proposal-smoking-cessation.pdf. Accessed August 21, 2009.

7. Unpublished data. New York City Department of Health and Mental Hygiene, Bureau of Epidemiology Services: New York City Youth Risk Behavior Survey, 2007. . Cited in presentation by Anne Pearson, Senior Legal Council for Policy. Bureau of Tobacco Control, New York City Department of Health and Mental Hygiene. June 24, 2009.

8. Factsheet by New York City Department of Health and Mental Hygiene, June 25, 2009. Proposed amendment to the New York City Health Code would require tobacco retailers to post health warning sigs at the point of sale. http://www.nyc.gov/html/doh/downloads/pdf/notice/proposal-smoking-cessation-faq.pdf. Accessed August 21, 2009.

9. Press Release dated August 3, 2009. NYACS opposes tobacco warning signs. State News Service. http://www.csnews.com/csn/cat_management/tobacco/article_
display.jsp?vnu_content_id=1003999446. Accessed August 21, 2009.

10. Premium Cigar Retailers Oppose New York City Anti-Tobacco Moves. July 30, 2009. PRWeb. http://www.topix.com/content/prweb/2009/07/premium-cigar-retailers-oppose-new-york-city-anti-tobacco-moves. Accessed August 21, 2009.

11. Unpublished data. New York City Department of Health and Mental Hygiene, Bureau of Epidemiology Services: New York City Community Health Survey 2008; April 2009. Cited in presentation by Anne Pearson, Senior Legal Council for Policy. Bureau of Tobacco Control, New York City Department of Health and Mental Hygiene. June 24, 2009. Accessed August 21, 2009.

12. Department of Health and Mental Hygiene, Board of Health. Notice of Intention to Amend Article 181 of the New York City Health Code. Notice of Public Hearing on July 30, 2009. http://www.nyc.gov/html/doh/downloads/pdf/notice/notice-of-intention-amend-article-181.pdf. Accessed August 21, 2009.

Photo Credits:
1. niznoz
2. skaterftf

Selected Bibliography on Retail Practices and Health by Industry

Posted on September 30, 2009 by Corporations and Health Watch

Selected Bibliography on Retail Practices and Health in the Alcohol, Automobile, Firearms, Food and Beverage, Pharmaceutical, and Tobacco industries.

Alcohol Industry

Cohen DA, GhoshDastidar B, Scribner R, Miu A, Scott M, Robinson P, et al. Alcohol outlets, gonorrhea, and the Los Angeles civil unrest: A longitudinal analysis. Soc Sci Med. 2006;62(12):3062-3071.
Gruenewald PJ, Freisthler B, Remer L, Lascala EA, Treno A. Ecological models of alcohol outlets and violent assaults: Crime potentials and geospatial analysis. Addiction. 2006;101(5):666-677.
Gruenewald PJ, Johnson FW, Treno AJ. Outlets, drinking and driving: A multilevel analysis of availability. Stud Alcoho. 2002;63(4):460-468.
Gruenewald PJ, Millar AB, Treno AJ, Yang Z, Ponicki WR, Roeper P. The geography of availability and driving after drinking. Addiction. 1996;91(7):967-983.
Kotecki JE, Fowler JB, German TC, Stephenson SL, Warnick T. Kentucky pharmacists’ opinions and practices related to the sale of cigarettes and alcohol in pharmacies. J Community Health. 2000;25(4):343-355.
Lapham SC, Gruenwald PJ, Remer L, Layne L. New Mexico’s 1998 driveup liquor window closure. Study I: Effect on alcohol involved crashes. Addiction. 2004;99(5):598-606.
Miller T, Snowden C, Birckmayer J, Hendrie D. Retail alcohol monopolies, underage drinking, and youth impaired driving deaths. Accid Anal Prev. 2006;38(6):1162-1167.
Montgomery JM, Foley KL, Wolfson M. Enforcing the minimum drinking age: State, local and agency characteristics associated with compliance checks and Cops in Shops programs. Addiction. 2006;101(2):223-231.
Reynolds RI, Holder HD, Gruenewald PJ. Community prevention and alcohol retail access. Addiction. 1997;92 Suppl 2:S261-S272.
Treno AJ, Gruenewald PJ, Johnson FW. Alcohol availability and injury: The role of local outlet densities. Alcohol Clin Exp Res. 2001;25(10):1467-1471.
Treno AJ, Gruenewald PJ, Wood DS, Ponicki WR. The price of alcohol: A consideration of contextual factors. Alcohol Clin Exp Res. 2006;30(10):1734-1742.
Treno AJ, Grube JW, Martin SE. Alcohol availability as a predictor of youth drinking and driving: A hierarchical analysis of survey and archival data. Alcohol Clin Exp Res. 2003;27(5):835-840.

Automobile Industry

Devaraj S, Matta KF, Conlon E. Product and Service Quality: The Antecedents of Customer Loyalty in the Automotive Industry. Production and Operations Management. 2001; 10(4): 424-439.
Hellinga LA, McCartt AT, Haire ER. Choice of teenagers’ vehicles and views on vehicle safety: Survey of parents of novice teenage drivers. J Safety Res.2007;38(6):707-713.
Joetan E, Kleiner BH. Incentive practices in the US automobile industry. Management Research News. 2004;27(7):49–62.
Koppel S, Charlton J, Fildes B, Fitzharris M. How important is vehicle safety in the new vehicle purchase process? Accid Anal Prev. 2008;40(3):994-1004.
Koppel S, Charlton J, Fildes B. How important is vehicle safety in the new vehicle purchase/lease process for fleet vehicles? Traffic Inj Prev. 2007;8(2):130-136.
Van Alst JW. Fueling Fair Practices: A Road Map to Improved Public Policy for Used Car Sales and Financing, National Consumer Law Center, (March 5, 2008), Available at http://www.nclc.org/issues/auto/content/report-fuelingfairpractices0309.pdf.

Firearms Industry

Cook, PJ, Molliconi S, Cole, TB.Regulating gun markets. The Journal of Criminal Law and Criminology. 1995;86(1):59-92.
Lewin NL, Vernick JS, Beilenson PL, Mair JS, Lindamood MM, Teret SP, Webster DW. The Baltimore Youth Ammunition Initiative: A model application of local public health authority in preventing gun violence. Am J Public Health. 2005;95(5):762-765.
Miller M, Azrael D, Hemenway D. Firearm availability and unintentional deaths, suicide, and homicide among 5-14 year olds. The Journal of Trauma. 2002;52(2):267-275.
Miller M, Azrael D, Hemenway D. Firearm availability and unintentional deaths. Accident Analysis and Prevention. 2001;33:477-484.
Miller M, Azrael D, Hemenway D. Firearm availability and unintentional deaths, suicide, and homicide among women. Journal of Urban Health. 2002; 79(1):26-38.
Sorenson SB, Berk RA. Handgun sales, beer sales, and youth homicide, California 1972-1993. Journal of Public Health Policy. 2001;22(2):182-197.
Vernick JS, Mair JS. How the law affects gun policy in the United States: Law as intervention or obstacle to prevention. J Law Med Ethics. 2002;30(4):692-704.
Vernick JS, Webster DW, Bulzacchelli MT, Mair JS. Regulation of firearm dealers in the United States: An analysis of state law and opportunities for improvement. J Law Med Ethics. 2006;34(4):765-775.
Webster DW, Vernick JS, Buzacchelli MT. Effects of a gun dealer’s change in sales practices on the supply of guns to criminals. The Journal of Urban Health. 2006; 83(5):778-787.
Webster DW, Bulzacchelli MT, Zeoli AM, Vernick JS. Effects of undercover police stings of gun dealers on the supply of new guns to criminals. Inj Prev. 2006;12(4):225-230.
Webster DW, Vernick JS, Bulzacchelli MT. Effects of state-level firearm seller accountability policies on firearm trafficking. J Urban Health. 2009;86(4):525-537.
Webster DW, Vernick JS, Hepburn LM. Relationship between licensing, registration, and other gun sales laws and the source state of crime guns. Inj Prev. 2001;7(3):184-189.
Wintemute GJ. Where the guns come from: The gun industry and gun commerce. The Future of Children. 2003;12(2):55-71.

Food and Beverage Industry

Altekruse SF, Yang S, Timbo BB, Angulo FJ. A multi-state survey of consumer food-handling and food-consumption practices. Am J Prev Med. 1999;16(3):216-221.
Angell SY, Silver LD, Goldstein GP, Johnson CM, Deitcher DR, Frieden TR, Bassett MT. Cholesterol control beyond the clinic: New York City’s trans fat restriction. Ann Intern Med. 2009;151(2):129-134.
Austin SB, Melly SJ, Sanchez BN, Patel A, Buka S, Gortmaker SL. Clustering of fast food restaurants around schools: A novel application of spatial statistics to the study of food environments. Am J Public Health. 2005;95(9):1575-1581.
Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Prev Chronic Dis. 2006;3(3):A76.
Borgmeier I, Westenhoefer J. Impact of different food label formats on healthiness evaluation and food choice of consumers: A randomized-controlled study. BMC Public Health. 2009;12(9):184.
Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health.2006;96(9):1669-1675.
Cassady D, Housemann R, Dagher C. Measuring cues for healthy choices on restaurant menus: Development and testing of a measurement instrument. Am J Health Promot. 2004;18(6):444-449.
Creel JS, Sharkey JR, McIntosh A, Anding J, Huber JC Jr. Availability of healthier options in traditional and nontraditional rural fast-food outlets. BMC Public Health. 2008;8:395.
Dumanovsky T, Nonas CA, Huang CY, Silver LD, Bassett MT. What people buy from fast-food restaurants: Caloric content and menu item selection, New York City 2007. Obesity (Silver Spring). 2009; 17(7):1369-1374.
Dwyer JJ, Macaskill LA, Uetrecht CL, Dombrow C. Eat Smart! Ontario’s Healthy Restaurant Program: Focus groups with non-participating restaurant operators. Can J Diet Pract Res. 2004.;65(1):6-9.
Economos CD, Folta SC, Goldberg J, Hudson D, Collins J, Baker Z, Lawson E, Nelson M. A community-based restaurant initiative to increase availability of healthy menu options in Somerville, Massachusetts: Shape Up Somerville. Prev Chronic Dis. 2009.;6(3):A102
Fielding JE, Aguirre A, Palaiologos E. Effectiveness of altered incentives in a food safety inspection program. Prev Med. 2001;32(3):239-244.
Ford PB, Dzewaltowski DA. Disparities in obesity prevalence due to variation in the retail food environment: Three testable hypotheses. Nutr Rev. 2008 Apr;66(4):216-228.
French SA, Harnack L, Jeffery RW. Fast food restaurant use among women in the Pound of Prevention study: Dietary, behavioral and demographic correlates. International Journal of Obesity & Related Metabolic Disorders. 2000;24(1):1353.
French SA. Pricing effects on food choices. J.Nutr. 2003;133(3):841S-843S.
French SA, Jeffery RW, Story M, Breitlow KK, Baxter JS, Hannan P, et al. Pricing and promotion effects on lowfat vending snack purchases: The CHIPS Study. Am J Public Health. 2001 ;91(1):112-117.
French SA, Story M, Neumark Sztainer D, Fulkerson JA, Hannan P. Fast food restaurant use among adolescents: Associations with nutrient intake, food choices and behavioral and psychosocial variables. Int J Obes Relat Metab Disord. 2001;25(12):1823-1833.
Fried EJ, Nestle M. The growing political movement against soft drinks in schools. JAMA.2002 ;288(1):2181-2181.
Gerend MA. Does calorie information promote lower calorie fast food choices among college students? J Adolesc Health. 2009;44(1):84-86.
Glanz K, Resnicow K, Seymour J, Hoy K, Stewart H, Lyons M, Goldberg J. How major restaurant chains plan their menus: The role of profit, demand, and health. Am J Prev Med. 2007;32(5):383-388.
Hannan P, French SA, Story M, Fulkerson JA. A pricing strategy to promote sales of lower fat foods in high school cafeterias: Acceptability and sensitivity analysis. Am.J.Health Promot. 2002 ;17(1):16,ii.
Hanni KD, Garcia E, Ellemberg C, Winkleby M. Targeting the taqueria: Implementing healthy food options at Mexican American restaurants. Health Promot Pract. 2009;10(2 Suppl):91S-99S.
Harnack LJ, French SA. Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: A review of the literature. Int J Behav Nutr Phys Act. 2008 Oct 26;5:51.
Harnack LJ, French SA, Oakes JM, Story MT, Jeffery RW, Rydell SA. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trial. Int J Behav Nutr Phys Act. 2008 ;5:63.
Jacobson MF, Brownell KD. Small taxes on soft drinks and snack foods to promote health. Am J Public Health 2000;90:854-857.
Jetter KM, Cassady DL. Increasing fresh fruit and vegetable availability in a low-income neighborhood convenience store: A pilot study. Health Promot Pract. 2009 Feb 12. [Epub ahead of print]
Kim D, Kawachi I. Food taxation and pricing strategies to “thin out” the obesity epidemic. Am. J. Prev. Med. 2006;30(5):430-437.
Kimathi AN, Gregoire MB, Dowling RA, Stone MK. A healthful options food station can improve satisfaction and generate gross profit in a worksite cafeteria. J Am Diet Assoc. 2009;109(5):914-917.
Kuo T, Jarosz CJ, Simon P, Fielding JE. Menu labeling as a potential strategy for combating the obesity epidemic: A health impact assessment. Am J Public Health. 2009;99(9):1680-1686.
Kwate N O A. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health and Place. 2008;14:32-44.
Kwate NO, Yau CY, Loh JM, Williams D. Inequality in obesigenic environments: Fast food density in New York City. Healthand Place. 2009;15(1):364-73
Lang T, Rayner G, Kaelin E. The Food Industry, Diet, Physical Activity and Health: A Review Of Reported Commitments And Practice Of 25 Of The World’s Largest Food Companies. 2006.
Larson NI, Story MT, Nelson MC. Neighborhood environments: Disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74-81.
Ludwig DS, Brownell KD. Public health action amid scientific uncertainty: The case of restaurant calorie labeling regulations. JAMA. 2009;302(4):434-435.
Lynch RA, Elledge BL, Griffith CC, Boatright DT. A comparison of food safety knowledge among restaurant managers, by source of training and experience, in Oklahoma County, Oklahoma. J Environ Health. 2003;66(2):9-14, 26.
Macdonald L, Cummins S, Macintyre S. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite. 2007l;49(1):251-254.
Maddock J. The relationship between obesity and the prevalence of fast food restaurants: State level analysis. Am J Health Promot. 2004;19(2):137-143.
Mashta O. UK firms sign up to display calories on menus. BMJ. 2009;338:b182.
Morland KB, Evenson KR. Obesity prevalence and the local food environment. Health and Place. 2009; 15(2):491-495
Nielsen SJ, Siega Riz AM, Popkin BM. Trends in food locations and sources among adolescents and young adults. Prev Med. 2002;35(2):107-113.
O’Dougherty M, Harnack LJ, French SA, Story M, Oakes JM, Jeffery RW. Nutrition labeling and value size pricing at fast-food restaurants: A consumer perspective. Am J Health Promot. 2006;20(4):247-250.
Phillips ML, Elledge BL, Basara HG, Lynch RA, Boatright DT. Recurrent critical violations of the food code in retail food service establishments. J Environ Health. 2006;68(10):24-30, 55.
Pomeranz JL, Brownell KD. Legal and public health considerations affecting the success, reach, and impact of menu-labeling laws. Am J Public Health. 2008;98(9):1578-1583.
Roberto CA, Agnew H, Brownell KD. An observational study of consumers’ accessing of nutrition information in chain restaurants. Am J Public Health. 2009;99(5):820-821.
Rose D, Hutchinson PL, Bodor JN, Swalm CM, Farley TA, Cohen DA, Rice JC. Neighborhood food environments and Body Mass Index: The importance of in-store contents. Am J Prev Med. 2009;37(3):214-219.
Rydell SA, Harnack LJ, Oakes JM, Story M, Jeffery RW, French SA. Why eat at fast-food restaurants: reported reasons among frequent consumers. J Am Diet Assoc. 2008;108(12):2066-2070.
Sharkey JR, Horel S, Han D, Huber JC Jr. Association between neighborhood need and spatial access to food stores and fast food restaurants in neighborhoods of colonias. Int J Health Geogr. 2009;8:9.
Song HJ, Gittelsohn J, Kim M, Suratkar S, Sharma S, Anliker J. A corner store intervention in a low-income urban community is associated with increased availability and sales of some healthy foods. Public Health Nutr. 2009:1-8.
Spencer EH, Frank E, McIntosh NF. Potential effects of the next 100 billion hamburgers sold by McDonald’s. Am.J.Prev.Med. 2005 ;28(4):379-381.
Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health. 2008;29:253-72.

Pharmaceutical Industry

Brooks JM, Doucette WR, Wan S, Klepser DG. Retail pharmacy market structure and performance. Inquiry. 2008;45(1):75-88.
Carroll NV. Estimating the impact of Medicare part D on the profitability of independent community pharmacies. J Manag Care Pharm. 2008;14(8):768-779.
Fincham JE. An unfortunate and avoidable component of American pharmacy: Tobacco. Am J Pharm Educ. 2008;72(3):57
Garattini L, Motterlini N, Cornago D. Prices and distribution margins of in-patent drugs in pharmacy: A comparison in seven European countries. Health Policy. 2008;85(3):305-313.
Gellad WF, Choudhry NK, Friedberg MW, Brookhart MA, Haas JS, Shrank WH. Variation in drug prices at pharmacies: Are prices higher in poorer areas? Health Serv Res. 2009;44(2 Pt 1):606-617.
Gitlin M, Wilson L. Repackaged pharmaceuticals in the California workers’ compensation system: From distribution and pricing options to physician and retail dispensing. Am J Ind Med. 2007;50(4):303-315.
Montoya ID, Jano E. Online pharmacies: Safety and regulatory considerations. Int J Health Serv. 2007;37(2):279-289.
Retail and mail copayments on the rise. Manag Care. 2009;18(6):50.
Rudholm N. Entry of new pharmacies in the deregulated Norwegian pharmaceuticals market– consequences for costs and availability. Health Policy.2008;87(2):258-263
Stafford E. Pharmacy initiatives target prescription drug costs. J Mich Dent Assoc. 2008;90(9):22.
Stevenson FA, Leontowitsch M, Duggan C. Over-the-counter medicines: Professional expertise and consumer discourses. Sociol Health Illn. 2008;30(6):913-928.

Tobacco Industry

Andersen BS, Begay ME, Lawson CB. Breaking the alliance: Defeating the tobacco industry’s allies and enacting youth access restrictions in Massachusetts. Am J Public Health. 2003;93(11):1922-1928.
Celebucki CC, Diskin K. A longitudinal study of externally visible cigarette advertising on retail storefronts in Massachusetts before and after the Master Settlement Agreement. Tob Control. 2002;11 Suppl 2:ii47-53.
Chriqui JF, Ribisl KM, Wallace RM, Williams RS, O’Connor JC, el Arculli R. A comprehensive review of state laws governing Internet and other delivery sales of cigarettes in the United States. Nicotine Tob Res. 2008;10(2):253-265.
Feighery EC, Ribisl KM, Achabal DD, Tyebjee T. Retail trade incentives: How tobacco industry practices compare with those of other industries. Am J Public Health. 1999;89(10):1564-1566.
Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their advertising and products in stores: Interviews with retailers about tobacco company incentive programmes. Tob Control. 2003;12(2):184-188.
Feighery EC, Ribisl KM, Schleicher N, Lee RE, Halvorson S. Cigarette advertising and promotional strategies in retail outlets: results of a statewide survey in California. Tob Control. 2001;10(2):184-188.
Feighery EC, Ribisl KM, Schleicher NC, Clark PI. Retailer participation in cigarette company incentive programs is related to increased levels of cigarette advertising and cheaper cigarette prices in stores. Prev Med. 2004;38(6):876-884.
Gilbertson T. Retail point-of-sale guardianship and juvenile tobacco purchases: assessing the prevention capabilities of undergraduate college students. J Drug Educ. 2007;37(1):1-30.
Gilpin EA, White VM, Pierce JP. How effective are tobacco industry bar and club marketing efforts in reaching young adults? Tob Control. 2005;14(3):186-192.
Glanz K, Sutton NM, Jacob Arriola KR. Operation storefront Hawaii: Tobacco advertising and promotion in Hawaii stores. J Health Commun. 2006;11(7):699-707.
Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette advertising near schools? Prev Med. 2008;47(2):210-4.
Henriksen L, Feighery EC, Schleicher NC, Haladjian HH, Fortmann SP. Reaching youth at the point of sale: cigarette marketing is more prevalent in stores where adolescents shop frequently. Tob Control. 2004;13(3):315-318.
Henriksen L, Feighery EC, Wang Y, Fortmann SP. Association of retail tobacco marketing with adolescent smoking. Am J Public Health. 2004;94(12):2081-2083.
Lavack AM, Toth G. Tobacco point-of-purchase promotion: Examining tobacco industry documents. Tob Control. 2006;15(5):377-384.
Loomis BR, Farrelly MC, Mann NH. The association of retail promotions for cigarettes with the Master Settlement Agreement, tobacco control programmes and cigarette excise taxes. Tob Control. 2006;15(6):458-463.
Loomis BR, Farrelly MC, Nonnemaker JM, Mann NH. Point of purchase cigarette promotions before and after the Master Settlement Agreement: exploring retail scanner data. Tob Control. 2006;15(2):140-
Pollay RW. More than meets the eye: on the importance of retail cigarette merchandising. Tob Control. 2007;16(4):270-274.
Sepe E, Ling PM, Glantz SA. Smooth moves: bar and nightclub tobacco promotions that target young adults. Am J Public Health. 2002;92(3):414-419.
Slater S, Chaloupka FJ, Wakefield M. State variation in retail promotions and advertising for Marlboro cigarettes. Tob Control. 2001;10(4):337-339.
Slater S, Giovino G, Chaloupka F. Surveillance of tobacco industry retail marketing activities of reduced harm products. Nicotine Tob Res. 2008;10(1):187-193.
Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’malley PM. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc. Med. 2007;161(5):440-445.
Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc Med. 2007;161(5):440-445.
Smith EA, Blackman VS, Malone RE. Death at a discount: how the tobacco industry thwarted tobacco control policies in US military commissaries. Tob Control. 2007;16(1):38-46.

Studies of Multiple Industries

Ashe M, Jernigan D, Kline R, Galaz R. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. Am J Public Health. 2003;93(9):1404-1408.
Feighery EC, Ribisl KM, Achabal DD, Tyebjee T. Retail trade incentives: how tobacco industry practices compare with those of other industries. Am J Public Health. 1999;89(10):1564-1566.
Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved. 2008; 19(1):26-40.
Hemenway D. The public health approach to motor vehicles, tobacco, and alcohol, with applications to firearms policy. J Public Health Policy. 2001;22(4):381-402.
Kotecki JE. Sale of alcohol in pharmacies: results and implications of an empirical study. J Community Health. 2003;28(1):65-77.

Selected Bibliography on Retail Practices and Health by Industry

Posted on September 20, 2009 by Corporations and Health Watch

Selected Bibliography on Retail Practices and Health in the Alcohol, Automobile, Firearms, Food and Beverage, Pharmaceutical, and Tobacco industries.

Alcohol Industry

Cohen DA, GhoshDastidar B, Scribner R, Miu A, Scott M, Robinson P, et al. Alcohol outlets, gonorrhea, and the Los Angeles civil unrest: A longitudinal analysis. Soc Sci Med. 2006;62(12):3062-3071.

Gruenewald PJ, Freisthler B, Remer L, Lascala EA, Treno A. Ecological models of alcohol outlets and violent assaults: Crime potentials and geospatial analysis. Addiction. 2006;101(5):666-677.

Gruenewald PJ, Johnson FW, Treno AJ. Outlets, drinking and driving: A multilevel analysis of availability. Stud Alcoho. 2002;63(4):460-468.

Gruenewald PJ, Millar AB, Treno AJ, Yang Z, Ponicki WR, Roeper P. The geography of availability and driving after drinking.Addiction. 1996;91(7):967-983.

Kotecki JE, Fowler JB, German TC, Stephenson SL, Warnick T. Kentucky pharmacists’ opinions and practices related to the sale of cigarettes and alcohol in pharmacies. J Community Health. 2000;25(4):343-355.

Lapham SC, Gruenwald PJ, Remer L, Layne L. New Mexico’s 1998 driveup liquor window closure. Study I: Effect on alcohol involved crashes. Addiction. 2004;99(5):598-606.

Miller T, Snowden C, Birckmayer J, Hendrie D. Retail alcohol monopolies, underage drinking, and youth impaired driving deaths. Accid Anal Prev. 2006;38(6):1162-1167.

Montgomery JM, Foley KL, Wolfson M. Enforcing the minimum drinking age: State, local and agency characteristics associated with compliance checks and Cops in Shops programs. Addiction. 2006;101(2):223-231.

Reynolds RI, Holder HD, Gruenewald PJ. Community prevention and alcohol retail access. Addiction. 1997;92 Suppl 2:S261-S272.

Treno AJ, Gruenewald PJ, Johnson FW. Alcohol availability and injury: The role of local outlet densities. Alcohol Clin Exp Res. 2001;25(10):1467-1471.

Treno AJ, Gruenewald PJ, Wood DS, Ponicki WR. The price of alcohol: A consideration of contextual factors. Alcohol Clin Exp Res. 2006;30(10):1734-1742.

Treno AJ, Grube JW, Martin SE. Alcohol availability as a predictor of youth drinking and driving: A hierarchical analysis of survey and archival data. Alcohol Clin Exp Res. 2003;27(5):835-840.

Automobile Industry

Devaraj S, Matta KF, Conlon E. Product and Service Quality: The Antecedents of Customer Loyalty in the Automotive Industry.Production and Operations Management. 2001; 10(4): 424-439.

Hellinga LA, McCartt AT, Haire ER. Choice of teenagers’ vehicles and views on vehicle safety: Survey of parents of novice teenage drivers. J Safety Res.2007;38(6):707-713.

Joetan E, Kleiner BH. Incentive practices in the US automobile industry. Management Research News. 2004;27(7):49–62.

Koppel S, Charlton J, Fildes B, Fitzharris M. How important is vehicle safety in the new vehicle purchase process? Accid Anal Prev. 2008;40(3):994-1004.

Koppel S, Charlton J, Fildes B. How important is vehicle safety in the new vehicle purchase/lease process for fleet vehicles?Traffic Inj Prev. 2007;8(2):130-136.

Van Alst JW. Fueling Fair Practices: A Road Map to Improved Public Policy for Used Car Sales and Financing, National Consumer Law Center, (March 5, 2008), Available at http://www.nclc.org/issues/auto/content/report-fuelingfairpractices0309.pdf.

Firearms Industry

Cook, PJ, Molliconi S, Cole, TB.Regulating gun markets. The Journal of Criminal Law and Criminology. 1995;86(1):59-92.

Lewin NL, Vernick JS, Beilenson PL, Mair JS, Lindamood MM, Teret SP, Webster DW. The Baltimore Youth Ammunition Initiative: A model application of local public health authority in preventing gun violence. Am J Public Health. 2005;95(5):762-765.

Miller M, Azrael D, Hemenway D. Firearm availability and unintentional deaths, suicide, and homicide among 5-14 year olds. The Journal of Trauma. 2002;52(2):267-275.

Miller M, Azrael D, Hemenway D. Firearm availability and unintentional deaths. Accident Analysis and Prevention. 2001;33:477-484.

Miller M, Azrael D, Hemenway D. Firearm availability and unintentional deaths, suicide, and homicide among women.Journal of Urban Health. 2002; 79(1):26-38.

Sorenson SB, Berk RA. Handgun sales, beer sales, and youth homicide, California 1972-1993. Journal of Public Health Policy. 2001;22(2):182-197.

Vernick JS, Mair JS. How the law affects gun policy in the United States: Law as intervention or obstacle to prevention. J Law Med Ethics. 2002;30(4):692-704.

Vernick JS, Webster DW, Bulzacchelli MT, Mair JS. Regulation of firearm dealers in the United States: An analysis of state law and opportunities for improvement. J Law Med Ethics. 2006;34(4):765-775.

Webster DW, Vernick JS, Buzacchelli MT. Effects of a gun dealer’s change in sales practices on the supply of guns to criminals. The Journal of Urban Health. 2006; 83(5):778-787.

Webster DW, Bulzacchelli MT, Zeoli AM, Vernick JS. Effects of undercover police stings of gun dealers on the supply of new guns to criminals. Inj Prev. 2006;12(4):225-230.

Webster DW, Vernick JS, Bulzacchelli MT. Effects of state-level firearm seller accountability policies on firearm trafficking. J Urban Health. 2009;86(4):525-537.

Webster DW, Vernick JS, Hepburn LM. Relationship between licensing, registration, and other gun sales laws and the source state of crime guns. Inj Prev. 2001;7(3):184-189.

Wintemute GJ. Where the guns come from: The gun industry and gun commerce. The Future of Children. 2003;12(2):55-71.

Food and Beverage Industry

Altekruse SF, Yang S, Timbo BB, Angulo FJ. A multi-state survey of consumer food-handling and food-consumption practices.Am J Prev Med. 1999;16(3):216-221.

Angell SY, Silver LD, Goldstein GP, Johnson CM, Deitcher DR, Frieden TR, Bassett MT. Cholesterol control beyond the clinic: New York City’s trans fat restriction. Ann Intern Med. 2009;151(2):129-134.

Austin SB, Melly SJ, Sanchez BN, Patel A, Buka S, Gortmaker SL. Clustering of fast food restaurants around schools: A novel application of spatial statistics to the study of food environments. Am J Public Health. 2005;95(9):1575-1581.

Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Prev Chronic Dis. 2006;3(3):A76.

Borgmeier I, Westenhoefer J. Impact of different food label formats on healthiness evaluation and food choice of consumers: A randomized-controlled study. BMC Public Health. 2009;12(9):184.

Burton S, Creyer EH, Kees J, Huggins K. Attacking the obesity epidemic: the potential health benefits of providing nutrition information in restaurants. Am J Public Health.2006;96(9):1669-1675.

Cassady D, Housemann R, Dagher C. Measuring cues for healthy choices on restaurant menus: Development and testing of a measurement instrument. Am J Health Promot. 2004;18(6):444-449.

Creel JS, Sharkey JR, McIntosh A, Anding J, Huber JC Jr. Availability of healthier options in traditional and nontraditional rural fast-food outlets. BMC Public Health. 2008;8:395.

Dumanovsky T, Nonas CA, Huang CY, Silver LD, Bassett MT. What people buy from fast-food restaurants: Caloric content and menu item selection, New York City 2007. Obesity (Silver Spring). 2009; 17(7):1369-1374.

Dwyer JJ, Macaskill LA, Uetrecht CL, Dombrow C. Eat Smart! Ontario’s Healthy Restaurant Program: Focus groups with non-participating restaurant operators. Can J Diet Pract Res. 2004.;65(1):6-9.

Economos CD, Folta SC, Goldberg J, Hudson D, Collins J, Baker Z, Lawson E, Nelson M. A community-based restaurant initiative to increase availability of healthy menu options in Somerville, Massachusetts: Shape Up Somerville. Prev Chronic Dis. 2009.;6(3):A102

Fielding JE, Aguirre A, Palaiologos E. Effectiveness of altered incentives in a food safety inspection program. Prev Med. 2001;32(3):239-244.

Ford PB, Dzewaltowski DA. Disparities in obesity prevalence due to variation in the retail food environment: Three testable hypotheses. Nutr Rev. 2008 Apr;66(4):216-228.

French SA, Harnack L, Jeffery RW. Fast food restaurant use among women in the Pound of Prevention study: Dietary, behavioral and demographic correlates. International Journal of Obesity & Related Metabolic Disorders. 2000;24(1):1353.

French SA. Pricing effects on food choices. J.Nutr. 2003;133(3):841S-843S.

French SA, Jeffery RW, Story M, Breitlow KK, Baxter JS, Hannan P, et al. Pricing and promotion effects on lowfat vending snack purchases: The CHIPS Study. Am J Public Health. 2001 ;91(1):112-117.

French SA, Story M, Neumark Sztainer D, Fulkerson JA, Hannan P. Fast food restaurant use among adolescents: Associations with nutrient intake, food choices and behavioral and psychosocial variables. Int J Obes Relat Metab Disord.2001;25(12):1823-1833.

Fried EJ, Nestle M. The growing political movement against soft drinks in schools. JAMA.2002 ;288(1):2181-2181.

Gerend MA. Does calorie information promote lower calorie fast food choices among college students? J Adolesc Health. 2009;44(1):84-86.

Glanz K, Resnicow K, Seymour J, Hoy K, Stewart H, Lyons M, Goldberg J. How major restaurant chains plan their menus: The role of profit, demand, and health. Am J Prev Med. 2007;32(5):383-388.

Hannan P, French SA, Story M, Fulkerson JA. A pricing strategy to promote sales of lower fat foods in high school cafeterias: Acceptability and sensitivity analysis. Am.J.Health Promot. 2002 ;17(1):16,ii.

Hanni KD, Garcia E, Ellemberg C, Winkleby M. Targeting the taqueria: Implementing healthy food options at Mexican American restaurants. Health Promot Pract. 2009;10(2 Suppl):91S-99S.

Harnack LJ, French SA. Effect of point-of-purchase calorie labeling on restaurant and cafeteria food choices: A review of the literature. Int J Behav Nutr Phys Act. 2008 Oct 26;5:51.

Harnack LJ, French SA, Oakes JM, Story MT, Jeffery RW, Rydell SA. Effects of calorie labeling and value size pricing on fast food meal choices: Results from an experimental trial. Int J Behav Nutr Phys Act. 2008 ;5:63.

Jacobson MF, Brownell KD. Small taxes on soft drinks and snack foods to promote health. Am J Public Health 2000;90:854-857.

Jetter KM, Cassady DL. Increasing fresh fruit and vegetable availability in a low-income neighborhood convenience store: A pilot study. Health Promot Pract. 2009 Feb 12. [Epub ahead of print]

Kim D, Kawachi I. Food taxation and pricing strategies to “thin out” the obesity epidemic. Am. J. Prev. Med.2006;30(5):430-437.

Kimathi AN, Gregoire MB, Dowling RA, Stone MK. A healthful options food station can improve satisfaction and generate gross profit in a worksite cafeteria. J Am Diet Assoc. 2009;109(5):914-917.

Kuo T, Jarosz CJ, Simon P, Fielding JE. Menu labeling as a potential strategy for combating the obesity epidemic: A health impact assessment. Am J Public Health. 2009;99(9):1680-1686.

Kwate N O A. Fried chicken and fresh apples: Racial segregation as a fundamental cause of fast food density in black neighborhoods. Health and Place. 2008;14:32-44.

Kwate NO, Yau CY, Loh JM, Williams D. Inequality in obesigenic environments: Fast food density in New York City.Healthand Place. 2009;15(1):364-73

Lang T, Rayner G, Kaelin E. The Food Industry, Diet, Physical Activity and Health: A Review Of Reported Commitments And Practice Of 25 Of The World’s Largest Food Companies. 2006.

Larson NI, Story MT, Nelson MC. Neighborhood environments: Disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74-81.

Ludwig DS, Brownell KD. Public health action amid scientific uncertainty: The case of restaurant calorie labeling regulations.JAMA. 2009;302(4):434-435.

Lynch RA, Elledge BL, Griffith CC, Boatright DT. A comparison of food safety knowledge among restaurant managers, by source of training and experience, in Oklahoma County, Oklahoma. J Environ Health. 2003;66(2):9-14, 26.

Macdonald L, Cummins S, Macintyre S. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite. 2007l;49(1):251-254.

Maddock J. The relationship between obesity and the prevalence of fast food restaurants: State level analysis. Am J Health Promot. 2004;19(2):137-143.

Mashta O. UK firms sign up to display calories on menus. BMJ. 2009;338:b182.

Morland KB, Evenson KR. Obesity prevalence and the local food environment. Health and Place. 2009; 15(2):491-495

Nielsen SJ, Siega Riz AM, Popkin BM. Trends in food locations and sources among adolescents and young adults. Prev Med.2002;35(2):107-113.

O’Dougherty M, Harnack LJ, French SA, Story M, Oakes JM, Jeffery RW. Nutrition labeling and value size pricing at fast-food restaurants: A consumer perspective. Am J Health Promot. 2006;20(4):247-250.

Phillips ML, Elledge BL, Basara HG, Lynch RA, Boatright DT. Recurrent critical violations of the food code in retail food service establishments. J Environ Health. 2006;68(10):24-30, 55.

Pomeranz JL, Brownell KD. Legal and public health considerations affecting the success, reach, and impact of menu-labeling laws. Am J Public Health. 2008;98(9):1578-1583.

Roberto CA, Agnew H, Brownell KD. An observational study of consumers’ accessing of nutrition information in chain restaurants. Am J Public Health. 2009;99(5):820-821.

Rose D, Hutchinson PL, Bodor JN, Swalm CM, Farley TA, Cohen DA, Rice JC. Neighborhood food environments and Body Mass Index: The importance of in-store contents. Am J Prev Med. 2009;37(3):214-219.

Rydell SA, Harnack LJ, Oakes JM, Story M, Jeffery RW, French SA. Why eat at fast-food restaurants: reported reasons among frequent consumers. J Am Diet Assoc. 2008;108(12):2066-2070.

Sharkey JR, Horel S, Han D, Huber JC Jr. Association between neighborhood need and spatial access to food stores and fast food restaurants in neighborhoods of colonias. Int J Health Geogr. 2009;8:9.

Song HJ, Gittelsohn J, Kim M, Suratkar S, Sharma S, Anliker J. A corner store intervention in a low-income urban community is associated with increased availability and sales of some healthy foods. Public Health Nutr. 2009:1-8.

Spencer EH, Frank E, McIntosh NF. Potential effects of the next 100 billion hamburgers sold by McDonald’s.Am.J.Prev.Med. 2005 ;28(4):379-381.

Story M, Kaphingst KM, Robinson-O’Brien R, Glanz K. Creating healthy food and eating environments: Policy and environmental approaches. Annu Rev Public Health. 2008;29:253-72.

Pharmaceutical Industry

Brooks JM, Doucette WR, Wan S, Klepser DG. Retail pharmacy market structure and performance. Inquiry. 2008;45(1):75-88.

Carroll NV. Estimating the impact of Medicare part D on the profitability of independent community pharmacies. J Manag Care Pharm. 2008;14(8):768-779.

Fincham JE. An unfortunate and avoidable component of American pharmacy: Tobacco. Am J Pharm Educ. 2008;72(3):57

Garattini L, Motterlini N, Cornago D. Prices and distribution margins of in-patent drugs in pharmacy: A comparison in seven European countries. Health Policy. 2008;85(3):305-313.

Gellad WF, Choudhry NK, Friedberg MW, Brookhart MA, Haas JS, Shrank WH. Variation in drug prices at pharmacies: Are prices higher in poorer areas? Health Serv Res. 2009;44(2 Pt 1):606-617.

Gitlin M, Wilson L. Repackaged pharmaceuticals in the California workers’ compensation system: From distribution and pricing options to physician and retail dispensing. Am J Ind Med. 2007;50(4):303-315.

Montoya ID, Jano E. Online pharmacies: Safety and regulatory considerations. Int J Health Serv. 2007;37(2):279-289.

Retail and mail copayments on the rise. Manag Care. 2009;18(6):50.

Rudholm N. Entry of new pharmacies in the deregulated Norwegian pharmaceuticals market– consequences for costs and availability. Health Policy.2008;87(2):258-263

Stafford E. Pharmacy initiatives target prescription drug costs. J Mich Dent Assoc. 2008;90(9):22.

Stevenson FA, Leontowitsch M, Duggan C. Over-the-counter medicines: Professional expertise and consumer discourses.Sociol Health Illn. 2008;30(6):913-928.

Tobacco Industry

Andersen BS, Begay ME, Lawson CB. Breaking the alliance: Defeating the tobacco industry’s allies and enacting youth access restrictions in Massachusetts. Am J Public Health. 2003;93(11):1922-1928.

Celebucki CC, Diskin K. A longitudinal study of externally visible cigarette advertising on retail storefronts in Massachusetts before and after the Master Settlement Agreement. Tob Control. 2002;11 Suppl 2:ii47-53.

Chriqui JF, Ribisl KM, Wallace RM, Williams RS, O’Connor JC, el Arculli R. A comprehensive review of state laws governing Internet and other delivery sales of cigarettes in the United States. Nicotine Tob Res. 2008;10(2):253-265.

Feighery EC, Ribisl KM, Achabal DD, Tyebjee T. Retail trade incentives: How tobacco industry practices compare with those of other industries. Am J Public Health. 1999;89(10):1564-1566.

Feighery EC, Ribisl KM, Clark PI, Haladjian HH. How tobacco companies ensure prime placement of their advertising and products in stores: Interviews with retailers about tobacco company incentive programmes. Tob Control. 2003;12(2):184-188.

Feighery EC, Ribisl KM, Schleicher N, Lee RE, Halvorson S. Cigarette advertising and promotional strategies in retail outlets: results of a statewide survey in California. Tob Control. 2001;10(2):184-188.

Feighery EC, Ribisl KM, Schleicher NC, Clark PI. Retailer participation in cigarette company incentive programs is related to increased levels of cigarette advertising and cheaper cigarette prices in stores. Prev Med. 2004;38(6):876-884.

Gilbertson T. Retail point-of-sale guardianship and juvenile tobacco purchases: assessing the prevention capabilities of undergraduate college students. J Drug Educ. 2007;37(1):1-30.

Gilpin EA, White VM, Pierce JP. How effective are tobacco industry bar and club marketing efforts in reaching young adults?Tob Control. 2005;14(3):186-192.

Glanz K, Sutton NM, Jacob Arriola KR. Operation storefront Hawaii: Tobacco advertising and promotion in Hawaii stores. J Health Commun. 2006;11(7):699-707.

Henriksen L, Feighery EC, Schleicher NC, Cowling DW, Kline RS, Fortmann SP. Is adolescent smoking related to the density and proximity of tobacco outlets and retail cigarette advertising near schools? Prev Med. 2008;47(2):210-4.

Henriksen L, Feighery EC, Schleicher NC, Haladjian HH, Fortmann SP. Reaching youth at the point of sale: cigarette marketing is more prevalent in stores where adolescents shop frequently. Tob Control. 2004;13(3):315-318.

Henriksen L, Feighery EC, Wang Y, Fortmann SP. Association of retail tobacco marketing with adolescent smoking. Am J Public Health. 2004;94(12):2081-2083.

Lavack AM, Toth G. Tobacco point-of-purchase promotion: Examining tobacco industry documents. Tob Control. 2006;15(5):377-384.

Loomis BR, Farrelly MC, Mann NH. The association of retail promotions for cigarettes with the Master Settlement Agreement, tobacco control programmes and cigarette excise taxes. Tob Control. 2006;15(6):458-463.

Loomis BR, Farrelly MC, Nonnemaker JM, Mann NH. Point of purchase cigarette promotions before and after the Master Settlement Agreement: exploring retail scanner data. Tob Control. 2006;15(2):140-

Pollay RW. More than meets the eye: on the importance of retail cigarette merchandising. Tob Control. 2007;16(4):270-274.

Sepe E, Ling PM, Glantz SA. Smooth moves: bar and nightclub tobacco promotions that target young adults. Am J Public Health. 2002;92(3):414-419.

Slater S, Chaloupka FJ, Wakefield M. State variation in retail promotions and advertising for Marlboro cigarettes. Tob Control. 2001;10(4):337-339.

Slater S, Giovino G, Chaloupka F. Surveillance of tobacco industry retail marketing activities of reduced harm products.Nicotine Tob Res. 2008;10(1):187-193.

Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’malley PM. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc. Med. 2007;161(5):440-445.

Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O’Malley PM. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc Med. 2007;161(5):440-445.

Smith EA, Blackman VS, Malone RE. Death at a discount: how the tobacco industry thwarted tobacco control policies in US military commissaries. Tob Control. 2007;16(1):38-46.

Studies of Multiple Industries

Ashe M, Jernigan D, Kline R, Galaz R. Land use planning and the control of alcohol, tobacco, firearms, and fast food restaurants. Am J Public Health. 2003;93(9):1404-1408.

Feighery EC, Ribisl KM, Achabal DD, Tyebjee T. Retail trade incentives: how tobacco industry practices compare with those of other industries. Am J Public Health. 1999;89(10):1564-1566.

Freudenberg N, Galea S, Fahs M. Changing corporate practices to reduce cancer disparities. J Health Care Poor Underserved.2008; 19(1):26-40.

Hemenway D. The public health approach to motor vehicles, tobacco, and alcohol, with applications to firearms policy. J Public Health Policy. 2001;22(4):381-402.

Kotecki JE. Sale of alcohol in pharmacies: results and implications of an empirical study. J Community Health. 2003;28(1):65-77.