Tobacco products are heavily marketed in retail spaces in urban communities. Combined with ready availability and low prices, advertising can increase consumption of unhealthy products and contribute to poor health. Previous research from multiple cities showed that tobacco outlets and tobacco advertising are concentrated in low-income and racial/ethnic minority areas and near child-serving institutions (1–5). Studies also showed an association between smoking rates and the number of outlets and advertisements (6,7). Outdoor and point-of-sale tobacco advertising increase smoking initiation among adolescents, undermine smokers’ quit attempts, and promote relapse among former smokers (7–16).

Smoking rates in the United States are strongly associated with income, with lower-income populations having higher rates of smoking (17). In Philadelphia, 34% of adults living below the federal poverty guidelines, 37% of participants in the Supplemental Nutrition Assistance Program (SNAP), and 23.1% of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are smokers, compared with 20% of nonpoor adults (27). Nationally, smokers earning less than $30,000 per year spend 14% of their income on cigarettes, exacerbating already challenging financial circumstances for themselves and their families (28). Over the life course, low socioeconomic status is associated with higher rates of smoking initiation and regularization and lower rates of quitting (27). Among Latinos, smokers are 30% to 50% more likely to be food insecure than nonsmokers, controlling for sex, age, and poverty status (17).

Because the largest 4 tobacco companies agreed in the Master Settlement not to advertise tobacco products on billboards, advertisements for tobacco products at tobacco retail outlets are the most prevalent form of tobacco advertising. These accessory or “on-premise” advertisements are regulated differently from nonaccessory advertisements such as billboards.

For this study, we used a survey and digital photographs to analyze the location of tobacco outlets in Philadelphia and the type and amount of tobacco advertisements on their exterior and interior. In addition to clustering of tobacco outlets relative to each other, proximity to schools, and the income and racial/ethnic characteristics of neighborhoods, we considered the association between retail outlet type — including whether outlets were authorized to accept SNAP and WIC — and different types of tobacco advertisements.

Of the 4,639 outlets included in the February 2012 version of PTRD, assessors completed surveys at 2,805 (60.5%). Of the remaining outlets, 10.1% were visited but they were not selling tobacco, 7.8% were visited but no retailer was found at the location, 5.0% were permanently closed, 2.0% were duplicate listings, 2.0% were viewed online and were closed, and 12.5% were viewed online and appeared to be selling tobacco.

Many of the retail outlets with tobacco licenses were also authorized to accept SNAP: 45.9% of the tobacco outlets were authorized to accept SNAP, and 81.9% of SNAP stores were licensed to sell tobacco. Nearly all WIC-authorized stores (97.7%) were also authorized to accept SNAP benefits, but only 1 in 3 SNAP-authorized stores (35.1%) was also authorized to accept WIC. Most WIC-authorized stores (72.3%) were licensed to sell tobacco.

Of the 3,356 tobacco outlets identified as open and selling tobacco products, 50.3% had at least 1 exterior tobacco advertisement. Of outlets with exterior tobacco advertisements, 18.4% were within 500 ft of a school. Of the 2,805 outlets where surveys were completed, 69.1% had at least 1 interior tobacco advertisement and 19.7% had tobacco advertisements near products targeted to children (Table 1).

In the bivariate logistic regression models, many of the independent variables were significant across the dependent variables, including SNAP and WIC status, downtown location (Center City), moderate poverty (30%–50%), and large black population (Table 2). Gas stations (odds ratio [OR], 4.83; 95% confidence interval [CI], 3.42–6.82) were the most likely to have exterior tobacco advertisements. Chain pharmacies (OR, 58.75; 95% CI, 8.20–421.12) were the most likely to have interior tobacco advertisements. Corner stores (OR, 4.79; 95% CI, 3.92–5.86) were the most likely to have tobacco advertisements near products targeted to children.

In multivariate analyses, SNAP and WIC status were significantly and positively correlated with all 3 dependent variables, with the strongest relationship between SNAP stores and interior tobacco advertisements (OR, 3.43; 95% CI, 2.80–4.20) and the weakest between WIC status and exterior tobacco advertisements (OR, 1.59; 95% CI, 1.27–2.00) (Table 3). Being in a tract where 30% to 50% of the population lives in poverty was a significant and positive predictor of exterior advertisements (OR, 1.19; 95% CI, 1.00–1.41) but only up to 50%, at which point the direction switched and the relationship was no longer significant. Outlets in Center City were significantly less likely to have all 3 types of advertisements, with ORs ranging from 0.32 to 0.63. Similarly, outlets within 500 ft of schools were less likely to have exterior and interior advertisements (not significant) but were significantly more likely to have tobacco advertisements near products targeted to children (OR, 1.40; 95% CI, 1.10–1.79). Being in a tract with 50% or more black residents increased the odds of exterior advertisements or advertisements near products targeted to children but decreased the odds of having interior advertisements.

The Ripley’s local K-function showed significant clustering of tobacco outlets relative to population distribution and outlets with outdoor tobacco advertisements relative to the distribution of tobacco outlets. The Figure shows significant clustering of tobacco outlets based on a search radius of 2,500 ft in parts of North, South, and West Philadelphia and Center City. The Figure also shows significant clustering of exterior tobacco advertisements relative to the distribution of tobacco outlets in subsections of some of those areas, in particular in Kensington and South Philadelphia. Nearly all of the areas showing significant clustering — with the exception of commercial areas with low residential populations in Center City and South and Southwest Philadelphia — had poverty rates above 25%. Many of those areas also demonstrated above-average smoking rates.

The most striking finding from this study was that SNAP and WIC status was significantly associated with greater likelihood of exterior advertisements, interior advertisements, and interior tobacco advertisements near products targeted to children, even when controlling for neighborhood poverty and racial composition. When we included a categorical variable for food stores (including chain convenience store, corner store, gas station, grocery store, supermarket, and deli) in the multivariate model, the WIC and SNAP status were no longer significant predictors of exterior advertisements, but WIC and SNAP status were still significant predictors of interior advertisements and advertisements near products targeted to children. Previous research (21) and our own interviews with tobacco outlet staff indicated that representatives from tobacco manufacturers commonly dictate the number and location of exterior and interior tobacco advertisements as part of contracts they establish that impact the prices at which outlets can sell tobacco products. The significance of SNAP and WIC status in our models raises the possibility that tobacco distributors are deliberately targeting SNAP and WIC stores. Alternatively, these outlets may have greater tobacco sales and thus attract the attention of tobacco distributors. Regardless, the effect is that, by virtue of redeeming their federal nutrition benefits, SNAP and WIC participants are likely to be exposed to tobacco sales and advertising.

We also found that controlling for store type, tobacco outlets in areas with large populations of blacks were more likely to have tobacco advertisements placed near products targeted toward children. This may reflect a disproportionate amount of low-cost single-serving sweet and salty products that draw children into corner stores in these communities (22,23). Including racial composition as a continuous variable or dichotomizing the percentage of black population based on a higher concentration did not yield significant results, suggesting that even a slight majority of black residents has the same effect.

Consistent with previous research (2,24), our study found that areas with moderate poverty (30%–50% below federal poverty guidelines) were more likely to have exterior tobacco advertisements and advertisements near products targeted to children. But we also found that outlets in areas with extreme poverty (>50%) were less likely to have all 3 types of advertisements. This could be due to the mix of store types in these neighborhoods. Twenty percent of tobacco retailers in these areas are restaurants/take-outs — a higher proportion than in other areas and a store type that is less likely to have tobacco advertisements. The lower likelihood of advertisements could also be due to lower tobacco sales in very poor communities, despite the fact that smoking rates are high.

Generally, this study demonstrated that tobacco outlets and advertisements for tobacco products are clustered in lower-income neighborhoods in Philadelphia that also have higher-than-average smoking rates. Such environments likely contribute to and perpetuate racial/ethnic and socioeconomic disparities in smoking and, possibly, food insecurity. Policy makers should consider these findings when making decisions about tobacco retail licensing, local sign control (advertising) rules, and SNAP and WIC authorization.

Among the limitations of this study was our inability to complete field visits at all tobacco outlets and the nonrandom nature of the sample not visited. We did not assess inter-rater reliability other than to have the project manager accompany all assessors on their initial visits. Geocoding tobacco outlets and SNAP and WIC outlets separately, then matching them based on x and y coordinates, may have prevented us from identifying all of the tobacco outlets that accept SNAP or WIC. This study was cross-sectional; the amount and content of advertisements change regularly. Differences in state-level tobacco licensing and municipal sign control regulations also limit the generalizability of our findings beyond Philadelphia. Among the strengths of this study was the commitment to verifying tobacco outlet locations and status and observing interior tobacco advertising practices as well as the use of multivariate regression and point pattern analysis.

Certain policy approaches could mitigate the disparate exposure to tobacco advertising in stores serving low-income populations and in predominantly black/African American neighborhoods. First, federal and state agencies responsible for setting rules on SNAP and WIC participation should consider incentive-based or restrictive approaches or both, as allowable by law, to reduce advertising for unhealthful products and increase advertising for more healthful products in retail spaces. The US Department of Agriculture has asked for comments on how to revise its guidelines for determining retailer eligibility to participate in the SNAP program (25). Both the intended and unintended consequences of such strategies should be considered, including whether they might exacerbate food insecurity. Second, some jurisdictions have limited the number or density of tobacco outlets through zoning rules (26), while others, like Boston and San Francisco, have banned tobacco sales in pharmacies. Third, content-neutral restrictions on retail signage, limiting the amount of window or wall space or both that can be used for advertising, had been implemented in cities such as Los Angeles, California; Austin, Texas; and, recently, Philadelphia. Because such a large portion of retail advertising in corner stores is for tobacco products, sugary drinks, junk foods, and alcohol, even content-neutral restrictions may decrease the amount of advertising for unhealthful products (2). Fourth, although First Amendment hurdles remain, the 2009 federal Tobacco Control Act gives states and localities the ability to restrict the time, place, and manner of advertising. Moreover, the Food and Drug Administration is still considering whether to prohibit exterior tobacco advertisements within 1,000 ft of schools. (Our results from Philadelphia show that 60% of tobacco outlets, and 31% of outlets with exterior tobacco advertisements, are within 1,000 ft of a school.) A final strategy would be to encourage retailers to voluntarily agree not to sell tobacco, following the models of Target and CVS (29), or via exclusionary zones already promoted by the Outdoor Advertising Association of America that prohibit stationary advertisements for products illegal for sale to minors within 500 ft of schools, playgrounds, and places of worship.

Further research is needed on how best to mitigate the health effects of tobacco advertising in communities. State and localities can further these efforts by making information about tobacco outlets available to researchers and requiring outlets to report WIC and SNAP status when applying for tobacco retail permits. The US Department of Agriculture should invest in research to better understand the role tobacco sales play in SNAP and WIC stores.