The association between objectively measured exposure to tobacco outlets and smoking cognitions: a study among non‐smoking adolescents in four Dutch cities

AIMS: Exposure to tobacco products and advertising at the point of sale may be associated with pro‐smoking cognitions. However, previous studies on this topic measured exposure based on self‐report and did not include European countries. The aim of this study was to assess the association between objectively measured exposure to tobacco outlets and non‐smoking adolescents' smoking attitudes, beliefs and norms. DESIGN: This cross‐sectional study combined survey data with Global Positioning Systems data using geographic information system. SETTING: The four Dutch cities of Amsterdam, Eindhoven, Haarlem and Zwolle. PARTICIPANTS: We retrieved data of 308 13 to 17‐year‐old non‐smoking adolescents, mainly girls (61%), adolescents attending pre‐university secondary education (71%) and without smoking friends (58%). MEASUREMENTS: Exposure was measured with a smartphone app registering for 2 weeks how often participants were within 10 m of a tobacco outlet. We distinguished between outlets without visible tobacco promotion (i.e. supermarkets), with only internal visibility and with both internal and external visibility. Participants' reported smoking cognitions were dichotomised into pro‐smoking or anti‐smoking. We applied multi‐level logistic regression analyses and adjusted for age, sex, educational level and smoking friends. FINDINGS: On average, adolescents were exposed to 1.18 (SD = 1.23) tobacco outlets per day. Higher exposure to tobacco outlets was associated with higher odds of pro‐smoking injunctive norm ( OR = 1.35, 95% CI = 1.04–1.75). Associations with attitude (OR = 1.12, 95% CI = 0.91–1.38), social beliefs (OR = 1.15, 95% CI = 0.93–1.43), health beliefs (OR = 1.18, 95% CI = 0.97–1.44) and descriptive norm (OR = 1.15, 95% CI = 0.91–1.44) were also positive, but non‐significant. Overall, associations were strongest for outlets with internal visibility, for instance, for injunctive norm (OR = 1.37, 95% CI = 1.03–1.81). CONCLUSIONS: Global Positioning Systems‐measured exposure to tobacco outlets was associated with pro‐smoking cognitions among non‐smoking adolescents in the Netherlands.