Receipt of Tobacco Direct Mail Coupons and Changes in Smoking Status in a Nationally Representative Sample of US Adults.

Introduction: Direct-to-consumer tobacco marketing, including direct mail and email coupons, is a potentially influential marketing strategy. We examined the associations between receipt of tobacco direct mail/email coupons and trajectories of smoking behavior among US adults. Methods: Data were from the US Population Assessment on Tobacco and Health (PATH) Study adult sample (n = 32160) collected during 2013-2014. Participants self-reported their smoking status (every day, some days, not at all) 12 months prior to the survey (T0) and at the time of the survey (T1). Three smoking trajectories were identified: nonsmokers progressing to current smokers, current smokers continuing to smoke, and among current smokers at T0, progressing to or continuing with daily smoking. Participants also reported receipt of direct mail/email tobacco coupons in the 6 months preceding T1 (yes/no). Weighted multiple logistic regression models were used to test the associations between receiving direct mail/email tobacco coupons and different smoking trajectories adjusted for demographic characteristics. Results: One in eight (12.4%) US adult nonsmokers and 36.2% adult smokers at T0 reported receiving tobacco coupons. Receipt of tobacco coupons was negatively associated with poverty status. Receipt of tobacco coupons was associated with increased odds of progression to current smoking (AOR = 1.76, 95% CI = 1.45 to 2.12), continuation of smoking (AOR = 1.34, 95% CI = 1.09 to 1.65), and current smokers' progression to or continuation with daily smoking (AOR = 1.70, 95% CI = 1.50 to 1.91). Conclusions: Direct-to-consumer tobacco coupons may promote progression of smoking among nonsmokers, and continuation of smoking and progression to daily smoking among smokers in US adults. Implications: Distributing direct mail coupons is a strategy employed by tobacco companies to promote their products. We found, in a US national study, that many adults received tobacco coupons, and receiving these coupons was associated with subsequent progression of smoking among nonsmokers, and continuation of smoking and daily smoking among smokers. Scrutiny over the use of direct mail coupons and its effects on population health is warranted. Future research is needed to evaluate the effect of different interventions to reduce the impact of these coupons on smoking behaviors.