The health impact of retail practices: towards a research agenda

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?

  1. 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.

  1. 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.

 

  1. 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.

  1. 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.

  1. 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.

 

  1. 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