Factors associated with tobacco sales to minors: lessons learned from the FDA compliance checks

"If You Just Tell Me You're 18, I'll Still Sell to You": A Qualitative Study of Underage Tobacco Product Purchasing Experiences in a Tobacco 21 Compliance Study

BACKGROUND

Tens of thousands of underage tobacco buy attempts are conducted each year for research, compliance, and public health surveillance. However, little research has qualitatively examined the perceptions and experiences of underage buyers participating in these programs. We sought to understand underage buyers' experiences and gather recommendations for protocol improvements.

METHODS

We conducted semi-structured interviews in the fall of 2022 to assess experiences with underage tobacco product purchasing. Participants (N = 19, 58% male, 42% White) were research assistants aged 18-20 in New Jersey, New York, or North Carolina. Interviews examined purchasing experiences in relation to store characteristics, clerk interactions, and buyer identities. We used deductive and inductive thematic coding to explore key themes related to buyer experiences.

RESULTS

We identified four themes: (1) non-chain stores lacked consistency in verifying age; (2) female data collectors experienced uncomfortable situations more frequently than male data collectors; (3) not identifying with the store's typical demographics impacted purchase attempts; and (4) participants suggested improvements for inspections and research during training.

DISCUSSION

Retailer education, widespread adoption of ID scanners, and enforcement could increase standardization of ID requests and verification. Male and female buyers can be trained on what they might expect based on their gender, as well as how to maneuver through unwanted situations. Consideration of shared identity is important for future waves of data collection and research. Efforts to improve training include more extensive mock purchase training with supervisors well-versed in this area.

IMPLICATIONS

Electronic ID verification and promoting compliance at non-chain retailers could impact access to tobacco products for underage buyers. Training for underage buyers in research and compliance assessments should focus on ways to enhance data collectors' confidence when making a purchase attempt, which may improve the validity of the rate of sales to individuals under 21.

Assessing the Effectiveness of Tobacco 21 Laws to Reduce Underage Access to Tobacco: Protocol for a Repeated Multi-Site Study

Prior to the federal law passed in December 2019, many states passed an increased age of sale law prohibiting youth under age 21 (or Tobacco 21) from purchasing tobacco products, including e-cigarettes. Although previous research has documented tobacco retail sale violations, fewer studies have examined age verification and illegal tobacco sales in the context of Tobacco 21 or repeated purchase attempts in various settings. In this study conducted between 2019 and 2022, buyers aged 18 to 20 years made repeated unsupervised purchase attempts of cigarettes, cigars, e-cigarettes, tobacco-free nicotine pouches, and smokeless tobacco at over 180 tobacco or e-cigarette retailers in New Jersey, New York City, and Pitt County (North Carolina). Buyers documented whether they were asked for identification and whether they were able to successfully purchase a tobacco or nicotine product at each visit. The primary outcome will be the percent of retailers that checked the buyers' identification at store visits and the percent of visits that resulted in a successful underage tobacco product purchase. We will compare the results across time periods, study sites, products, and buyer characteristics (i.e., gender, minoritized racial/ethnic identity) while controlling for repeated visits. These results will inform improvements to current compliance check inspection programs as well as interventions that reduce youth access to tobacco.

A Long-Term National Survey of Compliance with the Ban on Selling Tobacco Products to Adolescents of Taiwan’s Tobacco Hazards Prevention Act

The data on long-term trends and factors of tobacco retailers’ compliance in Taiwan are limited. The new regulations of the Tobacco Hazards Prevention Act were established in 2009. Now, the government is planning to raise the minimum legal age (MLA) for purchasing tobacco products from 18 to 20, so the results of this study will be an important reference to promote new regulations in the future. We carried out an observational mystery shopping study design and data were collected from 2009 to 2019. In total, 6320 undercover tests were conducted to investigate selling by tobacco retailers to persons aged less than 18 years by an impartial third party annually. Logistic regression was used to analyze the factors influencing compliance by adjusting test variables and independent variables. The compliance rate increased by 8.4% annually and was better among tests conducted during summer vacation (AOR = 1.324), chain convenience stores (AOR = 3.651), supermarkets or hypermarkets (AOR = 1.973), and verifications with age (AOR = 15.345). It is the first study to explore long-term and national tobacco retailers’ enforcement effects by an impartial third party in Asia. The findings suggest that local health agencies should enhance enforcement on those stores which were tested during non-summer holidays and weekends, betel nut stands, and grocery stores.

The Kentucky SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use

BACKGROUND

Smokeless tobacco (SLT) prevalence was decreasing in Kentucky before 2007, but has since increased. This study examines the impact of policies on cigarette and SLT use by applying the SimSmoke tobacco control policy simulation model.

METHODS

Using data from the large-scale Tobacco Use Supplement of the Current Population Survey (TUS-CPS) and information on state-specific tobacco policies, Kentucky SimSmoke is updated and extended to incorporate exclusive SLT and dual cigarette and SLT use. The model is validated using survey data through 2017. The model was used to estimate the impact on smoking and SLT prevalence and attributable deaths of policies implemented between 1993 and 2018 and the impact of stronger future policies implemented in 2018 and maintained through 2060.

RESULTS

SimSmoke generally reflects trends in exclusive cigarette use from the TUS-CPS and the Behavioral Risk Factor Surveillance System (BRFSS), but underestimated the increase in SLT prevalence in recent years. SimSmoke projects that policies implemented between 1993 and 2018 reduced male and female cigarette use by 23.7% and 23.0%, and male and female SLT use by 4.9% by 2018, averting 9018 tobacco-attributable deaths by 2018, increasing to 89 547 by 2060. The largest reductions in cigarette and SLT use were attributed to cigarette price increases. Strengthening tobacco control policies could reduce smoking prevalence by 41% and 40%, and reduce SLT prevalence by 33% and 25% for males and females by 2060.

CONCLUSION

Our results suggest that cigarette-oriented policies were effective in reducing SLT use but have been less successful in recent years. Future use rates can be further reduced through more restrictive statewide policies, which also target non-combustible nicotine products.

Sales of cigarettes to pseudo-underage mystery shoppers: Experiences from Stockholm County

Aims

There is an 18 years age limit for cigarette purchase in Sweden and in order to implement this law outlets need to perform ID checks. This study investigates the rate of cigarette sales and ID checks when pseudo-underage mystery shoppers attempted to purchase cigarettes. It explores possible factors associated with sales outcomes.

Design

Nine mystery shoppers (6 females and 3 males) attempted to purchase cigarettes without providing ID. The mystery shoppers were 18 years old but had a younger appearance as judged by an expert panel. During each attempt, the adolescents worked in pairs (shopper and observer). A total of 320 outlets in 13 municipalities in Stockholm County were randomly selected based on an outlet type stratum (i.e., gas station, convenience store, kiosk, grocery store). Effects of variables on sales outcomes were analysed using Pearson's chi-square and binominal regression analysis.

Results

In 25.4% of the purchase attempts (total n = 287), cigarettes were sold although the pseudo-underage mystery shopper did not provide a valid ID. In 82.6% of the attempts, the shopper was asked to provide ID, and cigarettes were sold in 9.7% of these cases. The rate of sales was significantly higher among female mystery shoppers (29.5%) compared to male (15.0%). Age limit signs were observed in 89.5% of the outlets but they were not significantly associated with the success rate in a regression analysis.

Conclusions

The results of the present study indicate that cigarettes could potentially and frequently be sold to underage adolescents by outlets within Stockholm County. Therefore, routines established for checking IDs clearly need to be improved. For example, strategies to improve adherence to the legal age limit on the purchase of cigarettes, such as compliance checks using mystery shopping with feedback to retailers, are needed.

Rural disparities in adolescent smoking prevalence

INTRODUCTION

Rural residence is a well-established risk factor for risk behaviors and subsequent morbidity and mortality in the United States. Smoking is the primary cause of preventable death and is more prevalent in rural America. As chronic smoking habits typically develop during adolescence, the discrepancy in smoking rates between rural and urban youth likely contributes to a significant geographic disparity in the long-term health of adults.

METHODS

Data were extracted from 12th-grader surveys of the US Monitoring the Future study from 1998 to 2018. The historic trends of smoking initiation, ever-regular and current-regular smoking rates of rural and urban adolescents were estimated with intercept-only time-varying effect models. Differences in prevalence between rural and urban youth were calculated for each smoking behavior.

RESULTS

Though overall smoking prevalence continues to decline, this trend is significantly attenuated among rural adolescents compared to urban youth. The absolute difference in lifetime smoking prevalence between rural and urban youth has markedly increased from 6.9% in 1998 to 13.5% in 2018, which is among the highest in the past 20 years and is a potentially alarming upward trend. However, the absolute differences in ever-regular and current-regular smoking prevalence have shown an overall net decline, decreasing from 6.4 to 4.8%, and from 5.5 to 3.0%, respectively.

CONCLUSIONS

This geographic disparity between rural and urban adolescents represents a potentially modifiable cause of increased morbidity and mortality in rural areas. Interventions and regulatory efforts should be tailored for rural adolescents to reduce the narrowing but persistent disparity in regular smoking.

Tobacco Advertising and ID Checks in Columbus, Ohio, in Advance of Tobacco 21

PURPOSE

In autumn 2017, Columbus, Ohio, joined numerous other US locations in raising their legal sales age for purchasing tobacco to 21 (ie, becoming "T21"). The present study sought to establish a baseline for ID checks in Columbus prior to T21 enforcement and to examine whether store type and marketing were associated with better rates of ID checks.

DESIGN

Fieldworkers aged 20 to 21 years visited a random sample of 110 tobacco retailers during summer 2017 (drawn from >10 000 licensed retailers in the county). After collecting store-related information, they attempted to purchase cigarettes and recorded whether their ID was checked (federal law requires ID checks for anyone who looks younger than 27 years).

SETTING

Columbus, Ohio.

MEASURES

Store type, external tobacco advertising, and ID check outcome.

ANALYSIS

Descriptive and inferential statistics.

RESULTS

Among stores where cigarettes were purchased, 61.1% did not conduct ID checks. Absent ID checks were associated with the store being a convenience store or tobacco shop, χ2(2) = 4.45, P = .035, and having a greater amount of external advertising, t(93) = 2.00, P = .049.

CONCLUSION

Overall, the low rate of ID checks for young adults purchasing tobacco in Columbus is concerning. Continued monitoring of retailer compliance will be important as retailers adjust to the arrival of T21. Targeted enforcement and additional outreach with tobacco shops, convenience stores, and stores with a high amount of external advertising may be particularly needed.

Source of cigarettes among youth smokers in Malaysia: Findings from the tobacco and e-cigarette survey among Malaysian school adolescents (TECMA)

INTRODUCTION

Understanding how and where youth obtain tobacco products are major factors in the development of suitable intervention programs to reduce youth smoking. This study aimed to determine the source of cigarettes and the associated factors among Malaysian school adolescent smokers.

METHODS

Our sample consisted of 1348 youth aged 10-17 years who were current smokers (having smoked at least once in the last 30 days). The source of cigarettes (commercial, over-the-counter purchases; or social, borrowing or obtaining from someone else) was the dependent variable, and multivariable logistic regression was employed to determine its association with independent variables (i.e. sociodemographics, smoking behavior, and knowledge of laws prohibiting sales of cigarettes to youth).

RESULTS

Over half (54.3%) of current smokers obtained cigarettes from commercial sources, with a proportion nearly two times higher (84.2% vs 43.7%) among frequent smokers (i.e. those smoking more than 20 days per month) compared to less-frequent smokers, and among young males (56.5% vs 32.0%) compared young females. Multivariable logistic regression indicated that in urban areas, young females (AOR=12.5, 95% CI: 1.38-99.8) frequent smokers (AOR=4.41, 95% CI: 2.05-9.46), and those studying in lower (AOR=3.76, 95% CI: 1.41-10.02) and upper secondary (AOR=4.74, 95% CI: 1.72-13.06) school students were more likely to obtain cigarettes from a commercial source. On the other hand, in rural areas, only frequent smokers were more likely to get their cigarettes from commercial sources, whilst other variables were not significant.

CONCLUSIONS

The proportion of youth smokers who obtained cigarettes from commercial sources appeared to be high, suggesting that law enforcement and health promotion activities should be enhanced to reduce the rate of smoking among Malaysian youth.

The US SimSmoke tobacco control policy model of smokeless tobacco and cigarette use

Background

Smokeless tobacco (SLT) prevalence had been declining in the US prior to 2002 but has since increased. Knowledge about the impact of tobacco control policies on SLT and cigarette use is limited. This study examines the interrelationship between policies, cigarette use, and SLT use by applying the SimSmoke tobacco control policy simulation model.

Methods

Using data from large-scale Tobacco Use Supplement and information on policies implemented, US SimSmoke was updated and extended to incorporate SLT use. The model distinguishes between exclusive SLT and dual use of SLT and cigarettes, and considers the effect of implementing individual and combined tobacco control policies on smoking and SLT use, and on deaths attributable to their use. After validating against Tobacco Use Supplement (TUS) survey data through 2015, the model was used to estimate the impact of policies implemented between 1993 and 2017.

Results

SimSmoke reflected trends in exclusive cigarette use from the TUS, but over-estimated the reductions, especially among 18–24 year olds, until 2002 and under-estimated the reductions from 2011 to 2015. By 2015, SimSmoke projections of exclusive SLT and dual use were close to TUS estimates, but under-estimated reductions in both from 1993 to 2002 and failed to estimate the growth in male exclusive SLT use, especially among 18–24 year olds, from 2011 to 2015. SimSmoke projects that policies implemented between 1993 and 2017 reduced exclusive cigarette use by about 35%, dual use by 32.5% and SLT use by 16.5%, yielding a reduction of 7.5 million tobacco-attributable deaths by 2067. The largest reductions were attributed to tax increases.

Conclusions

Our results indicate that cigarette-oriented policies may be effective in also reducing the use of other tobacco products. However, further information is needed on the effect of tobacco control policies on exclusive and dual SLT use and the role of industry.

Identification of Vape Shops in Two North Carolina Counties: An Approach for States without Retailer Licensing

Stores that sell electronic nicotine delivery systems (ENDS) as their primary product are a new phenomenon and often termed “vape shops”. While vape shops are now regulated by state and federal agencies, not all states maintain lists of vape shops in operation. Standard ways of identifying tobacco retailers through off-premise alcohol permits and business listing services may not identify vape shops. We used four online business listing services (i.e., Google Maps, ReferenceUSA, YellowPages.com, Yelp) to identify vape shops in two counties in North Carolina (NC). In one county, we also assessed four vaping web sites. We drove primary and secondary roads to physically validate the identified stores and attempt to identify stores not listed online. To assess the accuracy of the online searches, we calculated sensitivity and positive predictive values (PPVs). This research was conducted in spring and summer 2016 and identified 28 vape shops online. We confirmed 16 vape shops (seven in Pitt County, NC, USA, and nine in Durham County, NC, USA). Online searches ranged in sensitivity, 62.5%–81.3%, and PPVs ranged from 73.3% to 92.3%. Because of the range of sensitivity found among the business listing services, state policymakers should consider uniform licensing requirements for vape and tobacco retailers to more easily track retailers and ensure compliance with regulations.

Inequities in tobacco retailer sales to minors by neighbourhood racial/ethnic composition, poverty and segregation, USA, 2015

OBJECTIVE

Tobacco retailers are an important source of tobacco products for minors. Previous research shows racial discrimination in sales to minors, but no national study has examined neighbourhood correlates of retailer under-age sales.

METHODS

We accessed publicly available results of 2015 US Food and Drug Administration (FDA) inspections of tobacco retailers (n=108 614). In this cross-sectional study, we used multilevel logistic regression to predict the likelihood of retailer sale to a minor based on tract characteristics. We assessed the proportion of residents identifying as American Indian, Asian, Black, Latino and White; Isolation Index scores for each racial/ethnic group; the proportion of people less than age 65 living in poverty; and the proportion of residents age 10-17 in relation to retailer inspection results.

RESULTS

The proportion of American Indian residents, Black residents, Latino residents and residents less than age 65 under the poverty line in a neighbourhood are independently, positively associated with the likelihood that a retailer in that neighbourhood will fail an under-age buy inspection. The proportion of White residents and residents age 10-17 are independently, negatively associated with the likelihood of sale of tobacco products to a minor. Isolation Index scores show a similar pattern. In multivariable models holding neighbourhood characteristics constant, higher proportions of Black (+), Latino (+) and age 10-17 (-) residents remained significant predictors of the likelihood of under-age sale.

DISCUSSION

Regulatory agencies should consider oversampling retailers in areas with higher likelihood of sales to minors for inspection. Interventions with tobacco retailers to reduce inequities in youth access should be implemented.

Sociodemographic Disparities in Proximity of Schools to Tobacco Outlets and Fast-Food Restaurants

OBJECTIVES

To examine the association of school sociodemographic characteristics with tobacco outlet and fast-food restaurant availability near schools in a national study.

METHODS

Business lists and data from the National Center for Education Statistics were used to calculate the numbers of tobacco outlets and fast-food restaurants within 800 meters of public schools in 97 US counties.

RESULTS

More than 50% of schools with a majority of Hispanic students had both a fast-food restaurant and tobacco outlet nearby, compared with 21% of schools with a majority of White students. In adjusted models, each 10% increase in the number of low-income and Hispanic students enrolled in a school led to a 3% to 5% increase in the odds of the school having both a fast-food restaurant and a tobacco outlet nearby.

CONCLUSIONS

Low-income and Hispanic students are disproportionately exposed to both tobacco outlets and fast-food restaurants near their schools. Easy access to tobacco products and fast food may influence youth smoking initiation and contribute to poor dietary intake.

Facilitating Adolescent Smoking: Who Provides the Cigarettes?

Purpose.

Most adolescent smokers obtain cigarettes through social sources. We examine the extent to which cigarettes are provided by facilitators of legal age to purchase cigarettes.

Design.

Analyses of data from the 1999 California Tobacco Survey, a large population-based, random-digit–dialed telephone survey, are reported.

Setting.

California.

Subjects.

Data were from a subset of 1239 adolescent (12–17 years) respondents who reported ever having smoked a cigarette. The response rate for all adolescents selected for interview was 75.5%.

Measures.

We describe cigarette providers to adolescents in social (cigarettes given to the adolescent) and economic (someone else buys cigarettes for the adolescent) transactions by the reported facilitator's age.

Results.

Of the 82.2% ± 2.6% of adolescents who had ever smoked who usually obtained cigarettes from others, 21.6% ± 2.5% used economic transactions; most (60.6% ± 3.4%) were given cigarettes. The majority (73.3% ± 3.6%) of those relying on social sources were given cigarettes by someone <18 years of age; very few were given cigarettes by someone 21+ years old. Most (90.4% ± 2.0%) usually given cigarettes reported friends as facilitators. Of those who relied on economic transactions, 56.1% ± 6.6% reported facilitators who were 18- to 20-year-olds, another 24.7% ±6.3% had suppliers ≥21 years of age. Altogether, 80.8% ± 5.8% of facilitators in economic transactions were ≥18 years of age.

Conclusions.

Until peer approval of smoking and sharing cigarettes and adult facilitation of adolescent smoking is reduced, it will be difficult to significantly reduce adolescents' access to cigarettes.

"May I Buy a Pack of Marlboros, Please?" A Systematic Review of Evidence to Improve the Validity and Impact of Youth Undercover Buy Inspections

Most smokers become addicted to tobacco products before they are legally able to purchase these products. We systematically reviewed the literature on protocols to assess underage purchase and their ecological validity. We conducted a systematic search in May 2015 in PubMed and PsycINFO. We independently screened records for inclusion. We conducted a narrative review and examined implications of two types of legal authority for protocols that govern underage buy enforcement in the United States: criminal (state-level laws prohibiting sales to youth) and administrative (federal regulations prohibiting sales to youth). Ten studies experimentally assessed underage buy protocols and 44 studies assessed the association between youth characteristics and tobacco sales. Protocols that mimicked real-world youth behaviors were consistently associated with substantially greater likelihood of a sale to a youth. Many of the tested protocols appear to be designed for compliance with criminal law rather than administrative enforcement in ways that limited ecological validity. This may be due to concerns about entrapment. For administrative enforcement in particular, entrapment may be less of an issue than commonly thought. Commonly used underage buy protocols poorly represent the reality of youths' access to tobacco from retailers. Compliance check programs should allow youth to present themselves naturally and attempt to match the community's demographic makeup.

Youth retail tobacco access in Canada: regional variation, perceptions, and predictors from YSS 2010/2011

PURPOSE

Retail tobacco access is an important determinant of youth smoking prevalence. This study examines perceptions of ease in obtaining cigarettes and how prevalence of self-reported retail tobacco access among youth smokers varies by province in Canada. Additionally, relevant retail experiences, such as being asked for identification by a store clerk, are described.

METHODS

Data from grades 9-12 students who participated in the 2010/2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students (n=31396) were used to examine retail tobacco access and related experiences. Logistic regression models were used to examine differences in retail tobacco access and retail tobacco experiences by sociodemographic and regional characteristics.

RESULTS

79% of students who never smoked thought it would be easy to get cigarettes. About one-quarter of smokers reported usually buying cigarettes from stores, and the percent of student smokers usually buying cigarettes in stores ranged from 16% in British Columbia to 36% in Quebec. Compared to grade 9 students, grade 12 students had higher odds of report being asked for identification (OR=6.3, 95% CI 1.9-21.5).

CONCLUSIONS

Retail tobacco access appears to be a significant source of cigarette access among Canadian youth. Retail tobacco access varies significantly by province, which suggests provincial policies should be strengthened.

Prohibiting juvenile access to tobacco: Violation rates, cigarette sales, and youth smoking

BACKGROUND

Scholars who examine the efficacy of juvenile tobacco sales restrictions, especially the 1992 "Synar Amendment" that led all of fifty U.S. states to enact prohibitions on tobacco sales to minors, are notably divided as to impact on youth smoking. Some researchers claim that such policies have failed and ought to be abandoned (Craig & Boris, 2007; Etter, 2006; Glantz, 2002), while others insist that enforcement has indeed led to reduced tobacco use (DiFranza, 2011b; SAMHSA, 2011). The present study is the first to combine data on Synar violation rates from all states and years available since the amendment's implementation, assessing the connection to national rates of cigarette sales and youth smoking behavior.

METHODS

Using national data from the United States Substance Abuse and Mental Health Services Administration, the Tobacco Institute, and the Centers for Disease Control's Youth Risk Behavior Surveillance System across all U.S. states between 1996 and 2007, we employ hierarchical linear modeling to examine the connection between retailer Synar violations and youth smoking.

RESULTS

Controlling for state-level demographic variables, results indicate that retailer violation rates are significantly associated with greater youth smoking prevalence, as well as higher overall cigarette sales.

CONCLUSION

While critiques of Synar policies are substantive and should be addressed, laws prohibiting the sale of tobacco to juveniles appear to have had some degree of success.

Compliance with minimum price and legal age for cigarette purchase laws: evidence from NYC in advance of raising purchase age to 21

BACKGROUND

New York City (NYC) raised the minimum purchase age for cigarettes from 18 to 21 on 1 August 2014. The new law is intended to decrease current smoking rates and smoking initiation among the city's youth. Assessment of compliance with existing cigarette sales and tax laws could aid in determining what may be needed for successful implementation of the city's new law.

PURPOSE

To assess compliance with minimum sales price and purchase age laws in NYC, before change in law.

METHODS

Ten trained field investigators purchased cigarettes from different types of retailers throughout all five NYC boroughs, resulting in 421 purchases. Investigators noted whether they were asked for identification and the price of their purchase. Multivariable logistic and Ordinary Least Squares regression techniques were used to assess predictors of retailer compliance with sales price and minimum purchase age laws.

RESULTS

In 29% of purchases, investigators did not have to produce identification (p<0.05) to purchase cigarettes. Only 3.1% of sales were at prices lower than the minimum sales price. City borough was significantly associated with purchase without identification (p<0.001) and mean sales price (p<0.024). Vendor type (independent vs chain) was significantly related to investigators being able to purchase cigarettes without identification (p<0.001).

CONCLUSIONS

Variation in compliance with existing laws suggests that more active monitoring of compliance with the new minimum legal purchase age will be required in order to realise the new law's public health potential.

Trends in age verification among U.S. adolescents attempting to buy cigarettes at retail stores, 2000-2009

OBJECTIVE

This study assessed trends in age verification prior to cigarette sales to U.S. middle and high school students, and refusal to sell cigarettes to students aged <18 years during 2000-2009.

METHOD

Data were obtained from the 2000-2009 National Youth Tobacco Survey. Trends during 2000-2009 were assessed using binary logistic regression (p<0.05).

RESULT

The proportion of all students, who reported being asked to show proof of age prior to a cigarette purchase in the past 30 days did not change significantly between 2000 (46.9%) and 2009 (44.9%) (p=0.529 for linear trend). No significant trend in the proportion of students aged < 18 years who were refused a sale when attempting to buy cigarettes was observed between 2000 (39.8%) and 2009 (36.7%) (p=0.283 for linear trend). Refusal of a cigarette sale was significantly higher among under-aged boys compared to girls (adjusted odds ratio=1.48; 95% confidence interval: 1.28-1.70).

CONCLUSION

About half of U.S. middle and high school students who reported making a cigarette purchase were not asked for proof of age, and about three of five under-aged buyers successfully made a cigarette purchase in 2009. Intensified implementation and enforcement of policies requiring age verification among youths is warranted to reduce access and use of tobacco products.

Contextual and community factors associated with youth access to cigarettes through commercial sources

OBJECTIVES

This study examines contextual and community-level characteristics associated with youth access to tobacco through commercial sources in 50 non-contiguous mid-sized California communities.

METHODS

The study is based on data from access surveys conducted by four confederate buyers (two men and two women) in 997 tobacco outlets. City demographics, adult smoking prevalence, and measures of tobacco outlet density, local tobacco retailer licencing and cigarette tax were included.

RESULTS

Multilevel regression analyses indicated that buyer's actual age, a male clerk and asking young buyers about their age were related to successful cigarette purchases. Buyer's actual age and minimum age signs increased the likelihood that clerks will request an identification (ID). At the community level, a higher percentage of minors, higher education, and a greater percentage of African-Americans were associated with an increased likelihood of a successful purchase. Lower percentage of minors, lower education, lower percentage of African-Americans, and having a local tobacco retailer licencing were associated with the retailer asking for an ID. Additionally, supermarkets charged significantly more for a pack of cigarettes than small markets, whereas, smoke/tobacco shops and drug stores/pharmacies charged less. Higher prices were associated with higher median household income and greater percentage of Hispanics. Findings about community characteristics, however, differed by cigarette brand.

CONCLUSIONS

This study enhances our understanding of the associations between contextual and community characteristics and youth access to tobacco through commercial sources which can help policymakers to identify and target at-risk communities and outlets to decrease youth access to tobacco.

The tobacco-free generation proposal

The tobacco-free generation proposal advocates legislation precluding the sale and supply of tobacco to individuals born after a certain year. The measure is aimed at overcoming defects with current youth access laws that suffer from rite-of-passage and mixed signalling effects. Since its introduction in 2010, the proposal has attracted international attention, highlighting a number of matters that the present short article discusses. Efficacy issues, including retailer compliance, supply by surrogates and illicit sales, are addressed in the broader setting of community adherence to legislation. Encouragement for the likelihood of successful implementation is provided by historical precedents. In principle objections, relating to choice and generational fairness, are considered against the criteria of consistency and proportionality. It is concluded that the measure's emphasis on the welfare of future generations and its regard for the interests of existing stakeholders provide a feasible opportunity for the ultimate eradication of tobacco supply in appropriate jurisdictions.

Retailers' knowledge of tobacco harm reduction following the introduction of a new brand of smokeless tobacco

BACKGROUND

Tobacco retailers are potential public health partners for tobacco harm reduction (THR). THR is the substitution of highly reduced-risk nicotine products, such as smokeless tobacco (ST) or pharmaceutical nicotine, for cigarettes. The introduction of a Swedish-style ST product, du Maurier snus (dMS) (Imperial Tobacco Canada Limited), which was marketed as a THR product, provided a unique opportunity to assess retailers' knowledge. This study examined retailers' knowledge of THR and compliance with recommendations regarding tobacco sales to young adults.

METHODS

Male researchers, who may have looked younger than 18 years old, visited 60 stores in Edmonton that sold dMS. The researchers asked the retailers questions about dMS and its health risks relative to those from other tobacco products. They also attempted to purchase dMS to ascertain whether retailers would ask for identification to verify that they were at least 18 years old.

RESULTS

Overall, the retailers were only moderately knowledgeable about THR and the differences between dMS and other tobacco products. About half of the retailers correctly indicated that snus is safer than cigarettes; half of whom knew it is safer because it is smoke-free. Fifty percent incorrectly believed that snus causes oral cancer. Less than fifty percent indicated that dMS differs from chewing tobacco because it is in pouches and is used without spitting or chewing (making it more promising for THR). Most (90%) of the retailers asked the researchers for identification when selling dMS.

CONCLUSION

Tobacco retailers are potentially important sources of information about THR, particularly since there are restrictions on the promotion of all tobacco products (regardless of the actual health risks) in Canada. This study found that many retailers in Edmonton do not know the relative health risks of different tobacco products and are therefore unable to pass on accurate information to smokers.

[Tobacco purchase among underaged]

BACKGROUND

A previous Norwegian study showed that underaged smokers usually buy cigarettes for themselves. The Norwegian Medical Association has recently suggested that the minimum legal age for purchase of tobacco should be raised from 18 to 20 years. This study presents new data on underaged who buy cigarettes and snus for themselves; i.e. number of buyers and their characteristics.

MATERIAL AND METHODS

17,253 students- aged 13 to 17 years-participated in a school survey in 2004. They answered questions about use of cigarettes and snus and to what extent they bought these goods themselves.

RESULTS

40 % of smokers and 45 % of snus users reported that they mostly or always bought tobacco themselves. Those who used tobacco on a daily basis were more likely to buy it themselves. The adolescents bought about 60 % of all cigarettes and 70 % of all snus they used themselves. The likelihood that the underaged tobacco users mostly or always bought their own tobacco increased with age and was higher for boys, for those who appeared mature for their age and those who had used a false ID.

INTERPRETATION

Underaged tobacco users' purchase of tobacco for themselves seems to be as extensive as in the previous study. Authorities should consider measures to improve compliance with the minimum legal age for tobacco purchase.

The "We Card" program: tobacco industry "youth smoking prevention" as industry self-preservation

The "We Card" program is the most ubiquitous tobacco industry "youth smoking prevention" program in the United States, and its retailer materials have been copied in other countries. The program's effectiveness has been questioned, but no previous studies have examined its development, goals, and uses from the tobacco industry's perspective. On the basis of our analysis of tobacco industry documents released under the 1998 Master Settlement Agreement, we concluded that the We Card program was undertaken for 2 primary purposes: to improve the tobacco industry's image and to reduce regulation and the enforcement of existing laws. Policymakers should be cautious about accepting industry self-regulation at face value, both because it redounds to the industry's benefit and because it is ineffective.

Density of tobacco retailers near schools: effects on tobacco use among students

OBJECTIVES

We examined the relationship between students' tobacco use and the density and proximity of tobacco retailers near their schools.

METHODS

We used data from the 2003-2004 California Student Tobacco Survey and California retail licensing data. Measures included students' self-reported tobacco use and geocoded state-reported locations of tobacco retailers. We used random-intercept generalized linear mixed modeling to jointly evaluate individual-level and school-level predictors.

RESULTS

Density of retailers was associated with experimental smoking (odds ratio [OR] = 1.11; 95% confidence interval [CI] = 1.02, 1.21) but not established smoking (OR = 1.06; 95% CI = 0.94, 1.20). The effects on experimental smoking were confined to high school students (OR = 1.17; 95% CI = 1.06, 1.29) in urban areas (OR = 1.11; 95% CI = 1.01, 1.21); no effects were observed among middle school students or in rural schools. High school students were more likely to obtain cigarettes from a retailer; middle school students relied more heavily on social sources.

CONCLUSIONS

Our results support the plausibility of reducing rates of students' experimental smoking, but not established smoking, by restricting their access to commercial sources of tobacco in urban areas.

Old enough for a beer? Compliance with minimum legal age for alcohol purchases in monopoly and other off-premise outlets in Finland and Norway

AIM

To assess whether government monopoly outlets comply better with minimum legal age for purchase of alcohol compared to other off-premise outlets for alcohol sales.

METHODS

Under-age-appearing 18-year-olds attempted to purchase alcohol in off-premise outlets applying identical procedures in Finland (n = 290) and Norway (n = 170). Outcomes were measured as whether or not the buyers were asked to present an identity (ID) card and whether or not they succeeded in purchasing alcohol. RESULTS The buyers were asked to present an ID card in slightly more than half the attempts, and they succeeded in purchasing alcohol in 48% of the cases. The buyers were more likely to be requested to present an ID card and less likely to succeed in purchasing alcohol in monopoly outlets compared to other types of outlets, and also when other outcome predictors, such as age and gender of salesperson and crowdedness in the outlet, were taken into account.

CONCLUSION

Monopoly outlets may facilitate compliance with minimum legal age for purchase of alcohol.

The effect of smoke-free homes on smoking behavior in the U.S

BACKGROUND

Evidence from longitudinal population surveys is needed to establish whether smoke-free homes might influence smoking behavior.

METHODS

The Tobacco Use Supplement of the nationally representative U.S. Current Population Survey (TUS-CPS) interviewed 3292 adult recent smokers in 2002 and again 12 months later. Both surveys measured smoking status, rules on smoking in the home, and the number of cigarettes smoked per day (cpd). For the main study outcome, an early marker of successful cessation (>or=90 days quit) was used. Analysis was completed in 2008.

RESULTS

In the 12 months ending February 2003, the prevalence of smoke-free homes among recent smokers increased from 33% to 39%. A smoke-free home at baseline was associated with >or=90 days cessation at follow-up (10.9% vs 6.2%, AOR=1.44; 95% CI=0.97, 2.21), and those who maintained a smoke-free home were more likely to be >or=90 days quit than those who did not (12.9% vs 5.7%, AOR=1.99; 95% CI=0.93, 4.25). However, adopting a smoke-free home during the year was associated with a nearly fivefold increase in the percentage of >or=90 days quit (AOR=4.81; 95% CI=3.06, 7.59). This increase was seen among all smokers, including moderate-to-heavy smokers (>or=90 days quit: a smoke-free home=13.0% vs no smoke-free home=2.9%, p<0.001). Among continuing smokers with a smoke-free home at baseline, maintenance of te smoke-free home was associated with a decline in consumption (micro=or-2.18; 95 CI=or-1.24; -3.10 cpd). Among continuing smokers with no smoke-free home at baseline, adoption of that status was also associated with a decline in consumption (micro=or-1.72; 95% CI=or-0.58; -2.85 cpd).

CONCLUSIONS

This study provides strong evidence that the adoption of a smoke-free home is associated with successful quitting among smokers in the U.S.

Reducing underage cigarette sales in an isolated community: the effect on adolescent cigarette supplies

OBJECTIVE

The current study explored the practicality of preventing underage retail cigarette sales and the relationship to cigarette supplies among adolescents.

METHOD

In Fort Morgan, Colorado, an isolated rural community with below-average socioeconomic status and a large Latino population, supervised teenaged employees repeatedly attempted to buy cigarettes from every store over a 9-month period in 2005. Repeated violations were penalized. Cigarette acquisition and exchange among community adolescents were assessed before and after intervention using a high school student survey.

RESULTS

The measured violation rate declined from 47% in the first week to 3.4% during the final three months, and high school student reliance on retail cigarette purchases declined. Adolescent cigarette supplies declined by approximately 15%.

CONCLUSION

Isolated rural communities can reduce adolescent cigarette supplies by conducting consistent enforcement against retail cigarette sales to minors. Previous research suggests that reducing these sales may help reduce adolescent smoking. The current study demonstrates that enforcement is practical and effective.

Longitudinal patterns of youth access to cigarettes and smoking progression: Minnesota Adolescent Community Cohort (MACC) study (2000-2003)

OBJECTIVES

To measure community-level changes in the methods youth use to obtain cigarettes over time and to relate these methods to the progression of smoking.

METHODS

We analyzed 2000-2003 data from the Minnesota Adolescent Community Cohort study, where youth (beginning at age 12), who were living in Minnesota at baseline, were surveyed every 6 months via telephone. We conducted mixed model repeated measures logistic regression to obtain probabilities of cigarette access methods among past 30-day smokers (n=340 at baseline).

RESULTS

The probability of obtaining cigarettes from a commercial source in the past month declined from 0.36 at baseline to 0.22 at the sixth survey point while the probability of obtaining cigarettes from a social source during the previous month increased from 0.54 to 0.76 (p for both trends=0.0001). At the community level, the likelihood of adolescents obtaining cigarettes from social sources was inversely related to the likelihood of progressing to heavy smoking (p<0.001).

CONCLUSIONS

During this time, youth shifted to greater reliance on social sources and less on commercial sources. A trend toward less commercial access to cigarettes accompanied by an increase in social access may translate to youth being less likely to progress to heavier smoking.

Youth tobacco sales in a metropolitan county: factors associated with compliance

OBJECTIVE

To describe and identify factors associated with tobacco sales in a metropolitan county.

SETTING

King County, Washington is the largest county in Washington State with an estimated population of 1.8 million or about 30% of the state's population.

DATA SOURCE

The data analysis is based on compliance checks in King County between January 2001 and March 2005. The 8879 checks were conducted by 91 youth operatives aged 14-17. Analysis of data was completed in 2006.

STATISTICAL ANALYSIS

The outcome variable for this analysis was whether "a sale was made" to a youth operative during a compliance check. Associations between independent variables and the outcome variable were examined using 2 x 2 tables, univariate (unadjusted) logistic regression, and multivariate (adjusted) logistic regression analysis.

RESULTS

Overall tobacco sales during the 4-year and 3-month period was 7.7%. Convenience stores selling gas were significantly more likely to sell tobacco products to minors, whereas restaurants, bars, and tobacco discount stores were less likely to sell to minors. Other factors that were significantly associated with sales are described.

CONCLUSIONS

In a county that has adopted many of the required youth access laws, opportunities still exist to reduce sales of tobacco products to minors. Asking for age and photo identification still appears to be an effective strategy in reducing sales of tobacco products to minors.

Laws prohibiting the sale of tobacco to minors: impact and adverse consequences

This paper discusses the consequences of laws that prohibit the sale of tobacco to minors. When enforced, such laws may decrease tobacco sales to minors, but local authorities are often reluctant to enforce these laws. However, the prohibition of tobacco sales to minors is often followed by an increase in the use of tobacco obtained from social sources, mainly family and friends. Importantly, these laws do not decrease smoking prevalence among minors. Several local laws prohibit youths from purchasing, using, and possessing tobacco. However, these laws shift responsibility from retailers to youth, criminalizing young smokers. Those who advocate this type of approach have not documented the adverse consequences of laws that prohibit minors from purchasing, using, or possessing tobacco. In conclusion, youth access laws are ineffective and are not based on sound science.

Adolescent smoking behaviour and cigarette brand preference in Japan

OBJECTIVES

As part of efforts to develop a smoking control strategy for Japanese adolescents, the results of two nationwide surveys on adolescent smoking behaviour were compared.

DESIGN

Descriptive study on smoking behaviour among high school students was conducted. Self-reporting anonymous questionnaires were administered to 115,814 students in 1996 and 106,297 in 2000 through randomly sampled junior and senior high schools throughout Japan.

MAIN OUTCOME MEASURES

Smoking prevalence, proportion of smokers by usual sources of cigarettes, national estimated cigarettes consumed by minors, share of cigarette brands smoked by high school students.

RESULTS

The experiment rate among junior high school boys decreased in 2000 compared with that in 1996, whereas current and daily smoking rates did not. Although prevalence among Japanese girls was much lower than that among boys, prevalence among girls increased in 2000. The main source of cigarettes among high school smokers was vending machines. The proportion of smokers who usually purchased cigarettes from vending machines increased in 2000, in spite of the 1998 introduction of restrictions on night-time operations. Japanese adolescents were more likely than adults to smoke American cigarette brands, and the adolescent market share of American brands has increased rapidly, especially for menthol brands.

CONCLUSIONS

This survey revealed the seriousness of the problem of smoking behaviour among Japanese high school students, and suggested that this behaviour may be influenced by social environmental factors, including the marketing strategies of the tobacco industry. Action should be taken to reduce the prevalence and impact of pro-tobacco marketing messages and to abolish cigarette vending machines.

The federal initiative to halt the sale of tobacco to children--the Synar Amendment, 1992-2000: lessons learned

BACKGROUND

The Synar Amendment was enacted by the US Congress in 1992 to require states and territories to establish and enforce laws prohibiting the sale of tobacco to minors.

OBJECTIVE

To describe state and federal efforts to comply with the Synar mandate.

METHODS

State and federal actions were examined for the eight years following enactment.

DATA SOURCES

Federal documents from 1992-2003, annual block grant applications from 59 states and territories describing activities during federal fiscal years 1995-2000.

MEASURES

Whether applicants made a good faith effort to comply by enacting a law, enforcing it with inspections and penalties, conducting a valid survey and meeting violation rate targets set by the Department of Health and Human Services (DHHS).

RESULTS

Between 1996 and 2000, 26 states had made a good faith effort to comply with Synar every year. In 2000, 57 jurisdictions (excluding Maryland and Montana) had established laws without loopholes, 57 conducted a valid survey, and 54 actively enforced their laws. By 2002, violation rates had dropped substantially everywhere but Alaska and a few small territories. No state reached the violation rate goal of 20% without penalising violators.

CONCLUSIONS

The Synar Amendment has resulted in the universal adoption of laws prohibiting tobacco sales to minors and almost universal enforcement of those laws, resulting in dramatically reduced violation rates. Implementation was slowed significantly by a lack of good faith effort in many states and by DHHS's decision not to require states to enforce their laws by penalising lawbreakers.

Interventions for preventing tobacco sales to minors

BACKGROUND

Laws restricting sales of tobacco products to minors exist in many countries, but young people may still purchase cigarettes easily.

OBJECTIVES

The review assesses the effects of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group trials register, MEDLINE and EMBASE. Date of the most recent searches: September 2004.

SELECTION CRITERIA

We included controlled trials and uncontrolled studies with pre- and post intervention assessment of interventions to change retailers' behaviour. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's smoking behaviour, and perceived ease of access to tobacco products.

DATA COLLECTION AND ANALYSIS

One reviewer prescreened studies for relevance, and both reviewers independently assessed the studies for inclusion. One reviewer extracted data from included studies and the second checked them. Study designs and types of intervention were heterogeneous so results were synthesized narratively, with greater weight given to controlled studies.

MAIN RESULTS

We identified 34 studies of which 14 had data from a control group for at least one outcome. Giving retailers information was less effective in reducing illegal sales than active enforcement or multicomponent educational strategies, or both. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking.

AUTHORS' CONCLUSIONS

Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.

Methods, locations, and ease of cigarette access for American youth, 1997-2002

BACKGROUND

The purpose of this paper is to examine trends in middle and high school students' perceived ease, methods, and locations of access to cigarettes, and to assess differences related to their sociodemographic characteristics and smoking status.

METHODS

Annual data from nationally representative samples of 8th-, 10th-, and 12th-grade students were analyzed for the 1997-2002 period. Analyses were conducted in 2003.

RESULTS

Perceived ease of access decreased significantly among never and past smokers. Decreased individual purchasing in retail outlets, as well as decreased purchasing from vending machines, were reported by 8th- and 10th-grade students. All grades reported decreased purchasing from self-service placements of cigarettes. Decreases in access were not reported across all retailer types, and no significant increases were seen in the percent of underage purchasers who reported being asked to show identification. Both gender and ethnicity were significantly related to where and how underage youth reported obtaining cigarettes.

CONCLUSIONS

Cigarette access for minors has been declining, but remains high. Findings show that (1) perceived access to cigarettes clearly increases with level of smoking, and (2) policies to reduce such access may be having an impact as evidenced by decreased retail and vending machine purchases and self-service purchases. However, states should continue to strengthen efforts to reduce youth cigarette access, especially in the areas of confirming buyer age via identification checks, and should make efforts to decrease access across all retailer types. Federal regulations like those previously implemented by the Food and Drug Administration might strongly assist in reducing youth access to cigarettes.

Retailer participation in cigarette company incentive programs is related to increased levels of cigarette advertising and cheaper cigarette prices in stores

PURPOSE

The retail outlet is the cigarette companies' major marketing channel to reach present and future customers. Of the $11.2 billion spent by them to market their products in 2001, approximately 85% was spent on retailer and consumer incentives to stimulate sales. This study examines the extent of retailer participation in these incentive programs, and the relationship between participation and the amount and placement of cigarette marketing materials and products, and prices in stores.

METHODS

Observational assessments of cigarette marketing materials, products, and prices were conducted in 468 stores in 15 U.S. states. Telephone interviews were conducted with store owners or managers of these stores to determine the details of their participation in incentive programs.

RESULTS

Cigarette companies engaged 65% of retailers in an incentive program. Nearly 80% of participating retailers reported cigarette company control over placement of marketing materials in their stores. Stores that reported receiving over $3,000 from incentive programs in the past 3 months averaged 19.5 cigarette marketing materials, and stores receiving no money averaged only 8.2 marketing materials. In multivariate analyses, participation in incentive programs offered by Philip Morris and R.J. Reynolds was positively related to the number of cigarette marketing materials for each of these companies' brands in stores and the placement of their cigarettes on the top shelf. The price of Newports was significantly lower in stores that received incentives; no price difference was found for Marlboro.

CONCLUSIONS

Stores that participate in cigarette company incentive programs feature more prominent placement of cigarettes and advertising, and may have cheaper cigarette prices.

Does adolescent perception of difficulty in getting cigarettes deter experimentation?

BACKGROUND

Considerable controversy surrounds tobacco control emphasis on youth-access-to-tobacco laws, as there is limited evidence that such enforcement reduces youth smoking. In California, access-law enforcement increased substantially in 1996 compared to earlier in the decade.

METHODS

Two longitudinal cohorts of adolescent never smokers from the large, population-based California Tobacco Surveys of 1993 and 1996 were followed-up 3 years later (1993-1996 [n = 1764] and 1996-1999 [n = 2119]). We examined transition to any smoking by follow-up with adolescent perception that cigarettes are easy or hard to get, during periods with less and more access law enforcement.

RESULTS

Transition to any smoking by follow-up among 12- to 15-year-old never smokers was identical in the 1993-1996 cohort, regardless of whether they perceived cigarettes as hard or easy to get (about 38%), but was lower in the 1996-1999 cohort for those who perceived that cigarettes were hard (25.9%) vs. easy (36.1%) to get. This differential effect was confirmed in multivariate analyses that adjusted for demographics, cohort, and other known predictors of adolescent smoking.

CONCLUSIONS

Increased enforcement of access laws may help protect young adolescents from experimenting with cigarettes by strengthening societal anti-tobacco norms. Such enforcement appears warranted as part of a comprehensive tobacco control program.

Youth tobacco access: adult attitudes, awareness, and perceived self-efficacy in two Arizona counties

While a variety of steps have been taken to restrict youth access to tobacco, little has been done to explore adult attitudes, beliefs, and behaviors concerning this issue. To ameliorate this knowledge gap, 828 adults from Arizona's Maricopa and Pima counties were surveyed. Overall, adults perceived that the prevention of youth tobacco access was: an important issue, an issue they are willing to spend money on, and a responsibility shared by all adults. Further, when asked who was most responsible for keeping tobacco away from minors, 65.4% of adults surveyed perceived parents of the youth purchasing tobacco as most responsible. Responding to items soliciting opinions regarding appropriate penalties for minors purchasing tobacco and for those selling tobacco to minors, respondents recommended stiffer punishment for the sellers of tobacco. Almost 10% recommended a night in jail for vendors caught selling tobacco products to minors. Interestingly, respondents exhibited low perceived self-efficacy regarding the prevention of youth tobacco access. The majority of adults agreed that it is easy for minors to gain access to tobacco and that there is nothing they or the community can do to stop minors who wish to purchase tobacco. Future research efforts should investigate how adult self-efficacy can be increased and the impact that such a change would have on efforts to prevent youth tobacco access.

The ID effect on youth access to cigarettes

OBJECTIVE

To estimate the effect on cigarette sales rates when minors present identification (ID).

DESIGN

Controlled experiment in which minors attempting to purchase cigarettes either carried a valid photo ID (documenting they were minors) or carried no ID, and were instructed to show the ID or admit having no ID if the clerk requested proof of age.

SETTING

Census of retail stores in six urban and suburban Colorado counties.

SUBJECTS

Retail cigarette clerks, uninformed of the study.

MAIN OUTCOME MEASURES

Relative risk (RR) of cigarette sale to a minor when ID was requested and presented versus requested but not presented.

RESULTS

When clerks requested ID, sales were more than six times as frequent if minors presented ID than if they did not (12.2% v 2.0%, RR 6.2, p < 0.0001). The relative risk remained substantially unchanged under adjustment for demographic and circumstantial covariates.

CONCLUSIONS

Presentation of photo ID in compliance checks increases illegal cigarette sales to minors. The impact may vary among states or locales and depends strongly on how often clerks request proof of age. Clerk training and responsible cigarette sales practices should include age calculations from photo ID. Programmes relying on investigative purchase attempts to estimate actual rates of cigarette sales to minors should ascertain and replicate local ID presenting behaviours that minors typically use during genuine attempts to buy cigarettes.

Cigarette acquisition and proof of age among US high school students who smoke

OBJECTIVE

To determine how US high school students who are under 18 years of age and who smoke obtain their cigarettes and whether they are asked for proof of age.

DESIGN AND SETTING

Data from the Centers for Disease Control and Prevention's 1995, 1997, and 1999 national Youth Risk Behavior Surveys which employed national probability samples of students in grades 9-12 (ages 14-18 years).

MAIN OUTCOME MEASURES

Associations of usual source of cigarettes and request for proof of age with variables such as sex, race/ethnicity, grade, and frequency of smoking.

RESULTS

In 1999, among current smokers under age 18 years, 23.5% (95% confidence interval (CI), -4.5% to +4.5%) usually purchased their cigarettes in a store; among these students, 69.6% (95% CI -5.7% to +5.7%) were not asked to show proof of age. As days of past month smoking increased, reliance on buying cigarettes in a store (p < 0.001) and giving someone else money to buy cigarettes (p < 0.001) increased, and usually borrowing cigarettes decreased (p < 0.001). From 1995 to 1999, relying on store purchases significantly decreased (from 38.7% (95% CI -4.6% to + 4.6%) to 23.5% (95% CI -4.5% to +4.5%)); usually giving someone else money to buy cigarettes significantly increased (from 15.8% (95% CI -3.6% to +3.6%) to 29.9% (95% CI -4.5% to + 4.5%)).

CONCLUSIONS

Stricter enforcement of tobacco access laws is needed to support other community and school efforts to reduce tobacco use among youth. Furthermore, effective interventions to reduce non-commercial sources of tobacco, including social, need to be developed and implemented.

Interventions for preventing tobacco sales to minors

BACKGROUND

Laws restricting sales of tobacco products to minors exist in many countries, but young people may still purchase cigarettes easily.

OBJECTIVES

The review assesses the effects of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group trials register, MEDLINE and EMBASE. Date of the most recent searches: October 2001.

SELECTION CRITERIA

We included controlled trials and uncontrolled studies with pre- and post intervention assessment of interventions to change retailers' behaviour. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's smoking behaviour, and perceived ease of access to tobacco products.

DATA COLLECTION AND ANALYSIS

Studies were prescreened for relevance by one person and assessed for inclusion by two people independently. Data from included studies were extracted by one person and checked by a second. Study designs and types of intervention were heterogeneous so results were synthesised narratively, with greater weight given to controlled studies.

MAIN RESULTS

We identified 30 studies of which 13 were controlled. Giving retailers information was less effective in reducing illegal sales than active enforcement and/or multicomponent educational strategies. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking.

REVIEWER'S CONCLUSIONS

Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.

Sources of tobacco for youths in communities with strong enforcement of youth access laws

AIM

To determine how youths obtain tobacco in communities with strong enforcement of tobacco sales laws.

SETTING

Ten communities in Massachusetts with merchant compliance rates at or above 90%.

METHODS

Paper surveys and focus group discussions with 68 adolescent smokers.

RESULTS

Parents and friends are the primary sources of tobacco for new smokers. When stealing from parents can no longer satisfy the need for cigarettes, young adolescents ask strangers to buy them tobacco. For high school age smokers, teenage store clerks are a major source. Teenage clerks sell to other teenagers, steal tobacco, and help their friends steal from their employers. Friends who are 18 years of age or over are a second major source for older adolescents. Parents often purchase tobacco for older adolescents.

CONCLUSION

Recommended actions include raising the minimum age for the purchase of tobacco to 21 years, and prohibiting individuals less than 21 years of age from selling tobacco.

Is the standard compliance check protocol a valid measure of the accessibility of tobacco to underage smokers?

OBJECTIVE

To determine if the standard compliance check protocol is a valid measure of the experience of underage smokers when purchasing tobacco in unfamiliar communities.

SETTING

160 tobacco outlets in eight Massachusetts communities where underage tobacco sales laws are vigorously enforced.

PROCEDURE

Completed purchase rates were compared between underage smokers who behaved normally and inexperienced non-smoking youths who were not allowed to lie or present proof of age (ID).

RESULTS

The "smoker protocol" increased the likelihood of a sale nearly sixfold over that for the non-smokers (odds ratio (OR) 5.7, 95% confidence interval (CI) 1.5 to 22). When the youths presented an ID with an underage birth date, the odds of a completed sale increased dramatically (OR 27, 95% CI 3.4 to 212). Clerks judged to be under 21 years of age were seven times more likely to make an illegal sale (OR 7.6, 95% CI 2.4 to 24.0).

CONCLUSIONS

Commonly used compliance check protocols are too artificial to reflect accurately the experience of underage smokers. The validity of compliance checks might be improved by having youths present ID, and by employing either tobacco users, or non-tobacco users who are sufficiently experienced to mimic the self confidence exhibited by tobacco users in this situation. Consideration should be given to prohibiting the sale of tobacco by individuals under 21 years of age.