Can non-prosecutory enforcement of public health legislation reduce smoking among high school students?

School-based law enforcement strategies to reduce crime, increase perceptions of safety, and improve learning outcomes in primary and secondary schools: A systematic review

Background

School-based law enforcement (SBLE) has become a common intervention. Although SBLE is meant to make schools safer, critics suggest it may not accomplish this purpose, and may have unintended negative consequences such as increasing students' exclusionary discipline or contact with the criminal justice system. There may also be secondary effects related to perceptions of the school or student learning.

Objectives

The purpose of this review is to synthesize the literature evaluating the use of SBLE, including outcomes related to (a) crime and behavior problems; (b) perceptions of safety; and (c) learning.

Methods

We conducted a systematic literature search to identify studies that examined outcomes associated with SBLE use. Eligible studies used experimental or quasi-experimental designs; included samples of students, teachers/staff, schools, or school districts; reported on a policing strategy focused on crime prevention or school safety that did not involve officers teaching a curriculum; included a measure that reflects crime and behavior problems, perceptions of safety, or learning; and were in a primary or secondary school. Following a multi-stage screening process to identify studies eligible for inclusion, we estimated a series of meta-analytic models with robust variance estimation to calculate weighted mean effect sizes for each of three main categories of outcomes and commonly occurring subsets of these categories. We examined heterogeneity in these estimates across features of the primary studies' design.

Results

The search and screening process yielded 1002 effect sizes from 32 reports. There were no true experiments, and the quasi-experiments ranged from strictly correlational to permitting stronger causal inferences. SBLE use was associated with greater crime and behavior problems in studies that used schools as the unit of analysis. Within this category, SBLE use was associated with increased exclusionary discipline among studies that used both schools (g = 0.15, 95% confidence interval [CI] [0.02, 0.27]) and students (g = 0.003, 95% CI [0.002, 0.003]) as the unit of analysis. SBLE use was not associated with any measures of crime or violence in schools. SBLE use was associated with greater feelings of safety among studies that used schools as the unit of analysis (g = 0.18, 95% CI [0.13, 0.24]), although this estimate was based on only seven effect sizes from two correlational studies. All the other models, including those examining learning outcomes, yielded null results. None of the moderators tested showed meaningful relationships, indicating the findings were consistent across a variety of study design features.

Authors’ Conclusions

This study's findings provide no evidence that there is a safety-promoting component of SBLE, and support the criticism that SBLE criminalizes students and schools. Although we found no evidence of differences across methodological features, risk of bias in the primary studies limits our confidence in making causal inferences. To the extent that the findings are causal, schools that invest in strategies to improve safety will likely benefit from divesting from SBLE and instead investing in evidence-based strategies for enhancing school safety. Schools that continue to use SBLE should ensure that their model has no harmful effects and is providing safety benefits.

Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group

Objective

To present findings of a narrative review on the implementation and effectiveness of 17 Articles of the WHO Framework Convention on Tobacco Control (FCTC) during the Treaty’s first decade.

Data sources

Published reports on global FCTC implementation; searches of four databases through June 2016; hand-search of publications/online resources; tobacco control experts.

Study selection

WHO Convention Secretariat global progress reports (2010, 2012, 2014); 2015 WHO report on the global tobacco epidemic; studies of social, behavioural, health, economic and/or environmental impacts of FCTC policies.

Data extraction

Progress in the implementation of 17 FCTC Articles was categorised (higher/intermediate/lower) by consensus. 128 studies were independently selected by multiple authors in consultation with experts.

Data synthesis

Implementation was highest for smoke-free laws, health warnings and education campaigns, youth access laws, and reporting/information exchange, and lowest for measures to counter industry interference, regulate tobacco product contents, promote alternative livelihoods and protect health/environment. Price/tax increases, comprehensive smoking and marketing bans, health warnings, and cessation treatment are associated with decreased tobacco consumption/health risks and increased quitting. Mass media campaigns and youth access laws prevent smoking initiation, decrease prevalence and promote cessation. There were few studies on the effectiveness of policies in several domains, including measures to prevent industry interference and regulate tobacco product contents.

Conclusions

The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes. However, FCTC implementation must be accelerated, and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.

Restricting the retail supply of tobacco to minors

To examine the impact of enforcement of age-restricted tobacco sales on adolescent tobacco purchasing and smoking, we compared the Central Coast intervention area to the rest of New South Wales (NSW) and Australia. We collected data on students in school years 7-12 from triennial health surveys at baseline in 1993 through 2002. Attempts by minors to purchase tobacco in the intervention area declined by 73.6 per cent between 1993 and 2002. Between 1993 and 1996 the prevalence of smoking declined in the Central Coast intervention area, while remaining unchanged in NSW as a whole and nationally (P<0.0001). Between 1993 and 2002, the prevalence of current smoking in the intervention area was reduced by half. Effective enforcement of an age-restricted tobacco sales law was accompanied by a substantial reduction in attempted purchases of tobacco and of smoking by youth. The long-term follow-up in this study allows us to observe that the impact of the intervention was not only sustained but also increased with time.

Enforcement of underage sales laws as a predictor of daily smoking among adolescents: a national study

BACKGROUND

With a goal to reduce youth smoking rates, the U.S. federal government mandated that states enforce laws prohibiting underage tobacco sales. Our objective was to determine if state compliance with tobacco sales laws is associated with a decreased risk of current daily smoking among adolescents.

METHODS

Data on tobacco use were obtained from a nationally representative sample of 16,244 adolescents from the 2003 Monitoring the Future survey. The association between merchant compliance with the law from 1997-2003 and current daily smoking was examined using logistic regression while controlling for cigarette prices, state restaurant smoking policies, anti-tobacco media, and demographic variables.

RESULTS

Higher average state merchant compliance from 1997-2003 predicted lower levels of current daily smoking among adolescents when controlled for all other factors. The odds ratio for daily smoking was reduced by 2% for each 1% increase in merchant compliance. After controlling for price changes, media campaigns and smoking restrictions, a 20.8% reduction in the odds of smoking among 10th graders in 2003 was attributed to the observed improvement in merchant compliance between 1997 and 2003. A 47% reduction in the odds of daily smoking could be attributed to price increases over this period.

CONCLUSION

Federally mandated enforcement efforts by states to prevent the sale of tobacco to minors appear to have made an important contribution to the observed decline in smoking among youth in the U.S. Given similar results from long-term enforcement efforts in Australia, other countries should be encouraged to adopt the World Health Organization Framework on Tobacco Control strategies to reduce the sale of tobacco to minors.

Population tobacco control interventions and their effects on social inequalities in smoking: systematic review

OBJECTIVE

To assess the effects of population tobacco control interventions on social inequalities in smoking.

DATA SOURCES

Medical, nursing, psychological, social science and grey literature databases, bibliographies, hand-searches and contact with authors.

STUDY SELECTION

Studies were included (n = 84) if they reported the effects of any population-level tobacco control intervention on smoking behaviour or attitudes in individuals or groups with different demographic or socioeconomic characteristics.

DATA EXTRACTION

Data extraction and quality assessment for each study were conducted by one reviewer and checked by a second.

DATA SYNTHESIS

Data were synthesised using graphical ("harvest plot") and narrative methods. No strong evidence of differential effects was found for smoking restrictions in workplaces and public places, although those in higher occupational groups may be more likely to change their attitudes or behaviour. Smoking restrictions in schools may be more effective in girls. Restrictions on sales to minors may be more effective in girls and younger children. Increasing the price of tobacco products may be more effective in reducing smoking among lower-income adults and those in manual occupations, although there was also some evidence to suggest that adults with higher levels of education may be more price-sensitive. Young people aged under 25 are also affected by price increases, with some evidence that boys and non-white young people may be more sensitive to price.

CONCLUSIONS

Population-level tobacco control interventions have the potential to benefit more disadvantaged groups and thereby contribute to reducing health inequalities.

Youth tobacco access restrictions: Time to shift resources to other interventions?

There is limited data to guide policy makers as to whether youth tobacco access restriction is an effective strategy. Analysis of the limited data on youth access restriction suggests that (a) scalable models for access restriction are lacking, (b) enforcement of access restriction would be cost prohibitive, (c) the leaky commercial supply of cigarettes combined with the capacity of youth to tap into a "social supply" of cigarettes would hamper all but the most rigorously enforced efforts to restrict access to tobacco, and (d) access restriction may paradoxically increase allure of cigarettes for some youth. Although youth tobacco access restriction does not face strong political or industry opposition, the authors' analysis reveals that youth tobacco access restriction is likely to remain a failed strategy to control tobacco use in the United States.

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.

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.

Is restricting tobacco sales the answer to adolescent smoking?

Enforcement of legislation restricting retail access to tobacco is increasingly relied on to reduce adolescent smoking rates. In 1996, health authorities in the Northern Sydney Health Area began monitoring tobacco retailer compliance (PROOF program) with staged purchase attempts by adolescents below the legal age (18 years). Repeat cross-sectional surveys before (1995) and after (2000) the introduction of PROOF monitored changes in adolescent smoking behaviour. Students aged 12 to 17 years from 11 Northern Sydney metropolitan public secondary schools were surveyed for self-reported smoking and tobacco purchasing behavior in 1995 (n = 5,206) and 2000 (n = 4,120). Between 1996 and 2000, 545 retailer compliance checks found 34% unlawfully sold cigarettes to minors and 28% of these repeated the offence. Nine prosecutions resulted. Modelling revealed a significant association between the intervention and never having smoked (adjusted OR = 1.16, 95% CI = 1.01-1.33) although there was no significant association with being a current smoker. The odds of being a smoker were greater for students from coeducational schools, with this effect being modified by gender. There was no reduction in adolescent smoking with active enforcement of tobacco access laws despite an apparent increase in students who reported never to have smoked.

Youth access interventions do not affect youth smoking

OBJECTIVE

To determine the effectiveness of laws restricting youth access to cigarettes on prevalence of smoking among teens.

METHODS

We conducted a systematic review of studies that reported changes in smoking associated with the presence of restrictions on the ability of teens to purchase cigarettes. We calculated the correlation between merchant compliance levels with youth access laws and prevalence (30-day and regular) prevalence of youth smoking, and between changes in compliance and prevalence associated with youth access interventions. We also conducted a random effects meta-analysis to determine the change in youth prevalence associated with youth access interventions from studies that included control communities.

RESULTS

Based on data from 9 studies, there was no detectable relationship between the level of merchant compliance and 30-day (r =.116; n = 38 communities) or regular (r =.017) smoking prevalence. There was no evidence of a threshold effect. There was no evidence that an increase in compliance with youth access restrictions was associated with a decrease in 30-day (r =.294; n = 18 communities) or regular (r =.274) smoking prevalence. There was no significant difference in youth smoking in communities with youth access interventions compared with control communities; the pooled estimate of the effect of intervention on 30-day prevalence was -1.5% (95% confidence interval: -6.0% to +2.9%).

CONCLUSIONS

Given the limited resources available for tobacco control, as well as the expense of conducting youth access programs, tobacco control advocates should abandon this strategy and devote the limited resources that are available for tobacco control toward other interventions with proven effectiveness.

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.

A systematic review of interventions for preventing tobacco sales to minors

OBJECTIVE

To assess the effectiveness of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.

METHOD

Systematic literature review.

DATA SOURCES

The Cochrane Tobacco Addiction group specialised register and Medline. Studies of interventions to alter retailer behaviour were identified. The terms used for searching combined terms for smoking and tobacco use with terms for minors, children or young people, and retailers, sales or commerce.

STUDY SELECTION

Studies in which there was an intervention with retailers of tobacco, either through education about, or enforcement of, local ordinances. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's perceived ease of access to tobacco products, and changes in smoking behaviour. Controlled studies with or without random allocation of retail outlets or communities, and uncontrolled studies with pre- and post intervention assessment, were included.

DATA EXTRACTION

Two reviewers assessed studies for inclusion. One extracted data with checking by the second.

DATA SYNTHESIS

The results were synthesised qualitatively, with greater weight given to controlled studies. Thirteen of 27 included studies used controls.

RESULTS

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.

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.