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

Evaluations of Compliance With California's First Tobacco Sales Bans and Tobacco Marketing in Restricted and Cross-Border Stores

INTRODUCTION

Beverly Hills and Manhattan Beach were the first California cities to end tobacco sales. Previous research assessed retailers' perceptions of the laws. This study is the first to evaluate compliance (Study 1), assess whether branded or unbranded tobacco cues remain, and examine cigarette prices/discounts in cross-border stores (Study 2).

AIMS AND METHODS

Each of the four data collectors requested Marlboro or e-cigarettes (randomly assigned) in all restricted stores (n = 33) until four attempts were exhausted or a violation occurred. Follow-up visits recorded whether former tobacco retailers advertised tobacco or contained unbranded cues. In a random sample of 126 cross-border stores (half within 1 mile of no-sales cities and half 2-4 miles away), data collectors recorded price of Marlboro and presence of cigarette discounts. Mixed models (stores within tracts), tested for differences between near and far stores, adjusting for store type and median household income.

RESULTS

Compliance was 87.5%: three stores sold Marlboro (US $8, $10, and $10) and one sold Puff Bar (US $16). Tobacco-branded items and unbranded tobacco cues remained in one store each. Mean Marlboro price was US $10.61 (SD = 1.92) at stores within 1 mile of no-sales cities, averaging US $0.73 more than at stores farther away (p < .05). However, odds of advertising cigarette discounts did not differ between stores nearby and farther from no-sales cities.

CONCLUSIONS

Nearly all retailers complied with tobacco sales bans within 6-12 months of implementation. In addition, retail tobacco marketing was nearly eliminated in the two cities. There was no evidence of price gouging for Marlboro cigarettes in cross-border stores.

IMPLICATIONS

Evidence from two early adopters of tobacco sales bans suggests that such local laws can be implemented effectively in California, although results from these high-income cities in a state with a strong tobacco control record limits generalizability. Enforcement involving routine purchase attempts rather than visual inspection of tobacco products is recommended. Although Beverly Hills and Manhattan Beach are each surrounded by communities where tobacco sales persist, there was no evidence of price gouging for cigarettes or greater presence of discounts in cross-border stores. Evaluations of the economic impacts and public health benefits of tobacco sales bans are much needed.

Retailers' Compliance with Federal Age of Cigarette Sales Policies -- Pitt County, North Carolina, January-March 2022

BACKGROUND

Tobacco use remains a leading cause of preventable morbidity and premature mortality. In December 2019, the federal age of sale for tobacco products increased from 18 to 21 years of age. This study aimed to evaluate the implementation of federal tobacco 21 policies in Pitt County, North Carolina (NC), by conducting multiple purchase attempts for cigarettes.

METHOD

Stores in Pitt County that sold cigarettes were randomly sampled and visited by up to six different underage (18-20) buyers who attempted to buy cigarettes from January-March 2022. Buyers made a total of 217 cigarette purchase attempts from 49 Pitt County retailers. Analyses were conducted using SPSS Complex Samples (v.28/Macintosh) and estimate retailer prevalence of requesting identification (ID) and selling to underage buyers across multiple purchase attempts.

RESULTS

On average, retailers failed to request ID in 15.4% of purchase attempts (95% CI: 9.4%-21.3%) and sold to an underage buyer 34.2% of the time (95% CI: 27.0-41.4%). Additionally, 75.5% (95% CI: 63.4%-84.6%) of retailers sold to an underage buyer at least once.

LIMITATIONS

This study is limited to a single county in NC and to underage buyers aged 18 to 20.

CONCLUSION

There is widespread non-compliance with federal age of sale policies for tobacco products in Pitt County, NC. State enforcement is warranted, and NC's youth access law should be amended to match the federal age of sale. Changes to the law should allow research involving underage purchases.

"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.

Uncovering the advertising and promotional strategies of tobacco companies in Cambodia: recall of below-the-line marketing among young male smokers

INTRODUCTION

Tobacco companies have used below-the-line marketing in novel ways to promote their brands to youth in low/middle-income countries in Southeast Asia. This study explores how young male smokers in Cambodia experience below-the-line marketing strategies.

METHODS

Convenience sampling was used to recruit 147 young male smokers (18-24 years) in Cambodia in early 2020. Local research assistants conducted mixed-methods interviews with participants in Khmer or English. Participants recalled exposure to below-the-line marketing strategies and provided in-depth descriptions about their experiences with individual sales promotions. Quantitative data were analysed using descriptive statistics and qualitative data were analysed using thematic analysis.

RESULTS

54% of participants recalled exposure to at least one below-the-line marketing strategy, including point-of-sale promotions (32.7%), individual sales promotions (27.9%) and online advertising (14.3%). Participants described individual sales promotions in public settings, and recalled that promoters were mostly female, attractive and targeted young males. Tactics used to encourage young people to accept promotional offers included free cigarettes and sample packets, swapping current cigarettes for new brands and collecting consumer details after interviewing. The brands and product features of cigarettes being promoted were readily described by participants.

CONCLUSION

This study provides evidence that illegal below-the-line marketing is still occurring in Cambodia, and increased monitoring and enforcement of advertising restrictions is needed.

Rates of Age Verification for Cigarette and E-cigarette Purchases as a Function of State T21 Laws Before and After Implementation of the Federal T21 Law in the United States

INTRODUCTION

In the US, having a 21 minimum legal sales age for tobacco (T21) at the state level may have impacted age verification of cigarette and e-cigarette purchases among U.S. young adults (ages 18-26), before and/or after federal T21 implementation.

AIMS AND METHODS

This study examined this by analyzing data from cigarette and/or e-cigarette users (n = 618 and n = 864) in six metropolitan areas in six states. Participants reported frequency of being age verified ("almost always" vs. less frequently) for cigarette and/or e-cigarette purchases across 3 timepoints (ie, wave 1 [w1]: September-December 2018, w2: September-December 2019, and w3: September-December 2020). Multilevel modeling examined time-varying state T21 status and time (reflecting federal T21 implementation) in relation to age verification of cigarette and e-cigarette purchases, respectively.

RESULTS

The proportions almost always age verified for cigarette purchases in states with T21 versus without were: W1: 38.5% versus 37.7%, w2: 33.0% versus 39.1%, and w3: 45.4% versus 30.6%. For e-cigarettes, the proportions were: W1: 30.6% versus 40.3%, w2: 42.3% versus 50.5%, and w3: 56.0% versus 58.3%. In multilevel modeling, state T21 status was associated with greater likelihood of age verification for e-cigarettes (aOR = 1.67, CI = 1.13 to 2.45), but not for cigarettes. Age verification increased over time for e-cigarettes-both accounting for and not accounting for state T21 status. There were no changes for cigarettes.

CONCLUSIONS

State T21 status and time correlated with age verification for e-cigarettes, but not cigarettes. These self-reported age verification data contribute to evidence from compliance checks, indicating that retailers require additional prompts and enforcement to enhance compliance with T21 laws.

IMPLICATIONS

Current findings suggest that variations in regulations and gaps in enforcement may hinder the potential impact of increasing the minimum legal sales age, which ultimately may undermine the promise of such policies, specifically with regard to preventing tobacco use among the underage. Therefore, it is crucial to monitor retailer compliance with T21 laws and evaluate their efficacy to increase ID checks, minimize illegal sales, and curb underage use of tobacco. Relatedly, particular attention to enforcement efforts that may promote compliance is warranted.

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.

Underutilisation of no-tobacco-sale orders against retailers that repeatedly sell to minors, 2015-2019, USA

IMPORTANCE

Research demonstrates that policies aimed at retailers who sell to minors must be strongly enforced to have an impact on youth usage rates.

OBJECTIVES

In the USA, the Food and Drug Administration (FDA) conducts compliance checks, issues fines, and can order retailers to stop selling tobacco products (ie, no-tobacco-sale orders (NTSOs)) to enforce the Family Smoking Prevention and Tobacco Control Act. We sought to assess FDA's utilisation of NTSOs.

METHODS

We conducted a quantitative content analysis of FDA's enforcement actions for inspections decided between 1 October 2015 and 29 March 2019. From the 536 134 inspection records we identified 148 NTSOs and 249 720 unique retailer locations, of which 2095 had three or more violations. We randomly sampled NTSOs (n=76) and retail locations (n=152) with frequent violations. We calculated the proportion of NTSOs that could have been issued earlier by FDA. We then calculated the proportion of retailers that could have been issued an NTSO, and the proportion actually issued an NTSO using FDA's approach and a more stringent approach.

RESULTS

Among NTSOs, 94.7% (95% CI: 89.8% to 97.4%) of NTSOs could have been issued earlier under a more stringent approach. On average, when an NTSO could have been issued earlier, it could have been issued 453 days earlier (95% CI: 418 to 489; range: 89-1159). Among frequently violating retail locations, 73.6% (95% CI: 66.0% to 80.0%) were eligible for an NTSO. Of those, 1.9% (95% CI: 0.5% to 7.0%) had received an NTSO.

CONCLUSIONS

The FDA's failure to fully leverage its powers to address retailers' underage sales of tobacco products has weakened efforts to curb the youth e-cigarette epidemic.

Using place-based characteristics to inform FDA tobacco sales inspections: results from a multilevel propensity score model

BACKGROUND

Conducting routine inspections for compliance with age-of-sale laws is essential to reducing underage access to tobacco. We seek to develop a multilevel propensity score model (PSM) to predict retail violation of sales to minors (RVSM).

METHODS

The Food and Drug Administration compliance check of tobacco retailers with minor-involved inspections from 2015 to 2019 (n=683 741) was linked with multilevel data for demographics and policies. Generalised estimating equation was used to develop the PSM using 2015-2016 data to predict the 2017 RVSM. The prediction accuracy of the PSM was validated by contrasting PSM deciles against 2018-2019 actual violation data.

RESULTS

In 2017, 44.3% of 26 150 zip codes with ≥1 tobacco retailer had 0 FDA underage sales inspections, 11.0% had 1 inspection, 13.5% had 2-3, 15.3% had 4-9, and 15.9% had 10 or more. The likelihood of having an RVSM in 2017 was higher in zip codes with a lower number of inspections (adjusted OR (aOR)=0.988, 95% CI (0.987 to 0.990)) and penalties (aOR=0.97, 95% CI (0.95 to 0.99)) and a higher number of violations (aOR=1.07, 95% CI (1.06 to 1.08)) in the previous 2 years. Urbanicity, socioeconomic status, smoking prevalence and tobacco control policies at multilevels also predicted retail violations. Prediction accuracy was validated with zip codes with the highest 10% of the PSM 3.4 times more likely to have retail violations in 2019 than zip codes in the bottom decile.

CONCLUSION

The multilevel PSM predicts the RVSM with a good rank order of retail violations. The model-based approach can be used to identify hot spots of retail violations and improve the sampling plan for future inspections.

Retailer Compliance With Tobacco 21 in New Jersey, 2019-2020

This cross-sectional study assesses retailer compliance with the Tobacco 21 law in New Jersey during 2019 and 2020.

Inequalities in Tobacco Retailer Compliance Violations Across the State of Oklahoma, 2015-2019

OBJECTIVE

To evaluate the relationship between compliance check violations, and characteristics of the tobacco retailer and neighborhood social vulnerability in Oklahoma.

DESIGN

This cross-sectional study utilized the US Food and Drug Administration (FDA) Compliance Check Inspections of Tobacco Product Retailers database for 2015-2019. These data were combined with Neighborhood social vulnerability variables using the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index.

SETTING

The setting of this study is the state of Oklahoma, USA.

OUTCOME MEASURES

The outcome variable for this analysis was whether a sale was made to the youth during the compliance check (e.g., violation; yes/no) regardless of the outcome of the violation, and number of violations per a retailer.

RESULTS

We observed a strong association between having a violation and retailer store type, after controlling for socioeconomic vulnerability and percentage of mobile homes. The proportion of a tobacco retailer's violations also varied by store type.

CONCLUSIONS

More targeted enforcements and retailer education by store type may be necessary to increase compliance.

Evaluation of neighborhood deprivation and store characteristics in relation to tobacco retail outlet sales violations

INTRODUCTION

Regulations of the sale of tobacco products to minors have been effective at reducing adolescent tobacco use overall. However, these efforts may not be uniformly enforced in all areas, creating uneven protection against adolescent smoking. Knowledge regarding factors associated with tobacco retail outlet (TRO) violations could help inform better enforcement strategies.

METHODS

In this study, we used Bayesian index regression models to determine if tobacco sales to minors violations across Virginia (2012-2021) were related to store characteristics and neighborhood deprivation and identify geographic areas at significantly elevated risk for violations after adjusting for these factors.

RESULTS

Results show that there were multiple factors associated with a higher likelihood of tobacco sales violations. Store type was an important factor, as grocery stores and pharmacies had significantly lowered likelihood of violations compared with convenience stores. Being located near another TRO was significantly associated with increased risk of sales to a minor. Neighborhood deprivation was also positively associated with TRO sales violations. Further, there were statistically higher likelihood of sales violations occurring in specific areas (e.g., southwest and southeast) of the state that were not explained by neighborhood deprivation and store attributes.

CONCLUSIONS

Together, results highlight the need to better understand where and why TRO sales violations are occurring in order to improve efforts aimed at monitoring and remediating TRO sales violations.

Tobacco 21 Policies in the U.S.: The Importance of Local Control With Federal Policy

INTRODUCTION

In December 2019, the U.S. raised the minimum legal sales age of tobacco to 21 years, a law commonly known as Tobacco 21. This study examines local Tobacco 21 policies for the inclusion of model policy components: comprehensive tobacco definition, age verification and tobacco access, enforcement measures, tobacco retail license, and violation penalties.

METHODS

A document analysis of Tobacco 21 local policies passed in the U.S. before July 1, 2019 (N=477) was conducted in May 2020 using a Tobacco 21 policy assessment tool. Policies were coded by 2 independent coders for the inclusion of components.

RESULTS

Many localities included model component: comprehensive tobacco definition (65%), appearance age (70.9%), local tobacco retail license (72%), a graduated monetary penalty structure (93%), and tobacco retail license suspensions or revocations (74%) for repeated violations. However, only 17.4% of policies included an appearance age in compliance with federal law (30 years). Furthermore, few policies included enforcement components, such as a mandatory number of inspections (5.9%) or compliance checks (6.7%) per year, or a minimum age for the underage purchasers used during compliance checks (8.4%).

CONCLUSIONS

Local policies can play an important role in tobacco control by providing an added layer to ensure adequate enforcement of age-restriction policies and allow an avenue to introduce strict measures that may diffuse into higher branches of government for policy adoption. Although many local Tobacco 21 policies fill regulatory gaps within the state and federal laws, often there is a lack of model components to ensure that policies are implemented as intended.

Development of a tobacco 21 policy assessment tool and state-level analysis in the USA, 2015-2019

OBJECTIVE

Policies raising the minimum legal sales age (MLSA) of tobacco products to 21 are commonly referred to as tobacco 21. This study sought to identify components of tobacco 21 policies and develop an instrument to examine policy language within 16 state laws adopted by July 2019.

METHODS

The multistage tool development process began with a review of established literature and existing tobacco 21 policies. In a series of meetings, tobacco control experts identified key policy components used to develop an initial tool. After testing and revisions, the instrument was used to code the existing tobacco 21 state-level policies. Inter-rater reliability (κ=0.70) was measured and discrepancies were discussed until consensus was met. Policy component frequencies were reported by state.

RESULTS

While all 16 states raised the MLSA to 21, the laws varied widely. Two laws omitted purchaser identification requirements. Fifteen laws mentioned enforcement would include inspections, but only three provided justification for conducting inspections. All 16 states provided a penalty structure for retailer/clerk violations, but penalties ranged considerably. Fourteen states required a tobacco retail licence, nine renewed annually. Six laws contained a military exemption, five were phased-in and 10 contained purchase, use or possession laws, which penalised youth. Four states introduced or expanded pre-emption of local tobacco control.

CONCLUSIONS

The instrument developed is the first to examine policy components within state-level tobacco 21 laws. Policies that include negative components or omit positive components may not effectively prevent retailers from selling to youth, which could result in less effective laws.

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research

INTRODUCTION

The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated.

METHOD

A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018.

RESULTS

The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes.

CONCLUSION

This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry.

IMPLICATIONS

This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Asking for Identification and Retail Tobacco Sales to Minors

BACKGROUND AND OBJECTIVES

A previous single-county study found that retail stores usually asked young-looking tobacco customers to show proof-of-age identification, but a large proportion of illegal tobacco sales to minors occurred after the customers had shown identification proving they were too young to purchase tobacco. We sought to investigate these findings on a larger scale.

METHODS

We obtained state reports for federal fiscal years 2017 and 2018 from a federal agency that tracks tobacco sales to supervised minors conducting compliance checks in retail stores. We used descriptive and multivariable logistic regression methods to determine (1) how often stores in 17 states requested identifications, (2) what proportion of violations occurred after identification requests, and (3) if violation rates differed when minors were required versus forbidden to carry identification.

RESULTS

Stores asked minors for identification in 79.6% (95% confidence interval: 79.3%-80.8%) of compliance checks (N = 17 276). Violations after identification requests constituted 22.8% (95% confidence interval: 20.0%-25.6%; interstate range, 1.7%-66.2%) of all violations and were nearly 3 times as likely when minors were required to carry identification in compliance checks. Violations were 42% more likely when minors asked for a vaping product versus cigarettes.

CONCLUSIONS

Stores that sell tobacco to underage customers are more likely to be detected and penalized when youth inspectors carry identification during undercover tobacco sales compliance checks. The new age-21 tobacco sales requirement presents an opportunity to require identifications be carried and address other long-standing weaknesses in compliance-check protocols to help combat the current adolescent vaping epidemic.

Assurances of Voluntary Compliance: A Regulatory Mechanism to Reduce Youth Access to E-Cigarettes and Limit Retail Tobacco Marketing

Objectives. To evaluate assurances of voluntary compliance (AVCs) between state attorneys general and retail chains by assessing e-cigarette sales to underage decoys and tobacco marketing violations in corporate-owned stores (that sign AVCs) and franchise stores (that do not sign AVCs).Methods. Decoys 18 to 19 years of age attempted to purchase e-cigarettes without presenting ID in California convenience stores (n = 540). Auditors characterized the presence and content of age-of-sale signage and advertising for tobacco products. Data were collected and analyzed in 2018.Results. Corporate-owned stores were less likely than were franchise stores to violate ID requests (adjusted odds ratio [AOR] = 0.29; 95% confidence interval [CI] = 0.12, 0.71) and to sell e-cigarettes illegally (AOR = 0.37; 95% CI = 0.15, 0.88). Regardless of AVC category, advertising violations were common in stores (vaping products, 26.3%; other tobacco products, 74.3%).Conclusions. The differences in violation rates found in corporate and franchise stores imply that AVCs could reduce youth access to e-cigarettes. However, merchant education and routine enforcement are needed to better leverage restrictions on retail tobacco marketing in AVCs.Public Health Implications. Strengthening compliance with existing AVCs and establishing new agreements with retailers shown to be in violation through federal or state inspections could reduce youth access to e-cigarettes and exposure to tobacco marketing.

Youth source of acquisition for E-Cigarettes

As rates of traditional cigarette smoking have decreased among youth over the past several years, rates of e-cigarette use have increased. Little evidence exists on how youth obtain e-cigarettes. We used data from middle and high school students under the age of 18 who reported using an e-cigarette in the past 30 days from the 2017 North Carolina Youth Tobacco Survey (n = 640). We used chi-square tests and multivariable logistic regressions to examine correlates of access and place of acquisition. Over half (51.5%) of youth report acquiring e-cigarettes from a friend. Youth in 12th grade had higher odds of acquiring e-cigarettes from a vape shop (aOR: 2.54, 95% CI: 1.25, 5.15) or retail outlet (aOR: 2.40, 95% CI: 1.18, 4.90) than youth in middle school. Compared to non-Hispanic white youth, Hispanic youth had lower odds of acquiring e-cigarettes from a vape shop (aOR: 0.42, 95% CI: 0.20, 0.87). Youth living with someone who uses e-cigarettes, compared to those who did not, had higher odds of acquiring e-cigarettes from a family member (aOR: 3.95, 95% CI: 1.94, 8.05). Finally, current smokers had higher odds of acquiring e-cigarettes from a retail outlet (aOR: 3.28, 95% CI: 1.88, 5.70) and lower odds of acquiring e-cigarettes from a friend (aOR: 0.53, 95% CI: 0.36, 0.77). Youth primarily reported obtaining e-cigarettes from a friend. Living with someone who uses e-cigarettes may be a risk factor for acquiring e-cigarettes from family members. Identifying sources of e-cigarette acquisition will help inform interventions preventing youth e-cigarette access.

Comparison of Sampling Strategies for Tobacco Retailer Inspections to Maximize Coverage in Vulnerable Areas and Minimize Cost

Introduction

In the United States, tens of thousands of inspections of tobacco retailers are conducted each year. Various sampling choices can reduce travel costs, emphasize enforcement in areas with greater noncompliance, and allow for comparability between states and over time. We sought to develop a model sampling strategy for state tobacco retailer inspections.

Methods

Using a 2014 list of 10,161 North Carolina tobacco retailers, we compared results from simple random sampling; stratified, clustered at the ZIP code sampling; and, stratified, clustered at the census tract sampling. We conducted a simulation of repeated sampling and compared approaches for their comparative level of precision, coverage, and retailer dispersion.

Results

While maintaining an adequate design effect and statistical precision appropriate for a public health enforcement program, both stratified, clustered ZIP- and tract-based approaches were feasible. Both ZIP and tract strategies yielded improvements over simple random sampling, with relative improvements, respectively, of average distance between retailers (reduced 5.0% and 1.9%), percent Black residents in sampled neighborhoods (increased 17.2% and 32.6%), percent Hispanic residents in sampled neighborhoods (reduced 2.2% and increased 18.3%), percentage of sampled retailers located near schools (increased 61.3% and 37.5%), and poverty rate in sampled neighborhoods (increased 14.0% and 38.2%).

Conclusions

States can make retailer inspections more efficient and targeted with stratified, clustered sampling. Use of statistically appropriate sampling strategies like these should be considered by states, researchers, and the Food and Drug Administration to improve program impact and allow for comparisons over time and across states.

Implications

The authors present a model tobacco retailer sampling strategy for promoting compliance and reducing costs that could be used by US states and the Food and Drug Administration (FDA). The design is feasible to implement in North Carolina. Use of the sampling design would help document the impact of FDA's compliance and enforcement program, save money, and emphasize inspections in areas where they are needed most. FDA should consider requiring probability-based sampling in their inspections contracts with states and private contractors.

Nicotine Sales to Minors: Store-Level Comparison of E-Cigarette Versus Cigarette Violation Rates

Introduction

In recent years, e-cigarettes overtook cigarettes as the leading tobacco product used by US adolescents. Most states, as well as federal regulations, have added e-cigarettes to laws prohibiting tobacco products sales to minors. We tested compliance with the newer regulation among Colorado urban retail businesses, speculating that violations might be more common for e-cigarettes than smokable cigarettes.

Methods

Supervised minors visited a random sample of urban businesses and sequentially attempted to purchase an e-cigarette product and cigarettes. The protocol prescribed that the same minor make both attempts in each business, separated by at least a day to minimize influence of the first result on the second result. Data were collected during May 2014-January 2015.

Results

Among 238 businesses, more than one-fourth (26.1%; 95% confidence interval (CI), 18.9%-33.2%) sold at least one type of product, and 6.3% (CI, 1.8%-10.8%) sold both types. Violation rates were similar for e-cigarette products and cigarettes (17.6% vs. 14.7%, p = n.s.).

Conclusion

Enforcement to prevent retail tobacco sales to adolescents should include e-cigarette products. Dual testing of stores indicates that single visits underestimate the problem of underage tobacco sales.

Implications

Adolescents can buy e-cigarettes from retail stores as easily as they buy cigarettes. Enforcement of tobacco sales laws should include e-cigarettes, and test-retest protocols are needed to estimate the true extent of the problem.

Assessment of the US Federal Retailer Violation Rate as an Estimate of the Proportion of Retailers That Illegally Sell Tobacco to Adolescents

Importance

Despite progress against tobacco sales to minors, retailers continue to violate state and federal laws and supply adolescent smokers with tobacco products. Government-sanctioned surveys underestimate the extent of the problem, and retailer associations use these data to block stricter enforcement policies.

Objectives

To assess the validity of the US federal retailer violation rate (RVR) as an estimate of the proportion of retailers that sell tobacco to minors and to investigate what proportion always or almost always sells vs refuses to sell cigarettes to minors.

Design, Setting, and Participants

This survey study was conducted October 6, 2012, to September 8, 2013; data were analyzed between September 28, 2017, and March 21, 2018. The setting was a suburban county adjacent to Denver, Colorado. Participants were a systematically selected, population-based cluster sample of retailers that stock cigarettes for sale. Retailers were masked to the survey.

Main Outcomes and Measures

Each retailer was visited 6 times by supervised minors who attempted to purchase cigarettes at each visit. The main outcome was whether cigarettes were sold. Other measures included whether government-issued photo identification (ID) was requested as required by law, how ID was examined, and what the demographic characteristics of study minors and clerks were.

Results

The sample of 201 retailers (44.8% of the 449 listed population) included convenience stores (n = 77), liquor stores (n = 63), grocery stores/supermarkets (n = 33), pharmacies (n = 17), tobacco stores (n = 7), and stand-alone gas stations (n = 4). Bars, clubs, and adult establishments were excluded. A total of 1181 purchase attempts were analyzed; 25 (2.1%) were excluded for missing data. The mean RVR across 6 rounds of checks was 18.0% (95% CI, 14.7%-21.2%) and ranged from 13.7% to 28.0% per round. Most retailers (54.7% [110 of 201]) violated at least once in 6 visits, 26.4% (53 of 201) violated at least twice, and 11.9% (24 of 201) violated half or more times. How retailers examined proof of age largely determined whether violations occurred.

Conclusions and Relevance

The proportion of retailers that sold cigarettes to a minor at least once in 6 attempts was 3 times higher than the mean RVR based on a single inspection per retailer. Larger replication studies are needed. Enforcement protocols should reflect the fact that each retailer does not respond consistently when adolescents try to buy tobacco products, and many retailers are not properly validating ID that shows proof of age.

Longitudinal study of adolescent tobacco use and tobacco control policies in India

BACKGROUND

This project will use a multilevel longitudinal cohort study design to assess whether changes in Community Tobacco Environmental (CTE) factors, measured as community compliance with tobacco control policies and community density of tobacco vendors and tobacco advertisements, are associated with adolescent tobacco use in urban India. India's tobacco control policies regulate secondhand smoke exposure, access to tobacco products and exposure to tobacco marketing. Research data about the association between community level compliance with tobacco control policies and youth tobacco use are largely unavailable, and are needed to inform policy enforcement, implementation and development.

METHODS

The geographic scope will include Mumbai and Kolkata, India. The study protocol calls for an annual comprehensive longitudinal population-based tobacco use risk and protective factors survey in a cohort of 1820 adolescents ages 12-14 years (and their parent) from baseline (Wave 1) to 36-month follow-up (Wave 4). Geographic Information Systems data collection will be used to map tobacco vendors, tobacco advertisements, availability of e-cigarettes, COTPA defined public places, and compliance with tobacco sale, point-of-sale and smoke-free laws. Finally, we will estimate the longitudinal associations between CTE factors and adolescent tobacco use, and assess whether the associations are moderated by family level factors, and mediated by individual level factors.

DISCUSSION

India experiences a high burden of disease and mortality from tobacco use. To address this burden, significant long-term prevention and control activities need to include the joint impact of policy, community and family factors on adolescent tobacco use onset. The findings from this study can be used to guide the development and implementation of future tobacco control policy designed to minimize adolescent tobacco use.

Limited indications of tax stamp discordance and counterfeiting on cigarette packs purchased in tobacco retailers, 97 counties, USA, 2012

Increasing the per-unit cost of tobacco products is one of the strongest interventions for tobacco control. In jurisdictions with higher taxes in the U.S., however, cigarette pack litter studies show a substantial proportion of littered packs lack the appropriate tax stamp. More limited but still present counterfeiting also exists. We sought to examine the role of tobacco retailers as a source for untaxed and counterfeit products. Data collectors purchased Newport Green (menthol) or Marlboro Red cigarette packs in a national probability-based sample of tobacco retailers (in 97 counties) from June–October 2012. They made no effort to buy counterfeit or untaxed cigarettes. In this cross-sectional study, we assessed the presence, tax authority, and type (low-tech thermal vs. encrypted) of cigarette pack tax stamps; concordance of tax stamps with where the pack was purchased; and, for Marlboro cigarettes, publicly available visible indicators of counterfeiting. We purchased 2147 packs of which 2033 had tax stamps. Packs missing stamps were in states that do not require them. We found very limited discordance between store location and tax stamp(s) (< 1%). However, a substantial minority of cigarette packs had damaged tax stamps (13%). This occurred entirely with low-tech tax stamps and was not identified with encrypted tax stamps. We found no clear evidence of counterfeit products. Almost all tax stamps matched the location of purchase. Litter studies may be picking up legal tax avoidance instead of illegal tax evasion or, alternatively, purchase of illicit products requires special request by the purchaser.

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This study purchased 2147 cigarette packs in 97 U.S. counties.

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No clear indicators of cigarette counterfeiting were found.

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Virtually all packs had the correct tax stamp affixed.

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Inspection protocols for illicit cigarettes should consider real-world behaviors.

The effects of tobacco control policies on retailer sales to minors in the USA, 2015

BACKGROUND

Under the 2009 Family Smoking Prevention and Tobacco Control Act, the Food and Drug Administration (FDA) has been routinely inspecting tobacco retailers' compliance with under-age sales laws. We seek to identify factors associated with Retail Violation Rate for sale to minors (RVRm).

METHODS

We collected the tobacco retailer inspection data for 2015 from the FDA compliance check database. RVRm was calculated at the census tract level and overlaid with tobacco regulations and youth smoking prevalence at the state level. Multi-level spatial analysis was performed to examine the impacts of tobacco jurisdiction variations, youth smoking rates and neighbourhood social characteristics on RVRm.

RESULTS

A total of 136 816 compliance checks involving minors conducted by the FDA in 2015 were analysed. A higher RVRm was associated with higher youth smoking prevalence (aRR=1.04, p<0.0001). Tobacco regulations show significant relationships with RVRm. For every one dollar increase in cigarette tax per pack, the likelihood of retail violations was reduced by 2% (aRR=0.98, p=0.03). For every 10% increase in tobacco prevention spending towards Centers for Disease Control recommended funding targets, the likelihood of retail violations was reduced by 1% (aRR=0.99, p=0.01). RVRm increased in states that enacted stronger smoke-free air policies (aRR=1.08, p<0.0001).

CONCLUSION

We observed associations of tobacco regulations and neighbourhood social characteristics with tobacco retailers' compliance with under-age sales laws. This study provides evidence to support stronger tobacco regulations and control policies in reducing youth access to tobacco products.

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.