Addicted to Nicotine
A National Research Forum

Section III: Nicotine-Environmental Risk Factors for Initiation
Nancy J. Kaufman, R.N., Chair

ACCESS TO TOBACCO

Nancy A. Rigotti, M.D.
Massachusetts General Hospital,
Harvard Medical School

Introduction

Efforts to prevent the initiation of smoking must focus on children because nearly 90 percent of smokers start by the age of 18. Traditionally, public health efforts aim to reduce young people's demand for tobacco products through school-based tobacco education, price increases, and restrictions on tobacco advertising and promotion. In order to start smoking, however, young people must have a supply of tobacco products. Reducing youths' access to tobacco is a newer approach to preventing their tobacco use.

Policies with this goal are widely advocated, have strong public support, and have become a focus of Federal, State, and local tobacco control efforts in the past decade. These interventions generally aim to prevent the sale of tobacco products to minors. Laws in all 50 States have long prohibited tobacco sales to minors, but they are not enforced and compliance is poor. Most local and State efforts try to improve compliance with existing laws. Also appearing are measures to strengthen existing laws in ways that are expected to reduce youth access to tobacco. These measures ban vending machine sales of tobacco, self-service displays of tobacco products, sale of single cigarettes, and possession of tobacco by minors.

The Federal Government has taken two actions. In 1992 Congress passed legislation (Synar amendment) requiring States to act to reduce the sale of tobacco to minors in order to be eligible for substance abuse block grant funds. Regulations implementing this law went into effect in 1996. In 1997 Food and Drug Administration regulations established 18 as the national minimum age of tobacco sale and required vendors to verify a purchaser's age. Evidence about the impact of youth access policies has begun to accumulate, but because the supply-side approach to reducing youth tobacco use is relatively new, many questions remain about its effectiveness and role in the spectrum of tobacco control policy. A caveat: Reducing adults' access to tobacco in order to discourage their tobacco use is not a policy seriously considered by the public health community. The sale and use of tobacco by adults is legal, and the public health consensus is that prohibiting this would have no net benefit.

What We Know

• It Is Known Where and How Youths Obtain Cigarettes. In surveys, youths consistently report having little difficulty obtaining tobacco products. Over half of teen smokers regularly purchase their own cigarettes, and commercial sources of tobacco (especially convenience stores, gas stations, and vending machines) are consistently cited as primary sources by youths. Noncommercial sources (friends, relatives, older adolescents) also contribute, especially for younger teens and those just starting to smoke. Because younger teens have more trouble buying cigarettes than older teens, they rely more on vending machines or on shoplifting, which is facilitated by self-service displays of tobacco products. The availability of single cigarettes ("loosies") is also thought to facilitate youth smoking.

• Compliance With Existing Laws Banning Tobacco Sales to Minors Is Poor. Despite laws in all 50 States that prohibit the sale of tobacco to minors, studies have repeatedly shown that cigarettes and smokeless tobacco can be purchased by adolescents in test buys at rates averaging 67 percent of attempts.

• Merchant Education Alone Does Not Work. Educating merchants about tobacco sales laws has not produced sustained improvement in merchant compliance. Embedding merchant education in a communitywide public health campaign that raises awareness about youth access achieves better results, according to an unpublished study, but requires intensive efforts.

• Active Enforcement of Tobacco Sales Laws Changes Retailer Behavior. The failure of merchant education led to a focus on active enforcement of tobacco sales laws. In controlled studies, active enforcement consistently reduces the proportion of stores that sell tobacco to minors in a test buy (also known as a "compliance check"). It is more effective than merchant education. More frequent inspections produce better results.

• The Effect of Enforcement on Adolescent Tobacco Use Is Uncertain. Enforcement improves merchant compliance with tobacco sales laws, but whether this reduces young people's access to tobacco or tobacco use, as has been assumed, is not established. In several uncontrolled studies in single communities, teenage smoking was reduced after enforcement programs achieved very high levels of merchant compliance. More recent controlled studies have not replicated this finding. In one, merchant compliance increased more in three Massachusetts towns that enforced tobacco sales laws than in three matched controls, but enforcement was not associated with a fall in adolescents' self-reported access to tobacco products or tobacco use. Similar results were found in an unpublished study of 13 New York communities. However, a randomized controlled trial in Minnesota reported a small reduction in youth smoking in seven small rural towns assigned a community organizer to help them adopt and enforce tobacco sales laws compared with seven control towns not receiving this assistance. The intervention in this trial was more intensive than simple law enforcement, and whether the results could have been achieved with a less comprehensive intervention is unclear.

• The Effectiveness of Multilevel Governmental Regulations Is Unclear. A number of local, State, and Federal actions have already been taken to reduce youth access to tobacco. Their effectiveness is yet to be determined. There is no evidence that tobacco industry programs designed to prevent youth access are effective.

What We Need To Know More About

The first wave of studies examined intermediate endpoints (merchant compliance with laws). Studies using access to tobacco and tobacco use as endpoints are just beginning to appear. There is some evidence that restricting access to tobacco may discourage young people's tobacco use, but the exact nature, intensity, and duration of interventions necessary to achieve this result are undefined, and many questions remain:

• Can Enforcing Tobacco Sales Laws Reduce the Availability of Tobacco to Youth? What level of retailer compliance with the laws is sufficient to produce a meaningful reduction in young people's access to tobacco? Some investigators postulate a threshold effect such that merchant compliance rates of 90 percent or greater may be necessary in order to meaningfully reduce youth access to tobacco, but this has not been empirically tested. What characteristics of an enforcement program (e.g., frequency of inspection, size of fines) optimize retailer compliance?

• Will Reducing Young People's Access to Tobacco Prevent or Delay Onset of Tobacco Use? Will it do so by reducing the rate at which youths experiment with tobacco, make the transition from occasional tobacco use to regular use, and/or develop nicotine dependence? Some investigators hypothesize that reducing access to tobacco will have the greatest effect on stopping the transition from occasional to regular tobacco use. How long is the lag time between implementing a program and observing an effect on smoking behavior? Will the effect be observed for teens of all ages or only younger ages, as some evidence suggests?

• How Will Young People's Sources of Tobacco Change as Commercial Sources Become More Restricted? Young people also obtain tobacco through noncommercial means (friends, relatives). What interventions might reduce young people's access to tobacco from noncommercial ("social") sources?

• What Is the Impact of New Federal Policies Aimed at Reducing Youth Access to Tobacco? How effective is enforcement of the FDA regulations, and how effectively are the Synar regulations being implemented? What impact do the regulations have on rates of compliance with tobacco sales laws or adolescent smoking rates? Is there a relationship between state rates of underage tobacco sales and youth smoking rates?

• Some States and Communities Have Adopted Laws That Prohibit Minors' Possession of Tobacco. These are supported by the tobacco industry, but the public health community's opinion is divided. Do youth possession laws have a net positive or negative impact on youth attitudes, access to tobacco, or tobacco use? What is the effectiveness of newer approaches to reducing youth access, including banning self-service displays of tobacco?

• What Is the Relative Effectiveness of Efforts To Reduce the Supply of Tobacco Compared With Those That Aim To Reduce Demand? What is the marginal cost and benefit of adding youth access interventions to demand-reduction programs, or vice versa? Will either work alone, or are both necessary to achieve reduction in youth smoking?

What We Know about access to tobacco includes the following:

• Young people consistently report having little difficulty obtaining tobacco products.

• Most teen smokers regularly purchase their own cigarettes from stores and, to a lesser extent, vending machines. Noncommercial sources (friends, older adolescents, relatives) are also used.

• Compliance with existing laws banning tobacco sales to minors is poor because the laws are not enforced.

• Merchant education interventions alone do not work to improve compliance with tobacco sales laws.

• Active enforcement of tobacco sales laws changes retailer behavior, but whether this reduces young people's access to tobacco or their tobacco use has not been established.

• A number of local, State, and Federal actions have already been taken to reduce youth access to tobacco; their effectiveness is yet to be determined. Tobacco industry-sponsored programs do not work.

What We Need To Know More About

• Can the enforcement of tobacco sales laws reduce young people's access to tobacco? What level of retailer compliance with the laws is sufficient to produce a meaningful effect, and what are the characteristics of an optimal enforcement program?

• Will reducing young people's access to tobacco prevent or delay the onset of tobacco use?

• What interventions will reduce young people's access to tobacco from noncommercial sources such as friends and relatives? How will youths' sources of tobacco change as commercial sources become more restricted?

• What is the impact of the new Federal policies, the FDA and Synar regulations, aimed at reducing youth access to tobacco?

• Do youth possession laws have a net positive or negative impact on youth attitudes, access to tobacco, or tobacco use? What is the effectiveness of other new approaches to reducing youth access, such as banning self-service displays of tobacco?

• What is the relative effectiveness of efforts to reduce the supply of tobacco compared with those that aim to reduce demand for tobacco? Will either work alone or are both necessary to achieve reduction in youth smoking?

Recommended Reading

Altman, D.G.; Rasenick-Douss, L.; Foster, V.; and Tye, J.B. Sustained effects of an educational program to reduce sales of cigarettes to minors. Am J Public Health 81:891-893, 1991.

Cummings, K.M.; Hyland, A.; Saunders-Martin, T.; Perla, J.; Coppola, P.R.; and Pechacek, T.F. Evaluation of an enforcement program to reduce tobacco sales to minors. Am J Public Health 88:932-936, 1998.

DiFranza, J.R.; Savageau, J.A.; and Aisquith, B.F. Youth access to tobacco: The effects of age, gender, vending machine locks, and "It's the Law" programs. Am J Public Health 86:221-224, 1996.

Forster, J.L.; Murray, D.M.; Wolfson, M.; Blaine, T.M.; Wagenaar, A.C.; and Hennrikus, D.J. The effects of community policies to reduce youth access to tobacco. Am J Public Health, in press.

Forster, J.L., and Wolfson, M. Youth access to tobacco: Policies and politics. Ann Rev Public Health 19:203-235, 1998.

Gemson, D.H.; Moats, H.L.; Watkins, B.X.; Ganz, M.L.; Robinson, S.; and Healton, E. Laying down the law: Reducing illegal tobacco sales to minors in central Harlem. Am J Public Health 88:936-939, 1998.

Jason, L.A.; Ji, P.Y.; Anes, M.D.; and Birkhead, S.H. Active enforcement of cigarette control laws in the prevention of cigarette sales to minors. JAMA 266:3159-3161, 1991.

Rigotti, N.A.; DiFranza, J.R.; Chang, Y.C.; Tisdale, T.; Kemp, B.; and Singer, D.E. The effect of enforcing tobacco sales laws on adolescents' access to tobacco and smoking behavior. N Engl J Med 337:1044-1051, 1997.