You are here
- Home
- Archive
- Volume 11, Issue 1
- It is time to abandon youth access tobacco programmes
Responses
PDF
Other responses
Jump to comment:
- Douglas C. TuttPublished on: 13 May 2016
- Stanton A. GlantzPublished on: 13 May 2016
- Stanton A. GlantzPublished on: 13 May 2016
- Joseph R DiFranzaPublished on: 13 May 2016
- Published on: 13 May 2016
- Douglas C. Tutt, Director, Health Promotion Unit, Central Coast Health
Show MoreI disagree totally with Stan Glantz and his view that we abandon youth access efforts.
As usual in every argument there is truth on both sides. He is right in being concerned that this can be an easy way for tobacco companies to look good and that teens will attempt to substitute other social sources. But one of the main sources of such secondary supply is other minors purchasing and then selling on the 'black...
Show LessI disagree totally with Stan Glantz and his view that we abandon youth access efforts.
As usual in every argument there is truth on both sides. He is right in being concerned that this can be an easy way for tobacco companies to look good and that teens will attempt to substitute other social sources. But one of the main sources of such secondary supply is other minors purchasing and then selling on the 'blackmarket', and our experience has been that making the primary source more difficult has led to a doubling of the playground price - a good price deterrent.
However, he is wrong in applying his objections equally in all jurisdictions. Would he seriously suggest that I abandon a local level intervention that has been shown to work so well, reducing smoking among teenagers on the Central Coast of New South Wales by a third over six years (1)? There is no mention in the editorial of that work.
Why can't we have "smoke free workplaces and homes" (Australia has got legislation and campaigns), "taxes" (we've got far higher taxes than the U.S.), "media campaigns "(we've got those) and "secondhand smoke messages" (we've got those) PLUS youth access PLUS advertising and promotion restrictions ( the U.S. still has a long way to go there) PLUS good anti-litter laws PLUS Quit support PLUS whatever else will work?
Perhaps his conclusion should be that youth access doesn't work IF you haven't got a comprehensive approach to tobacco control and it is undermined by inaction on the enforcement aspects or by inaction on the other strategic fronts. It's certainly not sufficient by itself, but as I've shown here - it can be a very cheap way of creating non-smokers at one tenth the cost of Nicotine Replacement Therapy(2).
Douglas Tutt
1)Tutt D, Bauer L, Edwards C,Cook D. Reducing adolescent smoking rates. Maintaining high retail compliance results in substantial impovemnts. Health Promotion Journal of Australia 2000:10(1)20-24 2)Tutt D. Enforcing prohibition of tobacco sales to minors :an update. Proceedings of 13th Winter School in the Sun, Alcohol and Drug Foundation - Queensland, Brisbane, Australia 2000.
Conflict of Interest:
None declared. - Published on: 13 May 2016Fichtenberg and Glantz respond
- Stanton A. Glantz, Professor of Medicine
- Other Contributors:
- Caroline Fichtenberg
Show MoreSince DiFranza's criticism of the editorial by Ling et al.(1) concentrates mostly on criticism of the paper by Fichtenberg and Glantz, published in Pediatrics,(2) we are writing to respond to these criticisms separately. We recognize that this is unusual, since the standard procedure would have been for DiFranza to write Pediatrics after the paper was published there. DiFranza, however, chose to write Tobacco Control (b...
Show LessSince DiFranza's criticism of the editorial by Ling et al.(1) concentrates mostly on criticism of the paper by Fichtenberg and Glantz, published in Pediatrics,(2) we are writing to respond to these criticisms separately. We recognize that this is unusual, since the standard procedure would have been for DiFranza to write Pediatrics after the paper was published there. DiFranza, however, chose to write Tobacco Control (based on a preprint we provided him as a courtesy), so we are responding here.
The premise of youth access programs is that if merchant compliance reaches a high enough level, it will reduce youth access to cigarettes and, therefore, youth smoking. The goal of the first part of our analysis was to see if, based on the available literature, there was a relationship between merchant compliance and youth smoking. Whether or not the laws were being enforced at the time and if so, in what manner, is irrelevant to this analysis. If youth access programs work because high merchant compliance leads to lower smoking, there should be an association between high merchant compliance rates and low youth smoking rates, regardless of what led to those rates of compliance. If an intervention designed to increase merchant compliance was successful, we should see high compliance rates and low smoking. If the intervention was not successful, because they did not include enforcement as DiFranza suggests, there we should see low compliance and low smoking. (Whether there is prosecution of merchants or not (3) is irrelevant to testing whether making it difficult for teens to purchase cigarettes affects teen smoking prevalence.) Both of these cases would contribute to our test of the hypothesis that increased merchant compliance was associated with reduced smoking. The data to not exhibit such an association (Figure 1a of Fichtenberg and Glantz(2)).
All youth access program measure merchant compliance through undercover sales attempts by underage youth as was done in the Bagott(4) study. If merchant compliance measured in this was is not an accurate reflection of youth access, then none of the studies of youth access that base their effectiveness on merchant compliance are valid. The goal of our analysis was not to determine if compliance is a good measure of youth access but rather to relate the most commonly used metric for measuring the effectiveness of youth access programs, namely merchant compliance, and to youth smoking rates.
DiFranza says that we should not include studies from England because the legal age to purchase cigarettes is 16. We see no reason why youths aged 14-15 would not be affected by laws limiting purchase of cigarettes to those 16 and older.
DiFranza objects to including data from Australia, because 46% of the students lived outside the enforcement area.(10) As discussed above, whether or not active enforcement was involved is irrelevant to our analysis of the association between merchant compliance with youth access laws and youth smoking prevalence. All that is important is that compliance and smoking was assessed in the same community. In this case the authors point out that for the follow-up survey, 46% of students in the intervention community – which was defined based on school location – did not live in the intervention area. They conclude that this would be a problem if these children bought cigarettes closer to home rather than to school. Since there was no residence information from the baseline survey it was not possible to limit the analysis to student living in the intervention area. Nevertheless, we chose to include the study in our analysis despite this limitation. It is important to note that the results of this study were consistent with the others.
There is no problem with combining studies of different design in a quantitative meta-analysis as long as all studies are measuring the same endpoint. (11,12) As was reported in the methods section of our paper, the quantitative meta-analysis only included controlled studies. DiFranza objects to combining studies because the ages of the youths, and the methods used to test compliance, differed. (14) While we agree that factors such as age and gender of the youths may impact measured merchant compliance, we did not expect this variability to mask the effect of youth access programs, if they actually affected youth smoking rates. The small number, 5, of controlled studies of youth access programs which reported youth smoking made it impossible to stratify according to the age of the youths used in the compliance checks.
DiFranza objected to our evaluation of the change in youth smoking prevalence as a function of change in merchant compliance on the grounds that it is necessary to obtain compliance rates above 90% to have an effect on youth smoking prevalence. (15) In addition to the fact that the data shows no empirical evidence to support the hypothesis of such a threshold (Figure 1A in Fichtenberg and Glantz (2), reproduced as Figure 1 in Ling, et. al(1)), our basic premise is that if youth access programs actually reduced youth smoking, higher compliance rates would be associated with lower youth smoking rates. We examined this hypothesis in three ways. First we compared compliance and smoking rates in all communities for which both variables were measured at the same time. Since this is an ecological analysis which does not take into account trends over time, we then examined the relationship between changes in compliance and changes in smoking in case what mattered was whether there was a reduction in sales to youth rather than the absolute level of compliance at one time (Figure 1B in Fichtenberg and Glantz (2)) The data presented in Figure 1A demonstrate that there is no threshold of effectiveness at 90% compliance. Smoking rates for communities with compliance above 90% vary between 19.4%and 32.5%, with a mean of 25.9%. In communities with compliance rates below 90%, smoking rates vary between 15.6% and 37.7% with a mean of 25.7%. There is no evidence of a threshold of effectiveness.
DiFranza suggested that we control for a wide variety of socioeconomic and demographic factors. Because "When this type of analysis has been performed on a community and state level of analysis, reductions in youth smoking have been observed. (16,17)" Given the small number of studies available, it was not possible to explore the effects of potential confounders such as other tobacco control policies, price of cigarettes, socio-economic status. Nonetheless, in our discussion we report the results of population based studies, including but not limited to, those referred to by DiFranza. Chaloupka and Pacula (17) in the study cited by DiFranza do indeed find that statewide enactment and enforcement of youth access laws associated with reduced youth smoking. However in another analysis (18), the same authors found that this effect was restricted to black teens. The study by Siegel et al. (16) does indeed find that the presence of youth access laws was associated with decreased smoking initiation rates, however they conclude that this decrease was not mediated by decreased access because youths reported no decreased in perceived access.
In the first part of our analysis (Figure 1A), we compared compliance and smoking in all communities for which there was information. Since we were not trying to assess the effects of interventions but rather to see if there is a relationship between compliance and smoking, we did not make a distinction between control and intervention communities, or between baseline and follow-up data. As DiFranza points out, this type of analysis does not take into account temporal trends or other potential confounders. In order to take these into account we performed a quantitative meta- analysis using only controlled studies (n=5). This analysis yielded a pooled effect of a 1.5% decrease in youth prevalence (95%CI: 6% decrease to 3% increase).
Tutt cited a paper by his group (20) that was not included in our meta-analysis because it was not listed in Medline or cited in any of the other papers we located. Adding his results to those we report, however, does not affect the conclusions of our analysis. The correlation between merchant compliance and 30 day teen smoking prevalence including these data is .042 (P=.799) compared with .116 (P=.486) reported in Figure 1A of our paper. (2) Likewise the correlation between change in merchant compliance and change in youth smoking is -.163 (P=.504) compared with .294 (P=.237) without it. Thus, including Tutt, et. al's data actually strengthens the conclusions in our paper.
It is time for enthusiasts for youth access interventions to recognize that while these interventions may have seemed like a good idea, they do not achieve their primary goal of reducing youth smoking. All that happens is that youth obtain their cigarettes from other sources.(21)
Caroline Fichtenberg, MS, Department of Edidemiology, Johns Hopkins School of Public Health, Baltimore, MD Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education, University of California, San Francisco
References:
1. Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tobacco Control 2002;11:3-6. 2. Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking. Pediatrics (In press). 3. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between tobacco access and use among adolescents: A four community study. Soc. Sci. Med. 1999;48;759-775. 4. Baggot M, Jordan C, Wright C, Jarvis S. How easy is it for young people to obtain cigarettes and do test sales by trading standards have any effect? A survey of two schools in Gateshead. Child: Care, Health and Development 1998;24:2007-216. 5. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health 1998;22:332-335. 6. Rigotti NA, DiFranza JR, Chang YC, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco sales laws on youth's access to tobacco and smoking behavior: A controlled trial. New Engl J Med 1997;337:1044-51. 7. DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access laws at the community level. Tobacco Control 1999;8:152-155. 8. Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors. JAMA 1989;261:80-83. 9. Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of an educational program to reduce dales of cigarettes to minors. American Journal of Public Health 1991;81:891-893. 10. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health 1998;22:332-335. 11. O’Grady B, Asbridge M, Abernathy T. Analysis of factors related to illegal tobacco sales to young people in Ontario. Tobacco Control 1999;8:301-305. 12. Pettiti D. Meta-Analysis, Decision Analysis, and Cost Effectiveness Analysis. 2nd ed. New York, NY: Oxford University Press; 2000. 13. Stroup DF, Berlin JA, Morton SC. Meta-analysis of observational studies in epidemiology. JAMA 2000;283:2008-2012. 14. Teall AM, Graham MC. Youth access to tobacco in two communities. Journal of Nursing Scholarship 2001;33:175-178. 15. Levy D, Chaloupka F, Slater S. Expert opinions on optimal enforcement of minimum purchase age laws for tobacco. J Public Health Management Practice 2000.6:107-114. 16. Siegel M, Biener L, Rigotti N. The effect of local tobacco sales laws on adolescent smoking initiation. Preventive Medicine. 1999;29:334-342. 17. Chaloupka F, Pacula R. Limiting youth access to tobacco: the early impact of the Synar Amendment on youth smoking. Working paper: Department of Economics, University of Illinois at Chicago; 1998. 18. Chaloupka F, Pacula R. Sex and race differences in young people’s responsiveness to price and tobacco control policies. Tobacco Control 1999;8:373-77. 19. Glantz SA. Preventing tobacco use-the youth access trap. Am J Public Health. 1996;86:221-4. 20. Tutt D, Bauer L, Edwards C, Cook D. Reducing adolescent smoking rates: Maintaining high retail compliance results in substantial improvements. Health Promotion Journal of Australia 2000;10:20-24. 21. Jones SE, Sharp DJ, Husten CG, et al. Cigarette acquisition and proof of age among U.S. high school students who smoke. Tobacco Control 2002;11:20–5.
Conflict of Interest:
None declared. - Published on: 13 May 2016Ling, Landman, and Glantz respond
- Stanton A. Glantz, Professor of Medicine
- Other Contributors:
- Pamela Ling and Anne Landman
Show MoreFichtenberg and Glantz have responded separately to the technical issues that DiFranza raised about their paper.
Both Tutt and DiFranza are missing the larger point of our editorial. Unlike public health forces, the tobacco industry has unlimited resources to push their agenda. We made the point that in a real world of limited public health resources, those resources are better concentrated where they have been...
Show LessFichtenberg and Glantz have responded separately to the technical issues that DiFranza raised about their paper.
Both Tutt and DiFranza are missing the larger point of our editorial. Unlike public health forces, the tobacco industry has unlimited resources to push their agenda. We made the point that in a real world of limited public health resources, those resources are better concentrated where they have been shown to be most effective. Youth access is clearly not that area. Tobacco industry documents show that the industry has run rings around public health forces when it comes to youth access, successfully co-opting it to the point that it now serves the industry's purposes.
Conflict of Interest:
None declared. - Published on: 13 May 2016It is time to abandon bad science
- Joseph R DiFranza, physician
Show MoreMay 8, 2002 To the editor,
In their editorial “It is time to abandon youth access tobacco programmes,” Ling, Landman and Glantz1 base their argument on an in press meta-analysis of youth access interventions by Fichtenberg and Glantz.2 These authors conclude that there is no proof that youth access interventions work to reduce youth smoking rates. Sadly, this analysis includes ten methodological flaws, each o...
Show LessMay 8, 2002 To the editor,
In their editorial “It is time to abandon youth access tobacco programmes,” Ling, Landman and Glantz1 base their argument on an in press meta-analysis of youth access interventions by Fichtenberg and Glantz.2 These authors conclude that there is no proof that youth access interventions work to reduce youth smoking rates. Sadly, this analysis includes ten methodological flaws, each one of which individually renders the conclusions scientifically invalid.2 One of the invalid figures from the Fichtenberg analysis has been reprinted in Tobacco Control.1 1. Three of the eight studies included in the meta-analysis did not involve any actual enforcement of the law, and the authors of a fourth study concluded that enforcement was inadequate due to a political backlash from merchants.3-7 The inclusion of at least three of these studies is scientifically unjustifiable as it has been established for over a decade that merchant education programmes alone are ineffective at attaining the levels of merchant compliance that can be expected to reduce youth access to tobacco.8,9 Three out of the five studies included in the analysis of the effects of youth access restrictions on past 30-day smoking did not involve enforcement. The authors inappropriately list the Baggot study as including enforcement and fines when in actuality, the inspection method was so flawed that no merchant was ever caught and none were prosecuted.4 2. In the Baggot study, merchant compliance is reported as 100%.4 None of the stores sold to youths aged 13 or under during enforcement checks, yet 100% of smokers among the community youths surveyed reported that they regularly bought tobacco from stores and only rare subjects reported ever having been turned down. The study’s authors correctly concluded that the compliance inspections were an invalid measure of youth access. Yet Fichtenberg and Glantz included this invalid data in the analyses of a threshold effect and it is also included in the figure printed in Tobacco Control.2 3. It was improper to include a study from England where the legal age is 16 as the majority of secondary school students would be of legal age to purchase and no impact on youths ages 14-15 would be expected.4 4. It was improper to include the study from Australia. In addition to the fact that the study involved no enforcement, 46% of the students in the intervention group actually lived outside the intervention area!10 5. The meta-analysis improperly combined studies of different designs including cohort, cross-sectional, controlled interventions and non- controlled interventions. 6. Combining these studies is also inappropriate because the ages of the youths, and the methods used to test compliance, differed dramatically from study to study. For example, a compliance rate of 82% for a 14 year old is equivalent to a compliance rate of 62% for a 17 year old.11 A compliance rate of 42% for behind the counter sales is equivalent to a compliance rate of 58% for self-service sales.12 Differences in the techniques used to measure compliance render all of the computations and conclusions in this paper invalid. 7. The authors’ basic premise is that the percentage change in merchant compliance should correlate with the percentage change in the prevalence of youth smoking. The use of this measure represents a straw man. In my review of 176 articles concerning youth access, I cannot recall anybody in this field ever suggesting that the change in percentage of merchant compliance is an appropriate measure of youth access. To the contrary, there is wide agreement among experts in this field that absolute levels of merchant compliance above 90% as measured through realistic compliance checks using youths close to the legal limit will be necessary to effect a change in the prevalence of youth smoking.13 8. In the figure presented in the Tobacco Control editorial, intervention communities are being inappropriately compared to control communities from other continents and legal systems. If the authors wanted to compare smoking rates and youth access interventions across communities, a random sample should be used, uniform measures should be employed and other confounding factors such as socio-economic status and the cost of tobacco should be controlled for. When this type of analysis has been performed on a community and state level of analysis, reductions in youth smoking have been observed.14,15 9. It has been known for centuries that the prevalence of smoking increases during adolescence. This factor must be controlled for in cohort studies by the inclusion of a matched control group. During the period when most of these studies were conducted there was a secular trend of dramatically rising teen smoking rates observed in English speaking countries. Since merchant compliance would also be expected to increase over time in these intervention studies, it would be expected that a positive association between the intervention and smoking prevalence would be seen in both cohort and cross-sectional studies if enforcement were completely ineffective. The meta-analysis does not appropriately incorporate control communities for each intervention community. Only 3 control communities are included for 15 intervention communities across 7 studies. 10. In the same analysis, the few control communities are inappropriately included as additional “data points” in the mix. Baseline data rather than outcome data were used for one intervention community. These procedures indicate that the intention of this analysis was not to determine the impact of the interventions as the authors state.
The Fichtenberg and Glantz article is strongly reminiscent of the ‘scientific’ papers secretly commissioned by the now defunct Tobacco Institute. It is sad that the scientific literature continues to be poisoned for political ends. The Tobacco Control editorial which was based on this travesty of science also excludes and misinterprets data which contradict the authors’ long held biases.16
Joseph R DiFranza MD Professor of Family and Community Medicine Department of Family Medicine and Community Health University of Massachusetts Medical School 55 Lake Avenue Worcester, MA 01655 References 1. Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tobacco Control. 2002;11:3-6. 2. Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking. Pediatrics (In press). 3. Altman DG, Wheelis AY, McFarlane M, et al. The relationship between tobacco access and use among adolescents: A four community study. Soc. Sci. Med. 1999;48;759-775. 4. Baggot M, Jordan C, Wright C, Jarvis S. How easy is it for young people to obtain cigarettes and do test sales by trading standards have any effect? A survey of two schools in Gateshead. Child: Care, Health and Development. 1998;24:2007-216. 5. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health. 1998;22:332-335. 6. Rigotti NA, DiFranza JR, Chang YC, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco sales laws on youth's access to tobacco and smoking behavior: A controlled trial. New Engl J Med 1997;337:1044-51. 7. DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access laws at the community level. Tobacco Control. 1999;8:152-155. 8. Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors. JAMA. 1989;261:80-83. 9. Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of an educational program to reduce dales of cigarettes to minors. American Journal of Public Health. 1991;81:891-893. 10. Staff M, March L, Brnabic A, Hort K, Alcock J, Coles S, Baxter R. Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? Aust N Z J Public Health. 1998;22:332-335. 11. O’Grady B, Asbridge M, Abernathy T. Analysis of factors related to illegal tobacco sales to young people in Ontario. Tobacco Control 1999;8:301-305. 12. Teall AM, Graham MC. Youth access to tobacco in two communities. Journal of Nursing Scholarship. 2001;33:175-178. 13. Levy D, Chaloupka F, Slater S. Expert opinions on optimal enforcement of minimum purchase age laws for tobacco. J Public Health Management Practice. 2000.6:107-114. 14. Siegel M, Biener L, Rigotti N. The effect of local tobacco sales laws on adolescent smoking initiation. Preventive Medicine. 1999;29:334-342. 15. Chaloupka F, Pacula R. Limiting youth access to tobacco: the early impact of the Synar Amendment on youth smoking. Working paper: Department of Economics, University of Illinois at Chicago; 1998. 16. Glantz SA. Preventing tobacco use-the youth access trap. Am J Public Health. 1996;86:221-4.
Conflict of Interest:
None declared.