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Which interventions against the sale of tobacco to minors can be expected to reduce smoking?
  1. Joseph R DiFranza
  1. Correspondence to Dr Joseph R DiFranza, Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Avenue, Worcester, Massachusetts 01655, USA; difranzj{at}ummhc.org

Abstract

Objective Signatories of the Framework Convention on Tobacco Control have committed themselves to prohibiting the sale of tobacco to minors. The tobacco industry has a long history of legal challenges to such restrictions claiming that they cannot be expected to reduce youth smoking. The object of this study was to determine if disrupting the sale of tobacco to minors can be expected to reduce tobacco use by youths.

Methods A comprehensive literature search was conducted for studies that evaluated the impact on youth tobacco use of efforts to disrupt the sale of tobacco to youths.

Results There was little evidence that merely enacting a law without sufficient enforcement had any impact on youth tobacco use. There was no evidence that merchant education programmes had any impact on youth older than 12 years of age. There was no evidence that enforcement efforts that failed to reduce the sale of tobacco to minors had any beneficial impact. All enforcement programmes that disrupted the sale of tobacco to minors reduced smoking among youth.

Conclusions Government officials can expect that enforcement programmes that disrupt the sale of tobacco to minors will reduce adolescent smoking.

  • Addiction
  • youth
  • access
  • advertising and promotion
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Introduction

In 1987, the author proposed that if the sale of tobacco to children was halted, fewer children would use tobacco.1 There is now a global policy consensus that sales to minors should be prevented, as reflected by the Framework Convention on Tobacco Control (FCTC). The FCTC was unanimously adopted by the World Health Assembly in 2003 and has since attracted more than 172 signatories (member states) representing 87.3% of the world's population.2 While tobacco manufacturers claim to oppose the sale of tobacco to minors, they have worked to prevent the enforcement of underage sales laws,3 ,4 and tobacco retailers have a history of filing legal challenges to these laws.5 When a sale-to-minors law is challenged in court, the government might be required to demonstrate that the law is justified by a reasonable expectation that it will benefit public health.

The author was contracted by the WHO to conduct a systematic review concerning efforts to disrupt the sale of tobacco to minors, which resulted in a 99-page report (available from the author). The current paper provides public officials with a brief overview of the evidence that establishes that well enforced laws prohibiting the sale of tobacco to minors can be expected to reduce the number of children that use tobacco.

Methods

The materials reviewed include more than 400 published articles and 400 government reports concerning tobacco sales to minors archived by the author from 1987 to 2010. This collection was supplemented by a search on Medline and PsychInfo using the terms tobacco, youth and access. The abstracts of citations generated by the literature search were reviewed. Potentially relevant articles were obtained whenever possible; all studies that assessed an intervention against the commercial distribution of tobacco to minors were obtained. The references cited in all articles, including 30 prior review articles, were examined for additional publications. Requests were posted on the list serve for the international Society for Research on Nicotine and Tobacco for published and unpublished manuscripts.

Analytical approach

As it is impossible to prove what the future effect of a proposed law will be, the courts may require only that the government demonstrate that there is a reasonable expectation that the law will benefit public health. Legal standards are quite different from a scientific standard of proof of causality. It is not necessary to prove through randomised controlled experiments that a law will reduce youth smoking, it is necessary only to demonstrate that it is reasonable to expect it to do so. Documentation of a reduction in youth smoking following the implementation of a particular type of intervention would allow a reasonable expectation that the implementation of the same type of intervention in another jurisdiction would have a similar effect. The literature was reviewed to identify types of interventions that can and cannot be reasonably expected to reduce youth tobacco use.

Prior reviews employed a priori study selection criteria, which systematically excluded up to 90% of the literature from consideration.6 ,7 The current review is the first to analyse every article on this topic. Each document was read by the author and categorised by topic. All articles concerning an impact on youth tobacco use were examined in detail to extract the following information: date; setting; study design; sample size; type of intervention; duration of the study; the impact of the intervention on commercial distribution; the impact on smoking outcome measures; and quality issues. After initial review, it was evident that every study design was unique, rendering the data unsuitable for statistical meta-analysis. Studies were grouped according to the type of intervention that was evaluated with special attention to whether the sale of tobacco to minors had been disrupted.

Results and discussion

The Medline search produced 303 citations, and PsychInfo produced 103. The final document collection included 20 000 pages of US local, state and federal government documents, and government documents from other countries; tobacco industry documents describing their public relations programmes and their objections to youth access legislation and regulations; unpublished manuscripts and data; personal communications; books; doctoral theses; merchant education materials; and 424 academic documents. The articles fell into the following categories: 57 reports of retailer behaviour during purchase attempts; 56 reports on sources of tobacco for minors; 47 editorials, opinions, or policy recommendations; 41 studies with an evaluation of the impact on tobacco use by youth; 34 evaluations of programme outcomes other than the impact on youth tobacco use; 30 literature reviews; 28 descriptions of programmes; 27 articles focused on issues such as the sale of single cigarettes, self-service displays, vending machines, tax revenues and retailer density; 19 laws and regulations; 18 surveys of knowledge, attitudes and opinions; 17 articles on miscellaneous topics; 14 articles concerning purchase, use and possession laws; 13 evaluations of research methods; 13 studies assessing the impact of perceived availability; 6 articles on internet sales; 5 government reports; and 4 news accounts. All of these materials were read to ensure that the conclusions of this study were based on all available information on the topic.

Is it reasonable to expect that enacting a law prohibiting the sale of tobacco to minors will reduce youth smoking?

Since 1987 it has been known that the mere adoption of a law prohibiting the sale of tobacco to minors is insufficient to prevent the sale of tobacco to children.1 This fact has since been confirmed by dozens of studies from around the world.8–10 Many studies have used cross-sectional surveys to determine if features of the law affect the likelihood that a youth will use tobacco. Commonly considered features include bans on vending machines, self-service and single cigarette sales. While several studies found weak associations between the strength of a law and youth smoking,11–16 others did not.11 ,17 ,18 A problem with cross-sectional studies is that tougher laws may be enacted where anti-smoking sentiment has already reduced youth smoking, or conversely in response to high rates of youth tobacco use. Cross-sectional analyses often lack data on whether the sale of tobacco to minors has been disrupted by law enforcement. An analysis of US states failed to demonstrate any association between the strength of a law and the strength of enforcement.19 In summary, it cannot be expected that enacting a law, no matter how strong, will have any impact on adolescent smoking in the absence of effective enforcement.

Opponents of restrictions on the sale of tobacco to children claim that these laws encourage adolescent tobacco use by making tobacco a forbidden fruit.20 ,21 This claim has been refuted by dozens of studies that show no increase in smoking after the institution of such restrictions.

Are merchant education programmes sufficient to reduce youth tobacco use?

Staff et al conducted a controlled study involving over 6000 English youth to evaluate the impact of a merchant education campaign.22 The only indication of an impact on commercial distribution was that male students rated it harder to purchase from petrol stations. Logistic models indicated a 54% reduction of smoking uptake and a 39% reduction in daily smoking among 7th graders in the intervention group. No effect was seen among older youths.

A 3-year randomised controlled study of community mobilisation and merchant education without enforcement was conducted in four Arizona communities.23 The intervention produced a temporary reduction in cigarette purchases by 7th graders but not by 9th and 11th graders. During the period when 7th graders made fewer purchases, smoking was reduced by a relative 23% in this age group. Neither purchases nor smoking were reduced among older youth.

There is no evidence that merchant education programmes, in the absence of law enforcement, have any impact on smoking by youth older than about 12 years of age.

Can enforcement disrupt the commercial distribution of tobacco to minors?

Opponents of efforts to disrupt the sale of tobacco to minors claim that such efforts are futile because social sources will fill the void making tobacco more available.24–28 In reality, adolescents who purchase cigarettes are the primary social sources for other youth.29–31 The disruption of commercial distribution creates supply shortages, driving up the cost of tobacco on the street and discouraging sharing among peers as smokers protect their supply.32 ,33 In Texas it was demonstrated that enforcement resulted in a marked decline in smoking among middle school students and a simultaneous decrease in the number of commercial and social sources of tobacco.34 ,35

The disruption of the sale of tobacco to minors has resulted in fewer purchases made by youth,23 ,33 ,36–38 fewer youth reporting that commercial sources are their usual source,33 ,39 ,40 fewer youth reporting a commercial source for their last cigarette,36 ,41 ,42 and more reports that cigarettes are harder to purchase.22 ,43 There is ample proof that enforcement can disrupt the commercial distribution of tobacco to minors, and this is a crucial test of the quality of an enforcement programme. Therefore, we sorted enforcement programmes into those that did, or did not show evidence that the sale of tobacco to minors had been disrupted.

Can enforcement that is too weak to disrupt the commercial distribution of tobacco to minors be expected to impact youth tobacco use?

Two studies were conducted in England on the impact of a particularly ineffective approach to enforcement.44 ,45 Enforcement was conducted as is customary through test purchases conducted by underage decoys.19 However, the decoys were exceptionally young (under 13). The decoys were refused in 100% of their attempts to purchase tobacco. Yet 95% of young adolescent smokers in the same community reported that they purchased tobacco from shops at least once per week, and 55% purchased on a daily basis. Thus, cigarette sales to children remained vibrant in these communities despite the publicised enforcement programme. No impact on youth smoking was observed.

Rigotti et al conducted a six-community randomised controlled trial of enforcement in greater Boston.46 Legal challenges from tobacco retailers temporarily derailed enforcement efforts5 and the intervention failed to disrupt sales to minors as the percentage of youth who purchased tobacco did not change. There was no effect on tobacco use among students in grades 9–12.

There is no evidence that enforcement that is too weak to disrupt the commercial distribution of tobacco to minors has any effect, positive or negative, on youth smoking.

Can enforcement that disrupts the commercial distribution of tobacco to minors be expected to impact youth tobacco use?

Table 1 displays the 19 interventions in which the sale of tobacco to minors was disrupted. In each case the intervention was followed by a decline in youth tobacco use. Some of these studies will be described in more detail here.

Table 1

Studies that demonstrated a disruption of commercial distribution to minors (1991–2011)

Forster conducted a randomised controlled study involving seven pairs of communities in Minnesota. Local laws were enacted and enforced in all communities assigned to the intervention group. The intervention reduced the number of purchase attempts and the number of youth relying on commercial sources of tobacco.36 Among 8th and 10th graders, daily smoking in the intervention group was reduced by 28% relative to the controls. Substantial activity in the control communities during the long-term follow-up period prevented a long-term effect specific to the intervention communities from being seen. This randomised controlled trial provides strong evidence that the disruption of tobacco sales to minors reduced adolescent smoking rates.

Cummings examined youth smoking rates and purchasing behaviours in a longitudinal analysis of 12 communities.39 Test purchases were conducted to measure merchant compliance with the law. Frequent smoking increased by 28% in the communities with higher violation rates and decreased by 16% in the communities with low violation rates for a differential decrease of 44%.

Jason demonstrated that the number of youth purchasing tobacco in communities with high levels of enforcement was only about one-quarter that in the communities with less effective enforcement.52 Regular tobacco use among high school students in communities with high levels of enforcement was about half that seen in neighbouring low-enforcement communities.

The Health Promotion Unit of the Central Coast region of New South Wales, Australia initiated an effort to curtail the sale of tobacco to children by conducting test purchases and issuing $1000 fines to violators.37 ,38 Subsequent rounds of compliance tests and prosecutions revealed violation rates of 10%, 8% and by 1997, 0%. Over the ensuing decade, the Unit maintained violation rates consistently below 5%. Surveys conducted every 3 years from 1993 to 2002, revealed that the proportion of all youth who had recently attempted to purchase cigarettes fell from 21.6% to 5.7%, a reduction of 73.6%. The prevalence of current smoking among youth was reduced by 50% (from 26% in 1993 to 13% in 2002).38 Initially, a decrease in smoking was evident only in the youngest adolescents, with declines among the older adolescents being evident only as a birth cohort effect as youths who did not initiate smoking during early adolescence did not take it up later. With fewer older adolescents smoking, subsequent birth cohorts had fewer smoking role models and social sources of tobacco. The prevalence of smoking among youth on the Central Coast showed an uninterrupted decline over 9 years. Only after enforcement had spread to the rest of New South Wales did youth smoking rates begin to decline on the state level, and only after enforcement had spread across the country did youth smoking begin to decline in national surveys. This study demonstrated that (1) with tough enforcement very low violation rates can be maintained with minimal effort; (2) the number of purchase attempts goes down (by 73.6% in this case); (3) the youngest youth are impacted first; and (4) 9 years or more of follow-up are needed to observe the full impact on older adolescents.

Jason et al conducted a randomised controlled study involving four pairs of communities, comparing the effects of strict enforcement of sales and possession laws (merchant violation rate of 4%) to moderate enforcement of both laws (merchant violation rate of 17%).53 Compared to the control communities, smoking initiation and daily use were reduced by more than 70% among white adolescents. There was a fourfold reduction in the number of cigarettes smoked by white smokers.

Texas reported a statewide merchant violation rate of 13% for 1998 and 15% for 1999.59 Between 1998 and 1999, the proportion of middle school students who reported commercial access to tobacco dropped by two-thirds while the prevalence of tobacco use in this age group dropped by 31%.34 At the same time, commercial access to tobacco did not change among high school students and there was no reduction in the prevalence of tobacco use in this age group. The lack of change in the older adolescents makes it unlikely that the decline in smoking among younger youths was due to factors that would affect all youths such as media or pricing.

Pokorny et al included the density of non-compliant retailers as a factor in a cross sectional multivariate analysis of the determinants of smoking using data from 5234 6th–8th grade students from 11 Midwestern communities.55 Retail tobacco availability (RTA) was measured as the density of non-compliant merchants per 1000 youth aged 10–17 years. Increased RTA was associated with increased odds that a youth initiated smoking. RTA ranged from 0.7 to 5.4 non-compliant retailers per 1000 youths. Each additional non-compliant retailer per 1000 youths increased the odds of initiation by 49%, or from our perspective, the elimination of each additional non-compliant retailer decreased the odds of initiation.

Reductions in national adolescent smoking rates of 50% or more have been reported in the USA, Canada, Australia and The Netherlands following the implementation of enforcement programmes.38 ,50 ,58 ,60 In The Netherlands, the proportion of youth that smoked and bought their own tobacco fell by 53%, from 13.5% to 6.4%, while the prevalence of smoking among youth 13–15 years old fell by 64%, from 20.3% to 7.4%.58

From 1997 to 2008 smoking among US 8th graders fell by 65%.61 In 1992, the average merchant violation rate for 93 US cities was 77%.9 Since 2006, all states have had merchant violation rates under 20%.62 Between 1997 and 2001 reliance on store purchases by adolescent smokers decreased from 38.7% to 23.5% in national surveys, indicating that improved violation rates had reduced commercial access.26 From 1997 to 2003 the prevalence of daily smoking among US 10th graders fell by 51% nationwide.61 State-level merchant violation rates over this 7-year period were a significant predictor of youth smoking when controlled for prices, anti-tobacco media and clean indoor air policies. Smoking among 10th graders was reduced by an average of 1% for every 2% decrease in the state violation rate.50

Although enforcement started later in Canada than the US, Canada achieved very low violation rates more quickly than the US. Between 1999 and 2009, the prevalence of current smoking among 15–19-year-old Canadian youth dropped by 53%.60 While other factors may have contributed to the declines in youth smoking in the US, Canada, Australia and The Netherlands, the fact remains that youth smoking has fallen by at least 50% in all four countries that instituted enforcement programmes, and no other countries have reported a similar phenomenon.

Nine additional studies of various designs documented reductions in youth smoking in conjunction with efforts to prevent the distribution of tobacco to minors, but none of these studies clearly documented a disruption of commercial access.11–14 ,16 ,63–67 Among these is a study that demonstrated the adolescent smoking had declined in Sweden only in the two regions with the lowest merchant violation rates.64

In summary, there are many examples of interventions in which the disruption of the sale of tobacco to minors was followed by substantial declines in youth smoking. Some of the studies documenting this effect had strong designs with long follow-up periods and these studies had the strongest measured outcomes.36 ,38 ,42 The positive studies include non-controlled studies,33 ,41 ,49 non-randomised controlled studies,39 ,42 and randomised controlled studies.36 ,51 ,53 Positive effects were seen in rural communities,36 ,39 suburban communities,41 ,42 ,53 ,55 across large regions or states,37 ,38 ,40 and countrywide.50 ,58 Positive effects remained in all studies in which it was possible to adjust for other tobacco control initiatives.47 ,50 ,56 Against the many studies documenting enforcement programmes that resulted in a decline in youth smoking, there were zero publications in the literature that documented that an intervention had disrupted the commercial distribution of tobacco to minors without it having had a positive impact on youth smoking. Therefore, all available evidence indicates that interventions that successfully disrupt the sale of tobacco to minors can be expected to reduce the rate of tobacco use among adolescents. This conclusion contradicts those of prior reviews that concluded that youth access interventions are ineffective.

Starting in 19871 public health officials proceeded by trial and error through a series of supply-side initiatives of increasing aggressiveness to determine what was required to impact youth smoking. Initial efforts consisted of enacting local ordinances alone.41 When this was seen to be ineffective, aggressive merchant education programmes were tried.68 When these too failed to produce the desired result, enforcement programmes of different types were implemented. Persistence eventually paid off as the current review indicates that all enforcement programmes that disrupted the sale of tobacco to minors have had a favourable impact on youth smoking.

From the beginning there were individuals within the tobacco control community who were opposed to a shift of focus from clean indoor air to youth access.69 While public health workers struggled to develop successful interventions, these critics continuously called for them to abandon their efforts.7 ,20 ,27 ,28 ‘Rather than continue to devote scare (sic) resources to youth access effort (sic), it is time to accept the fact—now well documented and explained—that youth access is a failed policy and abandon it so that resources can be focused on policies that work’.27 ‘Given the limited resources available for tobacco control, as well as the expense of conducting youth access programmes, tobacco control advocates should abandon this strategy and devote the limited resources that are available for tobacco control towards other interventions with proven effectiveness’.7 A perceived battle over resources offers a motivation for creating a false controversy about the effectiveness of youth access.21 ,27 In reality, enforcement of tobacco sales laws is inexpensive, is typically paid for by license fees and is very efficient in terms of cost per year of life saved, and could be fully funded with a 1 cent per pack tax on cigarettes with no need to divert resources from other programmes.70

Since the disruption of the commercial distribution of tobacco to minors defines a supply-side intervention, this is a critical factor to assess in evaluating the suitability of studies for inclusion in a systematic review. However, no prior review even considered whether interventions had any impact on commercial distribution.7 ,21 ,24 ,71 By mixing ineffective interventions that had no impact on commercial distribution to minors with interventions that effectively disrupted commercial distribution, a false controversy about the effectiveness of the supply side strategy has been sustained. Systematic reviews that mixed failed and successful interventions are not valid since signatories of the FCTC are not constrained to adopt a mixture of failed and successful interventions as they address the issue of tobacco sales to minors.

Conclusions

Every intervention that has successfully disrupted the sale of tobacco to minors has been associated with an observed reduction in tobacco use by youth. In this regard, the literature is unambiguous. Among the 424 papers reviewed, there was not a single study that demonstrated a significant reduction in commercial distribution without its having had a favourable impact on youth smoking. There is no evidence to support strategies that do not disrupt commercial distribution, such as enacting laws without enforcing them, or relying entirely on merchant education. Enforcement programmes that disrupt the commercial distribution of tobacco to minors can be expected to improve public health by reducing the number of youth who use tobacco. All successful enforcement programmes employ routine inspections involving test purchases by minors.19 To withstand legal challenges and to ensure that their efforts will produce the desired outcome, signatories of the FCTC should incorporate into their laws plans for enforcement through routine inspections involving test purchases, as this is the only approach that can be reasonably expected to reduce smoking among youth.

What this paper adds

  • Prior reviews of the effectiveness of interventions to prevent the sale of tobacco to children failed to distinguish between interventions that successfully disrupted the sale of tobacco to children and those that did not.

  • This review found that in every study that documented a disruption in the sale of tobacco to children a reduction in tobacco use by youth was observed.

Acknowledgments

The author acknowledges funding from the World Health Organization.

References

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Footnotes

  • Funding Support for this project was provided by the WHO. The opinions expressed are those of the author and do not represent the funding organisation.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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