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The How and Why of Preventing the Sale of Tobacco to Minors: From Policy to Epidemiology

This article explores the critical public health challenge of preventing tobacco sales to minors, analyzing the effectiveness of policies and enforcement strategies. Key findings show that improved merchant compliance, as mandated by the Synar Amendment, leads to significant reductions in youth smoking rates. Through a review of national and international experiences, this study identifies effective strategies, including rigorous compliance testing and licensing reforms, while addressing the ongoing debate about enforcement and youth smoking trends.

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The How and Why of Preventing the Sale of Tobacco to Minors: From Policy to Epidemiology

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  1. Joseph DiFranza MD University of Massachusetts Medical School The How and Why of Preventing the Sale of Tobacco to Minors: From Policy to Epidemiology

  2. Sources of Tobacco for Nondaily Smokers • Friends who purchase tobacco • Stealing from family

  3. Sources of Tobacco for Daily Smokers • When the latency to craving shrinks to one day kids try to purchase their own tobacco. • Friends who purchase tobacco • Stealing from family • Shoulder tapping

  4. Youth Access to Tobacco • In 1987 an 11 year old girl successfully purchased tobacco in 75 of 100 attempts. • Perhaps fewer kids would smoke if it was harder for them to obtain cigarettes.

  5. Enforcement in Single Communities • In 3 US cities enforcement reduced smoking by 31%, 44% and 50% among middle school students.

  6. The Synar Amendment • Enacted late in 1992 • Went into force in 1996 • States must have a minimum age of 18 • States must enforce the law • States must conduct annual compliance tests • Compliance must exceed 80%

  7. The Controversy • Does enforcement result in fewer kids smoking? • Do access restrictions backfire by making youth want to smoke?

  8. The Synar Amendment • Has it decreased teen smoking in the US?

  9. The Synar Amendment • All states adopted laws • Merchant compliance improved in 49 states between 1997 and 2003. • Between 1997 and 2001, reliance on store purchases by smokers decreased from 38.7% to 23.5%. • Between 1997 and 2003, daily smoking among 10th graders fell 51% nationwide (from 18.0% to 8.9%).

  10. Possible Factors • Improved compliance • Cigarette price increases • A national anti-tobacco media campaign was launched in 2000. • Clean indoor air policies

  11. Study Objective • To determine if improved merchant compliance contributed to the reduction in smoking among youths. • Are kids who live in states with higher compliance less likely to smoke?

  12. Methods • A national survey of 16,244 10th graders. • We evaluated the impact of state merchant compliance from 1997-2003 on the odds that a youth was a current daily smoker. • Controlled for price, clean-air regulations, expenditures on anti-tobacco advertising, age, gender, race, ethnicity and parental education.

  13. Results • From 1997 to 2003 the average compliance increased by 10.4 percentage points, reducing the odds of daily smoking by an estimated 20.8%.

  14. Results • With an enforcement budget of $150/tobacco retailer our calculated 20.8% reduction in smoking equals a cost of $330 per year of life saved.

  15. Conclusion • The Synar Amendment has been an extremely cost effective and life-saving public health policy.

  16. Central Coast, Australia • Enforcement through compliance testing • >90% compliance over 9 years

  17. Monthly smoking

  18. Monthly smoking

  19. Recent purchase attempts-smokers

  20. Recent purchase attempts-all youth

  21. The Canadian Experience • In 2002,14% of 9th graders smoked • In 2008, 7% of 9th graders smoked • 50% reduction in youth smoking

  22. The Netherlands Experience • The proportion of youth buying their own cigarettes fell by 53% from 13.5% to 6.4%. • The prevalence of smoking among youth aged 13-15 fell by 64%, from 20.3% to 7.4%.

  23. National Programmes • All four countries for which data are available have reported reductions in youth smoking of at least 50%.

  24. Literature Review of 420 Studies • To determine if disrupting the sale of tobacco to minors decreases tobacco use. • 19 studies in which the disruption of the commercial distribution of tobacco to children had been evaluated. • All 19 studies found a beneficial effect on youth smoking.

  25. WHO and the FCTC • The Framework Convention on Tobacco Control adopted by WHO in 2003 • Over 172 signatories have committed themselves to preventing the sale of tobacco to minors.

  26. Winston Churchill • “We can always count on the Americans to do the right thing... • after they have exhausted all the other possibilities.” • 50 states- 50 experiments

  27. Ineffective Strategies • Passing a law with no enforcement • Merchant education • “Self-enforcement” • Compliance tests with no penalties

  28. Effective Strategies • A good law • Minimum age 18 or 21 • Licensing of retailers • Graduated penalties, including loss of license • Requirement to check proof of age • Designated enforcement agency • Merchant education • Publicized ongoing compliance tests with underage buyers

  29. Effective Strategies • Constant monitoring of merchant compliance rates in all jurisdictions • 100% coverage with controlled purchase operations

  30. Licensing • Fees can be nominal or enough to cover the costs of education/enforcement • Cuts the cost of enforcement • Identifies the person responsible • Addresses allow for mailings • Provides a tally retail outlets • Provides a registry to ensure complete coverage for CPO’s • License revocation for violations

  31. Licensing-untried policies • Requiring a test to obtain a license • Increasing the cost to reduce the number of outlets • Capping the number of outlets • Not issuing new licenses

  32. Youth Access-Recommendations • Licensing • Increase funding to provide for enforcement in all jurisdictions • Using older youths in CPOs • Provide color-coded proof of age • Annual reports on compliance rates for NZ and by local jurisdictions to monitor progress and identify problem areas

  33. Youth Access-Recommendations • Publish your data and publicize the CPO results on a regular basis • Update the law to allow for license revocation (1 week, 1 month, permanent) • Increase the age to 21 • Eliminate vending machines

  34. Youth Access-Recommendations • License both the businesses and the clerks. • Set a minimum age for clerks. • Require that business owners and clerks successfully complete a free online training program in responsible tobacco sales. • Both clerks and owners would be registered with the enforcement agency, allowing the agency to track them for repeated violations. • Licenses could be revoked for both businesses and clerks for repeated violations. • Make it an offense to sell tobacco without a license.

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