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

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

33. 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

34. 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

35. 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.