More Than You Ever Wanted to Know About Conducting a Youth Tobacco Purchase Survey

1. More Than You Ever Wanted to Know About Conducting a Youth Tobacco Purchase Survey Elizabeth A. Klonoff, Ph.D. San Diego State University Supported by funds provided by the California Department of Health Services, Community Tobacco Control Education Project, Grant nos. 96-26617, 94-20962, and 96-26617, and the Tobacco-Related Disease Research Program, Grant nos. 6RT-0081, 4RT-0348, and 9RT-0043.

2. Do Laboratory (YPS) Studies Match the Real World? • Perhaps there is something wrong with how we have been measuring youth access • Older youth say they can still buy cigarettes and we know that they are buying them and are supplying younger youth • Perhaps the methodology of sending youth confederates into stores to buy cigarettes somehow differs from what 17 year old smokers do

3. Summary of Results from Study of Youth found to be smoking in public places • Preferred places to buy (because of perceived and reported easy access) were • Liquor stores (70.7%) • Gas stations (58.4%) • Small grocery (51.2%) stores • Convenience stores (48.8%)

4. Preferred methods to acquire cigarettes were • Buying in their own neighborhood (77.2%) • Buying from a clerk who knows them (72.8%) • Lying about being underage (71.2%) • Less common methods were • Simultaneously buying non-tobacco items (59.9%) • Saying that the cigarettes are for an adult (24.5%) • Using fake ID (23.6%) • Bringing a fake note from their parents (7.1%) • All recommended going to clerks who knew them as the best method for a 16 year old

5. What does this mean? • Most common method is to buy it from clerks who know them as regular customers (e.g., to buy in their own neighborhoods) • Youth comments about this strategy (e.g., “If a clerk knows you, he’ll sell you anything”) indicated keen awareness of the familiarity effect entailed • This youth-smoker method differs from the widely-used, standard method where • Youth attempt to purchase tobacco in stores where they are strangers to the clerks • And they are truthful about their age

6. Clerk Compliance vs. Youth Behavior: Percentage of Cigarette Sales to Youth (in press, Health Psychology)

7. Interpretation of the above data • Studies have found that some youth attempt to manipulate clerks into selling tobacco to them and that these manipulations are successful • Here we found that such manipulations are effective only with clerks who fail to inspect youth ID as required by law • Youth access with these non-compliant merchants was far above 20% and was high (47.6%) even when youth behaved normally • It increased to 80% when youth lied about their age such that non-compliant merchants sold 89% of all of the cigarettes sold to the youth

8. In contrast, with merchants who demanded youth ID, access was extremely low (0.9%) when youth behaved normally and did not increase significantly when youth lied or otherwise manipulated • Merchants who complied with the requirements rarely sold tobacco to youth irrespective of how youth behaved

9. Things to remember • Youth access to tobacco from commercial sources (stores) remains a problem because of merchant non-compliance • Sales by men and Anglo clerks must be addressed through interventions • Differential sales to Black and in particular Latino youth must be addressed through additional interventions • Smoking is increasing among these youth and they have the highest access as a result of merchant discrimination • Youth do attempt to manipulate clerks into selling to them but it only works on clerks who are non-compliant with the law

10. Why Do a YPS? • Before you begin, need to know why you are doing YPS • Three main reasons • To assess the efficacy of an intervention • To educate policymakers in an effort to promote policy development and implementation • To identify stores that consistently violate the law

11. To Assess the Efficacy of an Intervention • By definition, you will need to do at least two YPSs • One pre- and one post-intervention • Time frame must be considered because rates can be affected by many things • “Pre-” should be done immediately before • “Post-” should be done immediately after • Need to consider doing at least one “follow-up” assessment 3 months to one year after your intervention

12. As Data for Policymakers • A number of studies suggest the value of youth access policies at all levels • States with more extensive youth access policies have significantly lower youth smoking rates • 12-15 year olds living in towns with local ordinances at baseline were less likely to smoke than youth in towns without these ordinances • Communities that passed policies to reduce youth access showed less pronounced increases in youth smoking than communities that did not

13. To motivate policymakers • First, consider what outcome you desire • Base the nature of your data collection on what you want to demonstrate • The more restrictive the policy you desire is, the better your data need to be • For example, to encourage passage of a local licensing law, you better have sales rates far above the 8-15% currently being obtained in the statewide survey

14. To aid law enforcement • Many legal requirements to ensure that, if a store is caught selling tobacco illegally, the prosecution will be successful • Audio- or video-taping the sale • Specific requirements for how the tobacco that was illegally obtained needs to handled (“chain of evidence”) • Other procedures

15. Unless working directly with law enforcement, it is unlikely that YPSs you do will result in prosecution • Can use data obtained, however, to direct law enforcement to specific stores or types of stores that may be more or less likely to illegally sell tobacco to youth

16. What types of stores? • Need to decide in advance based on why you are doing YPS • Different kids of stores have different sales rates • Lower than average in drug stores and major supermarket chains • Higher than average in small grocery, convenience, and liquor stores, as well as in “other” locations (e.g., donut shops)

17. How many youth should be used? • The more youth you use the better • Decreases the likelihood results are based on characteristics/skills of a specific youth • Each youth should probably visit no more than 25 stores • For smaller counties and jurisdictions, no youth should do more than about 25% of the total • Cannot use the same youth both pre- and post- • Consider “swapping” youth in smaller areas

18. How old should the youth be? • Age is one of the strongest predictors of sales • Unless there is good reason, should use youth who are at least 16 years old • Not only are sales rates higher, but this is consistent with what we know about how youth get tobacco • Younger children get tobacco from older ones, who tend to buy it

19. Is ethnicity of the youth a factor? • Numerous studies, using widely differing methods, have found that the ethnic group of the youth affects sales • In general, most have found that minority children have the highest access • Also important is the ethnicity of the community you will be surveying • As much as possible it is best to have the ethnicity of the youth match the ethnicity of the community

20. What about youth gender? • Results for gender are mixed • Many earlier studies found that girls were sold to more than boys • Theorized that this was because 1) girls look older and 2) men clerks were more likely to sell to them • We tested #2 and found that it did not hold • More recent studies have found no gender differences • Safest to have equal numbers of boys and girls participate

21. Strategies for obtaining immunity • Clearly articulate the purpose of the survey (i.e., the rationale, methods, use of the data) • Work through contacts you already have established • Involve community leaders to speak on your behalf (strong community support is essential) • Use results from prior YPS as evidence that this would be valuable

22. What if you are unable to obtain immunity? • Think through what other options are available to you • May want to only assess ID checking (i.e., stop sale after you see if ID is asked for) • In any case, always want to make sure local law enforcement knows when you are going to be doing your survey

23. Identifying survey sites • Define geographic area • Region- or county-wide surveys • Most difficult because involves most planning • Does allow you to compare results with other Regions or with statewide survey • City-specific random sample survey • Easier to complete but only true for city where done • To compare sales rates among cities, may have to do more in each city to have sufficient sample

24. Specialized studies of communities, products, or merchants • Particular neighborhoods (e.g., within ½ mile of schools) • Products (e.g., chew tobacco or herbal cigarettes) • Types of stores (e.g., “mom and pop” markets or gas stations)

25. How many stores need you do? • Difficult question with no simple answer • Goal is to get enough stores to conclude results are representative of region, type of store, county, etc. • More you limit your survey, the more stores you may need to ensure it is representative • Work with your evaluation consultant to arrive at the optimal number for your purposes

26. It is not unusual for 10% of retailers to go out of business each year • Means that 10% of your list will no longer be in operation, regardless of how you got the list • Select 10-20% more retailers than the sample size determined by you and your evaluation consultant to ensure you reach your target

27. Training Prior to the YPS • For the youth • Memorize a so that they all behave the same way (“Can I have a pack of Marlboros?”) • Role play making PAs with the researchers • Youth should be paid for every PA, irrespective of its success • For the adult accompanying them • Assuring the child’s safety • Providing the money for the PAs • Confiscating all tobacco purchased • Recording all data collected by youth • Supervising the youth’s PAs

28. Content of youth training • Goals and planned use of survey • Thorough review of exactly what the youth is being asked to do • How to check for self-service displays • Reminder that a “successful” PA is one that is completed, not necessarily one where they buy tobacco

29. The importance of ensuring clerks do not suspect what they are doing • Reminder that they will not be tricking or coercing clerks to sell • Confidentiality as defined by your protocol (particularly with regard to friends who smoke) • Review of safety considerations

30. Role play of various youth scenarios • How to make buys • Types of tobacco to look for • What to do if clerk realizes this is a YPS • What to do if clerk gets angry • What to do if clerk says something racist • What to do if customers speak to the youth • What to do if the youth knows either the clerk or someone in the store

31. Youth who participate must have written permission from parent or guardian • It is best to include parent in training session • Youth should also have a written description of what they will do • Permission should include riding in car with adult associated with YPS

32. Role play various scenarios accompanying adult may encounter • How to make buys (what youth will do) • What adult will do while youth is making PA • Types of tobacco to ask for • What to do if clerk realizes this is a PA • What to do if clerk gets angry • What to do if youth knows clerk or customer in store

33. Familiarize adults with the retail environment • Have example signs and products for them to view before doing actual YPS • Conduct a practice session in an actual store so all aspects of what will be required can be experienced before adult goes out • We usually go to one large and one small store that will not be part of YPS • Discuss problems and possible questions during practice session

34. Importance of safety • Most important task for adult drivers is ensuring youth’s safety • If either adult or youth feels uncomfortable at any time, terminate the PA • Reschedule PA for that store at a later time

35. Should remain on the lookout for • Small or large groups of teens or young adults loitering around the outside or inside a store • Anyone consuming alcohol around or near a store • Police activity (e.g., sirens, police cars) near or around a store

36. Other things to think about • How will money be distributed? • What receipts are necessary and what should be done with leftover funds at the end of the day? • If you go out for longer than 3 or 4 hours, what provisions will you make for snacks, lunch, and so forth, and who will pay for this?

37. “Actual” versus “Attempted” • Although actual buys are more expensive and require immunity from prosecution, they are recommended for three reasons • Clear evidence a sale was completed • No way to say “I was going to ask for ID right before I took the money” • “Attempted” buys require too many judgments • Anger from clerks secondary to increased suspicion

38. Should adult go in store or not? • If present, you will get better data and can better assess safety issues • However, increases suspicion, particularly in small or remote stores • Also increases cost (adult has to buy something) • If you do so, have adult count to 10 before entering store after youth • Have adult stall so youth leaves first—entire sale should be witnessed

39. Many do not have adult enter the store • Decreases suspicion somewhat • Slight increase in risk because adult does not assess • Reduces data obtained because you rely only on youth • Adult could enter after youth, but this also may increase suspicion

40. Standard Protocol • Youth enters store • Goes to counter and asks for tobacco • “May I have a pack of Marlboro please?” • Youth is truthful about age if asked • ID should be left in car so youth can be truthful about not having it • Only “lie” is if clerk asks if the cigarettes are for the youth

41. Have ID Protocol (new recommendation) • Some recent data support the following approach • Youth enters store, goes to counter and asks for cigarettes • Waits for clerk to ask for ID • If clerk does, youth then displays own ID which indicates youth is too young to buy cigarettes • If clerk merely asks age, youth confirms that he/she is old enough to buy cigarettes • Slightly more expensive as you need to provide Ids for youth who do not have them