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At least 516 million packs of cigarettes per year are consumed by minors and at least half of those are illegally sold to minors.1 The average age when people first try smoking a cigarette is 14.5 years, and 88% of persons who have ever tried a cigarette have done so by age 18.2 The average age when people become a daily smoker is 17.7 years; of those who have ever smoked daily, 71% have done so by age 18.2 Few adults initiate tobacco use. Therefore, reducing youth access to tobacco products must be an essential component of any coherent strategy to prevent nicotine addiction in children and youths, and thereby to reduce the number of deaths from smoking-related diseases. In the United States, the law's potential for reducing access and consumption has not been realized. Although selling tobacco to minors is illegal in every state, these laws are widely unenforced. Youths easily acquire tobacco products. Furthermore, the lack of enforcement erodes the efforts of educators, parents, and health professionals to convince youths that they should not use tobacco products: the implied message is that the purpose and intent of the law are not to be taken seriously.

Fortunately, governments at all levels have begun to address the problem of youth access. Last year the Congress passed legislation, the Synar Amendment, that links ongoing program funding to control of youth access to tobacco. In addition, the surgeon general and the secretary of health and human services have focused attention on youth access as it relates to disease prevention and the nation's health objectives for the year 2000. Some states, such as Florida and Vermont, have already taken steps toward meaningful enforcement of their youth access laws.3 Perhaps most important, in a growing number of localities, local governments, concerned citizens, advocacy groups, and health professionals are



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Page 199 At least 516 million packs of cigarettes per year are consumed by minors and at least half of those are illegally sold to minors.1 The average age when people first try smoking a cigarette is 14.5 years, and 88% of persons who have ever tried a cigarette have done so by age 18.2 The average age when people become a daily smoker is 17.7 years; of those who have ever smoked daily, 71% have done so by age 18.2 Few adults initiate tobacco use. Therefore, reducing youth access to tobacco products must be an essential component of any coherent strategy to prevent nicotine addiction in children and youths, and thereby to reduce the number of deaths from smoking-related diseases. In the United States, the law's potential for reducing access and consumption has not been realized. Although selling tobacco to minors is illegal in every state, these laws are widely unenforced. Youths easily acquire tobacco products. Furthermore, the lack of enforcement erodes the efforts of educators, parents, and health professionals to convince youths that they should not use tobacco products: the implied message is that the purpose and intent of the law are not to be taken seriously. Fortunately, governments at all levels have begun to address the problem of youth access. Last year the Congress passed legislation, the Synar Amendment, that links ongoing program funding to control of youth access to tobacco. In addition, the surgeon general and the secretary of health and human services have focused attention on youth access as it relates to disease prevention and the nation's health objectives for the year 2000. Some states, such as Florida and Vermont, have already taken steps toward meaningful enforcement of their youth access laws.3 Perhaps most important, in a growing number of localities, local governments, concerned citizens, advocacy groups, and health professionals are

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Page 200 working together to implement new approaches to reducing youth access, often achieving significant success and providing the rest of the country with valuable insight and models. As the public's attitudes evolve toward a tobacco-free norm, most American citizens, including many tobacco users, widely favor measures to prohibit youth access to tobacco.4 Yet, our national policy is lagging behind this emerging consensus regarding the public health importance of, and need for, meaningful restrictions on children's access to tobacco products. The time for effective action is at hand. We now know enough to design workable, effective legislation to curtail youth access without unduly burdening access to adults. BACKGROUND OF YOUTH ACCESS MEASURES A Brief History of the Emergence of Youth Access Measures The curtailment of sales of tobacco products to minors has a long history in the United States. After the turn of the twentieth century, techniques enabling the mass production of cigarettes and the invention of the portable match contributed to a rapid increase in tobacco consumption. Reformers who associated tobacco use with social problems of the emerging large industrial cities were concerned about tobacco's demoralizing effects on young people. Because of these concerns, many states enacted laws limiting youth access to tobacco. These laws varied widely. Most laws prohibited tobacco sales to persons under 18 or 21, but some statutes did not specify an age. Penalties generally ranged from $0 to $100. Many of these early access laws were more concerned with cigarettes than with other forms of tobacco because the relative mildness of cigarettes was thought to present a special temptation to young people; therefore, lower minimum age limits for purchase, or no limitations at all, were set on the sale of cigars, pipes, and snuff.5 A 1907 judicial decision, which upheld a regulatory distinction between cigarettes and other forms of tobacco, explained: "Before the day of the cigarette, mastery of the tobacco habit was obstructed by agonies of nausea usually sufficient to postpone it to a period of at least reasonable maturity."6 In 1944, another court noted that Tom Sawyer's experience with the "wallop" from a cigar encouraged boys to take up cigarettes instead.7 In part, youth access laws arose out of concerns about the health effects of tobacco use; many people associated tobacco use with heart disease and respiratory ailments. Often, these concerns were moralistic, intertwining the health effects of tobacco with arguments regarding the character of tobacco users.8 In 1937, a federal court found that a local ban on cigarette vending machines was justified to prevent "the evil . . . of the purchase of cigarettes by immature minors."9 Although youth access legislation was adopted throughout the country, it was largely unenforced. The general disregard of these laws may have reflected a national ambivalence about tobacco. The federal government actively supported the tobacco industry, for example by providing free tobacco as a basic

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Page 201 ration to U.S. soldiers. In 1942 Louisiana repealed its law prohibiting tobacco sales to minors because the law was unclear and unenforced. Wisconsin did the same in 1955 on the grounds that unenforced laws engendered disrespect for authority. Several other states rescinded their youth access laws during the 1960s as part of a general overhaul of juvenile codes.10 The approach to tobacco use as a public health issue began during the 1970s, but enforcement of youth access laws was still generally regarded as a low priority. In 1989, the surgeon general's report stated that in marked contrast to the trends in virtually all other areas of smoking control policy, the number of legal restrictions on children's access to tobacco products had actually decreased over the past quarter century. Studies indicated that vendor compliance with minimum-age-of-purchase laws was the exception rather than the rule.11 Likewise, in 1990, the Office of the Inspector General reported that despite youth access laws in 44 states, no state was effectively enforcing its laws.12 National attention turned toward youth access during the late 1980s. Local pockets of successful enforcement of state and local access laws began to develop, resulting from the initiative of local leaders, often in partnership with academic researchers and health advocates. The surgeon general and the secretary of health and human services became interested in the problem, initiating studies and calling for legislative action. Lack of Enforcement Despite increased national interest in curtailing underage smoking, minors still have virtually unimpeded access to tobacco products. Although all states prohibit the sale of tobacco to minors, the inspector general of the Department of Health and Human Services found in 1992 that only two states were enforcing their access laws.13 The secretary of health and human services estimates that three-fourths of the approximately one million tobacco outlets in the United States sell tobacco to minors, garnering over $1 billion in sales each year. 14 The University of Michigan's Monitoring the Future Study in 1993 found that 75% of eighth graders and 89% of tenth graders reported that cigarettes would be fairly easy or very easy to get.15 Nearly all teen smokers have purchased a pack of cigarettes at least once. Most minors who smoke purchase their own cigarettes. In a 1990 survey of ninth grade students, conducted as part of the National Cancer Institute's COMMIT trial, 67% of current smokers (those who had smoked at least once in the past month) reported that they usually bought their own cigarettes. Regular smokers (defined as smoking daily within the past month) were nearly twice as likely as occasional smokers to report buying their own cigarettes.16 In a vending machine industry survey, 72% of teenage smokers reported that they purchased their own cigarettes.17 In the COMMIT survey, 82%  of ninth grade students said that it would be easy for them to obtain cigarettes.18 The accuracy

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Page 202 of this perception has been confirmed in numerous trials designed to measure the prevalence of retail sales of tobacco to minors.19 The surgeon general recently summarized that in 13 studies of over-the-counter sales, the weighted average of the percentage of minors able to purchase tobacco was 67%, ranging from 32% to 87%. In studies including vending machine sales, the weighted average of successful purchase was 88%, ranging from 82% to 100%.20 In general, girls are able to purchase cigarettes more easily than boys.21 The most prevalent sources of cigarettes for underage buyers are small convenience stores and gas stations, followed by larger stores such as supermarkets.22 Among the youngest group of adolescents, vending machines are a popular source.23 RECENT INITIATIVES Local Initiatives Since the late 1980s, communities around the country have shown a strong willingness to take action to limit youth access to tobacco, resulting in substantial progress in designing and enforcing local ordinances and in developing strategies to change merchant practices. These localities now have become models for other localities and serve as sources of information about what is effective. To date, various measures to reduce access have been implemented, including partial bans on vending machines, increased enforcement (including sting operations), merchant education, posting of warning signs, increased penalties, and increased sales prices. In 1992, 52 localities were actively enforcing state or local youth access laws.24 In Minnesota, dozens of communities throughout the state have passed ordinances restricting minors' access to vending machines. Other pockets of enforcement include Minneapolis and White Bear Lake, Minnesota; Leominster and Brookline, Massachussets; King County, Washington; Allentown, Pennsylvania; Layton, Utah; and Marquette County, Michigan. One of the first (and now, the best known) community interventions occurred in Woodridge, Illinois. A systematic three-part program of establishing a retailer licensing system, using regular police stings, and imposing penalties for merchant sales violations reduced illegal sales to minors from 70% to less than 5% over a year and a half. A survey of seventh and eighth grade students before and after the intervention found that experimentation and regular tobacco use had decreased significantly, by over 50%.25 The Woodridge approach was implemented by several neighboring communities, such as Bolingbrook, Illinois, where sales dropped from 90% to 23% after the adoption and active enforcement of a tobacco licensing law. Numerous communities around the country have also used the experience of Woodridge to adopt stronger laws and effective enforcement.26 The community of Santa Clara County, California, experimented with a comprehensive community education program to reduce tobacco sales to minors.

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Page 203 In January 1988, minors between 14 and 16 years of age visited over 400 tobacco outlets to ascertain accessibility of tobacco to minors. The minors were able to buy cigarettes at 74% of the retail stores. In July 1988, after an intensive intervention including community education, direct merchant education, contact with chief executive officers of chains and franchises, and grassroots work with community organizations, the underage buying rate decreased to 39%.27 One year later, sales had rebounded considerably, suggesting that educational interventions alone may be insufficient to effect sustained reductions in youth access rates.28 In four suburban communities in Solano County, California, a comprehensive merchant and community education intervention was conducted from September 1988 through December 1988. In December 1988, after illegal tobacco sales to minors had decreased only slightly, a law enforcement intervention was introduced to supplement the ongoing educational campaign. Underage police cadets visited a total of 90 stores and issued citations to 34% of them. The three police departments involved spent about 8 hours each, including paperwork. In May 1990, illegal sales to minors decreased to 24%.29 Community action at the local and state levels is also increasing because of the National Cancer Institute's 17-state demonstration program called ASSIST—The American Stop Smoking Intervention Study. ASSIST, the largest and most comprehensive public-health-based smoking control project ever undertaken in the United States, was initiated in 1991 for a 7-year period. ASSIST is a coalition-based intervention that strategically uses the media to promote the adoption of tobacco control policies, and thereby to prevent tobacco use and to encourage cessation. ASSIST has made the issues surrounding youth access to tobacco a priority. Drawing upon ASSIST and other models, the Centers for Disease Control and Prevention recently funded non-ASSIST states to increase their capability for local smoking control efforts. The Role of DHHS and the Model Law Youth access to tobacco has aroused the attention of the U.S. Department of Health and Human Services (DHHS), which has taken a strong interest in assessing the problem and in providing information and guidance to state and local governments. In 1989, Dr. Louis Sullivan, then secretary of the DHHS, directed the Office of the Inspector General (OIG) to investigate how effectively states and localities were enforcing their laws prohibiting the sale of cigarettes to minors. In 1990, the OIG interviewed 1,200 health experts, students, parents, and vendors from 18 states and studied communities that were actively enforcing their youth access laws. The resulting report, Youth Access to Cigarettes, found that, despite laws in 45 states restricting sale of tobacco products to minors, state and local officials generally were not enforcing those laws.30 The report suggested that state governments and most communities have not considered en-

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Page 204 forcement of youth access laws sufficiently important to warrant use of limited resources and funds. On the basis of information from the OIG investigation, DHHS developed and distributed widely the ''Model Sale of Tobacco Products to Minors Control Act: A Model Law Recommended for Adoption by States or Localities to Prevent the Sale of Tobacco Products to Minors."31 The model law has the following features: (1) a retailer licensing system similar to the alcohol licensing system; (2) a graduated system of penalties, fines, and suspensions; (3) the required posting of warning signs at points of sale; (4) a designated state agency with primary responsibility for enforcement, supplemented by local efforts; (5) reliance on civil penalties to bypass overburdened court systems, but allowing the use of local courts to assess fines, similar to the traffic system; (6) a legal age of purchase set at 19; and (7) a ban on vending machines. The model law did not address penalties on possession by minors, the earmarking of revenues for enforcement, preemption of local ordinances, or the use of minors in compliance checks ("stings"). The model law attempted to minimize burdens on retailers, and emphasized that youth access can be reduced without significantly disrupting governments or the sales of tobacco to adults. In 1992, the Office of the Secretary of Health and Human Services and the Congressional Subcommittee on Health and the Environment requested that the OIG update its survey of how effectively states and localities were enforcing laws limiting youth access to tobacco. The OIG found that little had changed. While all but three states had banned the sale of tobacco products to youths under 18, most states were not enforcing their laws and were in danger of failing to comply with provisions in the Alcohol, Drug Abuse, and Mental Health Agency Administration (ADAMHA) Reorganization Act requiring the enforcement of youth access laws (see below). Despite the lack of state efforts, the OIG reported, localities were demonstrating that effective enforcement is possible.32 The Synar Amendment and Regulations A provision of the 1992 ADAHMA Reorganization Act (the "Synar Amendment") requires states to adopt laws prohibiting the sale and distribution of tobacco products to minors under age 18, to implement enforcement programs, and to provide annual reports to DHHS demonstrating that they have complied. If states fail to comply, they jeopardize state block grants for substance abuse prevention and treatment programs. States may lose up to 10% of federal funding for alcohol and drug programs in the first year of their failure to comply, 20% in the second year, 30% in the third year, and 40% in fourth and subsequent years. The Synar Amendment did not provide details on how states are to implement the statutory requirements. Specific guidelines that were originally contained in the Synar Amendment, including a ban on free sampling, were dropped.

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Page 205 DHHS was given the responsibility to draft regulations for implementing the statute. During the months between the passage of the Synar Amendment and the release of the draft regulations, the tobacco industry pressed legislators to pass state tobacco control measures favorable to the industry.33 These measures, while appearing to enact access restrictions, actually make them more difficult to enforce, typically by including preemption of local ordinances, weak restrictions on vending machines, prohibitions on youth possession, and prohibitions on youth sting operations unless supervised by sheriffs. Draft regulations were released by DHHS on August 26, 1993. Public comments were solicited and considered in drafting the final rules for implementation of the statute. The following key provisions are included in the draft regulations: (1) The state must conduct annual, random, and targeted unannounced inspections of both over-the-counter and vending machine outlets. Random inspections must be "scientifically sound" in estimating the actual sales to minors. (2) To protect grant funding, states must demonstrate that underage sales rates (based on random inspections) do not exceed 50% in FY 1994, 40% in FY 1995, 30% in FY 1996, and 20% in FY 1997 and subsequent years. (3) The states must implement other "well-designed procedures" for reducing the likelihood or prevalence of violations, such as a tobacco sales licensing system similar to the alcohol licensing system, a graduated schedule of penalties for illegal sales culminating in loss of license, controls on tobacco vending machines, publication of the names of outlets making illegal sales, or use of local enforcement to supplement central enforcement. (4) The states may not use block grant program funds for enforcement activities, but may use block grant administrative funds.34 Comments to the proposed regulations covered three general areas.  First, many focused on the methodology required for estimating sales to minors and therefore for assessing compliance. Some argued for a less demanding standard than "scientifically sound," while others recommended that DHHS prescribe a standard protocol. Second, a related concern was expressed regarding the states' conflict of interest in conducting compliance studies that determine whether they will continue to receive the federal block grant. Finally, attention was addressed to the cost of enforcement and the prohibition against using block grant funds for enforcement activities. Some commentators objected to an unfunded federal mandate. Comments were divided on whether DHHS had overestimated or underestimated the cost of enforcement. THE BENEFITS OF REDUCING ACCESS The Synar Amendment and the National Cancer Institute's ASSIST program signal a genuine commitment of the federal government to the goal of reducing access of tobacco products to minors. Important steps have

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Page 206 already been taken in many states to revitalize the enforcement of longstanding, though moribund, legal access restrictions. Widespread public support for these efforts suggests that they will continue. It would be a mistake to assume, however, that the measures now being undertaken are uncontroversial or that public policy in this area is now settled. Hard questions remain: To what extent should adult purchasers be inconvenienced in the effort to prevent sales to minors? To what extent should efforts to reshape the market accommodate the vested interests of retailers in existing modes of commerce? These questions lead to a practical point: At what cost? How much should be spent by federal, state, and local governments to enforce youth access restrictions? More than nothing, to be sure, but how much more? The answers to these difficult questions will turn in part on an assessment of the benefits of reducing access. For example, as a result of reduced access, will fewer children and adolescents experiment with tobacco products and become dependent on them? Even if underage access to tobacco products in commercial channels is significantly reduced, to what extent will underage consumers still be able to obtain tobacco products through other channels, for example, from older consumers or on a "gray" market? The answers are not definitive at this time, but there are preliminary indications that making it more difficult for minors to purchase tobacco may substantially reduce consumption. In Woodridge, Illinois, 2 years after the passage of successfully enforced youth access legislation, the number of seventh and eighth grade students surveyed who reported having experimented with cigarettes had decreased from a pre-ordinance 46% to 23%. The number of students surveyed who described themselves as smokers had decreased from  16% to 5%.35 In Leominster, Massachusetts, after active law enforcement of local age restrictions on tobacco sales, the number of students who identified themselves as smokers decreased from 22.8% at pre-test to 15.8% at post-test 2 years later.36 A long-term follow-up survey has not yet been conducted to determine if these effects have persisted. Despite this apparent success, caution about the potential effects of limiting access is warranted. Enforcement of youth access laws can be expected to have a significant direct effect on consumption only if, as in Woodridge and Leominster, the commercial accessibility of tobacco to minors is significantly reduced. Furthermore, the reductions in consumption witnessed in Woodridge and Leominster followed enforcement efforts whose intensity may be impossible to achieve in urban settings. The public health experience with restrictions on youth access to alcohol has had mixed results. Progress has been made, especially in reducing traffic fatalities, but alcohol remains widely available to underage youths, both through commercial sources and through parents, siblings, and friends.37 In the University of Michigan's Monitoring the Future Study, findings for 1993 show that 74% of eighth graders and 89% of tenth graders say that alcohol is fairly easy or very easy to get.38

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Page 207 In the long run, the real public health benefit of a reinvigorated youth access policy lies not in its direct effect on consumer choices but rather in its declarative effects—that is, in its capacity to symbolize and reinforce an emerging social norm that disapproves of tobacco use. Legal restrictions often have important educative effects and thereby help to shape attitudes and beliefs.39 They do this best when they are congruent with an emergent social norm accompanied by a strong social consensus, precisely the conditions that now exist in the context of tobacco control. The level of public support for youth access restrictions is high among youths as well as adults and among smokers as well as nonsmokers. This tobacco-free norm can be fostered through carefully coordinated, multidimensional programs as part of an integrated approach, both legal and nonlegal. Conversely, overt failure to implement the youth access restrictions actually undermines the tobacco-free norm; an unenforced restriction is probably worse than no restriction at all. Unenforced laws convey the message that the intent is not to be taken seriously and thereby undermine school and community attempts to educate youth regarding the serious health consequences of tobacco use. In the context of the emerging norm, contradictory messages should no longer be tolerated. Coupled with advertising images that convey the message that tobacco use is desirable, unenforced restrictions on sales to minors contribute to the web of psychosocial influences that lead children to begin using these products. The message should be strong and unequivocal that tobacco use is unhealthful and socially disapproved. Youth access laws are an essential part of that message. DESIGNING A YOUTH ACCESS POLICY Intergovernmental Roles All three levels of government are now involved in the design and implementation of youth access policy. Without a common agenda and a proper allocation of prerogatives, however, the opportunity for a major advance in public health may be squandered. Thus, before outlining the essential elements of a youth access policy, it is important to outline a framework for intergovernmental cooperation. In the present context, the federal role should be threefold: (1) to set the agenda and facilitate state and local efforts to effectuate the national public health goals; (2) to serve as a clearinghouse and resource center for information, models, and technical assistance for implementing access restriction programs; and (3) to use its spending power to induce states to adopt and implement state plans for tobacco control, including specific plans for enforcing access restrictions. In many respects, the Synar Amendment and its implementing regulations represent a valuable exercise of federal authority. The amendment signaled the need for public attention to an important public health issue, heightened the

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Page 208 awareness and interest of state governments, and set goals and standards derived from recent innovations in Woodridge and other localities. Unfortunately, however, several aspects of the Synar approach will be continuing sources of frustration to state and local governments and may ultimately undermine its overall effectiveness. First, the proposed regulations do not allow the states to use the substance abuse prevention and treatment monies to enforce youth access restriction. As a result, because the states need continued federal support for their substance abuse programs, the Synar Amendment becomes equivalent to an unfunded federal mandate—and a costly one if the states take their obligations seriously. Yet the states are given considerable leeway in measuring their own success in reaching the Synar goals (that is, in documenting retailer compliance with youth access restrictions). Thus, a state inclined to cut corners could establish an inadequate system for implementing youth access restrictions without jeopardizing its substance abuse grants. This is a prescription for failure. In the Committee's view, it would be more sensible for Congress to disentangle the Synar mechanism from the substance abuse block grant. Instead, the obligation to enforce youth access restrictions should be tied to eligibility for CDC grants for tobacco control activities, and these grants should include sufficient funds to cover the costs of enforcement during the developmental phase of the new program. In addition, the states should be required to establish a mechanism for independent assessment of retailer compliance with youth access restrictions. The Committee recognizes that the opportunity to receive CDC grants might be ignored by states uninterested in tobacco control. However, the Committee believes that the growing grassroots political support for tobacco control will press otherwise reluctant states to apply for these CDC grants and to satisfy the necessary conditions for funding. The relation between state and local authority is a second source of concern about the potential success of efforts to curtail youth access to tobacco products. The Synar Amendment properly locates ultimate responsibility for enacting and implementing youth access laws at the state level. The proposed regulations also properly allow the states considerable flexibility in allocating responsibility to state and local agencies. Unfortunately, however, enactment of a weak state law could undermine the entire effort if it preempts more aggressive local action. Whereas state governments have not yet proven themselves able to reduce youth access substantially or effectively, given shortages of resources and difficulties of scale, local governments have begun to play an important role. Local communities have implemented innovative programs, many of which have been evaluated by researchers. Local governments may be the best hope for effective enforcement of youth access laws. While state officials may have to be satisfied with moderate reductions in underage sales, local governments need not be. Local communities should be able to address their local health problems by enacting the measures they find necessary and feasible to protect their children. Their willingness to work with researchers and advocates to experiment with

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Page 209 new approaches has produced results that should be shared with communities throughout the nation. Localities should not lose the power to devise solutions with the speed and creativity possible only on the local level. Unfortunately, state legislatures sometimes unwisely preempt local initiatives. With preemption, localities lose their ability to be innovative and to mobilize the community. The communities lose control over their issues, and the tobacco industry gains the advantage at the state level where professional lobbyists enjoy access to state legislatures and where public health groups are not well organized.40 Washington state is an instructive example. During the late 1980s, in response to national attention on the problem of youth access to tobacco, King County, Washington, passed some of the toughest youth access legislation in the country. The ordinance included a ban on free samples and mail-in coupons, restrictions on vending machines, and the requirement that merchants check identification of all customers. The King County Health Department actively enforced the law by educating retailers, using underage youth in "sting" operations, imposing fines on violators, and enlisting the media to increase public pressure on merchants. The underage buying rate, which had been measured at 79% before the law was enacted, plunged to a countywide rate of 7% in May of 1993. The King County program aroused the attention of other Washington counties and was expected to serve as a model for other local ordinances and to give momentum to state health department enforcement efforts. Those expectations were dashed, however, by a preemptive state law enacted in response to the Synar Amendment requirements. The Washington state legislature enacted legislation significantly weaker than the King County ordinances and, more importantly, prohibited localities from passing stricter laws. Those jurisdictions with tough laws already in place were permitted to keep them, but they lost the right to amend them and to use their own inspectors to enforce them. Instead, localities had to rely on the state liquor control board, thought to be understaffed for the task.41 Preemption is not always explicit. Even without specific preempting language, courts sometimes interpret state laws to have been intended by the legislature to be exclusive in the field and therefore to preempt localities from enacting stricter ordinances in that field. Recently, numerous vending machine companies have used this argument in lawsuits that challenge community ordinances on vending machines. In most cases, the courts have upheld the ordinances.42 However, in some cases, communities have found their public health regulation efforts to control vending machines thwarted by interpretations of state laws with weaker provisions. For example, the Maryland Court of Appeals found that, although state laws did not explicitly address the placement of cigarette vending machines, state licensing and taxation of the vending machines preempted local ordinances restricting the location of vending machines.43 Therefore, to protect the perogative of local communities to adopt more restrictive measures, state governments must be explicit regarding their intent not to preempt. In sum, the Committee recommends:

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Page 220 also encourage community organizations to make tobacco access a focus of their activities. A survey of organizations conducting community-based anti-drug and anti-alcohol activities in the United States found that only 26% of responding organizations conduct extensive programs to prevent tobacco use.96 The Committee recommends: 12. The Centers for Disease Control and Prevention, through the Office on Smoking or Health, should provide technical assistance and resources to support states and localities wishing to implement youth access community education programs. Actively Enforce Youth Access Legislation The ultimate success of a youth access strategy lies in providing credible and effective mechanisms for enforcing the law. Community education and merchant education are important, but insufficient to reduce tobacco sales to minors. Active enforcement has been shown to be the most effective means to achieve long-term compliance with youth access restrictions.97 For example, in the King County, Washington, study mentioned above two years after an ordinance was enacted requiring compliance checks of retailers the rate of successful purchase by underage buyers dropped to 7%. In contrast, Seattle (located within King County), which was exempt from inspections, had a sales success rate of 34%.98 As noted above, an enforcement plan should implement a graduated penalty system proportionate to the extent of the violation, beginning with fines for minor violations, and followed by stronger penalties (license suspension, then revocation) for serious and repeated infractions. Retailers should be held strictly liable—and subject to appropriate penalties—for any sale to an underaged purchaser unless the salesperson has taken reasonable steps, such as checking a driver's license, to verify that the purchaser is at least 18. This approach places the incentive on the retailer to seek evidence of majority in all cases involving young purchasers and is therefore preferable to the DHHS model law, and the laws of many states, which only penalize the retailer who "knowingly" sells tobacco to a minor. (Such a high standard of culpability would be appropriate only if the offense were punishable by criminal penalties. As will be explained below, however, criminal sanctions for selling tobacco to minors would be counterproductive and should be avoided.) Penalties should be imposed against the owners of businesses. If clerks are penalized and the fines are not reimbursed by the owners, there is no penalty to the store, and therefore no significant incentive to comply with the law. Owners who have the economic incentive to avoid violations are more likely to establish company-wide policies and to incorporate tobacco law instruction into new employee training. Businesses can teach clerks how to handle pressure from underage persons who want to purchase tobacco. Clerks should not be in the position of having to understand and follow the law without the support of company policies.

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Page 221 Compliance inspections, in the form of police observation, are not adequate to obtain accurate assessments of the law's overall effects. As the primary device for monitoring sales to minors and other violations of youth access legislation, the enforcement plan should utilize teens to conduct purchase attempts. Compliance checks should be conducted by teens at least 16 years old because 16- to 17-year-olds have the highest rates of tobacco use and tobacco purchases; use of younger minors may yield compliance rates that are artificially high. The minors should be representative of the ethnic makeup of the communities where the purchases are attempted. The minors should make no attempt to disguise their age, nor should they lie about their age if asked. An adult observer should be present. A clearly designated enforcement agency is essential to an enforcement plan. Preferably, a single agency would administer the licensing system, collect licensing fees, monitor compliance, and administer civil penalties for violations. As a practical matter, however, it may be more efficient to allocate these responsibilities to existing agencies that already carry out similar duties. Many states currently use police officers, but studies have shown that law enforcement officials often view enforcement of youth access bans as a low priority. Other states, such as Florida, use the resources of the Division of Alcoholic Beverages and Tobacco. Ideally, unless a particular state's regulatory structure makes this infeasible, licensing and enforcement responsibility should be exercised by a public health agency. Public health agencies are likely to be more concerned and responsive.99 Designating a health agency to enforce youth access bans also reinforces the message that youth access is a public health issue. Many retailers have established relationships with health officials in the field, enabling health officials to implement a merchant education program. Historically, the most successful enforcement has occurred on the local level. However, by holding the states responsible for reducing tobacco sales to minors, the Synar Amendment prods the states to establish a centrally administered enforcement mechanism with a clearly designated enforcement agency at the state level. Central direction should not preclude the establishment of local ordinances and enforcement mechanisms or otherwise discourage local efforts. Indeed, the proposed regulations for the implementation of the Synar Amendment recommend the use of local enforcement to supplement centrally administered state enforcement.100 Four states have specifically encouraged and provided resources for local enforcement. California, New Jersey, North Dakota, and Utah currently make funds available to localities to improve enforcement and otherwise take action to reduce sales to minors.101 Also, local health and research institutions should be allowed to participate in the planning, conduct, and evaluation of compliance checks. They have played a vital role in bringing the low level of compliance to public attention and should be encouraged to remain in the field. Moreover, because states have a vested interest in documenting reduced sales to minors, independent inspections can provide an important verification of levels of compliance.

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Page 222 The Committee recommends: 13. Youth access laws should be effectively enforced. An enforcement plan should implement a graduated penalty system proportionate to the extent of the violation, beginning with fines for minor infractions and followed by stronger penalties (suspension, then revocation) for serious and repeated violations. Retailers should be held strictly liable—and subject to appropriate penalties—for any sale to a minor unless the salesperson has taken reasonable steps, including checking a driver's license, to verify that the purchaser is at least 18. Penalties should be imposed against business owners, not against store clerks. As the primary device for monitoring violations of youth access legislation, 16- and 17-year-olds should be utilized to conduct purchase attempts. The underage purchasers should be representative of the ethnic makeup of the community, should make no attempt to disguise their age, and should truthfully disclose their age if asked. An adult observer should be present. A state agency should be clearly designated to enforce the youth access plan. Unless a state's regulatory structure makes it infeasible, the state public health agency should be given responsibility to administer the licensing system, collect fees, monitor compliance, and administer civil penalties for violations. State enforcement plans should maximize local participation. Additional Considerations to Guide Youth Access Legislation Many of the recommendations set forth above aim to increase the likelihood that those charged with enforcing the law will want to enforce it. A rational assumption is that sanctions that are too costly or that are perceived to be unfair or disproportionate to the seriousness of the offense will not be enforced or, if enforced, will be applied erratically and discriminatorily. From this viewpoint, three additional points should be kept in mind. Youth access plans should not impose any legal penalties on youths who are able to obtain tobacco. Imposing penalties on minors for buying, possessing, or using tobacco products is controversial. At least 21 states currently prohibit smoking. and the use of tobacco products by minors. Proponents of these penalties argue that they may have some deterrent value, and that the failure to make possession illegal sends a mixed message, reinforcing the idea that tobacco use is a trivial infraction.102 However, the Committee believes that penalizing minors is an unwise and ineffective strategy. Criminal sanctions or delinquency adjudications are grossly disproportionate to the seriousness of the offense and would not be sought by

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Page 223 prosecutors or imposed by judges. Even if the offense were punishable with a civil fine, like a traffic ticket, the penalty would rarely be enforced. Because lack of enforcement would erode whatever deterrent effect the law might otherwise achieve, the only remaining rationale for such a prohibition is a symbolic one: the failure to make tobacco use an offense would somehow imply that tobacco use is not harmful or that it is socially acceptable. In the Committee's view, such speculative fears are groundless—social disapprobation is (or should be) strongly communicated by the laws on distribution, by warning labels, and by all of the other policies outlined in this report. Young people will not miss the point simply because their disapproved conduct is not against the law. Furthermore, purely symbolic prohibitions—laws that are not meant to be enforced—are harmful because they undermine respect for the law. Finally, imposing legal penalties on the underage purchaser also impedes the use of underage buyers to monitor retailer compliance with youth access restrictions. The need to obtain waivers unnecessarily increases the cost of enforcement. The Committee recommends: 14. Legal penalties should not be imposed on youths who are able to obtain tobacco products; existing legal penalties on minors should be repealed. Youth access plans should not impose criminal penalties on licensees who sell tobacco to minors. Studies have shown that imposing criminal penalties on licensees who sell tobacco products to minors is not the best approach. First, enforcement is likely to be less effective. The criminal justice system is already overburdened and violations are unlikely to be treated as a priority. The public has been less supportive of criminal penalties, seeing them as being too harsh and diverting much-needed police attention.103 Judges also tend to be unwilling to impose criminal penalties.104 Administrative processing of civil penalties is less time-consuming and less costly. Efficient and credible enforcement of civil penalties and license revocation is a much more powerful deterrent than sporadically imposed criminal sanctions. The Committee recommends: 15. Criminal penalties should not be imposed on licensees who sell tobacco to minors. Rather, appropriate civil penalties, including fines and tobacco license suspension or revocation, should be prescribed and enforced. Youth access plans should not set excessively high age limits. The presumptive age of adulthood in our society is 18. Exceptions have been made when compelling reasons arise. Teenagers younger than 18 are en-

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Page 224 titled to make their own medical decisions, reflecting constitutional respect for adolescent autonomy; but the minimum age for purchasing alcohol has been set at age 21, reflecting the government's compelling interest in reducing alcohol-related injuries and deaths on the nation's highways. In the present context, the Committee thinks that the presumptive age of adulthood should govern. From a public health standpoint, the primary focus of prevention is to reduce initiation by younger adolescents. The main argument for an age higher than 18 is to minimize spillover access to 16- to 17-year-olds; however, the Committee does not think that this argument is strong enough to overcome the presumptive case for an 18-year-old minimum age of purchase. Moreover, an unduly high age limit will be selectively ignored by retailers, thereby undermining respect for, and compliance with, the youth access ban. Although the model law recommends a minimum purchase age of 19, most states have wisely set the minimum age at 18, and the Synar Amendment also draws the line at 18.105 The Committee recommends: 16. Youth access plans should not set excessively high age limits; states should set the minimum age of purchase at age 18. SUGGESTIONS FOR ADDITIONAL POLICY INITIATIVES AND RESEARCH Further Initiatives Limiting the number of licensed outlets for tobacco purchases would facilitate more efficient monitoring of retailer compliance with restrictions on purchases by minors and on other restrictions on tobacco sales and promotion. Regulatory experience with alcoholic beverages also suggests that the overall level of consumption is affected by the number and density of outlets.106 However, because a substantial reduction in the number of outlets will inevitably curtail access of adults to tobacco products, such a strategy is not likely to be given serious consideration unless and until this country is ready to take the next major step on the road to a nation free of tobacco-related disease and death. Eventually, tobacco products should be available only through liquor stores or some equivalently restricted channel of distribution. In the meantime, however, two steps in the direction of outlet control would have special symbolic importance: banning tobacco sales within a prescribed distance of schools and banning sales in pharmacies would help to reinforce the changing normative climate toward tobacco use by young people. Tobacco-Free Zones Near Schools Convenient availability of tobacco products to children and youths has sent them mixed messages and has undermined health promotion efforts by schools

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Page 225 and other youth leaders. A sound access policy should fortify the work of educators by eliminating the sale and promotion of tobacco within a reasonable distance of schools, one of the most important environments in a youth's life. Although the nature of such a ban is largely symbolic, removing tobacco sales from the immediate vicinity of schools might make it more difficult for students to obtain tobacco products during school breaks. Bans on Pharmacy Sales Eliminating the sale of tobacco products in pharmacies would send a strong message to youths that tobacco products are incompatible with health. This approach has begun to gain support. A coalition consisting of the Michigan Pharmacists' Association, the Michigan Academy of Family Physicians, Lederle Laboratories, and the Michigan Department of Public Health recently launched the ''Tobacco-Free Pharmacy" campaign, which discourages pharmacists from selling tobacco and enlists their help in providing support and cessation counseling to their customers. As of October 1993, more than 60 pharmacies were participating in the program.107 In Canada, health advocates have also had some success in convincing a number of pharmacies to stop selling tobacco and have lobbied colleges of pharmacy to preclude the sale of tobacco products in their ethical codes. The province of Ontario is considering legislation that would prohibit tobacco sales in pharmacies. The Committee recommends: 17. States and localities should adopt long-term strategies for reducing the number of outlets licensed to sell tobacco products. Initial steps should include creation of tobacco-free zones around schools and bans of tobacco sales in pharmacies. Restrict Mail-Order Distribution Like the in-person distribution of tobacco samples, youth access through the distribution of tobacco products by mail cannot be meaningfully monitored. Signed statements that a purchaser meets the minimum age of purchase are not verifiable. The extent of mail-order purchase of tobacco products by minors is not known; however, it may be expected to become more prevalent as retail outlet sales to minors decrease. Recently, a survey of 12- to 17-year-olds found that 7.6% of the respondents were on tobacco company mailing lists.108 The mailing lists, which furnish their recipients with coupons, samples, and promotional items, suggest that mail-order sales are a potential conduit between tobacco companies and youths. In a survey of ninth graders in Erie County, New York, 24% of the daily smokers reported having received free packs of cigarettes in the mail.109

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Page 226 Distribution of tobacco products through the mail raises complex regulatory questions. Although this type of distribution can undermine youth access restrictions, it provides a convenient method of promoting and distributing tobacco products (especially cigars and pipe tobacco) to adults. Moreover, mail-order distribution of alcohol and pornography illustrates that there is no regulatory precedent for sealing the gap in youth access restrictions created by mail-order purchases. The Committee recommends: 18. As part of a long-term access strategy, Congress should enact a suitably limited federal ban on the distribution of tobacco products through the mail. At a minimum, the law should bar free distribution, as well as redemption of tobacco coupons, a promotional activity likely to be particularly attractive to children and youths. The Committee has focused its attention here on coupons redeemable by mail for cigarettes because of the possibility that this practice will increase as retail outlets dry up. It should be noted, however, that coupons are usually redeemed at retail for tobacco products, and that retailer compliance with youth access restrictions can be monitored and enforced regardless of whether the distribution involves a coupon redemption or a cash purchase. By contrast, redemption of coupons through the mail typically involves promotional items such as t-shirts and other articles. These promotional practices do not undermine youth access restrictions, although they may be objectionable on other grounds. The Committee notes, finally, that coupons and other types of direct price competition raise issues that go far beyond youth access policy because they can attenuate the consumption-reducing effects of a pricing policy. However, these practices are unavoidable in a competitive market and could be eliminated only under a very aggressive scheme of price regulation. In the analogous context of alcoholic beverage control regulation, the trend has been to loosen or remove these bans, and liquor couponing is now legal in most states. Additional Research Needed Innovations in youth access policy have been based on successful initiatives in a few localities. Little is known about the long-term effects of these initiatives or about their extension to more densely populated areas. It is therefore important to include in the programs now being developed in response to the Synar Amendment a component for evaluation research. In addition, the Centers for Disease Control and Prevention and other research sponsors should put in place ongoing information systems regarding the operation of the tobacco market in relation to youth access, especially as the market responds to restrictions on distribution in legal channels of commerce. The Committee recommends:

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Page 227 19. Sponsors of research should support (a) studies of retailers' motivation for compliance or noncompliance; (b) studies of the cost-effectiveness of various enforcement approaches being developed in response to the Synar Amendment; and (c) most important, a surveillance system  for monitoring the tobacco market in order to ascertain the sources (and cost) of tobacco products to youths, in both legal and illicit commerce. REFERENCES 1. Cummings, K. Michael, Terry Pechacek, and Donald Shopland. "The Illegal Sale of Cigarettes to U.S. Minors: Estimates by State." American Journal of Public Health 84:2 (1994): 300-302. 2. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People. A Report of the Surgeon General. S/N 0017-001-00491-0. Washington, DC: U.S. Government Printing Office, 1994. 67. 3. Office of the Inspector General. Youth Access to Tobacco. Department of Health and Human Services. OEI-02-92-00880. December 1992. 4. Marttila & Kiley, Inc. Highlights from an American Cancer Society Survey of U.S. Voter Attitudes Toward Cigarette Smoking. Boston: Sept. 1993. 5. Hawkins, Charles H. "Legal Restrictions on Minors' Smoking." American Journal of Public Health 54:10(1964): 1741-44. 6. Goodrich v. State. 133 Wis 242, 113 N.W. 388, 1907. 7. State v. Crabtree. 218 Minn. 36, 15 N.W. 2d 98, 1944. 8. Brandt, Allan M. "The Cigarette, Risk, and American Culture." Daedalus 119:4 (1990): 155176. 9. Illinois Cigarette Service Co. v. City of Chicago. 89 F. 2d 610 (7th Circuit), 1937. 10. Hawkins. 11. Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Publication No. (CDC) 89-8411, 1989. 593. 12. Office of the Inspector General. Youth Access to Cigarettes. Department of Health and Human Services. OEI-02-90-02310. May 1990. 13. OIG, 1992. 14. U.S. Department of Health and Human Services. "Model Sale of Tobacco Products to Minors Control Act: A Model Law Recommended for Adoption by States or Localities to Prevent the Sale of Tobacco Products to Minors." May 24, 1990; and DiFranza, Joseph R., and Joe B. Tye. "Who Profits From Tobacco Sales to Children?" Journal of the American Medical Association 263:20 (1990): 2784-2787. 15. Johnston, L., J. Bachman, and P. O'Malley. "Monitoring the Future Study." Press release. The University of Michigan, Ann Arbor. January 27, 1994. 16. Cummings, K. Michael, Eva Sciandra, Terry F. Pechacek, Mario Orlandi, and William R. Lynn. For the COMMIT Research Group. "Where Teenagers Get Their Cigarettes: A Survey of the Purchasing Habits of 13-16 Year Olds in 12 U.S. Communities." Tobacco Control 1 (1992): 264267. 17. Response Research, Inc. Study of Teenage Cigarette Smoking and Purchase Behavior. For the National Automatic Merchandising Association. Chicago: June/July 1989. 18. Cummings et al., 1992. 19. See for example: DiFranza, Joseph R., Billy D. Norwood, Donald W. Garner, and J. B. Tye. "Legislative Efforts to Protect Children from Tobacco." Journal of the American Medical Association 257:24 (1987): 3387-3389; DiFranza, Joseph R., Robert R. Carlson, and Ralph E. Caisse, Jr. "Reducing Youth Access to Tobacco." Tobacco Control. Letter to the Editor 1 (1992): 58; Centers for Disease Control and Prevention. "Accessability of Cigarettes to Youths Aged 12-17 Years-

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Page 228 United States, 1989." Morbidity and Mortality Weekly Report 41:27 (1992): 485-488; Hoppock. Kevin C., and Thomas P. Houston. "Availability of Tobacco Products to Minors." Journal of Family Practice 30:2 (1990): 174-176; Altman, David G., Valodi Foster, Lolly Rasenick-Douss, and Joe B. Tye. "Reducing the Illegal Sale of Cigarette to Minors." Journal of the American Medical Association 261:1 (1989): 80-83: Forster, Jean L., Mary E. Hourigan, and Paul McGovern. "Availability of Cigarettes to Underage Youth in Three Communities." Preventive Medicine 21:3 (1992): 320-328; and OIG, 1990. 20. Centers for Disease Control and Prevention, 1994. 249. 21. Altman et al., 1989; and Forster et al., "Availability," 1992. 22. Cummings et al., 1992, and Response Research. 23. Response Research. 24. OIG, 1992. 25. Jason, Leonard A., Peter Y. Ji, Michael D. Anes, and Scott H. Birkhead. "Active Enforcement of Cigarette Control Laws in the Prevention of Cigarette Sales to Minors." Journal of the American Medical Association 266:22 (11 Dec. 1991): 3159-3161. 26. Altman, David, Julia Carol, Christine Chalkley, Joe Cherner, Joseph DiFranza, Ellen Feighery, Jean Forster, Sunil Gupta, John Records, John Slade, Bruce Talbot, and Joe Tye. "Report of the Tobacco Policy Research Study Group on Access to Tobacco Products in the United States." Tobacco Control 1 (1992): S45-S51. 27. Altman et al., 1989. 28. Altman, D. G., L. Rasenick-Douss, V. Foster, and J. B. Tye. "Sustained Effects of an Educational Program to Reduce Sales of Cigarettes to Minors." American Journal of Public Health 81:7 (1991): 891-893. 29. Feighery, Ellen, David G. Altman, and Gregory Shaffer. "The Effects of Combining Education and Enforcement to Reduce Tobacco Sales to Minors: A Study of Four Northern California Communities." Journal of the American Medical Association 266 (1991): 3168-3171. 30. OIG, 1990. 31. USDHHS, 1990. 32. OIG, 1992. 33. Weisskopf, Michael. "Hill Bid to Curb Youth Tobacco Sales Falters." The Washington Post (10 July 1993): A10. 34. U.S. Department of Health and Human Services. "Substance Abuse Prevention and Treatment Block Grants." 45 CFR Part 96. Federal Register 58:164 (26 Aug. 1993): 45156-45174. 35. Jason et al. 36. DiFranza et al., 1992. 37. Wagenaar, Alexander C., John R. Finnegan, Mark Wolfson, Pamela S. Anstine, Carolyn L. Williams, and Cheryl L. Perry. "Where and How Adolescents Obtain Alcoholic Beverages." Public Health Reports 108:4 (July 1993): 459-464. 38. Johnston et al. 39. Bonnie, Richard J. "Discouraging the Use of Alcohol, Tobacco and Other Drugs: The Effects of Legal Controls and Restrictions." In Nancy Mello, ed. Advances in Substance Abuse Research, Vol. II. JAI Press, 1982. 145-184; and "The Efficacy of Law as a Paternalistic Instrument." In Gary Melton, ed. Nebraska Symposium on Human Motivation, 1985. Lincoln: University of Nebraska. 1986. 131-211. 40. Weisskopf. 41. Jaffe, Robert D.. and Helene Starks. "Reducing Illegal Tobacco Sales to Minors." Unpublished manuscript on a 4-year evaluation in King County, by Washington DOC, 1993. 42. See for example: CIC Corp. v. Township of New Brunswick. 628 A.2d 753 (N.J. Super. Ct. App. Div.), 1993; Bravo Vending v. City of Rancho Mirage. 16 Calif App. 4th 383 (4th Dis.), 1993; and Take Five Vending v. Town of Provincetown. 615 N.E. 2d 576 (Mass.), 1993 43. Allied Vending, Inc. v. City of Bowie. 631 A.2d 77 (Md.), 1993.

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Page 229 44. USDHHS, 1990. 45. OIG, 1990. 46. Jason et al. 47. Altman et al., "Report," 1992. 48. Cummings et al., 1994; and DiFranza and Tye, 1990. 49. Altman et al., "Report," 1992. 50. Jason et al. 51. Response Research. 52. Cummings et al., 1992. 53. Response Research. 54. Cismoski, Joseph. Fond du Lac School District Survey. Addendum to the Michigan Alcohol and Drug Survey. Kercher Center for Social Research, Western Michigan University. Kalamazoo, MI: January 1994 (unpublished). 55. Altman et al., "Report," 1992. 56. Altman et al., 1989. 57. Forster et al.. "Availability," 1992. 58. Marttila & Kiley, Inc. 59. OIG, 1992. 60. Feighery et al. 61. Forster, Jean L., Mary E. Hourigan, and S. Kelder. "Locking Devices on Cigarette Vending Machines: Evaluation of a City Ordinance." American Journal of Public Health 82:9 (1992): 12171219. 62. Ibid. 63. USDHHS, "Model Sale," 1990. 64. Forster et al., "Availability," 1992. 65. Cismoski, Joseph, and Marian Sheridan. "Availability of Cigarettes to Under-age Youth in Fond du Lac, Wisconsin." Wisconsin Medical Journal (Nov. 1993): 626-630. 66. Wakefield, Melanie, John Carrangis, David Wilson, and Christopher Reynolds. "Illegal Cigarette Sales to Children in South Australia." Tobacco Control 1 (1992): 114-117. 67. STAT. "Springfield Teen Tobacco Purchase Survey." News Release. November 11, 1993. 68. Response Research. 69. Cox, Dena, Anthony D. Cox, and George P. Moschis. "When Consumer Behavior Goes Bad: An Investigation of Adolescent Shoplifting." Journal of Consumer Research 17:2 (1990): 149-159. 70. Roswell Park Cancer Institute. Survey of Alcohol, Tobacco and Drug Use: Ninth Grade Students in Erie County, 1992. Buffalo, NY: Roswell Park Cancer Institute, Department of Cancer Control and Epidemiology, 1993. 71. Cismoski, 1994. 72. Cigarette Labeling and Advertising Act. P.L. No. 98-474, 98 Stat. 2201 (12 Oct. 1984) codified at 15 U.S.C. 1333 (a) (1986). 73. Klonoff, Elizabeth A., Jan M. Fritz, Hope Landrine, Richard W. Riddle, and Laurie Tully-Payne. "The Problem and Sociocultural Context of Single-Cigarette Sales." Journal of the American Medical Association 271:8 (23 Feb. 1994): 618-620. 74. Figures have been adjusted for inflation. Federal Trade Commission. Federal Trade Commission Report to Congress for 1991. Pursuant to the Federal Cigarette Labeling and Advertising Act. Washington, DC: Federal Trade Commission, 1994. 75. Davis, Ronald M., and Leonard A. Jason. "The Distribution of Free Cigarette Samples to Minors." American Journal of Preventive Medicine 4:1 (1988): 21-26. 76. Ibid. 77. Ibid. 78. Ibid. 79. Ibid.

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Page 230 80. Martilla & Kiley. 81. Davis and Jason. 82. Keay, Karen D., Susan I. Woodruff, Marianne B. Wildey, and Erin M. Kenney. "Effects of a Retailer Intervention on Cigarette Sales to Minors in San Diego County, California." Tobacco Control 2 (1993): 145-151. See also: Altman et al., 1991: and Feighery et al. 83. DiFranza et al., 1987. 84. Keay et al., and Altman et al., 1989. 85. Keay et al. 86. Feighery et al. 87. Keay et al. 88. Altman, David G., Juliette Linzer, Rick Kropp, Nancy Descheemaeker, Ellen Feighery, and Stephen P. Fortmann. "Policy Alternatives for Reducing Tobacco Sales to Minors: Results from a National Survey of Retail Chain and Franchise Stores." Journal of Public Health Policy 13:3 (1992): 318-331. 89. Keay et al. 90. Keay et al. 91. Feighery et al. 92. Jason et al. 93. Keay et al. 94. Biglan, Anthony, Jamye Henderson, Delaine Humphreys, Maija Yasui, Rebecca Whisman, Carol Black, and Lisa James. "Experimental Evaluation of a Community Intervention to Reduce Youth Access to Tobacco." Oregon Research Institute, 1993. Unpublished. 95. Feighery et al. 96. Join Together. Community Leaders Speak Out Against Substance Abuse. Boston: Join Together, 1993. 26. 97. Skretny, Michelle T., K. Michael Cummings, Russell Sciandra, and James Marshall. "An Intervention to Reduce the Sale of Cigarettes to Minors." New York State Journal of Medicine 90:2 (1990): 54-55. See also: Altman et al., 1991; Feighery et al.; and OIG, 1992. 98. Jaffe and Starks. 99. Chudy, N., R. Yoast, and P. Remington. "Child and Adolescent Smoking and Consumption." Wisconsin Medical Journal (Apr. 1993): 198-201. See also: Feighery et al.; and OIG, 1992. 100. USDHHS, "Substance Abuse," 1993. 101. OIG, 1992. 102. Jason et al., and DiFranza et al., 1987. 103. OIG, 1992. 104. Feighery et al. 105. USDHHS, "Substance Abuse," 1993. 106. Gruenewald, Paul J., William R. Ponicki, and Harold D. Holder. "The Relationship of Outlet Densities to Alcohol Consumption: A Time Series Cross-Sectional Analysis." Alcoholism: Clinical and Experimental Research 17:1 (Feb. 1993): 38-47. 107. U.S. Department of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives Update. Department of Health and Human Services. October/November 1993. 108. Slade, John. "Teenagers Participate in Tobacco Promotions." Abstract. Submitted to the 9th World Conference on Tobacco and Health (Paris), October 1994. 109. Roswell Park.