Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products (2015)

6

Evidence on the Effects of Youth Access Restrictions

Ultimately, the salient policy question concerning the minimum age of legal access to tobacco products (MLA) is whether and to what extent raising the MLA would reduce underage tobacco use. Although several U.S. localities have raised the MLA to 19 and 21 years, most of these actions have been done only very recently, and to date none has been systematically evaluated.¹ Furthermore, there have been only a handful of natural experiments in which the MLA for tobacco has been raised to 16 or 18, and they have taken place in other countries. Indeed, most of the relevant literature pertains not to raising the MLA but rather to enforcing an existing MLA more stringently. Therefore, conclusions about raising the MLA to ages higher than 18 must be extrapolated from review of other evidence on MLA laws and their enforcement as well as from analogous policy interventions.

To address the question whether and to what extent raising the MLA would reduce underage tobacco use, this chapter first reviews the limited international studies investigating the effect of raising the MLA for tobacco and then reviews evidence relating to the effects of raising the minimum legal drinking age for alcohol as an analogous policy intervention in a parallel domain. The remainder of the chapter reviews the body of literature

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¹ Although Needham, Massachusetts, the first jurisdiction in the United States to raise the MLA to 21, has been cited as having seen significant declines in tobacco use and tobacco-related disease, there are no published data on these outcomes. In addition, the little available data that exist (EDC, 2010a,b; NPHD, 2008, 2012) have no baseline measurements and are confounded by the presence of other tobacco control measures that occurred in the town and throughout the state of Massachusetts at the same time the MLA was increased.

investigating the effects of enforcing current youth access restrictions in the United States. Although these studies are beset by many challenges and limitations, they enabled the committee to reach some general conclusions about the nature and direction of the effects of enacting and enforcing a tobacco MLA, even though they do not provide a basis for estimating the precise magnitude of such effects. As an aid to interpreting this body of research, the committee developed a logic model identifying the behavioral mechanisms through which an MLA policy and its enforcement against commercial retailers would be expected to affect underage tobacco use. The committee believes that this body of scientific literature provides a reasonable predicate for policy making in the absence of direct evidence regarding the effectiveness of raising the MLA. It is used in Chapter 7 to inform the committee’s judgment about the probable effects of raising the MLA on the initiation of tobacco use by underage youth.

THE IMPACT OF ENACTING OR RAISING THE MINIMUM LEGAL AGE TO PURCHASE TOBACCO PRODUCTS

Only a small number of studies have examined the effects of enacting or raising an MLA on underage tobacco use. All of these studies have come from international experience: one from Finland (Rimpela and Rainio, 2004) and two from the United Kingdom (Fidler and West, 2010; Millett et al., 2011).² All of the studies that investigated the effect of the policy on tobacco use reported decreases in underage smoking prevalence.

Rimpela and Rainio (2004) examined the effect in Finland of enacting an MLA of 16 in 1977 and increasing it to 18 in 1995. Adolescent tobacco outcomes were assessed using a biennial, nationally representative postal survey of adolescents (ages 12, 14, 16, and 18) for 1977–2003 as well as an annual postal survey of eighth and ninth graders (ages 14–16) for 1996–2003. Following implementation of the original MLA legislation in 1977, there was a significant—but small and short-term—decrease both in tobacco purchases from commercial sources and in tobacco use. After the MLA increased to 18 in 1995, there was no immediate effect on tobacco use. However, after a 2000 revision of the MLA policy requiring tobacco retailers to develop and implement an enforcement plan to prevent sales to underage persons, experimental smoking and later daily smoking decreased significantly among adolescents ages 14 and 16 (i.e.,

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² Another small qualitative study (Borland and Amos, 2009) examined attitudes about raising the MLA from 16 to 18 in Scotland among 16- to 17-year-old regular smokers who had dropped out of high school and were attending a work skills program. However, given the small sample size and sample characteristics, these findings are likely not generalizable to larger or different populations. This study also provides no findings on the effect of raising the MLA on either reducing sales to adolescents or reducing underage tobacco use.

those targeted by the policy). Only experimental smoking decreased among 12-year-old adolescents, but the sample was too small for the daily smoking category. There was no change in either experimental or daily smoking observed among those ages 18 and older (i.e., those not targeted by the policy). In addition, Rimpela and Rainio (2004) found that purchases from commercial sources decreased, while obtaining tobacco from social sources (i.e., purchasing or being given tobacco from relatives, friends, or strangers) increased. Consistent with that finding, the frequency with which 18-year-olds, of legal age, also reported purchasing tobacco for friends was greater in 1999 than it had been in the 1970s. There were also changes in perceived access to tobacco: The proportion of adolescents reporting that it was rather difficult or very difficult to purchase tobacco was higher after the MLA increase, but the proportion of students reporting that it was very easy or fairly easy to purchase tobacco from commercial sources nevertheless remained high (72 percent in 2002–2003). In sum, these findings suggest that, among adolescents, raising the MLA decreased the amount of tobacco available from commercial sources, increased difficulty of obtaining tobacco, and reduced tobacco use despite adolescents having continued access to social sources.

Fidler and West (2010) assessed the effects on smoking prevalence of an increase in MLA from 16 to 18 in 2007 in England and Wales. Smoking outcomes were assessed using data from monthly cross-sectional household surveys of a representative sample of adults ages 16 and older. Following the 2007 increase in the MLA, smoking prevalence decreased significantly among all ages. This decline occurred against the background of a larger societal trend of an overall decrease in smoking prevalence, but the greatest percentage decrease during this period was seen among those of ages 16–17 (a 7.1 percent decrease) compared to those 18 and older (2.4 percent decrease), suggesting that raising the MLA did indeed decrease smoking prevalence beyond secular trends. Moreover, smoking prevalence was significantly higher among those 18 and over, and this difference in prevalence by age was significantly greater after the MLA increase than it had been before, suggesting that the MLA increase was successful in at least delaying initiation.

Millett and colleagues (2011) examined the effects of the same 2007 legislation that Fidler and West studied, but they looked at it in England, Scotland, and Wales, among younger ages (11–15) and by socioeconomic status (SES). Smoking outcomes were assessed using data from a national school-based survey of students in grades 7 to 11 from 2003 to 2008, excluding 2007, the year of the MLA increase. The effect of the policy on socioeconomic smoking disparities was assessed by comparing students who were eligible for free school meals (a proxy measure for low SES because eligibility for free school meals is assessed using parental employment

and income) with those not eligible. The study found that the MLA increase was associated with a significant reduction in regular smoking among all adolescents, with no differences found between those eligible and ineligible for free school meals. The study also assessed the effects of raising the MLA on perceived access to tobacco from retailers. After the MLA increase, the proportion of students who smoked regularly and perceived that purchasing cigarettes from a shop was difficult did not increase among those eligible for free school meals, but it did increase significantly among those not eligible. At the same time, the percentage of students reporting that purchasing cigarettes from a shop was easy did not change from before the MLA increase to afterwards. These findings suggest that increasing the MLA decreased tobacco use overall and that the decrease was neutral with respect to SES.

LESSONS FROM ALCOHOL

Given the paucity of directly relevant data from prior experience with raising the minimum age for tobacco, the committee recognized the opportunity to look at similar domains, most obviously alcohol, to see what lessons might be learned. The United States had direct experience with raising the minimum legal drinking age (MLDA) for alcohol from roughly 18 (with some variation across states) to a national standard of 21 years of age, and that experience came recently enough that the country has not changed dramatically in the interim but long enough ago for there to be an extensive literature evaluating its consequences. Furthermore, different states implemented the change at different times, resulting in a stronger basis for causal inference than if all had acted simultaneously.

Tobacco is, of course, different from alcohol in myriad ways. Tobacco products are psychoactive, but they are not intoxicants. Alcohol has been embedded within human culture for millennia, whereas modern, mass-produced tobacco products (namely, cigarettes) are, comparatively speaking, a relatively recent phenomenon. And, of course, the mechanism of consumption, the neural pathways triggered, the patterns of use and cessation, and various other specific details differ in a variety of ways. So one could hardly observe a point estimate of the reduction in alcohol use following the raising of the MLDA for alcohol and imagine that same number would necessarily be a best estimate for the corresponding reduction one might expect from increasing the MLA for tobacco products.

Nevertheless, there are obvious similarities between the two products, their legal status, and their industries’ practices. Both are dependence-inducing substances that are legal for adults but subject to legal and social constraints on underage use. Both are relatively inexpensive and widely used by both adults and underage users. Both cause very large numbers of premature deaths. Both are marketed aggressively by industries that have,

at least in some product classes, a high degree of market concentration. (Beer and cigarettes have higher degrees of market concentration than do wine or cigars.³) And, as is being considered with tobacco, the MLDA for alcohol was increased to 21—not to other ages and, particularly, not to higher ages.

In brief, the experience with raising the MLDA for alcohol is highly suggestive with respect to the prospects that raising the MLA for tobacco will appreciably reduce smoking rates. Kypri et al. (2006, p. 126) go so far as to say, “No traffic safety policy, with the possible exception of motorcycle safety helmet laws, has more evidence for its effectiveness than do the minimum legal drinking age laws.”

Of course, underage drinking still occurs, and it seems clear that if the MLA for tobacco is increased, there will still be some tobacco use by those under the legal age. Indeed, it would be unreasonable to expect that raising the MLA could completely eliminate all underage use. However, if the question is simply whether raising the MLA will noticeably reduce the use and use-related harms of tobacco among youth, then the academic literature evaluating the alcohol experience indicates that there will indeed be substantial benefits (e.g., Dejong and Blanchette, 2014; McCartt et al., 2010; Wagenaar and Toomey, 2002).

It is worth briefly mentioning the historical context. Following the repeal of national alcohol prohibition in 1933, MLDAs were set by the states, typically at 21. In the early 1970s, 29 states lowered their MLDAs to 18, 19, or 20. In response to increasing highway traffic fatalities, some states reversed course, and then in 1984 Congress passed the National Minimum Drinking Age Act (NMDAA). The NMDAA does not prescribe an MLDA of 21. Rather it encourages states to raise their MLDA to 21 by withholding a percentage of federal highway dollars if they fail to do so. By 1988 all states and the District of Columbia had an MLDA of 21.

By some measures, alcohol MLDAs are enforced fairly aggressively. For example, it is common for mere possession of alcohol to be an offense (known as a “minor in possession”). The severity of sanction for such offenses varies by state but can include fines and the loss of one’s driver’s license. Likewise, social host ordinances can lead to severe penalties for other individuals (not just businesses) who provide alcohol to underage drinkers. On the other hand, in many states parents are allowed to provide alcohol to their children. So comparisons between the intensity of the enforcement of alcohol MLDAs and the intensity of enforcement of either

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³ The Centers for Disease Control and Prevention reports that the market share of the dominant cigar firms is mostly below 20 percent even for specific types of cigars, and different firms dominate those different segments, whereas three companies control nearly 85 percent of the cigarette market (CDC, 2014a).

current or potential future tobacco MLAs are not straightforward, but on the whole, the severity of sanctions for the alcohol equivalent of purchase–use–possession (PUP) laws for tobacco may be greater than what might be contemplated under at least some scenarios involving raising the MLA for tobacco products.

The literature evaluating the effects of changing the MLDA for alcohol is large. DeJong and Blanchette (2014), McCartt et al. (2010), and Wagenaar and Toomey (2002) offer useful reviews. The trends that are observed in aggregate descriptive statistics are consistent with the idea that raising the MLDA has an effect on alcohol use. Specifically, the rates of drinking and binge drinking among those under 21 have been in sustained long-term decline since the MLA was raised, the death rates of 18- to 20-year-olds in nighttime driving accidents have fallen, and the rates of problem alcohol use are lower in the United States than they are in Europe, where drinking ages are lower. However, such correlations could be coincidental. The more persuasive comparisons involve looking at neighboring birth cohorts who reached an MLDA just before versus after the MLDA changed and looking at patterns of use by people who are just a little younger versus just a little older than a given MLDA (Carpenter and Dobkin, 2011). For example, the rates of binge drinking are appreciably higher for 21-year-olds than for 20-year-olds (SAMHSA, 2009).

A number of these studies have found that raising the MLDA for alcohol reduced consumption and consumption-related harms, with the estimate of nearly 1,000 premature deaths prevented per year being a typical number. Other studies have found no statistically significant effect (perhaps from a lack of statistical power), and a few outliers have found that consumption increased. For example, Wagenaar and Toomey (2002) reported that of 33 high-quality empirical analyses for which consumption was the outcome measure, 11 found that raising the MLDA decreased consumption, and only one found the opposite. The proportion of studies finding a favorable effect on traffic crashes was even greater (DeJong and Blanchette, 2014). An illustrative study, conducted by Shults et al. (2001), found that raising the MLDA reduced fatal and nonfatal crashes by 16 percent. Other studies identified less obvious outcomes. For example, Birckmayer and Hemenway (1999) estimated that raising the MLDA reduces teen suicide and, conversely, that lowering it from 21 back to 18 could lead to approximately 125 additional suicides per year among 18- to 20-year-olds.

DeJong and Blanchette’s (2014) review includes international comparisons. Notably, New Zealand reduced its MLDA from 20 to 18 in 1999, and Huckle and Parker (2014) and Kypri et al. (2006) reported that this led to significantly more alcohol-related crashes among 15- to 19-year-olds. Conover and Scrimgeour (2013) found similar effects on alcohol-related hospitalizations among those newly eligible to purchase alcohol. Interna-

tional studies on the direct effect of MLDA on alcohol consumption come to comparable conclusions. The 2004 report by the National Academies on underage drinking (IOM and NRC, 2004) found that lower drinking ages in European countries were associated with higher rates of drinking, problem drinking, and drinking by underage individuals, despite common conceptions that underage users drink less in Europe.

The experience with alcohol also suggests that raising the MLDA may even affect patterns of consumption for people who are over the new MLDA (Norberg et al., 2009). For example, Plunk et al. (2013) argue that the ability to purchase alcohol before age 21 increases rates of binge drinking later in life, although the overall drinking frequency is not changed because the increase in binge drinking is accompanied by a reduction in non-heavy drinking. O’Malley and Wagenaar (1991), as reported in DeJong and Blanchette (2014), found that high school seniors and recent high school graduates drank less when the MLDA was 21 and that they also drank less throughout their early 20s, after they had reached the legal age.

Summary

Although alcohol and tobacco have considerable differences, they are similar products in many respects. As such, U.S. and international experience with enacting and raising the minimum legal drinking age may provide insights into the potential effects of raising the minimum age of legal access to tobacco products. In particular, experience with alcohol suggests that raising the MLDA has reduced consumption behaviors among adolescents and adults as well as reducing alcohol-related adverse events.

A LOGIC MODEL FOR PREDICTING THE EFFECTS OF AN MLA

In light of the dearth of literature on the question of interest—whether raising the MLA for tobacco would reduce underage use—and acknowledging the indirect analogy of the U.S. experience with alcohol, the committee next focused on the scientific literature bearing on the effects of enforcing the existing MLA and other retailer interventions on underage access to and use of tobacco. In order to organize and interpret this literature, the committee developed a logic model to examine whether and to what extent

laws restricting the commercial retail availability of tobacco products to underage persons, and MLA laws in particular, have the potential to reduce underage tobacco use. This logic model (see Figure 6-1), which draws on bodies of research on legal deterrence and behavioral economics, details the behavioral mechanisms by which an MLA policy is expected to reduce underage tobacco use. According to the most simplified form of the model, an MLA policy is expected to affect the behavior of potential users and distributors by declaring social norms and by deterring illegal behavior. Deterrence depends on an expectation among sellers that the law will be enforced. Enforcement is expected to increase retailer compliance with the MLA law. High levels of retailer compliance are expected to reduce retail tobacco availability to underage individuals, which in turn is expected to reduce underage tobacco use. The logic model is described in more detail below.

Declarative Effects and Deterrent Effects of Legal Restrictions

An MLA law can affect the behavior of tobacco retailers (and other sellers) in two ways. First, it may have a “declarative” effect on both retailers and potential underage users because they are disposed to comply with legal norms or because enactment of the law affects their beliefs and attitudes toward tobacco use by minors (Bonnie, 1982; IOM and NRC, 2004). Second, the law and its anticipated enforcement may deter potential violators from using or selling tobacco by communicating a credible threat of detection and punishment for violations. The variables that are expected to affect the likelihood of a violation by the targeted population are the probability of detection, the severity of the expected punishment (a function of the prescribed punishment and the probability of its imposition), and the swiftness with which the penalty is imposed. “General deterrence” refers to the effect of the perceived threat of enforcement and punishment on the target population of potential sellers or users. “Specific deterrence” refers to the effect of the imposition of sanctions on detected violators. Figure 6-2 shows a somewhat expanded view of the logic model detailing these enforcement mechanisms.

FIGURE 6-1 Simplified logic model of the effects of prescribing and enforcing a minimum age of legal access to tobacco products.

FIGURE 6-2 Expanded view of the logic model detailing enforcement mechanisms.

Deterrence will not occur unless potential violators perceive a credible threat of detection and punishment (hereafter, “enforcement”). Accordingly, any MLA law will need to be actively enforced using random compliance checks to maintain the retailers’ perception that there is a significant risk that an illegal sale will be detected. The compliance checks are expected to have a “specific” deterrent effect on tobacco retailers caught selling to underage individuals, increasing the likelihood of future compliance by these retailers. In addition, an awareness of the possibility of such checks is expected to deter violations by the entire population of retailers who believe themselves to be at risk of compliance checks (“general deterrence”). If MLA laws achieve high rates of compliance (through the combined effect of declaring the legal norm and enforcing it), tobacco availability to underage consumers from commercial retail sources will likely be reduced. If these effects were complete, underage users would not be able to obtain tobacco from retailers. However, the more likely scenario is that enforcement increases the number of compliant retailers (or clerks) and increases the “search-time” costs incurred by underage users who are looking for a noncompliant retailer (or clerk).

Reducing Availability by Increasing Search-Time Costs

To fully understand the effects of the MLA enforcement on search-time costs, it is first necessary to consider that commercial retailers are only one among a range of sources from which underage users obtain tobacco. As

described in Chapter 5, other sources include commercial sellers such as Internet vendors and non-licensed retail sellers (i.e., black market trafficking of untaxed tobacco and single/unpackaged/loose cigarettes) and also social sources. “Social sources” are primarily relatives and peers who give tobacco to underage users or else proxy purchasers (including strangers as well as relatives and peers) who purchase cigarettes on behalf of underage users and are paid a small fee (e.g., a few dollars or a portion of tobacco) for their service. If the law applies only to retailers or is not enforced against noncommercial providers (i.e., social sources), it is likely that any decrease in retail tobacco availability will result in a corresponding increase in access from social sources, although this shift is likely to be incomplete. Nevertheless, if overall tobacco supply to underage users is successfully reduced, it is likely that the overall cost of tobacco will increase to the underage users who purchase tobacco outside the retail market. Together with the increase in “search-time” costs, this increase in monetary cost will make tobacco products more expensive and will likely reduce the demand for the products by underage users, thereby reducing consumption.

One of the most basic and widely documented empirical regularities in economics is the so-called law of demand, which is typically stated as, “All else being equal, when the price of a good goes up, consumers demand less of it.” There is ample literature documenting that the law of demand applies to tobacco products (Chaloupka and Warner, 2000), including for adolescents in the United States (Carpenter and Cook, 2008; Ross and Chaloupka, 2003) and abroad (e.g., Kostova et al., 2011; Nikaj and Chaloupka, 2014; Sen and Wirjanto, 2010). Indeed, there is considerable, although not unanimous, evidence that adolescents are more price responsive than are older smokers (e.g., Ding, 2003; Franz, 2008; Harris and Chan, 1999).

Although the law of demand is often stated informally in terms of “price,” which would connote the monetary price paid by the customer to the seller, the proper interpretation is broader. The underlying behavioral model is that whenever the total opportunity cost of obtaining the good goes up, then the quantity demanded will go down. This total cost includes the monetary price, of course, but it also includes other costs such as the time and inconvenience of locating the seller and consummating the transaction, which is sometimes referred to as search-time costs.

The modern American economy often offers low search-time costs; the very term “convenience store” derives precisely from the idea that those stores enable customers to obtain their goods quickly and easily. However, search-time costs can dramatically affect market outcomes both in general economic models (e.g., Stahl, 1989) and, specifically, for drugs whose purchase is banned. Indeed, these costs can be important even for illegal drugs, such as heroin, whose monetary price is so high that one might expect it

to dominate other considerations because sellers have difficulty advertising directly to banned customers, and parties to a transaction seek to avoid being detected by the authorities (Moore, 1973; Rocheleau and Boyum, 1994).

Penalties for Users

Raising the MLA can be understood as an attempt to raise these non-monetary costs for individuals who were not underage under the previous policy but are underage under the new policy and who are trying to obtain tobacco.⁴ The costs are not infinite, so purchase and acquisition by those under the legal age will not go to zero. But it is more convenient simply to walk into a store and purchase what one wants than it is to enlist the assistance of a proxy purchaser, and the counterfeit brands available from the Internet and black markets are not always equivalent in the qualities that smokers value.

Similarly, at least in theory, the demand for illegal drugs could be tempered by increasing the risk that users will be apprehended and punished for possession. There is some debate as to how effective that particular deterrent is, however. Specifically, while some find that decriminalization affects use (e.g., Model, 1993), others have argued that decriminalizing prohibited drugs will not meaningfully increase demand (Bonnie, 1982; Hughes and Stevens, 2010; MacCoun and Reuter, 2001), and still others argue that the term “decriminalization” covers such a wide range of actions that generalizations concerning its effects are suspect (Pacula et al., 2005). Presumably, however large the deterrent effect for illegal drugs, it could well be smaller for underage tobacco use because the sanctions imposed under purchase–use–possession laws tend to be much less severe than the maximum sentences permitted for possession of illegal drugs (see IOM, 2007). Nevertheless, to the extent that PUP provisions exist and are enforced, raising the MLA could also be seen as increasing that aspect of the total cost of underage smokers acquiring cigarettes.

Measures of Availability

To assess the overall effect of MLA laws and their enforcement on use, tobacco availability as a mediating variable can be assessed in two ways. First, it can be assessed as the “observed availability” measured as the num-

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⁴ In certain circumstances they may also increase the monetary cost (e.g., if only a subset of retail stores are willing to sell to underage customers, and that restriction makes it harder for youth to shop for the best prices, or when a youth enlists a proxy purchaser and the proxy purchase charges a fee for that service).

ber of noncompliant retailers (or rates of violations) within a specified area. Second, it can be measured as “perceived availability,” a subjective measure of how easy or difficult it is for underage users to get cigarettes, which is also a reflection of an underage individual’s willingness to seek out tobacco products and take up smoking. Presumably, “perceived availability” bears some relationship to the perceived difficulty of accessing tobacco from retail sources, which might be a function of the observed availability; whatever its relationship with observed availability, however, reducing the perceived availability itself may also serve as a mechanism that decreases demand, deterring underage users from purchasing and using tobacco. This includes deterring underage individuals from taking up or escalating smoking as well as increasing likelihood of quitting. In addition to this pathway through perceived availability, there is also likely to be a direct effect of the MLA policy on underage tobacco use through the declarative effect of enacting and enforcing the higher MLA as well as through any effects of enforcement against users. Because social sources are another principal means of accessing tobacco, the impact of restricting retail access on the use of social sources and the corresponding implications for the success of an MLA policy also must be considered. Figure 6-3 illustrates the complete logic model, including pathways through these various measures of availability.

FIGURE 6-3 Complete logic model of the effects of prescribing and enforcing a minimum age of legal access to tobacco products.

The Tobacco Control Context

Youth access restrictions are implemented in the context of other tobacco control programs. However, community-level natural experiments and controlled experiments may not take into account the potential contributions of existing tobacco control programs that may enhance or mitigate the potential effects of increasing the MLA. Thus, this chapter also reviews literature on the effects of an MLA policy and its enforcement in the context of other tobacco control programs aimed at preventing or reducing tobacco use among adolescents and young adults and across the population at large.

EFFECTS OF RETAILER INTERVENTIONS ON ACCESS TO AND USE OF TOBACCO

Within the framework of the logic model, this section reviews the scientific literature bearing on the effects of retailer interventions on underage access to and use of tobacco. The first subsection summarizes studies that assess the impact of enforcement activities on retailer compliance. Even if the number of noncompliant stores (or unsuccessful purchase attempts) is reduced, the question remains whether increased retailer compliance has a discernible impact on the availability of tobacco to underage users and, if so, whether it reduces underage use. The next two subsections summarize studies addressing these two questions. The section closes with methodological observations.

Effect of Retail Enforcement and Other Interventions on Retailer Compliance

In the previous chapter (Chapter 5), the committee reviewed the current status of federal, state, and local youth tobacco access laws in the United States as well as their enforcement under the Synar and the Food and Drug Administration (FDA) inspection contract programs. As discussed, the rates of illegal sales to minors under the Synar program have decreased significantly over the past 20 years. However, these data are challenging to assess because of a number of factors. For one, these data are derived from compliance protocols that can vary significantly by locality in terms of the frequency of inspections, the number of reinspections of a particular retailer, the characteristics of the sales clerk and underage decoy, and the time of day of purchase, among other factors. In addition, a number of other factors aside from inspection protocol, such as the total number of inspections in a region, whether neighboring retailers have been inspected, and whether a retailer has previously been cited for violations, may also influence compliance rates. Variations in each of these factors may influence a

state’s or locality’s compliance rate. As such, it is difficult to compare data collected under different enforcement programs and data collected over time as well as to assess the impact of such compliance data on underage tobacco use. It is also difficult to compare data across geographic regions of both the same and different scales (e.g., across states or from the local to state or state to national levels). These variations are equally a factor in observational studies on the effects of youth access restrictions.

Notwithstanding these limitations, it is possible to draw out several general findings from this body of research regarding the nature and direction of the effects of enforcing youth access restrictions against retailers, if not their magnitude. It is clear, first of all, that restrictions on youth tobacco access are much more seriously and consistently enforced and complied with now than they were two decades ago, when they were first implemented. Early studies (CDC, 1993; Cismoski and Sheridan, 1993; Erickson et al., 1993) examining the effects of enacting an MLA law reported high rates of sales, suggesting that tobacco retailers will not comply with MLA laws absent of active enforcement. Studies of experiences in other countries (Kuendig, 2011; Sanson-Fisher et al., 1992; Sundh and Hagquist, 2004, 2006, 2007) report similar findings. However, both the sales rates reported to Synar and the limited scientific evidence suggest that active enforcement of youth access restrictions using compliance checks paired with penalties for violations are effective at increasing retailer compliance with youth access laws. However, evidence bearing on the relationship between the intensity of enforcement and the rate of compliance is inconsistent.

General Deterrence

Most studies evaluating enforcement programs investigate the effect of these programs on the rates of illegal sales by retailers to underage buyers. These studies support the existence of general deterrence stemming from the threat of compliance checks. The studies are typically conducted at the town level and evaluate sales rates before and after the implementation of an active enforcement program. Most of these studies reported some reduction in sales rates following the implementation of enforcement activities, but the reported declines in underage purchases varied, ranging from less than 10 percent to as high as 68 percent (e.g., DiFranza et al., 2001a; Jason et al., 1991, 1996, 1999a; Junck et al., 1997; Ma et al., 2001; Mawkes et al., 1997; Pokorny et al., 2008; Rigotti et al., 1997; Tangirala et al., 2006). In addition to looking at the rates of illegal sales, some studies (e.g., CDC, 1996; Cummings et al., 1998; DiFranza et al., 2001a,b; Schofield et al., 1997) examined the effect of enforcement activities on other measures of retailer compliance (e.g., more frequent and consistent age verification using photographic identification, displaying requisite warning signs, and

adherence to other point-of-sale marketing and advertising restrictions) and typically reported that enforcement increased compliance with these other requirements as well. A small number of studies (e.g., Bagott et al., 1998; Cummings et al., 1998; Gemson et al., 1998) compared compliance rates in jurisdictions with active enforcement to those without, and findings were mixed.

Specific Deterrence

Several studies examined the effect of multiple or repeated inspections on the same vendor. Each of these found that prior checks increased future compliance, typically measured by reduced likelihood of future illegal sales (Jason et al., 1996; Pearson et al., 2007; Schensky et al., 1996), while one found increased age verification but no effect on sales (Cummings et al., 1998). Taken together, these studies suggest that active enforcement using compliance inspections may have the specific deterrent effect of increasing compliance among retailers who have been detected and sanctioned for illegally selling tobacco to minors as well as a general deterrent effect of increasing retailers’ perceived threat of enforcement.

Retailer Education

Targeted retailer education has also been employed as a strategy to increase retailer compliance with the MLA laws, either in lieu of or in addition to active enforcement. Such education may include direct mailings with information about the MLA law and potential penalties for violations, personal visits delivering education kits and other resources, phone calls presenting information, and letters from senior government officials (e.g., the mayor or police chief). Studies of retailer education are mixed. Many (e.g., Abernathy, 1994; Altman et al., 1989, 1991, 1999; Dovell et al., 1998; Feighery et al., 1991; Gemson et al., 1998; Keay et al., 1993; Naidoo and Platts, 1985; Wildey et al., 1995; Woodruff et al., 1993) have found education effective at increasing compliance as measured by decreases in the rates of illegal sales, although some (e.g., Forster et al., 1992; McDermott et al., 1998; Schofield et al., 1997) have found no effect. Other studies have found that education increases compliance with other requirements—for instance, age verification (Krevor et al., 2011) and warning signs (Skretny et al., 1990). One study that specifically investigated an education intervention alone compared with the education intervention combined with enforcement (Feighery et al., 1991) observed a slight reduction in sales following the education-only intervention and a much larger reduction when enforcement was added. As such, retailer education programs appear to be more effective when reinforced by enforcement activities than when implemented alone.

Comprehensive Youth Sales Interventions

Comprehensive youth sales interventions comprise the active enforcement of MLA laws, retailer and community education programs, and mass media campaigns. For example, Forster and colleagues (1998) conducted the Tobacco Policy Options for Prevention study, a controlled experiment that mobilized treatment communities to introduce, pass, and enforce a youth tobacco access ordinance. This and other studies examining the effect of such comprehensive MLA interventions on illegal tobacco sales to underage users (e.g., Altman et al., 1999; Biglan et al., 1995, 1996; CDC, 1996; Cook et al., 2000; Glanz et al., 2007; Kan and Lau, 2010; Landrine et al., 2000; Tutt et al., 2009; Watson and Grove, 1999) all found that comprehensive interventions are effective at decreasing sales.

Summary

Limited evidence suggests that the active enforcement of MLA laws using random, unannounced compliance checks of tobacco retailers and sanctions for violations tend to reduce underage sales and, as a result, probably reduces the availability of tobacco to underage individuals from commercial tobacco retailers. Furthermore, additional measures such as targeted retailer education about sales laws, community education and mobilization, and mass media campaigns appear to bolster the effect of enforcement activities on increasing retailer compliance. However, evidence on the relationship between the intensity of the enforcement of the tobacco MLA restrictions and retailer compliance is slim.

Relationship Between Retail Interventions and Underage Tobacco Use

While the evidence concerning the effects of enforcement of the MLA policies on retailer compliance inferentially supports the effectiveness of the MLA policy, this finding does not directly answer the ultimate question of interest: whether increased retailer compliance is associated with reduced underage use. Three types of studies bear on this question: those investigating whether the intensity of retailer enforcement is related to the levels

of underage use; those investigating whether levels of retailer compliance are related to levels of use; and those investigating whether comprehensive youth access programs, including retailer interventions, have an impact on underage use.

Studies attempting to ascertain the effects of retail enforcement on underage tobacco use primarily examine town-level interventions. Woodridge, Illinois, was one of the first jurisdictions to restrict youth access to tobacco from retailers; in 1989 it passed a cigarette ordinance with licensing, enforcement using compliance checks, and possession provisions. An observational study (Jason et al., 1991) assessing the impact of this ordinance on middle school smoking rates found significant reductions in experimental smoking (from 46 percent to 23 percent) and in smoking (from 16 percent to 5 percent) nearly 2 years later. Follow-up studies nearly a decade later (Jason et al., 1999a,b) found that low rates of regular smoking among middle school students had been maintained (5.3 percent in 1997) as well as similarly low rates of experimental (15.4 percent), social (19.5 percent), and regular (8.1 percent) smoking among high schoolers. Moreover, this rate of regular smoking—8.1 percent—in Woodridge, where there was active enforcement, was significantly lower than in towns in the same region that lacked active enforcement (15.5 percent). Similar results were observed elsewhere (e.g., Cook et al., 2000; DiFranza et al., 1992; Levinson and Mickiewicz, 2007), although some studies (e.g., Bagott et al., 1997, 1998) saw no effect. Interestingly, Rigotti and colleagues (1997) found an increase in adolescent smoking in communities that received the enforcement intervention, but not in the control communities, despite increasing retailer compliance.

Studies of retailer compliance are similar to those evaluating active enforcement, but rather than investigating whether any enforcement efforts affect underage tobacco use, studies of retailer compliance typically examine the relationship between tobacco sales rates or retailer compliance rates (as well as changes in those rates) and underage tobacco use. While analyses of town-level interventions have found high retail compliance to be associated with a number of reduced smoking outcomes (Cummings et al., 2003; Dent and Biglan, 2004; DiFranza et al., 2009; Pokorny et al., 2003), a meta-analysis that pooled studies of active enforcement into a single compliance measure (compliance rate) (Fichtenberg and Glantz, 2002) found no relationship between the level of retailer compliance and either 30-day or regular smoking prevalence. While some (e.g., Cummings et al., 2003; Rigotti et al., 1997) have hypothesized that sales restrictions and their enforcement must achieve high rates of compliance before they begin to affect underage tobacco use, findings are mixed (see, e.g., Cummings et al., 2003; Dent and Biglan, 2004; and Fichtenberg and Glantz, 2002).

Finally, findings about the effects of comprehensive interventions incorporating such actions as retailer and community education programs and

mass media campaigns on underage smoking are mixed. While two studies (Chen and Forster, 2006; Cook et al., 2000) found that comprehensive programs decreased smoking prevalence, one study (Altman et al., 1999) reported mixed results. A fourth study investigating effects of a comprehensive program on both adolescent and adult smoking (Rohrbach et al., 2002) found that multicomponent exposure was associated with reductions in adult but not adolescent smoking prevalence.

Overestimation of Retail Compliance

Some of the observed discrepancies in the effects of enforcement and compliance on underage tobacco use may be due to methodological errors that result in an inaccurate measurement of the true rate of illegal tobacco sales to minors. Specifically, the standard compliance check protocol requires the use of underage nonsmokers who have no experience purchasing tobacco, whereas underage smokers deploy a wide range of strategies to obtain tobacco from retail stores, including knowing and sharing knowledge of specific stores and clerks that are more likely to sell to underage persons and strategies to appear older (Crawford et al., 2002; DiFranza and Coleman, 2001; Robinson and Amos, 2010). Studies comparing inexperienced nonsmokers following the standard compliance inspection protocol with underage smokers behaving as they normally do (Croghan et al., 2005; DiFranza et al., 2001b) found that more realistic smoker protocols substantially increased the likelihood of sale. These methodological issues suggest that the standardized protocols may be too artificial and may cue retailers that the purchase attempts are not sincere attempts but, in fact, are enforcement inspections. Consequently, the rates of tobacco sales to underage persons reported through Synar and observed in enforcement interventions may underestimate the true rates of sales to minors. Furthermore, if enforcement interventions are unlikely to reduce commercial availability, they are also unlikely to reduce overall tobacco availability to underage individuals or the actual use of tobacco products. Indeed, in a recent review of the literature on interventions to reduce the sale of tobacco to minors, DiFranza (2012) argued that previous reviews of literature on MLA laws and their enforcement may have failed to find an association between the MLA laws and adolescent smoking because they did not distinguish interventions that successfully reduce retail tobacco availability from those that did not. Thus, in his review and analysis, DiFranza (2012) concluded that active enforcement programs that disrupt the sale of tobacco to minors will reduce adolescent smoking.

A Key Variable: Reliance on Social Sources

While it is certainly likely that some of the inconsistencies in the findings are due to measurement errors, some of the inconsistencies may also be genuine. Some critics of youth access policies have suggested that high rates of compliance may not affect use because of the shift to reliance on social sources (e.g., Craig and Boris, 2007; Etter, 2006; Ling et al., 2002). Given that only approximately 50 percent of underage tobacco users report obtaining tobacco from commercial retailers (see Tables 5-2 through 5-8 in Chapter 5), even a complete cut-off of retail tobacco to underage users will contain, but not eliminate, overall tobacco availability to them unless there is a major crackdown on social distribution.

Although the evidence is slim, a handful of studies (Dent and Biglan, 2004; Kim et al., 2013; Levinson and Mickiewicz, 2007; Millett et al., 2011; Rigotti et al., 1997; Rimpela and Rainio, 2004) suggest that the successful restriction of retail tobacco will effectively decrease adolescent purchases of tobacco from retail sources. At the same time, such a restriction is likely to increase reliance on social sources, including both proxy purchases and being given tobacco (DiFranza and Coleman, 2001; Levinson and Mickiewicz, 2007; Millett et al., 2011; Rigotti et al., 1997; Rimpela and Rainio, 2004). Interestingly, a study of Oregon adolescents (Dent and Biglan, 2004) found that increased compliance was associated with an increased reliance on social sources and a decreased use of commercial sources among 11th graders, but that the opposite was true for 8th grade students. It is possible that the younger students’ social networks were restricted to underage persons so that increased retail compliance reduced access from these social sources, leading to an increased need for the 8th graders to try to purchase tobacco for themselves. On the other hand, the older students may have been more likely to have social networks that included those who were old enough to buy tobacco products on their behalf.

It seems clear that curtailing retail access will lead to greater use of social sources. Whether the reduction in retail access has an effect on underage use depends on whether the substitution of the social sources for the commercial sources is complete. To the extent that this substitution of social sources for commercial sources is incomplete, the search-time costs for underage users to obtain tobacco will likely increase, and tobacco consumption among underage users will likely decrease. All of the evidence reviewed above is consistent with incomplete substitution.

Relationship Between Retail Interventions and Perceived Availability

Given the mixed findings regarding the relationship between retailer interventions and levels of tobacco use in adolescents, it is instructive to

consider whether the intensity of retailer intervention is related to subjective measures of reduced “access” by underage users. Two subjective factors reported by underage youth—the perceived availability of tobacco and self-reported decreases in the use of retail sources—can be considered to be proxy measures of actual underage access. Moreover, as intervening variables, both measures may moderate the effect of an MLA restriction and its enforcement on underage tobacco use.

Perceived Availability

One notable trend in adolescents’ access to cigarettes is that the perceived ease of access has declined considerably in recent years. The Monitoring the Future surveys ask 8th and 10th graders how difficult they think it would be for them to get cigarettes, if they wanted to. Among 8th graders in 1996, 77 percent said they could get cigarettes “fairly easily” or “very easily,” while in 2013 that figure had declined to 50 percent. Among 10th graders, the corresponding decline was from 90 percent to 70 percent. Thus, although most adolescents still believe they could easily obtain cigarettes, reports of easy access have declined considerably over time (Johnston et al., 2014). This finding is also consistent with reduced retail availability and incomplete substitution by social sources.

Impact of Enforcement on Perceived Availability

The perceived availability of tobacco represents a subjective assessment of an underage person’s actual opportunities to obtain tobacco (i.e., supply) and can be assessed either in reference to specific sources or location types (e.g., availability from home, school, or stores) or globally. Findings on the relation between MLA laws and their enforcement and perceived availability are mixed. However, while these studies typically assess perceived tobacco availability globally (e.g., Borland and Amos, 2009; Cummings et al., 2003; Jason et al., 1999a; Rigotti et al., 1997; Rimpela and Rainio, 2004; Staff et al., 1998; Thomson et al., 2004), Forster and colleagues (1997) assessed perceived availability in reference to specific sources and found that the intervention decreased the perceived availability from commercial but not social sources. This suggests that the MLA laws and their enforcement, as expected, may increase the difficulty of obtaining tobacco from commercial sources, but they do not have an impact on social sources. It is likely that the inconsistent findings concerning the impact of the MLA and its enforcement on perceived access may be due to the conflation of sources.

Relationship Between Perceived Availability and Underage Tobacco Use

The evidence on the relationship between perceived availability and underage tobacco use is challenging to interpret because this relationship is dependent on the relative availability of and reliance on tobacco from social sources. For example, Doubeni and colleagues (2008) found that high perceived availability increases the risk for multiple smoking outcomes and that high perceived availability and peer smoking together increased the risk of regular smoking and of smoking progression among initiators more than either variable alone. This is logical given that adolescents with more peers who smoke will likely have greater access to tobacco from these peers and also more positive attitudes toward tobacco use.

Perceived Availability as a Reflection of Social Norms

Perceived tobacco availability may also reflect perceptions of the social environment about tobacco use (e.g., social norms) as well as an underage individual’s willingness or intentions to attempt to get tobacco (i.e., demand). By bridging the interface between tobacco supply and demand, perceived availability can be understood as a psychosocial mechanism by which youth tobacco restrictions affect underage tobacco use. Interpreting the impact of perceived availability on consumption is even more challenging precisely because it may reflect changes in both tobacco supply and demand. For example, Gilpin et al. (2004) examined neighboring birth cohorts before and after implementation of a comprehensive, statewide tobacco control program in California and found that adolescents who perceived cigarettes easy to access were more likely to initiate smoking than those who perceived cigarettes hard to obtain, but only in the cohort under higher enforcement conditions. The authors therefore suggest that perceived availability was less a reflection of opportunities to obtain tobacco than of the declarative effect of the tobacco control program changing social norms and thereby decreasing demand to take up tobacco use. Finally, a cross-sectional study (Speizer et al., 2008) examined perceived availability from different sources and found that current and ever smokers were more likely to perceive easy access to cigarettes from all sources (home, school, and stores) than those who never smoked, which suggests that perceived ease of access reflects both a greater demand for tobacco and opportunities to access tobacco.

Summary

Findings about the effects of retail enforcement, retail compliance, and comprehensive interventions on underage tobacco use are difficult to

interpret. The difficulty is reflected in the discrepancy between observed commercial availability (as measured by the rates of retail compliance) and perceived tobacco availability, as self-reported by adolescents and young adults. Whereas all states are currently in compliance with Synar and have achieved average compliance rates of 90 percent, 50 to 70 percent of adolescents report fair or very easy access to cigarettes (Johnston et al., 2014). The apparent inconsistency may be partially attributable to an overestimate of compliance rates in compliance checks. In addition, changes in perceived availability may reflect changes not only in opportunities to obtain tobacco but also in social norms and demand for tobacco.

Overall, this body of evidence suggests that the enforcement of MLA laws increases the perceived difficulty of obtaining tobacco from commercial sources. Additionally, MLA laws are likely to change social norms, and thereby indirectly affect perceived ease of access from social sources, especially among younger adolescents. Insofar as the substitution of non-retail sources for commercial retail sources is incomplete, the total tobacco available to underage individuals is probably reduced. However, reduced access does not have a robust and easily measurable impact on use because of the youths’ increased reliance on social and other non-retail sources, especially by older adolescents and youth who are already daily smokers.

UNDERAGE ACCESS RESTRICTIONS IN THE CONTEXT OF OTHER TOBACCO CONTROL POLICIES

It is unlikely that any revised MLA laws will be aggressively enforced in isolation, so examining the MLA laws and their enforcement in the context of other tobacco control policies can help elucidate their likely effects in circumstances that more closely resemble the likely real world scenarios in which an MLA increase would be implemented. In particular, investigating the effect of the MLA laws in this way may help explain some of the observed variations in community-level natural experiments. Studies in these small localities may not account for the contributions of other concurrent tobacco control programs at the state and national levels (e.g., smoke-free policies, excise taxes and price, mass media campaigns), and they also may be subject to spillover effects from neighboring jurisdictions, in particular,

smuggling.⁵ The following section reviews the evidence on MLA retailer interventions in the context of other youth access restrictions, followed by other, general tobacco control programs.

Multiple Statewide Retailer Interventions and Underage Tobacco Consumption

In addition to MLA laws and their enforcement, youth access policies also include licensing requirements (i.e., requiring a license to sell tobacco products), signage requirements at the point of sale (i.e., posting warning signs about the MLA), vending machine restrictions, inspection requirements, clerk intervention policies (i.e., retailer and clerk education), penalties for retailers found to be in violation (especially graduated penalties), identification requirements, packaging restrictions (e.g., minimum pack size, labeling standards), restrictions on free distribution (i.e., bans on free samples), and establishing or designating a statewide enforcement authority. These policies are typically examined at the state level and can be examined both individually and in an aggregate measure of overall “extensiveness.” When examined in the aggregate, having more policies constitutes a higher score and is considered to be more extensive. In this context, it is imperative to control for the impact of other policies in order to isolate the independent effect of MLA on underage tobacco use and also to identify possible interactions.

Of the studies that examined multiple youth access policies, including an MLA and its enforcement, Chaloupka and Pacula (1998), Luke et al. (2000), and Powell et al. (2003), found that more extensive policies were associated with decreased teen current smoking prevalence. Further, Chaloupka and Pacula (1998) also showed that, when measured individually, the use of compliance inspections versus only observing retailers and the use of statewide sampling to measure compliance versus local or no sampling were both associated with significantly lower adolescent smoking prevalence. On the other hand, Thomson and colleagues (2004) examined six types of youth access ordinances (licensing, fines for merchants who

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⁵ Indeed, adolescents achieve increasing mobility as they begin to drive, and implementation at the town or county level may have a smaller effect than state- or national-level implementation due to the potential smuggling of tobacco from neighboring jurisdictions where tobacco availability is higher. Lessons from the alcohol experience suggest precisely this: Lovenheim and Slemrod (2010) and Dejong and Blanchette (2014) examined the effect of a minimum legal drinking age on fatal traffic accidents when states were implementing an MLDA of 21 in a patchwork while the national MLDA remained 18. Their analysis of county-level data found no reduction in fatal traffic crashes involving youth in counties with an MLDA of 21 that were within 25 miles of a state with a lower minimum drinking age, but significant reductions in fatal traffic crashes involving youth in counties further from the state borders.

sell to minors, vending machine restrictions, self-service bans, bans of the sale of single cigarettes, and bans on distributing free samples) in several Massachusetts towns and statewide and found that none of the youth access ordinances were associated with any measure of adolescent smoking. One study examined how state youth access policies in effect when study participants were age 17 affected their smoking after they became adults (Grucza et al., 2013). The researchers examined the effects of the policies both individually and in multi-policy models and found that multiple youth access policies together were associated with significant reductions in prevalence of both ever and current smokers among females (although not among males) despite the individual policies having only small effects in isolation. These findings suggest that individual youth access policies alone may have small, additive effects that contribute to more substantial impacts when implemented together.

Comprehensive Tobacco Control Policies and Underage Tobacco Consumption

Other policies that have an effect on tobacco use in addition to youth access initiatives are smoke-free laws, state-level expenditures, excise taxes, and minimum cigarette prices. As with studies of multiple youth access policies, studies of multiple tobacco control policies can examine the policies individually or in aggregate.

Of the studies attempting to isolate the independent effects of MLA laws in the context of other tobacco control policies, two (Botello-Harbaum et al., 2009; Farrelly et al., 2013) found no association between youth access policies and any adolescent smoking outcome after controlling for the other policies. However, Ross and Chaloupka (2001) found that the decision to smoke and smoking intensity were each negatively associated with retailer compliance in models that both included all policies together and controlled for the effects from the other tobacco control measures. Tworek et al. (2010) examined the effects of tobacco control policies, including an index of the strength of youth tobacco sales restrictions on adolescent smoking cessation, and found that youth access restrictions slightly increased the odds of non-continuation of smoking, but they were not associated with any other cessation measure.

Other studies have investigated the effects of comprehensive tobacco control programs; these can be considered to be studies of multiple tobacco control policies in aggregate. The multi-pronged tobacco-control approaches integrate educational, clinical, regulatory, economic, and social strategies to prevent or reduce tobacco use and to reduce tobacco-related diseases (CDC, 2014b; HHS, 2000). For example, Helakorpi et al. (2008) investigated the effects of the 1976 Tobacco Control Act in Sweden, which

prohibited smoking in public places, including public transit; prohibited tobacco sales to those under 16; required health warnings on cigarette packs; and established a tobacco tax whose revenue was earmarked for health education and tobacco-related research on adult smoking by gender and socioeconomic status. Among men, the researchers found that after the passage of the act, the prevalence of ever-daily smoking declined beyond secular trends for all SES groups, with the strongest declines observed among the higher SES group (white-collar employees). Among women, there was an increasing secular trend for all SES groups prior to the legislation, but after the act women’s ever-daily smoking prevalence reversed in all groups. A comprehensive tobacco control program in New Zealand was similarly effective at reducing tobacco use in adolescents and adults and also reducing tobacco-related death and disease (Laugesen and Swinburn, 2000).

Comprehensive programs in the United States have been shown to effectively reduce tobacco use among adolescents and adults (e.g., Farrelly et al., 2008, 2013, 2014; Kuiper et al., 2005; Pierce et al., 2009; Stillman et al., 2003; Tauras et al., 2005; Wakefield and Chaloupka, 2000; Zaza et al., 2005) as well as to reduce tobacco-related death and disease (e.g., Jemal et al., 2003; Kuiper et al., 2005). However, they frequently do not specify the inclusion of youth access policies (e.g, because comprehensive tobacco control efforts are frequently measured using state-level expenditures). Despite the lack of explicitly identified youth access program components, it is reasonable to assume that studies of state-level comprehensive tobacco control programs within the past two decades would have included youth access restrictions conducted in compliance with Synar. Moreover, the inclusion of youth access restrictions in comprehensive approaches is considered best practice, and stronger state-level tobacco control programs are likely to include extensive youth access measures (CDC, 2014b). Thus, it is likely that these comprehensive approaches to tobacco control that have proved effective at reducing tobacco use and tobacco-related morbidity and mortality include some youth access provisions.

Summary

Evidence on the independent effect of youth access policies in the context of other tobacco control policies is mixed. However, studies of multiple statewide retailer interventions that include active enforcement of the MLA restrictions suggest that these interventions are effective in reducing underage use. Moreover, there is some evidence that comprehensive tobacco programs that include youth access restrictions are effective at reducing underage tobacco use, although it is difficult to isolate the relative contributions of youth access restrictions in these comprehensive programs.

TOBACCO PURCHASE, USE, AND POSSESSION LAWS

Although the focus of this analysis is on sales restrictions, it is also important to consider the effects of supplementing bans on distribution and sales with laws targeting underage tobacco PUP. As noted in Chapter 5, the laws of 44 states and the District of Columbia penalize underage individuals for purchasing, using, or possessing tobacco products, typically by civil fines or community service. Proponents of the laws argue that PUP laws are another effective strategy for deterring underage tobacco use (e.g., Jason et al., 2009b; Lazovich et al., 2007; Livingood et al., 2001), while critics argue that PUP laws shift blame from retailers and tobacco industry marketing and advertising practices toward adolescents and young adults and, furthermore, that PUP laws may actually increase the desirability of tobacco as an aspirational, adult product, further enticing adolescents to use tobacco (e.g., Wakefield and Giovino, 2003). Opponents of PUP laws also suggest that enforcement would be difficult, expensive, and therefore realistically infeasible (Tworek et al., 2011). The IOM’s report Growing Up Tobacco Free (1994) elaborated on this, arguing that PUP laws lacking enforcement would only serve as a symbolic deterrent, which would be unlikely to deter tobacco use any more than laws punishing sellers, while also undermining respect for the law.

There is currently no systematic surveillance of PUP laws, and thus there is little information about either the extent to which they are enforced or their efficacy. The only available data on statewide enforcement that the committee was able to locate (Rogers et al., 2008) come from California, an aggressive tobacco control state, and the data show that, in 2007, 76 percent of youth access enforcement agencies across the state indicated that they did not “often” or “very often” issue citations to minors for PUP violations. Additionally, the average number of citations issued in the past 12 months across all 249 enforcement agencies statewide was 24.1 citations, or an average of two per agency per month. Similarly, qualitative studies also suggest that PUP laws are seldom enforced. Two studies using key informant interviews with individuals responsible for enforcing PUP laws (e.g., mayors, police officers, and school officials) found that PUP laws are poorly enforced and that only a small number of citations are issued (Hrywna et al., 2004); they also found that there was little knowledge about PUP enforcement, that active enforcement of PUP laws was not a priority, and that even when they were enforced, the enforcement was inconsistent (Hahn et al., 2007). Indeed, any widely violated and under-

enforced prohibition is likely to be plagued by selective enforcement, and PUP laws are no exception. For example, Gottlieb et al. (2004) found differential enforcement of PUP laws, such that African-American and Hispanic students had a significantly greater probability of receiving a citation than white students.

Despite lax enforcement efforts, limited empirical data suggest that active enforcement of PUP laws in addition to active enforcement of youth tobacco sales restrictions may be effective at reducing tobacco sales to underage persons and, ultimately, at reducing underage tobacco consumption. Most of these findings come from a series of studies conducted by Jason and colleagues in a convenience sample of small, suburban towns in Illinois, which may not be representative of the rest of the state or the country as a whole. They found that active enforcement of PUP laws in addition to sales restrictions is associated with reduced tobacco sales to underage users (Jason et al., 2003); decreased observed and perceived adolescent tobacco use (Jason et al., 2009a); slower increases in the rate of smoking compared to enforcing sales restrictions alone (Jason et al., 2008); reduced smoking, both among whites only (Jason et al., 2003) and, alternately, among all groups (Jason et al., 2007c); lowered rates of heavy smoking (Jason et al., 2009b); reduced use of other drugs (Jason et al., 2010), and reduced crime rates (Jason et al., 2000). They also found that underage individuals who were fined for PUP violations were more likely to reduce tobacco use or quit than those who participated in tobacco prevention education programs (Jason et al., 2007b). Additionally, fines had a bigger effect than education on changing parental and adolescent attitudes toward tobacco use (Jason et al., 2007b). Finally, Jason and colleagues also found that the presence of PUP laws facilitated the uptake of smoke-free policies (Jason et al., 2007a). Studies by other researchers have further supported these findings, including studies demonstrating that actively enforcing PUP laws may be effective at reducing underage tobacco use (Gottlieb et al., 2004; Lazovich et al., 2007; Livingood et al., 2001) and increasing adolescent smoking cessation (Langer and Warheit, 2000). Moreover, Gottlieb et al. (2004) found that the threat of driver’s license suspension as a penalty for PUP violations reduced smoking intentions among adolescent ever-daily smokers (but not ever or experimental smokers), suggesting a general deterrent effect. At the same time, having received a citation was associated with reduced smoking intentions in only some of the schools sampled, thus showing mixed findings with respect to specific deterrence.

On the other hand, two analyses also examined PUP laws in the context of other youth access restrictions, and neither found that they decreased adolescent smoking. Ross and Chaloupka (2001) found that punishing minors for the use or possession of cigarettes increased the number of cigarettes

adolescents smoked, while Tworek and colleagues (2010) found no association between PUP laws and any measure of adolescent smoking cessation.

In sum, there continues to be some controversy about the relative advantages and disadvantages of implementing PUP laws for tobacco. Although a small number of observational studies of PUP interventions suggest that they can contribute to the reduction of underage tobacco use if enforced, there is scant evidence of enforcement. Moreover, the few existing studies also suggest that, when enforced, the laws are selectively applied and that minority populations may carry a disproportionate burden of PUP violations.

SUMMARY

This chapter reviewed the existing evidence on the effects of raising the minimum legal age to purchase tobacco products, in particular the effect on underage tobacco use. No published evidence is yet available on the effects of raising the MLA to 21 in any of the localities in the United States that have done so. Limited international evidence suggests that raising the MLA from 16 to 18 in countries that already had an actively enforced MLA can be implemented successfully to reduce the availability of retail tobacco to newly underage persons and thereby reduce underage tobacco use. Experience with raising the minimum legal drinking age for alcohol in the United States from 18 to 21 is instructive for tobacco control, in that it has led to reductions in the use of alcohol and concomitant harms, such as motor vehicle accidents in the underage population, although it also demonstrates that the prevalence of underage drinking remains high.

In light of the dearth of direct evidence on the effects of raising the MLA for tobacco, the committee focused its attention on the substantial body of literature on the effects of enforcing the MLA restrictions that have already existed in the United States for more than two decades. This literature suggests that the MLA policies that are actively enforced and supported by other retailer interventions will likely increase retailer compliance and thereby reduce retail tobacco availability to underage individuals. Furthermore, although increased retailer compliance is predictably accompanied by a corresponding increase in the use of social sources to obtain tobacco, this substitution of sources is likely to be incomplete, leading to decreased

use, especially if the youth access policy is implemented in a robust comprehensive tobacco control context.

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