- freely available
Int. J. Environ. Res. Public Health 2009, 6(4), 1485-1514; doi:10.3390/ijerph6041485
1. Introduction: Preventing Tobacco Use among Youth
2.1. Literature Searches
2.2. Rating the Evidence
2.3. Summary of Findings
- What impact do access restrictions have on youth smoking behaviour and stage of smoking?
- When interventions can be compared, which are most effective in reducing illegal tobacco sales to youth?
- Are the interventions delaying rather than preventing the onset of smoking?
- How does the way that the intervention is delivered influence effectiveness?
- Does effectiveness depend on the status of the merchant?
- Does the site/setting influence effectiveness?
- Is sustained implementation or enforcement important?
- How does effectiveness vary according to the age, sex or ethnicity of young people?
- What are the facilitators and barriers to implementation?
3.1. What Impact Do Access Restrictions Have on Youth’s Smoking Behaviour and Stage of Smoking?
3.2. When Interventions Can Be Compared, Which Are Most Effective in Reducing Illegal Tobacco Sales to Youth?
1) Tobacco industry interventions
2) Multi-component interventions and active enforcement
3) Age and Identification Requests
3.3. Does Effectiveness Depend on the Status of the Merchant?
3.4. Does the Site/Setting Influence Effectiveness?
3.5. Is Sustained Implementation or Enforcement Important?
3.6. How Does Effectiveness Vary According to the Age, Sex or Ethnicity of Young People?
1) Age and Smoking Status
3.7. What Are the Facilitators and Barriers to Implementation?
Appendix A: Smoking uptake and young people search strategies.
- young person* or young people or young adult* or young individual*
- under 18* or underage* or under eighteen*
- boy or boys or girl or girls
- child* or adolescen* or kid or kids or youth* or youngster* or minor or minors or teen* or juvenile* or student* or pupil or pupils
- smoking or antismoking or anti-smoking or smoker or smokers or tobacco
- cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine
- (sale or sales or sell or selling or sold or supply or supplies or supplied or supply*) within 3 (tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine)
- (purchase* or retail*) within 3 (tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine)
- (buy or buys or buying or bought) within 3 (tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine)
- (vend or vends or vending) within 3 (tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine)
- (shop or shops or shopping or shopped) within 3 (tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine)
- (store or stores or supermarket*) within 3 (tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine) tobacconist*
- (prevent* or regulat* or control* or restrict* or prohibit* or ban* or limit* or illegal or law or legislat*or policy or policies) within 3 (smoke or smoking or tobacco or cigar* or bidi or bidis or beedi or beedis or kretek or handroll* or hand roll* or nicotine)
- limit to (english language and yr="1990–2007")
Appendix B. Excluded Studies
|Paper||Reason for exclusion|
|Altman, D.G.; Wheelis, A.Y.; McFarlane, M.; Lee, H.; Fortman, S.P. The relationship between tobacco access and use among adolescents: a four community study. Soc. Sci. Med. 1999, 48, 759–775.||Covered in Cochrane Review. Community-based intervention: Monterey County, CA|
|Altman, D.G.; Rasenick-Dous, L.; Foster, V.; Tye, J.B. Sustained Effects of an Educational Program to Reduce Sales of Cigarettes to Minors. Amer. J. Public Health 1991, 81, 891–893.||Covered in Cochrane Review. Community-based intervention: Santa Clara County, CA.|
|Banerjee, S.C.; Green, K. Analysis Versus Production: Adolescents Cognitive and Attitudinal Responses to Antismoking Interventions. J. Commun. 2006, 56, 773–794.||Not an intervention.|
|Chapman, S.; King, M. Effects of publicity and a warning letter on illegal cigarette sales to minors. Aust. J. Public Health 1994, 18, 39–42.||Covered in Cochrane Review.|
|Chen, V.; Foster, J.L. The long-term effect of local policies to restrict retail sale of tobacco to youth. Nicotine Tob. Res. 2006, 8, 371–377.||Community-based intervention: 14 communities in Minnesota.|
|Cheng, T.O. Peer, Parental, and Commercial Influences on Cigarette Smoking among Chinese Youth. J. Natl. Med. Assn. 2004, 96, 691–692.||Not an intervention. Commentary.|
|Cummings, K.M.; Hyland, A.; Saunders-Martin, T.; Perla, J.; Coppola, P.R.; Pechacek, T.F. Evaluation of an enforcement program to reduce tobacco sales to minors. Amer. J. Public Health 1998, 88, 932–936.||Covered in Cochrane Review.|
|Cummings, K.M.; Saunders-Martin, T.; Clarke, H.; Perla, J. Monitoring vendor compliance with tobacco sales laws: Payment vs. no payment approaches. Amer. J. Public Health 1996, 86, 750–751.||Not relevant to research question.|
|Curran, J.J., Jr. Preventing youth access to tobacco products in Maryland. Maryland Med. J. 1995, 44, 793–195.||Not an intervention|
|Dovell, R.A.; Mowat, D.L.; Dorland, J.; Lam, M. Changes among retailers selling cigarettes to minors. Can. J. Public Health 1996, 87, 66–68.||Covered in Cochrane Review. Community-based intervention: local intervention|
|Feighery, E. The effects of coming education and enforcement to reduce tobacco sales to minors: a study of four northern California communities. J. Amer. Med. Assn. 1991, 266, 3168–3171.||Covered in Cochrane Review. Community-based intervention: 4 cities in Solano County, California|
|Forster, J.L.; Murray, D.M.; Wolfson, M.; Blaine, T.M.; Wagenaar, A.C.; Hennrikus, D.J. The effects of community policies to reduce youth access to tobacco. Amer. J. Public Health 1998, 88, 1193–1198.||Covered in Cochrane Review.|
|Forster, J.L.; Hourigan, M.E.; Kelder, S. Locking devices on cigarette vending machines: Evaluation of a city ordinance. Amer. J. Public Health 1992, 81, 1217–1219.||Covered in Cochrane Review. Community-based intervention: St. Paul, MN|
|Gemson, D.H.; Moats, H.L.; Watkins, B.X.; Ganz, M.L.; Robinson, S.; Healton, E. Laying down the law: Reducing illegal tobacco sales to minors in central Harlem. Amer. J. Public Health 1998, 88, 936–939.||Covered in Cochrane Review,|
|Goldstein, A.O.; Sobel, R.A.; Martin, J.D.; Crocker, S.D.; Malek, S.H. How does North Carolina law enforcement limit youth access to tobacco products? N. C. Med. J. 1998, 58, 90–94.||No outcomes of interest.|
|Jason, L.A.; Ji, P.Y.; Anes, M.D.; Birkhead, S.H. Active enforcement of cigarettes control laws in the prevention of cigarette sales to minors. J. Amer. Med. Assn. 1991, 266, 3159–3161.||Covered in Cochrane Review. Community-based intervention: Santa Clara, CA.|
|Jason, L.A.; Berk, M.; Schnopp-Wyatt, D.L.; Talbot, B. Effects of enforcement of youth access laws on smoking prevalence. Amer. J. Commun. Psychol. 1999, 27, 143–160.||Covered in Cochrane Review. Community-based intervention: Woodridge, IL.|
|Jason, L.A.; Billows, W.D.; Schnopp-Wyatt, D.L.; King, C. Long-term findings from Woodridge in reducing illegal cigarette sales to older minors. Eval. Health Prof. 1996, 19, 3–13.||Covered in Cochrane Review. Community-based intervention: Woodridge, IL|
|Jason, L.A.; Katz, R.; Vavra, J.; Schnopp-Wyatt, D.L.; Talbot, B. Long-term follow-up of youth access to tobacco laws’ impact on smoking prevalence. J. Hum. Behav. Soc. Environ. 1999, 2, 1–13.||Covered in Cochrane Review. Community-based intervention: Woodridge, IL.|
|Jason, L.; Billows, W.; Schnopp-Wyatt, D.; King, C. Reducing the illegal sales of cigarettes to minors: Analysis of alternative enforcement schedules. J. Appl. Behav. Anal. 1996, 29, 333–344.||Covered in Cochrane Review. Community-based intervention: Chicago, IL.|
|Junck, E.; Humphries, J.; Rissel, C. Reducing tobacco sales to minors in Manly: 10 months follow-up. Health Promot. J. Aust 1997, 7, 29–34.||Covered in Cochrane Review. Community-based intervention: Manly, a suburb in Sydney, Australia.|
|Keay, D.K.; Woodruff, S.I.; Wildey, M.B.; Kenney, E.M. Effect of retailer intervention on cigarette sales to minors in San Diego County, California. Tob. Control 1993, 2, 145–151.||Covered in Cochrane Review. Community-based intervention: San Diego County, CA|
|Krevor, B.S.; Liebermn, A.; Gerlach, K. Application of consumer protection authority in preventing tobacco sales to minors. Tobacco Control 2002, 11, 109–111.||Not an intervention. No outcomes of interest. Special communication, descriptive study.|
|Krevor, B.; Capitman, J.A.; Oblak, L.; Cannon, J.B.; Ruwe, M. Preventing illegal tobacco and alcohol sales to minors through electronic age-verification devices: a field effectiveness study. J. Public Health Policy 2003, 24, 251–268.||No outcomes of interest. Not relevant to research question.|
|Perla, J.P. Effects of increase retailer compliance rates on youth smoking behaviours and access to cigarettes. Ph.D. thesis, State University of New York at Buffalo: Buffalo, NY, USA, 1998, pp. 1–163.||Community-based intervention: 13 suburban communities in Erie County, NY.|
|Powell, L.M.; Chaloupka, F.J. Parents, public policy, and youth smoking. J. Policy Anal. Manag. 2005, 24, 93–112.||No relevant outcomes. Emphasis on parental influences on smoking behaviour.|
|Powell, L.M.; Taurus, J.A.; Ross, H. The importance of peer effects, cigarette prices, and tobacco control policies on youth smoking behaviour. J. Health Economics 2005, 24, 950–968.||Tobacco control policies that were examined included local level policies. Furthermore, the paper was not focuses on prevention-participants were smokers. Key focus of paper was impact of peers on smoking.|
|Powell, L.M.; Chaloupka, F.J. Parents, public policy, and youth smoking. J. Public Policy Anal. Manag. 2005, 24, 93–112.||Key focus of paper was impact of parents on smoking. Lack of information on access restrictions. Access restrictions examined went beyond those within the scope of this review (i.e. packaging).|
|Rigotti, N.A.; DiFranza, J.R.; Chang, Y.; Tisdale, T.; Kemp, B.; Singer, D.E. The effect of enforcing tobacco-sales laws on adolescents’ access to tobacco and smoking behaviour. N. Engl. J. Med. 1997, 337, 1044–1051.||Covered in Cochrane Review. Community-based intervention: 5 Massachusetts communities.|
|Siegel, M.; Biener, L.; Rigotti, N. The effects of local tobacco sales laws on adolescent smoking initiation. Prev. Med. 1999, 29, 334–342.||Community-based intervention: local communities in Massachusetts|
|Skretny, M.T.; Cummings, K.M.; Sciandra, R.; Marshall, J. An Intervention to reduce the sale of cigarettes to minors in New York State. N. Y. State. J. Med. 1990, 92, 54–55.||Covered in Cochrane Review.|
|Staff, M.; Bennett, C.M.; Angel, P. Is restricting tobacco sales the answer to adolescent smoking? Prev. Med. 2003, 37, 529–533.||Covered in Cochrane Review. Community based intervention: 11 northern Sydney metropolitan public secondary schools.|
|Thomson, C.C.; Gokhale, M.; Biener, L.; Siegel, M.B.; Rigotti, N.A. Statewide evaluation of youth access ordinances in Practice: Effects of the implementation of a community-level regulation in Massachusettes. J. Public Health Manag. Pract. 2004, 10, 481–489.||Community-based intervention: communities in Massachusetts.|
|Widley, M.B.; Woodruff, S.; Agro, A.; Keay, K.; Kenney, E.M.; Conway, T.L. Sustained effects of educating retailers to reduce cigarettes sales to minors. Public Health Rep. 1995, 110, 625–629.||Covered in Cochrane Review. Community-based interventions: San Diego County, California.|
|Type and quality of evidence|
|Randomised Control Trial (RCT)
|Case Control Studies|
|Controlled Before and After (CBA) Studies|
|Interrupted Time Series (ITS) Studies|
|Grading the evidence|
||All or most of the quality criteria have been fulfilled|
Where they have been fulfilled the conclusions of the study or review are thought very unlikely to alter
||Some of the criteria have been fulfilled|
Where they have been fulfilled the conclusions of the study or review are thought unlikely to alter
||Few or no criteria fulfilled|
The conclusions of the study are thought likely or very likely to alter
Number of participants (randomised to each group or otherwise).
Age; Sex; S/E status; Ethnicity; Pregnant; Other, e.g. inpatient, ….
Length of follow-up, follow-up rate
|Backinger et al.|
USA Review (narrative synthesis)
|Data included smoking prevention studies published from January 1990 to May 2002 and conducted in the US. All identified smoking cessation studies for adolescents. Young adult data was limited to initiation and cessation studies.||To summarize the evidence on adolescent and young adult prevention and cessation, and provide future directions for research.
Funder not mentioned.
|Data was collected from published literature. Pubmed, PsychInfo, ERIC and SCCI were searched for evidence related to young adults and adolescents.||Findings reveal that studies on youth access show that young people continue to obtain cigarettes from non-commercial sources (friends and family) and commercial sources (convenience stores).||Many of the results were not relevant to the research questions and outcomes of this review. Selected data has been used in the review.|
|Chaloupka et al.|
|N= nationally representative students in grade 8, 10 and 12.||Examines the effectiveness of several tobacco control policies in discouraging cigarette smoking among youth. Policies include limits on the availability of tobacco products to youth. Funded by the Centres for Disease Control and the Robert Wood Johnson Foundation.||Data was collected from the 1992–1994 Monitoring the Future campaign surveys of grade 8, 10, 12 students. Limits on the availability of tobacco products to youth were measured by several variables including: state, minimum legal purchase, age, etc.||Limits on youth access to tobacco products appear to have little impact on youth cigarette smoking, likely due to weak enforcement of the laws.||A well conducted study that disaggregated results based on gender and race. More information on confounders and missing data would have been useful.|
|Chaloupka et al.|
|N= 198, 359 nationally representative students in grade 8, 10 and 12. Authors do not provide ethnic breakdown, but state that sample was “nationally representative”||Examine differences in youth responsiveness to changes in price or tobacco control policies.
Funded by the Centres for Disease Control and the Robert Wood Johnson Foundation.
|Data was collected from the 1992–1994 Monitoring the Future campaign surveys of grade 8, 10, 12 students. Indexes examined gender, SES, race, cigarette consumption, etc.||Found significant differences in youth’s responsiveness to tobacco control initiatives by race. Smoking rates among white youth are significantly influenced by anti-tobacco activities and clean indoor air restrictions (p<0.05, p<0.10, respectively), whereas smoking rates among black youth are not. Smoking rates among black youth are significantly influenced by smoker protection laws and restrictions on youth access (ps<0.10), whereas smoking rates among whites are not.||A well conducted study that disaggregated results based on gender and race. More information on confounders and missing data would have been useful.|
|Difranza et al
|Evaluate merchant compliance with laws prohibiting the sale of tobacco to minors.
Funded by the Massachusetts
|Stratified cluster sampling was used to select outlets from which youth aged 13–17 years attempted to purchase tobacco.||Crude violation rates were 35% in 1996 and 17% for 1997 (p<0.001).
Male clerks made more sales than female clerks (27% vs. 22%; p<0.05). Illegal sales were comparable for locked vending machines (19% of 47 attempts) and over the counter outlets (24% of 1075 attempts; p>0.05), but were more frequent in self service displays (37% of 75 attempts, p=0.01) vs. over the counter) and unlocked vending machines (64% of 58 attempts p<0.001 vs. over the counter).
Sales occurred in 1.5% of the 1180 attempts when proof of age was requested, as compared with 64% of the 712 attempts when it was not (p<0.001). Sales occurred in 5% of 317 attempts when age was asked and in 30% of 1502 when it was not (p<0.001).
|A well conducted study that discussed eligibility, sampling method and reliability of results. However, the study did not discuss reliability and validity of measurement methods and exposure, and did not discuss confounders.|
|DiFranza et al|
|N=480 cigarette purchase attempts. All of the tobacco merchants were located in 8 suburban and small urban communities. The over the counter vendors included convenience stores, pharmacies, liquor stores, and gasoline stations. All of the vending machines were located in restaurants.
One boy and one girl aged 12, 13, 14, 15, 16, & 17 were recruited through acquaintances to attempt to purchase tobacco.
|Evaluate the influence of age, gender, vending machine lockout devices and tobacco industry sponsored programmes (“It’s the Law” programmes) on underage youths’ ability to purchase tobacco.
Funded by a grant from the Massachusetts Tobacco Control Programme.
|12 young people made 480 attempts to purchase tobacco in Massachusetts from over the counter and vending machines with and without remote control lockout devices. Half the vendors were participating in “It’s the Law” programmes.||Youth were successful in 33% of their purchase attempts. Of the six opportunities to sell, 28% of the vendors never sold, 23% sold once, 16% sold twice, 9% sold three times, 13% sold four times, 6% sold five times, and 6% sold at every opportunity.
Apparent age was a significant predictor of purchase success. Youth who appeared to be 16–17 years old were much more successful than youth who appeared to be 11–15 (OR=3.4, 95% CI= 2.0, 5.8, p=0.0001). Girls had a greater purchase success rate (OR= 1.49, 95% CI=1.01, 2.19, p<0.05). This persisted as a trend when apparent age was controlled in regression analysis (OR=1.59, 95% CI=0.94, 2.7, p=0.08). Boys (29%) and girls (28%) were equally likely to be asked for proof of age even though girls appeared older.
Youth were much more successful purchasing from vending machines than from over the counter sources (OR= 3.0, 95% CI=1.9, 4.7, p=0.0001). In communities with no requirements for lockout devices, illegal sales were far more likely from vending machines than from over the counter sources (OR=5.9, 95% CI=3.3, 10.3, p=0.001). ‘It’s the Law’ programmes were not associated with a significant reduction in illegal sales when vending machine and over the counter sources were considered together (OR= 0.87, 95% CI=0.57, 1.35, p=0.5) or when they were considered separately.
|A well conducted study that took many steps to reduce bias. However, confounders were not accounted for and eligibility criteria were not outlined.|
|Difranza et al.|
|N=156 tobacco merchants in Massachusetts||Examine the efficacy of the Tobacco Institutes “It’s the Law” program.
Funder not mentioned.
|5 underage youth, both male and female made “sham” purchase attempts from merchants participating in “It’s the Law” campaign.||Only 4.5% of 156 merchants were participating in “It’s the Law” program. 86% of merchants who were participating in the program were willing to illegally sell cigarettes to children, compared with 88% who were not participating.||There was a lack of information on sampling method, eligibility criteria, and the type of analysis conducted. No p-values were provided.|
|Fichtenberg et al.|
|N= 9 studies
Inclusion criteria-studies must include compliance and prevalence data
Interventions ranged in intensity from simple enforcement of laws to merchant and community education, to education combined with active enforcement via compliance testing, warnings, fines and suspension of tobacco selling licences.
|To determine the effectiveness of laws restricting youth access to cigarettes on prevalence of smoking among teens.
Funded by the National Cancer Institute.
|Conducted a systematic review of studies that reported changes in smoking associated with the presence of restrictions on the ability of teens to purchase cigarettes.
Calculated the correlation between merchant compliance levels with youth access laws and prevalence (30 day and regular) prevalence of youth smoking, and between changes in compliance and prevalence associated with youth access interventions.
Conducted a random effects meta-analysis to determine the change in youth prevalence associated with youth access interventions from studies that included control communities.
|There was no statistically significant relationship between merchant compliance and 30-day (r=0.116, p=0.486) or regular (r=0.017, p=0.926) teen smoking prevalence.
There was no evidence that an increase in compliance with youth access restrictions was associated with a decrease in 30-day (r=0.294, p=0.237) or regular (r=0.274, p=0.287) prevalence. Although none of these correlations are statistically significant, their signs suggest a positive association between increased compliance and increased smoking prevalence.
There was no significant difference in youth smoking in communities with youth access interventions compared with control communities: the pooled estimate of the mean difference in 30-day prevalence in the intervention group was −1.5% (95% CI - 6.0%, +2.9%)
|A well conducted review. However it is not a Cochrane (which represents the benchmark for evidence-based medicine and reviews are conducted to extremely high standards).|
|Glanz et al.|
|N=across eight years the number of stores surveyed ranged from: 448 in 1998 to 209 in 2003||Study examines the findings of annual Synar inspections to assess compliance with federal and state legislation to limit minors’ access to tobacco products in Hawaii. Study also reports on factors associated with selling tobacco to minors for the most recent year of inspections.
Funded by Hawaii’s Department of Health’s Alcohol and Drug Abuse Division, Federal Substance Abuse Prevention and Treatment Block Grant and the
|Annual random unannounced inspections were conducted by minors over an 8 year period (1996–2003). Stores were randomly selected from a list of stores that sell tobacco products in Hawaii.||There was a decrease in the percent of successful purchases made over the period from 1996 to 2003 (44.5% vs. 6.2%). Based on multivariate analysis, only 2 variables were associated with whether a successful purchase attempt was made in 2003: whether the minors’ age (OR = 0.030, 95% CI =0.002, 0.426) or identification (OR = 0.001, 95% CI = 0.001, 0.020) was requested.||A very well conducted study that accounted for confounders, had a high participation rate, and dealt with missing data.|
|Hawaii Tobacco Control Settlement Fund.|
|Lantz et al.|
Review (narrative synthesis)
|N= not clear how many articles were reviewed (However there are 142 references in the reference list).||To provide a comprehensive review of interventions and policies aimed at reducing youth cigarette smoking in the US, including strategies that have undergone evaluation and emerging innovations that have not yet been accessed for efficiency.
Funded from Mr. Ted Klein, president of Ted Klein and Co., a New York City public relations firm.
|Medline literature searches, books, reports, electronic list servers, and interviews with tobacco control advocates.
Intervention and policy approaches were categorised into seven categories (school based, community interventions, mass media/public education, advertising restrictions, youth access restrictions, taxes and direct restrictions on smoking.
|Youth smoking prevention control efforts have had mixed results. However, this review suggests a number of prevention strategies that are promising, especially if conducted in a coordinated way to take advantage of potential synergies across interventions. Several types of strategies warrant additional attention and evaluation including aggressive media campaigns.||A well conducted review, however, studies were limited to the US. Furthermore, it is not a Cochrane review which is the benchmark for evidence-based medicine and reviews.|
|Landrine et al.|
|N=2,567 purchase attempts from 72 stores. Thirty-six children (18 girls, 18 boys) were recruited to participate in the study. There were 12 children in each of the three age groups (10-, 14-, and 16-year-olds) and 12 in each of the three ethnic groups (whites, Latinos, and African Americans)||Examined the role of asking age/ID in cigarette sales to minors and explored the possible demographic correlates of asking such questions.
Funded by Cigarette and Tobacco Surtax Fund of the State of California through the University of Calif. Tobacco Related Disease Research Program.
|36 minors, representing equal numbers of girls, boys, whites, blacks and Latinos of 10, 14, and 16 year olds each attempted to purchase cigarettes once from each of the 72 stores. The frequency of asking the children their age and/or for ID was analyzed along with the role of these questions in subsequent sales.||The data revealed that requesting age/ID was rare (occurring 17% of the time) despite the laws in California. If clerks asked children their age, sales were significantly less likely (x2=36.3, p<0.001). When age was asked, minors were refused cigarettes 95.8% of the time. Similarly, if clerks requested ID, sales were significantly less likely (x2=16.8, p<0.001). When ID was requested, minors were refused cigarettes 99% of the time. Requesting ID was more strongly associated with decreased sales than asking age.||Good reliability and validity, however, the study dates were not clear, confounders were not addressed and missing data was mentioned but not accounted for.|
|Levinson et al.|
Non-randomised controlled trial
|To estimate the effect on cigarette sales rates when minors present ID
Funded by State Tobacco Education and Prevention Partnership, Colorado Dept. of Health and Environment
|Controlled experiment in which minors attempting to purchase cigarettes either carried a valid ID (documenting that they were minors) or carried no ID< and were instructed to show their ID or admit having no ID if the clerk requested proof of age.||When clerks requested ID, sales were more than 6 times as frequent if minors presented ID than if they did not (12.2% vs. 2.0%, RR = 6.2, p<0.0001).||A well conducted study that adequately addressed concealment, treatment and control groups and comparison of results across sites.|
|Levy and Friend.
Review (narrative synthesis)
|N= 23 studies nationally representative sample||To review empirical studies of youth access policies to better understand the components of successful and unsuccessful interventions and their impact on youth smoking rates. The purpose of this review is to formulate future policies and create a framework for additional research||Interventions: Included enforcement efforts to reduce access by minors at stores, vending machines and social sources.
The relationship between youth access policies and smoking rates is inconsistent.
The researchers also found that in many cases the intervention had only short-term results.
|The researchers found that a successful policy that reduces retail sales usually has a multi-component approach that includes severe enforcement and penalties, as well as community education and mobilization.||A well conducted review that adequately addressed the significance of combining community, mobilization and enforcement to tackle smoking among youth.|
|N=980 stores were visited for controlled purchase operations (CPO’s) between 1996–1997||Reports on the initiative-increased enforcement of section 30(1) which prohibits the sale of tobacco products to persons under the age of 18.
Funder not mentioned.
|Ministry of Health coordinated a programme of CPO’s using under age volunteers to identify merchants illegally selling tobacco products to minors.||Between Sept 1996 and Jun 1997, 693 CPO’s were conducted, and 67 (9.7%) resulted in the sale of tobacco to minors. Between July and Dec 1997, a further 287 CPO’s were conducted and 17 (5.9%) resulted in sales. Therefore a total of 980 CPO’s were conducted, with 84 (6.8) resulting in sales. Of the 49 merchants prosecuted to date (December 1997), 41 were convicted.||No information on the type of analysis and no info on sampling frame. There was a general lack of information.|
|Ross et al.|
|N=16, 558 youth in grades 9–12.||Examine the differential effects of cigarette prices, clean indoor air laws, youth access laws and other socio-economic factors on smoking uptake among US high school students. The study also examines whether those at the final stages of uptake are more price responsive than those at the beginning stage.
Funder not mentioned.
|Youth in grade 9–12 completed the “study of smoking and tobacco use among young people” survey. Questions examined actual smoking behaviour, risk of uptake among non-smokers, and numerous variables examining SES, ethnicity, gender and age.||Compliance with youth access laws reduced the probability of being in a higher stage of smoking uptake (p<0.05). The finding that the impact of compliance is larger for those who are in later stages supports the hypothesis that social sources of cigarettes are more important in the earlier stages of smoking uptake.||A well conducted study, however, there was no baseline or comparison and no information on missing data (readers are told the data is missing but we are not told how this impacts the results).|
|Stead et al.|
Cochrane Review (narrative synthesis)
|N=34 studies (14=had data from a control group for at least one outcome)
Review included controlled trials and uncontrolled studies with pre and post intervention assessment of interventions to change merchants’ behaviour.
|1) Does the intervention with merchants, by education, active enforcement of laws, or combinations of strategies lead to decreased sales to minors? Is there evidence that any of the strategies is superior to the others?
2) Do reduced sales of tobacco to minors lead to a decrease in their self reported ease of access? 3.) Do reduced sales of tobacco to minors reduce the prevalence of tobacco use?
Sources of support: NHS Research and Development Programme UK, Department of Primary Health Care, University of Oxford UK.
|Assess the effects of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales.
Interventions: The review considered education, law enforcement, community mobilization, or combinations of strategies that aimed to deter merchants from selling tobacco to minors.
|Giving merchant’s information was less effective in reducing illegal sales than active enforcement or multi-component educational strategies, or both. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking.||The Cochrane reviews represent the benchmark for evidence-based medicine, and reviews are conducted to extremely high standards.|
|Sundh et al. 2006 Sweden Cross-sectional +||N= 3150 test purchases in three regions of Sweden.
Purchase attempts were made in supermarkets, food stores, after-hours supermarkets, newsagents and gas stations.
28 phone interviews with individuals in the tobacco prevention field (regional and local levels).
|Study the possible changes in adolescents’ opportunities for purchasing tobacco during the period 1996–2005. The study also investigated regional differences in adolescents’ opportunities for purchasing tobacco, and elucidated the efforts by authorities to affect the compliance with the minimum age law of 17.
Funded by the National Institute of Public Health in Sweden.
|In 1996, 1999, 2002, and 2005, 3150 test purchases of tobacco were conducted in controlled forms by 48 adolescents in three regions of Sweden. In addition, 28 structured phone interviews were conducted with key people in tobacco prevention work.||In 1996, 84% of test purchases in shops with a voluntary age limit resulted in successful purchases. A significant decline was observed in 2005, 8 years after the minimum age tobacco law was introduced, with 48% of test purchases resulting in successful purchases (p <0.001). Results showed differences between the three regions (p values ranging from 0.001 to 0.01) in compliance and in activities connected with the minimum age tobacco law.||This study was well conducted but lacked information on eligibility criteria, and was missing data (i.e. why specific communities were not involved in the study). Interview data/results were also lacking (rich data was not provided; all responses were categorized into three categories).|
|Sundh et al
Youth were 13, 15 and 17 years old.
|The purpose of this study was to increase understanding of the prerequisites for tobacco prevention. The situations before and after the introduction of a minimum age law were compared with respect to opportunities for adolescents to buy tobacco, and to attitudes towards the law.
Funded by the National Institute of Public Health in Sweden.
|Data was collected in 1996 and 2000 with a questionnaire examining tobacco, alcohol, drugs, health, family finances etc. Specific questions asked youth for their attitudes towards the minimum age law||Findings revealed that the proportion of boys and girls in year 7 who said that they had bought tobacco during the previous month had decreased significantly from 11.5% to 7.8% and from 11.6% to 6.9%, respectively (both p<0.0001). (p<0.0001) between 1996 and 2000, whereas the corresponding figures for older adolescents remained unchanged.
Restricting the analysis to smokers, the proportion of girls who bought tobacco in shops decreased in all ages groups (Year 7: 93.8% to 74.1%; Year 9: 94.3% to 84.8%; Year 2 of upper secondary school: 96.4% to 90.7%, p<0.001). Corresponding figures for boys showed a statistically significant decrease only among year 9 students (92.8% to 87.6%, p<0.05).
|A well conducted study that discussed the type of analysis conducted and eligibility. However, there was a lack of information on missing data, confounders and reliability.|
|Sundh et al
|N=1,500 purchase attempts
N=750 purchase attempts made before the law
N=750 after the law
|Purpose of the study is to compare the possibility of adolescents purchasing tobacco before and after the introduction of a minimum age law of 18 years, and to examine the factors that characterize the situations in which adolescents may or may not purchase tobacco.
Funded by the National Institute of Public Health in Sweden.
|Under controlled conditions adolescents of varying ages carried out test purchases of tobacco.||In 1996, 91% of purchase attempts were successful, whereas in 1999, 82% of purchase attempts were successful (p<0.001). Requests for age or ID substantially decreased the likelihood of successful purchase.||A well conducted study that included a baseline survey. However, participants who carried out test purchase attempts were legal (18 years old), and simply looked young. This could raise issues of reliability and validity.|
|Tangirala et al.|
|N= 5096 retail outlets in the state of Indiana including 1367 (26.82%) chain stores, 3729 (73.18%) independently owned stores. A total of 326 primary tobacco outlets were also identified via a database.||Determine whether inspections are effective as a means of increasing merchant compliance in restricting sales to persons under the age of 18 years, especially among merchants who have violated the law in the past.
This project is supported by the Master Tobacco Settlement fund through the Indiana Tobacco Prevention and Cessation Agency-administered through the Alcohol & Tobacco Commission and the Indiana Prevention Resource Centre.
|Secondary data analysis was performed on inspection date from 2001–2003. The investigative team identified tobacco retail outlets with more than one inspection within the last 19 month time frame.||The percentage of violations at Inspection 2 was significantly lower than the percentage of violations at Inspection 1 (25.9% vs. 32.3%, p<0.05), indicating that retail outlet inspections are associated with increased sales restrictions to youth.||Study was well conducted and outlined eligibility criteria. Study also does a good job of outlining limitations. However, it failed to account for confounders, and missing data.|
|Tutt et al.|
|N= 133 vendors (1994)
N= 126 (1995)
N= 44 (1996/97)
N= 51 (1997/98)
*Sample of merchants surveyed has been in decline as a result of store closures.
Merchants to be tested : all those located within a 3km radius of four high schools located across the research area plus the nearest main shopping centre.
|Examine retail compliance with prohibition of sales to minors. Proportion of youth smoking was also examined.
Funder not mentioned.
|Retail compliance with prohibition of sales to minors was monitored through a series of undercover compliance surveys between 1993 and 1999. Compliance rates were affected by a campaign aimed at increasing merchant awareness of their obligations under the new law and well publicised prosecutions.
Intervention: education and awareness of Public Health Act (prohibition of selling tobacco to minors). Active enforcement of law in 1995.
|In 1996 seven successful prosecutions occurred across the study area, with most resulting in $1000 penalties and extensive publicity. Since then only three merchants have been successfully prosecuted, 2 in 1997 and 1 in 1999.
Non-compliance in surveys dropped from 30.8% (1994) to 8.1% in May 1996.
The overall proportion of 12–17 year olds reporting at least monthly smoking dropped from 25.9% in 1993, to 22.7% in 1996, and to 17.1% in 1999. Greatest reductions were in youth who smoked “less than 1 a day”, or “1–5 a day” (x2=18.4, p=0.182).
|Confounders mentioned but not accounted for. Study outlined eligibility criteria and response rates. However, changes in the types and intensity of the intervention likely changed compliance checks.|
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