NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015 Jul 23.
Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors.
Washington (DC): National Academies Press (US); 2015 Jul 23.Laws aiming to reduce underage access to tobacco include restrictions on both distribution of tobacco products to and purchase of tobacco products by underage individuals. Laws limiting distribution apply both to commercial tobacco sales and to other methods of provision, such as giving tobacco to a minor or buying tobacco on behalf of a minor (i.e., proxy sales). Restrictions on purchase are distinguished from the restrictions on distribution by the fact that they punish the underage buyer. Purchase laws are commonly accompanied by restrictions on underage tobacco use and possession and are therefore frequently referred to as purchase–use–possession (PUP) laws. There is vast variation and inconsistency across the United States in youth access laws and how they are implemented and enforced. Despite the profusion and complexity of these laws, there is a common thread, which is that the enforcement of these restrictions has focused primarily on curtailing youth access to tobacco from commercial sources. Accordingly, that is the focus of this analysis. This chapter summarizes youth access restrictions in the United States and their enforcement, and it describes survey data regarding where underage users obtain their tobacco products.
In 1992 Congress enacted the Synar Amendment to reduce the availability of tobacco to underage individuals. This law requires states to enact and enforce laws prohibiting the sale and distribution of tobacco to underage persons or face the loss of federal block grant funding for substance abuse prevention and treatment programs. In 1996 the Food and Drug Administration (FDA) issued its Tobacco Rule, in which it asserted its authority to regulate tobacco products (HHS, 1996). As part of this effort, FDA issued regulations on the advertising and marketing of tobacco products to reduce the appeal of tobacco to children and adolescents and also issued restrictions on retail sales to underage persons to reduce youth access to tobacco. The tobacco industry challenged FDA's authority to regulate tobacco in court, and in 2000 the Supreme Court nullified FDA's rule on the grounds that Congress had not granted FDA explicit jurisdiction over tobacco (IOM, 2007).
At the same time that it was fighting federal efforts to regulate tobacco, the tobacco industry was also battling legal challenges brought by the attorneys general of individual states. In 1994 Mississippi Attorney General Michael Moore filed a lawsuit against the major tobacco companies to recoup state Medicaid expenditures on residents with tobacco-related diseases (IOM, 2007). Attorneys general from every state soon followed suit, and on November 23, 1998, the attorneys general from 46 states, the District of Columbia, and several U.S. territories signed the Master Settlement Agreement (MSA) with the major tobacco companies (NAAG, 1998). (Four states had previously reached a separate settlement with the tobacco companies, which awarded them $40 billion.) Although the primary aim of these suits and the resulting agreement focused on the tobacco companies' payment of $206 billion to the states, distributed from 2000 to 2025, as a reimbursement for health care costs that the states had incurred because of tobacco-related health issues, the terms of the agreement also included the establishment of a national charitable foundation (now known as the American Legacy Foundation) devoted to reducing adolescent and young adult smoking and to preventing tobacco-related diseases. The agreement also included tobacco sales and marketing provisions aimed at reducing youth access to tobacco. These provisions included bans on gifts to underage individuals in exchange for proof of purchase of tobacco products, gifts through the mail without proof of the recipient's age, and distribution of free samples except in locations restricted to adults. The MSA also restricted cigarette pack size to a minimum of 20 cigarettes and prohibited tobacco companies from opposing legislation restricting cigarette pack size through 2001. The MSA further prohibited tobacco companies from legally challenging the enforceability or constitutionality of state and local tobacco control laws enacted before June 1, 1998, including state and local youth access laws that may have been enacted in compliance with Synar.
In 2009 President Barack Obama signed the Family Smoking Prevention and Tobacco Control Act (hereafter referred to as the Tobacco Control Act) into law, granting FDA broad authority to regulate the manufacture, marketing, and sales of tobacco products to protect the public's health and to reduce adolescent tobacco use. 1 In pursuit of these goals, the act directs FDA to reissue its 1996 Tobacco Rule along with its advertising and access regulations. FDA regulations issued under the act currently apply to cigarettes, cigarette tobacco, and smokeless tobacco. They do not yet cover other tobacco and nicotine products, such as electronic nicotine delivery systems (ENDS), or e-cigarettes; cigars; snus; etc. However, FDA has formally proposed to “deem” e-cigarettes, little cigars, and other products to be “tobacco products” subject to its regulatory jurisdiction under the Tobacco Control Act (FDA, 2014a). When the final rule is issued and goes into effect, it will almost certainly extend federal youth access restrictions to these other products.
The advertising and marketing regulations issued under the Tobacco Control Act include federal bans complementing the MSA provisions at the state level: banning the sale of cigarette packs containing fewer than 20 cigarettes and prohibiting the distribution of free samples. The act authorizes FDA to restrict tobacco sales to minors, including requiring face-to-face sales, with exceptions for vending machines and self-service displays in adult-only facilities, and requiring age verification for all over-the-counter sales by checking a driver's license or other form of photographic identification of anyone under age 27. The Tobacco Control Act also grants FDA the authority to enforce these restrictions, provides a set of sanctions for violations, and directs FDA to contract with states to assist with retailer compliance checks—random, unannounced inspections of tobacco retailers—to determine whether retailers are illegally selling tobacco to underage individuals. In compliance with the congressional direction, FDA reissued its 1996 Tobacco Rule in 2010 (FDA, 2010).
The Tobacco Control Act also sets limits on FDA's authority. Limits relevant to youth access include prohibiting FDA from banning face-to-face sales by any specific type of tobacco retailer (i.e., FDA cannot ban all pharmacies or convenience stores from selling tobacco) and from raising the federal minimum age of legal access to tobacco products (MLA). The act does, however, establish a federal MLA of 18 without preempting existing state laws or penalties while allowing states and localities to establish a higher MLA.
Although federal law requires an MLA of 18, some states and localities have experimented with higher MLAs. Currently, 46 states have an MLA of 18, while 4 states (Alabama, Alaska, New Jersey, and Utah) have an MLA of 19. (See Appendix A for a list of select U.S. jurisdictions with an MLA of 19.) In the past decade, a number of localities have also adopted an MLA over 18. In 2005, Needham, Massachusetts, became the first location in the United States to establish an MLA of 21. The Needham Board of Health enacted a town regulation raising the age under a Massachusetts state provision that allows local boards of health to make “reasonable health regulations.” 2 Since 2005 numerous Massachusetts towns have followed suit; as of November 2014, 6 towns had an MLA of 19, 22 had an MLA of 21, and another 9 towns were considering proposals to raise the MLA to ages higher than 18. Outside of Massachusetts, Nassau, Onondaga, and Westchester counties in New York State have an MLA of 19, and Hawaii County (the big island in Hawaii), Suffolk County in New York State, and, most notably, New York City have also recently raised the MLA to 21. (See Appendix A for a list of select U.S. jurisdictions with an MLA of 21.) A number of states and localities, including Colorado, Maryland, New Jersey, Texas, Utah, and several localities in California, New Jersey, and Washington State have also considered proposals to raise the MLA to 21. These differing MLAs have not been in place long enough, however, for any differential effects on tobacco use to be detected. (See Appendix A for select states and localities with either proposed or enacted MLAs over 18.)
In compliance with the Synar Amendment, all 50 states and the District of Columbia (51 jurisdictions total) have enacted laws prohibiting the sale or distribution of tobacco products to underage persons. All 51 jurisdictions prohibit commercial transfers, while 48 states and the District of Columbia also prohibit noncommercial transfers (e.g., giving, exchanging, bartering, furnishing, or otherwise distributing tobacco). At least 18 states explicitly differentiate between commercial and noncommercial tobacco transfers for penalty purposes. Penalties vary significantly: 28 jurisdictions authorize license revocation or suspension for sales to minors; about two-thirds of the jurisdictions classify the offense as a criminal offense; and, of the 37 jurisdictions that increase the penalty for repeat violations, 25 authorize substantial fines of $1,000 or more. Currently, all 51 jurisdictions cover cigarettes and smokeless and roll-your-own tobacco, while 31 jurisdictions prohibit the distribution of ENDS. Appendix B provides full details on the laws regarding commercial and noncommercial tobacco transfers to underage individuals for the 50 states and the District of Columbia.
Currently, the youth access laws of 44 states and the District of Columbia penalize underage individuals for the purchase, use, or possession of tobacco. (Maryland, Massachusetts, Nevada, New Jersey, and New York have no PUP prohibitions.) In the vast majority of states, the offense is punishable as a civil infraction. Sanctions for violations of PUP laws include confiscation of the tobacco product, notifying parents of the violation, community service, participation in a tobacco prevention education program, and fines ranging from $5 to $300. In addition, in nine states underage users caught in violation of PUP laws may be subject to having their driver's license suspended or revoked or to having limits placed on their driving privileges (e.g., only from home to work or school and back). Appendix C provides more details on PUP laws for tobacco in the 50 states and the District of Columbia.
Finding 5-1: Although most states currently set the minimum age of legal access to tobacco products at 18, 4 states set it at 19, and New York City and several other localities around the country have raised the minimum legal access age to 21.
Finding 5-2: All 51 jurisdictions prohibit commercial transfers, while 48 states and the District of Columbia also prohibit noncommercial transfers (e.g., giving, exchanging, bartering, furnishing, or otherwise distributing tobacco).
Finding 5-3: All 51 jurisdictions cover cigarettes, smokeless tobacco, and roll-your-own tobacco, while 31 jurisdictions currently prohibit the distribution of electronic nicotine delivery systems.
Finding 5-4: The great majority of jurisdictions (47) prohibit underage individuals from purchasing, attempting to purchase, possessing, or using covered tobacco products. Sanctions typically include a fine or community service.
This section summarizes current enforcement policies and practices at the federal, state, and local levels pertaining to youth access restrictions. Because enforcement of these restrictions is largely focused on assuring compliance by licensed tobacco retailers, the committee's review and analysis is also focused here. However, this section also summarizes what little is known about the enforcement of MLA restrictions against Internet vendors and black market sellers as well as the noncommercial distribution of tobacco by so-called social sources.
States and localities in the United States did not seriously enforce youth access laws in the early 1990s, when these laws were first being implemented (IOM, 1994). Evidence from the United States and abroad further suggests that retailers are not likely to comply with MLA laws if there is no meaningful enforcement (e.g., compliance checks and sanctions for violations) (CDC, 1993; Cismoski and Sheridan, 1993; DiFranza, 1999, 2000; DiFranza and Coleman, 2001; Erickson et al., 1993; Kuendig, 2011; Rigotti et al., 1997; Schensky et al., 1996; Verdonk-Kleinjan et al., 2008).
The federal government oversees two comprehensive programs to enforce the MLA for tobacco products: the Synar program of the Substance Abuse and Mental Health Services Administration (SAMHSA) and FDA's tobacco retail compliance inspection contracts, which are implemented by states and localities.
The 1992 Synar Amendment requires states to enact and enforce laws prohibiting the sale or distribution of tobacco to persons under age 18 or face the loss of 40 percent of federal Substance Abuse Prevention and Treatment Block Grants. SAMHSA, charged with implementing the amendment, issued regulations in 1996 to provide further guidance to states. These regulations stipulate that, in addition to enacting laws restricting underage access to tobacco, states must also enforce these laws “in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under the age of 18” (SAMHSA, 1996, p. 1492); must develop a strategy to reduce the rate of illegal tobacco sales to underage persons to 20 percent or less by 2003; and must conduct annual compliance checks of retailers selling tobacco both over the counter and from vending machines to ensure compliance with the law. Moreover, because Synar primarily aims to survey the rate of illegal tobacco sales to underage persons, it requires states to demonstrate that their compliance checks include a statistically representative sample of tobacco retail outlets accessible to children and adolescents. These compliance checks may (but are not required to) include a state-level enforcement component. Thus, some programs may not have sanctions for violations and may instead use other measures, such as education programs targeted at retailers and mass media campaigns, to ensure high levels of compliance. Despite the lack of a regulatory requirement, a study of Synar implementation (DiFranza and Dussault, 2005) found that the Department of Health and Human Services pressured some states to adopt compliance checks as an instrument of enforcement instead of using those checks as a basis for retailer education alone. Furthermore, although federal block grants are conditioned on state enforcement of their youth access laws, states are explicitly prohibited from using the block grant funds to finance Synar compliance checks. The regulation also requires states to submit an annual report to SAMHSA detailing activities they conducted to reduce illegal sales of tobacco to underage persons (including methods used to conduct compliance checks), progress achieved, and plans for enforcing the youth tobacco access law in the next year. The Synar regulation applies to all 50 states, the District of Columbia, and 8 U.S. territories. It is not applicable to American Indian tribes.
FDA's tobacco retail inspection contracts provide funding to state partners to conduct compliance check inspections specifically for enforcement purposes. As such, violations may lead to escalating fines, from warning letters to civil monetary penalties to suspension or revocation of retailers' licenses to sell tobacco. Unlike Synar, FDA only requires inspection of over-the-counter tobacco retailers because the Tobacco Control Act restricts vending machines to adult-only facilities, to which underage persons should not have access. Additionally, since the program is not intended for comprehensive surveillance, FDA contracts neither require a statistically valid survey of tobacco retailers nor set a performance target. However, FDA requires inspections using older decoys (ages 16–17) in neighborhoods considered to be at higher risk for violations, including neighborhoods with greater concentrations of populations with low socioeconomic status or of racial/ethnic minorities; these communities tend to have a greater density of tobacco retailers or have traditionally been targeted by the tobacco industry (CTP, 2014). Furthermore, states and territories may use FDA inspection contract funds to support Synar compliance checks so long as compliance check protocols and grant recipients meet the requirements of both programs. Moreover, because FDA contracts are narrowly restricted to enforcement activities, it is likely that states and localities will need to continue to conduct other youth tobacco access prevention activities, such as mass media campaigns and community and retailer education programs, to meet the Synar performance target (i.e., an 80 percent rate of compliance). FDA is authorized to contract with all states, the District of Columbia, five U.S. territories (American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Puerto Rico, and the U.S. Virgin Islands), and—unlike Synar—also with American Indian tribes.
Under the two federal programs, enforcement activities are required to include compliance check inspections. However, because they are implemented at the state and local levels, enforcement activities and penalties for violations range considerably. A standard compliance check protocol involves sending supervised underage individuals into tobacco retailers to attempt to purchase tobacco. The underage decoys are typically nonsmokers who have no visible tattoos or piercings and are sent alone or in pairs. The decoys range in age (from 13 to 17), gender, and race. Most decoys ask to purchase cigarettes, but some are instructed to ask for smokeless or other tobacco products. Some carry and are instructed to present their own genuine photographic identification, while others are instructed not to present identification and to tell clerks that they have forgotten it. Some decoys carry out purchases, while others refuse the sale once it is verified that vendors were willing to sell to underage users. In some inspections, supervisors are stationed discreetly in the store to observe and record details of the transaction. In others, supervisors wait outside for the decoys to report a list of details about the store and their transactions immediately following each purchase attempt. Each of these variations in compliance check protocol may influence a state's compliance rate.
In addition to the variation in the compliance check protocol, there is significant variation in the frequency of inspections, whether and how often violators are reinspected, how and when violators are prosecuted, which (if any) agency has authority over enforcement, how much funding is available for enforcement, and the penalties for violations. Thus, although there is general agreement that youth tobacco access laws must be actively enforced to reduce illegal tobacco sales to minors, there remains a profusion of enforcement strategies and little evidence about the relative effectiveness and efficiency of these various activities. In an effort to identify best practices, a study by DiFranza (2005) examined 26 enforcement strategies in the 10 states with the highest retailer compliance rates and the 10 states with the lowest retailer compliance rates that had been reported to Synar. DiFranza concluded that the strategies essential for achieving high compliance include having a plan to enforce the state's MLA law, designating a single state agency to oversee and coordinate enforcement, conducting ongoing compliance check inspections, allocating state funding for enforcement inspections, prosecuting violators, setting penalties for violations, and practicing effective merchant education. He also identified a number of strategies that were recommended, but not essential, and also listed strategies that were not recommended because they waste resources or hinder enforcement. There were also a number of other strategies that could not be rated due to insufficient evidence. Indeed, despite the multitude of enforcement practices, relatively few of these practices have been evaluated, and there is little evidence about which specific enforcement practices successfully reduce the availability of tobacco to underage individuals.
Both the Synar Amendment and FDA's compliance testing program have resulted in considerable strengthening of state and local enforcement practices. Since the 1990s, all states have adopted youth access laws and have seen significant improvements in retailer compliance. In 1997, immediately following the implementation of Synar, the national average rate of illegal tobacco sales to minors reported to Synar was greater than 40 percent, with a high of 72.7 percent in one state (SAMHSA, 2014). By 2006 all states and the District of Columbia achieved compliance with the Synar requirements, including achieving the target sales rate of 20 percent or less (within the 3 percent margin of error), and they have continued to be in compliance since then (SAMHSA, 2014). In 2013 the national average rate of tobacco sales to minors for all states and the District of Columbia was 9.6 percent, and it ranged from the highest reported rate of 22.5 percent in Oregon to 1.0 percent in Minnesota and Nevada (SAMHSA, 2014). Since establishing its tobacco retail inspection contracts in 2010, FDA has granted more than $100 million in contracts in all 50 states, the District of Columbia, and five American territories (FDA, 2014b), which has resulted in more than 249,000 inspections of tobacco retailers, 12,600 warning letters, and 1,160 civil money penalties (Lindblom, 2014). Since FDA's program does not measure program performance, the degree to which these contracts have increased retailer compliance with MLA laws is unknown. Finally, although most data on illegal tobacco sales to underage individuals come from cigarette sales, some evidence suggests that rates of illegal sales of other tobacco products (e.g., smokeless tobacco, snus, and snuff) to underage adolescents are comparable to, if not higher than, those for cigarettes (Choi et al., 2014; Clark et al., 2000; Hanson et al., 2000).
Finding 5-5: Although the intensity of retailer enforcement continues to vary widely among the states, federal support has strengthened state and local enforcement practices across the country.
Finding 5-6: According to data collected by the federally supported compliance testing program, the average rate of tobacco sales to minors (i.e., noncompliance in all of the states) in 2013 was 9.6 percent nationally and ranged from 1 percent to more than 20 percent in the individual states.
Youth access laws vary widely in the range of sanctions prescribed for tobacco retailers who sell tobacco to underage individuals. Violations can be designated as either civil or criminal offenses. Minimum penalties for first offenses range from a warning letter to fines up to $1,000, while maximum penalties for subsequent offenses range from license revocation to fines up to $15,000. As noted above, criminal penalties are prescribed for violations in about two-thirds of the jurisdictions. However, the committee has been unable to identify systematic information about the nature and severity of the sanctions actually imposed in practice.
Although the evidence suggests that very few underage persons obtain tobacco from the Internet (Johnston et al., 2014b), Internet tobacco vendors are a new and growing potential source of tobacco for underage individuals, especially among the youngest smokers (Johnston et al., 2014b). Accordingly, there have been some efforts to curtail Internet sales to minors. A survey of Internet cigarette vendors (Ribisl et al., 2002) found that, while the majority of vendors had minimum age warnings on some part of their website, age verification procedures were generally weak, the most common being to ask users to check a box affirming that they were of legal age or to type their birth date. In 2002, California passed legislation requiring Internet cigarette vendors to verify the age of purchasers upon both purchase transaction and delivery (Williams et al., 2006). Unfortunately, an evaluation of this law found zero compliance (Williams et al., 2006). Although it was targeted at reducing illicit sales of untaxed cigarettes and only incidentally affected underage access, in 2005 the Bureau of Alcohol, Tobacco, Firearms and Explosives, in conjunction with several state attorneys general, entered into a voluntary agreement with major credit card and private shipping companies to ban payment transfers and the delivery of cigarettes purchased on the Internet. As with the California legislation, this effort was unsuccessful, and a study of Internet cigarette vendors and sales following these agreements found that despite increases in the proportion of vendors complying with these agreements, the overall number of Internet cigarette vendors increased, leading to a net increase in Internet cigarette sales (Ribisl et al., 2011). FDA's authority under the Family Smoking Prevention and Tobacco Control Act extends to online tobacco retailers, but as of September 2014 FDA's Center for Tobacco Products has issued only four warning letters to Internet vendors found selling to underage customers, and it is unclear to what extent the center will pursue these violations (FDA, 2014c).
Finding 5-7: Limited evidence suggests that youth access restrictions against Internet sellers are weakly enforced, and that tobacco products are relatively easily available to underage individuals.
An expected effect of restricting the retail sale of tobacco to minors is that underage persons will seek tobacco from alternative sources. These would include both alternative commercial sources (e.g., non-licensed dealers in illegal markets) and so-called social sources, such as proxy sales (i.e., tobacco purchases on behalf of an underage person) and gifts from peers, relatives, and strangers (Fichtenberg and Glantz, 2002; Glantz, 1996; Ling et al., 2002). Indeed, there is some evidence that when access from retail sources is restricted, there is a corresponding increase in recourse to the use of non-retail sources (Cummings et al., 2003; DiFranza and Coleman, 2001; Rigotti et al., 1997; Rimpela and Rainio, 2004). It is to curb these transactions that almost all state youth access laws prohibit non-retail sources of tobacco to underage individuals. These laws restrict other commercial sales, such as illegal suppliers (i.e., street vendors and those selling untaxed cigarettes), as well as noncommercial distribution. Unfortunately, there is little information on the enforcement of laws against sales and distribution by these other sources, much less the effects of such enforcement.
Aside from the occasional study on the purchase of single cigarettes, or “loosies,” from street vendors (e.g., Smith et al., 2007), there is little information available on the frequency of youth purchases on the illegal market (i.e., from commercial sellers other than retail stores) or on enforcement activities aiming to curtail sales to underage individuals. At the same time, there is little evidence that underage individuals are obtaining tobacco from the illegal commercial market. A recent report (NRC, 2015) estimates that underage individuals constitute at most 1 percent of the illicit market.
Finding 5-8: Although there is an illicit market for tobacco products diverted from legal channels, there is little evidence that underage persons are obtaining tobacco from the illegal commercial market.
Despite the facts that underage persons obtain most of their tobacco products from “social sources” (see next section) and that most state laws prohibit noncommercial distribution, there is no evidence indicating that youth access restrictions against noncommercial distributors are enforced. As is discussed in Chapter 6, similar prohibitions against the noncommercial distribution of alcohol are sometimes enforced—for example, against parents who facilitate underage drinking and against adults who agree to purchase alcohol for underage persons who recruit them to do so outside liquor stores (the so-called shoulder taps) (IOM and NRC, 2004). However, equivalent restrictions against tobacco transfers appear to be unenforced.
Finding 5-9: There is no evidence indicating that bans on noncommercial distribution of tobacco by friends, proxy purchasers, and other “social sources” are enforced.
Although the intensity of retailer enforcement continues to vary widely among the states, federal support has strengthened state and local enforcement practices across the country. According to data collected by the federally supported compliance testing program, the national average rate of tobacco sales to minors (i.e., noncompliance) was 9.6 percent in 2013 and ranged from 1 percent to 20 percent in the individual states. Limited evidence suggests that youth access restrictions against Internet sellers are weakly enforced and that tobacco products are relatively easily available to underage individuals who have credit cards. Although there is an illicit market for tobacco products diverted from legal channels, there is little evidence that underage individuals are obtaining tobacco from the illegal commercial market. Although almost all states ban noncommercial distribution to minors, there is no indication in the literature that these restrictions are being enforced, and the committee strongly suspects that these restrictions are essentially unenforced throughout the country. As discussed in Chapter 9, the committee does not expect that situation to change, whether or not the legal purchase age is raised.
Having described the scope and enforcement of underage access restrictions, this section reviews survey data indicating where underage persons obtain tobacco, whether use of these sources varies by age of the user, whether these sources have changed over time, and whether inferences can be drawn from these data regarding the effects of enforcing MLA restrictions on the availability of tobacco to underage users. As discussed above, underage users obtain tobacco from both commercial and social sources. Table 5-1 lists the primary sources considered in this report from which adolescents obtain tobacco. Although new patterns of tobacco use suggest that adolescents and young adults are increasingly using new and other types of tobacco products (Arrazola et al., 2013; Eaton et al., 2012), most empirical data about underage acquisition behaviors are largely restricted to cigarettes. Two national surveys of adolescent tobacco use provide some detailed information on how and where adolescents obtain their cigarettes: the National Youth Tobacco Survey (NYTS) and the Monitoring the Future (MTF) survey.
Sources of Tobacco for Underage Persons.
Table 5-2 provides the responses by current smokers in the 2012 NYTS survey, broken down by age group and gender, to the question: “During the past 30 days, how did you get your own cigarettes?”
Methods for Obtaining Cigarettes Among High School Students, by Age and Gender, National Youth Tobacco Survey, 2012.
Among all high school students, the most commonly reported answers to the question of where they got their tobacco were: Someone offered me a cigarette (40.2 percent); I asked someone to give me a cigarette (32.0 percent); I had someone else buy a pack of cigarettes for me (30.6 percent); and I bought a pack of cigarettes myself (27.9 percent). Less common responses were: I bought cigarettes from another person (8.3 percent); and I took cigarettes from a store or another person (9.9 percent). Sixteen percent said they got cigarettes some other way.
Responses varied considerably by age. The youngest age group (9 to 14 years old) was the most varied in the types of methods used to obtain cigarettes and included 40.1 percent who answered “some other way.” The oldest age group (18 and older), who can legally purchase cigarettes, cited fewer methods, with 71.1 percent saying they bought their own cigarettes. Responses did not vary greatly by gender.
Table 5-3 summarizes the responses by current smokers in NYTS, by age group and gender, to the question, “During the past 30 days, where did you buy your own cigarettes?” Among the students who said that they had purchased their own cigarettes, the most commonly cited specific source was “a gas station or convenience store” (45.8 percent of high school students). This was true even among the youngest age group (9 to 14 years old), although relatively few of these students (10.8 percent, as indicated in Table 5-2) actually purchased their own cigarettes. Responses did not vary greatly by gender.
Sources of Purchased Cigarettes Among High School Students, by Age and Gender, National Youth Tobacco Survey, 2012.
MTF surveys ask two questions about the sources of cigarettes for current smokers: (1) “During the last 30 days, about how many times (if any) have you bought cigarettes?” with a list of possible methods for purchasing offered as potential answers, and (2) “During the last 30 days, about how many times (if any) did you buy cigarettes for your own use?” with a list of possible places for purchasing offered as potential answers. Tables 5-4a and 5-4b provide the responses by grade and by year group. Among 12th graders, the responses are provided separately for those under age 18, who cannot legally purchase cigarettes, versus those 18 and older who can. “Having a friend or relative buy them for you” was the most often cited method of access for 12th-grade smokers under the age of 18. For 12th graders who were 18 or older, the most cited method was to purchase cigarettes for themselves. Twelfth graders under the age of 18 were less likely than those 18 or older to say they purchased their own cigarettes, but a considerable proportion did say they purchased their own cigarettes. For example, in 2010–2013, 47.4 percent purchased cigarettes in a store where the clerk had to hand them the pack or carton. With respect to the places where students purchased their own cigarettes, convenience stores and gas stations were clearly the most common, particularly for those 18 and older.
Trends in Sources of Cigarettes Among Current Smokers, 8th and 10th Grades, MTF, 1997–2013.
Trends in Sources of Cigarettes Among Current Smokers, 12th Grade, MTF, 1997–2013.
In both NYTS and MTF, a considerable portion of younger adolescents reported obtaining cigarettes in “some other way.” These responses likely include adolescents who are given cigarettes by family members but who are reluctant to disclose this and thereby inculpate their relatives (CDC, 2014; Johnston et al., 2014b). Among adolescents who reported buying cigarettes and were asked where (e.g., Table 5-3), the high rates of obtaining cigarettes “from some other place not mentioned here” likely refers to superstores (e.g., Kmart, Target, Walmart), which have proliferated recently and do not fall into the other survey response categories (CDC, 2014).
With respect to trends, Tables 5-4a and 5-4b show that self-service (i.e., purchasing cigarettes in a store where one can pick up a pack or carton and bring it to a checkout counter) has declined considerably since 1997–2001 among all three grade levels. Purchases from vending machines are also down, by about half in all groups. Purchasing cigarettes at a big supermarket or at a small grocery store has declined considerably over time. Purchases from a website have not changed noticeably and remain at very low levels.
In addition to trends observed in survey data, limited empirical evidence suggests that the relative reliance on different types of sources has also changed over time. An analysis of access to cigarettes in the Minnesota Adolescent Community Cohort (Widome et al., 2007) found that between 2000 and 2003 the likelihood of having obtained cigarettes from a commercial source in the past month declined, while the likelihood of having obtained cigarettes from a social source in the past month increased. A New Zealand study (Gendall et al., 2014) of adolescents' main source of tobacco supply between 2006 and 2011, which further differentiated by type of social source (friend, caregiver, or other), found a significant decline in the percentage of adolescents ages 14 to 15 reporting friends as a main source of cigarettes, significant increases in the percent reporting caregivers and others as a main source, and no significant change in the percentage who reported purchasing from a shop. This shift in sources likely reflects the success of youth access restrictions at decreasing adolescents' access to tobacco from commercial retailers. The mechanism by which this may be occurring is elaborated on in Chapter 6.
Unlike the case with cigarettes, adolescents were most likely to purchase other tobacco products for themselves, followed by someone else offering tobacco to adolescents. Table 5-5 shows the responses to the question in the 2012 NYTS: “During the past 30 days, how did you get your own cigars, cigarillos, or little cigars?” Among high school students who reported smoking cigars, cigarillos, or little cigars in the past 30 days, the most commonly reported answers were: I bought them myself (31.4 percent); someone offered it to me (26.6 percent); I had someone else buy them for me (25.5 percent); and I asked someone to give me one (14.4 percent). Very few younger students reported smoking cigars, cigarillos, or little cigars in the past 30 days, so data are not reported by age.
Methods for Obtaining Cigars, Cigarillos, or Little Cigars Among High School Students, by Gender, NYTS, 2012.
Table 5-6 summarizes the responses by current smokers in the 2012 NYTS, by gender, to the question, “During the past 30 days, where did you buy your own cigars, cigarillos, or little cigars?” As was the case with cigarettes, by far the most commonly cited specific source among all the current smokers was a gas station or convenience store (44.0 percent). No other specific source was cited by more than 6 percent of respondents. Responses did not vary much by gender.
Sources of Purchased Cigars, Cigarillos, or Little Cigars Among High School Students, by Gender, NYTS, 2012.
Table 5-7 shows the responses to the question in the 2012 NYTS: “During the past 30 days, how did you get your own chewing tobacco, snuff, or dip?” Among high school students who reported using chewing tobacco, snuff, or dip in the past 30 days, the most commonly reported answers were: I bought it myself (32.0 percent); someone offered it to me (27.7 percent); I had someone else buy it for me (26.4 percent); and I asked someone to give me some (23.9 percent). Very few younger students reported using chewing tobacco, snuff, or dip in the past 30 days, so the data are not reported by age.
Methods for Obtaining Chewing Tobacco, Snuff, or Dip Among High School Students, by Gender, NYTS, 2012.
Table 5-8 summarizes the responses by current users of chewing tobacco, snuff, or dip in the 2012 NYTS, by gender, to the question, “During the past 30 days, where did you buy your own chewing tobacco, snuff, or dip?” Among all the current users, and similar to the case for both cigarette and cigar purchases, by far the most commonly cited specific source was a gas station or convenience store (43.4 percent).
Sources of Purchased Chewing Tobacco, Snuff, or Dip Among High School Students, by Gender, NYTS, 2012.
Finding 5-10: The proportion of underage youth reporting that they obtained cigarettes from vending machines and from self-service displays has declined substantially since these practices were outlawed.
Finding 5-11: The proportion of underage youth reporting that they obtained cigarettes in a face-to-face retail transaction has declined significantly since 1997, while the proportion of underage users relying primarily on social sources has increased since 1997, probably reflecting increased retailer compliance with age verification requirements and sales prohibitions.
Finding 5-12: Although twelfth graders and 16- to 17-year-olds find it easier than younger teenagers to obtain cigarettes from a commercial retailer, the proportion who are able to do so has steadily declined in all age groups since 1997.
Arrazola RA, Dube S, King BA. Tobacco product use among middle and high school students—United States, 2011 and 2012. Morbidity and Mortality Weekly Report. 2013; 62 (45):893–897. [PMC free article : PMC4585347 ] [PubMed : 24226625 ]
CDC (Centers for Disease Control and Prevention). Minors' access to tobacco—Missouri, 1992, and Texas, 1993. Morbidity and Mortality Weekly Report. 1993; 42 (7):125–128. [PubMed : 8437540 ]
CDC (Centers for Disease Control and Prevention). National Youth Tobacco Survey. CDC, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. 2014. [February 7, 2015]. http://www .cdc.gov/tobacco /data_statistics/surveys/nyts .
Choi K, Fabian LE, Brock B, Engman KH, Jansen J, Forster JL. Availability of snus and its sale to minors in a large Minnesota city. Tobacco Control. 2014; 23 (5):449–451. [PMC free article : PMC4039575 ] [PubMed : 23303287 ]
Cismoski J, Sheridan M. Availability of cigarettes to under-age youth in Fond du Lac, Wisconsin. Wisconsin Medical Journal. 1993; 92 (11):626–630. [PubMed : 8303900 ]
Clark PI, Natanblut SL, Schmitt CL, Wolters C, Iachan R. Factors associated with tobacco sales to minors: Lessons learned from the FDA compliance checks. JAMA. 2000; 284 (6):729–734. [PubMed : 10927782 ]
Cummings KM, Hyland A, Perla J, Giovino GA. Is the prevalence of youth smoking affected by efforts to increase retailer compliance with a minors' access law? Nicotine & Tobacco Research. 2003; 5 (4):465–471. [PubMed : 12959784 ]
DiFranza JR. Are the federal and state governments complying with the Synar Amendment? Archives of Pediatrics and Adolescent Medicine. 1999; 153 (10):1089–1097. [PubMed : 10520619 ]
DiFranza JR. State and federal compliance with the Synar Amendment: Federal fiscal year 1997. Archives of Pediatrics and Adolescent Medicine. 2000; 154 (9):936–942. [PubMed : 10980799 ]
DiFranza JR. Best practices for enforcing state laws prohibiting the sale of tobacco to minors. Journal of Public Health Management and Practice. 2005; 11 (6):559–565. [PubMed : 16224293 ]
DiFranza JR, Coleman M. Sources of tobacco for youths in communities with strong enforcement of youth access laws. Tobacco Control. 2001; 10 (4):323–328. [PMC free article : PMC1747607 ] [PubMed : 11740022 ]
DiFranza JR, Dussault GF. The federal initiative to halt the sale of tobacco to children—The Synar Amendment, 1992-2000: Lessons learned. Tobacco Control. 2005; 14 (2):93–98. [PMC free article : PMC1748003 ] [PubMed : 15791018 ]
Eaton DK, Kann L, Kinchen S, Shanklin SL, Flint KH, Hawkins J, Harris WA, Lowry R, McManus T, Chyen D, Whittle L, Lim C, Wechsler H. Youth risk behavior surveillance—United States, 2011. Morbidity and Mortality Weekly Report. 2012; 61 (4):1–162. [PubMed : 22673000 ]
Erickson AD, Woodruff SI, Wildey MB, Kenney E. A baseline assessment of cigarette sales to minors in San Diego, California. Journal of Community Health. 1993; 18 (4):213–224. [PubMed : 8408751 ]
FDA (Food and Drug Administration). CFR, part 1140. Final rule. Federal Register. 2010;21; 75 (53):13225–13232. [PubMed : 20383919 ]
FDA (Food and Drug Administration). 21. CFR, parts 1100, 1140, and 1143. Proposed rule. Federal Register. 2014a; 79 (80):23142–23207.
FDA (Food and Drug Administration). FDA tobacco retail inspection contracts. 2014b. [October 31, 2014]. http://www .fda.gov/TobaccoProducts /ResourcesforYou /ucm228914.htm .
FDA (Food and Drug Administration). Inspections, compliance, enforcement and criminal investigations. 2014c. [October 31, 2014]. http://www .fda.gov/ICECI /EnforcementActions /WarningLetters/default.htm .
Fichtenberg CM, Glantz SA. Youth access interventions do not affect youth smoking. Pediatrics. 2002; 109 (6):1088–1092. [PubMed : 12042547 ]
Gendall P, Hoek J, Marsh L, Edwards R, Healey B. Youth tobacco access: Trends and policy implications. BMJ Open. 2014; 4 (4):e004631. [February 8, 2015]; http://bmjopen .bmj.com /content/4/4/e004631.full . [PMC free article : PMC3996823 ] [PubMed : 24742976 ]
Glantz SA. Preventing tobacco use—The youth access trap. American Journal of Public Health. 1996; 86 (2):156–158. [PMC free article : PMC1380318 ] [PubMed : 8633727 ]
Hanson K, Hatsukami D, Boyle R, Brown S. Minors' access to snuff: Purchase outcomes at corporate owned and independently owned convenience stores. Addictive Behaviors. 2000; 25 (2):289–293. [PubMed : 10795954 ]
HHS (Department of Health and Human Services). 21.CFR, parts 801, 803, 804, 807, 820, and 897: Regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents; final rule. Federal Register. 1996; 61 (168):44396–44618.
IOM (Institute of Medicine). Growing up tobacco free: Preventing nicotine addiction in children and youths. Lynch BS, Bonnie RJ, editors. Washington, DC: National Academy Press; 1994. [PubMed : 25144107 ]
IOM (Institute of Medicine). Ending the tobacco problem: A blueprint for the nation. Bonnie RJ, editor. Washington, DC: The National Academies Press; 2007.
IOM and NRC (Institute of Medicine and National Research Council). Reducing underage drinking: A collective responsibility. Bonnie RJ, editor. Washington, DC: The National Academies Press; 2004. [PubMed : 20669473 ]
Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE, Miech RA. Monitoring the Future: National survey results on drug use 1975–2013. Volume 1: Secondary school students. Ann Arbor: Institute for Social Research, University of Michigan; 2014a.
Johnston LD, O'Malley PM, Miech RA, Bachman JG, Schulenberg JE. Monitoring the Future: National survey results on drug use: 1975–2013: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan; 2014b.
Kuendig H. Enforcement of regional bans on tobacco sales to minors in Switzerland—Example of missed opportunity? European Journal of Public Health. 2011; 21 (6):750–752. [PubMed : 20943992 ]
Lindblom E. The health implications of raising the minimum age for purchasing tobacco products. Presentation at Committee on the Health Implications of Raising the Minimum Age for Purchasing Tobacco Products, February 4, 2014. Washington, DC: 2014. [February 25, 2015]. http://www .iom.edu/Activities /PublicHealth /TobaccoMinimumAge/2014-FEB-04.aspx .
Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tobacco Control. 2002; 11 (1):3–6. [PMC free article : PMC1747643 ] [PubMed : 11891349 ]
NRC (National Research Council). Understanding the U.S. illicit tobacco market: Characteristics, policy context, and lessons from international experiences. Washington, DC: The National Academies Press; 2015.
Ribisl KM, Kim AE, Williams RS. Are the sales practices of Internet cigarette vendors good enough to prevent sales to minors? American Journal of Public Health. 2002; 92 (6):940–941. [PMC free article : PMC1447488 ] [PubMed : 12036783 ]
Ribisl KM, Williams RS, Gizlice Z, Herring AH. Effectiveness of state and federal government agreements with major credit card and shipping companies to block illegal Internet cigarette sales. PLoS ONE. 2011; 6 (2):e16754. [PMC free article : PMC3038914 ] [PubMed : 21340032 ]
Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco-sales laws on adolescents' access to tobacco and smoking behavior. New England Journal of Medicine. 1997; 337 (15):1044–1051. [PubMed : 9321533 ]
Rimpela AH, Rainio SU. The effectiveness of tobacco sales ban to minors: The case of Finland. Tobacco Control. 2004; 13 (2):167–174. [PMC free article : PMC1747848 ] [PubMed : 15175535 ]
SAMHSA (Substance Abuse and Mental Health Services Administration). 45.CFR, part 96. Final rule. Federal Register. 1996; 61 (13):1492–1509.
SAMHSA (Substance Abuse and Mental Health Services Administration). FFY 2013 annual Synar reports: Tobacco sales to youth. 2014. [October 30, 2014]. http://www .samhsa.gov /sites/default/files /synar-annual-report-2013.pdf .
Schensky AE, Smith SS, Icenogle DL, Fiore MC. Youth tobacco sale compliance checks: Impact on vendor practices and community policy. Wisconsin Medical Journal. 1996; 95 (11):775–778. [PubMed : 8952440 ]
Smith KC, Stillman F, Bone L, Yancey N, Price E, Belin P, Kromm EE. Buying and selling “loosies” in Baltimore: The informal exchange of cigarettes in the community context. Journal of Urban Health. 2007; 84 (4):494–507. [PMC free article : PMC2219569 ] [PubMed : 17431795 ]
Verdonk-Kleinjan WMI, Knibbe RA, Bieleman B, De Groot HN, De Vries H. The tobacco sales ban and tobacco purchases by adolescents: A general population study in the Netherlands. European Journal of Public Health. 2008; 18 (5):498–503. [PubMed : 18579576 ]
Widome R, Forster JL, Hannan PJ, Perry CL. Longitudinal patterns of youth access to cigarettes and smoking progression: Minnesota Adolescent Community Cohort (MACC) study (2000-2003). Preventive Medicine. 2007; 45 (6):442–446. [PMC free article : PMC2255062 ] [PubMed : 17719080 ]
Williams RS, Ribisl KM, Feighery EC. Internet cigarette vendors' lack of compliance with a California state law designed to prevent tobacco sales to minors. Archives of Pediatrics and Adolescent Medicine. 2006; 160 (9):988–989. [PubMed : 16953026 ]
Family Smoking Prevention and Tobacco Control Act of 2009, Public Law 111-31 111th Cong. (June 22, 2009).
MASS. GEN. LAWS ch. 111 § 31.
