Enforcing bans on cigarette sales to kids reduces youth smoking

A new study finds that enforcing federal and state laws against tobacco sales to minors dramatically decreases underage smoking rates.

The results show that laws prohibiting sales of cigarettes to minors and stepped up enforcement of those laws in the United States have led to a 20.8 percent drop in the odds of 10th graders becoming daily smokers.

The study is the first nationwide review to show that laws prohibiting retailers from selling cigarettes to underage youth are working as intended. "Skeptics argued that prohibiting sales to minors wouldn't help, because kids would always be able to get cigarettes somewhere," said Joseph DiFranza, MD, Professor of Family Medicine and Community Health at the University of Massachusetts Medical School.

"Our data suggest that a 25 percent increase in compliance of laws prohibiting cigarette sales to minors has about the same deterrent effect as increasing the price by $2.00 in 2006 dollars," said DiFranza. But he emphasized that policy makers should not interpret this study as picking between two options. "We need to continue to raise tobacco taxes and improve compliance on laws preventing cigarette sales to minors as a part of a comprehensive approach to reducing smoking rates among youth."

Some smaller, earlier studies on the effectiveness of laws on cigarette sales to minors were inconclusive, in part because of lax penalties and uneven enforcement. But DiFranza said, "This study clearly demonstrates that enforcing these laws reduces smoking rates among youth." The study appears in the current issue of the journal BMC Public Health and was funded by the Substance Abuse Research Policy Program (SAPRP) of the Robert Wood Johnson Foundation.

The authors looked at enforcement between 1997 and 2003, after Congress passed the Synar Amendment in 1996, which for the first time required states to pass and enforce laws barring tobacco sales to minors. The law also forced states to monitor compliance by sending underage decoys into stores to try to purchase tobacco. The researchers analyzed this nationwide compliance data, and compared it with smoking rates among a nationally representative sample of 16,244 adolescents from the 2003 Monitoring the Future survey. They concluded that for every 1 percent increase in the rate of merchant compliance with the laws, daily smoking rates among 10th graders fell by 2 percent.

Overall, smoking rates among teens fell by half between 1997 and 2003. While the Synar Amendment was one important factor, rising cigarette prices, bans on smoking in restaurants and anti-tobacco advertising have also discouraged smoking among teens.

This study accounted for these changes and other risk factors and still found a strong correlation between strictly enforced bans on sales to minors and declining daily smoking. "This study is the first to look at the cumulative effects of seven years of enforcement," said DiFranza. "Banning sales sets up a virtuous cycle because younger kids see fewer and fewer older role models smoking cigarettes."

DiFranza's focus on enforcement grew out of his experience as a family physician. "I would work for a decade to help an adult smoker quit, and the next day a teenager would come in who had just started smoking," he said. Even states like Massachusetts, which passed laws against selling to minors, did little or nothing to enforce them. In 1987, DiFranza sent his 11-year-old daughter into 100 stores in Massachusetts to try and buy cigarettes. "Seventy-five percent of the merchants sold them to her," he said. "At that time, no one in the country had ever been charged with selling to a minor."

After the Synar legislation took effect, compliance improved dramatically in 49 states. Compliance is measured by sending out underage decoys to buy tobacco. It is the only effective way to get merchants to take the law seriously, the authors note. A previous study by the same author showed that the revenue generated by a two-cent per pack tax on cigarettes would be sufficient to fully fund a comprehensive compliance and enforcement program.

These findings could have a global impact on health policy and smoking rates. The World Health Organization Framework Convention on Tobacco Control recommends restricting the availability of tobacco to teens. Currently, though, only three countries—Canada, Australia and the US—have prohibited sales to minors and given these laws teeth. All three countries have seen teen smoking rates fall. "By demonstrating the direct link between tougher laws, enforcement and declines in daily adolescent smoking, this study may convince more countries to crack down on tobacco sales to teens," said DiFranza.