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LETTER |
The author is with the Center for Behavioral and Community Research, AMC Cancer Research Center, and the Department of Preventive Medicine and Biometrics, University of Colorado School of Medicine, Denver.
Correspondence: Requests for reprints should be sent to Arnold H. Levinson, MJ, PhD, AMC Cancer Research Center, 1600 Pierce St, Denver, CO 80214 (e-mail: levinsona{at}amc.org).
Landrine and Klonoff1 have revealed a major flaw in the way we measure underage tobacco sales. In most "compliance checks," a supervised youngster visits a store and tries to buy cigarettes. The weighted proportion of sales in a random sample of stores estimates the violation rate for an area. The known problem with this method is that compliance checks are unreliable. Results vary with the minor’s age and appearance,2 presentation (or not) of valid identification,3 honesty,4 and other elements. Thus, even when compliance checks produce single-digit violation rates, adolescent tobacco use often fails to decline.5 The disconnect is certainly an artifact of underestimation of underage sales, but null findings have fueled doubt that anything practical can be done about youth access to cigarettes.6
Some attention has shifted to kids giving kids cigarettes,7 and some advocates have intensified8 longstanding calls9 to abandon youth access interventions altogether. However, retail purchase remains the usual way that addicted adolescents get their cigarettes10—as well as the cigarettes they give experimenting peers headed for addiction. Abandonment of youth access interventions would only expand the social-source problem, which may prove as hard to control as retail underage sales have been.
US regulations require tobacco-sales compliance checks, and results are reviewed before states can be funded for substance abuse prevention and treatment. The rules have withstood previous findings that compliance checks are unreliable, but Landrine and Klonoff document a more fundamental problem. Currently, we send underage strangers into randomly chosen stores to attempt a single purchase each time. But in the real world, addicted adolescent smokers choose their stores nonrandomly, establish familiarity by making noncigarette purchases, then return repeatedly as regular cigarette customers. Put simply, we simply aren’t measuring youths’ access to retail cigarettes.
However, Landrine and Klonoff may have illustrated a better method. Adolescents in tobacco control programs could establish familiarity at retail tobacco outlets across their communities, then conduct compliance checks with penalties for violators. Clerks already warn one another when "stings" are under way—maybe they would spread the word that familiarity with young customers doesn’t provide safety when selling cigarettes. A feasibility study of this strategy is being developed. If it proves effective and practical, it might really reduce youth access to cigarettes. Only then will we be able to determine whether and to what extent adolescent smoking depends on underage retail tobacco sales.
References
1. Landrine H, Klonoff EA. Validity of assessments of youth access to tobacco: the familiarity effect. Am J Public Health. 2003;93:1883–1886.
2. 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;84:729–734.
3. Levinson A, Hendershott S, Byers T. The ID effect on youth access to cigarettes. Tob Control. 2002;11:296–299.
4. DiFranza JR, Savageau JA, Bouchard J. Is the standard compliance check protocol a valid measure of the accessibility of tobacco to underage smokers? Tob Control. 2001;10:227–232.
5. Cummings KM, Hyland A, Perla J, Giovino GA. Does increasing retailer compliance with a minor’s access law reduce youth smoking? Nicotine Tob Res. 2003;5:465–472.[Medline]
6. Warner KE, Jacobson PD, Kaufman NJ. Innovative approaches to youth tobacco control: introduction and overview. Tob Control. 2003;12(suppl I):i1–i5.
7. Forster J, Chen V, Blaine T, et al. Social exchange of cigarettes by youth. Tob Control. 2003;12:148–154.
8. Ling PM, Landman A, Glantz SA. It is time to abandon youth access tobacco programmes. Tob Control. 2002;11:3–6.
9. Glantz SA. Preventing tobacco use—the youth access trap. Am J Public Health. 1996; 86:156–158.
10. Emery S, Gilpin EA, White MM, Pierce JP. How adolescents get their cigarettes: implications for policies on access and price. J Natl Cancer Inst. 1999; 91:184–186.
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