The impact of local U.S. tobacco policies on youth tobacco use: a critical review

doi:10.4236/ojpm.2011.12006

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Vol.1, No.2, 34- 43 (

doi:10.4236/ojpm.2011.12006

2011) Open Journal of Preventive Medicine

The impact of local US tobacco policies on youth

tobacco u se: a critical revi ew

Karen B. Friend1*, Sharon Lipperman-Kreda2, Joel Grube2

1The Decision Sciences Institute, Pacific Institute for Research and Evaluation, Pawtucket, USA;

*Corresponding author: kfriend@pire.org

2Prevention Research Center, Pacific Institute for Research and Evaluation, Berkeley, USA.

Received 25 May 2011; revised 14 July 2011; accept ed 31 Ju l y 20 11.

AB S TRAC T

Tobacco use continues to be the leading pre-

ventab le cause o f p rem atu re deat h in the Un ited

States, killing over 430,000 people annually. To-

bacco initiation and use among youth remains a

significant public health concern. Despite de-

clines in U S youth tobacco use in recent yea rs,

state and national survey results are still cause

for alarm. Although traditional school-based

curricular programs are the most common

strategy to prevent or reduce youth tobacco use,

their effectiveness may be limited because

young people are immersed in a broader social

context in which tobacco is readily available.

Environmental strategies change this social

context by focusing on policy , enforcement, and

media. A compelling body of evidence suggests

that int ervention s at the state and federal l evels

can, when implemented in combination, reduce

youth tobacco use. The impact of policies im-

plemented at the local levels is less well un-

derstood and effects of env ironmental strategies

on smokeless tobacco consumption have been

largely ignored. The purpose of this paper is to

review the literature on environmental strategies

implemented at the local level on youth use of

both cigarettes and smokeless tobacco. We

highlight results of the extant literature, hypo-

thesize possible effects where research is

lacking, and suggest where futu re studie s might

be warranted.

Keywords: Tobacco; Youth; Environmental

Strategies; Local Policies

1. INTRODUCTION

1.1. Tobacco and Youth

Tobacco use continues to be the leading preventable

cause of premature death in the United States, killing

over 430,000 people yearly. Moreover, tobacco use costs

from $50 billion to $73 billion in excess medical expen-

ditures per year [1]. Most new smokers (59%) were

younger than age 18 when they first smoked cigarettes.

Perhaps more importantly, 37% of smokers were under

the age of 18 when they started smoking daily [2],

highlighting the danger of youth initiation. Among new

smokeless tobacco users, almost half (47.4%) initiated

use before age 18.

Cigarette smoking during adolescence is associated

with significant health problems, including increased

number and severity of respiratory illnesses, decreased

fitness, and potential retardation in the rate of lung

growth [3]. Smokeless tobacco use among teenagers can

lead to cardiovascular disease, oral cancer and gum

disease [4]. Despite declines in youth tobacco use in

recent years [5], state and national survey results are still

cause for alarm. Data from the 2009 Monitoring the

Future (MTF) survey show that 6.5%, 13.1% and 20.1%

of 8th, 10th, and 12th graders, respectively, reported ci-

garette smoking in the past 30 days [6]. Everyday

approximately 4000 young people between the ages of

12 and 17 years initiate cigarette smoking, and 1000

become daily cigarette smokers [2]. In addition, 2009

MTF results show that, while not at the peak levels seen

in the mid-1990’s, 30-day prevalence rates for smokeless

tobacco use increased significantly in 2009, especially

for boys, who represent the primary consumers. More

specifically, male 30-day prevalence rates were 6.5%,

11.1%, and 15.8% in Grades 8, 10, and 12, respectively,

compared to rates of 1.4%, 2.0%, and 1.7% among girls

[6].

1.2. Environmental Strategies to Prevent

and Reduce Youth Tobacco Use and

Problems

Although traditional sc hool-based curricular progra ms

K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43

are the most common strategy to prevent or reduce youth

tobacco use, their effectiveness may be limited because

young people are immersed in a broader social context

in which tobacco is readily available [7,8]. Environmen-

tal approaches change this social context by focusing on

policy, enforcement, and media campaigns [9-12]. En-

vironmental strategies may impact tobacco use behaviors

directly through decreased opportunities to obtain or use

tobacco. They may also help foster social norms that

discourage youth use and lessen the likelihood of adult

provision. Strategies include those that target access via

retail and social sources, clean air laws that restrict

where individuals can smoke, school policies, and minor

in possession laws. In addition, policies need to be ac-

companied by enforcement to ensure that policy viola-

tions carry penalties. Finally, mass media campaigns are

necessary to educate the community regarding the prob-

lem and garner support for policy changes and enforce-

ment resources [13]. Thus, the impact of environmental

strategies may depend upon the implementation of a

comprehensive approach whose effects are synergistic

[14-16]. The Centers for Disease Control and Prevention

recommend comprehensive programs as best practices

[17].

Although some interventions to reduce youth tobacco

use originate at the state or national level, others occur at

the local level. For the purpose of this review, we focus

on the latter. When we discuss “interventions”, “strate-

gies”, and “approaches”, we include the complement of

environmental policies and enforcement that synergisti-

cally target youth tobacco use. Some strategies may tar-

get both cigarette smoking and smokeless tobacco use

(e.g., retail access, taxation, outlet density), whereas

others target cigarette smoking specifically (e.g., clean

air laws). The two types have been shown to comple-

ment each other, since stricter cigarette policies may not

only reduce cigarette use, but also the use of other to-

bacco products [18].

Implementation and evaluation of these strategies,

however, has mainly focused on their impact on cigarette

smoking and less attention has been given to their im-

pact on smokeless tobacco use [19]. Where possible, we

highlight the effects on both tobacco types. Most of our

work is limited to research conducted in the United

States, though we occasionally cite investigations from

neighboring Canada .

2. METHOD

Studies for this review were identified using various

Internet searches, including Pubmed and other compu-

terized databases. We also reviewed references identified

from bibliographies of pertinent articles and books and

elicited suggestions from experts in the field of tobacco

control. Independent extraction was conducted by multi-

ple observers. For the sake of comparability, the analysis

was limited to studies conducte d in the United States and

Canada. The final review includes investigations pub-

lished in peer-reviewed journals that examined the

associations of local US tobacco control policies with

tobacco use, including smokeless tobacco, among youth.

To combine the results of the studies in a rigorous

manner, we considered using quantitative statistical tech-

niques. Sufficient quantitative data however, were often

not available for key outcome variables. In addition,

differences in local policy implementation made com-

paring results across studies o f questionable valid ity. We

opted instead to utilize a more qualitative approach.

3. RESULTS

3.1. Policies Targeting Tobacco Prices

Numer ous stud ies a t the nat iona l and state level s have

shown that higher cigarette prices are related to de-

creased youth cigarette smoking [20-22]. Higher ciga-

rette prices may affect youth smoking directly, by de-

creasing means to purchase, and indirectly, by changing

smoki ng no r ms, both o f whic h serve to red uce p erce ived

availability [23]. While limited research has examined

the relationship between smokeless tobacco prices and

smokeless tobacco use at the state level, results are con-

sistent with those found for cigarettes [24-26].

The extent to which differences in prices among local

communities affects youth tobacco use merits further

investigation. Differences in local prices, however, have

bee n re po r te d and sugge st t ha t l oc al pr ic e i nflue nc es use .

Toomey et al. found that price of different brands of

cigarettes varied by neighborhood characteristics and

store type in one metropolitan area [27]. For the same

brand of cigarettes, the maximum price was 1.7 to 1.8

times higher than the lowest price. Preliminary data fro m

our ongoing NCI-funded study of local tobacco policies

in California indicate that cigarette prices vary by 15%

to 26% among 50 communities, from $ 5.36 to $ 6.18

per pack of Marlboro cigarettes, and $ 5.48 to $ 6.93 per

pack of Newport cigarettes. Given that youth may be

more responsive to cigarette and smokeless tobacco

prices than adults [26,28-30], the examination of price

variability of tobacco by community and its effect on

youth smoking and smokeless tobacco use warrants at-

tention.

3.2. Policies Targeting Retail Access

3.2.1. Compliance Checks and Enforcement

One of the more well-studied of the tobacco policies

are those that seek to reduce youth access to tobacco

K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43

through retail channels [17,31]. In July 1992, the federal

government enacted the Synar Amendment (P.L. 103-

321, Section 1926), which required that states enact and

enforce laws prohibiting the sale or distribution of ciga-

rettes to individuals under the age of 18. By 2009, all

states showed violation rates under the mandated 20%

and 26 states had rates below 10% [32].

Accompanying this federal action was the implemen-

tation of new la ws and enforc ement efforts implemented

at the local level to help to reinforce federal efforts. Lo-

cal youth access interventions generally involve a com-

bination of compliance checks, penalties for violations,

merchant education and training programs, and commu-

nity education and mobilization. A compelling body of

empirical evidence confirms that retailer compliance

rates have increased, and cigarette sales to youth de-

creased, which may be largely attributable to the fact

that even moderate increases in enforcement can sub-

stantially reduce tobacco sales to minors, especially

when combined with media and other community and

policy activities [33-41].

Results of investigations of the effects of reduced

yout h sales on yout h use, ho weve r, remain i nconcl usive.

Some studies have shown positive correlations between

decreased youth sales and youth smoking [42-49]. In

contrast, some studies found no significant relationship

between reduced sales and use [50-52].

The relationship between retail access policies and

smokeless tobacco use has been less well-studied. In the

Biglan et al. investigation [42], results showed a reduc-

tion in smokeless tobacco use among 9th-grade boys.

Soldz et al. reported community efforts to increase en-

forcement of youth-access provisions in Massachusetts

were linked to a decline of lifetime smokeless tobacco

use among middle school students from 1993 to 1996

[53]. It is possible that policies targeting youth cigarette

purchases may generalize and discourage youth smoke-

less tobacco use. On the other hand, it is possible that

smokeless tobacco may be substituted for cigarettes

when policies focus largely on cigarette procurement

(e.g., taxes on cigarettes, compliance with cigarette sales

laws) and on smoking (clean air laws), rather than to-

bacco use more generally. Additional research is merited

to investigate these plausible relationships.

There are at least four reasons why local youth access

strategies may fall short of their desired goal. First, poli-

cies and enforcement may have to achieve some thresh-

old of intensity in order to prevent youth from buying

cigarettes [40, 51]. Second, even where sales rates are

relatively low, the probability of purchase success can be

very high with multiple attempts. Moreover, the density

of outlets in a community may increase the likelihood of

successful underage purchase simply by increasing op-

portunity. Third, non-retail, or social, sources of tobacco

may supplement or substitute for reduced retail avail-

ability [54-62]. These substitution effects can greatly

limit the effectiveness retail access strategies. Finally,

interventions targeting the entire population may have

more potent effects than those focusing on youth only

[52,63].

3.2.2. Tobacco Retailer Licensing

One way for states and localities to maintain stricter

control over retail compliance is to require that tobacco

venders obtain licenses to sell tobacco products. Licen-

sure policies both provide a readily accessible list of

tobacco outlets, as well as generate funds that can be

used towards enforcement efforts. As of 2004, 49 states

and the District of Columbia required retail licensing of

some kind to sell tobacco. Thirty-two states penalize

businesses for violating tobacco licensing requirements.

Licensure policies can complement other retail access

policies and may help to red uce youth sales through sev-

eral mechanisms. They can allow for more efficient en-

forcement because of the provision of a current list of

tobacco vendors. In addition, license suspension or revo-

cation can serve as a punishment for retailers violating

youth access regulations. In turn, license fees can be

earmarked to pay for enforcement and education. No

published studies to date have examined the impact of

licensure policies specifically on youth use or how local

policies may complement those implemented at the state

level.

3.2.3. Outlet Density

Regulating tobacco outlet density, commonly imple-

mented at the local level represents another mechanism

by which to decrease youth retail availability. Few stud-

ies, however, have examined tobacco outlet density and

tobacco use. Schneider et al. assessed the geographic

association between outlet density and income, race, and

ethnicity at the tract level of analysis for one county in

the Midwest. Census tracts with lower median house hold

income, a higher percentage of African Americans, or a

higher percentage of Latinos had a greater density of

cigarette retail outlets [64]. Applying a spatial analytical

approach, Yu et al. supported the association between

high tobacco outlet density and socio-economically dis-

advantage areas in New Jersey [65]. Similarly, H yland et

al. and Laws et al. investigated the relationship between

outlet density and neighborhood characteristics but did

not examine associations between outlet density and

actual smoking behavior [66,67].

Results of the few investigations on the relationship

between density and actual smoking behaviors have

been mixed and inconclusive. Reid et al. found positive

K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43

correlations between tobacco outlet density and smoking

prevalence for counties with a higher percentage of Af-

rican Americans [68]. Controlling for a range of con-

founders, Novak et al. reported that the youth living in

the 75th percentile in terms of outlet density were 13%

more li ke l y to have smo ked in the p ast mo nth than yout h

living in the botto m 25th percentile [69]. In another study

in Canada, a greater number of tobacco outlets near

schools were found to be related to an increased likeli-

hood that underage smokers would buy their own ciga-

rettes [70]. Also, the prevalence of current smoking was

found higher at schools in neighborhoods with the high-

est tobacco outlet density (>5 outlets) compared to

schools in neighborhoods without any tobacco outlets

[71]. Looking at the adult population, Li et al. showed

that high smoking prevalence in Massachusetts’ com-

munities was associated with higher density of tobacco

outlets [72]. In contrast, Pokorny et al. found no associa-

tion between density, defined as the number of outlets

per youth ages 10 - 17 years, and smoking, alone or in

interactions with gender, race, adult or peer users, per-

ceived tobacco access, or ability to purchase [49]. In a

study of Canadian high school neighborhoods, Lovato et

al. reported that the number of tobacco outlets was unre-

lated to school smoking prevalence [73]. More recently,

McCarthy et al. found that among high school and urban

students, but not middle school or rural students, there

was a small but significant relationship between tobacco

outlet density near schools and students’ reports of

smoking initiation but not reports of established smoking

[74]. No published studies have examined the impact of

outlet density on smokeless tobacco use.

Associations between alcohol outlet density and

drinking and alcohol-associated problems have been far

more well-studied and may provide guidance concerning

the relationship between local tobacco outlet density and

tobacco use behaviors. Although some discrepancies

have been reported [75,76], most studies have found

significant associations between outlet density and adult

alcohol consumption and problems, including violent

crime, and motor vehicle accidents [77-83]. Alcohol

outlet density has also been related to higher rates of

underage drinking and driving and riding with drivers

who are consuming alcohol [84]. This research also

suggests that differences in alcohol outlet density on a

small geographical scale (i.e., neighborhood) probably

have little or no relation to drinking-related outcomes,

whereas differences on a larger scale (e.g., zip codes)

can significantly affect consumption and problems [76].

3.3. Minor in Possession Policies

Despite reduced access through policies targeting re-

tail procurement, underage individuals are still able to

obtain tobacco through non-retail, or social, sources.

Croghan et al. found that 66% of occasional smokers

and 25% of regular smokers acquired cigarettes through

social channels [55]. Parents and friends are a particu-

larly important source for new smokers [56]. Similarly,

Huhtala et al. reported that 84% of daily/occasional snus

(i.e., moist smokeless tobacco) users and 79% of ex-

perimental users acquired it from friends or acquaintan-

ces [85].

Implementation and enforcement of minor in posses-

sion (MIP) policies are aimed at reducing social access

to tobacco products. Many states have adopted legisla-

tion that penalizes youth who purchase or possess to-

bacco. Penalties for violating these laws typically in-

clude fines, community service, tobacco awareness and

education classes, as well as driving license suspension.

Some have questioned the utility of such policies, how-

ever, because they are difficult to enforce and shift re-

sponsibility away from the suppliers of tobacco to mi-

nors [86,87]. Such approaches may also foster the per-

ception of a forbidden fruit nature of tobacco and serve

to heighten youth desire for tobacco products.

Few studies have examined the impact of local MIP

laws and enforcement on youth tobacco use. Although

results have varied, the general trend is promising re-

garding MIP policy effects on use. Livingood et al., re-

ported that youth in two Florida counties with the high-

est level of MIP law enforcement had a significantly

reduced likelihood of past 30-day smoking compared to

youth in two Florida counties with the lowest level of

enforcement [88]. In a twenty four-town randomized

study, Jason et al. found that 15% - 24% of children

fined for possession had quit smoking over a three-year

follow-up period [89]. Using a multi-level analytical

approach, data from this study also showed that student

in towns with hi gher levels of MIP law enforcement had

significantly smaller increase in rates of current smoking

than students in towns with less enforcement [90].

Moreover, youth in towns with low level of MIP law

enforcement had a significantly greater increase in the

percentage of heavy smokers [91]. Lazovich et al. found

that smoking prevalence was lower in Minnesota’s coun-

ties that allowed MIP-cited youth to attend a tobacco

diversion program than in counties without such pro-

grams [92], suggesting that MIP policies complemented

with treatment programs might increase the effectiveness

of the former. In contrast, Gottlieb et al. found that MIP

citation was unrelated to future smoking intentions of

youth in 14 east and central Texas communities, though

study authors noted that differential policy enforcement

by race and ethnicity might have influenced study results

[93].

K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43

3.4. Clean Air Laws

Research on policies implemented at the state level

provides strong evidence that laws restricting where

individuals can smoke are associated with reduced

smoking among youth [20,29,94-97]. Although these

laws specifically target cigarette s moking, the y may also

reduce the use of other tobacco products, including

smokeless tobacco [18]. In terms of their political and

economic feasibility, se veral studies have shown that the

implementation of local clean air laws in bars and

restaurants do not have a negative impact on revenue

and, in some cases, may even show financial benefits

[98,99]. In terms of their impact on youth tobacco-

related attitudes and behaviors, there is some evidence

that local policies are associated with stronger anti-

smoking norms among youth [100]. Results regarding

impact on youth use, however, have been inconclusive

[23], with some research suggesting local policies may

be associated with reduced youth use [101] and other

research reporting no such association [102]. A compli-

cating factor of this research, however, is that results of

studies related to local interventions may be confounde d

by the effects of state laws, as well as other tobacco

policies, such as ta x hikes.

3.5. Restrictions on Retail Marketing and

Advert i sing Equations

Since the 1998 Tobacco Master Settlement Agreement

(MSA), the retail arena has become one of the few re-

maining channels that tobacco companies can use to

target both minors and those legally permitted to pur-

chase tobacco. A compelling body of evidence has con-

sistently shown that tobacco marketing and promotion

increases the likelihood that adolescents will initiate and

use tobacco [103-107].

There is limited evidence regarding the local tobacco

advertising and its effects on youth tobacco use. This

lack is in part attributable to preemptive legislation at the

state level that prohibits localities from enacting laws

that vary or are stricter than state laws. As of Dec. 31,

2009, while fewer states still upheld such preemptions,

12 still enforced such restrictions [108]. Henriksen et al.

found that stores where adolescents shopped most fre-

quently contain more tobacco marketing than other

stores in the same community [109]. A recent study by

Seidenberg et al. found that storefront cigarette adver-

tising differs by community demographic profile, such

that advertisements in low-income/minority communi-

ties were more likely to be larger and promote menthol

products [110]. Like several of the interventions cited

above, methodological limitations of this body of re-

search includes the difficulty of determining the differ-

ential effects of state vs. local policies, and of marketing

and advertising restrictions vs. other tobacco policies

[107].

4. CONCLUSIONS AND SUGGESTIONS

FOR FUTURE RESEARCH

State tobacco policies are widely advocated for reduc-

ing youth tobacco use. The purpose of these policies is to

increase the effort and resources necessary for youth to

obtain tobacco and th e negative cons equences for posses-

sion and use [12,111]. The effects of local policies are far

less well-studied but appear to also reduce youth use and

may complement state efforts. Local policies may also

reinforce community norms against adults using tobacco

and providing it to youth [41]. Local tobacco policies to

prevent and reduce youth use often focus on increasing

retailer compliance with underage tobacco sales laws but

may also include implementation of outlet density restric-

tions, minor in possession laws, clean air laws, and res-

trictions on marketing.

Evidence regarding the effects of local policies on

tobacco use by young people is mixed and has focused

almost exclusively on smoking. Some studies have found

no ef fects of local ef forts on y ou th smoking [40,50]. More ,

however, have found reductions in smoking by youth

following local policy implementation, suggesting this

approach is a ripe area for advancing youth tobacco

control [42,46,47,112-114].

A number of shortcomings can be noted in extant

research on local tobacco policy and its impact on youth

attitudes and behaviors. First, there is a paucity of studies

examining associations between local tobacco policies

and youth smokeless tobacco use. Second, while nume-

rous investigations have examined the relationships of a

specific local policy with youth tobacco availability and

use, few have considered the effects of multiple policies

and how their impact may unfold over time. Third, few, if

any, studies have investigated the processes through

which potential effects of local policies on youth tobacco

use and trajectories may be mediated. As a result, little is

known about how and why such policies may influence

tobacco use behaviors. Fourth, although some studies

have invest igated how use of r etail and social sourc es of

tobacco are interrelated, additional research is necessary

to establish how changes in retail availability influences

the use of social and commercial sou rces of tobacco. Fifth,

most studies of policies targeting underage tobacco users

have rarely included other important factors known to

influence use, such as community, social, psychological,

and personal factors. Finally, most of the available re-

search has been cross-sectional. Only a few studies have

considered h ow diff erences in local env ironmental appro-

aches to youth tobacco control may affect initiation to

K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43

tobacco use and tobacco use trajectories over time.

To this end, we are currently conducting an NCI-

funded study of the impact of local tobacco policies on

youth tobacco attitudes a nd use in 50 cities in Cali fornia.

The study will proceed from a conceptual model that

includes commun ity-level v ariables (tobacco policies and

availability, population density, SES, ethnic composition,

communi ty disorgan ization), as well as n eighborhood and

individual-level factors (smoking, smoking beliefs, per-

ceived law enforcement, personal risk factors, background

characteristics). The model specifies how the effects of

community variables are mediated through and moderate

the effects of individual-level variables. Multi-level

regressi on and l aten t variable structu ral equ ations m ode ls

will be u sed to investigate relations between local policies

and smoking among youth in the communities and test

hypotheses generated by the model. The long-term

objective of the study i s to pro vide a better u nderstanding

of how local tobacco policies and enforcement relate to

adolescent smoking. Th is information in turn will provide

a better basis for designing and implementing more

effective community interventions to reduce and prevent

adolescent smoking. Ultimately, the results from this

study will help policymakers and community advocates

make better decisions about prevention policies and the

allocation of prevention resources.

5. ACKNOWLEDGEMENTS

This st udy was funded by th e National Canc er Institut e (NCI) Grant

No. R01-CA138956 (Local To bacco Policy and Youth Smoking) and the

Tobacco-Related Disease Research Program (TRDRP; http://www.

trdrp.org) Grant No. 19CA-016 (Retail Access to Tobacco and Youth

Smoking Behavior).

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