Vol.1, No.2, 34- 43 (
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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.
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
1.1. 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
1.2. Environmental Strategies to Prevent
and Reduce Youth Tobacco Use and
Although traditional sc hool-based curricular progra ms
K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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
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 .
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.
3.1. 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-
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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
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
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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
K. B. Friend et al. / Open Journal of Preventive Medicine 1 (2011) 34-43
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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.
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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