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No Single Approach Keeps Tobacco Away From Minors

May 04, 2019

Tobacco addiction starts early, and public health experts agree that it is important to keep tobacco out of the hands of adolescents. Still, what works for prevention is a matter of controversy, and a new systematic review suggests that there is no clear answer.

Review authors Lindsay Stead and Tim Lancaster at the University of Oxford examined 35 studies to determine whether programs targeting shopkeepers who sold tobacco to minors actually reduced how much teens smoked.

Simply informing merchants about the law had no effect on reducing sales to minors, the review found. Rather, the most successful initiatives used a variety of tactics, including retailer education, personal visits from law enforcement personnel, and posters and public information campaigns to increase community awareness.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

The 35 included studies examined a variety of interventions focused on retailers including educating them about the law, checking up on them via sting operations, notifying them of compliance check results and punishing violators with fines or license suspensions. Studies also looked at community-based strategies, such as public information campaigns.

Researchers measured how well strategies worked by (1) a reduction in illegal sales, which was assessed by test purchasing; (2) changes in young people's smoking behavior; and (3) surveys of teens to find out whether they thought it was easier or harder to procure forbidden smokes.

Getting access to cigarettes has gotten harder, but it is still relatively easy, according to the review: In 1996, 91 percent of kids surveyed said it was at least "fairly easy" to procure tobacco; a 2007 survey found that number had dropped to 78 percent.

The theory is that if kids cannot buy cigarettes or other tobacco products at stores, they will smoke less. The problem with focusing on retailers is that kids can also get tobacco in other ways: from their parents, siblings or friends or even by stealing. Therefore, spending money on enforcement of laws against selling to minors might not be cost-effective.

"You can clearly reduce the number of shopkeepers who make illegal sales by test purchaser or sting, but there are many reasons to think that's not a good way to measure real-life behavior," Stead said.

David Pearson, associate director of the Center for Community Health and Evaluation, said the review demonstrates how difficult it is to perform evaluations in community settings. "Rigorous, controlled trials are complex, expensive and subject to all the other influences in the communities," said Pearson, who had no affiliation with the review.

Community support appears to be crucial for several reasons. For one, if adults do not think adolescent smoking is a problem, some are willing to buy cigarettes for the kids. For another, one study found that judges tended to suspend sentences on clerks, because they felt the penalties were too harsh. It is also important that laws and penalties are somewhat standardized across the region; otherwise, merchants might resent the loss of tobacco revenue to their competitors a few miles down the road.

None of the controlled studies reviewed provided conclusive evidence that making it harder to buy cigarettes actually reduced underage smoking. The biggest problem, the authors found, was that intervening with retailers never put a complete stop to illegal sales.

Pearson said that cigarettes bummed from adults or peers is a major source of the contraband: "Even if access through retail outlets is effectively restricted, as we've been able to do in King County, Washington, an equally important issue is changing the culture that thinks it is OK for kids to get cigarettes from social sources."

Intervening with retailers could be an effective part of a comprehensive tobacco control strategy, but it does not seem to be the whole answer, the review found. "Put your money into community-wide efforts as well, instead of focusing on preventing the selling of tobacco to minors," Stead said. "If you can change community norms and reduce smoking among adults that will ultimately be more useful."

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit cochrane for more information.

Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors (Review). Cochrane Database of Systematic Reviews 2008, Issue 3.

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