Tobacco Use: Community Mobilization with Additional Interventions to Restrict Minors’ Access to Tobacco Products

The CPSTF finding is based on evidence from a systematic review of 9 studies (search period through May 2000). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to reducing tobacco use and secondhand smoke exposure.

Nine studies (10 intervention arms) qualified for the review.

• Self-reported tobacco use among youths over follow-up periods of 24-48 months: median decrease of 5.8 percentage points (4 studies)
• Retail tobacco sales to youth: median decrease of 33.5 percentage points (9 studies)

The study included in the economic review was a one-year study that modeled the cost effectiveness of active enforcement of tobacco sales to minors on a national level. The intervention included employing minors to attempt tobacco purchases, licensing tobacco vendors, and civil penalties for vendors who illegally sold tobacco products to minors.

• Primary outcome measures consisted of four levels of reduction in youth tobacco use ranging from 5% to 50%. Cost-effectiveness ratios ranged from $44 to $3100 per year of life saved.
• Program costs included personnel, salary, and benefits for minors and for adult inspectors; liability insurance; money to purchase tobacco; transportation; and overhead (analyses were based on enforcement costs of $50, $150, $250, and $350, where marginal expense is lowest at the community level and highest at the federal level).

These findings should be applicable to a variety of settings and populations in the U.S., including urban, suburban, and rural communities and African-American, Hispanic, or white populations.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for these reviews of interventions to restrict minors’ access to tobacco products: Active Enforcement of Sales Laws Directed at Retailers When Used Alone; Community Mobilization with Additional Interventions; Community Education About Youth Access to Tobacco Products When Used Alone; Laws Directed at Minors’ Purchase, Possession or Use of Tobacco Products When Used Alone; Retailer Education with Reinforcement and Information on Health Consequences When Used Alone; Retailer Education Without Reinforcement When Used Alone; Sales Laws Directed at Retailers When Used Alone.

Effectiveness

The studies identified in this review provide evidence of effectiveness of community mobilization when coordinated with other interventions in reducing both tobacco use among youth and youth access to tobacco from commercial sources. A better understanding of the relative impact of community mobilization on reducing youth demand for tobacco products would assist local programs significantly in setting priorities for future intervention efforts. Research issues identified by others overlap with the questions generated as the result of this review:

• What intervention combinations, intensity, and duration are the minimum required to reduce youth tobacco use?
• What effect, if any, do interventions to reduce youth access to tobacco products through commercial sources have on access through social sources? What effect, if any, do interventions to reduce youth access to tobacco products through social sources have on access through commercial sources?
• What is the required intensity and duration of active enforcement components?
• What effect does decreasing the number of outlets selling tobacco products have on youth access?
• How do age verification devices (such as scanners) affect retailer sales compliance?

Applicability

Community mobilization interventions included efforts to identify and incorporate community concerns. When tailored to resonate with the sociocultural composition of the population, community mobilization combined with additional interventions should be applicable to most U.S. settings. Some questions remain regarding applicability of these interventions in settings and populations other than those studied.

• Are there differences in the effectiveness of or barriers to these interventions in urban and rural settings or in communities that cross jurisdictions?

Other Positive or Negative Effects

This review did not identify any additional positive or negative effects of these interventions

Economic Evaluations

The information available for economic evaluation consisted of a single study evaluating one component (active enforcement directed at retailers) of an effective multicomponent intervention. Considerable research is, therefore, warranted regarding the following questions:

• What are the costs of these interventions?
• What is the cost-effectiveness of these intervention combinations?
• What is the cost-effectiveness, net cost, or net benefit of these intervention combinations when cost-effectiveness analysis includes cost savings of illness averted?
• What combination(s) of components are most cost effective?

Barriers

Significant barriers to implementing interventions to reduce youth access were noted in this review. Research issues important to communities and to local and state governments involving potential barriers include the following:

• What components of community mobilization are most effective in building and maintaining support for retailer compliance with sales laws?
• What components of community mobilization are most effective in building and maintaining support for active enforcement, including the consistent application of effective penalties?
• What aspects of efforts to prevent or to overturn state preemption laws are effective?

• The evaluated interventions either fostered or were coordinated with additional interventions, such as
  • stronger restrictions on retailer sales of tobacco products;
  • restrictions directed at youth purchase, possession, or use;
  • active enforcement of tobacco sales laws; and
  • retailer education interventions (with or without reinforcement).
• Educational components included
  • community-wide assessments of compliance by tobacco retailers with dissemination of the results through mass media events and news coverage
  • presentations to civic groups and local governments.
• Community and school meetings and activities, as well as direct contact with local governments through testimony, petitions, letters, and phone calls, also occurred.
• Interventions were conducted in a variety of settings and populations, including urban, suburban, and rural communities in the United States and Australia. In the United States, interventions were implemented in communities that included predominantly African-American, Hispanic or white populations.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Altman DG, Rasenick-Douss L, Foster V, Tye JB. Sustained effects of an educational program to reduce sales of cigarettes to minors. Am J Public Health 1991;81(7):891 3.

Altman DG, Wheelis AY, McFarlane M, Lee H, Fortmann SP. The relationship between tobacco access and use among adolescents: a four community study. Soc Sci Med 1999;48(6):759 75.

Biglan A, Ary DV, Smolkowski K, Duncan T, Black C. A randomised controlled trial of a community intervention to prevent adolescent tobacco use. Tob Control 2000;9(1):24 32.

Chapman S, King M, Andrews B, McKay E, Markham P, Woodward S. Effects of publicity and a warning letter on illegal cigarette sales to minors. Aust J Public Health 1994;18(1):39 42.

Feighery E, Altman DG, Shaffer G. The effects of combining education and enforcement to reduce tobacco sales to minors. A study of four northern California communities. JAMA 1991;266(22):3168 71.

Forster JL, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The effects of community policies to reduce youth access to tobacco. Am J Public Health 1998;88(8):1193 8.

Jason LA, Billows WD, Schnopp-Wyatt DL, King C. Long term findings from Woodridge in reducing illegal cigarette sale to older minors. Eval Health Prof 1996;19(1):3 13.

Junck E, Humphries J, Rissel C. Reducing tobacco sales to minors in Manly: 10 months follow-up. Health Promot J Aust 1997;70:29 34.

Wildey MB, Woodruff SI, Pampalone SZ, Conway TL. Self-service sale of tobacco: how it contributes to youth access. Tob Control 1995;4:355 61.

Additional Evidence about the Included Studies

Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors. JAMA 1989;261(1):80 3.

Biglan A, Ary DV, Koehn V, et al. Mobilizing positive reinforcement in communities to reduce youth access to tobacco. Am J Community Psychol 1996;24(5):625 38.

Biglan A, Henderson J, Humphrey D. Mobilising positive reinforcement to reduce youth access to tobacco. Tob Control 1995;4:42 8.

Erickson AD, Woodruff SI, Wildey MB, Kenney E. A baseline assessment of cigarette sales to minors in San Diego, California. J Community Health 1993;18(4):213 24.

Jason LA, Ji PY, Anes MD, Birkhead SH. Active enforcement of cigarette control laws in the prevention of cigarette sales to minors [see comments]. JAMA 1991;266(22): 3159 61.

Jason LA, Katz R, Vavra J, Schnopp-Wyatt DL, Talbot B. Long-term follow-up of youth access to tobacco laws’ impact on smoking prevalence. J Hum Behav Soc Environ 1999;2(3):1 13.

Keay KD, Woodruff SI, Wildey MB, Kenney EM. Effect of retailer intervention on cigarette sales to minors in San Diego County, California. Tob Control 1993;2:145 51.

Economic Review

DiFranza JR, Peck RM, Radecki TE, Savageau JA. What is the potential cost-effectiveness of enforcing a prohibition on the sale of tobacco to minors? Prev Med 2001;32(2):168 74.

Implementation Resource

Rural Health Information Hub, Tobacco Control and Prevention Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of tobacco control and prevention programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• Community Mobilization to Restrict Minors’ Access to Tobacco Products

Electronic searches for literature were conducted in Medline, EconLit, and the database of the Office on Smoking and Health (OSH) in the National Center for Chronic Disease Prevention and Health Promotion, at the Centers for Disease Control and Prevention. The review team also reviewed the references listed in all retrieved articles and consulted with subject-matter experts. All studies were published in journals. To be considered for inclusion in the review of study quality, a study had to meet the following criteria:

• Have a publication date of 1980 to January 2001
• Be a primary study rather than, for example, a guideline or review
• Take place in an established market economy ^a
• Be written in English
• Meet the team’s definition of the interventions
• Provide information on one or more outcomes identified in the intervention analytic framework
• Compare a group of people who had been exposed to the intervention(s) with a group of people who had not been exposed or who had been less exposed (comparisons could be concurrent or within a group over a period of time)

Initial database searches (January 1998 and August 1999) were supplemented by a focused search conducted in September 2000. Studies added after September 2000 were referred by members of the team or identified in the reference lists of retrieved articles.

^a Established Market Economies as defined by the World Bank are: Andorra, Australia, Austria, Belgium, Bermuda, Canada, Channel Islands, Denmark, Faeroe Islands, Finland, France, Germany, Gibraltar, Greece, Greenland, Holy See, Iceland, Ireland, Isle of Man, Italy, Japan, Liechtenstein, Luxembourg, Monaco, the Netherlands, New Zealand, Norway, Portugal, San Marino, Spain, St. Pierre and Miquelon, Sweden, Switzerland, the United Kingdom, and the United States.

There are several barriers to implementing and sustaining these types of interventions:

• The adoption or existence of a law at the state level that supersedes or precludes stronger local laws (preemption)
• Opposition by retailers, retail associations, and the tobacco industry
• Lack of resources or interest
• Judicial nullification of penalties directed at retailers (other reviews have suggested that replacing criminal offense statutes with specified civil penalties [e.g., graduated fines or license suspension] would improve enforcement efforts and minimize court appearances)
• Legislative efforts to weaken, replace, or prevent the implementation and conduct of interventions to reduce minors’ access

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce current tobacco use in adolescents — TU‑04
• Reduce current e-cigarette use in adolescents — TU‑05
• Reduce current cigarette smoking in adolescents — TU‑06
• Reduce current cigar smoking in adolescents — TU‑07
• Reduce current use of smokeless tobacco products among adolescents — TU‑08
• Reduce current use of flavored tobacco products in adolescents who use tobacco — TU‑09
• Eliminate cigarette smoking initiation in adolescents and young adults — TU‑10