Reducing underage cigarette sales in an isolated community: The effect on adolescent cigarette supplies

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Preventive Medicine 45 (2007) 447 – 453 www.elsevier.com/locate/ypmed

Reducing underage cigarette sales in an isolated community: The effect on adolescent cigarette supplies☆ Arnold H. Levinson a,⁎, Theresa Mickiewicz b a

Department of Preventive Medicine and Biometrics, University of Colorado at Denver/Health Sciences Center, and University of Colorado/AMC Cancer Center, 13001 East 17th Place, Mail Stop F542, P.O. Box 6508, Aurora, CO 80045 USA b DenverHealth, 605 Bannock Street, Denver, CO 80204, USA Available online 7 August 2007

Abstract Objective. The current study explored the practicality of preventing underage retail cigarette sales and the relationship to cigarette supplies among adolescents. Method. In Fort Morgan, Colorado, an isolated rural community with below-average socioeconomic status and a large Latino population, supervised teenaged employees repeatedly attempted to buy cigarettes from every store over a 9-month period in 2005. Repeated violations were penalized. Cigarette acquisition and exchange among community adolescents were assessed before and after intervention using a high school student survey. Results. The measured violation rate declined from 47% in the first week to 3.4% during the final three months, and high school student reliance on retail cigarette purchases declined. Adolescent cigarette supplies declined by approximately 15%. Conclusion. Isolated rural communities can reduce adolescent cigarette supplies by conducting consistent enforcement against retail cigarette sales to minors. Previous research suggests that reducing these sales may help reduce adolescent smoking. The current study demonstrates that enforcement is practical and effective. © 2007 Elsevier Inc. All rights reserved. Keywords: Adolescents; Adolescent behavior; Rural communities; Rural health; Smoking/pc [prevention and control]; Smoking/lj [legislation and jurisprudence]

Introduction Retail cigarette sales to adolescents are an extensively studied public health problem (Forster and Wolfson, 1998; Rigotti, 1999; Stead and Lancaster, 2005; Lantz et al., 2000), but the feasibility of solving the problem remains uncertain. By official estimates (DiFranza and Dussault, 2005), more than 80% of U.S. tobacco retailers comply with federal age restrictions on tobacco sales (US Department of Health and Human Services, 1993). By self-report, however, half of adolescent current smokers buy cigarettes from retail businesses (Johnston et al., 2004), and such purchases are widespread and easy (Centers for Disease Control ☆

Financial interest: The authors are under contract with the Colorado Alcohol and Drug Abuse Division to assist the State in complying with federal regulations against tobacco sales to minors. ⁎ Corresponding author. Fax: +1 303 724 3544. E-mail addresses: [email protected] (A.H. Levinson), [email protected] (T. Mickiewicz). 0091-7435/$ - see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2007.07.034

and Prevention, 2005; Centers for Disease Control and Prevention, 2002; Jones et al., 2002). The discrepancy between official estimates and adolescent self-report may reflect measurement problems in official estimates, which rely on random samples of stores. Most adolescent smokers are unlikely to choose stores at random, and instead attempt to buy cigarettes only in stores in which clerks are willing to sell to them (Levinson, 2004). Furthermore, the reliability of official estimates is indeterminate, because results vary widely with the age, gender, ethnicity, appearance and behavior of the supervised minors conducting simulated purchase attempts (Clark et al., 2000; Levinson et al., 2002; DiFranza et al., 2001a; Landrine and Klonoff, 2003). In summary, retail purchase remains a widely accessible source of adolescent cigarette supplies (Johnston et al., 2004) despite enforcement efforts and official estimates to the contrary. This fact has raised serious doubts that such sales can be prevented (Warner et al., 2003). Even if they can be prevented, some authors suggest that other sources are readily available.

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Adolescents widely engage in social exchange of cigarettes (Forster et al., 1997; Wolfson et al., 1997), and some have suggested that social sources may fill the void when underage retail access is blocked (DiFranza and Coleman, 2001b; Croghan et al., 2003). Others (Forster et al., 2003) point out that social exchange of cigarettes necessarily originates “upstream,” i.e., from someone's retail purchase, hence social exchange merely extends the reach of commercial sources rather than replacing them. Findings from a multi-community study are consistent with this mechanism: currently smoking students who bought cigarettes in the previous month were 50% more likely than non-buying current smokers to supply cigarettes to other students (Pokorny and Jason, 2006). An oft-cited example provides some evidence that underage cigarette sales can be prevented and that doing so reduces adolescent smoking. In the suburban Chicago village of Woodridge, cigarette sales to adolescents were vigorously pursued and prosecuted during a number of years, and smoking initiation rates among adolescents subsequently declined (Jason et al., 1999, 1991, 1996). However, this success has been discounted for requiring an “extraordinary” level of commitment to enforcement in order to achieve “extraordinarily high” levels of retail merchant compliance (Warner et al., 2003). The Woodridge example also might be impractical to disseminate because of competing police priorities to pursue violent and property crimes, especially in less affluent communities— Woodridge's median household income in 2002 was $64,350 (US Census Bureau, 2002), well above the U.S. average. The current report addresses two primary questions: is intensive enforcement against underage retail cigarette sales practical in a non-affluent community, and do social supplies of cigarettes increase when direct retail sales to adolescents are blocked? Using a case study approach, we observed the initiation and maintenance of rigorous enforcement against underage tobacco sales in a small rural community and analyzed the impact on the high school student “marketplace” of cigarette acquisition and sharing. The objectives were to determine (a) whether underage retail cigarette sales were prevented, (b) whether enforcement was practical, (c) and how adolescent cigarette supplies and acquisition were affected. We hypothesized that after intervention, (1) students would be less likely than before to cite direct retail purchase as their usual source of cigarettes; (2) students who smoked would have smaller supplies of cigarettes than before, and (3) social requests for cigarettes would increase, as would refusal of such requests (due to reduced supplies). Methods Site selection Criteria were police willingness to implement the enforcement intervention, school cooperation with student surveys, and geographic isolation from other municipalities to prevent confounding by unenforced cigarette sales. Two of three potential sites were ruled out when school cooperation could not be obtained. The enrolled site, Fort Morgan, Colorado, is an agricultural city of approximately 11,000 residents, 60% of whom are Anglo and 40% Latino. Median household income in 1999 was $33,128, which was 79% of the national level. One-third of Fort Morgan adults aged 25+ did not graduate from high school, and 8.8% of families lived in poverty (US Census, 2000a). Compared to

rural Colorado and the rural United States, Fort Morgan has lower median income, fewer high school graduates, and a larger Latino population.

Enforcement intervention The research team, local police, and state tobacco control enforcement personnel collaboratively developed the intervention protocol through an iterative process. The intervention consisted of rigorous enforcement of laws against selling cigarettes to minors, using staged cigarette purchase attempts with legal penalties for clerks and stores that sold. No media campaign or advocacy was conducted. Trained and supervised teenagers from the community regularly tried to buy cigarettes from every store that offered cigarettes for sale, including the only two nearby stores outside city limits (n = 33). Stores were visited approximately twice per month. After a first sale, a police officer returned within 3 days and served a warning notice to the clerk, and the state Tobacco Enforcement Unit concurrently issued an administrative warning to the business. If a clerk sold a second time, s/he was charged for the first and second violations; the statutory penalty is a $200 fine per violation. A clerk who received only one violation during the study period was not charged. A business with two violations was subject to the statutory $250 fine; subsequent violations subjected businesses to an escalating fine. The supervised teenagers entered stores unaccompanied. They were allowed to buy inexpensive food items as well as cigarettes. If asked their age, they were not allowed to state a false age but were allowed to answer vaguely or evasively (e.g., “I'm old enough,” or “Could I just have the cigarettes please?”). They did not carry identification documents. Attempts to buy cigarettes were aborted if needed to preserve teen employees' anonymity, to become familiar with a new clerk (Landrine and Klonoff, 2003), or to avoid contact with a previously hostile clerk. Hiring criteria were parental permission, age 14–17, no visible marks such as tattoos, average or better school performance, no tobacco use or apparent risk of initiation, and no local fame (i.e., football captain or homecoming queen). Three employees were 16-year-old Anglo females, one was a 17-year-old Latino male, and two were 16-year-old Anglo males. All reported never having previously tried to buy cigarettes. Teen employees were supervised by a school resource police officer and a civilian high school sports coach. All employees were paid hourly wages. Training for the teens addressed the purpose of the project, the problem of youth tobacco use, relevant laws, purchase attempt protocols, and the need for confidentiality. The teens role-played purchase attempts, and each made a supervised “practice” attempt to buy cigarettes; practice attempts resulting in sales did not trigger the enforcement protocol and are excluded from the current analysis. After 6 months of enforcement, an additional team was fielded to corroborate results, comprising a 16-year-old Anglo female and a 16-year-old Anglo male, supervised by the police officer's spouse. The existing team also remained in the field.

Data Enforcement data collection Results were recorded on site using laptop computers in a database designed for the study. High school survey A self-administered questionnaire was developed to measure ways of acquiring cigarettes and sharing behaviors. Existing questions were used where available. New items were drafted, reviewed by several U.S. researchers who study youth tobacco access, and cognitively pre-tested in a high school health class of 22 sophomores and juniors in a school district comparable to the study site. The final survey was administered in two waves, 1 year apart, to a census sample of students in attendance at the sole public high school.

Measures Enforcement data Measures included date, supervisor, minor's coded identity, store name and address, whether a cigarette purchase was attempted, whether identification was requested, and whether cigarettes were sold.

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449

Fig. 1. Study contacts with retail cigarette outlets in Fort Morgan (CO), 2005.

Student survey data Students who reported having ever smoked at least a puff on a cigarette were asked about current smoking level (number of days in past 30 days, average number of cigarettes on smoking days), cigarette supplies (number of days carrying a supply, largest number of cigarettes carried at one time), frequency of refusing requests for a cigarette from friends and from strangers, ease of asking a friend or a stranger for a cigarette, frequency of being offered a cigarette, personal way(s) of getting cigarettes, and frequency of being asked for age-verification or being refused a sale when attempting to purchase cigarettes in a store. Enforcement practicality For this feasibility study, measures included direct enforcement costs (adult and teen hourly payment, purchase of cigarettes and ancillary items), and indicators of community sentiment regarding the enforcement program (complaints to the police department, local news accounts).

Station, Texas, 2005). A small number (4.8%) of respondents who reported an ethnicity other than Anglo or Latino were omitted to allow standardization between years. Analysis of cigarette supplies and sharing was limited to students who reported ever having smoked. Cigarette acquisition was analyzed for eversmokers, current smokers (smoked any cigarettes in past 30 days), and “active” smokers (N15 lifetime cigarettes and smoking on N2 of past 30 days). Since students of any age may supply cigarettes to others, supplies were analyzed for all ages. Total daily supplies were computed as mean daily supply times weighted estimated number of carriers. Cigarette asking and refusing were analyzed separately for students aged 14–17 and students aged 18, who may legally buy cigarettes. Analysis of non-retail cigarette sources was limited to students aged 14–17, since those aged 18 are not potentially affected by prevention of underage cigarette sales. Statistical comparisons used two-tailed alpha = 0.05.

Results

Analysis

Store contacts

Teen employee contacts with stores were categorized and described by whether a cigarette purchase attempt occurred and, if so, whether a sale occurred. Pre- and post-intervention survey data were weighted for classroom-level nonresponse, directly standardized to initial year distributions of age, gender, and ethnicity, and analyzed using methods for complex samples (StataCorp., College

Teenaged employees visited retail tobacco outlets on 73 days during a 9 month period that started 2 months after the baseline student survey was administered. A total of 931 store contacts occurred in 34 of 39 weeks (mean 28.2 visits per outlet, one

Fig. 2. Underage cigarette sales rates (boxed %) at individual stores, ordered by number of purchase attempts, Fort Morgan (CO) 2005.

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Table 1 Characteristics of Fort Morgan (CO) high school survey respondents (unweighted % unless noted)

Sex Female Male Age 14 15 16 17 18 Ethnicity Anglo Latino Other City of residence Fort Morgan (study site) Other A parent or guardian smokes Yes No Do not know/not sure An older sibling smokes Yes No Do not know/not sure No older sibling Ever smoked cigarettes a Ages 14–15 years Ages 16–17 years Age 18 years Smoked cigarettes in past 30 daysa Ages 14–15 years Ages 16–17 years Age 18 years

2004

2005

(n = 540)

(n = 469)

55.3 44.7

49.2 50.8

17.3 28.5 22.9 19.9 11.4

16.5 31.5 23.7 19.2 9.2

55.4 40.4 4.3

51.4 43.3 5.3

95.8 4.2

94.2 5.8

43.1 52.2 4.8

42.4 53.6 4.0

22.2 55.3 3.6 18.9 52.6 50.3 51.0 67.8 19.9 22.0 17.0 23.8

22.5 52.0 5.5 20.0 54.9 47.4 56.8 74.7 18.2 16.0⁎⁎ 15.7 36.1

⁎⁎p b 0.01. a Weighted, standardized to 2004 population on age, sex, ethnicity.

every 9.7 days). Cigarette purchase attempts occurred in 29 weeks and during slightly more than half of contacts (n = 495, 53.2%). Other contacts involved attempts that were aborted because the employee saw someone s/he knew in the store, chose to avoid a previously hostile clerk, or bought noncigarette items to get familiar with a clerk before asking for cigarettes. Contact frequency was reduced for a few stores after the police supervisor and teens determined that underage sales did not occur in these businesses as a matter of vigilantly enforced store policy. Community-wide sales rates ranged from a high of 48% in the first week to zero percent during 17 weeks (Fig. 1). Storespecific sales rates were not associated with number of contacts (Fig. 2) or with ratio of purchase attempts to contacts (data not shown). Student survey respondents A total of 1009 high school students returned completed questionnaires, comprising 69% of 2004 school enrollment and 70% of 2005 enrollment. Annual samples did not differ sig-

Table 2 Daily cigarette supplies among Fort Morgan (CO) adolescents (aged 14–18, standardized to 2004 population on age, sex, ethnicity) 2004 Ever-smokers (n = 470) Carried any cigarettes in past 30 days Carried cigarettes every day or most days (if carried any) Carried 10 or more cigarettes at a time (if carried any) Current smokers (n = 182) Carried any cigarettes in past 30 days Carried cigarettes every day or most days (if carried any) Carried 10 or more cigarettes at a time (if carried any) Mean daily cigarette supply per carrier Estimated total daily cigarette supply carried a

2005

30.8% 33.8%

27.1% 20.4%⁎⁎

54.8%

39.7%⁎⁎⁎

73.4% 35.6%

73.0% 28.4%⁎

57.6%

44.0%⁎⁎ 5.5† 621

6.7 715

⁎p b 0.05, ⁎⁎p ≤ 0.01, ⁎⁎⁎p = 0.0001, †p = 0.06. a Mean daily supply times weighted estimated number of carriers.

nificantly by age, sex, ethnicity, city of residence, smoking behaviors of family members, prevalence of ever having smoked any cigarettes, or overall prevalence of current smoking (Table 1). Among students aged 14–15, current smoking was less prevalent after the intervention (16.0% vs. 22.0%, p b 0.01). Cigarette supplies, acquisition, and exchange behaviors Cigarette supplies were lower in 2005 than in 2004 (Table 2). Fewer ever-smokers who carried cigarettes did so daily or most days (20.4% vs. 33.8%, p = 0.01), fewer carried half a pack or more at a time (39.7% vs. 54.8%, p = 0.0001), and daily cigarette supplies were non-significantly lower (mean: 5.5 vs. 6.7, p = 0.06; total: 621 vs. 715, p = 0.41). Carrying trends among current smokers were similar to those among ever-smokers except that, in both years, more than 70% of current smokers reported carrying cigarettes. Among current smokers, asking for cigarettes became slightly more widespread, significantly so between friends (Table 3). Table 3 Cigarette social exchange in previous 30 days among adolescent current smokers in Fort Morgan (CO) (%) (standardized to 2004 population distribution of age, sex, ethnicity)

No friend asked for a cigarette No stranger asked for a cigarette Refused friend requests for cigarettes always or most times Refused stranger requests for cigarettes always or most times Very hard or pretty hard to ask a friend for a cigarette Very hard or pretty hard to ask a stranger for a cigarette ⁎p b 0.05, ⁎⁎p ≤ 0.01, ⁎⁎⁎p b 0.001.

Under purchase age (age 14–17, n = 147)

Legal purchase age (age 18, n = 22)

2004

2005

2004

2005

10.8 18.5 26.7

3.2⁎⁎ 13.8 26.1

30.0 27.0 20.0

11.0⁎ 14.0 21.0

52.0

64.0

76.0

25.0⁎⁎⁎

9.1

14.1

0.0

0.0

26.4

38.7⁎

25.0

26.0

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Frequency of refusal was unchanged, except students aged 18 were less likely after intervention to refuse cigarette requests from strangers (76% in 2004 vs. 25% in 2005, p b 0.001). Underage cigarette purchases were significantly less prevalent after the intervention among ever-smokers, current smokers, and active smokers (Table 4). The decline occurred in both lifetime and usual acquisition behaviors. Cigarette theft from stores also declined as a lifetime behavior. Other cigarette acquisition behaviors were unchanged. The most common usual source of cigarettes was proxy buyers, both before and after the intervention. Enforcement practicality Monthly enforcement expenses (excluding research) were $1712, an average of $16.55 per store contact or $31.13 per cigarette-purchase attempt. The expenses amounted to b0.8 percent of the city's police budget (City of Fort Morgan, 2006). The police department received a single complaint from a Table 4 Cigarette sources among Fort Morgan (CO) ever-smokers (%) under the legal age of cigarette purchase (n = 406, standardized to 2004 distribution on age, sex, ethnicity)

Ever bought cigarettes Ever-smokers Current smokers Active smokers a Ever had someone buy for me Ever-smokers Current smokers Active smokers Ever had someone give me cigarettes Ever-smokers Current smokers Active smokers Ever stole from a store Ever-smokers Current smokers Active smokers Ever ordered on the Internet Ever-smokers Current smokers Active smokers Usual way of getting cigarettes b Buy from store Someone buys for me Someone gives to me Take or steal them Some other way How often clerk asked for proof of age c Never Sometimes Half the time or more How often clerk refused to sell cigarettes c Never Sometimes Half the time or more

2004

2005

11.3 26.4 40.8

6.2⁎⁎ 13.8⁎⁎ 25.7⁎

33.0 66.8 81.8

34.0 72.6 91.4

47.4 22.9 11.5

47.5 15.2 9.9

5.3 10.2 13.0 2.2 4.8 6.5 22.6 40.3 27.0 6.2 4.0 52.5 26.6 21.0 61.8 12.8 25.9

1.9⁎⁎⁎ 3.1⁎⁎ 3.9⁎⁎ 1.7 3.4 5.8 ⁎⁎⁎ 3.5 48.6 34.2 6.9 6.8 ⁎⁎ 45.9 19.8 34.4 ⁎ 50.4 18.8 30.8

⁎p b 0.05, ⁎⁎p ≤ 0.01, ⁎⁎⁎p ≤ 0.001. a Smoked N15 cigarettes in lifetime and any cigarettes on N2 of past 30 days. b Among current smokers (smoked any cigarettes in past 30 days). c Among adolescents who attempted cigarette purchase in past 30 days.

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business owner shortly after the study began. The local newspaper published a three-part editorial criticizing the enforcement program as “entrapment.” The newspaper subsequently published a letter from the police chief and the study investigator which addressed factual errors and explained the program's rationale. No concerns were expressed by city officials (K Kuretich, personal communication). Discussion In an isolated rural community, continuous enforcement against underage tobacco sales may have reduced cigarette supplies among adolescents and was associated with significantly reduced smoking prevalence among students aged 14–15. Public concern was minimal and non-consequential. The results suggest that continuous community enforcement against underage tobacco sales is feasible, practical, and effective in reducing cigarette supplies among adolescents. The fact that the intervention was implemented in a non-affluent, ethnically diverse community is encouraging. Further research is needed to assess fiscal and political acceptability in other communities, as well as the reliability of the impact on adolescent cigarette supplies. Both before and after intervention, the most common way to get cigarettes was reliance on proxy buyers, which is also the leading access mode among rural Colorado high school smokers (Levinson AH, unpublished analysis). However, no access mode became more pronounced after the intervention, and adolescent cigarette supplies were reduced overall. This finding suggests that underage retail sales are not replaceable and remain an important source of cigarettes entering the adolescent social “marketplace.” Moreover, lifetime theft of cigarettes from stores became less prevalent. We speculate that clerks who are conditioned to regular enforcement may be more watchful over cigarettes when adolescents are in the store. Before enforcement, stores sold cigarettes to study teens nearly half the time, matching the rate reported by the community's high school students younger than 18. Just 9 months earlier, purchase attempts conducted in the same community but using the federal protocol yielded underage sales in only 12% of attempts. Previous studies have shown that the U.S. compliance check protocol underestimates retail tobacco availability to minors (DiFranza et al., 2001a), and a number of researchers have explored ways to more closely simulate genuine underage purchase attempts (DiFranza and Dussault, 2005; Clark et al., 2000; Levinson et al., 2002; DiFranza et al., 2001a; Landrine and Klonoff, 2003). Based on the current results, community authenticity – naturally looking and acting like a local resident – may be crucial for obtaining the normal responses clerks give to genuine underage cigarette customers. We note, however, that even after enforcement, adolescents reported higher levels of underage cigarette sales than the study detected. This finding casts further doubt on the feasibility of reliably estimating retail tobacco availability to minors (but not on the feasibility of constraining availability below currently acceptable levels). Before intervention, one in six active adolescent smokers usually relied on direct purchase for cigarettes, a level similar to

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the national rate of 18.9% among adolescent smokers (Centers for Disease Control and Prevention, 2003). Current smoking prevalence in the intervention site was also comparable to the national estimate of 22.3% (Centers for Disease Control and Prevention, 2005). These similarities indicate that the intervention effect may be replicable in other isolated rural communities. Study limitations and strengths The current study has several limitations: small sample size (n = 1 community), absence of a control condition, use of an isolated study site, and use of repeated-survey analysis. The n of one design leaves unanswered the broader potential of community acceptance and the reliability of the intervention's effect on supplies. These questions should be answered through further research. The absence of a control condition leaves open the possibility that adolescent cigarette supplies declined for historic reasons, for example, a price increase. Colorado's cigarette excise tax increased by 64 cents per pack (∼ 20% of price) between student survey waves, and such increases have been shown to reduce adolescent smoking. However, a price increase should similarly affect proxy buying, which requires adolescents to spend the same amount of money, albeit through a proxy purchaser. Proxy buying rates did not change, a finding that mitigates this concern. Study site isolation was an intentional selection criterion. Urban and suburban areas typically contain contiguous municipalities, each policed separately. At least some adolescents can literally cross a street to be in another jurisdiction, and vehicular mobility compounds this problem. The intervention reported here may need adaptation – for example, coordinated multi-city enforcement – to be effective in non-isolated cities. Use of repeated surveys to detect change can be confounded by age or cohort effects. Our analyses were standardized to control for age. We also conducted regression analyses with age and cohort as covariates, and underage cigarette purchase was still significantly less prevalent after intervention (results not shown). A study strength is the use of community isolation to reduce external influences on adolescent cigarette supplies. This design allows us to estimate that approximately 13% to 18% of these supplies may depend on retail cigarette sales to underage customers. An additional strength is the focus on a small rural community. Such communities are home to 10% to 20% of the U.S. population (US Census, 2000b), and adolescents in rural communities are at higher risk of smoking (Eberhardt et al., 2001). Consistent enforcement against underage cigarette sales could potentially produce a large positive effect on U.S. adolescent cigarette-related behaviors. Conclusions Isolated rural communities can reduce adolescent cigarette supplies by conducting consistent enforcement against retail tobacco sales to minors. Based on our study, such enforcement appears practical.

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