In measuring the impact of a state\\ide law for clean indoor air, researchers in Missouri examined self- reported data on EPS exposure from 1 YYO through 1993 (Brownson et al. 199%). Nonsmokers' exposure to ETS in the workplace declined slightly the vear the la\~ \~as passed and substantiallv more after the la\2 [vent into effect. Exposure to ETS in the home remained con- stant o\.er the stud\, period; this finding suggests that the declining ivorkplace exposure \vas more likelv linked to the smoking regulations than to the nl.erajl declining smoking pre\.alence obser\-ed during the study period. Despite improvements o\~er time, ETS exposure in the ivorkplace remained at 35 percent in the final vear of the stud\, (1993). Other data from California indicate that nonsmokers employed in w,orkplaces \lith no policy or a polic!, not co\.ering their part of the \i-orkplace \vere eight times more likel) to be exposed to ETS (at \2-ark) than those employed in smoke-free tvorkplaces (Borland et al. 1992). Attitudes Toward Restrictions and Bnrzs Studies ofalrareness and attitudes toivard Ivork- place smoking restrictions and bans hat-e been cow ducted in cross-sectional samples of the general population and among employees affected b!; bans. In a 1989 survey of 10 U.S. communities, most respon- dents favored smoking restrictions or smoke-free environments in all locations, including rzorkplaces, government buildings, restaurants, hospitals, and bars (CDC 1991). Although support for smoking restric- tions was higher among nonsmokers, across the 10 communities, 82-100 percent of smokers fairored re- strictions on smoking in public places. Support \vas highest for smoking bans in indoor sports arenas, hos- pitals, and doctors' offices. A 1993 survey from eight states showed greater support for ending smoking in fast-food restaurants and at indoor sporting e\-ents than in traditional restaurants and indoor shopping malls (CDC 1994a). Support for proposed changes may differ from support for actual, implemented changes. yet in stud- ies of smoke-free hospitals, patients, emplovees, and physicians have overwhelminglv supported ihe policv (Rigotti et al. 1986; Becker et al: 1989; Hudzinski ana Frohlich 1990; Baile et al. 1991; Offord et al. 1992). In some instances, a majority of smokers support a smoke-free hospital (Becker et al. 1989). Studies of smoking restrictions and bans in other industries also have found that nonsmokers overwhelmingly favor smoke-free workplaces (Petersen et al. 1988; Borland et al. 1990b; Gottlieb et al. 1990; Sorensen et al. 1991b). Time-and consequent habituation-can make changes more acceptable. In a prospective study of a smoking ban in a large workplace, Borland and colleagues (1990b) found that attitudes of both non- smokers and smokers toward the smoke-free work- place rzere more favorable six months after such a policy ivas implemented. Although most smokers re- ported being inconvenienced, they also reported that they recognized the overall benefits of the policy. Two studies from Massachusetts found that one and two vears after t\vo local 1aM.s for clean indoor air were enacted, 65 percent of the businesses surveyed favored the la\y (Rigotti et al. 1992, 1994). The authors con- cluded that a self-enforcement approach achieved high le\,els of abvareness (about 75 percent) and intermedi- ate levels of compliance (about 50 percent) (Rigotti et al. 199-l). Effects of Restrictiorls ad Bans OH Nousmokers' Exposure to ET5 As has been found in population-based research, studies conducted in individual workplaces have found that smoke-free lvorkplaces have been effective in reducing nonsmokers' exposure to ETS. Effective- ness has been measured bv the perceived change in air quality in the workplace after a smoke-free policy \vas instituted (Biener et al. 1989; Gottlieb et al. 1990) and hy measurement of nicotine vapor before and af- ter such a policy (Stillman et al. 1990). Conversely, Ivorkplace policies that allow smoking in designated areas without separate ventilation result in substan- tial exposure to ETS for nonsmokers (Repace 1994). An analysis of the effects of a smoke-free ivorkplace in The Johns Hopkins Medical Institutions found that concentrations of nicotine vapor had de- clined in all areas except restrooms at one to eight months after the ban (Stillman et al. 1990). In most areas, nicotine concentrations after the ban were be- loll- the detectable level of 0.24 pg/m'. Effects of Restrictions on Smoking Behavior An additional benefit from regulations for clean indoor air may be a reduction in smoking prevalence among workers and the general public. For example, in a multivariate analysis, moderate or extensive laws for clean indoor air were associated with a lower smok- ing prevalence and a higher proportion of quitters (Emont et al. 1993). Another study also found an as- sociation between local smoking restrictions and smok- ing preiralence (Rigotti and Pashos 1991). SUP~YUI G~ik~hii'. /L~jkvr .Y Table 5.2. Summary of studies on the effects of a smoke-free workplace on smoking behavior Authors/year Location AndreIvs 1983 Boston, Massachusetts Rigotti et al. 1986 Boston, Massachusetts Industry Hospital Hospital pediatric unit Sample size 965 93 Rosenstock et al. 1986 Puget Sound. Washington Petersen et al. 1988 Becker et al. 1989 Biener et al. 1989 Scott and Gerberich 1989 Borland et al. 199Ob Connecticut Baltimore, Maryland I'ro\.idencc, Rhode Island Midlvestern United States Australia Health maintenance organization Insurance company Children's hospital Hospital Insurance company Public service Centers for Disease Control 1YYOc Gottlieb et al. lY90 Pueblo, Colorado Psychiatric hospital 1,032 Government agency Hudzinski and Frohlich 19`~O Stillman et al. 1990 Baile et al. 1941 Borland et al. 1991 Ne\v Orleans, Louisiana Baltimore, .Llar~~land Tampa, Florida ,Austrnlia Sorensen et al. 1YYla Hospital Hospital Hospital Telecommunicatiolis companv Telephone company Brenner and lLIielck 1992 Goldstein et al. 1992 Augusta, Georgia National random sample Hospital Offord et al. lYY2 Wakefield et al. 1992b Rochester, Minnesota Hospital Australia Representative sample Jefferv et al. 1994 Minneapolis-St. Paul, Minnesota Diverse Lvorksites 447 1,210 704 535 452 2,113 1,158 1,946 2,877 349 620 1,120 439 1,997 10,579 1,929 32 worksites; total number of individuals not reported Change in individual or overall smokers' consumption Change in prevalence Not reported -8.5% at 20 months follow-up -2.3 cigarettes per shift (I' < 0.01) at 12 months folloiv-up; no change in No significant change o\rerall consumption -2.0 cigarettes per day (I' < 0.003) at 4 months follow-up No significant change -5.6 cigarettes per day at 12 months follo~v-up No change at 6 months follow-up 1.6'; at 13 months follokv-up -1.2'yr at 6 months follow-up -3.9 cigarettes per day at lvork at 12 months follo~r-up 22.5';; of smokers decreased consumption at 7 months follo\v-up No significant change -5.1 ?ir at 7 months follow-up -7.9 cigarettes per day in smokers ot 25 or more cigarettes per da\. at 6 months follow-up -1 .O'Z at 6 months follow-up -3.5 cigarettes per day at lvork at 13 months folio\\--up; -1.8 cigarettes per day over 24 hours -4.0% at 13 months follow-up 12.0% reduction in consumption of 15 or more cigarettes per day at lvork at 6 months follolv-up (I' < 0.001) -3.4% at 6 months follow-up 25% of smokers no longer smoked at work at 12 months follo\v-up -3.3 cigarettes per day at 6 months follorv-up (I' = 0.0001) Not reported -5.5'; at 6 months follow-up 407 of smokers decreased consumption at 4 months follow-up -3.5 cigarettes per day at 18 months follow-up (I' < 0.05) -1.5% at 4 months follow-up -3.1% at 18 months follow-up Not reported 21% of smokers quit at 20 months follow-up -1.8 cigarettes per day in men, -1.4 cigarettes per day in women Cessation proportion of 30% 57% of smokers reported they had cut down on number of cigarettes smoked Not reported 9% of smokers stated they had quit because of the ban -2.9% at 30 months follow-up -5 cigarettes per day on workdays vs. leisure days Not reported -1.2 cigarettes per day -20 at 24 months follow-up In recent !.cars, researchers ha1.e increasingly recognized the role of the enr-ironment' in influencing indi\-idual smoking behavior through perceived cues (NC1 1991; McKinlay 1993; Brownson et al. 1995b), many of xvhich ha1.e their origins in generally held rules about acceptable beha\,iors (i.e., social norms) (Robertson 1977). Smokers frequently respond to environmental cues when deciding kvhether to smoke at a given time (NC1 1991). For example, a smoker may recei\,e a per- sonal, habit-deri\.ed cue to smoke after a meal or on a Iyork break, but this cue may be \2-eakened (and even- tually even canceled) by a social, policy-derived cue not to smoke if the person is in a smoke-tree restaurant or worksite (Brownson et al. lY95b). Numerous studies have assessed the potential effects of workplace smoking bans on employee smoking behavior (Table 5.2). These studies have been conducted in health care settings (Andrekvs 1983; Rigotti et al. 1986; Rosenstock et al. 1986; Becker et al. 1989; Biener et al. 1989; CDC 1990~; Hudzinski and Frohlich 1990; Stillman et al. 1990; Baile et al. 1991; Goldstein et al. 1992; Offord et al. lY92), government agencies (Gottlieb et al. 19YO), insurance companies (Petersen et al. 1988; Scott and Gerberich lY8Y), and telecommunications companies (Borland et al. 1991; Sorensen et al. 1991a) and among random samples of the working population (Brenner and Mielck 1992; Wakefield et al. 1992b). Most of the studies based in hospitals or health maintenance organizations that banned smoking found a decrease in the average num- ber of cigarettes smoked per day. Se\.eral of the has- pita1 studies found significant declines in the overall prevalence of smoking among employees at 6-20 months follow-up (Andrelvs 1983; Stillman et al. 1990). Studies of smoking behavior in other industries ha\,c found similar results; in most settings, daily consump- tion, overall smoking pre\,alence, or both had de- creased at 6-20 months after \vorkplaces were made smoke free. In a population-based study of California resi- dents, the prevalence of smoking \vas 14 percent in smoke-free \vorkplaces and 21 percent in rzrorkplaces with no smoking restrictions (Woodruff et al. 1993). Consumption among continuing smokers eras also lower in smoke-free bvorkplaces, and the percentage of smokers contemplating quitting was higher. In 1992, Patten and colleagues (1995,) follo\ved up a large sample of persons (first inter\,ie\ved in 1990) to deter- mine the influences a change in lvorksite setting might have had on smoking. These researchers observed a statistically nonsignificant increase in smoking `The term "en\.ironment" is detincd Ivoaill!- to Include the Itpi, wcidl, tvmnorllii, dn~l ph\3ical en\ ircwmtwt (Clleadk et dl. 1 W.2). prevalence among the group that changed from a smoke-free fvorkplace to one at which smoking was permitted. The prevalence of smoking among other groups was unchanged or had declined. Although these results are tentative, particularly in view of sam- pling difficulties during the follow-up interview, they signal the potential impact workplace policies can have on smoking behavior. Case Studies of State and Local Smoking Restrictions Recent reviews have presented case studies on the passage of state and local laws for clean indoor air (Samuels and Glantz 1991; Fourkas 1992; Jacobson et al. 1992; Traynor et al. 1993). These studies describe the issues that states and local communities dealt with in enacting smoking restrictions in public places. In a case study of six states, the ability of key leg- islators to support legislation and the existence of an organized smoking prevention coalition were key de- terminants of lz.hether statewide legislation was en- acted for clean indoor air (Jacobson et al. 1992). Although the enactment of such legislation was not waranteed when these factors were favorable, enact- 0 ment \vas unlikely when they were unfavorable. Two other factors \vere cited as key in enacting legislation in the six states studied: an active executive branch that pressured the legislature to act, especially by mak- ing such legislation an executive policy priority, and existing local ordinances that created a policy environ- ment favorable to the enactment of statewide smok- ing restrictions. The study found that coalitions that succeeded in enacting legislation to restrict smoking in public places featured organized commitment, including both a full-time staff and a professional lobbyist. Success- ful coalitions also had established close working rela- tionships M.ith key legislative sponsors to develop appropriate policy alternatives and to coordinate leg- islative strategy. Finally, effective coalitions used me- dia and grassroots campaigns to mobilize public sr~pport for smoking restrictions. Another important component in the legislativ-e debate was how the issue of smoking restrictions was framed. In all six states reviewed, the tobacco industry tried to shift the focus from the credibility of the scien- tific evidence on the health hazards of ETS to the con- troversial social issue of personal freedom; specifically, the industry lobbied extensively for including nondis- crimination clauses in legislation to restrict smoking (Malouff et al. 1993). Another common strategy that the tobacco industry has used is to support the pas- sage oi state la\ys that preempt more stringent local ordinances (Brolvnson et al. 1993b). Because of the possible countereffect of preemp- tive legislation and because of the difficulty in enact- ing statelyide legislation, public health ad\rocates have suggested that advocates for reducing tobacco use should devote more resources to enacting local ordinances (Samuels and Glantz 1991; Fourkas 1992; Minors' Access to Tobacco Jacobson et al. 1992). A local strategy can usually im- pose more stringent smoking restrictions than state- M,ide legislation does. Like the study of Jacobson and colleagues (1992) on statewide initiatives, a study of local initiati\res found that two key ingredients for success ivere the presence of a strong smoking pre- \,ention coalition and sympathetic political leadership Ii-ithin the elected body (Samuels and Glantz 1991). Introduction Minors' access to tobacco products is an area of regulation relativelv free from the social and legal de- bate that often arises from other regulatory efforts. E\.en the staunchest opponents of reducing tobacco use concede that tobacco use should be limited to adults and that retailers should not sell tobacco products to children and adolescents. \r'et as \vas discussed in de- tail in the Surgeon General's report on smoking among young people, a significant number of minors use to- bacco, and a significant number of them obtain their tobacco through retail and promotional transactions, just as adults do (USDHHS 199-l; CDC 1996a,b; Kann et al. 1998). Whether intended exclusi\,elv for adults or not, these commercial transactions are supported bv vast resources. The multibillion-dollar tobacco in- d&try spends a large proportion of its marketing dol- lars to support a vast network of wholesale and retail activity. In 1997, cigarette makers spent $2.44 billion on promotional allo\vances to the wholesale and re- tail trade and an additional $1.52 billion on coupons and retail value-added promotions (FTC 1999). These figures were 42 percent and 26 percent, respectively, of the entire $5.1 billion spent on advertising and pro- moting cigarettes in the United States that year. In general, the availability of cigarettes to the adult population has not been a regulatory issue since the first quarter of the 20th century (see Chapter 21, although recent FDA statements about nicotine levels in cigarettes have raised the possibility of some regu- lation of adult use (see "Further Regulatory Steps," earlier in this chapter). The primarv regulatorv focus for cigarette access has been on reducing the'sale of tobacco products to minors (Forster et al. 1989; Hoppock and Houston 1990; Thomson and Toffler 1900; Altman et al. 1992; CDC 1992a; Cummings et al. 1 c)92; F~~fcrn/ RL's~s~P~ 1993, 1996). Broad-based public support for limiting minors' access to tobacco has de- \,eloped in the relatively brief time (since the mid- 1980s) that this issue has been in the public eye (DiFranza et al. 1987, 1996; CDC 1990a,b,c, 1993a, lYY-la, 1996a,d; Jason et al. 1991; Hinds 1992; Keay et al. 1993; Landrine et al. 1994, 1996; USDHHS 1994). Reducing the commercial availability of tobacco to minors is a potential avenue for reducing adoles- cent use. Groiying evidence suggests that tobacco products are widely available to minors. Uniformly, surveys find that teenagers believe they can easily obtain cigarettes (see, for example, Forster et al. 1989; Johnston et al. 1992; CDC 1996a; Cummings et al. 1998; University of Michigan 1999). As noted, this access is by no means confined to borrowing cigarettes from peers or adults or stealing them at home or from stores; purchase from commercial outlets is an important source for minors who use tobacco. An estimated 255 million packs of cigarettes were illegally sold to mi- nors in 1991 (Cummings et al. 1994), and daily smok- ers aged 12-17 vears smoked an estimated 924 million packs of cigarettes in 1997 (DiFranza and Librett 1999). Be&Teen 20 and 70 percent of teenagers who smoke report purchasing their own tobacco; the proportion \,aries by age, social class, amount smoked, and fac- tors related to availability (Forster et al. 1989; Response Research, Incorporated 1989; CDC 1992a, 1996a,d; Cummings et al. 1992, 1998; Cummings and Coogan 1992-93; Mark Wolfson, Ami J. Claxton, David M. Murray, and Jean L. Forster, Socioeconomic status and adolescent tobacco use: the role of differential avail- ability, unpuL7lished data). In a re\,iew of 13 local o\er-the-counter access studies published betivern 1987 and 1993, illegal sales to minors ranged from 32 to 87 percent Gtli dn approximate r\.eiglited-a\.erage of 67 percent. Several local studies published in 1996 and 1997 found somewhat lolver over-the-counter sales rates to minors: 22 percent (Klonoff et al. 1997) and 2Y percent (CDC 1996) in twro separate studies in California and 33 percent in Massachusetts (DiFranza et al. 1996). Nine studies of vending machine sales to minors published between 1989 and 1992 found ille- gal \.ending machine sales ranging from 82 to 100 per- cent Lvith an approximate ueighted-average of 88 percent (USDHHS 1994). Comparison of the results of these research studies lyith the results of later statewide Synar surveys (see below) is problematic for four reasons: (1) the research studies M'ere generally local surveys of a to\vn, city, or county, lvhereas the Synar surveys are based on statewide samples; (2) the sam- pling methods vary across the research studies; (3) store inspection methodologies \.arv; and (4) some of the research studies contain results of se\.eral surveys, often pre- and post-intervention (CSDHHS 1998a). Several factors suggest that rvidespread reduc- tion in commercial a\-ailability may result in reduced prevalence or delayed onset of tobacco use by young people: the reported importance of commercial sources to minors, the easv commercial availabilitv that has been demonstrat&, and the reductions in commercial a\,ailability demonstrated \vhen legal re- strictions have been tightened, as outlined belo\y (Ja- son et al. 1991; DiFranza etal. 1992; Hinds 1992; Forster et al. 1998). One psychological study supports the po- tential impact of limiting minors' access to cigarettes (Robinson et al. 1997). In this investigation of 6,967 seventh graders of mixed ethnicit, the best predictor of experimentation lvith cigarettes \j'as the perception of easv availability. Regular smoking \vas hea\.ilv in- fluenced by cost (see Chapter 6). Direct studies of factors that influencs minors' access bar-e produced mixed results, ho\l.e\rer. Set.- era1 investigators found that state lairs on minimum age for purchasing tobacco products did not bv them- selves ha1.e a significant effect on cigarette smoking among youth (Wasserman et al. 1991; Chaloupka and Grossman 1996). Other studies ha\,e pro\.ided el.i- dfnce in single communities (~~ithout comparison groups) that compliance lvith youth access regulations does lead to reductions in regular smoking by adoles- cents (Jason et al. 1491; DiFranza et al. 1992). In a nonrandoniired, controlled community trial (three intervention and three control communities), Rigotti and colleagues (lY97) found that although illegal sales rates to minors decreased significantlv more in the control communities than in the intervention commu- nities, there was no difference between control and intervention communities in either self-reported access to tobacco from commercial sources or in smok- ing behavior among youth. The authors suggest that illegal sales rates were not reduced sufficiently in the intervention communities to cause a decrease in com- mercial access that was substantial enough to impact youth smoking. Noting that these studies were lim- ited by their scope or sample size, Chaloupka and Facula (1998) analyzed data from the 1994 Monitor- ing the Future surveys on 37,217 youths. Using per- sonal and ecologic variables in a two-part multivariate model to estimate cigarette demand by youth and av- erage daily cigarette consumption, the investigators found thatadolescents are less likely to smoke and that those who smoke consume fewer cigarettes in the fol- lowing settings: where prices are higher, in states that use cigarette excise tax revenues for tobacco control activities, where there are stronger restrictions on smoking in public places, and in states that have adopted comprehensive approaches to measuring re- tailer compliance \vith youth access laws. The authors concluded that comprehensive approaches, including enforcement of minors' access laws, will lead to a re- duction in youth smoking. A large, community-based clinical trial-seven intervention and seven control communities-also found an intervention effect (Forster et al. 1998). In this study, communities that developed ne\v ordinances, changes in merchant poli- cies and practices, and changes in enforcement prac- tices experienced a significantly smaller increase in adolescent smoking than did the control communities. Further exploration of this issue may be required to substantiate the impact of the enforcement of minors' access 1acz.s. As commercial sales to minors are decreased, there is e\.idence that minors may shift their attempts to obtain cigarettes to "social" sources, e.g., other ado- lescents, parents, or older friends (Hinds 1992; Forster et al. 1998). One study found that adult smokers aged 18 and 19 years were the most likely group of adults to be asked by a minor for cigarettes (Ribisl1999). This study did not assess how frequently minors asked other minors for tobacco. There is also evidence, how- ever, that minors who provide tobacco to other minors are more likelv to purchase tobacco than other minors w,ho smoke (Wolfson 19971, and in any event, some of the cigarettes provided by minors to other minors were initiallv purchased from commercial sources (Forster et al. 1997). Whether the source is social or commer- cial, it is clear that a comprehensive approach to re- ducing minors' access is needed; smokers of all ages in addition to tobacco retailers must a\.oid pro\isio:l of tobacco to minors. Efforts to Promote Adoption and Enforcement of Minors' Access Laws Public organizations at the federal, state, and lo- cal levels ha1.e become acti1.e in encouragin;: state and local jurisdictions to adopt and enforce minors' access la\vs. The NCI-ACS collaboration knnlvn as ASSIST (American Stop Smoking Inter\.ention Stud)-) has iden- tified reducing minors' access to tobacco products ai one of its goals for its 17 demonstration states;. The Robert Wood Johnson Foundation's SmokeLess States program also encourages funded states to address minors' access. The USDHHS has ividel\- distributed a model state la\v as a result of an in\.estijiation b\, the Office of Inspector General (OIG) reporting little Or nc) cnforcenient of state lalvs on minimum ages for tw bacco sales (OlG 1990; USDHHS IYYO). C;,vi~~iii~~ C//J ~TOhiiO Flw: fIl'i'i'llt;il~~ h'iiclfi,lc' ~4tftfiitrc~ri iri C/lilifJl~~l ,711~j \i)llf/2, a report from the Institute ot Mcdicint~ (IOM), includes an estensil e study of minors' access and a series of recommendations about state and local lalvs in this area (Lynch and Bonnie 1991). A group of 75 state attorneys ieneral formed a Ivorking group on the issue and released a set of recommendations re- garding retail sales practices and legislation aimed at reducing tobacco sales to minors (Working Group of State Attorneys General 1991). Efforts to curb illegal sales to minors ha1.e also occurred at the federal level. The former FDA pro- gram (see description in Chapter 7) Leas a major effort for several years. Probably the most sustained and tvidespread attention to the issue of minors' access lairs and their enforcement \vas precipitated by the C.S. Congress, lvhich in 1992 adopted the Sonar Amendment as part of the Alcohol, Drug Abust; and h;lental Health Administration Reorganization Act (Public La\v 102-321, sec. 1926), lvhich amended the public Health Service Act. This provision requires states (at the risk of forfeiting federal block grant funds for substance abuse pre\w~tion and treatment) to adopt laws establishing minimum ages for tobacco sales, to enforce the law, and to sholv progressi1.e reductions in the retail availabilitv of tobacco products to minors. The implementation df the Synar Amendment, l,vhich initiallv was to go into effect during fiscal year 1991, leas delayed because regulations about how states Lvere to i&plement the statute had not yet been final- ized. During the considerable lag betw.een passage of the amendment and the issuance of final regulations, advocates for Synar-like restriction of youth smoking and those opposed to the Synar approach used the draft regulations to encourage states to adopt laws that in these parties' differing viekvs M'ere the minimum necessar\ for states to comply tvith the Synar Amend- ment (P:l~~fw~/ Rqi.r a re\ie\v of comments from the health commu- nit\,, state agencies, and the tobacco industry. Respon- sibilit,, for im~~lement~~tion was placed with the Substance Abuse and Mental Health Services Admin- istration (SXMHSA), ivhich in the course of 1996 con- ducted t\z.o technical assistance meetings with states and issut>d three separate guidance documents. Un- der these regulations, the Synar Amendment requires the 50 states, the District of Columbia, and U.S. juris- dictions to do the follo\ving: Ha1.r in effect a lalz prohibiting any manufacturer, retailer, or distributor of tobacco products from sell- ing or distributing such products to any person under the age of 18. Enforce such Iaivs in a manner that can be reason- able expected to reduce the extent to which tobacco pr&ucts are available to persons under the age of 18. Conduct annual random, unannounced inspections to ensure compliance with the law; inspections are to be conducted to pro\ride a valid sampling of out- lets accessible to underaged youth. De\-elop a strategy and time frame for achieving an inspection failure rate of less than 20 percent among outlets accessible to underaged youth. Submit an annual report detailing the state's ac- ti\,ities in enforcing the late, the success achieved, methods used, and plans for future enforcement. III the event ot noncompliance with these regu- lations, the Secretary of Health and Human Services is directed bv statute (42 U.S.C. section 300X-26[c]) to mal\c reducvti~,ns of from 10 percent (for the first applicable fiscal year) to 40 percent (for the fourth applicable fiscal \,ear) in the noncompliant state's fed- eral block grant for substance dhse programs. Al- though no additional monies ha\,e been appropriated to offset the costs of complying \\,ith these regulations, states mav use block grant funds for certain Synar- related administrative activities, such as developing and maintaining a list of retail outlets, designing the sampling methodology, conducting Synar survev in- . spections, and analyzing the sur\`ey results. In the several years following the issuance of the final Synar regulation, some significant advances have been made in enforcement of youth access laws. All states have laws prohibiting sale or distribution and they are enforcing those laws (USDHHS 1998a). Fur- ther, the median rate at which retailers failed to com- ply with laws prohibiting tobacco sales to minors in 1998 was 24.4 percent compared Ivith the median rate of 40 percent in 1997 and pre-1997 studies that found violation rates ranging from 60 to 90 percent (LSDHHS, in press). In the course of implementing Synar, every state has been required to establish a sam- pling methodology that measures the statewide retailer \,iolation rate lvithin a known confidence inter\.al and to establish inspection protocols for conducting the statelride sur\rey of tobacco retailers. These protocols include restrictions on the ages of minor inspectors and to establish procedures for recruiting and training of both minor inspectors and adult escorts. Addition- ally, the random, unannounced inspections conducted by the states in compliance M'ith the Synar regulation provide the largest body of stateivide data available on the level of retailer noncompliance. Tlventy-tw.0 states and tLt-0 U.S. jurisdictions modified their vouth access lairs iz.ithin a vear of implementing Synar inspections. These changes im- proved the states' ability to enforce the 1~71~ by clarify- ing responsibilitv for enforcement, defining violations, clarifying penalties, restricting vending machine sales, and establishing a list of tobacco vendors through re- tail licensure or vendor registration (USDHHS, in press). In spite of these acl\.ances in enforcement of youth access larvs, states also encountered difficulties while attempting to comply bsith the Svnar mandate. The Synar regulation does not allow fo; the allocation of federal dollars (e.g., the Substance Abuse Preven- tion and Treatment Block Grant) to be used for enforce- ment. For many states, this proved to be a significant problem, because enforcement of youth access laws had not been previouslv vielved as a priority, and states M'ere unwilling to redjrect already limited funds for prevention and treatment services to IaM enforcement. Some states addressed the problem by earmarking re\.enue derived from fines, fees, or taxes. Other states implemented collaborative enforcement efforts among several agencies so that the financial burden would be shared. And still other states relied heavily on the use of volunteer youth inspectors and adult escorts (USDHHS lYY8a). As the FDA became active in the youth access issue, a few states were able to use FDA funding for enforcement to cover some of the cost of Synar inspections in 1998. Another obstacle to enforcement involved devel- oping a valid random sample of tobacco outlets in the state when there was no accurate or current list of ven- dors available. Although a few states addressed this problem by working to pass retailer licensing laws at the state level, states initially had to build lists by rely- ing on information from wholesale tobacco distribu- tors and vending machine distributors and by searching existing lists that inadvertently identify to- bacco vendors (e.g., convenience store association membership lists) (USDHHS 1999). Other less frequently cited obstacles to enforcc- ment included fear of lawsuits from cited vendors, concerns \2-ith the liability issues associated with work- ing nith vouth, and opposition to conductingenforce- ment from state and local officials, law enforcement, and the general public in regions of the country where the economy is tied to the production of tobacco (USDHHS 1999). In addition to federal and state efforts targeting illegal tobacco sales to minors, a great amount of local activity has occurred. Many local ordinances have re- sulted from the lvork of various groups, particularly in California, Massachusetts, and Minnesota (DiFranza 1994a,b; Kropp 1995; Forster et al. 1996, 1998). These ordinances-which may, for example, prohibit vend- ing machine sales or all self-service sales of tobacco, require the tobacco sellers to be aged 18 years or older, require checking identification before sale, specify civil penalties for violators of the minimum-age law, require posting that law at the point of purchase, and require compliance checks with a specified timetable-permit creatilre responses at the local level to the minors' ac- cess problem. Compared with state officials, local of- ficials deal with fewer retailers and a more limited set of constraints and are freer to tailor their policy to lo- cal conditions. Tobacco interests are less influential at the local level, because industry representatives are more likely to be perceived as outsiders, and their cam- paign contributions are less likely to be important to local officials; moreover, community members and local advocacy groups are often more effective against tobacco interests at this level than they are in statewide policy arenas (Sylvester 1989). Policy implementation is also likely to be more consistent at the local le\rel, be- cause local advocates can monitor the process and be- cause enforcement officials are more likely to 1~ax.e been a part of the policy's adoption. Ho\ve\.er, many of the policies at the federal, state, and local le\rels are inter- related: the federal Synar Amendment is implemented through state lalvs and has led to enforcement at the state and local level (USDHHS 1998a). The former FDA enforcement program operated through contracts \vith state agencies or organizations to conduct compliance checks in communities across the states. State agen- cies often fund local coalitions and projects, and local efforts influence and support efforts at the state le\.el. For example, much of the local activity in California and Massachusetts ~\rould not 1~aL.e been possible \\-ithout actions implemented at the state level, spe- cifically designated funding. LaM-s enacted bv states pertaining to minors ac- cess to tobacco as oi December 31, 1999, ha\ e been compiled bv the CDC (CDC, Office on Smoking and f-Iealth, Sta;e Tobacco Activities Tracking and El-alua- tion System, unpublished data)(Table 5.3). Dates of enactment or amendment indicate that some legisla- ti\Te change occurred in all but one state from Januar\ 1990 to December 1997 (National Cancer Institute, Stati Cancer Legislative Database, unpublished data, Octo- ber 6, 1998). Restrictions on Distribution of Samples Tobacco product samples pro\.ide a lolv-cost or nn-cost initiation to their use and thus encourage ex- perimentation at early ages. Many states or other ju- risdictions have laws that prohibit not onlv sales but also any samples distribution of tobacco to minors, lvhereas some laws specify exceptions permitting par- ents or guardians to provide tobacco to their children. All states have a specific restriction on the distribu- tion of free samples to minors, and a fe\v states or lo- cal jurisdictions prohibit free distribution altogether because of the difficulty of controlling who receives these samples. A ban on product sample distribution can extend to coupons for free tobacco products. In Minnesota, the attorney general levied a $95,000 civil penalty against the Brown & Williamson Tobacco Cor- poration for allowing such coupons to be redeemed in the state (Minnesota Attorney General 1994). The re- ports from both the IOM (Lynch and Bonnie 1994) and the Working Group of State Attorneys General (1994) recommended a ban on the distribution of free tobacco products. The final FDA rules issued in August 1996 Tvould have prohibited the distribution of free samples (see "Further Regulatorv Steps," earlier in this chapter). The proposed multistate settlement pre- sumed congressional legislation that would uphold those rules (see "Legislative Developments" and "Mas- ter Settlement Agreement," earlier in this chapter). Regulation of Means of Sale Hobv tobacco can be sold may also be regulated to make it more difficult for minors to purchase it. His- toricallv, the first such restrictions adopted have been regulations of cigarette vending machines, which are an important source of cigarettes for younger smok- ers (Response Research, Incorporated 1989; Cummings et al. 1992, 1998; CDC 1996d). These regulations have taken the form of total bans, restrictions on placement (e.g., being \\sithin \,ielv of an employee instead of in coatrooms or entrances, or not being near candy or soda machines), restrictions on the types of businesses I\.here \-ending machines may be located (e.g., limited to liquor-licensed businesses, private businesses, or businesses lvhere minors are not permitted), and re- strictions on characteristics of the machines themselves (e.g., requiring electronic locking devices or coin slugs purchased over a sales counter) (Forster et al. 1992a; DiFranla et al. 1996). The final FDA rules would have prohibited vending machines except in certain night- clubs and other adults-only facilities totally inaccessible to persons under age 18. The proposed multistate settle- ment anticipated legislation supporting this prohibition. Forty-one states and the District of Columbia ha\.e lalvs that restrict minors' access to vending ma- chines, including two states, Idaho and Vermont, that ha\,e enacted legislation totally banning vending ma- chines. However, many of the state vending machine 1aMs are weak. For example, 21 states and the District of Columbia do not restrict placement if the machine is supervised, and Ne\v Jersey bans vending machines in schools only (CDC, Office-on Smoking and Health, unpublished data, 2000). However, more than 290 lo- cal jurisdictions, including New York City, have been able to adopt and enforce outright bans on cigarette vending machines or to severely restrict them to loca- tions, such as taverns, where minors are often excluded (American Nonsmokers' Rights Foundation, unpub- lished data, 2000). Representatives of tobacco manufacturers and retailers have strongly opposed bans on cigarette vend- ing machines and have argued instead for weaker re- strictions, if any, especially for what they term "adult" locations (Minnesota Automatic Merchandising Council 1987; Adkins 1989; Parsons 1989; Grow 1990; Moylan 1990; Pace 1990; Gitlin 1991). Many of these locations, including bars and other liquor-licensed Table 5.3. Provisions of state laws relating to minors' access to tobacco as of December 31,1999 Minimum age for tobacco State sales Tobacco Vending license machine required restrictions Alabama Alaska Arizona Arkansas California' 19 1Y 18 18 18 yes yes+ 110 yes 110 Colorado Connecticut' Delaware? District of Columbia Florida' 18 18 18 18 18 no yes+ yes yes+ ves Georgia Hawaii Idaho Illinois' Indiana' 18 18 18 18 18 yes 110 no no 110 Iowa' 18 Vt'S+ Kansas 18 vest Kentucky' 18 yes+ Louisiana' 18 yes Maine lti ves Maryland Massachusetts' Michigan' Minnesota Mississippi' 18 18 18 18 18 vest ves yes ves yes no yes yes yes yes ves Yes yes yes yes yes yes yes' yes yes ves ' yes yes yes ves no no VES ves yes Enforcement Sign-posting authority requirements* yes no no Yes no no Yes no Yes Yes Yes Yes Yes yes Yes yes yes no no'l' yes 110 Yes yes yes yes no yes yes 110 yes Yes yes yes no Yes yes no yes yes yes yes no yes yes ves no no no yes yes Prohibits purchase, possession, and/or use by minors Yes ye9 yes yes yes yes yes Yes no Yes yes yes yes yes yes yes yes yes yes** yes yes no yes-- yes yes"" *Refers to the requirement to post the minimum age for purchase of tobacco products. -Excludes chewing tobacco or snuff. TExcept minors at adult correctional facilities. `Some or all tobacco control legislation includes preemption. `Requires businesses that ha\-e vending machines to ensure that minors do not have access to the machines; however, the lall- does not specify the type of restriction, such as limited placement, locking device, or supervision. "Signage required for sale of tobacco accessories, but not for tobacco. **Except persons rvho are accompanied by a parent, spouse, or legal guardian 21 years of age or older or in a private residence. ++A pupil may not possess tobacco on school property. Source: Centers for Disease Control and Pre\.ention, Office on Smoking and Health, State Tobacco Activities Tracking and Elraluation System, unpublished data. Table 5.3. Continued State Missouri Montana' Nebraska Nevada' Ne\v Hampshire Ne\v Jersey' Ne\v Mexico' New, York' North Carolina' North Dakota Ohio Oklahoma' Oregon' Pennsyl\.ania' Rhode Island South Carolina' South Dakota' Tennesseei Texas Utah' Vermont Virginia' Washington' West Virginia' Wisconsin' Wvoming' Total Minimum age Tobacco Vending for tobacco license machine sales required restrictions 1X 18 IS 18 18 110 ves 18 18 18 18 18 vet; ves ves ves ves 18 18 18 18 1X no ves yes" ves 4i VeS WS' no ves *lO?C* i : \,t`S`" Vt?S' WS no Vt?S- yes- ves no no ves yes ves no vesT no ves no 35 ves \'es vcs ves VeS 18 18 18 18 18 18 18 18 18 18 18 ves ves \'t?S ves VCS 31 yes no yes yes 14 Enforcement authority no yes I10 VPS \'fS yes VtTS ves 110 no no ves Vt`S no ves no yes ves ves ves ves ves ves ves 110 no 33 Sign-posting requirements yes yes no no ves ves ves ves yes no yes yes yes no yes no no yes ves no yes yes yes no yes yes 36 Prohibits purchase, possession, and/or use by minors no ye@ yes no yes no yes no yes yes no yes yes no# yesqT no yes Yes yes yes yes yes yes yes yes yes 42 **A pupil mav not possess or use tobacco on school property "Except ven&ng machines. "A retail license exists for those retailers 12-ho manufacture their o\vn tobacco products or deal in nonpaid tobacco products. " On any public street, place, or resort. businesses, do not prohibit minors entry and ha1.e been shorz-n to be readily accessible to underaged buy- ers (Forster et al. 1992b; Wakefield et al. lYY2a; Cismoski and Sheridan 1993). Because less-restrictive measures must be consistently implemented to be ef- fective, and because such implementation is difficult, the USDHHS (1994) and the IOM (Lynch and Bonnie 1994) recommend a total ban on cigarette vending machines. The 1996 FDA rules Lvould have excluded locations that are inaccessible to minors, but the multistate settlement proposed a total ban. Restrictions on vending machines are a category of regulation of self-service cigarette sales. A general ban on self-service would require that tobacco be physically obtained from a salesperson and be stored so that products are not directly accessible to custom- ers. In one study of 4X9 over-the-counter purchase attempts, minors \vere successful at purchasing in 33 percent of locations where cigarettes ivere behind the counter and 15 percent of locations bzhere cigarettes were openly available (Forster et al. 19%). In another study, stores that did not give customers access to to- bacco products were less likelv to sell to minors (12.8 percent) than stores that permitted direct contact lvith tobacco products (30.6 percent)(Wildev et al. lYY5a). Finally, data suggest that shoplifting is an important commercial source of tobacco to underaged vouth (Cummings et al. 1992, 1995; Cismoski and Sheridan 1994; Lynch and Bonnie 1994; Forster et al. lYY5; Wilde! et al. 1995b; CDC lYY6d; Rosl\,ell Park Cancer Insti- tute 1997). Shoplifting mav be deterred bv regulations that specify that until the moment of purchase, single packs, any amount less than a carton, or all tobacco products must be physically handled by an emplo\,ee onlv (Cismoski 1991; Wildev et al. 1YYSa; Cald\veil et al. iY96). Several states have addressed the issue of self- service sales of tobacco products. For example, Idaho and Minnesota restrict self-service sales to onlv those stores that do not allo\v minors to enter and that ob- tain most of their sales from tobacco. Texas prohibits self-service sales in any location accessible to minors. Three hundred and ten localities have chosen to re- strict tobacco sales by prohibiting self-service displays (American Nonsmokers' Rights Foundation, unpub- lished data, 2000). Opposition to this measure is generally organized by tobacco distributors and retailers, who fear the loss of slotting fees-payments (often substantial) to retailers for ad\,antageous placement of tobacco products and for point-of- purchase advertising in their business (Gersten 1994; Thomas A. Briant, letter to Litchfield Tobacco Retail- ers, February 16, 1993; Cald\vell et al. lYY6). The 10M recommends a ban on self-service displays (Lynch and Bonnie 19941, and the Working Group of State Attor- nevs General (1994) recommends to tobacco retailers that they eliminate such displays. That this recom- mendation is not unreasonably burdensome has been demonstrated by one study in which 28 percent of re- tailers in 14 communities complied voluntarily (Forster et al. 1995) and by another study involving 15 cities in northern California (Kropp 1995). The 1996 FDArules would also have prohibited self-service displays except in certain adults-only facilities; thq proposed national settlement further stipulated that in non-adults-only facilities, tobacco products must be out of reach or otherwise inaccessible or invisible to consumers. Anecdotal reports have suggested that single or loose cigarettes are sold in some locations. Such sales are often prohibited by state or local law, at least im- plicitly because single cigarettes do not display the required state tax stamp or federal warning. Fre- quently, single cigarettes are kept out of sight and are available onlv by request. Researchers in California found that e\;en after a state law explicitly banned the sale of single cigarettes, almost one-half of tobacco re- tailers sold them to their customers (Klonoff et al. 1994). The study found that the stores that made loose ciga- rettes available sold them to almost twice as many minors as the); did to adults. That finding lends sup- port to the argument that single cigarette sales are an important avenue to addiction for some youth. A re- cent studv in Central Harlem has produced similar results: 7il percent of the licensed outlets sold single cigarettes to minors (Gemson et al. 1998). The IOM, the 1996 FDA rules, and the proposed multistate settle- ment ha\,e all recommended that the sale of loose or single cigarettes be explicitly prohibited (Lynch and Bonnie 1YYq). Regulation Directed at the Seller All states now have a law specifying the mini- mum purchaser's age for legal sale of tobacco prod- ucts. For all but two states, that age is 18; Alabama and Alaska specify age 19. Almost two-thirds of the states and many local jurisdictions require tobacco retailers to display signs that state the minimum age for sale. Some regulations specify the size, wording, and location of these signs. Other regulations specif!, the minimum age for salespersons; these regulations recognize the difficulty young sellers may experience in refusing to sell cigarettes to their peers. Most of these laws define violation either as a criminal offense (e.g., misdemeanor or gross misdemeanor), \2-ith accompanving penalties, or as a civil offense, \Vith specified ci\-il penalties (e.g., fines and license suspension). Ci\-il offense 1alt.s are thought to make enforcement easier and are therefore more likely to be carried out, since they do not generall) require court appearances. Many state or local lalvs specify penalties onlv against the salesperson. Apply- ing penalties to business oIl,ners, \j.ho generalI\. set hiring, training, super\?sing, and selling policiis, Is considered essential to pre\.enting the sale of tobacco to minors, although tobacco retailers ha1.e \,igorousl\ opposed these measures (Skretnv et al. 1990; FeighcrL - et al. 1991; McGrath 199Ja,b). More than one-half of the states and some local jurisdictions require that tobacco retailers obtain li- censes for over-the-counter sales, but smokeless to- bacco is exempted by 13 of these states (CDC, Office on Smoking and Health, unpublished data). Licen- sure sometimes is simpl!. a mechanism tor collecting taxes or generating re\.enue; in other states and cities, conditions are attached that relate to minors' access. In addition to civil penalties, retail licensure for tobacco represents another approach ior facilitating \,outh ac- cess la\v enforcement efforts and strengthen.ing sanc- tions for \.iolators of the la\\.. Retail liccnsure can facilitate the identification of retailers. The lack of a current and accurate list of tobacco \-endors has been cited by manv states involved in Svnar enforcement as d serious `impediment to efficient enforcement (USDHHS 1999). Retail licensure can also create an incentive for retail compliance. License suspensions or revocations could be imposed as penalties for via- lation of youth access lakes, resulting in revenue loss for retailers. Licensure \~ould also provide a source of funds to pav for enforcement and retailer educa- tion when licensing fees or fines for violations are ear- marked for such education purposes. Finally, retail licensure provides a mechanism for administrative adjudication of vouth access law violations. License holders byho fail-to comply M.ith the law could be held accountable before the licensing authoritv. No published empirical research examines the effects of tobacco retail licensure on either enforcement efforts or retail compliance. Studies on policies tar- geted to increase retail compliance, however, suggest several specific elements of licensure policies that should be present in order to increase the likelihood of positive effects. The points below outline the wavs in xvhich licensure policies could be used to enhance retail compliance efforts. Licensure la!vs must explicitly link the privilege of selling tobacco products to retail compliance with youth access laws (Levinson 1999). Licensure should cover both retail stores and vend- ing machines (Levinson 1999). License holders should be required to renew their license annually (LeLinson 1999; USDHHS 1999). License holders should be fined for violation of I\;outh access laws (Levinson 1999). Fines should be high enough to encourage vendors to comply with youth access laws but not so high as to risk loss of community or judicial support for the imposition of penalties (Lynch and Bonnie 1 YY1). Fines should be graduated so that greater conse- quences are associated \vith increased number of \ iolations. Repeated violations should lead to li- cense suspension or re\,ocation (CDC 1995a; NC1 1l.d.). License fees should be sufficient to cover the aver- age cost of compliance checks (CDC 1995a). The re\`enue from fines should subsidize the costs of enforcement (Working Group of State Attorneys General 1994). In addition to these items, several other policy elements have been suggested for incorporation into licensure la\vs. These licensure policy components should communicate clear and consistent messages about the illegality of tobacco sales to minors and should promote societal norms intolerant of youth ac- cess la\v violations (Kropp 1996). These elements in- clude mandatory posting of warning signs within clear sight of consumers, mandatory checking of age iden- tification, state provision of merchant and clerk edu- cation about vouth access law requirements (i.e., consequences for violations and techniques for im- proving merchants' and clerks' skills at detecting un- derage youth and refusing sales), restrictions or bans on self-service displays, and ensuring that clerks are at or above the legal purchase age. Without enforcement provisions, however, li- censing laws are not effective measures to restrict mi- nors' access. Before 1996, only 16 states with licensing laws specified the agency with enforcement responsi- bility, despite recommendations (USDHHS 1990; Lynch and Bonnie 1993; Working Group of State At- torneys General 1994) that states adopt a licensing re- quirement that has civil penalties and a designated enforcement agent. In its 1998 report, SAMHSA indi- cates that all but one state requiring licenses have a designated enforcement agency (USDHHS IYY8a; see "Enforcement of Laws on Minimum Ages for Tobacco Sales," later in this chapter). State laws and local ordinances can be a mecha- nism for increasing retailer awareness of youth access laws and retailer ability to comply with the law. Of- ten referred to as responsible vendor laws, this type of legislation can require retailer education and training as a condition of retail tobacco licensure or simply re- quire education and training for all tobacco vendors. Numerous studies have shown the potential benefit of comprehensive merchant education and training programs in helping to reduce illegal sales to minors (Altman et al. 1989, 1991, 1999; Feighery 1991; Keay 1993; Cummings et al. 1998). In many instances, rep- resentatives of tobacco retailers have supported the passage of responsible vendor laws (McGrath 1995a,b; Thomas A. Briant, Letter to Lit&field Tobacco Retail- ers, February 16, 1995) when these laws also exempt business owners from penalties or specify lower pen- alties for tobacco sales to minors if owners ha\,e trained their employees. Under such conditions, employee training would relieve retailers of responsibility for on- going supervision and monitoring of employee behav- ior and likely result in decreasing the impact of youth access laws. It should be noted, however, that as a result of both Synar and FDA attention to the problem of youth access to tobacco, several states have Lvorked to ensure the modification of youth access and/or re- tail licensure la\ys to mandate vendor education and training without the incorporation of clauses reliev- ing retailer responsibility (USDHHS 1998a). These ef- forts recognize that responsible vendor lags ha\,e the potential to be an effective rva); to increase the ability of retailers and clerks to comply with the larv bv accu- rately detecting underage purchases and confidently and safely refusing sales. The general availability of tobacco products in retail outlets that have pharmacies has led to some concerns. In the United States, stores that have phar- macies usually sell tobacco products, contrary to a 1971 policy recommendation of the American Pharmaceu- tical Association (1971) that cited the inconsistency of selling cigarettes with their function as health institu- tions. A few small chains and a growing number of independent stores with pharmacies are tobacco free, but all large chains and most independent stores sell tobacco products. Pharmacies (and stores that have pharmacies) that sell tobacco products are as likely as other outlets to sell to minors (Brown and DiFranza 1992). On the other hand, a study has shown that pharmacists who work in stores that do not sell to- bacco have a better understanding of the dangers of tobacco than do pharmacists who work in stores that sell tobacco, and they also feel more confident that they can help customers who use tobacco stop (Davidson et al. 1988). Two-thirds of pharmacists surveyed in Minnesota believed that members of the profession should not work in stores that sell tobacco products (Martinez et al. 19931, and many felt that the contigu- ity of tobacco products and pharmaceuticals produces professional dissonance (Taylor 1992; Kamin 1994). Both the Canadian Medical Association and the Ameri- can Medical Association are opposed to tobacco sales in pharmacies and in stores that have pharmacies (Staver 1987; Sullivan 1989). The Canadian provincial government of Ontario banned such sales in 1994 (An Act to Prevent the Provision of Tobacco to Young Per- sons and to Regulate its Sale and Use by Others, Stat- utes of Orleans, ch. 10, sec. 3[61 [1994] [Can.]). Regulation Directed at the Buyer State and local jurisdictions are increasingly im- posing sanctions against minors who purchase, at- tempt to purchase, or possess tobacco products (CDC 1996~; Forster et al. 1996). These laws are favored by some law enforcement officials and tobacco retailers because of the potential deterrent value (Parsons 1989; Talbot 1992). Some advocates for reducing tobacco use argue, however, that such laws are part of an effort to deflect responsibility for illegal tobacco sales from re- tailers to underaged youth; that these laws are not an efficient substitute for laws regulating merchants, be- cause so many more minors than retailers are involved; and that sanctions against minors are more difficult to enforce than those against retailers (Carol 1992; Cismoski 1994; Lynch and Bonnie 1994; Mosher 1995; Wolfson and Hourigan 1997). Other advocates have insisted that some of the responsibility must devolve on the purchaser and that laws prohibiting possession should be vigorously enforced (Talbot 1992). Although not taking a stand on the advisability of purchase and possession laws, the Working Group of State Attor- neys General (1994) recommended that such laws should be considered only after effective retail regula- tions are already in place. Enforcement of Laws on Minimum Ages for Tobacco Sales Although laws on the minimum age for tobacco sales have been part of many state statutes for decades, only in the past few years has attention been focused on enforcing these laws by federal, state, or local agen- cies (Lynch and Bonnie 1994; Fc,tf~rnI Rc:gi5fer 1996; LSDHHS, in press). As more information has become a\-ailable about the implementation and effects of v-ari- ous minors' access lalvs, it is becoming clear that orga- nized enforcement efforts are essential to realizing the potential of these Ialvs. Enforcement of minimum-age la\vs is more likely to occur Ivhen enforcement is self- supporting through license fees and revenues from pen- alties and tvhen the penaltv schedule includes civ,il penalties that are large enough to be tffectiv-e but are seen as reasonable and simple to administer (Working Group of State Attorneys General 199-l). La\v enforce- ment officials have sometimes balked at applving crim- nal penalties against clerks and retailers for selling tobacco to minors. Enforcement ma\' be more effecti\.e if sanctions can be imposed on managers or business owners rather than, or in addition to, salespersons (Working Group of State Attorncvs General IYYJ). Moreov,er, the lY92 enactment of the Svna~ Amendment (Public La\v 102-321, sec. 1926, discussed in the introduction to this section) has forciblvr Lxo~~gl~t this issue to the fore, because the amendmei~t requires states to enact and enforce legislation restricting the sale and distribution of tobacco products to minors. As a result, all states have law-s prohibiting the sale and distribution of tobacco to minors and all states enforce these law through a statewide coordinated program. Additionally, all states have no\z designated a lead agencv and all but one ha\-e an agency respon- sible for enforcing their minimum-age laiv (Table 5.4) (USDHHS, in press). In addition to federal and state enforcement efforts, a number of local jurisdictions around the countrv have begun activ,ely enforcing the law against tobacco sales to minors, and local ordi- nances can include a schedule of required compliance checks (Lynch and Bonnie 1994; Working Group of State Attorneys General 1994; Forster et al. 1996; DiFranza et al. 1998). Compliance checks are most often carried out by having an underaged buyer, under the supervision of a law enforcement officer, licensing official, or some other designated adult, attempt to purchase tobacco. In jurisdictions where the minor is held legally at fault if a purchase is made (and where no exceptions are made for compliance checks), minors participating in compliance checks are sometimes instructed not to complete the purchase even if the salesperson is will- ing; in these cases, the retailer is considered to be in noncompliance with the youth access law if the pur- chase is entered into the cash register (Hoppock and Houston 1990; Cummings et al. 1996). Selreral innolrative civil enforcement approaches have been attempted in California. The district attor- neys in Sonoma and Napa Counties have used the Cali- fornia Business and Professions Code section 17200 to file civ,il lawsuits against store owners whose outlets repeatedlv sold tobacco to minors. Civil enforcement has prol.ed to be more efficient than criminal citations and has resulted in fines and penalties as well as reduc- tions in tobacco sales to minors (Kropp and Kuh 1994). Increased emphasis on enforcement, coupled w,ith passage of laivs against possession of tobacco by minors, may result in enforcement resources being selectively funneled to apprehending underaged smokers rather than penalizing the merchants who sell tobacco to these minors. A survey of 222 police chiefs in Minnesota rev,ealed that although more than 90 per- cent \vere enforcing the law against minors' posses- sion, 10 percent reported applying penalties to minors, and onlv 6 percent reported any enforcement against merchants (Forster et al. 1996). A vigorous and multidimensional campaign has been mounted by the tobacco industry and its allies to prevent or undermine effective enforcement of minors' access laws and to resist the proposal that retailers be held accountable for their stores' compliance. Since 1992, laws sponsored by the tobacco industry but os- tensiblv intended to bring states into compliance with requirements of the Svnar Amendment have been passed in Georgia, Idaho, Kentucky, Louisiana, Mary- land, Mississippi, North Carolina, Oklahoma, South Dakota, and Tennessee (DiFranza 1994~; DiFranza and Godshall 1993). Tobacco industry representatives and their allies have lobbied successfully for the inclusion of language such as "knowingly" or "intentionally" in the lavv prohibiting sale of tobacco to minors; the impact of such language may be to render the law unenforceable. Industry interests have sought to in- clude various restrictions on how, how often, and by whom enforcement or compliance testing can be con- ducted. Examples of these restrictions include oppos- ing employing teens in compliance testing or requiring that only very young teens can function as buyers, in- sisting that enforcement be done only by the alcohol control authority or some other state agency, oppos- ing compliance checks carried out by advocacy groups or for public health research, and opposing require- ments that compliance checks occur on a specified schedule. The industry has further proposed imme- diate reentry and confrontation after an illicit sale-a procedure that could compromise collecting evidence. Industry representatives have also consistently main- tained that merchants ought not to be responsible for the costs incurred in complying with minimum-age Table 5.4. Agencies responsible for enforcing state laws on minimum age for tobacco sales as of fiscal year 1998 State/Territorv Lead agency Alabama Alaska Arizona Alcoholic Beverage Control Board Department of Health and Social Services, Division of Alcoholism and Drug Abuse Department of Health Services, Office of Substance Abuse and General Mental Health Arkansas California Colorado Connecticut Department of Health, Bureau of Alcohol and Drug Abuse Prevention Department of Health Services Department of Human Services, Alcohol and Drug Abuse Division Department of Mental Health and Social Serlrices, Office of Addiction Services Delalvare District of Columbia Department of Public Safet\j, Alcoholic Beverage Control Commission Department of Human Ser\~ices, Addiction Prevention and Recovery Administration Florida Department of Business and Professional Regulation, Division of Alcoholic Be\,erages and Tobacco Georgia Halvaii Department of Public Safety Department of Health, Alcohol and Drug Abuse Division Idaho Department of Health and Welfare, FACS Di\zision, Bureau of Mental Health and Substance Services Illinois Liquor Control Commission Indiana Family and Social Ser\,ices Administration, Di\.ision of Mental Health Iowa Department of Public Health, Di\,ision of Substance Abuse and Health Promotion Kansas Department of Social and Rehabilitation Seri-ices, Alcohol and Drug Abuse Services Kentucky Department of Alcoholic Beverage Control Enforcement agency Alcoholic Beverage Control Board Attorney General's Office Department of Health Services, Office of Substance Abuse and General Mental Health Tobacco Control Board Department of Health Services State and local law enforcement Department of Revenue Services Department of Public Safety, Alcoholic Beverage Control Commi&ion Department of Consumer and Regulatory Affairs and the Metropolitan Police Department Department of Business and Professional Regulation, Division of Alcoholic Beverages and Tobacco Department of Public Safety Department of Health with Department of the Attorney General Department of Health and Welfare, FACS Division, Bureau of Mental Health and Substance Services No one agency responsible for enforcement Indiana Alcoholic Beverage Commission Excise Police Department of Public Health, Division of Substance Abuse and Health Promotion Department of Revenue, Alcoholic Beverage Control Board Department of Agriculture (specified state law) with the Department of Alcoholic Beverage Control (appointed) Source: C.S. Department of Health and Human Services, in press Table 5.4. Continued State/Territory Louisiana h4aine \laryland h4assachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Nel\- Hampshire New Jersey New Mexico New York North Carolina Korth Dakota Lead agency Department of Rei-enue and Taxation, Office of Alcoholic Beverage and Tobacco Control Department of Mental Health and Mental Retardation, Office of Substance Abuse Department of Health and Mental Hygiene, Alcohol and Drug Abuse Administration Department of Public Health, Bureau of Substance Abuse Serl-ices Department of Communit\~ Health, Bureau of Substance Abuse Serl.ices Department of Human Services, Chemical Dependency Program Di\.ision Department of Mental Health, Di\-ision of Alcohol and Drug Abuse Department of Mental Health, Di\?sion of Alcohol and Drug Abuse Department of Public Health and Human Ser\-ices, Di\.ision of Addicti\.e and Mental Disorders Department of Health and Human Services Attorney General of the State of Ne\,ada Department of Health and Human Services, Bureau of Substance Abuse Services Department of Health and Senior Services Department of Regulation and Licensing, Alcohol and Gaming Division Department of Health, Office of Alcoholism and Substance Abuse Services Department of Human Resources, Division of Mental Health, Developmental Disabilities and Substance Abuse Services Department of Human Services, Division of Mental Health and Substance Abuse Services Enforcement agency Department of Revenue and Taxation, Office of Alcoholic Beverage and Tobacco Control Department of Mental Health and Mental Retardation, Office of Substance Abuse State Comptroller's Office Department of Public Health, Tobacco Control Program with the Attorney General's Office Department of Community Health, Bureau of Substance Abuse Ser\,ices Department of Human Services, Chemical Dependency Program Di\,ision Office of Attorney General Department of Mental Health, Division of Alcohol and Drug Abuse Department of Public Health and Human Services, Division of Addictive and Mental Disorders Nebraska State Patrol State Attorney General Department of Health and Human Services, Bureau of Substance Abuse Services Department of Health and Senior Services with local health agencies Department of Regulation and Licensing, Alcohol and Gaming Division (statutory), Department of Health and Department of Public Safety (by executive order) 37 local county health units and 10 district offices of the state's Department of Health Local police and sheriff's departments State and local law enforcement agencies are responsible for enforcing state and local laws prohibiting tobacco sales to minors. The Department of Human Services, Division of Mental Health and Substance Abuse Services, is responsible for conducting compliance surveys. State/Territory Ohio Oklahoma Oregon Pennsyl\,ania Rhode Island South Carolina South Dakota Tennessee Texas Ltah Vermont Virginia - \Vashington West Virginia Wisconsin Wyoming American Samoa Guam Marshall Islands Lead agency Department of Alcohol and Drug Addiction Services Alcoholic Beverage Laxv Enforcement Commission Department of Human Resources, Office of Alcohol and Drug Abuse Programs Department of Health, Office of Alcohol and Drug Abuse Programs Department of Health, Di\-ision of Substance Abuse Department of Alcohol and Other Drug Abuse Serlrices Department of Human Str\-ices, Division of Alcohol and Drug Abuse Department ot Agriculture Commission on Alcohol and Drug Abuse and Department of Health Department of Hum,ln Ser\.ices, Di\,ision of Substance Abuse Department of Liquor Control Department of Agriculturt~ and Consumer Serl-ices Department of Social and Health Ser\,ices, Dii-ision of .~lcohol and Substance Abuse Department of Health and Human Resources, Di\-ision of Alcoholism and Drug Abuse Department of Health and Family Serl?ces, Bureau of Substance Abuse Services Department of Health, Di\,ision of BehaL-ioral Health and Substance Abuse Program Department of Humm and Social Serv-ices, Social Services Di\,ision Department of Mental Health and Substance Abuse Office of the Attornev General - Enforcement agency Department of Alcohol and Drug Addiction Services Alcoholic Beverage Law Enforcement Commission Oregon State Police Department of Health, Office of Alcohol and Drug Abuse Programs Department of Health, Division of Substance Abuse (The Division of Substance Abuse transferred from the Rhode Island Department of Health to the Department of Mental Health, Retardation, and Hospitals on September 1,1998.) Department of Revenue and Taxation Di\,ision of Alcohol and Drug Abuse coordinates enforcement with the Attorney General's Office and 66 county state's attornevs Department of Agriculture State Comptroller Department of Human Services, Division of Substance Abuse Enforcement and Licensing Division of the Department of Liquor Control Alcohol Be\.erage Control Board Liquor Control Board Alcohol Be\,erage Administration Department of Health and Family Services, Bureau of Substance Abuse Serlrices Local law enforcement agencies Department of Public Health Department of Mental Health and Substance Abuse Chief Prosecutor of the Office of the Police Comntissioner Table 5.4. Continued State/Territory Lead agency Micronesia Department of Health Northern Marianas Department of Public Health Palau Ministrv of Justice, Bureau of Public Safet! M.ith Ministrv of Commerce and Trade (responsible ior licensing) Puerto Rico Department of Health, Mental Health and Anti-Addiction Ser\+ces Administration Virgin Islands Department of Health, Di\-ision of Mental Health, Alcoholism and Drug Dependent\ Ialvs, such as the costs of making tobacco inaccessible to minors or of ha\ing merchants monitor their ON'II staff (DiFranza 1991~; DiFranza and Godshall 1YY-L). Despite, or in some cases in response to, these indus- trv efforts, many states ha1.e successfully strengthened their youth access laws and/or removed industry- inspired loopholes and provisions for affirniati1.e de- fense. Six states amended state lal\- to permit minors to participate in compliance checks conducted for en- forcement purposes. Tlventy-three states IIOIV ha1.e this provision in their minors' access la\v. T\VO states passed legislation that will provide a more accurate list of tobacco retailers for compliance checks and three states added provisions that address funding for en- forcement and education programs (USDHHS, in press). The reports from both the 10M (Lynch and Bonnie 1994) and the Working Group of State Attor- new General (1994) include strong recommendations that active enforcement of minors' access la\vs be implemented, that merchants be held responsible for sales in their stores, and that access la\vs supported by the tobacco industry be rejected. Using another type of enforcement, some pri\.ate groups and states have conducted lawsuits against commercial outlets that violate minors' access laws. `4 selection of these cases, one of which also named a tobacco company as a codefendant, is discussed in "Enhancing Prohibitory Regulation by Private Litiga- tion," later in this chapter. Traditional law enforcement agencies often re- sist conducting tobacco enforcement for a number of reasons. Thev believe that tobacco enforcement diverts limited resoirces from other more pressing crime and Enforcement agency No single agency; enforcement by local police and health departments Department of Public Health Bureau of Public Safety Department of Treasury Department of Licensing and Consumer Affairs that the public does not support the use of officers for such enforcement. They have also argued that the ill- feeling of members of the business community gener- ated by the issuance of citations negatively affects other enforcement efforts. Finally, the officers themselves frequently resist because they do not want to facilitate potential job loss for a clerk for \vhat they perceive to be a "minor" infraction or because they believe that prosecutors and judges lvill be reluctant to penalize (USDHHS 1999). Other agencies can be a suitable alternative for the conduct of enforcement. Chief among them are public health departments, tzrhich recognize the im- portance of conducting enforcement, and alcohol bev- erage control agencies (ABCs), which are highly experienced in conducting undercover compliance checks. ABCs retain a staff of inspectors that are fa- miliar tvith the protocols that may be employed dur- ing retail inspections (i.e., consummated and unconsummated buys). ABCs also tend to recognize a connection betbveen alcohol and tobacco enforcement and accept the importance of conducting tobacco in- spection for practical reasons if not for health reasons. This, in turn, results in less of a philosophical resis- tance to actually issuing citations for violations. Fi- nally, because ABC authorities regularly engage in enforcement directed at retailers, tobacco enforcement conducted by this agency will not likely generate as negatixre a backlash from retailers and the general public as enforcement conducted bv traditional law enforcement (USDHHS 1999). State Settlements All four states that settled their la\vsuits against the tobacco industry in 1997-1998 tvon youth access re- strictions in their settlement agreements. (The e\,ents leading up to these four settlements, along with their implications as a litigational tool for reducing tobacco use nationw,ide, are discussed in "Recovery Claims by Third-Party Health Care Payers," later in this chapter.) For example, the tobacco industry defendants in the state of Florida case agreed to support IWLV state la\vs or regu- lations to prohibit the sale of cigarettes in vending machines, except in adult-onlv locations or facilities (Floriiin ~1. AIIIUI'CITII fi~Iwcco Co., cii.il Action No. 95-1166 AH, sec. II.A.2 [Fla., Palm Beach Cty. Aug. 35, 19973). The industry also agreed to support new state laws in Florida to increase civil penalties for sales of tobacco products to minors (including retail license suspension or revocation) and to strengthen civil penalties for the possession of tobacco by minors. The Florida settlement (sec. lI.B) further requires the tobacco industry to pay 5200 million for a two-vear pilot program to reduce to- bacco use by minors, -including enforcement, media, educational, and other vouth-directed programs. L'outh access provisions of the Texas settlement that pertain to nelv state laM-s mirror the terms of the Florida agree- ment (fil.~~?s il. A11wriii7~7 fi~clborio CO., No. 5YhCV-9 1 (E.D. Tex. Jan. 16, 19981, sets. 7[a-cl). The state of Minnesota LVOII the most compre- hensive array of public health and youth access restric- tions to date IThen it settled its case after a highly publicized trial in 1998 (h/li~~rwwf~? ~1. Plri/ifT h-lw~i~ I/K., iit& irk 13.2 TPLR 3.39). One provision of the Minne- sota settlement forbids tobacco manufacturers from di- rectlv or indirectly opposing state statutes or regulations intended to reduce tobacco use bv minors. A list of 1egislatil.e proposals col.ered b!' the prohibi- tion is attached to the settlement agreement (Schedule B) and includes the folIoEying measures: Expansion of self-service restrictions and remo\,al of the current exception for cigars. Amendment of the current law, for restricting youth access to vending machines to clarify that machines w?th automatic locks and machines that use tokens are covered. "Enhanced or coordinated funding" for enforce- ment efforts under sales-to-minors provisions of the criminal code or the statute and ordinances invol\,- ing youth access. La~vs to "encourage or support the use of technol- ogy to increase the effectiveness of age-of-purchase laws" (e.g., programmable scanners or scanners to read drivers' licenses). Restrictions on wearing, carrying, or displaying to- bacco indicia in school-related settings. Establishment or enhancement of nonmonetary in- centi\:es for youth not to smoke (e.g., expand com- munity services programs for youth). Moreover, prohibiting tobacco companies from challenging the enforceability or constitutionality of current Minnesota laws encompasses some key youth I access statutes, such as those pertaining to the sale of tobacco to minors (Minnesota Statutes sec. 609.685) and the distribution of samples (Minnesota Statutes sec. 325.77) (Mirzrrcsotn ~1. Pl~ilip Movris Iuc., cited ill 13.2 TPLR 3.39, sec. IV.A.2). Another injunctive provision, forbid- ding the tobacco industry from targeting children through advertising, promotion, or marketing, also prohibits the industry from "taking any action the pri- mary purpose of which is to initiate, maintain or in- crease the incidence of underage smoking in Minnesota" (Miri!~~sc~fn ~1. Philip Morris ~IIC., No. Cl-94 8363 [Minn., Ramse]l: Cty. May 8, 19981, cifclf ir? 13.2 TPLR 2.112, 2.113 [1998]). The Minnesota settlement also includes a large industry-funded program to reduce teen smoking. The program includes counteradvertising, classroom edu- cation, community partnerships, research, advocacy, and prevention components (Milztwofn ~7. Philip Mor- ris Ir~c., cjf~`~1 irz 13.2 TPLR 3.39, sec. VIII.A.2). Although Mississippi (the first state to settle) did not initially secure public health restrictions, it later imported some of those contained in the sweeping- Minnesota settlement by exercising the "most favored nation" clause (discussed in "Recovery Claims by Third-Party Health Care Payers," later in this chapter) in its original settlement agreement (I'R Newswire 1998a). Intended to ensure that Mississippi would re- cei1.e the benefits any later similar settlement might receive, the most favored nation clause also enabled the state to substantially increase the dollar amount of- its settlement with the industry. Furthermore, although the revised agreement prohibits Mississippi from gain- ing any additional monetary benefit based on future state settlements, it does not limit the incorporation of additional public health provisions or financial adjust- ments in the event that Congress adopts national to- bacco legislation. Preemption of Local Action by State Policy As noted earlier in this section (see "Efforts to promote Adoption and Enforcement of Minors' Access La~vs"), the initiati1.e to address minors' access, as 1vell as many creati1.e solutions, has come from the local Ic\.el. In state legislatures, the balance of po\\`er be- t\j-een forces for and against reducing tobacco use is most often tipped in favor of tobacco USC. The re\.erse is often true at the local le\-el, \Vhere jurisdictions 1ial.e enacted inno\.ative approaches that l1aL.e been c\-alu- ated by researchers. At the state level, ho\ve\-er, to- Lmxo industry representati\.es ha\ e sought to preclude legislative or enforcement authority at the local lel,el b!r including preemption language, usualI!. attached to rveak statelvide restrictions. As of 1998, 30 states had preempti\ e tobacco COP trol larvs, although they \.ar\' \videl\. in the kind of re-