Sources of tobacco for youths in communities with strong enforcement of youth access laws

AIM: To determine how youths obtain tobacco in communities with strong enforcement of tobacco sales laws. SETTING: Ten communities in Massachusetts with merchant compliance rates at or above 90%. METHODS: Paper surveys and focus group discussions with 68 adolescent smokers. RESULTS: Parents and friends are the primary sources of tobacco for new smokers. When stealing from parents can no longer satisfy the need for cigarettes, young adolescents ask strangers to buy them tobacco. For high school age smokers, teenage store clerks are a major source. Teenage clerks sell to other teenagers, steal tobacco, and help their friends steal from their employers. Friends who are 18 years of age or over are a second major source for older adolescents. Parents often purchase tobacco for older adolescents. CONCLUSION: Recommended actions include raising the minimum age for the purchase of tobacco to 21 years, and prohibiting individuals less than 21 years of age from selling tobacco.     

Analysis of factors related to illegal tobacco sales to young people in Ontario

OBJECTIVE: To identify and to discuss factors influencing illegal merchant sales of tobacco to underage people in Ontario, Canada. DESIGN: Results were obtained through random retail compliance checks of tobacco merchants. A multivariate analysis specified the relationship between selected independent variables and the willingness of tobacco merchants to sell to minors. The selected independent variables included retail operation type, community population size, the presence of tobacco production, signage, sex and age of volunteers, smoking prevalence rates, and enforcement rates. PARTICIPANTS: A random, stratified sample of 438 tobacco retailers in 186 communities in Ontario. MAIN OUTCOME MEASURE: Willingness of merchants to sell tobacco to minors. RESULTS: Older youths and girls were more likely to be sold tobacco products. Purchase attempts carried out in tobacco-producing regions were also statistically related to illegal sales. CONCLUSIONS: Policy efforts to control youth access to tobacco in Canada may need to invoke legislation requiring merchants to request proper identification from customers who appear to be under the age of 25, and who seek to purchase tobacco products. Further attention could also be directed at tobacco control policies and enforcement strategies that need to consider the unique challenges faced by jurisdictions where the tobacco industry is a powerful presence.     

Is the standard compliance check protocol a valid measure of the accessibility of tobacco to underage smokers?

OBJECTIVE: To determine if the standard compliance check protocol is a valid measure of the experience of underage smokers when purchasing tobacco in unfamiliar communities. SETTING: 160 tobacco outlets in eight Massachusetts communities where underage tobacco sales laws are vigorously enforced. PROCEDURE: Completed purchase rates were compared between underage smokers who behaved normally and inexperienced non-smoking youths who were not allowed to lie or present proof of age (ID). RESULTS: The "smoker protocol" increased the likelihood of a sale nearly sixfold over that for the non-smokers (odds ratio (OR) 5.7, 95% confidence interval (CI) 1.5 to 22). When the youths presented an ID with an underage birth date, the odds of a completed sale increased dramatically (OR 27, 95% CI 3.4 to 212). Clerks judged to be under 21 years of age were seven times more likely to make an illegal sale (OR 7.6, 95% CI 2.4 to 24.0). CONCLUSIONS: Commonly used compliance check protocols are too artificial to reflect accurately the experience of underage smokers. The validity of compliance checks might be improved by having youths present ID, and by employing either tobacco users, or non-tobacco users who are sufficiently experienced to mimic the self confidence exhibited by tobacco users in this situation. Consideration should be given to prohibiting the sale of tobacco by individuals under 21 years of age.     

A systematic review of interventions for preventing tobacco sales to minors

OBJECTIVE: To assess the effectiveness of interventions to reduce underage access to tobacco by deterring shopkeepers from making illegal sales. METHOD: Systematic literature review. DATA SOURCES: The Cochrane Tobacco Addiction group specialised register and Medline. Studies of interventions to alter retailer behaviour were identified. The terms used for searching combined terms for smoking and tobacco use with terms for minors, children or young people, and retailers, sales or commerce. STUDY SELECTION: Studies in which there was an intervention with retailers of tobacco, either through education about, or enforcement of, local ordinances. The outcomes were changes in retailer compliance with legislation (assessed by test purchasing), changes in young people's perceived ease of access to tobacco products, and changes in smoking behaviour. Controlled studies with or without random allocation of retail outlets or communities, and uncontrolled studies with pre- and post intervention assessment, were included. DATA EXTRACTION: Two reviewers assessed studies for inclusion. One extracted data with checking by the second. DATA SYNTHESIS: The results were synthesised qualitatively, with greater weight given to controlled studies. Thirteen of 27 included studies used controls. RESULTS: Giving retailers information was less effective in reducing illegal sales than active enforcement and/or multicomponent educational strategies. No strategy achieved complete, sustained compliance. In three controlled trials, there was little effect of intervention on youth perceptions of access or prevalence of smoking. CONCLUSIONS: Interventions with retailers can lead to large decreases in the number of outlets selling tobacco to youths. However, few of the communities studied in this review achieved sustained levels of high compliance. This may explain why there is limited evidence for an effect of intervention on youth perception of ease of access to tobacco, and on smoking behaviour.     

Survey of city ordinances and local enforcement regarding commercial availability of tobacco to minors in Minnesota, United States

OBJECTIVES: To determine the extent and nature of local ordinances to regulate tobacco sales to minors, the level of enforcement of local and state laws concerning tobacco availability to minors, and sanctions applied as a result of enforcement. DESIGN: Tobacco control ordinances were collected in 1993 from 222 of the 229 cities greater than or equal to 2000 population in Minnesota, United States. In addition a telephone survey with the head of the agency responsible for enforcement of the tobacco ordinances was conducted. MAIN OUTCOME MEASURES: Presence or absence of legislative provisions dealing with youth and tobacco, including licensure of tobacco retailers, sanctions for selling tobacco products to minors, and restrictions on cigarette vending machines, self-service merchandising, and point-of-purchase advertising; and enforcement of these laws (use of inspections and "sting" operations, and sanctions imposed on businesses and minors). RESULTS: Almost 94% of cities required tobacco licences for retailers. However, 57% of the cities specified licences for cigarettes only. Annual licence fees ranged from $10 to $250, with the higher fees adopted in the previous four years. More than 25% of the cities had adopted some kind of restriction on cigarette vending machines, but only six communities had banned self-service cigarette displays. Three cities specified a minimum age for tobacco sales staff. Fewer than 25% of police officials reported having conducted compliance checks with minors or in-store observations of tobacco sales to determine if minors were being sold tobacco during the current year. Police carrying out compliance checks with youth were almost four times as likely to issue citations as those doing in-store observations. More than 90% of police reported enforcement of the law against tobacco purchase or possession by minors, and nearly 40% reported application of penalties against minors. CONCLUSIONS: Almost 75% of the cities have done nothing to change policies or enforcement practices to encourage compliance with tobacco age-of-sale legislation, and only a few of the remaining cities have adopted optimal policies. In addition, officials in Minnesota cities are much more likely to use enforcement strategies against minors who buy tobacco than against merchants who sell tobacco.


     

Tobacco industry efforts hindering enforcement of the ban on tobacco sales to minors: actions speak louder than words

OBJECTIVE: The tobacco manufacturers state that they want to see laws that prohibit the sale of tobacco to minors enacted and enforced. Our purpose was to compare these public statements with the US tobacco industry's legislative agenda at the federal and state levels. DESIGN: A review of the industry's comments to the US Department of Health and Human Services (DHHS) regarding proposed federal regulations, and an analysis of pro-tobacco state legislation concerning tobacco sales to minors. RESULTS: The industry is strongly opposed to federal regulations requiring states to effectively enforce their laws prohibiting the sale of tobacco to minors. A food industry newsletter reports that the Tobacco Institute has circulated a model state bill concerning underage tobacco sales. Striking similarities between bills from several states would seem to confirm this report. These bills strip communities of enforcement authority while making effective enforcement by state officials virtually impossible. CONCLUSION: The evidence strongly suggests an industry strategy to undermine efforts to enforce laws prohibiting the sale of tobacco to minors. As has been the case in the past, the tobacco industry is publicly endorsing a socially responsible goal while apparently taking action behind the scenes to ensure that the goal is not achieved.


     

Application of consumer protection authority in preventing tobacco sales to minors

In the USA, the enforcement of state sales of tobacco products to minors laws has had only limited impact upon reducing youth access. The application of consumer protection authorities by state attorneys general to alter the sales and promotion practices of tobacco retailers provides a complementary and highly leveraged strategy to increase compliance with tobacco sales to minors laws.     

Case study of attempts to enact self service tobacco display ordinances: a tale of three communities

OBJECTIVE: To examine self service tobacco displays (SSTDs) and youth retail tobacco access by comparing longitudinal illegal tobacco sales rates in three communities in Santa Barbara County, California, that considered or implemented ordinances banning SSTDs. A confirmatory survey was also conducted to substantiate the longitudinal data. DESIGN: A longitudinal case study design was utilised. Five undercover tobacco buys were conducted between 1994 and 1997 (n = 332). In addition, one confirmatory survey was conducted in a geographically separated area, which had no ordinances banning SSTDs (n = 57). RESULTS: Decreases in youth buy rates were reported in all three communities. Most notably, the first city to enact a SSTD ban, Carpinteria, achieved a 0% sales rate, which was maintained throughout the study period. In contrast, Santa Barbara and Goleta experienced considerable drops in their illegal sales rates, but neither community obtained results as dramatic as those found in Carpinteria. The confirmatory survey showed that 32.1% of stores with SSTDs sold cigarettes to minors; this compares to a sales rate of 3.4% in stores without SSTDs (chi(2) (1) = 8.11, p = 0.004). CONCLUSIONS: Efforts to enact self service bans are likely to meet with retail and tobacco industry opposition, as was the case in this study's three communities. The process of community debate, resultant publicity surrounding the issue, and enactment of SSTD ordinances may serve to not only increase merchant awareness of youth tobacco laws and their penalties but also may contribute to reduced youth cigarette sales rates. Implications and limitations of the findings are discussed.     

Relation between access to tobacco and adolescent smoking

Objective: To examine the relation between rates of sales of tobacco to minors and youth smoking prevalence.

Design: Repeated annual cross sectional surveys.

Setting: Seventy five communities in Oregon.

Participants: A random sample of students in grades 8 and 11 (ages 13 and 17 years) and retail outlets in each participating community.

Main outcome measures: Thirty day and daily smoking prevalence.

Results: The rate of illegal merchant sales in the communities was related to the smoking rate for 11th graders in those communities, but not for 8th graders. For every 10% increase in illegal sales rates there was an estimated 0.8% increase in 11th grade 30 day smoking prevalence and a 0.4% increase in daily smoking. Communities with lower illegal merchant sales rates had expanded use of social sources and reduced use of commercial sources by 11th graders, with the opposite pattern seen in 8th graders.

Conclusions: There appears to be a relatively small positive linear relation between the community rate of sales to minors and 11th grade youth smoking prevalence in those communities. Youth adjust their tobacco sources depending on the level of commercial availability.

     

Tobacco compliance check in Hong Kong.

We examined tobacco retailers' rates of compliance to the law forbidding the sale of tobacco products to persons under 18 years of age in Hong Kong. The overall compliance rate was only 18.9%. The low compliance rate may be attributed to poor enforcement of the youth access law. Overseas experiences show that regular checking is an effective way to evaluate the compliance of tobacco retailers to restrictions on youth access to tobacco. Periodic tobacco compliance checks should be adopted in Hong Kong to exert pressure on law enforcement bodies and tobacco retailers.     

Store tobacco policies: a survey of store managers, California, 1996-1997

OBJECTIVE: To identify store tobacco policies and retailer perception and beliefs that may have contributed to changes in compliance with youth access laws in California. DESIGN: In the winter of 1996-7, a cross sectional, follow up telephone survey was conducted of California store managers whose stores were anonymously surveyed for illegal tobacco sales in the summer of 1996 (that is, 1996 Youth Tobacco Purchase Survey, YTPS). SETTING: A simple random sample of stores from a list of California stores likely to sell tobacco, used in the 1996 YTPS. PARTICIPANTS: 334 managers (77%) of the 434 stores surveyed in 1996 responded to the survey. After eliminating stores that stopped selling tobacco or were under new management or ownership, 320 responses of store managers were included in the analysis. The stores were analysed by type of ownership: chain, which included corporate managed (n = 61); franchise owned (n = 56); and independent (n = 203). MAIN OUTCOME MEASURES: Responses of store managers were linked with the 1996 YTPS outcomes. Manager responses were compared by chi2 tests. Logistic regression analyses were conducted to identify store factors associated with illegal tobacco sales. RESULTS: A lower likelihood of illegal sales rate was associated with the chain stores when compared with the independent stores (odds ratio (OR) = 0.4, 95% confidence interval (CI) 0.2 to 0.9). A lower likelihood of illegal tobacco sales was found in stores that implemented tobacco related activities in the previous year such as changing tobacco displays (OR = 0.5, 95% CI 0.2 to 0.9) or adding new warning signs (OR = 0.7, 95% CI 0.4 to 1.2). Store managers' beliefs that youth were sent to their stores to do compliance checks also resulted in a lower likelihood of illegal sales (OR = 0.7, 95% CI 0.4 to 1.1). CONCLUSIONS: Store tobacco youth access policies, and managers' beliefs about the extent of youth access enforcement in the community, are important in reducing illegal tobacco sales to minors.     

Effect of local youth-access regulations on progression to established smoking among youths in Massachusetts

Objective

To test whether community‐level restrictions on youth access to tobacco (including both ordinances and enforcement) are associated with less smoking initiation or less progression to established smoking among adolescents.

Design

Prospective cohort study of a random sample of adolescents in Massachusetts whose smoking status was assessed by telephone interviews at baseline and 2‐year follow‐up, and linked to a state‐wide database of town‐level youth‐access ordinances and enforcement practices.

Participants

A random sample of 2623 adolescents aged 12–17 years who lived in 295 towns in Massachusetts in 2001–2 and were followed in 2003–4.

Main outcome measures

The relationship between the strength of local youth access restrictions (including both ordinances and level of enforcement) and (1) never‐smokers'' smoking initiation rates and (2) experimenters'' rate of progression to established smoking was tested in a multilevel analysis that accounted for town‐level clustering and adjusted for potential individual, household and town‐level confounders.

Results

Over 2 years, 21% of 1986 never‐smokers initiated smoking and 25% of 518 experimenters became established smokers. The adjusted odds ratio (OR) for smoking initiation was 0.89 (95% CI 0.61 to 1.31) for strong versus weak youth‐access policies and 0.93 (95% CI 0.67 to 1.29) for medium versus weak policies. The adjusted OR for progression to established smoking among adolescents who had experimented with smoking was 0.79 (95% CI 0.45 to 1.39) for strong versus weak local smoking restrictions and 0.85 (95% CI 0.50 to 1.45) for medium versus weak restrictions.

Conclusions

This prospective cohort study found no association between community‐level youth‐access restrictions and adolescents'' rate of smoking initiation or progression to established smoking over 2 years.Nearly 90% of smokers start smoking during adolescence.¹ Consequently, preventing teenagers from starting to smoke is a public health priority.^2,3 To start smoking, adolescents need access to tobacco products. A teenager''s first few cigarettes usually come from friends or family members, but, once smoking becomes more established, youths turn to commercial sources of cigarettes (eg, stores and vending machines) to ensure a reliable supply.^3,4,5,6 They are able to do so despite laws in all US states that ban the sale of tobacco to minors, because compliance with these laws is limited.^3,7,8If youths could be prevented from easily obtaining cigarettes from commercial sources, it is hypothesised that fewer youths would become smokers.^3,8 Efforts to reduce youth access to tobacco have focused on enforcing bans on tobacco sales to minors in retail stores—the source of most tobacco bought by youths. A complementary strategy bans self‐service displays of tobacco products in retail stores. These displays facilitate youth access to tobacco by encouraging shoplifting and by minimising a young person''s contact with a salesperson, thereby making it more likely that a sale will occur.^3,8,9,10 Cigarette sales in vending machines have also been targeted because vending machines are more important tobacco sources for younger teens who have more difficulty in buying tobacco in stores.^3,8 Effective strategies include banning vending machine sales of cigarettes or limiting vending machines to adults‐only locations. Equipping vending machines with locking devices that must be deactivated by a clerk who presumably verifies the purchaser''s age has little evidence of efficacy.³Measures to restrict youths'' access to tobacco products have been widely advocated since the early 1990s and are now incorporated into global tobacco control efforts.¹¹ The World Health Organization''s Framework Convention on Tobacco Control includes a provision requiring ratifying nations to adopt and implement laws that prohibit the sale of tobacco to minors.¹² In the US, the federal Synar amendment has, since 1996, required all states to have and enforce youth‐access laws and document a specific level of compliance or risk loss of federal block grant funds.¹³ Many US communities have gone beyond state laws and adopted local ordinances with stronger youth‐access provisions.^3,7,14 In Massachusetts, for example, the number of towns with some form of youth‐access regulation increased from 35 (10%) in 1994 to 244 (70%) in 2000.³Despite the widespread adoption of youth‐access restrictions, this approach remains controversial because evidence to support its efficacy in reducing adolescent smoking is limited.^{3,8,11,15,16,17} In 2004, a systematic review of interventions to reduce minors'' access to commercial sources of tobacco products was conducted by the Cochrane Tobacco Addiction Group. It concluded that active enforcement of youth‐access laws could reduce illegal sales to minors, but found little evidence that these interventions reduced the prevalence of adolescent smoking or perceived ease of access to tobacco products.^18,19 An earlier meta‐analysis also found no evidence that increases in merchant compliance with youth‐access laws were associated with the prevalence of youth smoking,²⁰ although that review''s methods were challenged.¹⁷Another source of evidence comes from observational studies. These do not test specific interventions but examine the association between adolescent''s exposure to youth‐access laws or perceived ease of access to tobacco products and their prevalence of smoking. These studies have conflicting results. A cross‐sectional study of adolescents in 314 towns in Massachusetts found no consistent association between living in a town with a youth‐access ordinance and prevalence of adolescent smoking or perceived ease of access to tobacco products, but the study had no data on the extent to which merchants actually complied with the laws.²¹ By contrast, a cross‐sectional study of 75 communities in Oregon found a small positive linear relationship between a town''s measured rate of illegal sales to minors and the prevalence of smoking of 11th graders, but not of 8th graders.²² A cross‐sectional analysis of 11 towns in Illinois found that teenagers in towns with higher rates of illegal tobacco sales to minors were more likely to initiate but not to continue to smoke,²³ However, the cross‐sectional design of these studies limits their ability to support causal inferences. Among 12 communities in New York, those reaching a high (>80%) rate of retailer compliance with youth‐access laws had a smaller increase in adolescents'' rate of frequent smoking over 4 years, as measured by two cross‐sectional school surveys.²⁴Few observational studies have used the stronger prospective cohort design. A cohort study of 592 adolescent non‐smokers in Massachusetts found that those living in towns with a local tobacco sales ordinance at baseline were less likely to progress to established smoking over 4 years than youths in towns without these ordinances. However, the finding lost statistical significance after adjustment for potential confounders and there was no information on actual compliance with the laws.²⁵ Gilpin et al²⁶ followed two cohorts of adolescent non‐smokers in California over 3 years. In the first cohort, followed when merchant compliance with youth access laws was low, smoking initiation rates did not differ between youths who initially perceived that cigarettes were difficult or easy to obtain. In the second cohort, conducted after overall merchant compliance state‐wide had improved, youths who perceived that cigarettes were hard to obtain were less likely to initiate smoking.The current study adds to the existing literature on the effect of youth access restriction in several ways.¹ It includes data from a representative cohort of adolescents living in a large number of communities that range in size and demographic characteristics.² A town‐level clustered multilevel analysis allows us to control for a large variety of individual, environmental and town‐level characteristics, including the community''s baseline anti‐smoking sentiment.³ A longitudinal design provides stronger evidence for causal inferences.⁴ The extent to which youth‐access laws are actually enforced is measured.⁵ The study deconstructs smoking uptake into two components: youths'' experimentation with tobacco products and their progression to established tobacco use. Restrictions on youth‐access laws are hypothesised to affect the latter more than the former.^3,8     

Public health foundations and the tobacco industry: lessons from Minnesota

Objective: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study.

Design: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials.

Results: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001–2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court.

Conclusion: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.

     

Tobacco point-of-purchase promotion: examining tobacco industry documents

In the face of increasing media restrictions around the world, point-of-purchase promotion (also called point-of-sale merchandising, and frequently abbreviated as POP or POS) is now one of the most important tools that tobacco companies have for promoting tobacco products. Using tobacco industry documents, this paper demonstrates that tobacco companies have used point-of-purchase promotion in response to real or anticipated advertising restrictions. Their goal was to secure dominance in the retail setting, and this was achieved through well-trained sales representatives who offered contracts for promotional incentive programmes to retailers, which included the use of point-of-sale displays and merchandising fixtures. Audit programmes played an important role in ensuring contract enforcement and compliance with a variety of tobacco company incentive programmes. Tobacco companies celebrated their merchandising successes, in recognition of the stiff competition that existed among tobacco companies for valuable retail display space.     

How tobacco companies ensure prime placement of their advertising and products in stores: interviews with retailers about tobacco company incentive programmes

Background: About 81% of cigarette manufacturers' marketing expenditures in the USA is spent to promote cigarette sales in stores. Relatively little is known about how these expenditures help the manufacturers achieve their marketing goals in stores. A better understanding of how tobacco companies influence the retail environment would help researchers and tobacco control activists to monitor industry presence in stores.     

Consequences of marketing exceptions in the Master Settlement Agreement: exposure of youth to adult-only tobacco promotions.

The Master Settlement Agreement between a consortium of tobacco companies and 46 states contains many restrictions on tobacco sales and advertising that were designed to reduce youth exposure to tobacco promotions. Most of the restrictions include an exception for "adult-only" facilities. The present study investigated the extent to which youth are being exposed to marketing that is presumably limited to adults. Using data from a statewide random-digit-dialed survey of 3,863 Massachusetts youth aged 12-17 years, we found that about half of all youth in this age group reported seeing cigarettes advertised at events, concerts, bars, or clubs in the past 12 months, and that about 5% of youth in this age group reported being present at a venue where free samples of cigarettes were being distributed. Youth exposed to this marketing were those most at risk for progression to established smoking. To our knowledge, this is the first study to estimate youth exposure to advertisements designed for adult-only venues. In light of the large body of evidence that exposure to tobacco advertising and promotion increases tobacco use among youth, our findings demonstrate the need to close the "adult-only" loophole.     

Development of a state wide tobacco treatment specialist training and certification programme for Massachusetts

OBJECTIVE: To describe the research conducted to structure and develop a statewide tobacco training and certification programme for tobacco treatment specialists (TTSs) in Massachusetts. DESIGN: Qualitative research strategies were used to obtain information on certification development and opinions regarding TTS training and certification from key informants. A role definition and validation study was then conducted to determine the core competencies for TTSs. A comprehensive training programme was developed, piloted, and finalised, and a certification programme was initiated. PARTICIPANTS: Key informants included: individuals involved in the development of their professional certification programmes; tobacco treatment providers from across Massachusetts; and national tobacco treatment experts. MAIN OUTCOME MEASURES: Participants' opinions about the need for and structure of a training and certification programme for individuals specialising in the provision of moderate to intensive tobacco treatment; delineation of core competencies for TTSs, using the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) clinical practice guideline as a foundation for the development of evidence based standards of practice for the treatment of nicotine dependence. RESULTS: The data support a comprehensive training and certification programme for TTSs in Massachusetts. Main concerns include the cost of obtaining certification, the potential to exclude uncertified healthcare professionals from delivering basic tobacco treatment, and the role of the TTS in the healthcare delivery system and the community. The training programme developed for Massachusetts was piloted, and the structure of a statewide training and certification programme for TTSs was finalised. CONCLUSIONS: The research provides support for the need and acceptance of a training and certification programme for TTSs in Massachusetts, and presents the challenges to be addressed. We demonstrated the feasibility of developing and implementing an evidence based training programme, and of initiating a statewide certification programme in Massachusetts. This work will add to a national dialogue on the development of a training and certification programme for tobacco treatment providers and encourage further research into the potential impact of statewide and national certification.     

Evolution of a comprehensive tobacco control programme: building system capacity and strategic partnerships--lessons from Massachusetts

BACKGROUND: Since the passage of a voter approved state referendum in 1992 to establish a 25 cent increase on the excise tax on cigarettes and smokeless tobacco, Massachusetts has received an average of $40 million annually for its tobacco control programme. This funding allowed Massachusetts to expand and develop its tobacco control programme to become one of the most comprehensive in the world. OBJECTIVES: The development of the Massachusetts Tobacco Control Program is outlined, focusing on three stages of development: formation, strategic partnership building, and shared leadership. METHODS: The development of management structures, programmatic infrastructure, communication and partnership networks, and advisory structures are tracked throughout the three phases. RESULTS: The use of pre-existing public health resources, implementation of a strong training component, a geographical management structure, the creation of public and private partnerships, and the development of a shared leadership model contributed to building consensus and provided the foundation for coordinated approaches to tobacco control. CONCLUSION: Other states and countries can use lessons learned from Massachusetts about the organisational development of a comprehensive tobacco control programme as they embark upon similar efforts.     

A comprehensive review of state laws governing Internet and other delivery sales of cigarettes in the United States.

All U.S. states regulate face-to-face tobacco sales at retail outlets. However, the recent growth of delivery sales of tobacco products by Internet and mail-order vendors has prompted new state regulations focused on preventing youth access and tax evasion. To date, there are no comprehensive and systematic analyses of these laws. The objectives of this study were to: (a) document the historical enactment of the laws; (b) assess the nature and extent of the laws; and (c) examine the relationship between the presence of laws and state tobacco control policy and other contextual variables. Between 1992 and 2006, 34 states (67%) enacted a relevant law, with 27 states' laws (45%) effective between 2003 and 2006. Five states banned direct-to-consumer shipment of cigarettes. The remaining 29 states' laws included a combination of requirements addressing minimum age/ID, payment issues, shipping, vendor licensure and related issues, tax collection/remittance, and penalties/enforcement. States with delivery sales laws have stronger youth tobacco access policies and state tobacco control environments, as well as higher state cigarette excise tax rates and revenue, past-month cigarette use rates, and perceptions of risk of use by adolescents. This paper provides the policy context for understanding Internet and other cigarette delivery sales laws in the U.S. It also provides a systematic framework for ongoing policy surveillance and will contribute to future analyses of the impact of these laws on successfully reducing youth access to cigarettes and preventing tax evasion.     

Web sites selling cigarettes: how many are there in the USA and what are their sales practices?

OBJECTIVES: To estimate the number and geographic location of web sites selling cigarettes in the USA, and to examine their sales and marketing practices. METHODS: Comprehensive searches were conducted using four keyword terms and five popular internet search engines, supplemented by sites identified in a news article. Over 1800 sites were examined to identify 88 internet cigarette vendors. MEASURES: Trained raters examined the content of each site using a standardised coding instrument to assess geographic location, presence of warnings, products sold, and promotional strategies. SETTING: USA. RESULTS: Internet cigarette vendors were located in 23 states. Nearly half (n = 43) were located in New York state, and many were in tobacco producing states with low cigarette excise taxes. Indian reservations housed 49 of the 88 sites. Only 28.4% of sites featured the US Surgeon General's health warnings and 81.8% featured minimum age of sale warnings. Nearly all sites (96.6%) sold premium or value brand cigarettes, 21.6% sold duty-free Marlboros, and 8.0% sold bidis. Approximately one third featured special promotional programmes. CONCLUSIONS: Internet cigarette vendors present new regulatory and enforcement challenges for tobacco control advocates because of the difficulty in regulating internet content and because many vendors are on Indian reservations.