IJE Advance Access originally published online on January 4, 2006
International Journal of Epidemiology 2006 35(1):31-33; doi:10.1093/ije/dyi280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cochrane Column |
Cochrane Column
South African Cochrane Centre, Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa. E-mail: taryn.young{at}mrc.ac.za
The Cochrane Column highlights Cochrane systematic reviews of relevance to public health, and aims to stimulate debate on relevance, feasibility, and acceptability. This Column features a Cochrane systematic review that assessed the effectiveness of reducing underage access to tobacco products by deterring shopkeepers from illegal sales.
|
The Cochrane Collaboration (http://www.cochrane.org) is an international, non-profit organization that prepares and disseminates up-to-date systematic reviews on the effects of healthcare interventions in order to help people make well-informed decisions. Systematic reviews aim to answer focused healthcare questions by systematically identifying and evaluating all relevant research studies and synthesizing their results.
If you are interested in contributing to the Cochrane Column or The Cochrane Collaboration, contact me at the South African Cochrane Centre.
 |
Notes |
|---|
A summary of Cochrane reviews (and protocols) of relevance to health promotion and public health can be viewed on the Cochrane Health Promotion and Public Health website: http://www.vichealth.vic.gov.au/cochrane/
Interventions for preventing tobacco sales to minors: Cochrane systematic review
|
Background |
|---|
 Top Background MethodsResultsDiscussionReferencesReferences |
|---|
Controlling access is one approach to reducing consumption of harmful substances. Many countries have legislation restricting the sale of tobacco products to children, but compliance with these is known to be poor. Interventions that increase compliance with legislation might help prevent young people from starting to smoke.
|
Methods |
|---|
|
TopBackgroundMethodsResultsDiscussionReferencesReferences |
|---|
Relevant interventions could use education, law enforcement, community mobilization, or combinations of strategies to deter retailers from selling tobacco to minors. Searches of the Tobacco Addiction Group specialized register, MEDLINE, and EMBASE used a combination of tobacco related, age related, and sales related terms. Eligible study designs included randomized or controlled trials, interrupted time series and uncontrolled before and after evaluations. Outcomes were compliance as measured by test purchasing, youth perceptions of ease of access, or smoking behaviour of minors. A narrative synthesis was used, with greater weight given to randomized studies that assessed both compliance and smoking behaviour. Two authors assessed potentially relevant reports independently. Data were extracted by one author and checked by a second.
|
Results |
|---|
|
TopBackgroundMethodsResultsDiscussionReferencesReferences |
|---|
Thirty-four studies were identified, of which 13 had a control group. Nine of these were randomized, six by store and three by community. The main interventions were: education about legal requirements; notification of the results of compliance checks; warning of enforcement; and implementation of enforcement by police or health officials. Some studies tested different frequencies of enforcement activity and different channels of information. Thirty studies assessed retailer compliance with the law using test purchasers. Eleven studies assessed the effect of an intervention on the smoking behaviour of underage youth, of which six were controlled. Greatest weight was given to three controlled studies that assessed both the behaviour of retailers and the smoking behaviour of minors. Both controlled and uncontrolled studies demonstrated that interventions could reduce access as measured by test purchasers. Although the change in compliance was often large, compliance rates of over 90% were seldom achieved. Four of seven controlled trials detected some beneficial effect of the intervention on youth smoking behaviour; in two this was limited to younger ages. In one of the four there was no difference in the change in compliance so the effect might have been due to other components of the intervention.
|
Discussion |
|---|
|
TopBackgroundMethodsResultsDiscussionReferencesReferences |
|---|
Legislation alone is not sufficient to prevent tobacco sales to minors. Both enforcement and community policies improve compliance by retailers, but the impact on underage smoking prevalence using these approaches alone may be small if the level of compliance attained does not sufficiently restrict access. Compliance checks may not accurately reflect availability to young people who are known to store staff, so may overestimate the difficulty of access. Young people have multiple alternative sources of cigarettes. They may get adults or older friends to buy for them, or be given cigarettes by others. The number of outlets in a local area that continue to sell illegally may be more relevant than the proportion. Reliance on interventions to restrict commercial access to tobacco may not be an efficient way to reduce smoking initiation.
The full text of the Cochrane Review is available in The Cochrane Library. Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001497 [GenBank] .pub2. DOI: 10.1002/14651858.CD001497.pub2.
Commentary: Interventions for preventing tobacco sales to minors
Global Public Health, Yale School of Public Health, USA
The recently adopted WHO Framework Convention on Tobacco Control (FCTC) includes restrictions on sales of tobacco products to minors as one element of a comprehensive tobacco control policy.1 Article 16 of the FCTC covers sales to and by minors and states that: ‘Each Party shall adopt and implement effective legislative, executive, administrative or other measures at the appropriate government level to prohibit the sales of tobacco products to persons under the age set by domestic law, national law or eighteen.’
Of all the measures included, it is one of the most weakly supported by evidence and the toughest to effectively implement. Despite this, it is supported by all countries and tobacco companies! For governments, it sounds like a sensible policy. For tobacco companies, it gives an illusion of support for tobacco control.
Stead and Lancaster's review confirms the findings of the World Bank who regard such supply side measures as ineffective except under special circumstances.2 Their review is entirely based on studies from three countries: USA, UK, and Australia. All have mature tobacco control policies, a strong legal and policing tradition, few opportunities for tobacco sales in the informal sector, and community support for tobacco control. This is not the case in many countries around the world. In many developing countries, tobacco products are sold through unlicensed outlets and the informal market—often by children. This makes law enforcement problematic. Community awareness about the hazards of youth tobacco use are not strong; non-governmental organizations are weakly placed to advocate stronger measures; tobacco prices are low and marketing ubiquitous. All of these factors hamper the prospects of successfully implementing a ban on sales to children.
There are additional problems with implementation in countries where vending machines are common. The vending machine owners in some countries have responded to this concern by equipping new models with ways of identifying the age of the purchaser—but even this is a flawed approach that youth can easily overcome.
Despite these limitations, the principle of preventing children from buying tobacco products remains important. Comprehensive tobacco control policies as spelt out in the FCTC will achieve this objective. An immediate way of improving enforcement is available but has yet to be applied—namely permitting governments at national or local levels to contract tobacco control NGOs to be enforcement officers and to be paid from fines received. That would create an incentive for enforcement and an increased probability of being fined.
|
References |
|---|
|
TopBackgroundMethodsResultsDiscussionReferencesReferences |
|---|
1 WHO. Fifty-Sixth World Health Assembly Resolution WHA56.1. of 21 May 2003. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization, 2003.
2 World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington DC: World Bank, 1999.
Commentary: Interventions for preventing tobacco sales to minors
National Council Against Smoking, PO Box 1242, Houghton 2041, South Africa
Around the world children find it easy to buy cigarettes and are rarely refused purchases.1 Stead and Lancaster's review confirms that laws prohibiting tobacco sales to minors do not reduce underage smoking.2 Is it then time to abandon youth access laws or do they still have some use and can their weaknesses be overcome?
The basic premise for such laws is sound enough: if children cannot obtain tobacco they cannot use it. In practice the law fails for many reasons. First the financial incentive for selling cigarettes to youth is great. In the US, it is estimated that illegal sales to minors amount to $1.5 billion annually. Second, the rate of enforcement compared with the rate of violation is negligible. Every day 
400 000 underage youngsters buy cigarettes in South Africa, yet in 2004 there was not a single prosecution for such illegal sales. The large number of informal traders selling cigarettes in the streets also makes enforcement more difficult. Finally, as the war on drugs has shown, measures to reduce supply are less likely to succeed than measures to reduce demand. As one supplier is shut down another supplier gains an incentive to enter the market.
On the other hand, the likely result of abandoning youth access laws is that merchants would once again openly sell tobacco to minors. Overt sales will replace covert sales. Does it matter? Yes, it does. Repealing youth access laws will bolster the tobacco companies claim to be a ‘legal’ industry selling a ‘legal’ product. The counter message that tobacco is an illegal product when it is sold to children will be lost.
The wide distribution and easy availability of tobacco is an important part of the industry's strategy for targeting youth. A 1990 memo from the RJ Reynolds tobacco company revealed how the sales team was actively encouraged to focus on tobacconists near schools and colleges. Abandoning youth access laws would give free reign to such programmes, which result in adolescents overestimating the extent, and underestimating the social disapproval, of smoking. Further, a key part of the US Justice Department's landmark case against the tobacco companies under the Racketeer-Influenced and Corrupt Organisations Act is the charge that the industry marketed cigarettes to youth while falsely denying they have done so.
Enforcement is a problem for all tobacco control legislation. Smoke-free policies work because they are largely self-policing. It is the demand for clean air from non-smokers that has made workplaces smoke-free and not policemen sitting in every cinema and restaurant waiting to arrest lawbreakers. The challenge is to convert public support for youth access laws into public action. Campaigns for parents to boycott outlets that sell tobacco to their children may be one solution.
In reality, the most effective way to deter children from taking up smoking is to increase taxes on cigarettes. Youth access laws are secondary in importance to demand reduction strategies such as price increases and tobacco advertising bans but still have a place in the armoury. Rather than forsake this law the challenge is to find innovative strategies for its effective implementation.
|
References |
|---|
|
TopBackgroundMethodsResultsDiscussionReferencesReferences |
|---|
1 The Global Youth Tobacco Survey Collaborative Group. Tobacco use among youth: a cross country comparison. Tob Control 2002;11:252–70.
2 Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001497.pub2.DOI: 10.1002/1465
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||