Accessibility of Tobacco Products to Youths Aged 12-17 Years -- United States, 1989 and 1993

Although the sale of tobacco products to minors is illegal in all states and the District of Columbia (1), the prevalence of cigarette smoking among adolescents has continued to increase (2), and most minors are able to purchase tobacco products (3). Reducing sales to minors is believed to be an effective measure for reducing the prevalence of tobacco use (4). To determine recent patterns of minors' access to tobacco products from retail outlets and vending machines, data were analyzed from the 1989 and 1993 Teenage Attitudes and Practices surveys (TAPS I and TAPS II). This report summarizes the results of that analysis, which indicate that most minors who use tobacco purchase their own tobacco and that small stores are the sources of most purchases.

Samples for both TAPS I and II were drawn from households that participated in the National Health Interview Survey (NHIS), a continuing nationwide household survey that collects information from a representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years. Both TAPS I and II collected information on adolescents' knowledge, attitudes, and practices regarding tobacco use. TAPS I data were collected by telephone interviews; TAPS II data were collected by telephone and personal interviews and included both a new probability sample and a follow-up of respondents from TAPS I. Data for persons aged 12-17 years in each survey were analyzed (n=7773 for TAPS I; n=6165 for TAPS II) and weighted to provide national estimates. SUDAAN was used to calculate standard errors for determining 95% confidence intervals (CIs) and to perform multivariate logistic regression analyses of TAPS II data; simultaneous adjustments were made for age, sex, race/ethnicity, and region of the country. Differences between TAPS I and TAPS II for selected estimates were assessed by using the Generalized Estimating Equations software (5). Adjustments were made for subject correlation and age.

Adolescents in both TAPS I and II who were current smokers were asked about purchase practices, and all respondents were asked about perceived ease of purchase (6). In TAPS II, adolescents who usually bought, ever bought, or ever tried to buy their own cigarettes were asked, "Have you ever been asked to show proof of age when buying/trying to buy cigarettes?" With the exception of questions regarding purchase from vending machines, similar questions were asked of TAPS II adolescents regarding the purchase of smokeless tobacco (SLT) products. Data were analyzed by race/ethnicity because, after controlling for sociodemographic differences, the prevalence of cigarette smoking is higher among minors in some racial/ethnic groups (3).

The overall percentage of smokers aged 12-17 years who usually bought their own cigarettes was higher in 1993 than in 1989 (Table_1). In 1993, minors residing in the Northeast (adjusted odds ratio {AOR}=2.2; 95% CI=1.2-3.8) and South (AOR=1.8; 95% CI=1.1-3.0) were more likely than minors residing in the West to report they usually bought their own cigarettes. * In addition to the 61.9% of U.S. smokers aged 12-17 years who usually bought their own cigarettes in 1993, 15.5% reported they ever (but not usually) had bought cigarettes, and 2.3% reported they ever had tried unsuccessfully to buy their own cigarettes.

Among minors aged 12-17 years who usually bought their own cigarettes, 14.6% in 1989 and 12.7% in 1993 often or sometimes bought their cigarettes from vending machines; 49.6% in 1989 and 36.8% in 1993 often or sometimes bought from large stores; and 84.6% in 1989 and 88.5% in 1993 often or sometimes bought from small stores (Table_2). In 1993, minors aged 12-15 years were more likely than those aged 16-17 years (AOR=2.1; 95% CI=1.1-4.3) to often or sometimes use vending machines; those aged 12-15 years were less likely than those aged 16-17 years to often or sometimes buy their cigarettes from small stores (AOR=0.5; 95% CI=0.4-0.7).

In 1993, 55.3% (95% CI=51.0%-59.6%) of minors aged 12-17 years reported ever having been asked to show proof of age when buying or trying to buy cigarettes. Blacks (AOR=0.4; 95% CI=0.2-0.9) were less likely than whites to ever have been asked for proof of age, and Hispanics (AOR=0.3; 95% CI=0.1-0.6) were less likely than non-Hispanics to ever have been asked for proof of age. ** Minors residing in the Northeast (AOR=0.4; 95% CI=0.2-0.7) or in the Midwest (AOR=0.4; 95% CI=0.2-0.8) were less likely than minors residing in the West to ever have been asked for proof of age.

In 1993, among minors aged 12-17 years who never had smoked a cigarette, 44.6% (95% CI=42.8%-46.3%) believed it would be easy for them to buy cigarettes, including 34.4% (95% CI=32.4%-36.3%) of minors aged 12-15 years and 76.4% (95% CI=73.8%-79.0%) of minors aged 16-17 years. In 1993, 51.7% (95% CI=43.9%-59.5%) of minors aged 12-17 years who had used SLT on one or more of the 30 days preceding the survey usually purchased their own SLT; 18.3% of SLT users in 1993 ever (but not usually) had bought their own SLT, and 3.1% ever had tried unsuccessfully to buy SLT. Among minors aged 12-17 years who usually bought their own SLT, 82.1% (95% CI=74.2%- 90.0%) often or sometimes bought from small stores, and 40.5% (95% CI=33.3%-47.9%) often or sometimes bought from large stores. In 1993, 43.2% (95% CI=34.4%-52.0%) of minors aged 12-17 years reported ever having been asked to show proof of age when buying or trying to buy SLT. Among males aged 12-17 years who had never used SLT in 1993, 39.0% (95% CI=36.7%-41.4%) believed it would be easy for them to buy SLT, including 28.1% (95% CI=25.6%-30.7%) of minors aged 12-15 years and 70.7% (95% CI=67.0%-74.5%) of minors aged 16- 17 years.

Reported by: Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report are consistent with previous documentation of the ease with which minors can purchase tobacco products over the counter and from vending machines and of the more frequent use of vending machines by younger adolescents (3). In surveys of tobacco outlets using unannounced over-the-counter purchase attempts by minors, purchase rates were usually highest in small stores and gas stations (3). In addition, previous studies using self-reported surveys of minors' tobacco use indicate that these locations are the most common source of purchased cigarettes by minors (3,6).

Differences in access among racial/ethnic groups may be influenced by differences in socioeconomic status and by racial and cultural phenomena. The substantial race/ethnicity-specific differences for some of the variables in this analysis indicate the need to examine factors including attitudes of vendors, enforcement practices, and community norms.

Vendors' requiring proof of age is an important method of preventing tobacco sales to minors (3,4; CDC, unpublished data, 1994). Widespread adherence to laws requiring age verification should assist substantially in preventing tobacco sales to minors. However, in 1993, approximately half of minors who ever had attempted to purchase their own tobacco products reported they never had been asked to show proof of age.

The findings in this report are subject to at least two limitations. First, TAPS II may be associated with nonresponse bias; for example, TAPS I respondents who were followed up in TAPS II were less likely to be smokers in 1989 than were those who could not be reinterviewed, possibly contributing to the lower smoking prevalence estimates in TAPS II when compared with other national surveys (CDC, unpublished data, 1993). Second, because the information was collected during telephone and personal interviews, young persons may have been reluctant to disclose tobacco-related behavior when a parent was in the household during the interview (3).

Although all states have enacted youth access laws, enforcement of these laws varies and needs to be strengthened. In 1994, enforcement activities were maintained only in 24 (44%) states and territories (7). Federal regulations now require states to develop a strategy and a time frame for achieving an inspection failure rate of less than or equal to 20% (8).

The establishment and enforcement of laws that prohibit sales to minors are consistent with and reinforce existing social norms (4). One of the national health objectives for the year 2000 is to enforce laws to reduce the sales rate observed during compliance checks to 20% (objective 3.13) (9). In the United States, approximately 70% of purchase attempts made by minors are successful (3).

In August 1995, the Food and Drug Administration proposed regulations that could reduce for minors both access to and the appeal of nicotine-containing cigarettes and SLT products (10). The regulations would 1) require retailers to verify the age of persons who want to purchase cigarettes or SLT products; 2) eliminate "impersonal" methods of sale and distribution that do not readily allow age verifications (e.g., mail orders, self-service displays, free samples, and vending machines), 3) limit advertising to which minors may be exposed to a text-only format; 4) ban outdoor advertising of tobacco products within 1000 feet of schools and playgrounds; 5) prohibit the sale or distribution of brand-identifiable nontobacco items and services; and 6) prohibit the sponsorship of events in the brand name. FDA is reviewing public comments on the proposed regulations.

References

1. CDC. State laws on tobacco control -- United States, 1995. MMWR 1995;44(no. SS-6).

2. Johnston L, Bachman J, O'Malley P. Cigarette smoking among American teens rises again in 1995. Ann Arbor, Michigan: University of Michigan News and Information Services, December 11, 1995.

3. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

4. Institute of Medicine. Growing up tobacco free: preventing nicotine addiction in children and youths. Washington, DC: National Academy Press, 1994.

5. Karim MR. GEE1 Macro {SAS-IML versions for PC}. Baltimore, Marlyand: Johns Hopkins University, Department of Biostatistics, 1989.

6. CDC. Accessibility of cigarettes to youths aged 12-17 years -- United States, 1989. MMWR 1992;41:485-8.

7. US Department of Health and Human Services. State oversight of tobacco sales to minors. Washington, DC: US Department of Health and Human Services, Office of Inspector General, Office of Evaluation and Inspections, 1995; publication no. OEI-02-94-00270.

8. Substance Abuse and Mental Health Services Administration. Final regulations to implement section 1926 of the Public Health Service Act regarding the sale and distribution of tobacco products to individuals under the age of 18. Federal Register 1996;13:1492- 1500.

9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- midcourse review and 1995 revisions. Washington, DC: US Department of Health and Human Services, Public Health Service, 1995.

10. Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco products to protect children and adolescents: proposed rule analysis regarding FDA's jurisdiction over nicotine-containing cigarettes and smokeless tobacco products -- proposed rule. Federal Register 1995;155:41,314-75.

* Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. 

** Numbers for other racial/ethnic groups were too small to calculate precise estimates.

TABLE 1. Percentage of smokers * aged 12-17 years + who usually bought their own
cigarettes in 1989 and 1993, by selected characteristics -- United States, Teenage
Attitudes and Practices Surveys I and II, 1989 & and 1993 &
=====================================================================================
                          1989                    1993
                 -----------------------  -------------------------  % Point change
Characteristic   No.   (%)    (95% CI @)   No.    (%)    (95% CI)     1989 to 1993
-------------------------------------------------------------------------------------
Age (yrs)
  12-15          439  (45.4)  (+/- 4.9%)   264   (52.4)  (+/- 6.3%)      + 7.0
  16-17          559  (66.6)  (+/- 4.1%)   446   (69.1)  (+/- 4.3%)      + 2.5

Sex
  Male           521  (59.6)  (+/- 4.5%)   367   (63.6)  (+/- 4.8%)      + 4.0
  Female         477  (55.3)  (+/- 4.8%)   343   (60.5)  (+/- 5.7%)      + 5.2

Race **
  White          914  (58.7)  (+/- 3.3%)   639   (62.1)  (+/- 4.0%)      + 3.4
  Black           64  (43.3)  (+/-11.5%)    52   (64.1)  (+/-14.3%)      +20.8

Ethnicity ++
  Hispanic        68  (41.3)  (+/-12.8%)    56   (59.1)  (+/-13.8%)      +17.8
  Non-Hispanic   924  (59.0)  (+/- 3.3%)   654   (62.4)  (+/- 3.9%)      + 3.4

Region &&
  Northeast      218  (58.8)  (+/- 6.8%)   146   (68.4)  (+/- 8.4%)      + 9.6
  Midwest        275  (55.0)  (+/- 5.5%)   225   (61.6)  (+/- 6.2%)      + 6.6
  South          305  (61.5)  (+/- 5.9%)   201   (66.2)  (+/- 6.2%)      + 4.7
  West           200  (53.6)  (+/- 7.6%)   138   (50.9)  (+/- 9.4%)      - 2.7

Total            998  (57.5)  (+/- 3.2%)   710   (61.9)  (+ 3.9%)      + 4.4
-------------------------------------------------------------------------------------
*  Youths who reported smoking at least one cigarette during the 30 days preceding
   the survey.
+  As of November 1, 1989, or March 15, 1993.
&  Prevalence estimates were calculated from weighted data.
@  Confidence interval.
** Excludes 39 persons of other, multiple, and unknown races because numbers were
   too small to calculate precise estimates.
++ Excludes six persons with unknown Hispanic origin.
&& Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey,
   New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois,
   Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North
   Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware,
   District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland,
   Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas,
   Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii,
   Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.
@@ The log odds ratio for the change in the overall prevalence of "bought own
   cigarettes" from 1989 to 1993 estimated using the Generalized Estimating
   Equations software is 0.21 (odds ratio=1.2) This log odds ratio was significantly
   different than zero at the 0.05 level. The logistic model used to calculate the
   above included age as a covariate.
=====================================================================================

TABLE 2. Percentage of smokers * aged 12-17 years + who usually bought their own cigarettes
and who often/sometimes purchased cigarettes from a vending machine, large store, or small
store, by selected characteristics -- United States, Teenage Attitudes and Practices Survey,
1989 & and 1993 &
=======================================================================================================
                    Vending machine               Large store                Small store
                ------------------------   ------------------------   ------------------------
                              % Point                    % Point                     % Point
                               change                     change                      change
Characteristic  1989  1993  1989 to 1993   1989  1993  1989 to 1993   1989  1993  1989 to 1993
-------------------------------------------------------------------------------------------------------
Age (yrs)
  12-15          20    18      - 2.0        41    36      - 4.9        79    83       +3.5
  16-17          12    10      - 2.3        54    37      -17.2        87    92       +4.7
Sex
  Male           18    12      - 5.8        51    36      -15.0        82    90       +8.3
  Female         11    13      + 2.3        49    38      -10.9        88    88       -0.5

Region @
  Northeast      15    18      + 3.3        50    30      -20.1        84    88       +3.8
  Midwest        20     8      -12.2        51    33      -17.5        89    88       -0.8
  South          12    15      + 2.3        50    44      - 6.2        85    90       +5.6
  West           11     9      - 1.8        47    37      -10.3        80    88       +8.8

Total            15    13      - 2.1        50    37      -13.1        85    89       +4.2 **
-------------------------------------------------------------------------------------------------------
*  Youths who reported smoking at least one cigarette during the 30 days preceding the survey.
+  As of November 1, 1989, or March 15, 1993
&  Prevalence estimates were calculated with weighted data.
@  Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York,
   Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan,
   Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama,
   Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland,
   Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virgina, and West
   Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico,
   Oregon, Utah, Washington, and Wyoming.
** The log odds ratio (LOR) for the change in the overall prevalence from 1989 to 1993 using the
   Generalized Estimating Equations software was calculated for those who usually bought their
   own cigarettes and who often/sometimes purchased cigarettes from a vending machine (LOR=0.17; odds
   ratio {OR}=1.18), large store (LOR=0.51; OR=1.67), or small store (LOR=0.34; OR=1.40). The LORs
   were significantly different than zero at the 0.01 level for large stores and at the 0.05 level
   for small stores. The logistic model used to calculate the above included age as a covariate.
=======================================================================================================

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