Illegal Sales of Cigarettes to Minors -- Mexico City, Mexico, 1997

Because of the increasing prevalence of tobacco use among youth in the United States and Mexico (1,2), in 1996 the United States-Mexico Binational Commission (US-MBC) Health Working Group identified prevention of tobacco use, with an emphasis on adolescents, as one of its four priority health concerns. From 1970 to 1990, annual death rates for the leading causes of smoking-related deaths in Mexico nearly tripled and, in 1992, an estimated 10,253 persons in Mexico died as a result of smoking-related diseases, 9% of all deaths that year (3). In addition, from 1988 to 1993, the prevalence of current smoking among minors aged 12-17 years increased from 6.6% to 9.6%, respectively (in Mexico City, the 1993 prevalence was 12.8%), and in 1993, 72% of adult smokers in Mexico reported becoming regular smokers before age 18 years (2,4). Although since 1984 the General Health Law of Mexico has prohibited the sale of tobacco products to minors aged less than 18 years, compliance with this law has not been assessed. As part of the Mexican national program to reduce the prevalence of cigarette smoking among children and adolescents and in support of the goals of the US-MBC, during 1997 the General Directorate of Epidemiology (GDE) in the Secretariat of Health (SOH) conducted a survey of tobacco outlets in Mexico City to assess the percentage of retailers willing to sell cigarettes to minors. This report summarizes the results of the survey, which indicate that virtually no surveyed retailers asked minors attempting to purchase cigarettes about their age and that most retailers sold cigarettes to minors.

This survey, the first assessment in Mexico of illegal sales of cigarettes to minors, was conducted during March 23-April 4, 1997, in the 16 districts composing Mexico City proper (1990 population: 8.5 million, excluding the surrounding metropolitan area). Because neither commercial business lists of tobacco outlets nor tobacco licensure lists were available and because resources were not available for SOH staff to enumerate a comprehensive list of all operational tobacco outlets in the city, stores were selected as the survey teams visited socioeconomically diverse commercial and residential neighborhoods in each of the 16 districts. Survey teams visited 35 stores in each of 15 districts and 36 stores in one district. The 561 stores included in the non-systematic sample were categorized as small neighborhood stores (302 {54%}), street stalls (137 {24%}), pharmacies (96 {17%}), convenience stores (19 {3%}), and large supermarkets (seven {1%}) (gasoline stations in Mexico are government owned and do not sell cigarettes). Chi-square tests were used to calculate statistical differences in the sales rates associated with selected variables.

The minors who participated in the survey were recruited from the families of staff at GDE and included eight boys aged 10-14 years and seven girls aged 11-15 years. The adult survey escorts were medical residents from the Field Epidemiology Training Program of GDE. Teams consisting of one medical resident, one GDE staff driver, and two minors made one purchase attempt per store using the following protocol: the medical resident entered the store shortly before one of the minors entered the store. The medical resident noted whether age-of-sale warning signs were posted inside the store and unobtrusively observed the transaction between the retailer and the minor as the minor attempted to purchase a pack of cigarettes. If asked by the retailers, the minors were instructed to truthfully state their age and that they carried no age identification. The purchase attempt was considered successful if cigarettes were purchased and was considered unsuccessful if the sale was refused for any reason. If the attempt was successful, the minor promptly left the store with the cigarettes and gave them to the medical resident after the resident exited the store.

Of the 561 stores visited, 443 (79.0%) of the retailers sold cigarettes to the minors (Table_1). Purchase attempts by the oldest minors (aged 14-15 years) were more likely to be successful than those by the youngest minors (aged 10-11 years) (92.2% versus 66.0%, respectively {p less than 0.01}) and by girls than by boys (84.0% versus 72.7%, respectively {p less than 0.01}). Sales were transacted at all types of stores. Although the proportion of successful sales did not vary by sex of the retailer, the proportion was higher for attempts involving male clerks and girls than for those involving male clerks and boys (88.3% versus 68.1%, p less than 0.01). Age-of-sale warning signs were displayed in 64 (11.8%) stores; the presence of a warning sign was not associated with lower sales rates. Four (0.7%) retailers asked the minor's age; one (0.2%) asked for proof of age; and 30 (5.4%) asked for whom the cigarettes were being purchased. Of the 118 retailers who did not sell cigarettes to the participating minors, 73 (62%) indicated to the participants that they do not sell cigarettes to minors.

Reported by: P Kuri-Morales, MD, P Cravioto, MSc, M Hoy, MD, S Huerta, MD, A Revuelta, MD, B Jasso, MD, R Tapia-Conyer, MD, Secretariat of Health, Mexico City, Mexico. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Most of the retailers included in the sample in this survey in Mexico City illegally sold cigarettes to the participating minors. In the United States, a national health objective for 2000 is to reduce to less than or equal to 20% the proportion of retailers who sell tobacco to minors (objective 3.13) (5). Among 13 local U.S. studies published during 1989-1993, rates of over-the-counter cigarette sales to minors ranged from 32% to 87% (6). Compliance surveys estimating the overall rate of cigarette sales to minors also have been conducted in Canada (52.1% in 1995 and 39.5% in 1996) (7) and Adelaide, Australia (46% in 1991) (8).

The findings in this report are subject to at least two limitations. First, because this survey used a nonsystematic sample of retail businesses, the findings probably do not uniformly represent the patterns of tobacco sales to minors throughout Mexico City. For example, even though the survey teams visited all districts of Mexico City, some types of stores and neighborhoods at some socioeconomic levels -- especially those at lower levels -- may not have been included in the sample. However, it is not known whether sales rates in lower socioeconomic neighborhoods differed from those in higher socioeconomic neighborhoods. Second, the rate may have been underestimated because retailers in small neighborhood stores and street stalls in particular may have suspected that the adult team member, who entered the store or approached the stall before the minor, was accompanying the minor.

Based on current global patterns of smoking, the World Health Organization (WHO) has projected that 200-300 million persons who are aged less than 20 years in 1997 will die from smoking-related diseases later in life (9). In 1986, the World Health Assembly adopted a resolution urging member states to consider a comprehensive tobacco-control strategy containing nine elements (10), including one that targets the prevention of smoking by children and adolescents. However, in the early 1990s, WHO determined that only approximately 25 countries had established laws prohibiting the sale of cigarettes to minors (the age of prohibition varied from 16 to 21 years), and that among these, only a limited number had attempted to enforce the laws. To decrease cigarette sales to minors, WHO recommends that countries adopt the following four measures: 1) establish a minimum age of purchase of 18 years or older; 2) create a tobacco-sales licensing system to identify tobacco retailers and inform them of their legal responsibilities; 3) establish a graduated schedule of civil law penalties for illegal sales, ranging from warnings to license revocations; and 4) enlist the assistance of teenagers in efforts of enforcement officers to assess retailers' compliance with the prohibition of sale to minors. Other categories of legislation also may be effective in decreasing sales to minors. For example, several local studies in the United States demonstrated substantially reduced tobacco sales to minors when retailers requested photo identification or other proof of age from persons attempting to purchase tobacco products (1).

SOH will use the results of this survey to emphasize the need for assessing compliance of retailers in other cities with the federal law prohibiting tobacco sales to minors in Mexico and to underscore the need for resources to support increased enforcement activities. In addition to the enforcement of strong minors' access laws, a comprehensive approach for preventing initiation of smoking by youth should include provisions that reduce the appeal of cigarettes to minors through restrictions on advertising and promotion and through educational programs (1).

References

1. Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco products to protect children and adolescents: final rule. Federal Register 1996;61:41,314-75.

2. Secretariat of Health. The National Addiction Survey {Spanish}. Mexico City, Mexico: Secretariat of Health, General Directorate of Epidemiology, 1993.

3. CDC. Smoking-attributable mortality -- Mexico, 1992. MMWR 1995;44:372-3,379-81.

4. Tapia-Conyer R, Medina-Mora ME, Sepulveda J, et al. The National Addiction Survey of Mexico {Spanish}. Salud P�blica Mex 1990;32:507-22.

5. 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.

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

7. AC Nielsen. Measurement of retailer compliance with respect to tobacco sales to minors legislation: wave 2, 1996. Montreal, Quebec: AC Nielsen, 1996.

8. Wakefield M, Carrangis J, Wilson D, Reynolds C. Illegal cigarette sales to children in South Australia. Tobacco Control 1992;1:114-7.

9. World Health Organization. Guidelines for controlling and monitoring the tobacco epidemic. Geneva, Switzerland: World Health Organization, 1997 (in press).

10. World Health Organization. Tobacco or health: first global status report. Geneva, Switzerland: World Health Organization, 1997 (in press).

TABLE 1. Number of retail businesses surveyed and number and percentage of successful attempts by
minors * to purchase cigarettes, by category -- Mexico City, Mexico, 1997
=====================================================================================================
                                                                           Successful attempts
                                                                         ----------------------------
Category                               No. retail businesses             No.       (%)    p value
-----------------------------------------------------------------------------------------------------
Age group (yrs) of minor
 10-11                                            247                     163    (66.0)      <0.01
 12-13                                             44                      31    (70.5)
 14-15                                            270                     249    (92.2)
Sex of minor
 Male                                             253                     184    (72.7)      <0.01
 Female                                           308                     259    (84.0)
Type of store
 Large supermarket                                  7                       3    (42.9)      <0.01
 Convenience                                       19                      11    (57.9)
 Small neighborhood                               302                     238    (78.8)
 Pharmacy                                          96                      71    (74.0)
 Street stalls                                    137                     120    (87.6)
Warning sign
 Yes                                               64                      47    (73.4)       0.25
 No                                               497                     396    (79.7)
Sex of retailer
 Male                                             300                     237    (79.0)       0.98
 Female                                           261                     206    (78.9)
Total                                             561                     443    (79.0)
-----------------------------------------------------------------------------------------------------
* Persons aged <18 years.
=====================================================================================================

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