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Preventing teenage tobacco addiction
Joseph R. DiFranza
Tobacco use remains a major health problem among children and
adolescents. Restrictive school policies on tobacco use and
enforcement of laws prohibiting the sale of tobacco to minors can
produce substantial reductions in tobacco use among this population.
This article provides practical, step-by-step instructions to help
physicians get these policies implemented in their communities.
Key words. Tobacco; adolescent behavior; health promotion. J Fam
Pract 1992; 34:753-756.
Despite a steady decline in adult smoking, tobacco use among
children and teenagers continues at alarming rates.[1] Smoking among
high school seniors dropped by 29% in the 4 years preceding 1981, but
since then the decline has slowed to less than one tenth of that rate.
Furthermore, the use of smokeless tobacco by youths has increased
dramatically during the past two decades.[2]
Two recent studies have unveiled a new tool that is producing
important results in reducing tobacco use among teenagers.[3,4] If you
are concerned about this problem in your community, there is now
something simple and effective you can do.
Whereas early research suggested that peer pressure and parental
example were the key factors contributing to tobacco use by
adolescents, more recent studies indicate that three factors are of
greater importance: the sale of tobacco to minors,[3,4] school
policies on smoking,[5] and the advertising and promotion of
tobacco.[6] Policies are more easily changed than peer or parental
behavior. This article concerns the importance of policies regarding
smoking in schools and access to tobacco purchases.
School Policies
During the 1970s and 1980s, many schools made it convenient for
students to smoke by setting up smoking areas within schools. This was
done even in states where it was illegal to purchase or possess
tobacco products before the age of 18 or 19. School smoking areas
then, as now, provided students with a safe haven where they could
obtain and experiment with tobacco without fear of repercussions.
School smoking areas have been a public health policy disaster. A
British study showed early in the 1980s that smoking rates were much
higher among students graduating from schools that permitted student
smoking.[5]
Smoke-free school policies have been endorsed by the National
School Boards Association.[7] A model school smoking policy[8] is
shown in Table 1.
Table 1. Model School Policy on Tobacco
1. Students shall not be allowed to possess tobacco products on
school grounds. Tobacco brought onto school grounds
shall be confiscated.
2. Use of tobacco products by students, staff, and visitors
shall be
prohibited in school buildings, on school property, and
at school
functions.
3. If students possess tobacco products, their parents shall
be
notified and invited to meet with school personnel concerning
the
matter.
4. Students possessing tobacco products shall be offered
treatment
for potential nicotine addiction.
5. Help with smoking cessation shall be offered to students in
school
on a regular basis.
6. Students possessing tobacco products shall face appropriate
disciplinary action.
7. All grades, K through 12, shall receive instruction
concerning
tobbacco on an annual basis.
Adapted from DiFranza,[8] with permission.
You can determine what the smoking policy is in your school system
by calling the superintendent's office. If students are allowed to
smoke, your first priority should be to get this policy changed. A
letter from you and concerned colleagues can be addressed to the
superintendent of schools and to the school board. If the policy is
not changed quickly, the next step is to request an opportunity to
address the school board on the issue. Through your practice you
should be able to identify concerned and articulate parents to
accompany you to the board meeting. If there is a parent-teachers
association (PTA) it may provide help as well. It is unlikely that
there would be significant opposition to a ban on student smoking.
Access to Tobacco
Laws in 46 states that prohibit the sale of tobacco to underage
purchasers have been widely ignored.[9] Across the country, the age at
which young people are legally permitted to buy cigarettes ranges from
16 to 19, yet 75% of tobacco retailers illegally sell tobacco to
children as young as 11 years of age.[10,11] The tobacco industry
asserts that the illegal sale of their products to minors has no
effect on teenagers' use of tobacco. Yet when Woodridge, Illinois,
became the first community in the United States to stop the illegal
sale of tobacco to minors, daily smoking among junior high school
students in Woodridge dropped by an astounding 69%.[3] In Leominster,
Massachusetts, initial enforcement efforts have so far managed to
convince about two thirds of retailers to obey the law.[4] Even with
this limited compliance, smoking at the junior high school level fell
by 40% over a 1-year period. These studies strongly suggest that the
careless sale of tobacco to children is a major factor in continuing
high rates of tobacco use in this population.
The purpose of the Woodridge and Leominster programs is quite
simple: find out who is selling tobacco to minors and make them stop.
Retailers who are selling to minors are identified by test buys
conducted by underage buyers employed by the enforcing agency.
Underage buyer inspections should be conducted 5 to 6 times each year.
A system of fines and license suspensions should be used to encourage
retailers to refrain from making future sales to minors (Table 2).
Table 2. Model Regulations Concerning the Sale and
Distribution of Tobacco
* It is illegal to sell, give, or furnish tobacco in any form to an
to an
individual under the age of 21.
* Before tobacco is sold to an individual, the retailer must obtain
positive proof that the customer is of legal age to purchase
tobacco.
* The distribution of free samples of tobacco is prohibited.
* The sale of candy products manufactured to resemble tobacco
products is prohibited.
* Tobacco may be sold only to licensed tobacco retailers.
* The sale of tobacco from a vending machine is prohibited.
* These regulations will be enforced through routine compliance
testing conducted by law enforcement officials employing
enderage
shoppers.
* A violation of these regulations will be considered a civil
offense
punishable by a fine or a license suspension or both.
Even if you live in a state that does not prohibit the sale of
tobacco to minors, your community should still be able to adopt a
local ordinance.
The effort to halt the illegal sale of tobacco to children is best
portrayed as exactly what it is: a children's health issue. The first
step is to generate community concern over the problem of children
using tobacco. At the same time you will want to start to identify
other people in your community who will support your efforts.
Family physicians have successfully used two techniques to raise
community awareness and concern. One is to demonstrate how common
tobacco use is among children in your community by conducting a survey
of junior and senior high school students. This can be arranged by
contacting a school nurse, a sympathetic teacher, or a member of the
school administration. The survey should be anonymous and can be quite
brief (Table 3).
Table 3. Sample School Survey
Age _____ Male Female
Have you ever smoked even a single cigarette?
Yes _____ No _____
Have you ever tried using chewing tobacco or snuff?
Yes _____ No _____
How old were you when you first used tobacco?
Never have used_____
Have you smoked or used chewing tobacco or snuff in the past
week?
Yes _____ No _____
Where do you buy most of your tobacco?
Vending machine
Convenience stores
Supermarkets
Drug Stores
Gas stations
Other _____ (write in)
If the school is small, you may want to survey all the students. If
it is large, a representative sample from each grade is sufficient.
The school can tell you how many students are enrolled in each grade.
Since the prevalence of tobacco use is inversely related to academic
performance, do not survey only the honors classes.
When you obtain your results remember that the only acceptable rate
of tobacco use among teenagers is zero. From the smoking rates
obtained for each grade, extrapolate to the entire school population
to determine the number of underage smokers in the community. By
assuming that each teenaged smoker smokes one half pack of cigarettes
each day, you can estimate the number of illegal sales of tobacco that
occur in the community each year.
These data should be shared with elected officials and members of
the health department, the police, and the school department. Ask
these persons for a commitment to help end the illegal sale of tobacco
to minors.
You will probably want to release the data to the local media. If
the community is served by a local paper, the publisher will
undoubtedly want to give this issue considerable coverage. You should
talk to the assignment editor of the paper to determine which reporter
covers health issues. That reporter will appreciate being informed
about future antismoking activities. It may also be helpful to meet
with the newspaper editorial board to explain your concerns and plans.
The second technique, which has been widely used to generate
concern, is to demonstrate how easy it is for children to buy tobacco.
This is done by enlisting the cooperation of a young child. Illegal
sales to children who are 11 or 12 years old generate much more
concern than sales to 16-year-old. Girls have more success at
purchasing tobacco than boys, so it may be most productive to enlist
the aid of an 11- or 12-year-old girl. An adult should take the child
to 10 or more stores. While the adult waits outside, the child
attempts to purchase tobacco. A record is made of each attempt and the
results. Be sure to include vending machines. If you do not want to
undertake the investigation yourself, you may suggest it to a local
reporter.
If it is illegal in your state for children to purchase or possess
tobacco, obtain permission from your local law enforcement officials
first or conduct "sham" buys. In a sham buy, the child asks
for tobacco but, when it is clear that the salesperson is willing to
make the sale, the child states that she does not have enough money to
pay for it. With a vending machine the child inserts the correct
change, and if she has not been stopped by then, simply pulls the coin
return lever and retrieves the money instead of making the purchase.
It is important not to create the impression that you are against,
or trying to embarrass, the local business community. Most retailers
do not want children to smoke and will cooperate with efforts to
enforce the law if they see it a positive health effort rather than an
attempt to get them into trouble. Thus, do not release the names of
offending stores to the news media.
Once you have identified teenagers' tobacco use as a problem, the
next step is to propose a solution. In most communities some effort is
usually made to obtain voluntary compliance with the law by educating
vendors (Table 4). This may be as simple as a letter from the police
chief or as elaborate as a multimedia campaign. Studies have shown
that such efforts will usually result in a moderate increase in
compliance that diminishes with time.[12] After efforts to obtain
voluntary compliance have been completed, it is time to conduct a test
of merchant compliance using underage buyers. The failure of voluntary
compliance efforts will make it clear to the community that active law
enforcement is necessary.
[TABULAR DATA OMITTED]
Model tobacco-access laws are available.[10,13-15] Some key
provisions are outlined in Table 2. The established standard is that
proof of age is required for all tobacco purchases.
Most state laws on access to tobacco make enforcement difficult
since they consider the sale of tobacco to a minor to be a criminal
rather than a civil offense. This requires that violations of the law
be prosecuted through the court system. This may be burdensome and
time consuming. It is preferable that sales to minors be considered a
civil offense, similar to a parking violation, which can then be
handled administratively outside of the courts through the issuance of
a citation. Violations may be punishable by fining the retailer, or by
suspending or revoking the retailer's tobacco permit or license.
A permit or license should be required for all tobacco retailers.
This provides enforcement authorities with both a list of tobacco
retailers and the funds to support the small cost of enforcement.
Officials may then use the threat of suspension of revocation of the
licenses of violators as a means of enforcement.
Tobacco vending machines should be banned because they provide easy
access to minors even when they are located in bars. If a total ban on
vending machines does not seem achievable, your efforts can be
directed toward the requirement that all vending machines have remote
control locking devices installed to prevent them from being used by
minors without authorization.
In many communities, the board of health has the authority to
establish regulations concerning tobacco sales. Alternatively, the
local governing body may authorize ordinances or bylaws. It should
take only a few telephone calls to determine which municipal body is
appropriate. In the long run, tobacco use should be a higher priority
problem for the health department than for the police department, so
if possible, it would be best to approach the board of health.
Conclusions
The adoption of appropriate school policies on tobacco use and the
enactment and enforcement of laws prohibiting the sale of tobacco to
minors have proven to be effective at reducing tobacco use by
adolescents. With all that is known today about the addictive and
dangerous properties of tobacco, there is no excuse for communities to
fail to enact and enforce these lifesaving policies.
References
[1.] Johnston LD, O'Malley PM, Bachman JG, Drug use among American
high school seniors, college students and young adults, 1975-1990. US
Department of Health and Human Services, 1991. DHHS publication no. (ADM)
91-1813. [2.] Connolly GN, Winn DM, Hecht SS, et al. The reemergence
of smokeless tobacco, N Engl J Med 1986; 314:1020-7. [3.] Jason LA, Ji
PY, Anes MD, Birkhead SH. Active enforcement of cigarette control laws
in the prevention of cigarette sales to minors. JAMA 1991;
266:3159-61. [4.] Difranza JR, Carlson R, Caisse R [Letter]. Tobacco
Control 1992; 1(1):58. [5.] Porter A. Disciplinary attitudes and
cigarettes smoking: a comparison of two schools. Br Med J 1982;
285:1725-6. [6.] DiFranza JR, Richards JW, Paulman P, et al. RJR
Nabisco's cartoon camel promotes Camel cigarettes to children. JAMA
1991; 266:3149-53. [7.] National School Boards Association Smoke-free
schools: a progress report. Alexandria, Va: National School Boards
Association, 1989. [8.] DiFranza JR. School tobacco policy: a medical
perspective. J Sch Health 1989; 59;398-400. [9.] Kim TF. Laws ban
minors' tobacco purchases, but enforcement is another matter. JAMA
1987; 257-3387-9. [10.] DiFranza JR, Norwood BD, Garner DW, Tye JB.
Legislative efforts to protect children fom tobacco. JAMA 1987; 257:
3387-9. [11.] Tye JB. Results of trials by minors purchasing
cigarettes. Tobacco and Youth Reporter 1989; 4(2):5 [12.] Altman DG,
Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of
cigarettes to minors. JAMA 1989; 261;80-3. [13.] More being done to
prevent cigarettes sales to minors. Tobacco and Youth Reporter 1989;
4(2):6. [14.] Model legislation on the enforcement of laws to restrict
children's access to tobacco. Chicago: American Medical Association
1987. AMA proceedings No. 193. [15.] Youth access to cigarettes. New
York: Office of Inspector General, May 1990. OEI-02-90-02310.
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