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Table 1. Comparison of Full and Reduced Data Sets of First Compliance Checks in Unique Stores*
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Table 2. Variables Associated With Sales to Minors
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Table 3. Percent Sales by Sex of Minor, Age of Minor, and Sex of Clerk
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1.
DiFranza JR, Librett JJ. State and federal revenues from tobacco consumed by minors.  Am J Public Health.1999;89:1106-1108.
2.
Forster JL, Klepp KI, Jeffery RW. Sources of cigarettes for tenth graders in two Minnesota cities.  Health Educ Res.1989;4:45-50.
3.
Johnston LD, O'Malley PM, Bachman JG. National Survey Results on Drug Use From the Monitoring The Future Study, 1975-1993, Volume I: Secondary School Students. Rockville, Md: US Dept of Health and Human Services; 1994.
4.
Johnston LD, O'Malley PM, Bachman JG. Cigarette smoking among American teens continues gradual decline. Ann Arbor: University of Michigan News and Information Services; December 1999. Available at: http://www.monitoringthefuture.org. Accessed March 16, 2000.
5.
US Department of Health and Human Services.  Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga: US Dept of Health and Human Services, Office on Smoking and Health; 1994.
6.
Forster JL, Wolfson M. Youth access to tobacco: policies and politics.  Annu Rev Public Health.1998;19:203-235.
7.
O'Grady B, Asbridge M, Abernathy T. Analysis of factors related to illegal tobacco sales to young people in Ontario.  Tob Control.1999;8:301-305.
8.
DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access laws.  Tob Control.1999;8:152-155.
9.
Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco-sales laws on adolescents' access to tobacco and smoking behavior.  N Engl J Med.1997;337:1044-1051.
10.
Forster JL, Hourigan M, McGovern P. Availability of cigarettes to underage youth in three communities.  Prev Med.1992;21:320-328.
11.
DiFranza JR, Norwood BD, Garner DW, Tye JB. Legislative efforts to protect children from tobacco.  JAMA.1987;257:3387-3389.
12.
Radecki TE, Zdunich DD. Tobacco sales to minors in 97 US and Canadian communities.  Tob Control.1993;2:300-305.
13.
Keay KD, Woodruff SI, Wildey MB, Kenney EM. Effect of a retailer intervention on cigarette sales to minors in San Diego County, California.  Tob Control.1993;2:145-151.
14.
Landrine H, Klonoff EA, Fritz JM. Preventing cigarette sales to minors: the need for contextual, sociocultural analyses.  Prev Med.1994;23:322-327.
15.
Jason LA, Billows WD, Schnopp-Wyatt DL, King C. Long-term findings from Woodridge in reducing illegal cigarette sales to older minors.  Eval Health Prof.1996;19:3-13.
16.
Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors.  JAMA.1989;261:80-83.
17.
Cismoski J, Sheridan M. Availability of cigarettes to under-age youth in Fond du Lac, Wisconsin.  Wis Med J.1993;92:626-630.
18.
Langemann HA. Tobacco sales to minors in 97 U.S. and Canadian communities.  Environ Health Rev.1996;40:6-10.
19.
Sanson-Fisher RW, Schofield MJ, See M. Availability of cigarettes to minors.  Aust J Public Health.1992;16:354-359.
20.
 Estimates of retailers willing to sell tobacco to minors—California, August-September 1995 and June-July 1996.  MMWR Morb Mortal Wkly Rep.1996;45:1095-1100.
21.
Hoppock KC, Houston TP. Availability of tobacco products to minors.  J Fam Pract.1990;30:174-176.
22.
 Cigarette sales to minors—Colorado, 1989.  MMWR Morb Mortal Wkly Rep.1990;39:794, 801.
23.
DiFranza JR, Coleman M, St Cyr D. A comparison of the advertising and accessibility of cigars, cigarettes, chewing tobacco, and loose tobacco.  Prev Med.1999;29:321-326.
24.
Food and Drug Administration.  Regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents: Final Rule.  Federal Register.1996;61:44369-45318.
25.
DiFranza JR, Savageau JA, Aisquith BF. Youth access to tobacco: the effects of age, gender, vending machine locks, and "It's the law" programs.  Am J Public Health.1996;86:221-224.
26.
Gratias EJ, Krowchuk DP, Lawless MR, Durant RH. Middle school students' sources of acquiring cigarettes and requests for proof of age.  J Adolesc Health.1999;25:276-283.
27.
National Association of Convenience Stores.  Preventing Tobacco Sales to Minors [CD-ROM Series]. Alexandria, Va: National Association of Convenience Stores; 1997 [revised 1999].
28.
Myllyluoma J, Mowery PD. Community Context Study of Minor's Access To Tobacco: Final Report. Baltimore, Md: Battelle Centers for Public Health Research and Evaluation; 1996.
29.
Arday DR, Klevens RM, Nelson DE, Juang P, Giovino GA, Mowery P. Predictors of tobacco sales to minors.  Prev Med.1997;26:8-13.
30.
Boyle RG, Stedman J, Forster J. Availability of smokeless tobacco to underage youth in two Minnesota communities.  Health Values.1995;19:10-16.
31.
 Minors' access to smokeless tobacco—Florida, 1994.  MMWR Morb Mortal Wkly Rep.1995;44:839-841.
32.
 Accessibility to minors of smokeless tobacco products—Broward County, Florida, March-June 1996.  MMWR Morb Mortal Wkly Rep.1996;45:1079-1082.
33.
O'Grady W, Asbridge M, Abernathy T. Illegal tobacco sales to youth: a view from rational choice theory.  Can J Criminol.January 2000;42:1-20.
34.
 Food and Drug Administration v Brown & Williamson Tobacco Corp . US 98-1152 (March 21, 2000).
Original Contribution
August 9, 2000

Factors Associated With Tobacco Sales to MinorsLessons Learned From the FDA Compliance Checks

Author Affiliations

Author Affiliations: Centers for Public Health Research and Evaluation, Battelle Memorial Institute, Baltimore, Md (Drs Clark and Iachan, Ms Schmitt, and Mr Wolters); and Office of Tobacco Programs, US Food and Drug Administration, Rockville, Md (Ms Natanblut).

JAMA. 2000;284(6):729-734. doi:10.1001/jama.284.6.729
Context

Context Tobacco products continue to be widely accessible to minors. Between 1997 and 1999, the US Food and Drug Administration (FDA) conducted more than 150,000 tobacco sales age-restriction compliance checks. Data obtained from these checks provide important guidance for curbing illegal sales.

Objective To determine which elements of the compliance checks were most highly associated with illegal sales and thereby inform best practices for conducting efficient compliance check programs.

Design and Setting Cross-sectional analysis of FDA compliance checks in 110,062 unique establishments in 36 US states and the District of Columbia.

Main Outcome Measure Illegal sales of tobacco to minors at compliance checks; association of illegal sales with variables such as age and sex of the minor.

Results The rate of illegal sales for all first compliance checks in unique stores was 26.6%. Clerk failure to request proof of age was strongly associated with illegal sales (uncorrected sales rate, 10.5% compared with 89.5% sales when proof was not requested; multivariate-adjusted odds ratio [OR], 0.03; 95% confidence interval [CI], 0.03-0.04). Other factors associated with increased illegal sales were employment of older minors to make the purchase attempt (adjusted ORs for 16- and 17-year-old minors compared with 15-year-olds were 1.52 [95% CI, 1.46-1.63] and 2.43 [95% CI, 2.31-2.59], respectively), attempt to purchase smokeless tobacco (adjusted OR, 2.16 [95% CI, 1.90-2.45] vs cigarette purchase attempts), and performing checks at or after 5 PM (adjusted OR, 1.28 [95% CI, 1.21-1.35] vs before 5 PM). Female sex of clerk and minor, Saturday checks, type of store (convenience store selling gas, gas station, drugstore, supermarket and general merchandise), and rural store locations also were associated with increased illegal sales.

Conclusions This analysis found that a request for age verification strongly predicted compliance with the law. The results suggest several ways in which the process of compliance checks might be optimized.

After more than a decade of efforts to reduce youth access to tobacco, tobacco products remain widely available to adolescents through retail sources. In 1999, it was estimated that 3.76 million daily smokers aged 12 to 17 years consume an estimated 924 million packs of cigarettes per year, generating a retail value of $1.86 billion.1 Surveys consistently show that minors believe they can easily obtain cigarettes,24 and that adolescents can readily purchase tobacco in retail outlets.5 Curtailing easy youth access to tobacco is a crucial component in the primary prevention of tobacco use, and restricting retail sales is an important element of reducing youth access. Given that tobacco control resources are limited, it is important to understand the predictors of sales to minors and thus design efficient compliance check programs to identify retailers who sell tobacco to minors. This analysis of 110,062 compliance checks performed by the US Food and Drug Administration (FDA) was undertaken to determine what elements of the compliance check process are most likely to result in illegal sales and therefore might be used in formulating best practices for efficient checks.

Previous articles focused on youth access issues have identified factors associated with illegal sales, including sex of the minor and the clerk, age of the minor, ethnicity of the minor, and type of store visited. These studies have reported conflicting findings about the direction and magnitude of sales predictors, making it difficult to use the previously published literature to determine the best practices for conducting checks.6

Older minors buy more often than younger minors.715 The sex of the minor has a mixed influence on illegal tobacco sales rates, with some investigators finding girls could buy more often than boys,14,1618 others finding that boys buy more often than girls,19 and some investigators have found no sex difference.12,16,17 Studies that have reported the likelihood of sales by retail outlet type are also mixed. At least 2 studies have shown lowest sales rates in pharmacies,20,21 1 found mid-level sales rates in pharmacies,10 and 1 found high sales in pharmacies.22 Inconsistencies among previous studies may be the result of small samples, few minors employed in the checks, and wide ranges in the minors' ages. Employing few minors may be particularly problematic given that the apparent age and maturity of a particular youth and that youth's experience with conducting compliance checks can affect his or her ability to purchase tobacco. These factors could partially account for the varying sales outcomes when minors of the same age and sex try to buy tobacco. For instance, DiFranza et al 23 reported widely varying buy rates for three 16-year-old boys they employed to attempt to buy smokeless tobacco. Purchase rates for each of the 3 ranged from 26.5% to 88.4%. This would suggest that a large sample of compliance checks performed by a large number of minors is required to offset the differences between minors that might affect their ability to successfully purchase tobacco. The large FDA data set, composed of data from compliance checks performed by more than 3000 minors, provides such information.

In 1996, the FDA asserted jurisdiction over cigarettes and smokeless tobacco products and issued a rule regulating youth access to these products.24 The youth access provisions made it illegal for retailers to sell cigarettes or smokeless tobacco to anyone under the age of 18 years and required that retailers verify the age of anyone under the age of 27 years by checking photographic identification (ID). To enforce the rule, the FDA contracted with the states and territories to perform unannounced compliance checks in which undercover minors visit retail cigarette outlets and attempt to purchase tobacco products.

By December 1999, when this analysis was begun, more than 150,000 compliance checks had been completed in 43 states and territories, providing the largest number ever performed under a relatively uniform protocol.

METHODS

The FDA trained and commissioned state officials to conduct compliance checks on its behalf under protocols prescribing such things as ages of the minors attempting the purchase, the procedures for conducting the purchase, and the handling of evidence. In brief, trained and commissioned adult investigators accompanied minors to the stores. The FDA required the adult agents be in the store when the minors made purchase attempts unless the agent believed that his or her presence in the store would signal a compliance check (usually in very small stores). The minors attempted to buy the cigarette brands or smokeless tobacco products frequently used by young people in their area and had the option of purchasing other items, such as gum or chips, at the same time. They were encouraged to carry valid photographic ID, if owned, and were required to produce it at the request of a clerk. In addition, they were not allowed to lie about their ages or for whom the tobacco purchase was made.

Characteristics of the Minors

During the first year of the program, only 15- or 16-year-old minors were employed. Subsequently, 17-year-olds were included, with the FDA requiring a substantially equal mix of the 3 age groups. Minors were instructed to maintain their normal, everyday appearance. If they typically wore make-up or facial hair, they were permitted to do so during compliance checks, but were not permitted to alter their appearance to appear older. States were instructed to select minors who reflected the ethnic and racial characteristics of the communities in which they conducted the checks. For reasons of safety, minors did not conduct checks in their own communities. Minors were typically paid by the states for their participation.

Selection of Stores to Check

The FDA generally required that states conduct a minimum of 375 checks per month. States that license tobacco retailers used their licensure lists as a basis for identifying outlets to check. If a state could not generate a list of tobacco retailers, the FDA provided a retailer list from a commercial source. There was no attempt by the FDA to systematically sample stores in the states; rather, the intention was to do a complete census of all tobacco retail outlets. The store checks analyzed here represent checks of approximately 10% of the retail tobacco outlets in the United States.

Statistical Analyses

This analysis used the first compliance check done in each unique store (n = 110,062). The outcome variable was the outcome of the purchase attempt (sale or no sale) at that first check. The relationships among potential explanatory variables and between independent and dependent variables were explored through frequency tables, appropriately stratified.

Logistic regression analysis was used to investigate the contribution of the independent variables to the probability of illegal sales to minors. Variables included in the model were those significantly associated with sales in an exploratory analysis (including 2- and 3-level interaction terms) and those reported as associated with sales in the published literature. Dummy variables were constructed when appropriate. Odds ratios (ORs) were constructed to reflect the ratio of the odds of a sale while controlling for the simultaneous effects of the independent variables. Ninety-five percent confidence intervals for ORs were calculated using SEs estimated by the Wald statistic.

To account for potential clustering of stores within communities, SUDAAN (Research Triangle Institute, Research Triangle Park, NC) software was used to account for any effect of clustering within states or within ZIP codes. Measures of precision for the model parameters were approximately the same as those generated by a simple log-linear model, suggesting that the degree of homogeneity between stores within clusters was small and did not affect overall results.

Sources of Data Used in the Analyses

The Compliance Check Record. Agents supervising compliance checks were required to complete a written report immediately following each buy attempt. This written report documented the outcome of the check, the type of establishment visited (convenience store, convenience plus gas station, gas station, drugstore, general merchandise, supermarket, tobacco store, or other), the date and time of the check, the sex of the store clerk, the type of tobacco the minor attempted to buy (cigarettes or smokeless tobacco), the minor's ID code, whether the minor was asked for proof of age, and whether the minor carried a valid ID card.

The FDA's contract with the states did not require that they report age and sex of the minors, and not all states had the resources to abstract the sex and age of the minors from their records, particularly from their earliest checks for the purpose of this analysis. The sex and age of the minors was available for 81,181 checks (74% of first compliance checks). Table 1 shows a comparison of all first-time checks and checks for which minor data were available.

Urbanicity of the Community in Which the Check Occurred. The actual store address, including the postal ZIP code, was available for most stores. Postal ZIP codes often cross over urban, suburban, and/or rural areas. An urbanicity variable was constructed to represent the largest proportion of households within each ZIP code, using 1990 US Census Bureau data. Because uncorrected sales rates were lowest in predominantly urban ZIP codes, dummy variables were constructed for suburban and rural areas, with urban areas as the reference category.

Approximately 8000 ZIP codes were missing because a business address was different than the address of the store location. After using commercial business lists to locate as many missing store location ZIP codes as possible, 3733 (3.4%) remained missing.

RESULTS

The FDA completed 151,301 compliance checks in 110,062 unique tobacco retail outlets between 1997 and 1999. The postal ZIP codes and minor characteristics were available for 78,812 (72%) of the compliance checks in 36 states and the District of Columbia. The rate of sales for all first compliance checks in unique stores was 26.6%. The rate was 27.7% for checks in which there were complete data. Characteristics of the checks are shown in Table 1 and results of the logistic regression modeling are shown in Table 2.

Characteristics of the Minors and Clerks

Older age of the minor was associated with illegal tobacco sales, with the odds of buying increasing with each year of age. Girls were more likely to be able to successfully buy than were boys, and female clerks were more likely to sell than were male clerks. The percent sales, corrected only for minor sex and age and clerk sex, are shown in Table 3. Two- and 3-way interaction terms for sex of the minor, age of the minor, and sex of the clerk were not significant in the exploratory analysis and are not included in the model.

Requesting Photographic ID

Clerks' requests for proof of age were highly associated with denial of sales to the minors. However, some sales (10.5%) occurred even though the clerk requested proof of age. The minors had been trained to produce valid photographic ID for inspection if requested, although it is not known how many actually did show an ID. The model was reproduced with the reduced data set of only checks done by minors who carried their own valid ID cards (n = 39,726). Results were similar, with 9.8% of sales completed when an ID card was requested.

Buying Smokeless Tobacco

Minors attempted to buy either cigarettes or smokeless tobacco. Only 2.3% of all buy attempts were for smokeless tobacco products. The corrected buy rate was significantly higher when the attempt was for smokeless tobacco compared with cigarettes.

Day of the Week and Time of Day

Only 17% of the checks occurred after 5 PM (16% by boys and 18% by girls). The rate of sales was flat until that hour, and then rose so that completed sales were significantly higher after 5 PM compared with before 5 PM. Sales were significantly higher on Saturdays than on any other day of the week.

Type of Store

The type of store was categorized by the agent, using his or her best judgment. Consistent with past studies, there was variation in the sales rate by the type of retail store visited. Convenience stores not selling gasoline had the lowest rate of sales in the exploratory analysis, so that category was set as the reference value. Sales rates were highest in gas stations. Only the category "other" did not have a significantly higher sales rate than did convenience stores.

Urbanicity of the Store Community

More than half of buy attempts were in urban areas. In the logistic model, both suburban and rural areas were significantly associated with increased sales compared with urban areas.

COMMENT

This was an analysis of the largest available set of compliance checks conducted under a relatively uniform protocol. The analysis suggested several ways in which the process of compliance checks might be optimized. As with most previous studies, older minors were more likely to be able to buy tobacco products than were younger minors.715 To determine which retailers are more diligently complying with age restriction laws, it is vital that older teens be included in the mix of teens doing compliance checks.

Some of the most conflicting results in previously published reports have been the effects of the sex of the minor.10,1619 As previously discussed, these disparate results may be due in part to the relatively few minors used in those studies, such that differences in perceived maturity by sex may have contributed to the variation in results. Approximately 3172 minors contributed to the compliance checks for the FDA, providing stable estimates of sales by age and sex.

In keeping with past research, this study found that a request for age verification strongly predicted compliance with the law.15,23,25,26 It is not clear how often asking for an ID card is a serious request for proof of age eligibility and how often it is the verbal mechanism that merchants use to terminate the transaction when they have already decided that the buyer is too young.

Interestingly, in 10% of the compliance checks in which clerks asked for proof of age, they still sold to minors. Sales rates under these conditions have ranged from 6% to 33% in previous studies.1523 These findings may suggest an incomplete understanding of the "carding" or age-verification process. The process necessitates 3 actions by the clerk: requesting the ID card, inspecting the card, and calculating or verifying the age of the buyer. If retailers merely request an ID card, without the requisite inspection and calculation or verification of age, then age verification may not actually occur. Clerks may sell tobacco even after requesting proof of age because they cannot calculate age eligibility from a birth date. Training programs for clerks typically teach them that they must request an ID card and know how to spot a fake one, but they may not teach the clerk how to make a correct decision about age eligibility once a card is presented.27,28

Previous studies have shown slightly lower or similar success rates for smokeless tobacco purchases compared with cigarettes.21,23,2932 In this analysis, attempts to buy smokeless tobacco products were almost twice as successful as attempts to buy cigarettes. This phenomenon deserves more study to determine why it occurs, and smokeless tobacco should more frequently be included in compliance check programs.

The time of day when purchase attempts occur has been suggested as a potential confounding variable.6 O'Grady et al33 also found higher sales among checks performed later in the day, with 6% sales among checks performed in the morning, 18% in the afternoon, and 21% among checks performed after 6 PM. It is not known why late afternoon sales rates were significantly higher in this and the previous study, but it is possible that clerks who are on duty after 5 PM are younger than daytime clerks and more inclined to sell tobacco products to their contemporaries. Evening clerks may have less training, or they may be supervised and monitored less closely than their daytime counterparts. Sales were higher on Saturday than other days of the week, perhaps for the same reasons. Two conclusions are clear: it is important to conduct some compliance checks during later hours and on Saturdays, and owners and managers should improve the training and supervision of evening and weekend clerks.

The sales rates in this sample were highest for gas stations and convenience stores that also sold gas. The different sales rate by outlet type, however, was not so great that any particular store class should be excluded from compliance check programs.

Sales rates were higher in rural and suburban areas compared with urban areas, but more than half of the checks were performed in urban areas. These results suggest that a better mix of stores will be an important component of future compliance check programs, even though the relative proximity of stores in urban areas makes urban checks more efficient to perform.

As with other analyses of administrative data sets, some additional cautions are warranted. It is not known whether the loss of almost 30% of the compliance checks because of missing data (primarily missing sex or age of the minor and missing ZIP codes) may have introduced some bias. The stores were not randomly sampled, and no national estimates of sales rates can be inferred. It is not known if the sampling of stores for inclusion produced any biases in the results. Also, when data are not acquired under a research protocol, misclassification errors may be more likely. The most likely source of error in this data set was in classification of the store type, which was left to the judgment of the agent. In addition, the use of postal ZIP codes for definition of urbanicity does not provide the precision that would exist if the store neighborhoods were identified at the census block level. Whether or not the adult accompanied the minor into the store was not consistently reported; another important predictor of sales, the ethnicity of the minor, was not identified. There is need for further research that explores the interaction between clerk, minor, and neighborhood characteristics and the effect of witnesses to the transaction on illegal tobacco sales.

CONCLUSION

This analysis explored a wide range of variables related to the illegal sale of cigarettes or smokeless tobacco from a very large number of compliance checks conducted across the country. These results provide important guidance for public health officials responsible for curbing illegal sales to minors.

Retailers interested in stopping illegal sales in their own stores can also learn from this analysis. First, all retailers need to understand that no type of store is risk free. This study should serve as a wake-up call to pharmacy employees, for example, who may not realize how easy it is for minors to buy tobacco from them. Also, retailers must recognize the need to train their clerks that a tobacco sale to a 17-year-old minor is just as illegal as a sale to a 15-year-old minor. By the same token, a sale in which a clerk asks for a photographic ID but sells anyway is as illegal as one in which the clerk does not ask for an ID card. The results suggest that additional training and monitoring of clerks who work in the evening and the weekends may be needed. All clerks must be trained that selling smokeless tobacco products to minors is illegal.

Between 1997 and 1999, the FDA completed more than 150,000 compliance checks in about 110,000 retail establishments throughout the United States. While that is the largest number of checks ever conducted by a single entity, it represents only about 10% of the approximately 1 million retailers selling tobacco in this country. On March 21, 2000, the Supreme Court ruled that the FDA lacked the authority to regulate tobacco as customarily marketed.34 As a result of that decision, the FDA will no longer be conducting compliance checks. Further, it is unlikely that sufficient funding will be available from other sources to conduct compliance checks in every store even once a year. As a result, efficient compliance check programs are needed to conserve limited resources, while reducing illegal sales of tobacco to minors.

References
1.
DiFranza JR, Librett JJ. State and federal revenues from tobacco consumed by minors.  Am J Public Health.1999;89:1106-1108.
2.
Forster JL, Klepp KI, Jeffery RW. Sources of cigarettes for tenth graders in two Minnesota cities.  Health Educ Res.1989;4:45-50.
3.
Johnston LD, O'Malley PM, Bachman JG. National Survey Results on Drug Use From the Monitoring The Future Study, 1975-1993, Volume I: Secondary School Students. Rockville, Md: US Dept of Health and Human Services; 1994.
4.
Johnston LD, O'Malley PM, Bachman JG. Cigarette smoking among American teens continues gradual decline. Ann Arbor: University of Michigan News and Information Services; December 1999. Available at: http://www.monitoringthefuture.org. Accessed March 16, 2000.
5.
US Department of Health and Human Services.  Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga: US Dept of Health and Human Services, Office on Smoking and Health; 1994.
6.
Forster JL, Wolfson M. Youth access to tobacco: policies and politics.  Annu Rev Public Health.1998;19:203-235.
7.
O'Grady B, Asbridge M, Abernathy T. Analysis of factors related to illegal tobacco sales to young people in Ontario.  Tob Control.1999;8:301-305.
8.
DiFranza JR, Rigotti NA. Impediments to the enforcement of youth access laws.  Tob Control.1999;8:152-155.
9.
Rigotti NA, DiFranza JR, Chang Y, Tisdale T, Kemp B, Singer DE. The effect of enforcing tobacco-sales laws on adolescents' access to tobacco and smoking behavior.  N Engl J Med.1997;337:1044-1051.
10.
Forster JL, Hourigan M, McGovern P. Availability of cigarettes to underage youth in three communities.  Prev Med.1992;21:320-328.
11.
DiFranza JR, Norwood BD, Garner DW, Tye JB. Legislative efforts to protect children from tobacco.  JAMA.1987;257:3387-3389.
12.
Radecki TE, Zdunich DD. Tobacco sales to minors in 97 US and Canadian communities.  Tob Control.1993;2:300-305.
13.
Keay KD, Woodruff SI, Wildey MB, Kenney EM. Effect of a retailer intervention on cigarette sales to minors in San Diego County, California.  Tob Control.1993;2:145-151.
14.
Landrine H, Klonoff EA, Fritz JM. Preventing cigarette sales to minors: the need for contextual, sociocultural analyses.  Prev Med.1994;23:322-327.
15.
Jason LA, Billows WD, Schnopp-Wyatt DL, King C. Long-term findings from Woodridge in reducing illegal cigarette sales to older minors.  Eval Health Prof.1996;19:3-13.
16.
Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing the illegal sale of cigarettes to minors.  JAMA.1989;261:80-83.
17.
Cismoski J, Sheridan M. Availability of cigarettes to under-age youth in Fond du Lac, Wisconsin.  Wis Med J.1993;92:626-630.
18.
Langemann HA. Tobacco sales to minors in 97 U.S. and Canadian communities.  Environ Health Rev.1996;40:6-10.
19.
Sanson-Fisher RW, Schofield MJ, See M. Availability of cigarettes to minors.  Aust J Public Health.1992;16:354-359.
20.
 Estimates of retailers willing to sell tobacco to minors—California, August-September 1995 and June-July 1996.  MMWR Morb Mortal Wkly Rep.1996;45:1095-1100.
21.
Hoppock KC, Houston TP. Availability of tobacco products to minors.  J Fam Pract.1990;30:174-176.
22.
 Cigarette sales to minors—Colorado, 1989.  MMWR Morb Mortal Wkly Rep.1990;39:794, 801.
23.
DiFranza JR, Coleman M, St Cyr D. A comparison of the advertising and accessibility of cigars, cigarettes, chewing tobacco, and loose tobacco.  Prev Med.1999;29:321-326.
24.
Food and Drug Administration.  Regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and adolescents: Final Rule.  Federal Register.1996;61:44369-45318.
25.
DiFranza JR, Savageau JA, Aisquith BF. Youth access to tobacco: the effects of age, gender, vending machine locks, and "It's the law" programs.  Am J Public Health.1996;86:221-224.
26.
Gratias EJ, Krowchuk DP, Lawless MR, Durant RH. Middle school students' sources of acquiring cigarettes and requests for proof of age.  J Adolesc Health.1999;25:276-283.
27.
National Association of Convenience Stores.  Preventing Tobacco Sales to Minors [CD-ROM Series]. Alexandria, Va: National Association of Convenience Stores; 1997 [revised 1999].
28.
Myllyluoma J, Mowery PD. Community Context Study of Minor's Access To Tobacco: Final Report. Baltimore, Md: Battelle Centers for Public Health Research and Evaluation; 1996.
29.
Arday DR, Klevens RM, Nelson DE, Juang P, Giovino GA, Mowery P. Predictors of tobacco sales to minors.  Prev Med.1997;26:8-13.
30.
Boyle RG, Stedman J, Forster J. Availability of smokeless tobacco to underage youth in two Minnesota communities.  Health Values.1995;19:10-16.
31.
 Minors' access to smokeless tobacco—Florida, 1994.  MMWR Morb Mortal Wkly Rep.1995;44:839-841.
32.
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