The impact of local U.S. tobacco policies on youth tobacco use: A critical review

Rural-Urban Cancer Incidence and Trends in the United States, 2000 to 2019

BACKGROUND

Despite consistent improvements in cancer prevention and care, rural and urban disparities in cancer incidence persist in the United States. Our objective was to further examine rural-urban differences in cancer incidence and trends.

METHODS

We used the North American Association of Central Cancer Registries dataset to investigate rural-urban differences in 5-year age-adjusted cancer incidence (2015-2019) and trends (2000-2019), also examining differences by region, sex, race/ethnicity, and tumor site. Age-adjusted rates were calculated using SEER∗Stat 8.4.1, and trend analysis was done using Joinpoint, reporting annual percent changes (APC).

RESULTS

We observed higher all cancer combined 5-year incidence rates in rural areas (457.6 per 100,000) compared with urban areas (447.9), with the largest rural-urban difference in the South (464.4 vs. 449.3). Rural populations also exhibited higher rates of tobacco-associated, human papillomavirus-associated, and colorectal cancers, including early-onset cancers. Tobacco-associated cancer incidence trends widened between rural and urban from 2000 to 2019, with significant, but varying, decreases in urban areas throughout the study period, whereas significant rural decreases only occurred between 2016 and 2019 (APC = -0.96). Human papillomavirus-associated cancer rates increased in both populations until recently with urban rates plateauing whereas rural rates continued to increase (e.g., APC = 1.56, 2002-2019).

CONCLUSIONS

Rural populations had higher overall cancer incidence rates and higher rates of cancers with preventive opportunities compared with urban populations. Improvements in these rates were typically slower in rural populations.

IMPACT

Our findings underscore the complex nature of rural-urban disparities, emphasizing the need for targeted interventions and policies to reduce disparities and achieve equitable health outcomes.

Can I see some ID? Examining validity of the marijuana purchase task among late adolescent cannabis users

Cannabis demand (i.e., reinforcing value) can be assessed using a marijuana purchase task (MPT; assesses hypothetical purchasing of cannabis at escalating prices) and has been related to use frequency, problems, and cannabis use disorder symptoms in adults. Cannabis demand has yet to be studied in adolescents, which can inform prevention and intervention efforts to reduce cannabis-related risks. The present study sought to validate the MPT with a sample of late adolescent lifetime cannabis users. Participants aged 15-18 years old (n = 115, Mage = 16.9, SD = 0.9) residing in a state with legalized cannabis use completed online assessments at baseline and 6-month follow-up. Convergent and divergent validity was examined, while principal component analysis was conducted to determine the factor structure and assess predictive validity. Three indices, Omax (i.e., maximum expenditure on cannabis), breakpoint (i.e., price suppressing consumption to zero), and alpha (i.e., degree to which consumption decreases with increasing price) were all significantly associated with cannabis use, consequences, craving, and expenditures and significantly differentiated low-risk users and high-risk users as measured by the Cannabis Use Disorders Identification Test-Revised (CUDIT-R). A two-factor solution reflecting amplitude (intensity, alpha, Omax) and persistence (breakpoint, Pmax) was observed. Both factors were associated with cannabis use and consequences in baseline regression models. At follow-up, persistence was associated with consequences; amplitude was not associated with either outcome. These findings provide initial evidence that the MPT is a valid measure for assessing cannabis demand among adolescents and can be used to understand mechanisms of adolescent cannabis use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predictors of e-cigarette initiation and use among middle school youth in a low-income predominantly Hispanic community

Introduction

E-cigarette use among middle and high school youth increased from 2. 5 million in 2014 to 9.2 million in 2019, becoming the most common tobacco product used among youth. Hispanic youth, the largest ethnic minority in the United States, have higher rates of tobacco use, including e-cigarettes, than non-Hispanics. Identifying factors that put youth at risk for future e-cigarette use is vital to focusing prevention efforts. Informed by social cognitive theory, this study identifies predictors of e-cigarette uptake among e-cigarette naïve youth in a predominantly low-income Hispanic community.

Methods

1,249 students (6-8th grades) from two middle schools in El Paso, Texas consented to participate in this longitudinal survey during the 2016-2017 school year. The study sample for analysis was restricted to e-cigarette naïve students (n = 862). Outcome measures were e-cigarette initiation and current use at follow-up. Logistic regression models tested six hypotheses about predictors of e-cigarette initiation and current use: (1) intention, (2) outcome expectations, (3) knowledge, (4) friendship network exposure, (5) normative beliefs, and (6) social acceptability.

Results

Among e-cigarette naïve students at baseline, 8% (n = 71) reported initiation at follow-up; of these, 3% (n = 23) reported current use. Significant predictors of initiation were intention (AOR = 2.46; 95% CI 1.69-3.59; p < 0.001), outcome expectations (AOR = 1.73; 95% CI 1.14-2.61; p = 0.009), friendship network exposure (AOR = 1.53; 95% CI 1.11-2.11; p =0.01), normative beliefs (AOR = 2.12; 95% CI 1.47-3.08; p < 0.001), and social acceptability (AOR = 1.91; 95% CI 1.28-2.85; p = 0.002). Significant predictors of current use were intention (AOR = 1.98; 95% CI 1.07-3.69; p = 0.03) and friendship network exposure (AOR = 1.69; 95% CI 1.06-2.70; p = 0.03).

Conclusions

With the increasing popularity of e-cigarettes, age appropriate and culturally sensitive prevention strategies tailored at altering these predictive factors are essential in preventing future e-cigarette use.

Further Consideration of the Impact of Tobacco Control Policies on Young Adult Smoking in Light of the Liberalization of Cannabis Policies

INTRODUCTION

Changing patterns of cannabis consumption related to the liberalization of cannabis policies may have a countervailing effect on tobacco use. We analyzed whether cannabis policies have tempered the effects of tobacco control policies as well as the extent to which they were associated with young adult cigarette smoking.

AIMS AND METHODS

Combining data on tobacco and cannabis policies at the state, county, and city levels with the nationally-representative geocoded National Longitudinal Survey of Youth 1997 and Census data, we use multilevel regression and fixed effect analyses to examine the impact of cannabis policies on any past 30-day cigarette smoking, frequency of smoking, and past 30-day near-daily smoking among young adults while accounting for community and individual covariates.

RESULTS

Tobacco control policies, including significant effects of comprehensive smoking bans, total vending machine restrictions, single cigarette sale restrictions, and advertising restrictions, remain robust in reducing young adult smoking, net of cannabis policy liberalization, including the legal status of possession, penalties for sale, and medical cannabis. Cannabis policies do not directly affect young adult smoking patterns in an adverse way.

CONCLUSIONS

This paper provides evidence that the liberalization of cannabis laws has not adversely affected the efficacy of tobacco control efforts.

IMPLICATIONS

While the effects of tobacco control policies on smoking are well-established, little research has considered how the liberalization of cannabis policies may affect these relationships, which is important given the co-use of these substances. This paper provides evidence that the liberalization of cannabis laws has not adversely affected tobacco control efforts.

Trends in opioid misuse by cigarette smoking status among US adolescents: Results from National Survey on Drug Use and Health 2015-2018

Increasing rates of opioid-related emergency department visits and deaths among adolescents in the United States are a public health concern. Adolescent cigarette smoking may be a risk factor for opioid misuse; though, there is a paucity of research on adolescents' cigarette smoking and opioid misuse. This study investigates current trends and the association between cigarette smoking and opioid misuse among US adolescents. Using pooled youth samples (ages 12-17) from the National Survey on Drug Use and Health (NSDUH) 2015-2018 (N = 54,866), we calculated weighted estimates of past-year opioid misuse by cigarette smoking status across years. We further estimated a multivariable logistic regression model to examine the past-year opioid misuse by ever-cigarette-smoking, controlling for sociodemographics and other substance use. While there was a significant reduction in opioid misuse among the entire sample and among never-smokers over time (2.5% in 2015 to 1.9% in 2018), this trend was not significant among ever-smokers (14.2% in 2015 to 11.1% in 2018). Multivariable logistic regression showed ever-smokers (vs. never-smokers) had higher odds of past-year opioid misuse (aOR = 2.01; 95% CI = 1.66, 2.43). Findings suggest that comprehensive tobacco control policies and opioid misuse prevention programs are warranted to curb opioid misuse among adolescents.

[The Effect of Neighborhood Characteristics and Friends' Smoking Status on the Habitual Smoking Onset in Adolescents]

PURPOSE

The aim of this study was threefold, to longitudinally examine the risk of habitual smoking onset in adolescents, to delineate the effects of neighborhood characteristics and friends' smoking status on the habitual smoking onset, and to investigate whether the association between friends' smoking status and habitual smoking onset was moderated by neighborhood characteristics.

METHODS

This study conducted multilevel discrete-time survival analysis, using cohort data from the 3rd to 6th waves of the Korean Child and Youth Panel Survey, which excluded habitual smokers, matched with 2010 census data on respondents' residence.

RESULTS

Habitual smoking onset risk increased from the 8th to the 11th grade, and then slightly decreased from the 11th to the 12th grade. Friends' smoking status (B = 0.60, p < .001), smoking rate (B = 0.06, p = .038), and the number of tobacco outlets in the respondents' neighborhood (B = 0.51, p = .003) were positively associated with habitual smoking onset risk. Furthermore, the association between friends' smoking status and habitual smoking onset risk was moderated by the number of tobacco outlets in the neighborhood. Specifically, the association was stronger in neighborhoods with more tobacco outlets (B = 0.58, p = .048).

CONCLUSION

Friends' smoking status and living in neighborhoods that are more susceptible to smoking increase the risk of habitual smoking. The number of tobacco outlets in the neighborhood enhances the peer effect of adolescent's smoking behavior. Therefore, policies or interventions designed to reduce youth's tobacco use should focus on not only on reducing peer smoking, but also restricting smoking by adults and the number of neighborhood tobacco outlets.

Youth Access to Cigarettes Across Seven European Countries: A Mixed-Methods Study

Background

Despite widespread age-of-sale restrictions on tobacco, adolescents continue to obtain cigarettes and experiment with smoking. This mixed-methods study aimed to understand how European adolescents access cigarettes and how the policy context may influence this process, using a realist evaluation approach. This is the first study to assess access to cigarettes across various European contexts.

Methods

A survey of 4104 students was combined with qualitative data from focus groups among 319 adolescents aged 14–19 across seven European countries. Data were synthesized to explore mechanisms via which young people obtain cigarettes despite age-of-sale restrictions.

Results

While purchasing cigarettes from supermarkets was widely regarded as difficult, many participants purchased cigarettes from noncompliant retailers (often in smaller shops or cafes). Other contra-mechanisms included circumventing age checks, proxy purchases, and/or social sources. Dominant forms of access differed across the seven contexts, with direct purchases more common where perceived enforcement was low (eg, Belgium) and proxy purchases more important where perceived enforcement of age-of-sale laws was high (eg, Finland). The effectiveness of age-of-sale restrictions in reducing youth access appears to be influenced by a range of contextual factors including retailer compliance, the availability of vending machines, and the specific minimum age-of-sale.

Conclusions

Our findings illustrate the relevance of programme theory in understanding the contra-mechanisms that undermine the effectiveness of age-of-sale laws in discouraging youth smoking. Young people’s access to cigarettes could be further limited by addressing these contra-mechanisms, including an increase in the legal sales age (particularly in Belgium), banning vending machines, and strengthening enforcement.

Implications

Despite widespread implementation of age-of-sale laws, a substantial proportion of minors continue to access cigarettes. Young people use a number of contra-mechanisms to circumvent age-of-sale restrictions. These include accessing cigarettes via social sources, proxy sales or by circumventing age checks. Our findings show that in contexts where perceived enforcement of age-of-sale restrictions is high, young people are more reliant on irregular forms of access such as proxy sales. Young people’s access to cigarettes may be further reduced by policy interventions that address these contra-mechanisms—for example, banning vending machines, strengthening enforcement of age-of-sale laws, and increasing the minimum age-of-sale.

E-cigarette Tobacco Retail Licensing Laws: Variance Across US States as of January 1, 2020

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws.Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length).Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws.Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

Never-smoking adolescents' perceived accessibility of cigarettes following an increase in the tobacco age-of-sale from 16 to 18: A quasi-experimental study of two cities in the Netherlands and Belgium

BACKGROUND

The Netherlands increased the tobacco age-of-sale from 16 to 18 in 2014, paired with mass-media campaigns. We evaluated changes in perceived accessibility of cigarettes between 2013 and 2016 among adolescent never-smokers in the Netherlands compared with Belgium, where the age-of-sale remained 16 and no campaigns were conducted.

METHODS

Repeated cross-sectional surveys were conducted in 2013 and 2016 among 4112 13-17-year-olds at a total of 22 schools in Amersfoort (the Netherlands) and Namur (Belgium). Multilevel Poisson regression quantified changes over time in prevalence of easy perceived accessibility to cigarettes (i.e., thinking it would be fairly/very easy to get cigarettes). Interaction terms were used to test whether changes differed between the Netherlands and Belgium. Analyses were stratified by age (13-15 and 16-17 years), sex (male and female), family smoking (0 and ≥1 smoking family members), and friend smoking (no and at least some smoking friends).

RESULTS

Perceived accessibility to cigarettes decreased in the Netherlands (Prevalence Ratio (PR): 0.82; 95% CI: 0.72-0.93) and Belgium (PR: 0.78; 95% CI: 0.70-0.87), to a similar extent (PR interaction: 1.04; 95% CI: 0.90-1.21). Results by sex, age, and family/friend smoking were similar to those for the total population; there were no significant differences in the decrease in perceived access over time between the Netherlands and Belgium within each of these subgroups.

CONCLUSION

This study found approximately the same rate of decline between 2013 and 2016 in adolescent never-smokers' perceived access to cigarettes in the Netherlands as in Belgium. This implies that we did not find clear evidence for an effect of the 2014 increase in legal age of tobacco sales from 16 to 18 years in the Netherlands.

E-cigarette Retail Licensing Policy and E-cigarette Use Among Adolescents

PURPOSE

The present study evaluated whether Pennsylvania's 2016 law requiring a retail license for the sale of e-cigarettes was associated with adolescent e-cigarette use.

METHODS

Data were drawn from the 2015-2017 Youth Risk Behavior Surveillance System. We examined the prepolicy and postpolicy change in e-cigarette use for the state with the retail licensing requirement (Pennsylvania) compared with control states (New York and Virginia).

RESULTS

Results showed that e-cigarette licensing policy was significantly associated with e-cigarette use. E-cigarette use among Pennsylvania adolescents reduced by 5.2 percentage points in 2017 when compared with New York adolescents, and a corresponding 21.6% decrease from its baseline prevalence level in 2015. Similarly, there was a 7.4 percentage point decrease in e-cigarette use in Pennsylvania when compared with Virginia (30.7% relative decrease from the baseline prevalence).

CONCLUSIONS

An e-cigarette retail licensing requirement may be a useful policy tool in reducing e-cigarette use among adolescents.

Moving Upstream: The Effect of Tobacco Clean Air Restrictions on Educational Inequalities in Smoking Among Young Adults

Education affords a range of direct and indirect benefits that promote longer and healthier lives and stratify health lifestyles. We use tobacco clean air policies to examine whether policies that apply universally-interventions that bypass individuals' unequal access and ability to employ flexible resources to avoid health hazards-have an effect on educational inequalities in health behaviors. We test theoretically informed but competing hypotheses that these policies either amplify or attenuate the association between education and smoking behavior. Our results provide evidence that interventions that move upstream to apply universally regardless of individual educational attainment-here, tobacco clean air policies-are particularly effective among young adults with the lowest levels of parental or individual educational attainment. These findings provide important evidence that upstream approaches may disrupt persistent educational inequalities in health behaviors. In doing so, they provide opportunities to intervene on behaviors in early adulthood that contribute to disparities in morbidity and mortality later in the life course. These findings also help assuage concerns that tobacco clean air policies increase educational inequalities in smoking by stigmatizing those with the fewest resources.

Youth smoking and anti-smoking policies in North Dakota: a system dynamics simulation study

BACKGROUND

The current study utilizes system dynamics to model the determinants of youth smoking and simulate effects of anti-smoking policies in the context of North Dakota, a state with one of the lowest cigarette tax rates in the USA.

METHODS

An explanatory model was built to replicate historical trends in the youth smoking rate. Three different policies were simulated: 1) an increase in cigarette excise taxes; 2) increased funding for CDC-recommended comprehensive tobacco control programs; and 3) enforcement of increased retailer compliance with age restrictions on cigarette sales.

RESULTS

The explanatory model successfully replicated historical trends in adolescent smoking behavior in North Dakota from 1992 to 2014. The policy model showed that increasing taxes to $2.20 per pack starting in 2015 was the most effective of the three policies, producing a 32.6% reduction in youth smoking rate by 2032. Other policies reduced smoking by a much lesser degree (7.0 and 3.2% for comprehensive tobacco control program funding and retailer compliance, respectively). The effects of each policy were additive.

CONCLUSIONS

System dynamics modeling suggests that increasing cigarette excise taxes are particularly effective at reducing adolescent smoking rates. More generally, system dynamics offers an important complement to conventional analysis of observational data.

When Marijuana Is Used before Cigarettes or Alcohol: Demographic Predictors and Associations with Heavy Use, Cannabis Use Disorder, and Other Drug-related Outcomes

Recent loosening of state and federal policy restrictions on marijuana, along with changes in social norms regarding marijuana use and decreases in prevalence of other types of substance use, may lead to increases in youth initiating marijuana before other types of substances such as alcohol and tobacco. We investigated predictors and potential consequences of initiating marijuana before other drugs for youth aged 12-21-years in the USA. Nationally representative, cross-sectional survey data from the US National Survey on Drug Use and Health supplied self-reported age of first marijuana, cigarettes, alcohol, other tobacco, and other illegal drug use among 12-21-year-old samples from 2004 to 2014 (n = 275,559). We first examined the degree to which initiating marijuana use first was associated with sex, age, race/ethnicity, and survey year. Then, we examined whether using marijuana first predicted heavy marijuana use, cannabis use disorder (CUD), alcohol use disorder (AUD), nicotine dependence (ND), or lifetime use of other illegal drugs. Among all survey youth (substance users and non-users), the proportion using marijuana first increased from 4.8 to 8.8% from 2004 to 2014. Those using marijuana first (vs. alcohol or cigarettes first) were more likely to be male and older and Black, American Indian/Alaskan Native, multiracial, or Hispanic than White or Asian. Among substance users and adjusting for age of onset and the number of substances used, using marijuana first was associated higher odds of heavy current marijuana use and CUD. In recent years, youth have been increasingly likely to use marijuana as their first drug and sequence of initiation is associated with race/ethnicity, gender, and age. Using marijuana first might increase the chance of heavy use and CUD.

How can a ban on tobacco sales to minors be effective in changing smoking behaviour among youth? - A realist review

The aim of the study was to understand, from the perspective of youth, how and under which circumstances a ban on tobacco sales to minors can be effective in influencing youth smoking behaviour. We searched Medline, Embase, and PsychINFO in February 2016. A systematic search for studies about a ban on sales to minors and smoking behaviour was performed. Only studies that addressed potential mechanisms were included, resulting in thirty-three studies. We extracted evidence from 26 quantitative, 5 qualitative, and 2 mixed-methods studies, explaining how the ban may be effective in reducing smoking behaviour, and contextual factors that may influence these mechanisms. We identified two mechanisms and three contra-mechanisms. First, when direct access to commercial sources is limited, cigarette consumption may be reduced because minors have restricted access to commercial cigarettes. Minors' access to social sources and the various ways in which they continue to buy cigarettes by circumventing the ban, are two contra-mechanisms that undermine this effect. Second, when the ban is strongly enforced, an anti-smoking norm may be created and adolescents may smoke less as a result. One contra-mechanism may possibly undermine this effect: the 'forbidden fruit' effect. Whether these (contra-)mechanisms occur depends on contextual and individual factors such as level of enforcement, the minors' social network, and their dependence on smoking. The ban can be effective if well enforced. However, minors' access to social sources and their ways to circumvent the ban should be addressed to achieve its full potential.

Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England

INTRODUCTION

England introduced a tobacco display ban for shops with >280 m² floor area ('partial ban') in 2012, then a total ban in 2015. This study assessed whether these were linked to child awareness of and access to cigarettes.

METHODS

Data come from the Smoking, Drinking and Drug Use survey, an annual survey of children aged 11-15 years for 2010-2014 and 2016. Multivariate logistic regression models assessed changes in having seen cigarettes on display, usual sources and ease of access to cigarettes in shops RESULTS: During the partial display ban in 2012, 89.9% of children reported seeing cigarettes on display in the last year, which was reduced to 86.0% in 2016 after the total ban (adjusted OR 0.58, 95% CI 0.50 to 0.66). Reductions were similar in small shops (84.1% to 79.3%)%) and supermarkets (62.6% to 57.3%)%). Although the ban was associated with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops (57.0% in 2010 to 39.8% in 2016), we did not find evidence of changes in perceived difficulty or being refused sale among those who still did.

DISCUSSION

Tobacco point-of-sale display bans in England reduced the exposure of children to cigarettes in shops and coincided with a decrease in buying cigarettes in shops. However, children do not report increased difficulty in obtaining cigarettes from shops, highlighting the need for additional measures to tackle tobacco advertising, stronger enforcement of existing laws and measures such as licencing for tobacco retailers.

Compliance with point-of-sale tobacco control policies and student tobacco use in Mumbai, India

BACKGROUND

We measured how student tobacco use and psychological risk factors (intention to use and perceived ease of access to tobacco products) were associated with tobacco vendor compliance with India's Cigarettes and Other Tobacco Products Act provisions regulating the point-of-sale (POS) environment.

METHODS

We conducted a population-based cross-sectional survey of high school students (n=1373) and tobacco vendors (n=436) in school-adjacent communities (n=26) in Mumbai, India. We used in-class self-administered questionnaires of high school students, face-to-face interviews with tobacco vendors and compliance checks of tobacco POS environments. Logistic regression models with adjustments for clustering were used to measure associations between student tobacco use, psychological risk factors and tobacco POS compliance.

RESULTS

Compliance with POS laws was low overall and was associated with lower risk of student current tobacco use (OR 0.48, 95% CI 0.26 to 0.91) and current smokeless tobacco use (OR 0.40, 95% CI 0.21 to 0.77), when controlling for student-level and community-level tobacco use risk factors. Compliance was not associated with student intention to use tobacco (OR 0.50; 95% CI 0.21 to 1.18) and perceived ease of access to tobacco (OR 0.73; 95% CI 0.53 to 1.00).

CONCLUSIONS

Improving vendor compliance with tobacco POS laws may reduce student tobacco use. Future studies should test strategies to improve compliance with tobacco POS laws, particularly in low-income and middle-income country settings like urban India.

A Multilevel Test of Constrained Choices Theory: The Case of Tobacco Clean Air Restrictions

According to Bird and Rieker's sociology of constrained choices, decisions and priorities concerning health are shaped by the contexts-including policy, community, and work/family-in which they are formulated. While each level received attention in the original and subsequent research, we contend their constrained choices theory provides a powerful multilevel framework for modeling health outcomes. We apply this framework to tobacco clean air restrictions, combining a comprehensive database of tobacco policies with the National Longitudinal Survey of Youth 1997 from ages 19 to 31. Using multilevel panel models, we find that clean air policies lower the odds of past 30 day smoking and dependence while controlling for other policy-, city-, and individual-level constraints. We also find unique between- and within-person effects, as well as gender effects, for the constraint levied by smoking bans. We argue for the theory's broad applicability beyond commonly cited findings regarding gender and biological influences.

Tobacco outlet density, retailer cigarette sales without ID checks and enforcement of underage tobacco laws: associations with youths' cigarette smoking and beliefs

AIMS

To estimate the relationships of tobacco outlet density, cigarette sales without ID checks and local enforcement of underage tobacco laws with youth's life-time cigarette smoking, perceived availability of tobacco and perceived enforcement of underage tobacco laws and changes over time.

DESIGN

The study involved: (a) three annual telephone surveys, (b) two annual purchase surveys in 2000 tobacco outlets and (c) interviews with key informants from local law enforcement agencies. Analyses were multi-level models (city, individual, time).

SETTING

A sample of 50 mid-sized non-contiguous cities in California, USA.

PARTICIPANTS

A total of 1478 youths (aged 13-16 at wave 1, 52.2% male); 1061 participated in all waves.

MEASUREMENTS

Measures at the individual level included life-time cigarette smoking, perceived availability and perceived enforcement. City-level measures included tobacco outlet density, cigarette sales without ID checks and compliance checks.

FINDINGS

Outlet density was associated positively with life-time smoking [OR = 1.12, P < 0.01]. An interaction between outlet density and wave (OR = 0.96, P < 0.05) suggested that higher density was associated more closely with life-time smoking at the earlier waves when respondents were younger. Greater density was associated positively with perceived availability (β = 0.02, P < 0.05) and negatively with perceived enforcement (β = -0.02, P < 0.01). Sales rate without checking IDs was related to greater perceived availability (β = 0.01, P < 0.01) and less perceived enforcement (β = -0.01, P < 0.01). Enforcement of underage tobacco laws was related positively to perceived enforcement (β = 0.06, P < 0.05).

CONCLUSIONS

Higher tobacco outlet density may contribute to life-time smoking among youths. Density, sales without ID checks and enforcement levels may influence beliefs about access to cigarettes and enforcement of underage tobacco sales laws.

School policies for preventing smoking among young people

BACKGROUND

School tobacco policies (STPs) might prove to be a promising strategy to prevent smoking initiation among adolescents, as there is evidence that the school environment can influence young people to smoke. STPs are cheap, relatively easy to implement and have a wide reach, but it is not clear whether this approach is effective in preventing smoking uptake.

OBJECTIVES

To assess the effectiveness of policies aiming to prevent smoking initiation among students by regulating smoking in schools.

SEARCH METHODS

We searched seven electronic bibliographic databases, including the Cochrane Tobacco Addiction Group specialized register, MEDLINE, EMBASE, PsycINFO and ERIC. We also searched the grey literature and ongoing trials resources. The most recent search was performed in May 2014.

SELECTION CRITERIA

We included cluster-randomised controlled trials (c-RCTs) in which primary and secondary schools were randomised to receive different levels of smoking policy or no intervention. Non-randomised controlled trials, interrupted time series and controlled before-after studies would also have been eligible. Cross-sectional studies were not formally included but we describe their findings and use them to generate hypotheses to inform future research.

DATA COLLECTION AND ANALYSIS

We independently assessed studies for inclusion in the review, and present a narrative synthesis, as the studies are too limited in quality to undertake a formal meta-analysis.

MAIN RESULTS

We found only one study which was eligible for inclusion in the review. It was judged to be at high risk of bias. The study compared two 'middle schools' from two different regions in China. The experimental conditions included the introduction of a tobacco policy, environmental changes, and communication activities, while the control condition was no intervention. After a year's follow-up the study found no differences in smoking prevalence between intervention and control schools. We also described 24 observational studies, the results of which we considered for hypothesis generation. In these, policy exposure was mainly described using face-to-face interviews with school staff members, and the outcome evaluation was performed using self-administered questionnaires. Most studies reported no differences in students' smoking prevalence between schools with formal STPs when compared with schools without policies. In the majority of studies in schools with highly enforced policies, smoking bans extended to outdoor spaces, involving teachers and including sanctions for transgressions, with assistance to quit for smokers plus support by prevention programmes, there was no significant difference in smoking prevalence when compared to schools adopting weaker or no policies.

AUTHORS' CONCLUSIONS

Despite a comprehensive literature search, and rigorous evaluation of studies, we found no evidence to support STPs. The absence of reliable evidence for the effectiveness of STPs is a concern in public health. We need well-designed randomised controlled trials or quasi-experimental studies to evaluate the effectiveness of school tobacco policies.

Rating the effectiveness of local tobacco policies for reducing youth smoking

Important questions remain regarding the effectiveness of local tobacco policies for preventing and reducing youth tobacco use and the relative importance of these policies. The aims of this paper are to: (1) compare policy effectiveness ratings provided by researchers and tobacco prevention specialists for individual local tobacco policies, and (2) develop and describe a systematic approach to score communities for locally-implemented tobacco policies. We reviewed municipal codes of 50 California communities to identify local tobacco regulations in five sub-domains. We then developed an instrument to rate the effectiveness of these policies and administered it to an expert panel of 40 tobacco researchers and specialists. We compared mean policy effectiveness ratings obtained from researchers and prevention specialists and used it to score the 50 communities. High inter-rater reliabilities obtained for each sub-domain indicated substantial agreement among the raters about relative policy effectiveness. Results showed that, although researchers and prevention specialists differed on the mean levels of policy ratings, their relative rank ordering of the effectiveness of policy sub-domains were very similar. While both researchers and prevention specialists viewed local outdoor clean air policies as least effective in preventing and reducing youth cigarette smoking, they rated tobacco sales policies and advertising and promotion as more effective than the other policies. Moreover, we found high correlations between community scores generated from researchers' and prevention specialists' ratings. This approach can be used to inform research on local policies and prevention efforts and help bridge the gap between research and practice.

Youth tobacco access: trends and policy implications

OBJECTIVE

We examined whether the supply routes via which New Zealand adolescents aged 14-15 years accessed tobacco had changed during a period of dynamic policy activity.

SETTING

We analysed data from seven consecutive years (2006-2012) of the New Zealand Action on Smoking and Health (ASH) Year 10 survey, a nationwide cross-sectional annual survey.

PARTICIPANTS

All New Zealand schools teaching Year 10 students are invited to participate in the survey; school-level participation rates have ranged between 44% and 58% and more than 25 000 students have responded to the survey in each year. The results presented draw on the subsample who reported smoking when surveyed (N∼9200). The data were weighted by age, ethnicity and school socioeconomic status (SES) to remove effects of systematic over-response by New Zealand Europeans and under-response by those in lower SES groups from trend analyses.

PRIMARY AND SECONDARY OUTCOME MEASURES

The survey measured adolescents' main reported tobacco supply source.

RESULTS

Smoking prevalence declined significantly (8.1%) over the period examined (linear tend coefficient: -0.74; 95% CI -1.03 to -0.45, significant p<0.01). Friends showed a significant decline in relative importance as a supply source while caregivers and other sources showed a significant increase over the period examined.

CONCLUSIONS

The findings show that social supply, particularly via friends, caregivers and others, such as older siblings, is a key tobacco source for adolescents; commercial supply is much less important. The findings raise questions about the additional measures needed to reduce smoking among youth. Endgame policies that make tobacco more difficult to obtain and less appealing and convenient to gift merit further investigation.

Community-level adult daily smoking prevalence moderates the association between adolescents' cigarette smoking and perceived smoking by friends

Few studies have investigated the complex interactions among the individual- and community-level social risk factors that underlie adolescents' smoking behaviors. This study investigated whether community-level adult daily smoking prevalence is associated with adolescents' smoking and whether it moderates the associations between perceived friends' smoking approval and smoking behavior and adolescents' own smoking. Self-reported data from 1,190 youths (50.3% female; 13-18 years old) in 50 midsized Californian cities were obtained through telephone interviews. Community characteristics were obtained from 2010 GeoLytics data. Community adult daily smoking prevalence was ascertained from telephone interviews with 8,918 adults conducted in the same 50 cities. Multilevel analyses, controlling for individual and city characteristics, were used to predict adolescents' past 12-month smoking from perceived friends' smoking approval and smoking behavior and from community adult daily smoking prevalence. Results showed that perceived friends' smoking approval and behavior were associated positively with adolescents' smoking, as was the community-level prevalence of adult daily smoking. Furthermore, the association between perceived friends' smoking behavior and adolescents' own smoking was moderated by the prevalence of adult daily smokers in the community. Specifically, the association was stronger in cities with higher prevalence of adult smokers. These results suggest that adult community norms that are more supportive of smoking may enhance the influence of friends' smoking behavior. Therefore, interventions designed to prevent or reduce youths' smoking should also focus on reducing smoking by adults.

Highlights from a workshop on opportunities for cancer prevention during preadolescence and adolescence

In an effort to explore opportunities for cancer prevention during preadolescence and adolescence, the Cancer Prevention Across the Lifespan workgroup within the Division of Cancer Prevention and Control at the Centers for Disease Control and Prevention (CDC) convened an informal panel of experts for a 2-day workshop August 9-10, 2011. In this report, we provide highlights from the workshop. A central theme of the workshop was that preadolescence and adolescence are times of unique susceptibility and vulnerability within the lifespan. Participants discussed the evidence linking exposures during adolescence (e.g., risky behaviors, chemicals, medical imaging procedures) and subsequent cancer risk during adulthood. Participants also discussed potential opportunities to intervene on risk factors for cancer at multiple levels during adolescence, the importance of more focused approaches to adequately address health disparities, and the ongoing need for transdisciplinary and translational prevention research. Future opportunities for the CDC include further leveraging surveillance data from sources such as the National Health and Nutrition Examination Survey, the Youth Risk Behavior Surveillance System, and the National Children's Study and continuing to build on collaborations with other federal agencies and with national, state, and local organizations. Many ideas and insights generated during the workshop will be put into action as CDC continues to explore opportunities for cancer prevention during youth and across the lifespan.