Impact of laws restricting the sale of tobacco to minors on adolescent smoking and perceived obtainability of cigarettes: an intervention-control pre-post study of 19 European Union countries : Youth tobacco access laws in Europe

The relative index of inequality and the slope index of inequality are the two major indices used in epidemiologic studies for the measurement of socioeconomic inequalities in health. Yet the current definitions of these indices are not adapted to their main purpose, which is to provide summary measures of the linear association between socioeconomic status and health in a way that enables valid between-population comparisons. The lack of appropriate definitions has dissuaded the application of suitable regression methods for estimating the slope index of inequality.

Enforcing laws banning tobacco sales to minors is widely advocated as a way to reduce young people's access to tobacco and tobacco use. Whether this approach is successful is not known. In a two-year controlled study, we assessed sales of tobacco to minors and young people's access to and use of tobacco in six Massachusetts communities. Three communities (the intervention group) enforced tobacco-sales laws, whereas three matched communities (the control group) did not. To assess compliance with the law, minors working for the study investigators attempted to purchase tobacco from all retail vendors in each community every six months. Three annual anonymous surveys of a total of 22,021 students in grades 9 through 12 (response rate, 84 percent) measured access to tobacco and smoking behavior. At base line, 68 percent of 487 vendors sold tobacco to minors. Compliance with the law improved significantly faster in the intervention communities than in the controls (P<0.001). By the study's end, 82 percent of the merchants in the intervention communities complied with the law, as compared with 45 percent in the control communities (P<0.001). However, adolescents under 18 years old reported only a small drop in their ability to purchase tobacco and no decline in its use. Communities with and those without enforcement programs did not differ with respect to these outcomes. Enforcing tobacco-sales laws improved merchants' compliance and reduced illegal sales to minors but did not alter adolescents' perceived access to tobacco or their smoking. Test purchases of tobacco do not accurately reflect adolescents' self-reported access to tobacco, and reducing illegal sales to less than 20 percent of attempts -- the goal of a new federal law-- may not decrease young people's access to or use of tobacco.