Illegal Sales of Cigarettes to Minors -- Ciudad Juarez, Mexico; El Paso, Texas; and Las Cruces, New Mexico, 1999

In 1996, the United States-Mexico Binational Commission (US-MBC) Health Working Group identified prevention of tobacco use, particularly among adolescents, as a priority and subsequently recommended joint efforts toward reducing illegal sales of cigarettes to minors. A 1997 survey of 561 commercial cigarette outlets in Mexico City found that 79% of retailers sold cigarettes to minors (1). To assess the illegal sale of cigarettes to minors in other regions of Mexico and on both sides of the U.S.-Mexico border, during January-February 1999 the General Directorate of Epidemiology in Mexico, the Chihuahua State Department of Health Services (CDH), the Ciudad Juarez Department of Health (CJDH), the Texas Department of Health (TDH), and the New Mexico Department of Health (NMDH) surveyed cigarette outlets in Ciudad Juarez, Mexico; El Paso, Texas; and Las Cruces, New Mexico. This report summarizes the results of these surveys, which indicate that almost all retailers in the surveyed outlets in Ciudad Juarez sold cigarettes to minors and that sales rates to minors were substantially lower in El Paso and Las Cruces.

Although survey methods were the same in each location, sampling methods varied. In Ciudad Juarez, where no list of cigarette outlets was available, the sample was selected by using a stratified cluster design. Within each of eight geographic areas, 23 clusters were selected, each with an equal probability of selection. All stores within each selected cluster were visited by adults, and the operational cigarette outlets were identified and surveyed. In El Paso, where a list of licensed cigarette outlets was available, a stratified cluster design was used in which the strata were six geographic areas within the city limits and the clusters were postal ZIP code areas. Within each of the six areas, two clusters were selected with a probability of selection proportional to the number of cigarette outlets; within a selected cluster, all outlets were surveyed. In Las Cruces, a list of all operational cigarette outlets was available and all outlets were surveyed. Because the Las Cruces list was a census and not a sample, confidence intervals were not calculated. For both Ciudad Juarez and El Paso, sampling weights were calculated using the inverse probability of selection for each cluster within a stratum. Standard errors and 95% confidence intervals were calculated using SUDAAN (2).

Minors who participated in the surveys were recruited from local schools in Ciudad Juarez and El Paso and from a youth organization in Las Cruces. Adult survey escorts were staff of the local or state health departments and volunteers. Teams comprising one adult and two minors attempted to make one purchase per store using the following protocol (1,3): the adult entered the store before one of the minors and noted whether age-of-sale warning signs were posted. Then the adult observed the transaction between the retailer and minor as the minor attempted to purchase a pack of cigarettes. If asked by the retailer, minors were instructed to state truthfully their age and that they carried no identification. An illegal sale was defined as a transaction in which a retailer sold a pack of cigarettes to a minor. If a sale was completed, the minor left the store with the cigarettes and gave them to the adult.

Illegal sales rates to minors in the teams were higher in Ciudad Juarez (98.1%) than in El Paso (18.0%) or Las Cruces (6.1%) (Table 1). In Ciudad Juarez, sales rates did not vary by age or sex of the minors, sex or estimated age of the retailers, or type of store. In El Paso, sales rates were significantly lower for boys, minors aged 15 or 17 years, and if the retailer asked for identification. Illegal sales did not differ by store type in El Paso. In Las Cruces, sales rates were lower for boys, for minors aged 15 or 16 years, if warning signs were present, and if the retailer appeared to be aged greater than or equal to 25 years, female, or asked for age or identification.

Reported by: R Adame-Moreno, MD, O Ibarra-Heredia, MD, Ciudad Juarez Dept of Health, Ciudad Juarez, Chihuahua; H Torres-Simental, MD, State Dept of Health, Chihuahua; P Kuri-Morales, MD, M Hoy, MD, General Directorate of Epidemiology; R Tapia-Conyer, MD, Secretariat of Health, Mexico City, Mexico. M Escobedo, MD, R Zima, P Huang, MD, D Satterwhite, Texas Dept of Health. Al Vizcarra, Teens Needing Teens Program, Las Cruces Housing Authority, Las Cruces; S Babb, MPH, ASSIST Program, L Escobedo, MD, Border Health Office, New Mexico Dept of Health. Office of International and Refugee Health, US Dept of Health and Human Svcs. Program Svcs Br, Epidemiology Br, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

Editorial Note: The substantial difference in the percentage of retailers willing to sell tobacco to minors between Ciudad Juarez and the two U.S. border cities may reflect efforts in the United States to enforce minors' access laws and to provide comprehensive retailer education programs. In surveys conducted during 1987-1993, rates of over-the-counter sales to minors ranged from 32% to 87% and sales from vending machines ranged from 82% to 100% (4). However, since those studies were conducted, enforcement of laws against the sale of tobacco to minors has increased in the United States at the local, state, and federal levels (3,4).

Enforcement inspections in the United States use the same methodology as this study, except that retailers who sell tobacco to minors are given warnings or fines or can lose their retail tobacco license for repeated illegal sales. The Synar Amendment, administered by the Substance Abuse and Mental Health Services Administration, requires all states to 1) enact and enforce laws against tobacco sales to minors, 2) conduct annually a representative inspection survey (i.e., Synar surveys) to determine the percentage of retailers in compliance with laws prohibiting sales to minors, and 3) develop a strategy and time frame for achieving a noncompliance rate of less than or equal to 20% or risk losing some federal funds (5). In 1998, Synar surveys in Texas and New Mexico found that retailer noncompliance rates were 13.0% and 13.5%, respectively (J. Steele, Texas Commission on Alcohol and Drug Abuse and D. Maestas, New Mexico Behavioral Services Division, personal communication, 1999).

In El Paso, enforcement has been conducted by local officers, and state-funded enforcement has been conducted in communities adjacent to El Paso. Federal level enforcement and retailer education in El Paso were funded directly by the Food and Drug Administration (FDA) (6) and indirectly through activities required by the Synar Amendment. In Las Cruces, nine compliance-check surveys conducted during 1996-1998 resulted in warning notices to noncompliant retailers, media publicity, extensive retailer education, and recognition for compliant retailers. Synar Amendment-related enforcement activities have been conducted in New Mexico for several years, and the FDA has distributed retailer education material to tobacco outlets.

In Mexico, the sale of tobacco to minors has been prohibited since 1984. The Mexican Secretariat of Health has developed proposals for strengthening minors' access laws, including requiring identification, prohibiting sale of loose cigarettes and packs with less than 14 cigarettes, eliminating vending machines in places accessible to minors, and decreasing marketing to youth.

The findings in this report are subject to at least two limitations. First, although this study used standard methods during the store visits, the methods may underestimate the ability of underaged persons to purchase cigarettes because they may use false identification, lie about their age, dress to appear older, persuade retailers to sell them cigarettes, or target retailers known to sell cigarettes to minors (7). Second, because sales rates varied by age and sex of minors in El Paso and Las Cruces, some of the difference in sales rates between these locations can be explained by differences in the percentage of young persons aged 15-17 years who participated in the surveys.

The World Health Organization (WHO) supports a comprehensive approach to tobacco control, including legislative action. However, few countries enact or enforce minors' access laws. To reduce tobacco sales to young persons, WHO recommends that countries 1) establish a minimum age of purchase of greater than or equal to 18 years; 2) create a tobacco-sales licensing system so retailers can be identified and informed of their legal responsibilities; 3) establish a graduated schedule of civil law penalties for illegal sales, ranging from warnings to license revocation; 4) enlist the assistance of teenagers in the efforts of law enforcement officers to assess retailers' compliance with the prohibition of sales to minors; 5) end tobacco sales in health care, educational, and athletics facilities; and 6) end tobacco sales in vending machines and from self-service displays (8,9). Other strategies include requesting photo identification or other proof-of-age from persons attempting to purchase tobacco products (3,4,10).

The Mexican Secretariat of Health, CDH, and CJDH will use the results of this survey to demonstrate the need for stricter policies prohibiting the sale of tobacco to minors and to intensity enforcement and retailer education. TDH and NMDH plan to publicize the results of the study to show that enforcement and education efforts must continue. In addition to the enforcement of strong minors' access laws and retailer education, a comprehensive approach to preventing young persons from using tobacco should include raising tobacco taxes and reducing the appeal of tobacco to minors through restrictions on advertising and promotion and through counter-advertising and other educational programs (3,4,6,8). The US-MBC will continue to conduct bilateral collaborative tobacco research.

References

1. CDC. Illegal sales of cigarettes to minors--Mexico City, Mexico, 1997. MMWR 1997;46:440-4.
2. Shah BV, Barnwell BG, Bieler GS. SUDAAN user's manual, release 6.4. 2nd ed. Research Triangle Park, North Carolina: Research Triangle Institute, 1996.
3. Forster J, Wolfson M. Youth access to tobacco: policies and politics. Public Health Reports 1998;19:203-35.
4. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.
5. Substance Abuse and Mental Health Services Administration. Final regulations to implement section 1926 of the Public Health Service Act regarding the sale and distribution of tobacco products to individuals under the age of 18. Federal Register 1996;13:1492-1500.
6. Food and Drug Administration. Regulations restricting the sale and distribution of cigarettes and smokeless tobacco products to protect children and adolescents--final rule. Federal Register 1996;61:41,314-75.
7. 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;337:1044-51.
8. World Health Organization. Guidelines for controlling and monitoring the tobacco epidemic. Geneva, Switzerland: World Health Organization, 1998.
9. World Health Organization. Tobacco or health: a global status report. Geneva, Switzerland: World Health Organization, 1997.
10. Forster JL, Murray DM, Wolfson M, Blaine TM, Wagenaar AC, Hennrikus DJ. The effects of community policies to reduce youth access to tobacco. Am J Public Health 1998;88:1193-8.

TABLE 1. Number and percentage of store visits and of retailers who sold cigarettes to minors,* by category and location -
Ciudad Juarez, Mexico; El Paso, Texas; and Las Cruces, New Mexico, 1999
================================================================================================================================================================
                                              Ciudad Juarez, Mexico                            El Paso, Texas                      Las Cruces, New Mexico
                                    ------------------------------------------   -----------------------------------------   -----------------------------------
                                                          Retailer sold                               Retailer sold                            Retailer sold
                                    Store visits       cigarettes to minors      Store visits      cigarettes to minors      Store visits   cigarettes to minors
                                    -------------    -------------------------   -------------   -------------------------   -------------  --------------------
Category                            No.    (%)+      No.     (%)&    (95% CI@)   No.    (%)+     No.    (%)&     (95% CI)    No.     (%)      No.   (%)**
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Minor's age (yrs)
  15                                159   ( 66.1)    151    (95.2)    (+/-3.7)    94   ( 26.3)     8   (10.2)    (+/- 6.8)    38   ( 38.8)      0   ( 0.0)
  16                                 81   ( 33.9)     80    (98.0)    (+/-3.9)   162   ( 45.4)    38   (25.9)    (+/- 6.3)     4   (  4.1)      0   ( 0.0)
  17                                  0   (  -- )     --    ( -- )      ( -- )   101   ( 28.3)    11   (11.2)    (+/- 6.5)    56   ( 57.1)      6   (10.7)

Minor's sex
  Male                              141   ( 58.7)    135    (95.3)    (+/-4.2)   175   ( 49.0)    15   ( 8.8)    (+/- 4.5)    69   ( 70.4)      1   ( 1.4)
  Female                             99   ( 41.3)     96    (97.2)    (+/-3.3)   182   ( 51.0)    42   (26.1)    (+/- 6.1)    29   ( 29.6)      5   (17.2)

Retailer's estimated age (yrs)
   <25                               53   ( 22.1)     51    (97.0)    (+/-4.3)   131   ( 36.7)    31   (25.3)    (+/- 7.1)    43   ( 43.9)      5   (11.6)
  >=25                              187   ( 77.9)    180    (95.9)    (+/-3.3)   226   ( 63.3)    26   (13.6)    (+/- 4.8)    55   ( 56.1)      1   ( 1.8)

Retailer's sex
  Male                              125   ( 52.3)    120    (96.3)    (+/-3.7)   173   ( 48.6)    27   (17.6)    (+/- 6.0)    43   ( 43.9)      4   ( 9.3)
  Female                            114   ( 47.7)    110    (95.9)    (+/-4.2)   183   ( 51.4)    30   (18.4)    (+/- 5.5)    55   ( 56.1)      2   ( 3.6)
  Unknown                             1                1                           1               0                           0                0

Retailer asked age
  Yes                                 8   (  3.3)      6        ++          ++    33   (  9.2)     2   ( 7.1)    (+/- 9.5)    19   ( 19.4)      0   ( 0.0)
  No                                232   ( 96.7)    225    (97.2)    (+/-2.3)   324   ( 90.8)    55   (19.1)    (+/- 4.1)    79   ( 80.6)      6   ( 7.6)

Retailer asked
  for identification
  Yes                                 2   (  0.8)      2        ++          ++   285   ( 79.8)     8   ( 3.0)    (+/- 2.0)    84   ( 85.7)      1   ( 1.2)
  No                                238   ( 99.2)    229    (96.1)    (+/-2.8)    72   ( 20.2)    49   (69.8)    (+/-10.6)    14   ( 14.3)      5   (35.7)

Warning signs present
  Yes                                 3   (  1.3)      2        ++          ++   218   ( 61.2)    31   (15.2)    (+/- 4.8)    48   ( 49.0)      0   ( 0.0)
  No                                237   ( 98.7)    229    (96.4)    (+/-2.7)   138   ( 38.8)    25   (21.6)    (+/- 7.0)    50   ( 51.0)      6   (12.0)
  Unknown                             0                0                           1               1                           0                0

Total                               240   (100.0)    231    (98.1)    (+/-2.8)   357   (100.0)    57   (18.0)    (+/- 3.8)    98   (100.0)      6   ( 6.1)
----------------------------------------------------------------------------------------------------------------------------------------------------------------
 * Aged <18 years.
 + Unweighted percentages.
 & Weighted percentages.
 @ Confidence interval.
** Because percentage of successful purchase attempts represented all cigarette outlets in Las Cruces, 95% CIs are not presented.
++ Numbers were too small to calculate precise estimates.
================================================================================================================================================================

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