Commentary on Fidler & West (2010): Curtailing tobacco sales to minors

In a seminal study, Jason et al. assessed the effects of Sergeant Bruce ‘Buzz’ Talbot's enforcement of a law prohibiting tobacco sales to minors under age 18 [1,2]. Sergeant Talbot enforced the law by sending a minor into stores to attempt to purchase cigarettes. After several rounds of inspections and prosecutions, merchant compliance with the law surpassed 90% and smoking among youth was cut in half. Based on this success, in 1992 the US Congress mandated that states enforce tobacco sales laws. Winston Churchill observed ‘you can always count on Americans to do the right thing—after they've tried everything else’. Although Sergeant Talbot had a proven method, states did try everything else. In the end, using decoys to attempt purchases was the only effective enforcement method [3]. It has been implemented across the United States, Canada and Australia, followed by substantial drops in youth smoking in all three nations. Enforcement is credited with cutting youth smoking in half in Australia [4], and contributing substantially to a 70% reduction in tobacco use among American youth [5,6]. Although British officials have used purchase attempts to enforce their laws, the effectiveness of their efforts have not measured up to those of Britain's former colonies [7]. One glaring problem has been that the minimum age for tobacco sales was only 16 years in Great Britain, compared to 18 years in the United States, Canada and Australia. In the first evaluation of the effect of raising the age for tobacco sales, Fidler & West studied the impact of an increase in the minimum age from 16 to 18 years in England and Wales. One thing is certain: raising the minimum age did not trigger an increase in youth smoking by making tobacco a forbidden fruit, as critics had predicted [8,9]. Nor did it result in a reduction in youth smoking of 0.5%, as the government's Regulatory Impact Assessment had predicted (quoted in [9]). Over just 3 years, smoking among youth aged 16–17 years dropped from 23.7% to 16.6%, a proportional decrease of 32.5%. Apparently, one can also count on the British to do the right thing in the end. Some caution should be exercised in interpreting these results as it was not possible to control for the impact of other policies, such as a recently implemented indoor smoking ban. However, there is scant evidence that indoor smoking bans reduce smoking by youth [5], and certainly none to suggest that a reduction of this magnitude could be attributed to such a policy. The evaluation of laws cannot reasonably be held to a standard that holds the randomized controlled trial to be the only valid source of knowledge [10]. The impact of national laws cannot be evaluated by assigning randomly scores of sovereign nations to change their laws, or not. We must learn what we can by evaluating natural experiments. While the results of this study are not conclusive, they are well within the range of the reductions in youth smoking observed in previous studies and they provide important encouragement that the government's efforts are now having the desired effect. There has been unfortunate confusion regarding the effectiveness of enforcing restrictions on underage sales of tobacco. Many published literature reviews came to invalid conclusions because they pooled data from enforcement programs that were effective in curtailing illegal sales with data from programs that did not curtail illegal sales [10–12]. This makes as much sense as pooling data from studies of effective cancer treatments with data from studies of treatments offered by con artists and on that basis concluding that the literature is mixed and cancer should not be treated. In every study in which there was a documented disruption in the supply of tobacco to minors from commercial sources, there has been a documented reduction in youth smoking [13]. Conversely, in every study that reported that an intervention failed to impact youth smoking, the authors failed to demonstrate that the intervention had convinced merchants to stop selling to minors [13]. The literature establishes that enforcement is only effective in reducing youth smoking when it is pursued with sufficient vigor to ensure that merchants obey the law. When enforcement programs reduce the commercial supply of tobacco to minors, fewer children smoke [13]. The evidence supporting the efficacy of youth access interventions was sufficient to convince the World Health Organization to include a youth access provision in the Framework Convention on Tobacco Control. A total of 168 signatory parties have committed themselves to ban the sale of tobacco to minors [14]. The benefit derived from their efforts will depend entirely upon how well the ban is enforced. Cigarettes are the only legal product that kills a substantial portion of its users when used as intended by the manufacturer [15]. The study by Fidler & West [16] provides one more piece of evidence supporting the wisdom of enforcing a ban on the sale of tobacco products to children. Author has declared a connection with Pfizer Pharmaceuticals.

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