Statewide evaluation of youth access ordinances in practice: effects of the implementation of community-level regulations in Massachusetts.

The objectives of the study described in this article were to test whether community-level youth access ordinances reduce adolescents' perceived access to tobacco, purchase attempts, and tobacco use. A telephone survey was performed of a random sample of 3,831 Massachusetts adolescents linked to a database of all town-level youth access ordinances in the state. Respondents' perceived ease of access to tobacco, attempts to purchase tobacco, and tobacco use (ever smoking and current [past 30-day] smoking) were assessed. The association of these outcomes with the characteristics of youth access ordinances in the respondents' town of residence (n = 314) was tested in multilevel analyses that included town-level clustering, controlled for multiple individual and environmental characteristics, including a measure of community-level anti-smoking sentiment. Community-level youth access ordinances were not associated with adolescents' perceived access to tobacco, purchase attempts, or tobacco use, with two exceptions: (1) banning free-standing displays was associated with a 40% reduction in perceived access to tobacco (OR = 0.6; 95% CI, 0.4-0.9) and (2) a vending machine ban was associated a 30% higher report of perceived access to tobacco (OR = 1.3; 95% CI, 1.1-1.5). This study found no consistent associations between community-level youth access ordinances and adolescents' perceived access to tobacco, purchase attempts, or smoking prevalence.     

Sociocultural variables in youth access to tobacco: replication 5 years later

BACKGROUND: A prior study presented the only systematic investigation of the role of sociocultural variables in youth access to tobacco. White, black, and Latino girls and boys attempted to purchase cigarettes in the same 72 stores at the same time of day. Results revealed significantly greater sales to girls than to boys and to minorities than to whites. Before concluding that sociocultural variables must be addressed in merchant intervention programs designed to reduce youth access to tobacco, this study must be replicated, particularly in light of the significant decreases in youth access in the past 5 years. This article presents that replication. METHOD: The stores used in the prior study were selected, and 12 white, black, and Latino girls and boys attempted to purchase cigarettes in those stores at the same time of day. Results Youths' access rate in 1999 (12.7%) was significantly lower than in the prior (1993-1995) study (41%). No effect for minors' gender was found, but the ethnicity effect again emerged: Black and Latino youth were 2.5 times more likely to be sold cigarettes than their white counterparts. CONCLUSIONS: Multiple sociocultural variables affect youth access to tobacco when access rates are high, but only youth ethnicity plays a role when access rates are low. Merchant interventions designed to reduce youth access to tobacco must address ethnic issues.     

Middle school students' perceived access to cigarettes in Virginia

OBJECTIVE: To examine correlates of perceived access to cigarettes at home, school, and the store among youth. METHODS: Virginia middle school youth were surveyed before beginning tobacco prevention programs. Multivariate analyses examined household smoking, peer smoking, and perceived community tobacco use for their relationship to perceived access at home, school, and the store. RESULTS: Perceived access at home was associated with parent, sibling, and friend smoking. Perceived access at school and stores was associated with perceived peer and community smoking. CONCLUSIONS: Youth tobacco prevention programs should target the commercial and social sources of tobacco access to reduce experimentation, adoption, and addiction among youth.     

Long-Term Effects of Laws Governing Youth Access to Tobacco

Objectives. We sought to examine the association between policies governing access to tobacco during adolescence and subsequent adult smoking.Methods. We analyzed adult smoking data from the 1998 through 2006–2007 administrations of the US Current Population Survey Tobacco Use Supplement by employing a quasi experimental approach. Participants (n = 105 519) were adults, aged 18 to 34 years at the time of the survey. Smoking outcomes included having ever smoked 100 cigarettes, smoking at the time of the survey, and having smoked 10 or more cigarettes a day conditioned on being an ever smoker. These were predicted from exposure to state youth access policies at age 17 years.Results. Four of the 9 policies exhibited significant associations with reduced prevalence of 1 or more smoking outcomes, primarily among women. Lesser effects for other policies could not be ruled out.Conclusions. Restrictions on youth access to tobacco might lead to reduction in smoking prevalence later in adulthood. The effect might be limited to women; we estimate that having all policies in place could be associated with a 14% reduction in lifetime smoking prevalence for women, and an additional 29% reduction in heavy smoking among ever smokers.Both opponents of smoking and purveyors of cigarettes have recognized the significance of adolescence as the period during which smoking behaviors are typically developed.1,2 Accordingly, initiatives to curb youth smoking were among the first federal policy restrictions placed on cigarette sales in the United States.3,4 Adoption of these initiatives was accelerated by passage of the 1992 Synar Amendment to the Federal Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act, which mandated withholding federal block-grant money from states that failed to prohibit distribution of tobacco products to persons younger than 18 years, or failed to enforce such prohibitions. Various measures were implemented by individual states to increase retailer compliance with de jure purchase ages, such as restricting physical access to cigarette vending machines and banning the sale of single cigarettes.5,6Adaptation of these policies was partly motivated by community intervention studies suggesting that more uniform compliance with legal purchase age policies would reduce smoking rates among youths.7–11 Some postimplementation studies have suggested that youth access restrictions are effective at reducing smoking among adolescents,12–14 whereas other studies have cast doubt on their effectiveness.6,15–17 Furthermore, opponents argue that youth access policies could inadvertently glamorize smoking as a sophisticated adult behavior, thus reinforcing messages historically associated with tobacco advertising.18 Hence, some argue that youth access restrictions divert resources away from well-established and universally targeted tobacco control policies, such as clean indoor air policies, price increases, and media campaigns.16,19Youth access measures were not designed to merely delay smoking, but presumably to deter progression by delaying onset or reducing the intensity of smoking during adolescence. As such, reductions in smoking that persist into adulthood are the proper benchmarks by which these policies should be assessed. In the current study, we examined whether youths who face a restrictive policy environment are less likely to smoke as adults. We analyzed long-term associations between state youth access policies and subsequent adult smoking by taking advantage of state-by-state and year-by-year policy differences as states adopted various measures in response to the Synar Amendment. We expect that policies effective in mitigating youth smoking also influence subsequent adult smoking. It has been shown, for example, that exposure to stricter drinking age laws are associated with lower prevalence of alcohol problems in adulthood, but to our knowledge, parallel studies have not been conducted for tobacco policy.20–22 Hence, we examined whether policy encountered during adolescence is associated with smoking behaviors during adulthood. This hypothesis is consistent with contemporary neurobiological views of adolescence as a critical period for the development of addiction.23–25     

State-level tobacco control policies and youth smoking cessation measures

ObjectiveResearch on the effects of state-level tobacco control policies targeted at youth has been mixed, with little on the effects of these policies and youth smoking cessation. This study explored the association between state-level tobacco control policies and youth smoking cessation behaviors from 1991 to 2006.MethodsThe study design was a population-based, nested survey of students within states. Study participants were 8th, 10th, and 12th graders who reported smoking “regularly in the past” or “regularly now” from the Monitoring the Future study. Main cessation outcome measures were: any quit attempt; want to quit; non-continuation of smoking; and discontinuation of smoking.ResultsResults showed that cigarette price was positively associated with a majority of cessation-related measures among high school smokers. Strength of sales to minors’ laws was also associated with adolescent non-continuation of smoking among 10th and 12th graders.ConclusionsFindings suggest that increasing cigarette price can encourage cessation-related behaviors among high school smokers. Evidence-based policy, such as tax increases on tobacco products, should be included as an important part of comprehensive tobacco control policy, which can have a positive effect on decreasing smoking prevalence and increasing smoking cessation among youth.     

The role of public policies in reducing smoking prevalence and deaths: the Argentina Tobacco Policy Simulation Model.

OBJECTIVES: To compare tobacco control policies independently and as a package through a simulation model to project smoking prevalence and associated future premature mortality in Argentina beginning in 2001. METHODS: A simulation model of tobacco control policies known as SimSmoke was modified using data for Argentina on population, fertility and mortality, smoking prevalence, and tobacco control policies in effect between 2001 and 2004. We used the Argentina Tobacco Policy Simulation model (ATPSM) to consider the effect on smoking prevalence of changes in taxes and prices, clean air laws, media campaigns, cessation programs, and youth access policies on smoking initiation and cessation rates. Smoking prevalence and relative risks of smoking were used to estimate smoking-attributable mortality. The ATPSM was used to project smoking prevalence and smoking-attributable deaths during the period 2001-2034. RESULTS: The largest reductions in smoking prevalence and premature mortality were predicted for a comprehensive tobacco control policy package, but relative reductions of as much as 30% were also predicted for large tax increases. Adding a media campaign along with programs to publicize and enforce clean air laws, advertising bans, and youth access laws would further reduce smoking rates by up to 45% by the year 2034, and would save almost 16 000 lives per year. CONCLUSIONS: Tobacco control policies can substantially reduce smoking rates, which can save many lives. Without such policies, deaths from smoking, and associated medical costs, will increase. The ATPSM is expected to provide guidance in filling the most important information gaps pertinent to both modeling and policy-making in Argentina, e.g., the lack of data on initiation and cessation rates, and the need for studies on the impact of policies. Similar models might be developed for other Latin American countries.     

Tobacco cessation in adolescent females in Appalachian communities

Adolescents who live in tobacco-growing areas use tobacco at earlier ages and more frequently than other youth. These adolescents, like all tobacco users, have many health risks. To be successful, cessation efforts targeting these youth must reflect the cultural, social, and economic import of tobacco in their communities. Six focus groups with girls aged 12 to 14 who lived in tobacco-growing communities in Appalachian Ohio, Tennessee, and Virginia and 20 interviews with key informants were conducted. Barriers identified by informants included community norms around tobacco use, family use of tobacco, school practices and policies, peer influences, youth attitudes, and logistical difficulties with cessation program efforts. Key findings indicated: (1) the social community in tobacco-growing communities is a significant influence in tobacco use; (2) family is important among young people in tobacco-growing communities and influences cessation positively and negatively; (3) parental smoking was an influence to smoke (4) some parents condone and even facilitate tobacco use by their children, but others actively discourage use; and (5) concern for the health of younger brothers and sisters elicits a strongly protective reaction from youth in discussions of health risks related to secondhand smoke. Youth in tobacco-growing regions have many similarities to others, but they also have unique cultural characteristics pertinent in the development and delivery of tobacco cessation programs.     

Sustained effects of educating retailers to reduce cigarette sales to minors.

Despite state laws prohibiting the purchase of tobacco by minors, the ease with which underage youth can purchase cigarettes has been documented nationwide. The public health community as well as policy makers have called for a combination of retailer education and enforcement of laws prohibiting tobacco sales to minors. Enforcement activity may not be feasible in many communities, however, and an educational intervention may be the only option. This paper reports results of a 6-month followup assessment following a face-to-face education intervention with retailers to reduce cigarettes sales to minors in San Diego County, CA. A control-experimental group, pre-post design was employed to study the sustained effects of the program on the illegal sale of cigarettes to minors. A total of 236 stores were visited by minors, ages 14-17 years, with the intent of purchasing cigarettes. Information was collected three times: pre-test, immediately following the intervention, and 6 months after the intervention ended. The groups included a no-treatment control group of 108 stores and an intervention group of 128 that received three educational visits from project staff over a 1-year period. Community education via media and informational presentations was also conducted. As previously reported, a 68-percent pretest sales rate was found for stores overall. Immediately following the intervention, 32 percent of the intervention group and 59 percent of the control group sold cigarettes to minors. These results were maintained 6 months following the conclusion of the intervention. Results are discussed in terms of education versus use of enforcement.     

Is restricting tobacco sales the answer to adolescent smoking?

Enforcement of legislation restricting retail access to tobacco is increasingly relied on to reduce adolescent smoking rates. In 1996, health authorities in the Northern Sydney Health Area began monitoring tobacco retailer compliance (PROOF program) with staged purchase attempts by adolescents below the legal age (18 years).Repeat cross-sectional surveys before (1995) and after (2000) the introduction of PROOF monitored changes in adolescent smoking behaviour. Students aged 12 to 17 years from 11 Northern Sydney metropolitan public secondary schools were surveyed for self-reported smoking and tobacco purchasing behavior in 1995 (n = 5,206) and 2000 (n = 4,120).Between 1996 and 2000, 545 retailer compliance checks found 34% unlawfully sold cigarettes to minors and 28% of these repeated the offence. Nine prosecutions resulted. Modelling revealed a significant association between the intervention and never having smoked (adjusted OR = 1.16, 95% CI = 1.01-1.33) although there was no significant association with being a current smoker. The odds of being a smoker were greater for students from coeducational schools, with this effect being modified by gender.There was no reduction in adolescent smoking with active enforcement of tobacco access laws despite an apparent increase in students who reported never to have smoked.     

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.     

The role of public policies in reducing smoking and deaths caused by smoking in Vietnam: results from the Vietnam tobacco policy simulation model

A simulation model is developed for Vietnam to project smoking prevalence and associated premature mortality. The model examines independently and as a package the effects of five types of tobacco control policies: tax increases, clean air laws, mass media campaigns, advertising bans, and youth access policies. Predictions suggest that the largest reductions in smoking rates will result from implementing a comprehensive tobacco control policy package. Significant inroads may be achieved through tax increases. A media campaign along with programs to publicize and enforce clean air laws, advertising bans and youth access laws would further reduce smoking rates. Tobacco control policies have the potential to make large dents in smoking rates, which in turn could lead to many lives saved. In the absence of these measures, deaths from smoking will increase. The model also helps to identify information gaps pertinent both to modeling and policy-making.     

Evaluation of a multi-component community tobacco intervention in three remote Australian Aboriginal communities

OBJECTIVES: To assess the effect of community tobacco interventions in Aboriginal communities. METHODS: The study consisted of a pre- and post-study of the effect of a multi-component tobacco intervention conducted in six Aboriginal communities in the Northern Territory (NT). The intervention included sports sponsorship, health promotion campaigns, training health professionals in the delivery of smoking cessation advice, school education about tobacco, and policy on smoke-free public places. The study was conducted in three intervention communities and three matched control communities. Surveys were used to measure changes in prevalence of tobacco use, changes in knowledge, and attitudes to cessation in intervention communities. RESULTS: Tobacco consumption decreased in one intervention community compared with the matched control community; the trends of consumption (as measured by tobacco ordered through points of sale) in these communities were significantly different (t = -4.5, 95% CI -33.6 - (-12.5), p < or = 0.01). Community samples in intervention communities included 920 participants. There was no significant change in the prevalence of tobacco use, although knowledge of the health effects of tobacco and readiness to quit increased. CONCLUSIONS: Although it is difficult to demonstrate a reduction in tobacco consumption or in the prevalence of tobacco use as a result of multi-component community tobacco interventions delivered in Aboriginal communities, such interventions can increase awareness of the health effects of tobacco and increase reported readiness to cease tobacco use.     

Predictors of different cigarette access behaviours among occasional and regular smoking youth

BACKGROUND: Understanding the different ways underage youth access tobacco is required in order to develop more effective tobacco access restrictions. The purpose of this study was to examine characteristics that predict whether underage smoking youth buy their own cigarettes, buy their cigarettes from friends, or get someone else to buy their cigarettes. METHODS: Logistic regression analyses were used to examine the predictors of three different tobacco access behaviours among 737 occasional smoking and 2,050 regular smoking youth. RESULTS: Most smoking youth were asked their age less than half of the time when trying to buy cigarettes. Occasional smokers usually buy their cigarettes from a friend (59.5%) and the majority of regular smokers usually buy their own cigarettes (59.8%). Occasional smokers were less likely to buy their own cigarettes (OR 0.85) and more likely to ask someone else to buy their cigarettes (OR 1.24) the more frequently they were asked their age on purchase attempts. Regular smokers were also less likely to buy their own cigarettes (OR 0.70) and more likely to buy their cigarettes from someone else (OR 1.51) or a friend (OR 1.18) the more frequently they were asked their age on purchase attempts. INTERPRETATION: Point-of-sale restrictions are insufficient to prevent youth from acquiring cigarettes because youth commonly access cigarettes from social sources. A more comprehensive approach for restricting access is required that targets both underage youth and individuals who purchase tobacco for underage youth.     

The role of public policies in reducing smoking prevalence and deaths caused by smoking in Arizona: results from the Arizona tobacco policy simulation model.

Arizona was one of the first few states to implement a comprehensive tobacco control program. The effect of that program is examined using a computer-simulation model (SimSmoke) developed for the purposes of evaluation, planning, and justifying policies. This approach assesses the impact to date of tobacco control policies on smoking prevalence and generates predictions about the effects of tobacco control policies on past and future smoking prevalence and associated future premature mortality. SimSmoke estimates indicate that tobacco control policies reduced smoking rates in Arizona by about 20 percent over the period 1993-2002. A previous CDC study obtains similar effects, but does not net out the effects of individual policies. SimSmoke attributes much of the reduction, about 61 percent, to price increases and attributes 38 percent of the overall effect to media policies, leaving only a small percentage of the smoking reductions attributed to quitlines, youth access policies, and the weak clean air laws. Tobacco control policies implemented as comprehensive strategies have significantly affected smoking rates in Arizona, which leads to large reductions in deaths attributable to smoking. It will be important to maintain these efforts over time to reduce or keep smoking prevalence down and to minimize smoking-attributable deaths.     

School and Community Predictors of Smoking: A Longitudinal Study of Canadian High Schools

Objectives. We identified the most effective mix of school-based policies, programs, and regional environments associated with low school smoking rates in a cohort of Canadian high schools over time.Methods. We collected a comprehensive set of student, school, and community data from a national cohort of 51 high schools in 2004 and 2007. Hierarchical linear modeling was used to predict school and community characteristics associated with school smoking prevalence.Results. Between 2004 and 2007, smoking prevalence decreased from 13.3% to 10.7% in cohort schools. Predictors of lower school smoking prevalence included both school characteristics related to prevention programming and community characteristics, including higher cigarette prices, a greater proportion of immigrants, higher education levels, and lower median household income.Conclusions. Effective approaches to reduce adolescent smoking will require interventions that focus on multiple factors. In particular, prevention programming and high pricing for cigarettes sold near schools may contribute to lower school smoking rates, and these factors are amenable to change. A sustained focus on smoking prevention is needed to maintain low levels of adolescent smoking.Adolescent tobacco use remains a major public health priority to reduce the disease burden of smoking-related illness. In addition to the health consequences of tobacco use that typically begin in adolescence, the total financial costs of smoking in the United States are estimated at $167.8 billion annually1 and in Canada, $17 billion annually.2 A significant challenge in addressing the problem is that youth smoking behaviors occur in many complex environments, including the home, school, community, and wider policy context. An ecological model provides a framework for understanding the complex influence and interactions of the broader environment on individual health behaviors.3 Focusing on broader environmental approaches to adolescent tobacco control may serve to decrease opportunities for youths to obtain tobacco and foster social norms that discourage youths from smoking. To inform the development and implementation of more effective approaches to adolescent tobacco control, researchers need to identify the multiple influences of school, neighborhood, and community characteristics on adolescent smoking.4–6School-based approaches to addressing adolescent tobacco use have been the focus of much research and public health policy. Despite this, findings from studies examining the effectiveness of school-based policies7–21 and prevention programs22–24 on student smoking remain mixed. Previous research has shown that smoking rates vary across schools, irrespective of individual factors, suggesting a school effect on smoking rates.8 School-level determinants have been found to explain between 4% and 40% of the variation in smoking across middle and high schools.7,25,26 Moreover, factors in a school’s community, including the implementation of strategies such as educational programs, policies, and municipal regulations are likely to influence adolescent smoking. A study examining the impact of broader tobacco control policies (e.g., clean air policies, cigarette taxes) over a 15-year period found an association with lower adolescent smoking.27 Ecological models have suggested that to better understand the influence of school contextual variables on smoking rates, the relationships among school-based tobacco control policies, programs, and other characteristics of the broader school and community environment need to be explored simultaneously. An integrated approach such as this would help determine the most effective mix of policy and program factors that support low school smoking rates.Most smoking outcomes have been assessed at the individual level. Although the purpose of school-based tobacco control policies and programs is to influence individual smoking behavior, they are also designed to modify the school setting by enhancing nonsmoking norms. Therefore, investigating and understanding smoking outcomes at the school level is important. Studying school-level smoking behavior will help to identify the relative importance of various factors in students’ school environments that have an impact on school-level smoking prevalence. For the relatively immobile high school student, local areas are very important for accessing goods and services, including those detrimental to health.28 As such, school- and community area–targeted programs can be informed to increase capacity for change.We designed the Project Impact study to examine the relationship between adolescent smoking and the broader school and community environment. Previous findings from this study have suggested that significant differences exist in tobacco retailer variables between schools with high and low smoking rates,6,25 that smoking rates vary across schools, and that policy characteristics can explain some of this variation.6,14,29 Evidence has also shown that community characteristics are related to smoking rates.6 However, evidence is lacking regarding how multiple factors, across school and community environments, work in combination and over time to influence adolescent smoking at the school level.The purpose of this study was to follow a cohort of Canadian schools over time to determine the influence of school-based tobacco control policies, programs, the areas surrounding schools (neighborhoods), and regional environments (municipality) on school smoking prevalence. We sought to identify factors within the schools and their communities that are associated with school smoking rates. Findings will be useful to policymakers in informing decision making that advances tobacco control.     

Durability of tobacco control activities in 11 north American communities: life after the Community Intervention Trial for Smoking Cessation (COMMIT)

Durability of tobacco control activities in the 11 intervention sites of the Community Intervention Trial for Heavy Smokers (COMMIT) was examined. Although continuation of COMMIT activities was not a major goal, all communities made plans to continue some tobacco control activity. Information was gathered at focus groups of former COMMIT volunteers and staff who were assembled in each community and asked to describe tobacco control activities in their communities during the past 12-16 months-the period after the termination of COMMIT funding. It was found that a tobacco coalition, board or other structure was still operating in nine of the 11 communities and 10 had some level of paid staff dedicated to smoking control. There was also substantial activity in three of the four channels that COMMIT used as an intervention framework: worksites, public education and cessation resources. Many communities were currently engaged in considerable smoking control activity aimed at youth, an area that was intentionally de-emphasized by COMMIT. Implications for the durability of health promotion programs by communities are discussed.     

The role of tobacco outlet density in a smoking cessation intervention for urban youth

This study investigates the role of tobacco outlet density in a randomized controlled trial of a text messaging-based smoking cessation intervention conducted among a sample of 187 primarily African American youth in a midsize U.S. city. A moderated mediation model was used to test whether the indirect effect of residential tobacco outlet density on future smoking was mediated by the intention to smoke, and whether this indirect effect differed between adolescents who received the intervention and those who did not. Results indicated that tobacco outlet density is associated with intention to smoke, which predicts future smoking, and that the indirect effect of tobacco outlet density on future smoking is moderated by the intervention. Tobacco outlet density and the intervention can be viewed as competing forces on future smoking behavior, where higher tobacco outlet density acts to mitigate the sensitivity of an adolescent to the intervention's intended effect. Smoking cessation interventions applied to youth should consider tobacco outlet density as a contextual condition that can influence treatment outcomes.     

Expert opinions on optimal enforcement of minimum purchase age laws for tobacco.

A questionnaire on how youth access laws should be enforced was sent to 20 experts who had administered and/or evaluated a youth access enforcement program. Respondents agreed on the need for a high level of retail compliance, checkers representative of the community, checks at least twice per year, a graduated penalty structure with license revocation, and bans on self-service and vending machines. Respondents indicated the need for research on the effects of ID use, frequency of checks, penalty structures, and the effects on smoking rates of youth access policies alone and in conjunction with other tobacco control policies.     

The effect of local tobacco sales laws on adolescent smoking initiation

BACKGROUND: More than 700 communities have en acted laws prohibiting the sale of tobacco to minors, but little is known about the impact of such laws on youth smoking behavior. The objective of this study was to determine whether local tobacco sales laws de crease the rate of progression to established smoking among adolescents. METHODS: We conducted a prospective cohort study of 592 Massachusetts youths who did not smoke and were ages 12-15 years at the time of a baseline, random-digit-dial, telephone survey in 1993 and who were reinterviewed in 1997. RESULTS: Youths living in towns with a local tobacco sales ordinance at baseline were significantly less likely to progress to established smoking (defined as having smoked at least 100 cigarettes in one's life) than youths living in a town without an ordinance (odds ratio = 0.60; 95% confidence interval 0. 37, 0.97). The magnitude of this effect was unchanged after control ling for potential confounding variables. However, there was no relationship between living in a town with an ordinance and youths' perceived access to tobacco. CONCLUSIONS: Local tobacco sales laws are associated with reduced rates of adolescent smoking initiation, but in this setting, this effect did not appear to be mediated through reduced access to cigarettes.