Synar Amendment Implementation: Quality of State Data on Reducing
Youth Access to Tobacco Could Be Improved (07-NOV-01, GAO-02-74).
								 
Every day, about 3,000 young people become regular smokers. It is
estimated that one-third of them will die from smoking-related	 
diseases. If children and adolescents can be prevented from using
tobacco products they are likely to remain tobacco-free for the  
rest of their lives. In 1992, Congress enacted legislation, known
as the Synar amendment, to reduce the sale and distribution of	 
tobacco products to individuals under the age of 18. States are  
required to enforce laws that prohibit tobacco sales to minors,  
conduct random inspections of tobacco retail or distribution	 
outlets to estimate the level of compliance with Synar		 
requirements, and report the results of these efforts to the	 
Department of Health and Human Services (HHS). The Synar	 
amendment and regulation are the only federal requirements that  
seek to prohibit the sale and distribution of tobacco products to
minors. Weaknesses in the states' implementation of Synar and in 
HHS oversight can adversely affect the quality and comparability 
of state-reported estimates of the percentage of retailers that  
violate laws prohibiting tobacco sales to minors. First, some	 
states used inaccurate and incomplete lists of over-the-counter  
and vending machine tobacco outlets from which to select samples 
for inspection, which affect the estimated statewide violation	 
rate. Second, states allowed the use of minors younger than 16 as
inspectors, even though research suggests that using such minors 
can artificially lower violation rates. Third, HHS approved a few
states' reported violation rates even though the rates included  
inspection results that were invalid because of the ages of the  
inspectors and the outcomes of the inspections were unknown.	 
Fourth, HHS relied on states to validate their own inspection	 
results with limited verification of the accuracy of state data  
even though the potential reduction in a state's block grant	 
award for not meeting annual violation-rate goals could be an	 
incentive for states to report artificially low rates. A little  
more than half the states reported for fiscal year 1999 that they
used fines and suspension or revocation of retailers' licenses to
penalize violators of youth tobacco access laws as part of their 
enforcement strategy. States also reported issuing warning	 
letters and citations. HHS requires states to report evidence of 
actions taken to enforce state laws but does not require the use 
of penalties as an enforcement tool. Research shows that	 
penalties reduce minors' access to tobacco products.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-74						        
    ACCNO:   A02429						        
  TITLE:     Synar Amendment Implementation: Quality of State Data on 
Reducing Youth Access to Tobacco Could Be Improved		 
     DATE:   11/07/2001 
  SUBJECT:   Health hazards					 
	     Tobacco industry					 
	     Teenagers						 
	     Children						 
	     Law enforcement					 
	     Fines (penalties)					 
	     Minors						 
	     SAMHSA Substance Abuse Prevention and		 
	     Treatment Block Grant Program			 
								 

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GAO-02-74
     
Report to the Ranking Minority Member, Committee on Government Reform, House
of Representatives

United States General Accounting Office

GAO

November 2001 SYNAR AMENDMENT IMPLEMENTATION

Quality of State Data on Reducing Youth Access to Tobacco Could Be Improved

GAO- 02- 74

Page i GAO- 02- 74 Reducing Youth Access to Tobacco Letter 1

Results in Brief 3 Background 5 Implementation and Oversight Weaknesses
Adversely Affect the

Quality and Comparability of Retailer Violation Rates 8 Penalties Have Been
Used By States as an Enforcement Tool 16 Conclusions 19 Recommendations for
Executive Action 20 Agency Comments 20

Appendix I Selected Characteristics of States? Synar Implementation
Strategies Reported for Fiscal Year 1999 22

Appendix II Percentage of State Tobacco Outlet Inspections Conducted by 14-
and 15- Year- Olds, Fiscal Year 1999 24

Appendix III Comments From the Department of Health and Human Services 25

Table

Table 1: State Violation- Rate Calculation Excluding Invalid Inspections,
Fiscal Years 1998 and 1999 14

Figure

Figure 1: States with the Highest Percentage of Inspections Conducted by 14-
and 15- Year- Olds for Fiscal Year 1999 12 Contents

Page 1 GAO- 02- 74 Reducing Youth Access to Tobacco

November 7, 2001 The Honorable Henry A. Waxman Ranking Minority Member
Committee on Government Reform House of Representatives

Dear Mr. Waxman: An estimated 57 million Americans currently smoke, putting
themselves at risk of serious health problems, such as cancer, heart
disease, and high blood pressure. Each year, over 430,000 deaths nationwide
are attributable to smoking- related diseases, making tobacco use the
leading preventable cause of death and disease in the United States. 1 Total
spending by the Department of Health and Human Services (HHS) to prevent
tobacco use and dependence is estimated at $900 million for fiscal year
2001. Tobacco use, and the resulting nicotine addiction, begins
predominantly in childhood and adolescence. Every day, about 3,000 young
people become regular smokers. It is estimated that one- third of these
youth will die from smoking- related diseases. 2 In addition to long- term
health consequences, these youth are at risk for numerous early
consequences, such as a general decrease in physical fitness, early
development of artery disease, and a slower rate of lung growth. If children
and adolescents can be prevented from using tobacco products, however, they
are likely to remain tobaccofree for the rest of their lives. 3

In 1992, the Congress enacted legislation, referred to as the Synar
amendment, to reduce the sale and distribution of tobacco products to

1 ?HHS Fact Sheet: Preventing Disease and Death From Tobacco Use?, U. S.
Department of Health and Human Services, Jan. 8, 2001. 2 The National
Clearinghouse for Alcohol and Drug Information, ?Tips For Teens: The Truth
About Tobacco?, SAMHSA?s National Clearinghouse for Alcohol and Drug
Information,

http:// www. health. org/ govpubs/ phd633/ (viewed April 2, 2001). 3 U. S.
Department of Health and Human Services, ?Preventing Tobacco Use Among Young
People: A Report of the Surgeon General?, (Atlanta, Ga: U. S. Department of
Health and

Human Services, Public Health Service, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1994).

United States General Accounting Office Washington, DC 20548

Page 2 GAO- 02- 74 Reducing Youth Access to Tobacco

individuals under the age of 18. 4 HHS? Substance Abuse and Mental Health
Services Administration (SAMHSA) is responsible for promulgating regulations
and overseeing states? compliance with the Synar requirements. Synar and its
regulation require states and territories to have and enforce laws that
prohibit tobacco sales to minors, conduct random inspections of tobacco
retail or distribution outlets 5 to estimate the level of compliance with
Synar requirements, and report the results of these efforts to the Secretary
of HHS. In 1996, the Food and Drug Administration (FDA) also began
regulating the sale and distribution of tobacco products to individuals
under the age of 18. Under the FDA regulation, the sale of tobacco products
to minors was a violation of federal law that, unlike Synar, carried a civil
monetary penalty against retailers. However, in March 2000 the U. S. Supreme
Court ruled that FDA does not have the authority to regulate tobacco
products as customarily marketed, and the program was discontinued. The
Synar amendment and regulation are therefore the only federal requirements
directed toward the goal of prohibiting the sale and distribution of tobacco
products to minors and thereby reducing tobacco use by children and
adolescents.

A key to helping evaluate the nation?s progress toward this goal is credible
information on the percentage of retailers that sell tobacco products to
minors and on the enforcement by states of their youth tobacco access laws.
In fiscal year 1997, states began reporting to SAMHSA their estimates of
retailer violations and enforcement actions taken, including the assessment
of penalties, against retailers who violated tobacco access laws. Because of
your interest in Synar implementation and actions taken to protect children
from the effects of tobacco, you asked us to (1) describe factors that can
affect the quality and comparability of the retailer violation rates that
states develop and (2) determine whether penalties against retailers are
being used as part of enforcement strategies to reduce the sale and
distribution of tobacco products to minors.

To determine the factors that affect the quality and comparability of
retailer violation rates, we reviewed SAMHSA?s guidance to states on
developing and implementing sample design procedures and protocols for

4 Section 1926 of the Public Health Service Act as added by the Alcohol,
Drug Abuse, and Mental Health Administration Reorganization Act (P. L. 102-
321, section 202). 5 SAMHSA defines an outlet as ?any location which sells
at retail or otherwise distributes tobacco products to consumers, including
(but not limited to) locations that sell such products over- the- counter or
through vending machines.?

Page 3 GAO- 02- 74 Reducing Youth Access to Tobacco

inspecting tobacco outlets. We also examined Synar inspection information
reported by the 50 states and the District of Columbia. 6 SAMHSA extracted
the information from the states? Substance Abuse Prevention and Treatment
(SAPT) block grant applications for federal fiscal years 1998 and 1999- the
most recent data available. 7 In addition, we reviewed SAMHSA?s fiscal year
1997 report to the Congress and fiscal year 1998 report to the Secretary of
HHS on Synar compliance. To determine whether penalties are being used as
part of states? enforcement strategies, we examined SAMHSA?s summary of data
on enforcement activities that states reported in their fiscal year 1999
SAPT block grant application. We also reviewed information on FDA?s tobacco
control program to determine how penalties against retailers were used as an
enforcement tool. In addition, we reviewed the literature on evaluations of
tobacco control programs and interviewed researchers and officials from
SAMHSA, FDA, and eight states 8 and representatives of the National
Governors? Association (NGA) and the National Association of State Alcohol
and Drug Abuse Directors (NASADAD) to obtain their views on Synar
implementation issues. We performed our work from June 2000 through
September 2001 in accordance with generally accepted government auditing
standards.

Weaknesses in the states? implementation of Synar and in SAMHSA?s oversight
can adversely affect the quality and comparability of statereported
estimates of the percentage of retailers that violate laws prohibiting
tobacco sales to minors. There are several factors that may affect the
quality of the violation rates developed for fiscal years 1998 and 1999.
First, in implementing their sample designs, some states used

6 We included the District of Columbia with the 50 states in our analyses of
Synar data. We refer to these 51 entities as states throughout this report.
7 The Synar inspection and enforcement information that states report in
their annual SAPT block grant applications should reflect state activities
completed during the previous federal fiscal year. For example, the
inspection data reported in the federal fiscal year 1999 application should
be based on inspections completed by the end of federal fiscal year 1998.
Our analyses in this report are primarily based on state data reported in
their federal fiscal years 1998 and 1999 block grant applications. SAMHSA
did not provide complete data for fiscal year 1997 because, according to
SAMHSA officials, not all states submitted complete data. The states had
approximately 6 months to prepare for and implement SAMHSA?s sample design
and inspection guidance, which was not issued until 1996.

8 We interviewed representatives of Georgia, Idaho, Iowa, New Hampshire, New
York, Tennessee, Texas, and Wyoming responsible for implementing the Synar
amendment. Results in Brief

Page 4 GAO- 02- 74 Reducing Youth Access to Tobacco

inaccurate and incomplete lists of over- the- counter and vending machine
tobacco outlets from which to select samples for inspection, which can
affect the validity of the estimated statewide violation rate. Second, in
their inspection protocols, states allowed the use of minors younger than 16
as inspectors, that is, to act as purchasers of tobacco products during
inspections to measure retailer compliance with tobacco access laws, even
though research suggests that using such minors can artificially lower
violation rates. For fiscal year 1999, 43 states reported using 14- and
15year- olds as inspectors, and 16 of these states used them in more than 50
percent of their inspections. Five of the 16 states reported that a high
percentage of their inspections- 73 to 94 percent- were conducted by 14and
15- year- olds. Third, SAMHSA approved a few states? reported violation
rates even though the rates included inspection results that were invalid
because the ages of the inspectors and the outcomes of the inspections were
unknown. Fourth, SAMHSA relied on states to validate their own inspection
results with limited verification of the accuracy of state data even though
the potential reduction in a state?s block grant award for not meeting
annual violation- rate goals could be an incentive for states to report
artificially low rates. These data quality factors, coupled with the lack of
standardization in the protocols states use when inspecting outlets, can
limit the comparability of retailer violation rates across states.

A little more than half the states reported for fiscal year 1999 that they
used fines and suspension or revocation of retailers? licenses to penalize
violators of youth tobacco access laws as part of their enforcement
strategy. Other types of law enforcement actions that states reported using
include the issuance of warning letters or citations. SAMHSA requires states
to report evidence of actions taken to enforce state laws but does not
require the use of penalties as an enforcement tool. Under FDA?s
discontinued tobacco control program, penalties against retailers who sold
tobacco products to minors were used as an enforcement tool. SAMHSA
officials said that ensuring state enforcement of youth tobacco access laws
had not been their primary focus because they had been relying on FDA?s
enforcement activities. Research shows that enforcement strategies that
include the assessment of penalties are successful at reducing minors?
access to tobacco products.

We are making several recommendations to the Secretary of HHS to improve the
quality and comparability of state- reported tobacco retailer violation
rates. In commenting on a draft of this report, HHS generally agreed with
our findings and recommendations and stated that the report is useful
guidance for making changes in the direction of the Synar program.

Page 5 GAO- 02- 74 Reducing Youth Access to Tobacco

In 1996, SAMHSA issued a regulation implementing the Synar amendment. The
regulation requires all 50 states, the District of Columbia, and eight
insular areas 9 to (1) have in effect and enforce laws that prohibit the
sale and distribution of tobacco products to people under 18 years of age,
(2) conduct annual random, unannounced inspections, using a valid
probability sample of outlets that are accessible to youth, 10 of all
tobacco outlets within the state to estimate the percentage of retailers who
do not comply with the laws, and (3) report the retailer violation rates to
the Secretary of HHS in their annual SAPT block grant applications. SAMHSA
requires that each state reduce its retailer violation rate to 20 percent or
less by fiscal year 2003. SAMHSA and each state negotiated interim annual
target rates that states are required to meet to indicate their progress
toward accomplishing the 20 percent goal. Beginning in fiscal year 1997 for
most states and in subsequent years for all states, the Secretary can
withhold 40 percent of a state?s Substance Abuse Prevention and Treatment
(SAPT) block grant award if it does not comply with the rate reduction
requirements. State fiscal year 2000 SAPT block grant awards ranged from
about $2.5 million to $223 million.

Also in 1996, SAMHSA provided guidance to states on implementing Synar
requirements. SAMHSA issued sample design 11 and inspection guidance 12 to
help states comply with the Synar requirement for conducting random,
unannounced inspections of tobacco outlets to estimate the statewide

9 The eight insular areas are American Samoa, Guam, the Marshall Islands,
the Federated States of Micronesia, the Commonwealth of the Northern Mariana
Islands, the Republic of Palau, Puerto Rico, and the Virgin Islands.
Information on these jurisdictions is not included in this report.

10 A valid probability sample for the purpose of the Synar regulation is a
random sample that includes two key elements: (1) the sample is drawn from
the population of all outlets accessible to youth and (2) each outlet has a
known probability of greater than zero of being selected for inspection. The
sample must reflect the distribution of the outlets in the state that are
accessible to youth under the age of 18, and the random inspections must be
generalizable to the entire state. SAMHSA instructed states to conduct
random unannounced inspections during the fiscal year with a 95- percent
probability that the sampling error would be no greater than 3 percentage
points.

11 SAMHSA, Synar Regulation: Sample Design Guidance (Rockville, Md.: Center
for Substance Abuse Prevention, Aug. 1996). 12 SAMHSA, Implementing the
Synar Regulation: Tobacco Outlet Inspection (Rockville, Md.: Center for
Substance Abuse Prevention, Aug. 1996). Background

Page 6 GAO- 02- 74 Reducing Youth Access to Tobacco

violation rate. 13 The guidance consists primarily of recommended strategies
to give states flexibility in selecting a sample design and inspection
protocol tailored to their particular circumstances, including state and
local laws. For example, SAMHSA?s inspection protocol guidance suggests that
states recruit minors to attempt to purchase tobacco products when
conducting inspections but gives states some flexibility regarding the ages
of the minors that are used. SAMHSA?s guidance requires states to develop
and implement a consistent sample design from year to year and a
standardized inspection procedure for all inspections so that measurements
of violation rates over time are comparable across jurisdictions within a
state. SAMHSA?s guidance includes a Synar requirement that the states
enforce their laws in a manner that can reasonably be expected to reduce the
extent to which tobacco products are available to minors. The guidance
suggests that states use a variety of activities in their enforcement
strategy, such as merchant education, media and community involvement, and
penalties. The enforcement activities could be conducted by different
agencies, such as those responsible for substance abuse prevention and
treatment programs, law enforcement, and state health departments.

SAMHSA reviews state- reported information to determine whether states have
complied with requirements for enforcing state laws and conducting random
unannounced inspections of retail tobacco outlets. In addition to requiring
states to provide evidence of their enforcement activities, SAMHSA requires
states to provide their sampling methodology, inspection protocol, and
tobacco outlet inspection results in their annual SAPT block grant
applications. In its review, SAMHSA and its contractor 14 determine whether
(1) the sample size is adequate to estimate the statewide violation rate and
all tobacco outlets (including over- the- counter and vending machines) in
the state have a known probability of being selected for inspection; (2) the
state assessed the accuracy of lists used to identify the universe of
tobacco outlets from which its sample is drawn; (3) the sample design and
inspection protocols are consistently implemented each year within the
state; and (4) the statewide violation

13 SAMHSA also developed guidance documents on enforcement methods, sources
of cigarettes for minors, retailer education programs, and tobacco
prevention initiatives, and sponsored annual national Synar workshops and
multi- state technical assistance meetings to help states with Synar
implementation.

14 SAMHSA contracts with R. O. W. Sciences, Inc., to provide analysis of the
Synar sampling methodology and the results portion of the states? SAPT block
grant applications.

Page 7 GAO- 02- 74 Reducing Youth Access to Tobacco

rate is correctly calculated, meets the negotiated annual target, and shows
progress toward the 20- percent goal. When data provided in the application
are not sufficient to determine state compliance, SAMHSA requests additional
information from the state before a final decision on state compliance is
made.

SAMHSA collects the state- reported data from the SAPT block grant
applications and in 1996, began storing it in an automated database. These
data are used to monitor states? compliance with Synar requirements, compare
state progress from year to year, and produce an annual report to the
Secretary of HHS and the Congress on Synar implementation. SAMHSA also uses
the data to help finalize the states? annual retailer violation rates, which
are released to the public.

For fiscal years 1997 through 1999, the states? reported violation rates
showed an overall increase in retailer compliance with state laws
prohibiting the sale of tobacco products to minors. The median retailer
violation rate declined from 40 percent in 1997 15 to 24.2 percent in 1999.
Violation rates range from 7.2 percent in Florida to 72.7 percent in
Louisiana for 1997 and from 4.1 percent in Maine to 46. 8 percent in the
District of Columbia for 1999.

SAMHSA has cited 10 states over the 3- year period for being out of
compliance with Synar requirements because they did not reach their
violation- rate target. The Secretary of HHS, however, has not reduced any
state?s SAPT block grant for noncompliance with Synar. In fiscal years 1997
and 1998, states that failed to comply with Synar requirements were not
assessed a penalty because they successfully argued that there were
extraordinary circumstances that hindered their inspection efforts. The
states that were faced with a potential penalty by the Secretary of HHS for
failing to reach their fiscal year 1999 target rates chose to commit

15 The median violation rate in fiscal year 1997 excludes seven states that
were unable to pass the required tobacco access laws because their
legislatures were not scheduled to meet within the time frames covered by
Synar.

Page 8 GAO- 02- 74 Reducing Youth Access to Tobacco

additional funds to ensure compliance with the following year?s
violationrate target. 16

State Synar implementation practices and SAMHSA oversight adversely affect
the quality and comparability of state- reported retailer violation rates.
Although SAMHSA approved states? sample designs, inspection protocols, and
inspection results, the quality of the estimated statewide violation rates
reported for fiscal years 1998 and 1999 is undermined because of several
factors: First, some states used inaccurate and incomplete lists from which
to select samples of tobacco outlets to inspect. Second, most states used
minors younger than 16 to inspect tobacco outlets, and SAMHSA instructed the
states to tell minors not to carry identification on inspections. Both of
these protocols tend to lower the violation rate. Third, SAMHSA approved
some states? violation rates even though they included invalid inspections.
Fourth, SAMHSA relied on states to validate violation rates without ensuring
that the accuracy of the supporting data was verified, even though a
potential reduction in a state?s block grant award for not complying with
Synar could be an incentive to report artificially low rates. These data
quality factors, coupled with the lack of standardization in the protocols
states use when inspecting outlets, limit the comparability of retailer
violation rates across states.

According to SAMHSA officials, some states used inaccurate and incomplete
lists to select random statistical samples of tobacco outlets to inspect,
which could have affected the validity of the samples and compromised
violation rates reported for fiscal years 1998 and 1999. Most states used a
list- based sampling methodology in their sample design, 17 as SAMHSA
recommends. When states use list- based sampling to select a

16 To avoid a 40- percent SAPT block grant reduction for noncompliance, a
provision of the fiscal year 2000 HHS Appropriations Act permitted a state
to certify that it would commit state funds in an amount equal to 1 percent
of that state?s SAPT block grant award for each percentage point by which it
missed the noncompliance sales rate (P. L. 106- 113, sect. 218 [1999]). Under
this provision, the Secretary of HHS could agree to a smaller commitment of
additional funds from the seven states excluded from the fiscal year 1997
median violationrate calculation. This discretion was not given to the
Secretary of HHS in the fiscal year 2001 HHS Appropriations Act.

17 Other sampling methods states can use include area sampling, in which
outlets in randomly selected geographic areas or locations within the state
are chosen; list- assisted area sampling; and census sampling, which seeks
to inspect all outlets. Some states use area sampling to supplement their
list- based sample. Implementation and

Oversight Weaknesses Adversely Affect the Quality and Comparability of
Retailer Violation Rates

States? Use of Inaccurate Lists of Tobacco Outlets Affects the Validity of
Samples for Inspection

Page 9 GAO- 02- 74 Reducing Youth Access to Tobacco

sample of tobacco outlets for inspection, SAMHSA requires that they report
evidence that they have verified the accuracy and completeness of lists for
both over- the- counter and vending machine outlets. However, we found that
for fiscal year 1998, 40 states reported to SAMHSA that they did not know
the accuracy of the lists they were using. 18 States can use different lists
to develop their population of tobacco outlets, but the accuracy and
completeness of these lists vary. For example, states can use lists of
state- licensed tobacco outlets, but these lists are not always updated by
the responsible state agencies. Also, national and state commercial listings
can be used, but they often contain many establishments that do not sell
tobacco products or may identify the owners of the business but not
necessarily each retail outlet. In some rural areas and Midwestern states,
developing a complete list of outlets can be difficult because tobacco
products are sometimes sold from individuals? homes or other places that are
not known to be tobacco outlets. Comments made by several state officials
indicate a need by some states for more technical assistance from SAMHSA in
addressing state- specific issues- particularly sample design- that affect
their compliance with Synar.

Accurately identifying the population of vending machine outlets accessible
to youth in a state is also important, according to SAMHSA?s fiscal year
1997 report of Synar implementation 19 and other documents, because vending
machines have been a major source that children use to obtain tobacco
products. In our review of the state data that SAMHSA provided from SAPT
block grant applications for fiscal year 1999, we found that of the 37
states reporting that they inspected vending machine outlets, 11 did not
report the population of vending machines accessible to

18 Ten states (Alabama, Connecticut, Kansas, Maryland, Mississippi, Montana,
New Mexico, Utah, Washington, and Wisconsin) reported that they knew a
certain percentage of their list to be accurate. The reported accuracy of
the lists for 9 of these states ranged from 70 percent to greater than 99
percent. The remaining state, New Mexico, reported that its list was about
36 percent accurate. One state, Colorado, reported that it used a list-
assisted area sampling methodology, and therefore did not report on the
accuracy of its list. SAMHSA officials said that this information was
obtained from SAPT block grant applications and interviews with state
officials. SAMHSA officials said they began requesting that states describe
the accuracy and coverage of their sampling list in their fiscal year 1999
SAPT block grant applications. According to SAMHSA, 8 states did not report
this information. However, SAMHSA did not provide any data on the percentage
of accuracy or completeness of sampling lists for those states that did
report.

19 Synar Regulation Implementation: Report to Congress on FFY 1997 State
Compliance, Center for Substance Abuse Prevention, Substance Abuse and
Mental Health Services Administration, U. S. Department of Health and Human
Services.

Page 10 GAO- 02- 74 Reducing Youth Access to Tobacco

youth in their states as SAMHSA requires. (See app. I) Further, our review
of a few block grant applications showed that states reported that they
inspected vending machine outlets when they found them during random
inspections of over- the- counter outlets. Some states have had difficulty
developing accurate and complete lists of vending machine outlets, in
particular, because many of the machines are privately owned and their
portability makes them difficult to track. Officials we interviewed told us
that over the years there has been a significant decline in vending machine
tobacco outlets accessible to minors. However, an NGA representative said
that vending machines are and will continue to be a source of tobacco
products for minors in some states. The results of a 1999 national survey of
middle school and high school students? access to cigarettes 20 show that
vending machines continue to be a source of tobacco products for youth,
particularly middle school students. For example, when students were asked
where during the past 30 days, they bought their last pack of cigarettes,
2.7 percent of the high school students reported that their purchase was
from vending machines. However, 12.9 percent of middle school students
reported their last pack of cigarettes was purchased from vending machines.

SAMHSA officials told us that states need to be more aggressive in
identifying tobacco outlets. An NGA study of best practices in implementing
and enforcing Synar requirements notes that programs that require tobacco
retailers to be licensed provide an effective source of information for
identifying the outlets. 21 Not all states, however, require tobacco outlets
to be licensed. SAMHSA officials said that they believe tobacco licensure
programs that require the identification of every tobacco outlet and regular
license renewals afford states the best opportunity to develop accurate and
complete statewide lists of over- thecounter and vending machine tobacco
outlets. However, in comments on a draft of this report, HHS stated that
SAMHSA does not have the authority to license tobacco retailers or require
states to enact legislation mandating tobacco retailer licensing or
registration.

20 Y outh Access to Cigarettes: Results from the 1999 National Tobacco
Survey, Legacy First Look Report 5, American Legacy Foundation, Oct. 2000.
21 NGA, Health Policy Studies Division, Issue Brief, ?State Best Practices
in Enforcing and Implementing Synar Law and Regulations,? Aug. 25, 2000. The
study was based on interviews with representatives of state agencies from 18
states.

Page 11 GAO- 02- 74 Reducing Youth Access to Tobacco

The quality of states? violation rates can be particularly affected by the
age of the minors used to inspect the tobacco outlets. Research shows that
minors who are younger than 16 years of age are much less successful at
purchasing tobacco products than older youths. 22 Research also shows, 23
and SAMHSA officials told us that, a small difference in the age of minors
can make a significant difference in a state?s violation rate because the
younger the minor inspectors appear, the less likely store clerks will sell
them tobacco. As a result, using minors younger than 16 could bias the
outcome of state inspections by lowering the violation rate. Even though
SAMHSA officials are aware of the research results, they allow states to
include minors younger than 16 in their inspection protocols. SAMHSA?s
inspection protocol guidance recommends that states use 15- and 16- yearolds
as inspectors because minors younger than 15 are likely to look very young,
and their appearance could discourage some retailers from selling them
tobacco products. Nearly all states report using as inspectors, youth from a
combination of two age cohorts, 14- and 15- year- olds and 16- and 17- year-
olds. 24 For fiscal year 1999, 43 states reported using 14- and 15year- olds
as inspectors, and 16 of these states used them in more than 50 percent of
their inspections. (See app. II.) Five of the 16 states (Georgia, New
Hampshire, North Carolina, Tennessee, and Texas) reported the highest
percentages of inspections that were conducted by 14- and 15- year- olds--
73 percent to 94 percent. (See fig. 1.) Four of the 5 states also reported
that a large proportion of their fiscal year 1998 inspections were conducted
by 14- and 15- year- olds. Tennessee and Texas officials told us they did
not purposely try to recruit large numbers of 14- and 15- year- olds. They
said that they selected those minors that were willing to participate in the
inspections.

22 Joseph R. DiFranza and others, ?Youth Access to Tobacco: The Effects of
Age, Gender, Vending Machine Locks, and ?It is the Law? Programs,? American
Journal of Public Health, Vol. 86, No. 2 (Feb. 1996).

23 Pamela I. Clark, and others, ?Factors Associated With Tobacco Sales to
Minors,? Journal of the American Medical Association, Vol. 86, No. 2 (Aug.
9, 2000). 24 SAMHSA requires states in their SAPT block grant applications
to report by cohort the ages of minors used to conduct inspections of
tobacco outlets. States are encouraged to use two age cohorts- 14- and 15-
year- olds, and 16- and 17- year- olds. However, SAMHSA also allows states
to report inspections by minors under 12 years of age, 12 through 13 years,
and 18 and older, provided states justify their use. Using Younger Minors as

Inspectors Can Bias Results

Page 12 GAO- 02- 74 Reducing Youth Access to Tobacco

Figure 1: States with the Highest Percentage of Inspections Conducted by 14-
and 15- Year- Olds for Fiscal Year 1999

Source: GAO analysis based on SAMHSA?s summary of information reported by
the 51 states in their fiscal years 1998 and 1999 SAPT block grant
applications.

Inspection data supporting the violation rates for North Carolina and
Tennessee show that inspections conducted by 14- and 15- year- olds resulted
in lower purchase rates than inspections by 16- and 17- year- olds. For
example, Tennessee reported that 14- and 15- year- old inspectors were able
to purchase tobacco 16 percent of the time, whereas the 16- and 17year- olds
had a 51- percent purchase rate. New York state officials? analysis of their
state inspection results for fiscal year 2000 showed that 14- and 15year-
olds were able to purchase tobacco 8 percent of the time, whereas the 16-
and 17- year olds had a 21- percent purchase rate. At the time of our
review, SAMHSA officials told us that they had not thoroughly examined

0 20

40 60

80 100 Percent

66 41

74 28

52 48

94 6

94 6 78

22 81

19 73

27 25 74 77

23 Ages 14- 15 Ages 16- 17

1998 1999 Georgia

1998 1999 New Hampshire

1998 1999 North Carolina

1998 1999 Texas 1998 1999

Tennessee

Page 13 GAO- 02- 74 Reducing Youth Access to Tobacco

states? use of 14- and 15- year- old inspectors and the potential impact on
retailer violation rates, but they acknowledged that this is something that
will require a more comprehensive evaluation.

Another age- related inspection protocol procedure that can affect retailer
violation rates is whether minor inspectors are told to carry valid
identification on inspections and required to show it when asked. The
research on this issue is mixed. Some research suggests that when minors are
asked to show identification, retailers are less likely to sell them tobacco
products. Other research suggests, and some state officials told us, that
the likelihood of an illegal sale is greater if minors show identification
when asked than if identification is not shown. As a result, having and
showing identification when asked could potentially result in an illegal
tobacco sale and a higher retailer violation rate. About half of the illegal
sales in one state?s inspections occurred after the minor showed proof of
age. 25 Research suggests that some clerks may sell minors tobacco products
because they have difficulty quickly determining an individual?s age from a
date- of- birth on his or her identification. According to HHS, because of
safety concerns, SAMHSA recommends that minors not carry identification but
answer truthfully about their age if asked by a store clerk. Research also
suggests that the sex of the minor inspector can bias the inspection result.
For example, when controlling for the effects of both age and sex of the
inspector, one researcher found that girls were able to purchase at a 39-
percent rate compared to boys who had a 28- percent purchase rate. 26 Unlike
previous research, this research controlled for the effects of both age and
sex.

SAMHSA approved four states? retailer violation rates for fiscal years 1998
and 1999 that were inaccurately calculated because they included inspections
in which the ages of minor inspectors and the inspection results were not
known. SAMHSA requires states to report the ages of minor inspectors in part
to confirm that the ages of the inspectors are within an acceptable range.
When the ages of minors used in state inspections are unknown, SAMHSA
officials told us that they consider the inspections invalid, and the
inspection results should be excluded from the

25 Joseph R. DiFranza, ?State and Federal Compliance With the Synar
Amendment- Federal Fiscal Year 1997,? Archives of Pediatric Adolescent
Medicine, Vol. 154, No. 9 (2000), pp. 936- 42.

26 Joseph R. DiFranza and others. A Few States? Violation

Rates Have Included Invalid Inspection Results

Page 14 GAO- 02- 74 Reducing Youth Access to Tobacco

violation rate computation. However, we found that SAMHSA approved and
published violation rates reported by Florida, Kansas, Louisiana, and
Minnesota that included inspection results in which the ages of the minor
inspectors were unknown. Moreover, three of these states? violation rates
included some inspections where neither the age of the minors nor the
outcomes of the inspections were known. Had the invalid inspections been
excluded, the violation rates for Florida, Louisiana, and Minnesota would
have been higher (See table 1.) However, none of the four states would have
missed its target based on the recalculated rate.

Table 1: State Violation- Rate Calculation Excluding Invalid Inspections,
Fiscal Years 1998 and 1999

State and Fiscal Year Target Rate

(percentage) Approved

Violation Rate (percentage)

Rate Excluding Invalid Inspections (percentage)

Percentage Point Difference in

Reported Violation

Rate

Louisiana, 1998 60.00 39.00 43.37 4.37 Minnesota, 1998 26.00 28.10 27.99
-0.11 Florida, 1998 20.00 7.11 8.36 1.25 Kansas, 1999 38.00 35.00 39.76 4.76

Source: GAO analysis based on SAMHSA?s summary of information reported by
the 51 states in their fiscal years 1998 and 1999 SAPT block grant
applications.

SAMHSA officials said that there were reasons for accepting the states?
violation rates. For example, they said that they did not exclude Kansas?
invalid inspections because the state provided the outcomes of the
inspections. Even though Florida?s retailer violation rate was based
entirely on inspections in which the ages of the inspectors and the outcomes
by age were unknown, SAMHSA accepted the rate because of the large number of
inspections the state conducted and its low reported violation rate.

SAMHSA did not ensure that the accuracy of the data that states used to
support their fiscal year 1998 and 1999 estimates of retailer violation
rates was verified. SAMHSA reviewed the information states reported in their
SAPT block grant applications. However, SAMHSA relied on the states to
assess the quality of the data they used to develop their rates, even though
the potential 40- percent reduction in a state?s block grant for not meeting
annual violation rate goals could provide an incentive for some states to
Verification of the

Accuracy of State Inspection Data Was Limited

Page 15 GAO- 02- 74 Reducing Youth Access to Tobacco

report artificially low violation rates. To improve their oversight, during
the time of our review, SAMHSA officials completed pilot testing of their
state data review protocol and began visiting states to evaluate their
systems of data collection and documentation for Synar implementation. The
draft review protocol SAMHSA officials said they were using includes
questions about the states? sampling and inspection procedures and practices
that could help in making an assessment of the quality of the data states
used to develop violation rates. SAMHSA officials said that because of
resource constraints, they plan to conduct these reviews approximately once
every 3 to 4 years for each state.

Differences in how states implement their inspection protocols, along with
data quality weaknesses, limit the comparability of retailer violation rates
across states. SAMHSA does not require all states to use the same set of
protocols when conducting inspections of tobacco outlets. Although SAMHSA
provides inspection guidelines, each state is allowed the flexibility to
develop inspection protocols in keeping with its own circumstances,
including restrictions in state law. Given this flexibility, there is
inconsistent implementation of inspection protocols across states, which
makes comparisons of retailer violation rates difficult.

States? use of different ages and sexes of minor inspectors and different
criteria in determining what type of tobacco sale is a violation punishable
under state law can limit comparisons of violation rates across states. For
example, the ages of minor inspectors is an issue in comparisons because
some states use higher proportions of younger inspectors than other states
and younger minors tend to have lower purchase rates than older minors.
Also, the states? use of minor boys and girls as inspectors in different
proportions can limit comparisons of violation rates because females tend to
have higher tobacco purchase rates than males. Another inspection procedure
that can limit the comparability of violation rates between states is
whether the state uses the ?consummated? or the

?unconsummated? buy protocol. In a consummated buy, the minor inspector
completes the purchase and takes possession of the tobacco product, whereas
in an unconsummated buy the minor inspector attempts or asks to purchase the
tobacco product and the clerk accepts payment, but the inspector leaves
without taking the product.

Some states use the unconsummated- buy protocol to protect minor inspectors,
who cannot legally purchase tobacco products. For Synar inspections, if a
sale is made, it is considered a successful attempt, or a violation,
regardless of which protocol is used. However, according to Differences in

Implementation of Synar Limit the Comparability of Retailer Violation Rates
Across States

Page 16 GAO- 02- 74 Reducing Youth Access to Tobacco

SAMHSA and other officials we interviewed, choice of the buy protocol can
affect a state?s violation rate. When the unconsummated- buy protocol is
used, there could be a question of whether a violation of state law actually
occurred if the minor did not take possession of the tobacco product. Some
merchants are challenging in court the penalties states assess under state
law for violations based on unconsummated buys. If these challenges are
upheld or not resolved in those states, merchants may continue to sell
tobacco products to minors because they would not expect a penalty for their
actions and the states? retailer violation rates could be adversely
affected. This inconsistent application of the consummated- and
unconsummated- buy protocols by states and the potential effect on retailer
violation rates could limit comparison of rates across states. SAMHSA?s
fiscal year 1999 data show that 39 states used the consummated- buy protocol
and 12 states used the unconsummated- buy protocol when inspecting tobacco
outlets. (See app. I.)

Comparing retailer violation rates across states could be useful in
determining national progress toward the goal of reducing minors? access to
tobacco products and in identifying best practices used by states that seem
to be making better progress than others. Because of the lack of uniform
inspection protocols across states, however, SAMHSA officials and others do
not suggest making such comparisons.

A little more than half the states reported in their fiscal year 1999 block
grant applications that violators of youth tobacco access laws were
penalized as part of the state?s enforcement strategy. All states have laws
that allow the use of penalties, but not all states reported that penalties
were assessed, according to SAMHSA data. The states reported using a variety
of enforcement actions, such as warnings, fines, and suspensions of
retailers? licenses. SAMHSA officials said that in their review of
statereported information for Synar compliance, they look for evidence of
active enforcement, such as the assessment of penalties, and make inquiries
to state officials when the evidence is not apparent. However, SAMHSA
officials also said that ensuring state enforcement of youth tobacco access
laws has not been their primary focus because they were relying on FDA?s
enforcement activities, which included assessing monetary civil penalties
against retailers. The officials said that because of the discontinuation of
FDA?s program, they need to examine states? evidence of active enforcement
more closely to ensure that states are enforcing their youth tobacco access
laws. Research shows that enforcement strategies that include the assessment
of penalties are successful at reducing minors? access to tobacco products.
Penalties Have Been

Used By States as an Enforcement Tool

Page 17 GAO- 02- 74 Reducing Youth Access to Tobacco

In our review of SAMHSA?s summary data for fiscal year 1999, we found that
28 states reported specific evidence of having imposed penalties for
violations of state youth tobacco access laws. (See app. I.) These penalties
included fines against retailers and sales clerks and the suspension or
revocation of retailers? licenses. Seven states reported that they took
other law enforcement actions against violators, such as issuing warning
letters or citations. All states have laws that allow the assessment of
penalties, but not all states reported using penalties as part of their
enforcement strategies. For fiscal year 1999, for example, although states
have the flexibility to determine which enforcement strategies are
appropriate for compliance with Synar, SAMHSA maintains that state laws are
more successful in changing retailer behavior regarding selling tobacco to
minors when penalties are used, and SAMHSA encourages states to use them.
Florida is an example of a state that has adopted a statewide enforcement
strategy that penalizes violators of its youth tobacco access laws. In its
fiscal year 1998 application, Florida reported that 3 percent of the
merchants who were found out- of- compliance with the state?s law had their
licenses revoked or suspended and 93 percent were assessed fines ranging
from $250 to $1,000. SAMHSA officials said they look for evidence of active
enforcement, such as the assessment of penalties, in statereported
information on Synar compliance and in some cases ask the state for an
explanation when the evidence is not apparent. SAMHSA officials also said,
however, that prior to the discontinuance of the FDA tobacco control program
in March 2000, they relied on FDA to ensure enforcement of requirements to
reduce youth access to tobacco products.

As a regulatory agency, FDA took an approach different from that taken by
SAMHSA in prohibiting the sale of tobacco products to minors. FDA?s
discontinued tobacco control program focused on enforcement and required
that penalties be assessed against repeat violators of FDA?s regulation. FDA
contracted with states to conduct inspections of tobacco outlets. FDA?s
contract stipulated that each state conduct at least 375 unannounced monthly
compliance inspections of merchants that sold tobacco products over- the-
counter, and states were instructed to reinspect violators. FDA?s goal was
to have compliance checks performed throughout the entire state. 27 If an
inspection resulted in a violation, the state was expected to re- inspect
the establishment within 90 days and

27 Depending on the availability of resources, some states were allowed to
negotiate a lower number of checks and focus on selected sites. About Half
of States

Report Using Penalties in Their Enforcement Strategies

Retailers Were Assessed Monetary Penalties for Violating FDA?s Tobacco
Control Regulation

Page 18 GAO- 02- 74 Reducing Youth Access to Tobacco

continue inspections until compliance was achieved. For the first violation,
the retailer would receive a warning letter. For subsequent offenses, civil
monetary penalties were to be assessed ranging from $250 for a second
offense to $10,000 for a fifth offense. At the time the program was
discontinued, FDA had imposed a maximum penalty of $1,500 and collected an
estimated total of $1 million.

Although states were allowed to use FDA contract funds for enforcement,
SAMHSA officials said that states are permitted to use SAPT block grant
funds for enforcement activities only if a citation is issued for a
violation at the time of the inspection. States are permitted to use SAPT
block grant funds to develop sample designs and conduct inspections of
tobacco outlets. SAMHSA officials told us that states would need federal
funds to support broader enforcement activities now that FDA?s program has
been discontinued. Although NGA recognizes the importance of funding
enforcement, an NGA representative told us that the association is not
currently advocating additional federal funding for state enforcement
activities. In commenting on this report, HHS noted that state funds and
tobacco settlement funds are other possible sources of funding for
enforcement activities.

Officials for SAMHSA, FDA, and a state we consulted told us that they
believe that without FDA?s enforcement of its regulation against the sale of
tobacco products to minors, some tobacco retailers will become more lax and
sales to minors will increase. FDA officials also said they do not believe
tobacco retailers will change their behavior without knowing that violations
will result in penalties. SAMHSA officials said that they have not focused
as much on state enforcement actions under Synar implementation because of
their reliance on FDA to enforce its tobacco control regulation, which
included penalties against retailers. They said that because FDA?s program
was discontinued in March 2000, they see the need to ensure that states show
evidence of active enforcement of their laws.

Research suggests that enforcement strategies that incorporate inspections
of all retailers followed by penalties and re- inspections are successful in
reducing the availability of tobacco to minors. 28 The components of an
effective enforcement strategy include an enforceable

28 Joseph R. Difranza, ?Are the Federal and State Governments Complying With
the Synar Amendment?? Archives of Pediatrics and Adolescent Medicine, Vol.
153 (Oct. 1999).

Page 19 GAO- 02- 74 Reducing Youth Access to Tobacco

law with penalties sufficiently severe to deter potential violators,
according to the research. NGA concluded from its interviews with
representatives of state agencies on best practices in enforcing Synar that
the single most effective factor in reducing tobacco access to minors is the
establishment of a statewide inspection and enforcement program that holds
merchants and clerks accountable for their actions. Some state officials
told us they believe that aggressive penalties assessed against the retailer
can be very effective in changing merchant behavior. New York, for example,
plans to begin confiscating merchants? lottery licenses for failure to
comply with laws prohibiting the sale of tobacco products to minors.

The goal of the Synar amendment is to help reduce the sale of tobacco
products to minors through state laws that make it illegal for retailers to
sell them tobacco products. States are responsible for enacting and
enforcing laws that restrict youth access to tobacco products and for
reporting the progress in retailer compliance with Synar requirements.
However, state implementation of Synar and SAMHSA?s oversight raise concern
about the quality of state estimates of the percentage of retailers that
sell tobacco products to minors. These concerns center on the use of
inaccurate lists of retail outlets from which to draw a sample to inspect;
the use of inspection protocols among the states that could bias retailer
violation rates and limit their comparability, such as the age of minor
inspectors; the acceptance of violation rates that contain invalid
inspection results; and the reliance on states to validate their inspection
results without ensuring that the supporting data are verified. SAMHSA
recently began visiting states to check their inspection practices, but more
could be done to improve the quality of the inspection results and enhance
the usefulness of retailer violation rates in evaluating national progress
toward reducing minors? access to tobacco products.

The states have flexibility in developing strategies to help enforce their
youth tobacco access laws. According to researchers and state and SAMHSA
officials, assessing penalties for selling tobacco to minors, as done under
FDA?s program, can be an effective enforcement tool for reducing minors?
access. For fiscal year 1999, a little more than half the states reported
evidence of using penalties to help enforce their laws. In its oversight of
state enforcement activities, SAMHSA has decided to more closely examine
states? use of different enforcement strategies, including the assessment of
penalties as sanctions against violators of youth tobacco access laws.
Conclusions

Page 20 GAO- 02- 74 Reducing Youth Access to Tobacco

To help ensure the quality of states? estimates of tobacco retailer
violation rates under the Synar amendment and to make the rates more
comparable across states, we recommend that the Secretary of HHS direct the
Administrator of SAMHSA to

 help states improve the validity of their samples by working more closely
with them in developing ways to increase the accuracy and completeness of
the lists of tobacco outlets from which they draw random samples for
inspections;

 revise the inspection protocol guidance to better reflect research
results, particularly regarding the ages of minor inspectors, and work with
states to develop a more standardized inspection protocol consistent with
state law, and more uniform implementation across states; and

 ensure that all states? retailer violation rates exclude invalid
inspections, particularly those in which the ages of minors and outcomes of
inspections are unknown.

We obtained comments on a draft of this report from HHS. (See app. III for
agency comments.) In general, HHS agreed with our findings and
recommendations and found our report to be useful guidance for future
changes in Synar implementation. HHS disagreed with our recommendation that
SAMHSA require more standardization in inspection protocol development
consistent with state laws and more uniform implementation across states.
HHS stated that this action would accomplish very little in the way of
meaningful comparisons of violation rates across states without federal
legislation requiring states to modify their practices and possibly lead to
changes in state laws pertaining to inspection protocols. We believe,
however, that federal legislation may not be necessary. There are
consistencies that currently exist in inspection protocols among many of the
states, such as in the ages of minors used to conduct inspections.
Identifying other key inspection protocols that states may be able to adopt,
such as whether minor inspectors should carry identification, would provide
a core group of protocols that could enhance comparisons of retailer
violation rates across states. In light of HHS? comment, however, we revised
our recommendation to have the Secretary of HHS direct SAMHSA to collaborate
with states in developing more standardization in protocols and uniform
implementation across states. HHS officials also provided comments intended
to increase the report?s accuracy. Where appropriate, we have incorporated
HHS? suggested changes and technical comments in this report.
Recommendations for

Executive Action Agency Comments

Page 21 GAO- 02- 74 Reducing Youth Access to Tobacco

As we agreed with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
from the date of this letter. We will then send copies to others who are
interested and make copies available to others who request them.

If you or your staff have any questions about this report, please contact me
at (202) 512- 7119 or James O. McClyde at (202) 512- 7152. Darryl W. Joyce,
Paul T. Wagner, Jr., and Arthur J. Kendall made key contributions to this
report.

Sincerely yours, Janet Heinrich Director, Health Care- Public Health Issues

Appendix I: Selected Characteristics of States? Synar Implementation
Strategies Reported for Fiscal Year 1999

Page 22 GAO- 02- 74 Reducing Youth Access to Tobacco

State Did not report the

population of vending machines Inspected vending

machines Used the

unconsummated- buy protocol

Type of law enforcement action taken

Alabama X Fines Alaska X License suspensions Arizona X X e Arkansas X a X
License suspensions,

warnings California d Fines Colorado X b X Fines, warnings Connecticut X X
Fines, warnings Delaware d Fines District of Columbia X Warnings Florida X
License revocations and

suspensions, fines, warnings Georgia X e Hawaii d Fines, citations Idaho X
Citations Illinois X X License revocations,

fines, citations, warnings Indiana d X Warnings and arrest

tickets Iowa d e Kansas d Fines Kentucky X a X Fines, citations Louisiana X
a X Citations Maine d e Maryland X a X X Citations Massachusetts X Fines,
citations Michigan X X e Minnesota X e Mississippi d Warnings Missouri Fines
Montana X Fines Nebraska X a X Fines Nevada X Fines New Hampshire X X e New
Jersey X Fines, summonses,

warnings New Mexico c X Fines, citations New York X a X License suspensions
North Carolina X Defendants charged

under misdemeanor statute

Appendix I: Selected Characteristics of States? Synar Implementation
Strategies Reported for Fiscal Year 1999

Appendix I: Selected Characteristics of States? Synar Implementation
Strategies Reported for Fiscal Year 1999

Page 23 GAO- 02- 74 Reducing Youth Access to Tobacco

State Did not report the

population of vending machines Inspected vending

machines Used the

unconsummated- buy protocol

Type of law enforcement action taken

North Dakota X License suspensions, fines warnings Ohio X a X Fines,
warnings Oklahoma X Fines, citations Oregon d Fines, citations Pennsylvania
X a X e Rhode Island X Fines, warnings,

citations South Carolina X Fines South Dakota X Fines, warnings Tennessee X
X Fines, citations Texas X X Citations, warnings Utah d e Vermont d e
Virginia X c X X e Washington d e West Virginia X e Wisconsin X c X e
Wyoming X e

Total 11 37 12

a State did not report the specific number of vending machine outlets
because its (1) lists of businesses or state- licensed outlets did not
specify vending machines from other types of outlets or (2) the number of
vending machine outlets was unknown because the state licenses vending
machine companies or owners. b Because state used area sampling, reporting
the population of vending machines was not necessary.

c Information not provided. d State laws or regulations either banned
tobacco vending machines or restricted youth access. According to SAMHSA
officials, states that have laws that restrict tobacco vending machines are
not required to inspect them. e Specific law enforcement action taken was
not reported.

Source: Summary of information SAMHSA extracted from states? fiscal year
1999 SAPT block grant applications and SAMHSA?s comments on a draft of this
report.

Appendix II: Percentage of State Tobacco Outlet Inspections Conducted by 14-
and 15Year- Olds, Fiscal Year 1999

Page 24 GAO- 02- 74 Reducing Youth Access to Tobacco

States With Greater Than 50 Percent of Inspections by 14- and 15- Year- Olds
(Percentage)

New Hampshire 94 Maryland 60 North Carolina 94 Washington a 59 Tennessee 77
Pennsylvania 54 Georgia 74 West Virginia 54 Texas 73 Arkansas 53 Delaware 70
Alabama 53 Indiana 66 Oklahoma 53 Nebraska 63 California 52

States With Less Than 50 Percent of Inspections by 14- and 15- Year- Olds

Virginia 49 Alaska 32 South Carolina 49 Illinois 30 Colorado 47 Louisiana 28
Florida 46 Ohio 28 Wisconsin 46 Kentucky 27 Oregon 43 Missouri 24 New York
43 Iowa 21 New Mexico 43 Minnesota 19 Maine 42 Utah 13 Rhode Island 42
Nevada a 6 New Jersey 42 Arizona 0 Massachusetts 42 Connecticut 0 Hawaii 40
District of

Columbia 0 Mississippi 35 Idaho 0 Montana 34 North Dakota 0 Kansas a 32
South Dakota 0 Michigan 30 Vermont 0

Wyoming 0 Note: Table is based on 51 states that reported the ages of minor
inspectors. Three states reported using minors younger than 14. a Percentage
excludes inspections in which the ages of minor inspectors were not reported
in SAPT

block grant applications. Source: SAMHSA?s summary of information states
reported in their fiscal year 1999 SAPT block grant applications.

Appendix II: Percentage of State Tobacco Outlet Inspections Conducted by 14-
and 15- Year- Olds, Fiscal Year 1999

Appendix III: Comments From the Department of Health and Human Services

Page 25 GAO- 02- 74 Reducing Youth Access to Tobacco

Appendix III: Comments From the Department of Health and Human Services

Appendix III: Comments From the Department of Health and Human Services

Page 26 GAO- 02- 74 Reducing Youth Access to Tobacco

Appendix III: Comments From the Department of Health and Human Services

Page 27 GAO- 02- 74 Reducing Youth Access to Tobacco

Appendix III: Comments From the Department of Health and Human Services

Page 28 GAO- 02- 74 Reducing Youth Access to Tobacco

Appendix III: Comments From the Department of Health and Human Services

Page 29 GAO- 02- 74 Reducing Youth Access to Tobacco (201103)

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