Attachment D1 - Reducing Yourth Access to Tobacco Report

United States General Accounting Office

GAO

Report to the Ranking Minority
Member, Committee on Government
Reform, House of Representatives

November 2001

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

GAO-02-74

Contents

Letter

Appendix I

Appendix II

Appendix III

1
Results in Brief
Background
Implementation and Oversight Weaknesses Adversely Affect the
Quality and Comparability of Retailer Violation Rates
Penalties Have Been Used By States as an Enforcement Tool
Conclusions
Recommendations for Executive Action
Agency Comments

3
5
8
16
19
20
20

Selected Characteristics of States’ Synar
Implementation Strategies Reported for Fiscal Year
1999

22

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

24

Comments From the Department of Health and
Human Services

25

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

14

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

12

Table

Figure

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United States General Accounting Office
Washington, DC 20548

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).

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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 outlets5 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.”

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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 states8 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.

Results in Brief

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.

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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.

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Background

In 1996, SAMHSA issued a regulation implementing the Synar amendment.
The regulation requires all 50 states, the District of Columbia, and eight
insular areas9 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 design11 and inspection guidance12
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).

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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 contractor14
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.

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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 199715 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.

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

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

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.

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

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, § 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.

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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 implementation19 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.

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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 cigarettes20 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

Youth 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.

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Using Younger Minors as
Inspectors Can Bias
Results

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 15year-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.

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Figure 1: States with the Highest Percentage of Inspections Conducted by 14- and 15-Year-Olds for Fiscal Year 1999
100 Percent
94

94

80

81
78

77
74

74

73

66
60
52
48
40

41

28

27

25

23

22

20

19

6

6

0
1998

1999
Georgia

1998
1999
New Hampshire

1998
1999
North Carolina

1998

1999
Tennessee

1998

1999
Texas

Ages 14-15
Ages 16-17

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

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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.

A Few States’ Violation
Rates Have Included
Invalid Inspection Results

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.

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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
Louisiana, 1998
Minnesota, 1998
Florida, 1998
Kansas, 1999

Target Rate
(percentage)
60.00
26.00
20.00
38.00

Approved
Violation Rate
(percentage)
39.00
28.10
7.11
35.00

Rate Excluding
Invalid
Inspections
(percentage)
43.37
27.99
8.36
39.76

Percentage
Point
Difference in
Reported
Violation
Rate
4.37
-0.11
1.25
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.

Verification of the
Accuracy of State
Inspection Data Was
Limited

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

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

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

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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.

Penalties Have Been
Used By States as an
Enforcement Tool

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.

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About Half of States
Report Using Penalties in
Their Enforcement
Strategies

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.

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

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.

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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).

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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.

Conclusions

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.

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Recommendations for
Executive Action
•

•

•

Agency Comments

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.

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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

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GAO-02-74 Reducing Youth Access to Tobacco

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

State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida

Did not report the
population of
vending machines

a

X

Inspected vending
machines
X
X
X
X
d
X
X

b

X

Used the
unconsummated-buy
protocol

X

X

d

X
X

Type of law
enforcement action
taken
Fines
License suspensions
e

License suspensions,
warnings
Fines
Fines, warnings
Fines, warnings
Fines
Warnings
License revocations and
suspensions, fines,
warnings
e

Georgia
Hawaii
Idaho
Illinois

X

Indiana

d

Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey

d

e

d

Fines
Fines, citations
Citations

New Mexico
New York
North Carolina

d

X
X

a

X
a
X

X
X

X
X
d

a

X

X
X
X
X

e

X

Citations
Fines, citations

X

e
e

d

X
X
X
X
X

a

X

c
a

X

X
X

Page 22

Fines, citations
Citations
License revocations,
fines, citations, warnings
Warnings and arrest
tickets

Warnings
Fines
Fines
Fines
Fines
X

X

e

Fines, summonses,
warnings
Fines, citations
License suspensions
Defendants charged
under misdemeanor
statute

GAO-02-74 Reducing Youth Access to Tobacco

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

State
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Total

Did not report the
population of
vending machines

Inspected vending
machines
X

a

X

Used the
unconsummated-buy
protocol

X
X
d

a

X

e

X
X
X
X
X
X

c

X

c

11

X
X

Fines, warnings,
citations
Fines
Fines, warnings
Fines, citations
Citations, warnings

d

e

d

e

X

X

Type of law
enforcement action
taken
License suspensions,
fines warnings
Fines, warnings
Fines, citations
Fines, citations

X

e

d

e

X
X
X
37

e
e
e

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.

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GAO-02-74 Reducing Youth Access to Tobacco

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

Appendix II: Percentage of State Tobacco
Outlet Inspections Conducted by 14- and 15Year-Olds, Fiscal Year 1999
States With Greater Than 50 Percent of Inspections by 14- and 15-Year-Olds (Percentage)
New Hampshire
North Carolina
Tennessee
Georgia
Texas
Delaware
Indiana
Nebraska

94
94
77
74
73
70
66
63

Maryland
a
Washington
Pennsylvania
West Virginia
Arkansas
Alabama
Oklahoma
California

60
59
54
54
53
53
53
52

States With Less Than 50 Percent of Inspections by 14- and 15-Year-Olds
Virginia
South Carolina
Colorado
Florida
Wisconsin
Oregon
New York
New Mexico
Maine
Rhode Island
New Jersey
Massachusetts
Hawaii

49
49
47
46
46
43
43
43
42
42
42
42
40

32
30
28
28
27
24
21
19
13
6
0
0
0

Mississippi
Montana
a
Kansas
Michigan

35
34
32
30

Alaska
Illinois
Louisiana
Ohio
Kentucky
Missouri
Iowa
Minnesota
Utah
a
Nevada
Arizona
Connecticut
District of
Columbia
Idaho
North Dakota
South Dakota
Vermont
Wyoming

0
0
0
0
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.

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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

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GAO-02-74 Reducing Youth Access to Tobacco

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

(201103)

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GAO-02-74 Reducing Youth Access to Tobacco

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