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 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.”
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 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.

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 15-

year-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 14-

and 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 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.

10A 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.

11SAMHSA, Synar Regulation: Sample Design Guidance (Rockville, Md.: Center for

Substance Abuse Prevention, Aug. 1996).

12SAMHSA, 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 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

 13SAMHSA 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.

14SAMHSA 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 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

 15The 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

 16To 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.

17Other 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 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

 18Ten 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.

19Synar 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 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.

 20Youth Access to Cigarettes: Results from the 1999 National Tobacco Survey, Legacy First

Look Report 5, American Legacy Foundation, Oct. 2000.

21NGA, 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 15-

year-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.

 22Joseph 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).

23Pamela I. Clark, and others, “Factors Associated With Tobacco Sales to Minors,” Journal

of the American Medical Association, Vol. 86, No. 2 (Aug. 9, 2000).

24SAMHSA 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 17-

year-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 15-

year-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

 25Joseph 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.

26Joseph 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

 27Depending 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

 28Joseph 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 Xa X License suspensions,

warnings

California d Fines

Colorado Xb 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 Xa X Fines, citations

Louisiana Xa X Citations

Maine d e

Maryland Xa X X Citations

Massachusetts X Fines, citations

Michigan X X e

Minnesota X e

Mississippi d Warnings

Missouri Fines

Montana X Fines

Nebraska Xa X Fines

Nevada X Fines

New Hampshire X X e

New Jersey X Fines, summonses,

warnings

New Mexico c X Fines, citations

New York Xa 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 Xa X Fines, warnings

Oklahoma X Fines, citations

Oregon d Fines, citations

Pennsylvania Xa 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 Xc X X e

Washington d e

West Virginia X e

Wisconsin Xc 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 15-

Year-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 Washingtona 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 Nevadaa 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

Kansasa 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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