In 1996, SAMHSA issued a regulation implementing the Synar amendment. The regulation requires all 50 states, the District of Columbia, and eight insular areas 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, of all tobacco outlets within the state to estimate the percentage of retailers who do not comply with the laws, and (3) report the retailer violation rates to the Secretary of HHS in their annual SAPT block grant applications. SAMHSA requires that each state reduce its retailer violation rate to 20 percent or less by fiscal year 2003. SAMHSA and each state negotiated interim annual target rates that states are required to meet to indicate their progress toward accomplishing the 20 percent goal. Beginning in fiscal year 1997 for most states and in subsequent years for all states, the Secretary can withhold 40 percent of a state’s Substance Abuse Prevention and Treatment (SAPT) block grant award if it does not comply with the rate reduction requirements. State fiscal year 2000 SAPT block grant awards ranged from about $2.5 million to $223 million. Also in 1996, SAMHSA provided guidance to states on implementing Synar requirements. SAMHSA issued sample design and inspection guidanceto help states comply with the Synar requirement for conducting random, unannounced inspections of tobacco outlets to estimate the statewide violation rate. 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 contractordetermine 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 rate is correctly calculated, meets the negotiated annual target, and shows progress toward the 20-percent goal. When data provided in the application are not sufficient to determine state compliance, SAMHSA requests additional information from the state before a final decision on state compliance is made. SAMHSA collects the state-reported data from the SAPT block grant applications and in 1996, began storing it in an automated database. These data are used to monitor states’ compliance with Synar requirements, compare state progress from year to year, and produce an annual report to the Secretary of HHS and the Congress on Synar implementation. SAMHSA also uses the data to help finalize the states’ annual retailer violation rates, which are released to the public. For fiscal years 1997 through 1999, the states’ reported violation rates showed an overall increase in retailer compliance with state laws prohibiting the sale of tobacco products to minors. The median retailer violation rate declined from 40 percent in 1997 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 additional funds to ensure compliance with the following year’s violation- rate target. 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, as SAMHSA recommends. When states use list-based sampling to select a 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. States can use different lists to develop their population of tobacco outlets, but the accuracy and completeness of these lists vary. For example, states can use lists of state-licensed tobacco outlets, but these lists are not always updated by the responsible state agencies. Also, national and state commercial listings can be used, but they often contain many establishments that do not sell tobacco products or may identify the owners of the business but not necessarily each retail outlet. In some rural areas and Midwestern states, developing a complete list of outlets can be difficult because tobacco products are sometimes sold from individuals’ homes or other places that are not known to be tobacco outlets. Comments made by several state officials indicate a need by some states for more technical assistance from SAMHSA in addressing state-specific issues—particularly sample design—that affect their compliance with Synar. Accurately identifying the population of vending machine outlets accessible to youth in a state is also important, according to SAMHSA’s fiscal year 1997 report of Synar implementation 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 youth in their states as SAMHSA requires. (See app. I) Further, our review of a few block grant applications showed that states reported that they inspected vending machine outlets when they found them during random inspections of over-the-counter outlets. Some states have had difficulty developing accurate and complete lists of vending machine outlets, in particular, because many of the machines are privately owned and their portability makes them difficult to track. Officials we interviewed told us that over the years there has been a significant decline in vending machine tobacco outlets accessible to minors. However, an NGA representative said that vending machines are and will continue to be a source of tobacco products for minors in some states. The results of a 1999 national survey of middle school and high school students’ access to cigarettes 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. 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-the- counter 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. 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. Research also shows,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-year- olds 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. 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. 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 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. 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. 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 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. 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 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 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 state- reported 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. 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 state- reported 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 re- inspect violators. FDA’s goal was to have compliance checks performed throughout the entire state. If an inspection resulted in a violation, the state was expected to re-inspect the establishment within 90 days and 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. The components of an effective enforcement strategy include an enforceable 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. 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. 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. Warnings Fines Fines Fines Fines Fines, summonses, warnings Fines, citations License suspensions Defendants charged under misdemeanor statute Type of law enforcement action taken License suspensions, fines warnings Fines, warnings Fines, citations Fines, citations Fines, warnings, citations Fines Fines, warnings Fines, citations Citations, warnings 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. Specific law enforcement action taken was not reported.

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