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TABLE 1 Prevalence of Sociodemographic Characteristics, Lifetime, and Current (Last 30-Day) Use of <br />Each Tobacco Product at Baseline and Rates of Product Initiation at follow-up Among Youth <br />Residing in a Jurisdiction With ALA Reduced Tobacco Sales, Grade A or D or F <br />Sex <br />Male <br />Female <br />Ethnicity <br />Hispanic white <br />Non -Hispanic white <br />Other <br />Parent education <br />Less than or equal to high school <br />Some college <br />College or more <br />Prevalent ever tobacco product use at baseline <br />Cigarette <br />E-cigarette <br />Hookah <br />Cigars <br />Any tobacco product <br />Prevalent past 30-d tobacco product use at baseline <br />Cigarette <br />E-cigarette <br />Hookah <br />Cigars <br />Any tobacco product <br />Initiation of tobacco product use (between baseline and follow- <br />up)b <br />Cigarette <br />E-cigarette <br />Hookah <br />Cigars <br />Any tobacco product <br />Initiation with past 30-d tobacco product use at fallow -up° <br />Grade A Grade D or F <br />N (%a) N (%a) <br />324 (49.7) 735 (50.9) <br />328 (50.3) 710 (49.1) <br />349 (53.5) 736 (50.9) <br />230 (35.3) 504 (34.9) <br />73 01.2) 205 04.2) <br />245 (41.3) 460 (34.3) <br />219 (36.9) 502 (37.4) <br />129 (21.8) 379 (28.3) <br />89 (13.7) <br />302 (21.0) <br />123 (19.0) <br />379 (26.4) <br />158 (24.3) <br />411 (28.6) <br />69 (10.6) <br />204 (14.2) <br />214 (32.9) <br />564 (39.2) <br />24 (3.7) <br />95 (6.6) <br />56016) <br />145(10.1) <br />62 (9.5) <br />162 (11.3) <br />21 (3.2) <br />55 (3.8) <br />107 (16.5) <br />267 (18.6) <br />52 (13.1) <br />156 (18.0) <br />92 (24.7) <br />235 (29.7) <br />55 (15.9) <br />146 (18.9) <br />49 (12.0) <br />158 (17.1) <br />85 (27.7) <br />198 (30) <br />Cigarette 17 (4.3) 52 (6.0) <br />E-cigarette 17 (4.7) 69 (8.9) <br />Hookah 16 (4.7) 32 (4.2) <br />Cigars 12 (2.9) 36 (3.9) <br />Any tobacco product 24 (7.9) 78 (12.1) <br />The denominator (852 in grade A. 1445 in grade D or F) varies because of missing values in covanates <br />b Restricted to nonusers of each product (or of any tobacco product) at baseline. <br />initiation of e-cigarettes (OR 0.74; <br />95% Cl 0.55-0.99) and of initiation <br />with past 30-day use (OR 0.45; 95%CI <br />0.23-0.90) were also lower in A -grade <br />than D- or F-grade jurisdictions. In <br />sensitivity analyses adjusting for time <br />since turning 18 at follow-up, there <br />was no change in the protective effect <br />estimate of living in awell-regulated <br />(A -grade) jurisdiction (results not <br />shown). Participants still living in <br />their jurisdiction of origin at follow-up <br />evaluation would have had consistent <br />exposure to the same regulatory <br />environment In this sample, there <br />were stronger protective A -grade <br />compared with D- or F-grade <br />associations with cigarette and <br />e-cigarette initiation at follow-up (and <br />of initiation of e-cigarettes with past <br />30-day use) than in the entire sample <br />(results not shown). The protective <br />association of A -grade residence with <br />initiation of cigar use was similar in <br />magnitude to the association with <br />cigarette and e-cigarette use but was <br />not statistically significant <br />DISCUSSION <br />Central features of the ALA TRL <br />grade include a licensing fee <br />sufficient to fund compliance checks <br />and enforcement of regulations <br />prohibiting tobacco sales to minors <br />and penalties for violating the law, <br />features of TRL that have been <br />reported to be necessary to reduce <br />sales to and use by youth.? Compared <br />with living in a jurisdiction with poor <br />TRL policy, youth in a jurisdiction <br />satisfying these criteria were less <br />likely to smoke in high school. In a <br />prospective follow-up of the cohort, <br />the odds of initiation of e-cigarette <br />use, with or without past 30-day <br />use, and of initiation of cigarette use <br />were also lower in well -regulated <br />jurisdictions. Stronger associations <br />among participants still living in their <br />jurisdiction of origin at follow-up <br />evaluation, with consistent exposure <br />to the same regulatory environment <br />throughout, also suggest that the <br />benefits of good TRL policy extended <br />both beyond cigarette use to <br />e-cigarette use and into early adult <br />life at age 18 when the sale of tobacco <br />products was legal at the time of the <br />study. The protective associations <br />were large, with risk lower by one- <br />third to a half in the strong compared <br />with weak TRL jurisdictions <br />(depending on the outcome). <br />There has been uncertainty <br />regarding the effects of youth access <br />restrictions on cigarette use 6,7,16 <br />Some authors of prospective studies <br />in which age -specific prevalence of <br />tobacco use was assessed before <br />and after regulatory intervention <br />to restrict youth access found <br />reductions in cigarette use,17-10 but <br />others found no benefit"," Authors <br />of 1 review of studies that reported <br />changes in smoking associated with <br />youth access restrictions found no <br />relationship of vendor compliance <br />or of changes in vendor compliance, <br />with smoking prevalence in a <br />meta -analysis of available studies,6 <br />perhaps because the restriction of <br />commercial access resulted in a shift <br />to social sources of cigarettes such <br />as older friends or siblings. Authors <br />of other observational studies have <br />Downloaded from www.aappublications.org/news by guest on May 7, 2019 <br />ASTOR et al <br />