Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density

YOUTH ACCESS TO TOBACCO: TOBACCO 21 ENFORCEMENT STUDY AND TOBACCO RETAIL OUTLET DENSITY

KHI/19-26 APRIL 2019 Informing Policy. Improving Health. Kansas Health Institute 212 SW 8th Avenue | Suite 300 Topeka, Kansas, 66603-3936 785.233.5443 | web: khi.org Facebook: /KHIorg | Twitter: @KHIorg | LinkedIn: KHIorg

Unified Government Public Health Department 619 Ann Ave Kansas City, KS 66101 913.573.8855 | web: Wycokck.org/health Facebook: /WYCOHealthDept

212 SW 8th Avenue | Suite 300 Topeka, Kansas | 66603-3936 785.233.5443 khi.org /KHIorg @KHIorg

Copyright© Kansas Health Institute 2019. Materials may be reprinted with written permission. Reference publication number KHI/19-26 or view online at khi.org/policy/article/19-26. YOUTH ACCESS TO TOBACCO: TOBACCO 21 ENFORCEMENT STUDY AND TOBACCO RETAIL OUTLET DENSITY

APRIL 2019

Authors Hina B. Shah, M.P.H. Madison Hoover, M.S. Steve Corbett, Ph.D.

Acknowledgments This report was produced through a partnership of the Kansas Health Institute (KHI) and the Unified Government of Wyandotte County and Kansas City, Kansas, Public Health Department (UGPHD). KHI authored the report and UGPHD provided content review. The authors would like to thank Edward Ellerbeck, M.D., M.P.H., of the University of Kansas Medical Center for his peer review of the report. They also would like to thank KHI colleagues who provided feedback on the report: D. Charles Hunt, M.P.H., and Wen-Chieh Lin, Ph.D.

KHI supports effective policymaking through nonpartisan research, education and engagement. KHI believes evidence-based information, objective analysis and civil dialogue enable policy leaders to be champions for a healthier Kansas. Established in 1995 with a multiyear grant from the Kansas Health Foundation, KHI is a nonprofit, nonpartisan educational organization based in Topeka.

UGPHD is a local public health agency working to prevent disease and improve health and quality of life in Wyandotte County, Kansas.

Table of Contents

Executive Summary ...... iii Introduction ...... 1 Methods ...... 3 Enforcement Study in Kansas City, Kansas ...... 3 Research Question 1 – Retailer Compliance ...... 3 Research Question 2 – Tobacco Retailer Density ...... 6 Results ...... 8 Research Question 1 – Retailer Compliance ...... 8 By Census Tract ...... 8 By Retailer Type ...... 10 Population Characteristics by Inspection Status ...... 11 Research Question 2 – Tobacco Retail Outlet Density ...... 12 Variation Among Counties ...... 12 Near High Schools ...... 12 Discussion ...... 18 Limitations ...... 18 Conclusions ...... 19 Appendix A. Additional Figures ...... A-1 Appendix B. Endnotes ...... B-1

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ii  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Executive Summary

Tobacco 21 (T21) is a tobacco control initiative that raises the minimum age of legal access (MLA) for the sale of tobacco productsi to persons age 21 and older and complements other strategies to reduce tobacco use. The MLA in the state of Kansas is age 18 and Kansas City, Kansas, was the first locality to adopt T21 in November 2015. As of February 1, 2019, a total of 24 localities have adopted T21 in Kansas. Youth access policies are enforced by the state of Kansas for sale to persons under age 18, and none of the local T21 ordinances adopted in Kansas include provisions or funding mechanisms for enforcement of those between age 18 and age 21. Through external funding, Kansas City, Kansas, completed a local enforcement study in 2017. In this report, two issues were examined: (1) retailer compliance; and (2) density of tobacco retail outlets, particularly near schools, in three Kansas counties.

Retailer Compliance. The Unified Government of Wyandotte County and Kansas City, Kansas, completed an enforcement study from November 7-29, 2017, to assess retailer compliance of T21 in Kansas City, Kansas. A total of 272 inspections were completed at 129 tobacco retail outlets; some tobacco retail outlets were revisited up to three times for an inspection. Results of the enforcement study include: • Overall, of the 272 inspections, 35 had a failure (i.e., a sale to a person under age 21) resulting in an overall failure rate of 12.9 percent;

• Of 129 retailers visited for an inspection, 32 had one or more failures resulting in a retailer violation rate of 24.8 percent;

• The retailer violation rate was highest among Gasoline Stations with Convenience Stores and Convenience Stores combined (31.9 percent), followed by All Other General Merchandise Stores (22.7 percent), a category which includes retailers such as Family Dollar and Dollar General;

• When compared to Supermarkets and Other Grocery (except Convenience) Stores, the retailer violation rate was 2.1 times higher for Gasoline Stations with Convenience Stores and Convenience Stores combined; and ______i For the purposes of this report, “tobacco products” is defined as products regulated by the Food and Drug Administration (FDA), which includes cigarettes, all cigars (including cigarillos), dissolvables, roll-your-own tobacco, pipe tobacco, smokeless tobacco (including dip, snuff, snus and chewing tobacco), hookah tobacco, nicotine gels and e-cigarettes (also could include vaporizers, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, hookah pens and other electronic nicotine delivery systems).

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density iii • When aggregating census tracts with at least one failed inspection and census tracts with no failed inspections, there was little or no relationship between the population characteristics (age, race/ethnicity or poverty status) and the outcome of a failed inspection.

Tobacco Retailer Density. The density of tobacco retail outlets in the county and near schools was examined in three Kansas counties – Wyandotte, Johnson and Sedgwick. Study results include: • When comparing the number of tobacco retail outlets per 1,000 population, Wyandotte County has a rate of 1.0, Sedgwick County has a rate of 0.7 and Johnson County has a rate of 0.4.

• Seven out of nine (77.8 percent) high schools in Wyandotte County have a tobacco retail outlet within a half mile (easy walking distance) of the school. Two high schools in Wyandotte County have no retail outlet within a mile (reasonable walking distance) of the school – Bonner Springs High School and Piper High School.

• Fourteen out of 23 (60.9 percent) high schools in Johnson County have at least one tobacco retail outlet within a half mile. Every high school in Johnson County has at least one tobacco retail outlet within a mile of the school.

• Sixteen out of 31 (51.6 percent) high schools in Sedgwick County have at least one tobacco retail outlet within a half mile. Four high schools in Sedgwick County have no tobacco retail outlet within a mile of the school – Eisenhower High School, Wichita Heights High School, Northeast Magnet High School and Wichita Southeast High School.

Limitations. The study limitations include possible selection bias in the number of inspections completed at each tobacco retail outlet and the accuracy of recorded tobacco retail outlet locations in the enforcement study.

Conclusions. Momentum for Tobacco 21 in Kansas could continue to build if awareness and support among retailers and the public is demonstrated. New and current adopters of T21 might consider enforcement provisions and funding mechanisms in their ordinances. Stricter enforcement, particularly in tobacco retail dense locations and among tobacco retail outlets in close proximity to schools, also should be considered.

iv  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Introduction

Tobacco 21 (T21) is a tobacco control initiative that raises the minimum age of legal access (MLA) for sale of tobacco products (including electronic vapor products or e-cigarettes) to persons age 21 and older and complements other strategies to reduce tobacco use.1 Studies suggest that raising the MLA will reduce the ability of youth to purchase tobacco products, especially from older friends, and prevent or delay tobacco use initiation.2,3,4 For the purposes of this report, “tobacco products” is defined as products regulated by the Food and Drug Administration (FDA), which includes cigarettes, all cigars (including cigarillos), dissolvables, roll-your-own tobacco, pipe tobacco, smokeless tobacco (including dip, snuff, snus and chewing tobacco), hookah tobacco, nicotine gels and e-cigarettes (also could include vaporizers, e- cigars, e-pipes, vape pipes, vaping pens, e-hookahs, hookah pens and other electronic nicotine delivery systems).5

Tobacco use continues to be the leading cause of preventable death in the U.S. Most tobacco users become addicted before age 18 because adolescent brains have a heightened sensitivity to the rewarding effects of nicotine.6 According to the U.S. Surgeon General, when a still- developing brain is exposed to nicotine, it is reshaped “in a way that introduces long-lasting vulnerability of addiction to nicotine and other substances of abuse.”7 Consequently, adolescent tobacco use leads to heavier daily consumption, stronger nicotine addiction and more difficulty quitting tobacco later in life.8 In Kansas, 78 percent of adult smokers started smoking tobacco products by age 18, and 97 percent started by age 26.9 The Institute of Medicine estimated that T21 policies could reduce the smoking prevalence rate among adults age 18 and older (decrease from 15.2 percent in 2014 to 9.7 percent by 2040) as well as decrease the incidence of low birth weight, preterm births and chronic diseases in future decades.10 According to the 2017 Youth Risk Behavior Survey, current use of cigarettes was 7.2 percent and cigar use (including cigarillos) was 7.6 percent among Kansas high school students.11 An emerging trend is the use of electronic vapor products among youth; 10.6 percent reported currently using an electronic vapor product in 2017.12

To achieve the full benefits of a Tobacco 21 policy, enforcement is necessary to ensure a high rate of compliance. Youth access policies are enforced at the local and state level. State level enforcement is conducted annually under the Synar Amendment ‒ which passed in 1992 when Congress enacted the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (P.L. 102-321)13 ‒ and by the FDA ‒ which contracts with states (and localities) to assist

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 1 with compliance check inspections in tobacco retail outlets under the Tobacco Control Act (P.L. 111-31).14 However, both programs currently assess compliance for sales to a person under age 18, in accordance with state law. While the MLA in the state of Kansas is age 18, there are 24 localities that have adopted Tobacco 21 ordinances, including most of the greater Kansas City metropolitan area, Iola, Garden City, Shawnee County (unincorporated), Topeka (under litigation),ii Parsons, Holcomb, Douglas County (unincorporated), Finney County (unincorporated) and, most recently, Edwardsville.15 None of the local ordinances adopted in Kansas have specific funding mechanisms to assess compliance for sales to a person between ages 18-20, and federal funding provided to states under the Synar and FDA programs cannot be used to enforce local policies which set MLA at age 21.16,17,18

Kansas City, Kansas, was the first locality in Kansas to adopt the Tobacco 21 ordinance, effective November 26, 2015.19 With grant funding, the Unified Government Public Health Department (UGPHD) and Kansas City, Kansas, Police Department (KCKPD) completed an enforcement study two years after raising the MLA to age 21 to assess the compliance of T21 in Kansas City, Kansas. The Kansas Health Institute (KHI) was engaged by UGPHD to analyze the results of the enforcement study in Kansas City, Kansas, and to assess the density of tobacco retail outlets in Wyandotte County. The research questions for this report follow.

1) What is the retailer compliance of the Tobacco 21 policy in Kansas City, Kansas, and is there a difference in retailer compliance based upon the type of retailer or characteristics of the population living near the retailer?

2) Is there a disproportionately higher number of tobacco retail outlets, overall and near high schools, in Wyandotte County compared to Johnson and Sedgwick counties in Kansas?

______ii A Shawnee County District Court judge entered a permanent injunction prohibiting the enforcement of the Tobacco 21 ordinance in Topeka on March 22, 2018. The ruling appears to conflict with the opinion issued by Kansas Attorney General Derek Schmidt on December 28, 2017. The Topeka ordinance is being challenged in the Kansas Supreme Court.

2  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Methods

Enforcement Study in Kansas City, Kansas

The T21 ordinance adopted by Kansas City, Kansas, prohibits the sale of tobacco products, e- cigarettes, other vapor products and alternative nicotine products to those under age 21 and requires a retailer to post the following notice in a conspicuous place: "By law, cigarettes and tobacco products may be sold only to persons 21 years of age and older.”20 Provisions and penalties for sales violations are as follows: the person (clerk at retail dealer) who directly sells the cigarettes, electronic cigarettes or tobacco products to any person under age 21 or the retail dealer who has actual knowledge of such selling by such individual or both will be prosecuted.21 Violation of this ordinance is a class B violation punishable by a minimum fine of $200.22

The Unified Government Public Health Department (UGPHD) partnered with the Kansas City, Kansas, Police Department (KCKPD) to complete an enforcement study two years after the implementation of T21 in Kansas City, Kansas. The enforcement study was conducted from November 7-29, 2017. To conduct the enforcement study, KCKPD deployed “decoy” underage purchasers (19- and 20-year old cadets) to purchase cigarettes from retailers that sold tobacco products, under the supervision of an officer. Each inspection at a tobacco retail outlet was recorded. Using a list of tobacco retail outlets and locations provided by the local Synar officer, KCKPD completed at least one inspection in every tobacco retail outlet in its jurisdiction and some tobacco retail outlets were revisited for an inspection up to three times based upon past experience and at the discretion of KCKPD.

Research Question 1 – Retailer Compliance

This section discusses the methodology for analysis of data from the enforcement study.

Background. Kansas City, Kansas, is located in Wyandotte County. According to the 2017 Kansas Behavioral Risk Factor Surveillance System (BRFSS), 21.8 percent of adults currently smoke cigarettes in Wyandotte County.23 Targeted tobacco marketing disproportionately affects many marginalized populations. An estimated 61.5 percent of residents in Kansas City, Kansas, belong to a racial and/or ethnic minority and 22.2 percent of families live under the poverty level.24 A study conducting a systematic review on neighborhood disparities in point-of-sale tobacco marketing found that that there is a higher prevalence of marketing of menthol cigarettes in urban neighborhoods and neighborhoods with more non-Hispanic Black residents, while smokeless tobacco marketing was more prevalent in rural neighborhoods and areas with

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 3 more non-Hispanic White residents.25 The study also found that neighborhoods with lower income have more tobacco marketing.26 A report by the Surgeon General has found that tobacco retailer advertising targets people with the lowest income and education and that there is more in-store tobacco advertising in minority and low-income neighborhoods.27 Convenience stores, in particular, are popular among adolescents and have more tobacco marketing than other types of stores.28

Further, adolescents and young adults may identify certain retailers who will sell tobacco products to them while underage. The latest data is from the 2013 Youth Risk Behavior Survey (YRBS), which found that 10.8 percent of Kansas high school students reported obtaining their own cigarettes by buying them in a store such as a convenience store, supermarket, discount store or gas station.29 National data from the 2017 YRBS found that 13.6 percent of U.S. high school students who currently use electronic vapor products bought them in a store. In 2017, YRBS changed its question from obtaining cigarettes to obtaining electronic vapor products.

Study Population. For research question 1, retailer compliance was examined by retailer type and census tract in the enforcement study area. Additionally, census tracts for each tobacco retail outlet (“retailers”) location were identified to examine characteristics of the population living near the retailers. These retailers were further classified by retailer type as defined by the North American Industry Classification System (NAICS): Super Markets and Other Grocery (except Convenience) Stores (445110); Convenience Stores (445120); Pharmacies and Drug Stores (446110); Gasoline Stations with Convenience Stores (447110); Tobacco Stores (453991); and All Other General Merchandise Stores (452319).

Data Sources. Based upon data from the enforcement study period, KCKPD visited 136 retailers and conducted 288 inspections. Data from 129 retailers and 272 inspections were used in the analysis – 16 inspections were removed for instances where the KCKPD arrived at the location but could not complete an inspection because the retailer no longer existed or no longer sold tobacco products. Other data sources included U.S. Census Bureau Cartography Boundary Shapefiles for the census tracts in the Kansas City, Kansas, study area as well as the 2017 Kansas Department of Revenue (KDOR) Active Cigarette, Consumable Material and Tobacco Licensee Database for information on tobacco retail outlets with active licenses during the study period. The U.S. Census Bureau American Community Survey 5-Year Estimates (2013-2017) provided estimates of demographic and socioeconomic characteristics for all census tracts in Kansas City, Kansas, indicating whether a tobacco retail outlet was present.

4  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Measures and Variables. The outcome measure (dependent variable) of the enforcement study was a sale to a person under age 21. Because 91 out of 129 tobacco retail outlets (“retailers”) were revisited for an inspection, retailer compliance was examined using two measures: “overall failure rate” at the inspection level and “retailer violation rate” at the retailer level.

• An inspection was considered “failed” if there was a sale to a person under age 21 at the encounter. The overall failure rate was derived to provide an overall proportion of underage sales for the study area and was computed as the number of failed inspections divided by the number of total inspections.

• A retailer was considered “in violation” if there was a sale to a person under age 21 during any inspection conducted at the tobacco retail outlet. Using the data provided, retailer violation rate (RVR) was computed as the number of retailers in violation divided by the number of retailers with at least one inspection.

Data elements (or variables) from the enforcement study for this analysis included the following: • Date of inspection ‒ mm/dd/yyyy;

• Tobacco retail outlet (“retailer”) location ‒ address where the inspection was conducted, including building number, street name, city, state and zip code;

• Retailer type ‒ six-digit NAICS code;

• Sale to a person under age 21 ‒ yes/no/n.a. (n.a. = retailer no longer sells tobacco products; property closed, etc.); and

• Clerk age 21 and older: yes/no (only recorded when cigarettes were sold to a person under age 21).

Select population characteristics at the census tract level also were examined, including the proportion of the population that were: • Youth and young adults age 15-20 (target population for T21);

• Minorities – any population other than non-Hispanic Whites; and

• Families in poverty – people living in households with family incomes less than 100 percent of the federal poverty level ($24,600 for a family of four in 2017).

Analysis. Descriptive statistics on the number of retailers, number of inspections, number of failed inspections and number of retailer violations were summarized by census tract and

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 5 retailer type. The retailer violation rate and overall failure rate were calculated for each census tract and retailer type.

Estimates of the proportion of people age 15-20, proportion of minorities and proportion of people living under the federal poverty level for each census tract were produced for demographic characteristics and socioeconomic status. Summary statistics also were produced for census tracts aggregated with and without at least one failed inspection.

All analyses were conducted using SAS 9.4. A map for failed inspections by census tract was developed by using ArcGIS Pro version 2.2.

Research Question 2 – Tobacco Retailer Density

This section discusses the methodology for analysis of the density of tobacco retail outlets, including near schools, in three Kansas counties. Note that the study area has been expanded from city to county-level for this research question.

Background. This report further examines the density of tobacco retail outlets. Studies have shown that tobacco marketing is more prevalent in retailers located near schools, where adolescents are likely to shop, and could affect tobacco use initiation rates among adolescents.30 Other studies have shown that neighborhoods with relatively large low-income and/or minority populations tend to have higher numbers of tobacco retailers.31 The density of tobacco retail outlets around the home might influence tobacco use among youth and adults.32,33 Retailers market tobacco products, and a high density of tobacco retail outlets in a neighborhood increases exposure among children, youth and adults living in those neighborhoods.34

Study Population. The study population included tobacco retail outlets and high schools in Wyandotte, Johnson and Sedgwick counties. Johnson County was selected based upon proximity to Wyandotte County, and Sedgwick County was selected based upon its size, urbanicity, and demographic and socioeconomic makeup.35 Additionally, the adult smoking rate is similar in Sedgwick (19.1 percent) and Wyandotte (22.9 percent) counties.

Data Sources. Information about tobacco retail outlets with active licenses in 2017 (the enforcement study timeframe) was obtained from the 2017 Kansas Department of Revenue (KDOR) Active Cigarette, Consumable Material and Tobacco Licensee Database. High school location data for the respective counties were provided by the Unified Government of Wyandotte

6  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute County and Kansas City, Kansas, DotMaps; Johnson County Automatic Information Mapping System; and Sedgwick County Geographic Information Systems. The U.S. Census Bureau American Community Survey 5-Year Estimates (2013-2017) provided population estimates for each county.

Measures and Variables. Geographic coordinates of tobacco products retailers were used to develop a county-level measure of tobacco retail outlet density in each county. The outcome measure was the number of tobacco retail outlets per 1,000 people for each county, which was calculated by dividing the number of tobacco retail outlets by the total population in each county, then multiplying by 1,000. Similarly, geographic coordinates of high schools were used to develop a county-level measure of tobacco retail outlet density near schools – specifically within 0.5 (easy walking distance) and 1.0 mile (reasonable walking distance) – in each county. The outcome measure was the number of tobacco retail outlets per high school, which was calculated as the number of tobacco retail outlets within 0.5 and 1.0 mile of a high school divided by the total number of high schools in each county.

Analysis. Maps were developed to conduct a spatial analysis to examine the distribution of high schools and tobacco retail outlets in Johnson, Sedgwick and Wyandotte counties. Analysis of the density of tobacco retailers within a 0.5 mile and 1.0 mile radius of a school was completed. ArcGIS Pro version 2.2 was used to geocode tobacco retail outlets and high schools in each county and conduct a spatial analysis to measure the density of tobacco retail outlets near high schools.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 7 Results

Research Question 1 – Retailer Compliance

This section presents results of the enforcement study conducted in Kansas City, Kansas, and differences in failure rates by census tract and retailer type. From November 7-29, 2017, KCKPD conducted 272 inspections at 129 tobacco retail outlets (“retailers”) in Kansas City, Kansas. During the study period, 38 retailers had one inspection, 42 retailers had two inspections, 46 retailers had three inspections and three retailers had four inspections.

Of 272 inspections conducted, 35 had a failure (i.e., a sale to a person under age 21) resulting in an overall failure rate of 12.9 percent. Of 129 retailers visited, 32 had one or more failures resulting in a retailer violation rate of 24.8 percent.

By Census Tract

When examining compliance by census tract, the number of inspections conducted by KCKPD ranged from one to 13 inspections, and the number of tobacco retail outlets in each census tract ranged from one to six retailers. Overall, the number of failed inspections ranged from zero to three across census tracts in the study area, and the number of retailers with a violation ranged from zero to two. More than half (53.8 percent) of census tracts had at least one failed inspection in the study area (Figure 1, page 9). The overall failure rate for inspections conducted in each census tract as well as the retailer violation rate for each census tract varied widely across census tracts (Figure A-1, page A-1). Both rates were dependent upon the number of inspections KCKPD conducted at each tobacco retail outlet.

8  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure 1: Number of Failed Inspections in Tobacco Retail Outlets by Census Tract, Kansas City, Kansas, November 2017

Note: Of the 129 tobacco retail outlets (“retailers”) inspected in this study, 91 were revisited for an inspection up to three times. Two measures were used to examine retailer compliance: Overall Failure Rate was computed as the number of failed inspections (35) divided by the number of total completed inspections (272); and Retailer Violation Rate was computed as the number of retailers in violation (32) divided by the number of retailers with at least one inspection (129). Source: KHI analysis of data from the U.S. Census Bureau and the 2017 Kansas City, Kansas, Enforcement Study.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 9 By Retailer Type

The retailer violation rate (RVR) was highest among Gasoline Stations with Convenience Stores and Convenience Stores combined (31.9 percent), followed by All Other General Merchandise Stores (22.7 percent), a category which includes retailers such as Family Dollar and Dollar General (Figure 2). When compared to Supermarkets and Other Grocery (except Convenience) Stores, the retailer violation rate was 2.1 times higher for Gasoline Stations with Convenience Stores and Convenience Stores combined.

Figure 2. Overall Failure Rate and Retailer Violation Rate by Retailer Type, Kansas City, Kansas, November 2017

Inspections Retailers

Retailer Type Overall Retailer # Total # Failed # Retailers # Retailer Failure Violation Inspections Inspections Inspected Violations Rate Rate Gasoline Stations with Convenience 164 25 15.2% 69 22 31.9% Stores and Convenience Stores All Other General 49 5 10.2% 22 5 22.7% Merchandise Stores Supermarkets and Other Grocery 20 2 10.0% 13 2 15.4% (except Convenience) Stores Tobacco 5 0 0.0% 3 0 0.0% Stores Other 34 3 8.8% 22 3 13.6% Summary 272 35 12.9% 129 32 24.8% Note: Overall failure rate is computed as the number of failed inspections divided by number of total inspections. Retailer violation rate (RVR) is computed as the number of retailer violations divided by the number of retailers inspected. Source: KHI analysis of data from the 2017 Kansas City, Kansas, Enforcement Study.

10  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Population Characteristics by Inspection Status

When examining select population characteristics (age, race/ethnicity and poverty status) in census tracts that had an inspection, there was wide variation among these characteristics across census tracts (Figure A-2, page A-3). When aggregating census tracts with at least one failed inspection and census tracts with no failed inspections, there was little or no relationship between the population characteristics and the outcome of an inspection among census tracts (Figure 3).

Figure 3. Proportion of Persons Age 15-20, Minorities, and Families in Poverty by Inspection Status Among Census Tracts, Kansas City, Kansas, 2017

Families in Persons Living in… Age 15-20 Minorities Poverty Kansas City, Kansas 7.6% 61.5% 22.2% Census Tract with an Inspection 7.8% 62.0% 22.2% Census Tracts with Failed Inspection(s) 8.5% 64.9% 22.3% Census Tracts with No Failed Inspection 6.9% 58.4% 22.1% Census Tracts with No Inspection 6.2% 57.6% 22.8% Note: Census Tracts with No Inspections had no tobacco retail outlet, no inspection conducted or the inspection was not used in the analysis in the geographic area. T21 policies affect access of tobacco products to people age 15-20. Minorities includes any population other than non-Hispanic Whites. Families in poverty includes people living in households with family incomes less than 100 percent of the federal poverty level ($24,600 for a family of four in 2017). Source: KHI analysis of data from the 2017 Kansas City, Kansas, Enforcement Study and from the U.S. Census Bureau 2013-2017 American Community Survey 5-Year Estimates.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 11 Research Question 2 – Tobacco Retail Outlet Density

This section presents results of the density of tobacco retail outlets ("retailers”) near high schools in three Kansas counties (Wyandotte, Johnson and Sedgwick).

Variation Among Counties

The density of tobacco retail outlets per 1,000 population is substantially higher in Wyandotte County (1.0) – more than two-and-a-half times the density of tobacco retail outlets in neighboring Johnson County (0.4), and nearly one-and-half times the density of tobacco retail outlets in Sedgwick County (0.7) (Figure 4).

Figure 4. Number of Tobacco Retail Outlets (“Retailers”) with an Active Cigarette, Consumable Material and Tobacco License by County per 1,000 Population, 2017

Retailers Per 1,000 County # Retailers Total Population Population Wyandotte County 164 163,227 1.0 Johnson County 257 578,797 0.4 Sedgwick County 380 510,484 0.7 Source: KHI analysis of data from the U.S. Census Bureau 2013-2017 American Community Survey 5-Year Estimates and from the Kansas Department of Revenue, 2017.

Near High Schools

The number of tobacco retail outlets within a half mile (easy walking distance) and one mile (reasonable walking distance) of a high school varies among all three counties.

Wyandotte County. Seven out of nine (77.8 percent) high schools in Wyandotte County have a tobacco retail outlet within a half mile of the school (Figure 5, page 13; and Figure 6, page 14). Five of these seven high schools had a failed inspection within a half mile of the school. Wyandotte and Sumner Academy High Schools have the highest number of tobacco retail outlets within a half mile and one mile of the schools. Piper High School and Bonner Springs High School have no tobacco retail outlets within one mile of the school.

12  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure 5. Density of Tobacco Retail Outlets (“Retailers”) Near a High School and Failed Inspection(s) in Wyandotte County, by High School, 2017

Failed Failed Retailers Inspection(s) Retailers Inspection(s) High School Within Within Within 1.0 mile Within 0.5 mile 0.5 mile 1.0 mile Not in study Not in study Bonner Springs High School 0 0 area area Endeavor High School 2 1 6 1 F.L. Schlagle High School 2 0 6 0 J.C. Harmon High School 2 1 7 1 Piper High School 0 No retailers 0 No retailers Sumner Academy of Arts 8 1 18 2 and Science Turner High School 1 0 1 0 Washington High School 2 1 3 2 Wyandotte High School 7 3 19 4 Source: KHI analysis of data from the Kansas Department of Revenue and from the 2017 Kansas City, Kansas, Enforcement Study.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 13 Figure 6. Location of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Wyandotte County, by High School, 2017

Note: The darker, inner circle shows the 0.5 mile radius (easy walking distance). The lighter, outer circle shows the 1.0 mile radius (reasonable walking distance). Source: KHI analysis of data from the Kansas Department of Revenue and from the Unified Government of Wyandotte County and Kansas City, Kansas.

14  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Johnson County. Of the 23 high schools in Johnson County, the number of tobacco retail outlets ranges between zero and five retailers within a half mile of the school (Figure 7 and Figure A-3, page A-6). Fourteen out of 23 (60.9 percent) high schools in Johnson County have at least one tobacco retail outlet within a half mile. Three high schools in the county have five tobacco retail outlets within a half mile of the school – Blue Valley Academy, Blue Valley Center for Advanced Professional Studies and Shawnee Mission North. Every high school in Johnson County has at least one tobacco retail outlet within one mile of the school.

Figure 7. Number of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Johnson County, by High School, 2017

Retailers Within Retailers Within High School 0.5 mile 1.0 mile Blue Valley Academy 5 10 Blue Valley Center for Advanced Professional Studies 5 10 Blue Valley High School 0 3 Blue Valley North High School 2 7 Blue Valley Northwest High School 0 5 Blue Valley Southwest High School 0 0 Blue Valley West High School 1 1 De Soto High School 4 5 Gardner Edgerton High School 1 2 Horizons High School 2 9 Mill Valley High School 0 9 Olathe Advanced Technical Center 3 8 Olathe East High School 0 8 Olathe North High School 3 8 Olathe Northwest High School 1 1 Olathe South High School 3 8 Olathe West High School 0 2 Shawnee Mission East High School 0 4 Shawnee Mission North High School 5 10 Shawnee Mission Northwest High School 2 14 Shawnee Mission South High School 0 8 Shawnee Mission West High School 2 7 Spring Hill High School 0 0 Source: KHI analysis of data from the Kansas Department of Revenue and Johnson County.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 15 Sedgwick County. Of the 31 high schools in Sedgwick County, the number of tobacco retail outlets ranges between zero and nine retailers within a half mile of the school (Figure 8 and Figure A-4, page A-7). Sixteen out of 31 (51.6 percent) high schools in Sedgwick County have at least one tobacco retail outlet within a half mile. Four high schools in the county have five or more retailers within a half mile of the school – Chester I. Lewis Learning Center (9), Wichita South High School (9), Wichita East High School (6) and Wichita West High School (5). Four high schools have no tobacco retail outlet within a mile of the school – Eisenhower, Wichita Heights, Northeast Magnet and Wichita Southeast High School.

Figure 8. Number of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Sedgwick County, by High School, 2017 Retailers Within Retailers Within High School 0.5 mile 1.0 mile Andale High School 0 1 Bishop Carroll Catholic School 0 9 Cheney High School 4 4 Chester I. Lewis Learning Center 9 19 Clearwater High School 1 3 Complete High School 0 2 Derby High School 4 5 East High School 6 22 Eisenhower High School 0 0 Garden Plain High School 1 1 Goddard Academy 0 4 Goddard High School 0 2 Haysville Alternative High School 4 6 Heights High School 0 0 Independent High School 1 7 Kapaun Mt. Carmel Catholic High School 2 4 Learning by Design Virtual Charter School 4 6 Maize High School 0 2 Maize South High School 0 3 Mulvane High School 0 3 North High School 4 16 Northeast Magnet 0 0

16  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure 8 (continued). Number of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Sedgwick County, by High School, 2017

Retailers Within Retailers Within High School 0.5 mile 1.0 mile Northwest High School 4 10 South High School 9 14 Southeast High School 0 0 The Learning Center 4 5 Trinity Academy 1 2 Valley Center High School 0 1 West High School 5 18 Wichita Collegiate High School 0 2 Andale High School 0 1 Source: KHI analysis of data from the Kansas Department of Revenue and Sedgwick County.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 17 Discussion

Despite ongoing litigation in Topeka, several localities in Kansas recently have adopted Tobacco 21 (T21). This demonstrates a continued strong interest in adopting T21 as a tobacco control and prevention strategy for youth tobacco use. The enforcement study conducted in Kansas City, Kansas, is the first in the state (to our knowledge) to assess retailer compliance after implementing the T21 ordinance and the local retailer violation rate was 24.8 percent in 2017; it is not conclusive due to limitations in the study design. Along with T21 retailer compliance studies conducted in other parts of the country, this study has demonstrated the need for awareness and support to improve compliance with tobacco sales to persons under age 21.36,37

Gasoline Stations with Convenience Stores and Convenience Stores combined had the highest retailer violation rate (31.9 percent) among retailer types and studies have shown that adolescents frequently shop in such establishments. The 2012 Surgeon General report found that heavy advertising in convenience stores, especially in predominantly ethnic and low-income neighborhoods, could expose youth to pro-smoking messages leading to an increase in initiation rates.38 Retail-dense Wyandotte County might consider selective enforcement checks of youth access laws among this retailer type as well as other tobacco retail outlets in close proximity, such as Sumner Academy and Wyandotte High School. In addition, Wyandotte County also could consider restricting the number of tobacco retail outlets, especially near schools.39

Limitations

This study has some limitations. First, the data collected by KCKPD was a convenience sample – although every tobacco retail outlet in the study area had an inspection, only select retailers had more than one inspection. Selection bias of retailers could have been introduced when KCKPD revisited some tobacco retail outlets for an inspection at their discretion. Second, outdated or incorrect tobacco retail outlet address information posed a challenge to match the location of some tobacco retail outlets reported in the enforcement study to the active cigarette, consumable material and tobacco licenses in 2017 from KDOR as well as the locations listed by the Synar officer. This might have led to an incorrect count and location of tobacco retail outlets in the study area of Kansas City, Kansas.

18  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute While this analysis did not examine the age of the clerk, which was collected for failed inspections only, future enforcement studies could collect clerk age for all inspections to examine any association between clerk age and failed inspections. Other future considerations could include examining the compliance of displaying appropriate signage or asking clerks whether they are aware of the Tobacco 21 policy, which could provide a more robust analysis of retailer awareness and compliance.

Conclusions

Momentum for Tobacco 21 (T21) in Kansas could continue to build if awareness and support among retailers and the public is demonstrated. Stricter enforcement, particularly in tobacco retail dense locations and among retailers in close proximity to schools, should be considered. Localities might want to consider policies around robust enforcement and point-of-sale restrictions, which in turn might limit access to and exposure to tobacco products. Localities also might consider imposing distance requirements between existing tobacco retail outlets, capping the number of tobacco retail outlets in a given geographic area, establishing a maximum number of tobacco retail outlets proportional to population size, and prohibiting sales at certain types of establishments, such as pharmacies, or within a certain distance of locations serving youth. For instance, the City of Shawnee approved a moratorium on March 26, 2018, and recently extended it until July 1, 2019, limiting the number of businesses selling vaping or e- cigarette products.40 Hence, new and current adopters of T21 might want to consider enforcement provisions and funding mechanisms in their ordinances, and also review other evidence-based policy initiatives related to tobacco retail outlet density.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density 19 (This page intentionally left blank.)

20  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Appendix A. Additional Figures

Figure A-1. Results of the Enforcement Study in Kansas City, Kansas, by Census Tract, November 2017

Inspections Retailers Census Overall Retailer Tracts with # # Failed # Retailers # Retailer Failure Violation Inspections Inspections Inspection(s) Visited Violations Rate Rate 400.01 1 0 0.0% 1 0 0% 402 2 1 50.0% 1 1 100.0% 403 2 0 0.0% 1 0 0.0% 404 6 0 0.0% 2 0 0.0% 405 3 0 0.0% 1 0 0.0% 406 1 0 0.0% 1 0 0.0% 407 4 0 0.0% 2 0 0.0% 411 2 1 50.0% 1 1 100.0% 412 2 1 50.0% 1 1 100.0% 413 8 0 0.0% 5 0 0.0% 415 2 1 50.0% 2 1 50.0% 416 4 1 25.0% 2 1 50.0% 417 8 1 12.5% 5 1 20.0% 418 8 0 0.0% 6 0 0.0% 419 4 1 25.0% 2 1 50.0% 421 3 2 66.7% 2 1 50.0% 422 7 1 14.3% 4 1 25.0% 423 12 2 16.7% 6 2 33.3% 424 9 0 0.0% 4 0 0.0% 425.01 2 0 0.0% 2 0 0.0% 425.02 6 1 16.7% 2 1 50.0% 426 6 1 16.7% 2 1 50.0% 427 12 1 8.3% 5 1 20.0% 428 8 0 0.0% 3 0 0.0% 433.01 3 0 0.0% 1 0 0.0% 434 3 1 33.3% 1 1 100.0% 435 3 1 33.3% 2 1 50.0%

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density A-1 Figure A-1 (continued). Results of the Enforcement Study in Kansas City, Kansas, by Census Tract, November 2017

Inspections Retailers Census Overall Retailer Tracts with # # Failed # Retailers # Retailer Failure Violation Inspections Inspections Inspection(s) Visited Violations Rate Rate 436 9 1 11.1% 6 1 16.7% 437 3 0 0.0% 1 0 0.0% 438.03 6 0 0.0% 2 0 0.0% 438.04 7 1 14.3% 2 1 50.0% 439.03 9 1 11.1% 4 1 25.0% 439.04 8 0 0.0% 4 0 0.0% 439.05 7 1 14.3% 4 1 25.0% 440.01 6 0 0.0% 3 0 0.0% 440.03 2 0 0.0% 1 0 0.0% 441.01 3 1 33.3% 2 1 50.0% 441.02 6 0 0.0% 3 0 0.0% 441.03 3 1 33.3% 1 1 100.0% 441.04 3 2 66.7% 1 1 100.0% 442.01 12 2 16.7% 5 2 40.0% 442.02 6 1 16.7% 2 1 50.0% 443.01 13 1 7.7% 5 1 20.0% 443.02 3 0 0.0% 1 0 0.0% 444 3 2 66.7% 2 2 100.0% 445 1 0 0.0% 1 0 0.0% 447.03 4 0 0.0% 2 0 0.0% 447.04 6 3 50.0% 2 2 100.0% 448.03 7 0 0.0% 3 0 0.0% 450 8 1 12.5% 3 1 33.3% 452 6 0 0.0% 2 0 0.0% Summary 272 35 12.9% 129 32 24.8% Note: Overall failure rate is computed as the number of failed inspections divided by number of total inspections. Retailer violation rate (RVR) is computed as the number of retailer violations divided by the number of retailers inspected. Source: KHI analysis of data from the 2017 Kansas City, Kansas, Enforcement Study.

A-2  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure A-2. Proportion of Persons Age 15-20, Minorities, Families in Poverty and Number of Failed Inspections in Kansas City, Kansas, by Census Tract, 2017

Census # Failed Families in Tracts with # Inspections Age 15-20 Minorities Inspection(s) Poverty Inspections 400.01 1 0 - - - 400.02 - - - - - 402 2 1 17.1% 97.8% 41.7% 403 2 0 9.6% 90.6% 38.5% 404 6 0 12.5% 94.5% 20.8% 405 3 0 10.2% 79.6% 17.2% 406 1 0 8.9% 89.9% 28.0% 407 4 0 7.8% 95.5% 39.8% 408 - - 5.7% 97.3% 25.3% 409 - - 6.2% 67.9% 30.6% 410 - - 4.5% 98.6% 53.3% 411 2 1 7.0% 97.5% 62.4% 412 2 1 7.7% 97.0% 33.8% 413 8 0 6.5% 85.9% 35.7% 415 2 1 11.4% 82.7% 24.3% 416 4 1 8.8% 72.9% 16.2% 417 8 1 8.4% 83.7% 16.3% 418 8 0 0.8% 79.5% 49.5% 419 4 1 8.9% 52.4% 25.1% 420.01 - - 8.5% 77.4% 36.0% 420.02 - - 9.9% 87.1% 46.6% 421 3 2 6.9% 82.3% 31.1% 422 7 1 6.9% 71.9% 20.2% 423 12 2 9.8% 83.3% 48.8% 424 9 0 9.3% 89.3% 31.6% 425.01 2 0 - - - 425.02 6 1 - - - 426 6 1 5.6% 74.4% 24.5% 427 12 1 9.2% 80.9% 37.4% 428 8 0 7.4% 64.1% 28.2%

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density A-3 Figure A-2 (continued). Proportion of Persons Age 15-20, Minorities, Families in Poverty and Number of Failed Inspections in Kansas City, Kansas, by Census Tract, 2017

Census # Failed Tracts with # Inspections Age 15-20 Minorities Families Inspection(s) Inspections in Poverty 430 - - 0.0% 60.8% 20.0% 433.01 3 0 3.4% 58.7% 26.8% 434 3 1 6.6% 49.6% 11.6% 435 3 1 7.5% 31.3% 9.9% 436 9 1 8.4% 40.3% 10.4% 437 3 0 7.4% 40.7% 9.4% 438.02 - - 5.9% 10.4% 10.1% 438.03 6 0 7.3% 23.7% 5.0% 438.04 7 1 - - - 439.03 9 1 12.2% 73.1% 21.3% 439.04 8 0 8.2% 78.8% 36.3% 439.05 7 1 11.3% 52.5% 29.7% 440.01 6 0 8.1% 50.4% 12.9% 440.03 2 0 2.2% 26.0% 28.2% 440.04 - - 4.4% 38.6% 44.4% 441.01 3 1 11.4% 74.3% 22.7% 441.02 6 0 10.6% 41.1% 6.1% 441.03 3 1 5.8% 54.4% 10.6% 441.04 3 2 12.9% 75.0% 26.1% 442.01 12 2 6.6% 42.2% 3.1% 442.02 6 1 9.5% 58.5% 12.0% 443.01 13 1 5.0% 50.0% 28.0% 443.02 3 0 4.1% 61.9% 11.5% 443.03 - - 11.2% 82.6% 13.3% 444 3 2 7.8% 75.5% 14.3% 445 1 0 5.9% 65.6% 28.4% 446.01 - - 7.0% 35.1% 11.2% 446.02 - - - - - 446.03 - - - - - 447.03 4 0 5.6% 26.1% 4.4%

A-4  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure A-2 (continued). Proportion of Persons Age 15-20, Minorities, Families in Poverty and Number of Failed Inspections in Kansas City, Kansas, by Census Tract, 2017 Census # Failed Tracts with # Inspections Age 15-20 Minorities Families Inspection(s) Inspections in Poverty 447.04 6 3 5.1% 38.8% 3.7% 448.03 7 0 6.9% 23.0% 5.3% 448.04 - - 4.1% 32.0% 5.9% 450 8 1 5.4% 46.1% 30.8% 451 - - 2.0% 68.5% 38.5% 452 6 0 4.0% 39.6% 26.1% Note: Census tracts with no tobacco retail outlet or no persons living in the geographic area are indicated by a dash. T21 policies affect access of tobacco products to people age 15-20. Minorities includes any population other than non-Hispanic Whites. Families in poverty include persons living in households with family incomes less than 100 percent of the federal poverty level ($24,600 for a family of four in 2017). Source: KHI analysis of data from the Unified Government Public Health Department and from the U.S. Census Bureau 2013-2017 American Community Survey 5-Year Estimates.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density A-5 Figure A-3. Location of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Johnson County, by High School, 2017

A-6  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure A-4. Location of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Sedgwick County, by High School, 2017

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density A-7 Figure A-5. Comparison of Location of Tobacco Retail Outlets (“Retailers”) Within 0.5 and 1.0 Mile of a High School in Wyandotte, Johnson and Sedgwick Counties, by High School, 2017

Wyandotte County

Johnson County

Sedgwick County

Note: The darker, inner circle shows the 0.5 mile radius (easy walking distance). The lighter, outer circle shows the 1.0 mile radius (reasonable walking distance). The high school abbreviations can be cross-referenced in Figure A-6, page A-9. Source: KHI analysis of data from the Kansas Department of Revenue and from Wyandotte, Johnson and Sedgwick counties.

A-8  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Figure A-6. Table of Symbols on Figure A-5 and High School Names in Wyandotte, Johnson and Sedgwick Counties County Name Symbol Wyandotte Bonner Springs High School B Wyandotte Endeavor High School E Wyandotte F.L. Schlagle High School FS Wyandotte J.C. Harmon High School JCH Wyandotte Piper High School P Wyandotte Sumner Academy of Arts and Science SA Wyandotte Turner High School T Wyandotte Washington High School W Wyandotte Wyandotte High School WY Johnson Blue Valley Academy BVA Johnson Blue Valley Center for Advanced Professional Studies CAPS Johnson Blue Valley High School BV Johnson Blue Valley North High School BVN Johnson Blue Valley Northwest High School BVNW Johnson Blue Valley Southwest High School BVSW Johnson Blue Valley West High School BVW Johnson De Soto High School DS Johnson Gardner Edgerton High School GE Johnson Horizons High School H Johnson Mill Valley High School MV Johnson Olathe Advanced Technical Center OATC Johnson Olathe East High School OE Johnson Olathe North High School ON Johnson Olathe Northwest High School ONW Johnson Olathe South High School OS Johnson Olathe West High School OW Johnson Shawnee Mission East High School SME Johnson Shawnee Mission North High School SMN Johnson Shawnee Mission Northwest High School SMNW Johnson Shawnee Mission South High School SMS Johnson Shawnee Mission West High School SMW Johnson Spring Hill High School SH Sedgwick Andale High School AH Sedgwick Bishop Carroll Catholic School BCC Sedgwick Campus High School Ca Sedgwick Cheney High School CH

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density A-9 Figure A-6 (continued). Table of Symbols on Figure A-5 and High School Names in Wyandotte, Johnson and Sedgwick Counties County Name Symbol Sedgwick Chester I. Lewis Learning Center CIL Sedgwick Clearwater High School Cl Sedgwick Complete High School Co Sedgwick Derby High School D Sedgwick East High School WE Sedgwick Eisenhower High School E Sedgwick Garden Plain High School GP Sedgwick Goddard Academy GA Sedgwick Goddard High School GH Sedgwick Haysville Alternative High School HA Sedgwick Heights High School H Sedgwick Independent High School I Sedgwick Kapaun Mt. Carmel Catholic High School K Sedgwick Learning by Design Virtual Charter School LD Sedgwick Maize High School M Sedgwick Maize South High School MS Sedgwick Mulvane High School MH Sedgwick North High School WN Sedgwick Northeast Magnet NM Sedgwick Northwest High School NW Sedgwick South High School WS Sedgwick Southeast High School SE Sedgwick The Learning Center TLC Sedgwick Trinity Academy TA Sedgwick Valley Center High School VC Sedgwick West High School WW Sedgwick Wichita Collegiate High School WCH

A-10  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute Appendix B. Endnotes

1 Meernik, C., Baker, H. M., Lee, J. G., & Goldstein A. O. (2017). The Tobacco 21 movement and electronic nicotine delivery system use among youth. Pediatrics,139(1), e20162216.

2 Kessel Schneider, S., Buka, S. L., Dash, K., et al. (2016). Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Tobacco Control, 25, 355–359.

3 DiFranza, J. R., & Coleman, M. (2001). Sources of tobacco for youths in communities with strong enforcement of youth access laws. Tobacco Control, 10, 323–328.

4 White, M. M, Gilpin, E. A., Emery, S. L, et al. (2005). Facilitating adolescent smoking: who provides the cigarettes? American Journal of Health Promotion, 19, 355–360.

5 U.S. Food & Drug Administration. (2018, December 4). Products, Ingredients and Components. Retrieved from https://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm20081732.htm.

6 Institute of Medicine. (2015). Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, D.C.: National Academies Press.

7 Ibid.

8 Kendler, K. S., Myers, J., Imad Damaj, M. I., & Chen, X. (2013). Early smoking onset and risk for subsequent nicotine dependence: a monozygotic co-twin control study. American Journal of Psychiatry, 170, 408–413.

9 Kansas Department of Health and Environment. (2014). Tobacco Use in Kansas Adults: 2012-2013 Adult Tobacco Survey. Retrieved from http://www.kdheks.gov/tobacco/download/Tobacco_Use_in_Kansas_2012_2013.pdf

10 Institute of Medicine. (2015). In: Bonnie, R. J., Stratton, K., & Kwan, L. Y., (Eds.), Public health implications of raising the minimum age of legal access to tobacco products. Washington, D.C.

11 Centers for Disease Control and Prevention. (2005 and 2017). Youth Risk Behavior Survey. Retrieved from https://nccd.cdc.gov/Youthonline/App/Results.aspx?TT=J&OUT=0&SID=HS&QID=QQ&LID=KS&YID= YY&LID2=&YID2=&COL=T&ROW1=N&ROW2=N&HT=C02&LCT=LL&FS=S1&FR=R1&FG=G1&FA= A1&FI=I1&FP=P1&FSL=S1&FRL=R1&FGL=1&FAL=A1&FIL=I1&FPL=P1&PV=&TST=False&C1=&C2 =&QP=G&DP=1&VA=CI&CS=Y&SYID=2005&EYID=2017&SC=DEFAULT&SO=ASC

12 Ibid.

13 Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act. (1992). Pub. L. No. 102- 321.

14 The Family Smoking Prevention and Tobacco Control Act. (2009). Pub. L. No. 111-31.

15 Tobacco 21. (n.d.). Retrieved March 28, 2018, from https://tobacco21.org/

16 Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act. (1992). Pub. L. No. 102- 321.

17 The Family Smoking Prevention and Tobacco Control Act. (2009). Pub. L. No. 111-31.

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density B-1

18 Kansas Health Institute. (2018). Understanding the Tobacco 21 Initiative and Implementation of Tobacco 21 Laws. Retrieved from https://www.khi.org/assets/uploads/news/14844/tobacco-21-laws- r1.pdf

19 Bavely, A., & Horsley, L. (2015, November 19). KC, Wyandotte County Raise Legal Age for Tobacco Purchases to 21. Retrieved from https://www.kansascity.com/living/health-fitness/article45537861.html

20 Ord. No. O-65-15 § 1, 2015. │Unified Government of Wyandotte County and Kansas City, Kansas. Retrieved from https://library.municode.com/ks/wyandotte_county__unified_government/codes/code_of_ordinances? nodeId=CH22MIPROF_ARTVIOFAGPUMO_DI V1GE_S22- 204SEGIFUCITOPRMISECITOPRANPEUN21YEAG

21 Ibid.

22 Ibid.

23 Kansas Behavioral Risk Factor Surveillance System Local Data. (2017). Wyandotte County. Retrieved from http://www.kdheks.gov/brfss/HRSReports/2017/County/wyandotte_2017chrs.pdf

24 U.S. Census Bureau. (2018). 2013-2017 American Community Survey 5-Year Estimates. Retrieved from https://factfinder.census.gov/faces/nav/jsf/pages/searchresults.xhtml?refresh=t

25 Lee, J. G., Henriksen, L., Rose, S. W., Moreland-Russell, S., & Ribisl, K M. (2015). A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing. American Journal of Public Health, 105(9), e8-e18.

26 Ibid.

27 U.S. Department of Health and Human Services. (2012). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

28 U.S. Department of Health and Human Services. (2012). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

29 Centers for Disease Control and Prevention. (2013). Youth Risk Behavior Survey. Retrieved from https://nccd.cdc.gov/youthonline/App/Results.aspx?TT=J&OUT=0&SID=HS&QID=QQ&LID=KS&YID= YY&LID2=&YID2=&COL=T&ROW1=N&ROW2=N&HT=QQ&LCT=LL&FS=S1&FR=R1&FG=G1&FA=A 1&FI=I1&FP=P1&FSL=S1&FRL=R1&FGL=G1&FAL=A1&FIL=I1&FPL=P1&PV=&TST=&C1=&C2=&Q P=G&DP=1&VA=CI&CS=Y&SYID=&EYID=&SC=DEFAULT&SO=ASC

30 Ibid.

31 Ibid.

32 Ibid.

33 Cantrell, J., Pearson, J. L., Anesetti-Rothermel, A., Xiao, H., Kirchner, T. R., & Vallone, D. (2015). Tobacco Retail Outlet Density and Young Adult Tobacco Initiation. Nicotine & Tobacco Research: The Official Journal of the Society for Research on Nicotine and Tobacco, 18(2), 130-7.

B-2  Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density Kansas Health Institute

34 U.S. Department of Health and Human Services. (2012). Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

35 County Health Rankings. (2019). Compare Counties: Wyandotte, KS and Sedgwick, KS. Retrieved from http://www.countyhealthrankings.org/app/kansas/2019/compare/snapshot?counties=20_209%2B20_1 73

36 Macinko, J., & Silver, D. (2018). Impact of New York City’s 2014 Increased Minimum Legal Purchase Age on Youth Tobacco Use. American Journal of Public Health, 108(5), 669–675. Retrieved from https://doi.org/10.2105/AJPH.2018.304340

37 Zhang, X., Vuong, T. D., Andersen-Rodgers, E., & Roeseler, A. (2018). Evaluation of California’s ‘Tobacco 21’ law. Tobacco Control, 27, 656–662. Retrieved from https://doi.org/10.1136/tobaccocontrol-2017-054088

38 Kessel Schneider, S., Buka, S. L., Dash, K., et al. (2016). Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Tobacco Control, 25, 355–359.

39 Ribisl, K. M., Luke, D. A., Bohannon, D. L., Sorg, A. A., & Moreland-Russell, S. (2016). Reducing Disparities in Tobacco Retailer Density by Banning Tobacco Product Sales Near Schools. Nicotine & Tobacco Research: The Official Journal of the Society for Research on Nicotine and Tobacco, 19(2), 239-244.

40 City of Shawnee. (2018, November 13). Consider Resolution Extending Moratorium Related to Permits for the Operation or Establishment of New Vape Shops. City Council Memorandum. Retrieved from https://cityofshawnee.civicweb.net/document/16924/Consider%20Resolution%20Extending% 20Moratorium%20Relate.pdf?handle=2A0FE8F027CA42B5B6B8B48F069CFC53

Kansas Health Institute Youth Access to Tobacco: Tobacco 21 Enforcement Study and Tobacco Retail Outlet Density B-3

KANSAS HEALTH INSTITUTE The Kansas Health Institute supports effective policymaking through nonpartisan research, education and engagement. KHI believes evidence-based information, objective analysis and civil dialogue enable policy leaders to be champions for a healthier Kansas. Established in 1995 with a multiyear grant from the Kansas Health Foundation, KHI is a nonprofit, nonpartisan educational organization based in Topeka. Unified Government Public Health Department The Unified Government Public Health Department (UGPHD) serves Wyandotte County, Kansas, by creating and maintaining conditions for a healthy community through an array of services and initiatives. Informing Policy. Improving Health.