Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest.

OBJECTIVES: We examined the exposure to tobacco direct mail marketing and its effect on subsequent smoking behaviors in a US Midwest regional cohort of young adults. METHODS: Data were collected from 2622 young adults (mean age = 24 years) in 2010 to 2011 (baseline) and 2011 to 2012 (follow-up). We collected information on demographics, tobacco use, and exposure to tobacco direct mail materials in the previous 6 months at baseline. Smoking behaviors were reassessed at follow-up. We investigated the characteristics associated with receiving these materials at baseline, and the associations between receiving cigarette coupons in the mail at baseline and smoking behaviors at follow-up. RESULTS: Thirteen percent of participants reported receiving tobacco direct mail materials in the previous 6 months. Receipt of these materials was associated with age, education, and tobacco use (P < .05). Among those who received these materials, 77% and 56% reported receiving coupons for cigarettes and other tobacco products, respectively. Among baseline nonsmokers and ex-smokers, receiving coupons was associated with becoming current smokers at follow-up (P < .05). Among baseline current smokers, receiving coupons was associated with lower likelihood of smoking cessation at follow-up (P < .05). CONCLUSIONS: Tobacco direct mail marketing promoted and sustained smoking behaviors among US Midwest young adults. Regulating this marketing strategy might reduce the prevalence of smoking in this population.

Transitions in smoking behavior during emerging adulthood: a longitudinal analysis of the effect of home smoking bans.

OBJECTIVES: We studied the effect of home smoking bans on transitions in smoking behavior during emerging adulthood. METHODS: We used latent transition analysis to examine movement between stages of smoking from late adolescence (ages 16-18 years) to young adulthood (ages 18-20 years) and the effect of a home smoking ban on these transitions. We used data from the Minnesota Adolescent Community Cohort study collected in 2004 to 2006. RESULTS: Overall, we identified 4 stages of smoking: (1) never smokers, (2) experimental smokers, (3) light smokers, and (4) daily smokers. Transition probabilities varied by stage. Young adults with a home ban during late adolescence were less likely to be smokers and less likely to progress to higher use later. Furthermore, the protective effect of a home smoking ban on the prevalence of smoking behavior was evident even in the presence of parental smoking. However, this effect was less clear on transitions over time. CONCLUSIONS: In addition to protecting family members from exposure to secondhand smoke, home smoking bans appear to have the additional benefit of reducing initiation and escalation of smoking behavior among young adults.

Latent classes of young adults based on use of multiple types of tobacco and nicotine products.

INTRODUCTION: New tobacco and nicotine products such as snus, hookah, and electronic cigarettes have risen in popularity in recent years. Use of these products among young adults is of particular interest given that experimentation with new products is common in young adulthood. METHODS: We conducted latent class analysis among a population-based sample of young adults to identify separate classes based on use of 6 types of tobacco or nicotine products: snus, hookah, electronic cigarettes, cigarillos, snuff, and cigarettes. We then examined how identified classes differed on demographic characteristics and marijuana and alcohol use. RESULTS: We identified 5 classes: the largest group (60%) was characterized as reporting no or limited use of any of the products, while the smallest group (7%) was characterized by use of many types of products (poly-users). Of the 3 middle classes, 2 were the same size (10%) and were characterized by primarily using 2 of the products: one class used snus and snuff, and the other used cigarillos and hookah; the third class (13%) was characterized by primarily cigarette smoking. Numerous differences were seen across classes, including the poly-users being less likely to be college students/graduates and more likely to be male and use marijuana and alcohol. CONCLUSIONS: We found that young adults can be grouped into 5 subgroups based on types of tobacco/nicotine products they do and do not use. A poly-use group that uses all types of tobacco products is concerning, particularly given high levels of marijuana and alcohol use reported in this group.

Designing and evaluating culturally specific smoking cessation interventions for American Indian communities.

INTRODUCTION: American Indians have the highest smoking rates in the United States, yet few randomized controlled trials of culturally specific interventions exist. This study assessed American Indians' opinions about evidence-based treatment and attitudes toward participating in clinical trials. METHODS: Six focus groups were conducted based on smoking status (current/former smoker), sex, and elder status (55 years and older or younger). Meetings were held at local American Indian community organizations. This project was accomplished in partnership with the American Indian Community Tobacco Projects, a community-academic research partnership at the University of Minnesota. Thematic qualitative data analyses were conducted. RESULTS: Participants desired the following: (a) programs led by trained American Indian community members, (b) the opportunity to connect with other American Indian smokers interested in quitting, and (c) programs promoting healthy lifestyles. Strategies desired for treatment included (a) free pharmacotherapy, including nicotine replacement therapy (NRT); (b) nominal incentives, e.g., gift cards for groceries; and (c) culturally specific program components such as American Indian images, education on traditional tobacco use, and quit-smoking messages that target the value of family and include narratives or story telling in recruitment and program materials. Biochemical verification of smoking abstinence, such as salivary cotinine or carbon monoxide breathalyzers, is likely acceptable. Standard treatment or delayed treatment control groups were viewed as potentially acceptable for randomized study designs. CONCLUSIONS: Rigorously conducted randomized controlled trials of culturally specific smoking cessation interventions are sorely needed but will only be accomplished with the commitment of funders, researchers, and collaborative trusting relationships with the community.

Availability of snus and its sale to minors in a large Minnesota city.

INTRODUCTION: Previous studies examining tobacco retailers' compliance with youth tobacco access policies have mostly evaluated retailers' likelihood of selling cigarettes to minors, and none have evaluated the likelihood of selling snus (a new smokeless tobacco product) to minors. We assessed the availability of snus and the likelihood of selling snus to adolescents in tobacco retailers in a large city in Minnesota. METHODS: We randomly selected 71 eligible retailers located in a large city in Minnesota, and assessed the availability of snus through Camel snus retailer listings and phone inquiry. Purchase attempts by an underage buyer were used to assess the likelihood of selling snus to minors. χ2 tests were used to examine the store and neighbourhood characteristics associated with availability of snus. RESULTS: We found that 31 retailers (43.7%) carried snus in the store, and 4 (12.9%) sold snus to the underage buyer. Retailers who sold gasoline were more likely to carry snus in the store (p<0.01). Neighbourhood demographic characteristics were not associated with availability of snus (p>0.10). CONCLUSIONS: Prevalence of snus sales to minors appeared to be higher than that of cigarette sales to minors according to the 2011 Synar report. Futures studies are needed to determine whether tobacco retailers are more likely to sell snus than cigarettes to minors. Interventions such as public and retailer policies are needed to reduce the likelihood of tobacco retailers selling snus to minors.

Do Sources of Cigarettes Among Adolescents Vary by Age Over Time?

Trends in sources of cigarettes among adolescents were assessed using data from a teen cohort (2000-2006). Five sources-bought from store, got from other teen, stole from others, bought from others, and got from an adult-were measured over time by age. The most common source among all ages was other teens. Fewer teens bought cigarettes from stores, with a downward trend for all ages. Among all ages there was an upward trend in stealing with younger teens more likely to steal cigarettes. In addition to targeting cigarette sales, interventions are needed to target other youth cigarette sources.

Individual and neighborhood socioeconomic status effects on adolescent smoking: a multilevel cohort-sequential latent growth analysis.

OBJECTIVES: We examined the prospective effects of parental education (as a proxy for individual socioeconomic status [SES]) and neighborhood SES on adolescent smoking trajectories and whether the prospective effects of individual SES varied across neighborhood SES. METHODS: The study included 3635 randomly recruited adolescents from 5 age cohorts (12-16 years) assessed semiannually for 3 years in the Minnesota Adolescent Community Cohort study. We employed a cohort-sequential latent growth model to examine smoking from age 12 to 18 years with predictors. RESULTS: Lower individual SES predicted increased levels of smoking over time. Whereas neighborhood SES had no direct effect, the interaction between individual and neighborhood SES was significant. Among higher and lower neighborhood SES, lower individual SES predicted increased levels of smoking; however, the magnitude of association between lower individual SES and higher smoking levels was significantly greater for higher neighborhood SES. CONCLUSIONS: We found evidence for differential effects of individual SES on adolescent smoking for higher and lower neighborhood SES. The group differences underscore social conditions as fundamental causes of disease and development of interventions and policies to address inequality in the resources.

Receipt and redemption of cigarette coupons, perceptions of cigarette companies and smoking cessation.

BACKGROUND: Although it is known that cigarette companies use cigarette coupons to market their products, little is known about the characteristics of those who receive these coupons. The influence of receipt and redemption of these coupons is also unknown. METHODS: Participants of the Minnesota Adult Tobacco Survey Cohort Study who were smokers in 2008, completed surveys in 2008 and 2009, and had smoked for at least 6 months between those surveys, were included. In 2009, participants reported whether they had received cigarette coupons in the past 12 months, and whether they had used the coupons. They also reported their perceptions of cigarette companies and their smoking status. Multivariate logistic regressions were used to assess associations between receiving and redeeming coupons, perceptions of cigarette companies, and smoking status. RESULTS: Overall, 49.4% of the sample reported receiving cigarette coupons, and 39.9% redeemed them (80.1% of those who received these coupons). Female, younger and heavier smokers were more likely to report receiving these coupons (p<0.05). Smokers who received these coupons were more likely to agree that cigarette companies care about their health and do the best they can to make cigarettes safe, and less likely to agree that cigarette companies lie (p<0.05). Smokers who used these coupons were less likely to quit smoking (p<0.05). CONCLUSIONS: Our findings suggest a negative association between cigarette coupons and smoking cessation. Longitudinal studies are needed to establish whether cigarette coupons influence smoking behaviour to inform the necessity for policies to prohibit the use of these coupons to assist smokers to quit smoking.

Did a local clean indoor air policy increase alcohol-related crime around bars and restaurants?

OBJECTIVE: To evaluate whether the adoption of a local clean indoor air (CIA) policy in St. Paul, Minnesota, was associated with changes in alcohol-related crimes outside on-premises alcohol-licensed businesses. DESIGN: The enactment of a comprehensive CIA policy on 31 March 2006 was used as the intervention time point in an interrupted time-series analysis to assess changes in weekly crime frequency prior to the policy enactment compared with the period after the policy was established (n=261 weeks). SETTING: St. Paul, Minnesota, USA. SUBJECTS: On-premise alcohol-licensed business addresses were collected from St. Paul, Minnesota, for the period of January 2003 to December 2007, and geocoded. A 500-foot (152.4 m) buffer was drawn around each business. MAIN OUTCOME MEASURES: Alcohol-related crime (ie, arrest) data were obtained from the St. Paul Police Department; crimes had been geocoded by the police department. They were aggregated by week to include only those crimes that occurred within the drawn buffer. Relevant types of crimes included serious (eg, aggravated assaults, homicide, robbery, rape and theft) and less serious (eg, lesser assault, fighting, noise violations, public drunkenness/lewdness or other liquor law violations) crimes. RESULTS: Within a buffer of 500 foot of alcohol-licensed businesses, 23 978 serious alcohol-related crimes and 49 560 less serious alcohol-related crimes occurred over 5 years. Using interrupted time-series analyses to compare the weekly alcohol-related crime frequency in proximity with the bars and restaurants, we found no significant change in either type of crime associated with the local comprehensive CIA policy (p=0.13) after adjustment for seasonal differences and overall crime frequencies. CONCLUSIONS: Evidence from this study suggests that alcohol-related crimes were not significantly affected by a local comprehensive CIA policy that banned smoking in public workplaces in St. Paul, Minnesota.

The relationship of neighborhood demographic characteristics to point-of-sale tobacco advertising and marketing.

OBJECTIVES: Exposure to tobacco marketing has been associated with an increased likelihood that youth start smoking and may interfere with tobacco cessation. We aimed to describe the prevalence, placement, and features of tobacco advertising at the point of sale by race, ethnicity, and other neighborhood demographics, as well as by store type. DESIGN: A cross-sectional assessment of the advertising environment in establishments that held tobacco licenses in our study region (a metropolitan area in the Midwest USA) was conducted in 2007. Stores were geocoded and linked with block group demographic data taken from the Year 2000 US census. We calculated associations between our hypothesized predictors, race, ethnicity, and other neighborhood demographics, and two types of outcomes (1) amount and (2) characteristics of the advertising. RESULTS: Tobacco advertising at the point of sale was most common in gas stations/convenience stores, liquor stores, and tobacco stores. A 10% difference in a block group's African-American/Black population was associated with 9% (95% confidence interval [CI]=3%, 16%) more ads as well as a greater likelihood that ads would be close to the ground (prevalence ratio [PR]=1.15 [95% CI=1.04, 1.28]). Block groups with greater African-American/Black, Asian, people on public assistance or below 150% of the poverty threshold, or people under the age of 18 years had more ads for menthol brands. Block groups with greater proportions of Whites were more likely to have ads that used health words, such as 'light' or 'natural' (PR for 10% difference in White population=1.41 [95% CI=1.17-1.70]). Chain stores were more likely to have greater amounts of advertising, ads close to the ground, ads for price deals, or ads that use words that imply health. CONCLUSION: Tobacco advertising targets communities with various racial and ethnic profiles in different ways. Now that US Food and Drug Administration has the authority to regulate the marketing and sale of tobacco products, there is new opportunity to reduce the harmful impact of tobacco advertising.

Smokeless tobacco advertising at the point of sale: prevalence, placement, and demographic correlates.

INTRODUCTION: We aimed to describe the prevalence, in-store location, and neighborhood predictors of point-of-sale smokeless tobacco advertising. METHODS: In 2007, we conducted assessments of smokeless tobacco advertising at the point of sale in 484 establishments, which held tobacco licenses and sold tobacco products in a Midwest metropolitan area. Associations between store characteristics, neighborhood characteristics (based on U.S. 2000 census block groups), and smokeless tobacco advertising were calculated. RESULTS: Advertisements for smokeless tobacco were found in 21% (n = 103) of stores. Approximately, 12% (n = 58) of stores had ads within 6 feet of the counter, 3% (n = 14) had ads less than 3 feet from the ground, and 2% (n = 9) had advertisement less than 1 foot from candy or snacks. The racial/ethnic composition and number of households on public assistance within the block group in which a store was situated were related to the amount of smokeless advertising in stores. For instance, having a higher proportion of the population identifying as White was associated with more advertising. Gas stations/convenience stores had more advertising than any other store types. Chain stores had double the amount of advertising as independent stores (p < .05) even after adjustment for other factors. CONCLUSIONS: Smokeless tobacco advertising is not uncommon even in an urban metropolitan community. These products are being advertised in a way that youth, especially those living in neighborhoods with certain demographic characteristics, can encounter. With Food and Drug Administration regulation, there are new opportunities to regulate advertising at the point of sale.

Tribal Tobacco Use Project II: Planning, Implementation, and Dissemination Using Culturally Relevant Data Collection among American Indian Communities.

American Indians have substantially higher commercial tobacco-related cancer rates when compared to the general population. To effectively combat commercial tobacco-related cancer, it is important that tribal nations obtain current and accurate community-specific data on commercial tobacco use and exposure-related attitudes and behaviors. With the goal to collect, synthesize, and disseminate data on tobacco use, including the role traditional tobacco plays among American Indian people, the American Indian Cancer Foundation (AICAF) and various stakeholders developed and implemented the Tribal Tobacco Use Project II (TTUP II) during 2018-2021. Building upon its predecessor, the Tribal Tobacco Use Project I (TTUP I), TTUP II used principles of community-based participatory research and culturally appropriate methods, such as Reality-Based Research, in partnership with tribal nations. We describe the TTUP II rationale, methods for participant recruitment and data collection, emphasizing the importance of using culturally relevant survey items to disentangle commercial tobacco use from traditional tobacco use. American Indian traditional tobacco is viewed as medicine in these communities with a unique socio-cultural context that must be addressed when engaging in commercial tobacco control efforts in American Indian communities. This approach may be useful to other tribal nations who are interested in conducting culturally relevant tobacco surveillance efforts.

Adolescents' use of indoor tanning: a large-scale evaluation of psychosocial, environmental, and policy-level correlates.

OBJECTIVES: We evaluated psychosocial, built-environmental, and policy-related correlates of adolescents' indoor tanning use. METHODS: We developed 5 discrete data sets in the 100 most populous US cities, based on interviews of 6125 adolescents (aged 14-17 years) and their parents, analysis of state indoor tanning laws, interviews with enforcement experts, computed density of tanning facilities, and evaluations of these 3399 facilities' practices regarding access by youths. After univariate analyses, we constructed multilevel models with generalized linear mixed models (GLMMs). RESULTS: In the past year, 17.1% of girls and 3.2% of boys had used indoor tanning. The GLMMs indicated that several psychosocial or demographic variables significantly predicted use, including being female, older, and White; having a larger allowance and a parent who used indoor tanning and allowed their adolescent to use it; and holding certain beliefs about indoor tanning's consequences. Living within 2 miles of a tanning facility also was a significant predictor. Residing in a state with youth-access legislation was not significantly associated with use. CONCLUSIONS: Current laws appear ineffective in reducing indoor tanning; bans likely are needed. Parents have an important role in prevention efforts.

Smoke-free laws in bars and restaurants: does support among teens and young adults change after a statewide smoke-free law?

OBJECTIVE: We assessed changes in levels of support for smoke-free bars and restaurants among teens and young adults before and after implementation of a statewide smoke-free law. METHODS: We measured support for smoke-free bars and restaurants among teens and young adults aged 16-24 years living in Minnesota (n=2,785) and five comparison states (n=404), up to 12 months before and up to six months after Minnesota's smoke-free law went into effect in October 2007. We compared changes in support among three subgroups-Minnesota participants who lived with a previous local smoke-free law, Minnesota participants who did not live with a previous local smoke-free law, and participants from the comparison states-before and after Minnesota's statewide smoke-free law went into effect. RESULTS: Support for smoke-free restaurants and bars among participants in Minnesota and comparison states increased after Minnesota's smoke-free law went into effect. Minnesotans, both those living with and without a previous local smoke-free law, showed similar increases in support for smoke-free restaurants as participants in comparison states. However, Minnesotans living without a previous local law showed larger increases in support for smoke-free bars than both those in comparison states and those living in Minnesota with a previous local smoke-free law. CONCLUSIONS: Our study employed a more robust design than similar studies and focused on the teen and young adult population. Our results will help advocates and policy makers demonstrate how public support for smoke-free laws increases following smoke-free legislation, particularly among those who were not previously living with a local smoke-free law.

Economic effects of clean indoor air policies on bar and restaurant employment in Minneapolis and St Paul, Minnesota.

OBJECTIVES: Clean indoor air (CIA) policies have been adopted by communities across the United States and internationally to protect employees in all workplaces from exposure to environmental tobacco smoke. Concerns have been raised that banning smoking in workplaces, particularly in bars and restaurants, will result in severe, negative economic effects. Although objective studies have consistently found no significant economic effects from CIA policies, the concerns persist that CIA policies will negatively affect hospitality businesses. METHODS: Employment in bars and restaurants in Minneapolis and St Paul, Minnesota, was independently evaluated over a five-year period during which CIA policies were established in each city. An interrupted time series analysis was used to evaluate the short-, intermediate, and longer-term economic effects of the local CIA policies, accounting for the rest of the hospitality industry. RESULTS: The CIA policies were associated with an increase of three percent to four percent in employment for restaurants in Minneapolis and St Paul, after accounting for the rest of the hospitality industry. The CIA policies were inconsistent in their association with bar employment. A comprehensive CIA policy in Minneapolis was associated with an increase of five percent to six percent in bar employment, and St Paul had a one percent nonsignificant decrease in bar employment. The CIA policies continue to yield the best protection against workplace exposure to environmental tobacco smoke for bars and restaurant employees and were not associated with large employment changes for the short or longer term in two urban Midwestern cities in the United States.

Did youth smoking behaviors change before and after the shutdown of Minnesota Youth Tobacco Prevention Initiative?

INTRODUCTION: No previous studies document the effects of both comprehensive tobacco control and its defunding on youth smoking. This study tests the effect of the youth-focused Minnesota Youth Tobacco Prevention Initiative (MYTPI) and its shutdown on youth smoking and determines whether these effects differed by age. METHODS: The Minnesota Adolescent Community Cohort is a population-based, observational study designed to evaluate the MYTPI. The sample included cohorts of youth aged 12-16 years at baseline in Minnesota (N = 3,636) and a comparison group in six other Midwestern states (n = 605). Biannual surveys assessed youth smoking from October 2000, 5 months after the MYTPI launch, through October 2005, 2 years postshutdown. Adjusted piecewise linear trajectories predicted smoking stage (measured on a 1-6 continuum) comparing Minnesota with a comparison group during the MYTPI (Slope 1) and postshutdown (Slope 2) for each baseline age cohort. Analysis then compared baseline age cohorts with each other by centering their intercepts on age 16. RESULTS: Neither slope of smoking stage differed between Minnesota and comparison groups, showing no period effects for the MYTPI or shutdown. However, younger cohorts, with early teen experience of MYTPI, smoked less than older cohorts by the same age. Mean smoking stage at age 16 differed by almost a half stage from the youngest (2.04) to the oldest (2.46) age cohort. DISCUSSION: The study offers no evidence of period effects for the MYTPI or its shutdown. Design limitations, national or continued post-MYTPI statewide tobacco control efforts, or program flaws could explain the findings.

Do cigarette prices vary by brand, neighborhood, and store characteristics?

OBJECTIVE: We assessed the price variability of cigarettes by brand, neighborhood characteristics (racial/ethnic and youth composition, number of schools, and number of stores), and store type. METHODS: Trained research staff purchased three different brands of cigarettes (premium, menthol, and discount-all produced by the same company) at 214 stores in one metropolitan area. We assessed associations between price and neighborhood/store characteristics through multivariate regression, using four price variables as dependent variables-the price of each brand of cigarettes and the mean price across the three brands. RESULTS: We found that the price of cigarettes varied by neighborhood and store characteristics, although this variability differed by brand. For the same brand, the maximum price was 1.7 to 1.8 times higher than the lowest price. We found a positive association between the percentage of a neighborhood that was nonwhite and the price of discount and premium cigarettes as well as the overall mean price of cigarettes, but not with the price of the menthol brand. We found a negative association between the percentage of youth in a neighborhood and the price of premium cigarettes as well as the mean price, but not with the price of the other two brands. In addition, we found a greater likelihood of higher discount brand prices at independent vs. chain-operated stores. CONCLUSIONS: Our findings showed that cigarette prices do vary by brand, the youth and racial/ethnic composition in a neighborhood, and store type, suggesting that the tobacco industry might vary its marketing strategies based on brand as well as neighborhood and store characteristics.

Area-level variation in adolescent smoking.

INTRODUCTION: The purpose of this study is to 1) examine the variability in the prevalence of adolescent smoking in 60 geographic areas of Minnesota and 2) assess how variability in area-level smoking prevalence is associated with area-level sociodemographic characteristics. METHODS: Smoking data were collected from 3,636 adolescents residing in 60 areas of the state of Minnesota. Area-level characteristics were obtained from the 2000 US Census. Coefficient of variation was calculated to assess variability in smoking prevalence across areas, and mean smoking prevalence was compared above and below the median for each area-level characteristic. RESULTS: Substantial variation was found in adolescent smoking prevalence rates. Across the 60 areas, the percentage of adolescents that ever smoked varied from 13% to 53%, and the percentage of adolescents that smoked in the past 30 days ranged from 3% to 19%. Mean lifetime smoking prevalence was higher in areas with a higher percentage of residents with less than a high school education, a lower percentage of residents living in an urban area, lower median housing value and a lower median household income, a higher percentage of residents aged 16 years or older who were unemployed, and a higher percentage of residents with an income-to-poverty ratio less than 1.5. Similar results were found for past 30-day smoking prevalence among girls; however, no area-level characteristics were significantly associated with past 30-day smoking prevalence among boys. CONCLUSION: Results suggest that area-level characteristics may play an important role in adolescent smoking, particularly for girls.

Characterizing and comparing young adult intermittent and daily smokers.

We interviewed 732 smokers (from five US upper Midwestern states) via telephone in 2006 to examine young adult smoking patterns. We first defined two groups of intermittent smokers-low (who smoked for 1-14 days in the past 30 days) and high (who smoked for 15-29 days in the past 30 days), and then analyzed differences between these two groups and daily smokers. Low intermittent smokers were much less likely to consider themselves smokers, feel addicted, or smoke with friends than high intermittent smokers. Daily smokers were more likely to feel addicted and have trouble quitting smoking than high intermittent smokers. Implications, limitations, and ideas for future studies will be discussed.

Enforcement of state indoor tanning laws in the United States.

INTRODUCTION: Twenty-eight US states have passed legislation for indoor tanning facilities. To our knowledge, whether these state laws are actually enforced has not been evaluated previously in all 28 states. Therefore, we interviewed key informants in these states to assess enforcement practices. METHODS: Two trained interviewers used a structured survey instrument to interview 28 key informants who were knowledgeable about enforcement practices for laws regarding indoor tanning. Respondents provided information specific to the most populous city in their states. RESULTS: Licensure for indoor tanning businesses was required in 22 of the 28 cities. Slightly less than half of the cities gave citations to tanning facilities that violated state law. Approximately 32% of the cities did not inspect indoor tanning facilities for compliance with state law, and another 32% conducted inspections less than annually. Of those cities that inspected at all, most conducted unannounced inspections. CONCLUSION: The relatively low rates of annual inspections and citations are of concern. We recommend that future studies assess whether legislation, enforcement practices, or a combination of the 2 affects the practices of indoor tanning facilities or of consumers.