After a decade of consistent decreases in tobacco use by teenagers, The National Youth Tobacco Survey reports that in 2014 overall use of tobacco among youth rose, exposing dangerous new trends. Clever marketing by the tobacco industry, pushing small cigars, hookahs, e-cigarettes, and flavored vaping products, has put millions of young people at risk of lifelong lethal nicotine addiction.
There is no one magic bullet for preventing youth tobacco use. Increased taxes, counter-marketing and school programs all play a role. However, funding has shriveled and tax increases face mounting opposition causing fewer and fewer to be enacted. There is now growing interest in another tool: access restriction to age 21.
The momentum is surging across the nation. In November of 2013, New York City and the Big Island of Hawaii both passed legislation to restrict access to nicotine and tobacco before age 21. Meanwhile, two pediatricians in Massachusetts, Drs. Jonathan Winickoff and Lester Hartman, successfully campaigned in over 100 communities in Massachusetts, persuading each to raise its access age to 21. In late 2015, Kansas City and Cleveland became the first major Midwestern cities to raise their tobacco age to 21, and Boston and San Francisco joined the list of big cities to adopt Tobacco 21. Similar local efforts around the country have also succeeded, and statewide efforts began in earnest in 2015, and continued into 2016. As of August, 2016, over 180 municipalities in 12 states, and the entire states of Hawaii and California, have taken this important step, covering nearly 60 million people. Similar legislation has passed the Senate in New Jersey and Massachusetts.
The popular support is overwhelming. In July of 2015 the CDC released a study (found here and here) concluding that an astounding 75% of adults favor raising the tobacco age to 21, including 70% of current smokers and 65% of those aged 18-24.
Finally, there is strong outcome-based data to support the issue. Before 2005 an age-21 policy had never been tried anywhere, even though other inherently risky activities, including alcohol and handgun sales as well as casino gambling, are routinely restricted until age 21. Over a three-year period from 2005-2008, Needham, Massachusetts, gradually raised their legal sales age for tobacco from age 18 to 21. It seemed largely a symbolic gesture at the time as other Boston suburbs tightly surround Needham. Surely young people would just buy nearby?
But there was a surprise. The MetroWest Health Foundation, serving 29 Boston suburbs, began surveying high school students on risk behaviors every two years beginning in 2006. By 2010 cigarette smoking by Needham High School students had dropped by more than half (red) while the surrounding MetroWest suburbs (blue) fell only slightly. Experts attribute this decrease to loss of social sources. Teen smoking is not powered by illegal sales nearly as much as by legal sales to older youth. Raising access to age 21 puts legal purchasers outside the social circle of most high school students.
These results mirror those of raising the age for alcohol to 21. That intervention, undertaken by most states in the 1980s to reduce deaths caused youthful drunk drivers, had the added benefit of dramatically reducing teenage drinking including binge drinking and daily drinking. In fact, as those young people have grown up their alcohol use is still remains lower than before the drinking age was 21.
And the Institute of Medicine agrees. In March of 2015, the Institute of Medicine, on behalf of the Food and Drug Administration (FDA), released a seminal report detailing the potential public health benefits of enacting a nationwide Tobacco 21 policy. Among the remarkable results was a 25% drop in youth smoking initiation, a 12% drop in overall smoking rates, and 16,000 cases of preterm birth and low birth weight averted in the first 5 years of the policy, an impact that would be recognized immediately. Their conservative estimate is that if age 21 were adopted throughout the U.S. it would prevent 4.2 million years of life lost to smoking in kids alive today.
The most compelling argument for taking tobacco to age 21 comes from the tobacco industry itself: “Raising the legal minimum age for cigarette purchase to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” They know their markets, it’s time we listened.
The health consequences of smoking are staggering. Smoking currently provokes over 500,000 annual premature deaths nationwide, and 6 million worldwide. For teens, cigarettes are a gateway drug to alcohol, marijuana, and cocaine use, and are heavily implicated in the development of ADHD, PTSD, Depression, Anxiety Disorders, and Schizophrenia, compounding the damage. All told tobacco takes more lives than AIDS, auto accidents, homicides, alcohol, illegal drugs, suicides, and fires combined.
The economic losses are equally sobering. The direct health care costs and indirect losses to the American economy from tobacco use are estimated to be nearly $330 billion per year, much of that at the expense of employers paying health insurance premiums and taxpayers financing Medicaid and Medicare. The American Lung Association estimates that each pack of cigarettes consumed costs our society $18.05 in increased health care and work related expenditures.
We have strong evidence that moving alcohol to age 21 reduced youth usage. America performed a striking social experiment with alcohol access during the 70’s and 80’s. After the Vietnam War and the reduction of the voting age to 18, many states lowered their drinking age. The disastrous drunk driving results of this action prompted our nation to move all states drinking ages to 21. Not only did drunk driving deaths plummet, but youth usage and binge drinking fell by a third.
Age 21 protects younger teens better. The younger the buyer is, the less likely they are to achieve a purchase even with current shoddy enforcement. Moreover, most social sources of tobacco for teens are themselves younger than 21. Age 21 reduces initiation in younger kids and inhibits consolidation of addiction in older teens.
Age 18 is not magic. Well-heeled industry lobbyists constantly whisper to lawmakers the mantra, “Old enough to fight and vote, old enough to drink and smoke.” They imply smoking is a right and a benefit, not an addiction and a societal burden. Our society has always recognized that young people are vulnerable to impulsive and risky behaviors and granted our kids gradually increasing access to potentially dangerous activities. We allow partial work permits at age 14 then driver’s licenses at 16 and legal responsibilities at 18. Finally we grant access to alcohol, and in most states gambling and handguns, at age 21. In the four states (Alaska, Oregon, Colorado, and Washington) that have legalized marijuana, the legal sales age is set at 21. Smoking is statistically much more deadly than any of these other risky behaviors. How many hundreds of thousand of lives should be traded for the shortsighted sophistry of “18 = adult”?