Raising the minimum legal age to buy cigarettes is a strategy to prevent or delay tobacco use by adolescents and young adults, particularly those ages 15 to 17. But what’s the right age?
A new study from the University of Michigan and the University of Virginia shows that raising the minimum age to 21 would likely have a substantially greater impact on reducing the initiation of tobacco use—defined as having smoked 100 cigarettes—than raising it to 19. But, the added effect of raising the minimum legal age (MLA) beyond age 21 to age 25 would probably be considerably smaller.
Underage users rely primarily on social sources — friends and relatives — to get tobacco. But between ages 15 and 17, teenagers may have more ways to get cigarettes, such as from peers who are already of legal age. Therefore, increasing the MLA to 19 may not result in substantial changes, but raising it to 21 likely would.
Over the past 50 years, tobacco control efforts in the United States have led to an estimated 8 million fewer premature deaths, but tobacco use continues to significantly affect public health — and more than 40 million Americans still smoke. Although the Family Smoking Prevention and Tobacco Control Act of 2009 granted the US Food and Drug Administration broad authorities over tobacco products, it prohibited the FDA from establishing a nationwide MLA for tobacco products above 18 years of age.
In response to congressional direction, the FDA asked the Institute of Medicine to assess the potential public health implications of raising the MLA without making a recommendation about whether the MLA should be raised.
The committee conducted its analysis within the context of existing youth access laws and enforcement policies across the US, which vary considerably. Although is most states, the minimum legal age is 18, it is 19 in four states (Alabama, Alaska, New Jersey, Utah), and New York City and several other localities around the country have raised it to 21.
“While the development of some cognitive abilities is achieved by age 16, the parts of the brain most responsible for decision-making, impulse control, and peer susceptibility and conformity continue to develop until about age 25,” says Dr. Richard Bonnie, professor of medicine and law at the University of Virginia.
“A balance needs to be struck between the personal interests of young adults in being allowed to make their own choices and society’s legitimate concerns about protecting the public health and discouraging young people from making decisions they may later regret, due to their vulnerability to nicotine addiction and immaturity of judgment. These concerns support an underage access restriction, but they do not resolve the policy question about the specific age at which the line should be drawn.”
Researchers emphasize that policy decisions about the MLA should consider other factors in addition to projected health outcomes, including the relative maturity of adolescents and young adults.
Of people who have ever smoked daily, 90 percent first tried a cigarette before 19 years of age, and nearly all others tried their first cigarette before the age of 26. This strongly suggests that if someone is not a regular tobacco user by age 25, it is highly unlikely he or she will become one.
Researchers say if the MLA was raised now, in 2100 there would be about a 3 percent decrease in smoking prevalence for an MLA of 19, a 12 percent decrease for an MLA of 21, and a 16 percent decrease for an MLA of 25.
Given the likelihood that raising the MLA would decrease the rates of initiation of tobacco use, tobacco-related disease and death consequently also would decrease. For example, if the MLA were raised now to age 21 nationwide, there would be 249,000 fewer premature deaths, about 45,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost among people born between 2000 and 2019.
“These are considerable long-term health benefits that would accumulate throughout the lifetime of these individuals in addition to short-term and intermediate effects,” says Dr. Rafael Meza, assistant professor of epidemiology at the University of Michigan.
Although reductions in smoking-related deaths following an increased MLA would not be observed for at least 30 years, some direct health benefits, including reduced exposures to secondhand smoke, would be immediate. An increase in the MLA for tobacco products would also likely improve maternal, fetal, and infant outcomes by reducing the likelihood of maternal and paternal smoking.
Specifically, if the MLA were raised now to age 21 nationwide, the models project that by 2100 there would be approximately 286,000 fewer preterm births, 438,000 fewer cases of low birth weight, and roughly 4,000 fewer sudden infant death cases among mothers ages 15 to 49
“So the health benefits would occur first in adolescents and young adults but progressively translate to older and even younger individuals,” Dr. Meza says.
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