Banning tobacco sales to under 21s could have significant impacts on population health

By Dr. Ananya Mandal, MDJul 29 2019

A new study from researchers at the Yale School of Public Health has found that restricting the sale of tobacco and tobacco products for persons under the age of 21 years could lead to a decline in smoking rates across the country.

The study is titled, “Do Local Tobacco-21 Laws Reduce Smoking among 18 to 20 Year-Olds?” and was published in the latest online version of the journal Nicotine & Tobacco Research.

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The study was conducted by two researchers led by Abigail S. Friedman, Assistant Professor at Yale School of Public Health and Rachel Wu, an undergraduate student at Yale College. The researchers looked at the effect of the tobacco-21 laws on smoking among young adults aged 18 to 20 years who live in metropolitan/micropolitan statistical areas (MMSAs). The MMSAs were defined as clusters of counties around an urban centre with at least ten thousand population.

The authors explain that thus far, there have been no studies looking at the efficacy of tobacco sale restriction among youngsters.

The team gathered data from Behavioural Risk Factor Surveillance System regarding smoking among 18-20 years olds between 2011 and 2016. The association between the tobacco-21 policies and the rates of smoking among these 18 to 20 year olds was analysed in detail from the collected data.

Results revealed that there was a declining trend in smoking among the 18 to 20 year olds in the MMSAs. This trend was not seen among those aged between 20 to 25 years. In 2016, there was a decline in smoking rates from 16.5 percent in 2011 to 8.9 percent.

In an MMSA covered by the tobacco-21 policy the overall reduction of likelihood of smoking was 3.1 percentage points, wrote the researchers. If the implementation of the policy was partial, the researchers noted that the likelihood of becoming a smoker reduced by 1.2 percent compared to MMSAs where there are no tobacco-21 policies among the same age group.

The team say that this reduction in smoking starting risk translated into an overall reduction of 10 percent in smoking rates. If the whole state were to observe the tobacco-21 laws strictly, explain the researchers, there could be a greater reduction in smoking rates.

Smoking is responsible for over 400,000 deaths in the United States alone every year, with the vast majority of smokers initiating use before age 21. Our analysis indicates that tobacco-21 laws are an effective way to reduce such take-up, even when they are implemented at the local level.”

Abigail S. Friedman, Senior Author

The researchers emphasize that this study shows the importance of raising the tobacco purchasing age to 21 in an effort to reduce the incidence of smoking among young adults. They add that not upholding these policies could adversely affect public health.

At present, 18 states and over four hundred localities have laws in place that ban the sale of tobacco to individuals under age 21. In 16 states, however, there are pre-emption policies that have stopped the local jurisdictions to raise the minimum legal age for sale of tobacco. In these states, the minimum age of sale of tobacco is 18 years.

Over 20% of the U.S. population under age 21 lives in a preemption state without a state-level tobacco-21 law. This study's findings suggest that such preemption laws prevent residents who support tobacco-21 policies from improving their community's health.”

Abigail S. Friedman, Senior Author

How widespread is tobacco use in the USA?

Earlier this year, the Centre for Disease Control and Prevention (CDC) warned that if cigarette smoking remains at its present level in the United States, “5.6 million of today’s Americans younger than 18 will die early from a smoking-related illness. That’s about 1 of every 13 Americans aged 17 years or younger who are alive today.”

The report states that 90 percent of smokers try their first cigarette by the age of 18 and 98 percent try it before they are 26 and each day around 2000 youngsters aged 18 years and below smoke for the first time and daily 300 under-18s become smokers.

The report states that two major drivers in under-age smoking are flavored cigarettes and tobacco products and the use of e-cigarettes.

Mass media showing smoking as “cool”, one or both parents smoking, mental health problems such as anxiety and depression often drive people to take up smoking in their youth, according to the report.

Belonging to lower socioeconomic status, lack of support and involvement of caregivers, availability and accessibility, low self-image or esteem are major risk factors to smoking in the youth.

The CDC report says that “National, state, and local program activities have been shown to reduce and prevent youth tobacco product use when implemented together.”

This includes policies to raise tobacco and tobacco product prices, the prohibition of smoking in common areas such as workplaces and schools, raising the minimum age of sales of tobacco to 21 years, mass media messages, community awareness programs.

The report concludes, “It is important to keep working to prevent and reduce the use of all forms of tobacco product use among youth.”