Public Health Implications of
Raising the Minimum Age
of Legal Access to
Tobacco Products
Committee on the Public Health Implications of
Raising the Minimum Age for Purchasing Tobacco Products
Board on Population Health and Public Health Practice
Richard J. Bonnie, Kathleen Stratton, and Leslie Y. Kwan, Editors
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
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This study was supported by Contract/Grant No. HHSF22301031T between the National Academy of Sciences and the Department of Health and Human Services: Food and Drug Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
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Suggested citation: IOM (Institute of Medicine). 2015. Public health implications of raising the minimum age of legal access to tobacco products. Washington, DC: The National Academies Press.
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OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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COMMITTEE ON THE PUBLIC HEALTH
IMPLICATIONS OF RAISING THE MINIMUM AGE
FOR PURCHASING TOBACCO PRODUCTS
RICHARD J. BONNIE (Chair), Harrison Foundation Professor of Medicine and Law, Professor of Psychiatry and Neurobehavioral Sciences, Director of the Institute of Law, Psychiatry, and Public Policy, University of Virginia
ANTHONY J. ALBERG, Blatt Ness Distinguished Endowed Chair in Oncology, Professor, Public Health Sciences, Interim Director of Hollings Cancer Center, Medical University of South Carolina
REGINA BENJAMIN, NOLA.com/Times Picayune Endowed Chair in Public Health Sciences, Xavier University, New Orleans
JONATHAN CAULKINS, Professor, Operations Research and Public Health Policy, Heinz College of Public Policy and Management, Operations Research Department, Carnegie Mellon University
BONNIE HALPERN-FELSHER, Professor, Department of Pediatrics, Director of Research, Associate Director of Adolescent Medicine Fellowship Program, Division of Adolescent Medicine, Stanford University
SWANNIE JETT, Executive Director, Florida Department of Health in Seminole County
HARLAN JUSTER, Director, Bureau of Tobacco Control, New York State Department of Health
JONATHAN D. KLEIN, Associate Executive Director, Julius B. Richmond Center of Excellence for Children and Secondhand Smoke, American Academy of Pediatrics
PAULA M. LANTZ, Professor and Chair, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University
ROBIN MERMELSTEIN, Director of the Institute for Health Research and Policy, Professor of Psychology, Clinical Professor of Community Health Sciences, School of Public Health, University of Illinois, Chicago
RAFAEL MEZA, Assistant Professor, Department of Epidemiology, University of Michigan
PATRICK O’MALLEY, Research Professor, Institute for Social Research, University of Michigan
KIMBERLY THOMPSON, Professor of Preventive Medicine and Global Health, University of Central Florida College of Medicine, President, Kid Risk, Inc.
Consultants
THEODORE R. HOLFORD, Susan Dwight Bliss Professor of Public Health (Biostatistics) and Professor of Statistics, Yale School of Medicine, Yale University
DAVID T. LEVY, Professor, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center
MARIA RODITIS, Postdoctoral Research Fellow, Adolescent Medicine, Division of Adolescent Medicine, Department of Pediatrics, Stanford University
IOM Staff
KATHLEEN STRATTON, Study Director
LESLIE Y. KWAN, Research Associate
BETTINA RITTER, Research Assistant
ANNA MARTIN, Senior Program Assistant
DORIS ROMERO, Financial Associate
ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
ANNETTE M. BACHAND, Colorado State University
SANJAY BASU, Stanford Prevention Research Center
CHRISTINE DELNEVO, Rutgers School of Public Health
EDWARD EHLINGER, Minnesota Department of Health
MICHAEL P. ERIKSEN, Georgia State University
THOMAS J. GLYNN, Stanford University and American Cancer Society
STEVEN A. SCHROEDER, University of California, San Francisco
JOSHUA M. SHARFSTEIN, Maryland Department of Health and Mental Hygiene
LAURENCE STEINBERG, Temple University
JENNIFER IRVIN VIDRINE, University of Texas MD Anderson Cancer Center
KENNETH W. WACHTER, University of California, Berkeley
ALEXANDER C. WAGENAAR, University of Florida
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by SUSAN J. CURRY, University of Iowa, and RONALD S. BROOKMEYER, University of California, Los Angeles. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Preface
The Surgeon General’s clarion call in 1964 for “appropriate remedial action” to address the hazards of smoking is often credited with having launched the nation’s public health campaign against cigarettes. Effective federal action was impeded for more than three decades by a symbolic congressional action in 1965 mandating weak package warnings and then by the regressive decision by Congress in 1969 to preempt the states from regulating tobacco advertising “based on smoking and health.” The 1969 legislation also banned tobacco advertising on television and thereby erased the country’s first major tobacco control initiative—the hugely significant ruling by the Federal Communications Commission that broadcasters who aired tobacco advertisements were required by the agency’s fairness doctrine to make time available for antismoking messages.
Attention then shifted to the states, largely driven by a grassroots movement for public smoking restrictions. The campaign was given major boosts by an important Surgeon General report emphasizing the addictive properties of nicotine (1988) and an Environmental Protection Agency report on the environmental hazards of tobacco smoke (1992). Another key building block of contemporary tobacco control was the initiative aiming to reduce youth smoking spearheaded by Congressman Mike Synar in 1992. The Synar Amendment requires states to enact and enforce youth access restrictions or else forfeit 40 percent of their block grants for substance abuse prevention and treatment. Within 2 years, the Synar Amendment was followed by two major reports by the Surgeon General and by the Institute of Medicine (IOM) on preventing the onset of nicotine addiction in adolescents and by a rhetorically and politically important initiative by Food and
Drug Administration (FDA) Commissioner David Kessler characterizing nicotine addiction as a “pediatric disease.” Despite some dissension within the ranks of tobacco control advocacy, preventing youth initiation took its place as one of the core strategic components of tobacco control.
The campaign against secondhand tobacco smoke and the new focus on child protection and the prevention of addiction played pivotal roles in the gradual evolution of public support for aggressive tobacco control in the 1990s. The cause of tobacco control was also fundamentally accelerated by the emerging evidence that cigarettes have been engineered to be addictive and by the public distaste for industry advertising campaigns that seemed so obviously targeted at children and adolescents. In 1995, as the policy context for tobacco control rapidly evolved, FDA announced its innovative initiative to declare jurisdiction over cigarettes as “nicotine delivery devices” and its intention to develop a new rule aiming to reduce youth smoking. FDA’s proposed rule included limitations on advertising and promotion as well as federal restrictions on youth access. Although the age of access in FDA’s regulation was 18, the agency considered setting the minimum age at 21. Whatever the reasoning within FDA may have been, the consensus within the IOM committee that authored the 1994 report on youth smoking was that setting the age at 21 was too large a leap for reform in a political and social context in which existing youth access restrictions were largely unenforced and cigarettes were easily available to children old enough to put coins in a vending machine.
FDA’s Tobacco Rule was proposed in 1995, promulgated in 1996, and invalidated by the Supreme Court in 2000. However, momentum for aggressive tobacco control continued to build throughout this period. The state attorney generals’ lawsuits against the tobacco companies to recover Medicaid costs attributable to smoking—and the accompanying disclosures of industry documents—led to the Master Settlement Agreement in 1998 and to aborted negotiations regarding federal tobacco regulation. Meanwhile, social norms toward smoking have been transformed, prevalence has gradually declined, more reports on tobacco have been issued by the IOM and by Surgeons General, and the Family Smoking Prevention and Tobacco Control Act was enacted in 2009. Tobacco advocates have begun to focus on the “end game” for cigarette smoking.
It is in this context that Congress directed FDA in the Tobacco Control Act to commission a report on the public health implications of raising the minimum age of legal access to tobacco products. Many states and localities are considering proposals to raise the age, and some have already done so. In light of the extraordinary momentum achieved by tobacco control advocacy over the past three decades, talking about raising the age of youth access may seem anticlimactic. However, cigarette smoking is a stubborn and costly public health problem, and the tobacco industry is resourceful
and creative. Adult prevalence remains about 18 percent, and smoking-related deaths approach 480,000 per year.
Although initiation rates have been dropping in recent years, history shows that they can reverse course just as easily. And investments in tobacco control tend to erode whenever the economy weakens. The development and marketing of new products is a wild card in the epidemiology of tobacco use. E-cigarettes and modified-risk tobacco products may eventually reduce the prevalence of cigarette smoking, but it is also possible that these products could serve as starter products for people who would not otherwise have begun smoking cigarettes and could also reduce incentives for cessation by addicted smokers who otherwise would have quit. Bringing these products within FDA’s regulatory jurisdiction is imperative.
Vigilance is always advisable in tobacco control. It is prudent for federal policy makers and state and local authorities to strengthen all policies aimed at reducing the initiation of smoking, including the design and enforcement of youth access restrictions. The minimum age of legal access to tobacco products was set at 18 by the states more than two decades ago in response to federal incentives and is now required by federal law. However, states and localities remain free to raise the age. By assessing the public health implications of raising the minimum age, this report aims to provide the scientific guidance the states and localities need. In return, I urge states and localities that decide to raise the age to make sure that the necessary data are collected to evaluate the new policy in achieving its ultimate goal—the reduction and eventual elimination of tobacco use by children and youth.
Richard J. Bonnie, Chair
Committee on the Public Health
Implications of Raising the Minimum
Age for Purchasing Tobacco Products
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Acknowledgments
The committee would like to express its sincere gratitude to the many people who contributed time and expertise in the development of this report. The work would not have been possible without the support of our sponsor, the Center for Tobacco Products of the Food and Drug Administration.
The committee would also like to acknowledge several consultants who contributed to this study. First and foremost, the committee extends its immense gratitude to Theodore R. Holford (Yale University) and David T. Levy (Georgetown University Medical Center), whose development, knowledge, and application of the Yale Lung Cancer/Cancer Intervention and Surveillance Modeling Network and SimSmoke models were integral to the deliberations of the committee and contributed significantly to the quality of the report. We thank them for their patience, expertise, and many hours of hard work. The committee is also grateful to Maria Roditis (Stanford University), who provided consultation and editorial support on draft materials on adolescent and young adult development, and Robert Pool for his assistance in editing the report.
Many individuals volunteered significant time and effort to address and educate the committee during our information-gathering meetings (see Appendix E for the names of these speakers). We are grateful to each of them for sharing their expertise and responding to our questions. The committee would like to add special thanks to Neal Benowitz (University of California, San Francisco) for his additional consultation and technical review of material on developmental neurobiology and neurological response to nicotine.
The committee also expresses its deep appreciation to the staff of the
Institute of Medicine and the National Academies for their invaluable assistance on this study. We thank the National Academies Research Center staff for their diligent help with research and references. We are grateful for the leadership of Rose Marie Martinez, senior board director of the Board on Population Health and Public Health Practice, and for the energetic and resourceful contributions of research associate Leslie Kwan, research assistant Bettina Ritter, and senior program assistant Anna Martin. Finally, we extend special thanks to study director Kathleen Stratton, whose wisdom and guidance throughout the study process were indispensable.
Contents
Interpreting the Statement of Task
Adolescent and Young Adult Developmental Trajectories and Patterns of Tobacco Use
Current Practices Regarding Youth Access Restrictions
Effects of Raising the MLA on Tobacco Use
Adolescents Less Than 18 Years of Age
Young Adults 18 to 20 Years of Age
Young Adults 21 to 24 Years of Age
Health Effects of Raising the MLA
Considerations for Policy Makers
Tobacco Use in Adolescents and Young Adults
Brief History of Tobacco Control
2 PATTERNS OF TOBACCO USE BY ADOLESCENTS AND YOUNG ADULTS
Prevalence of Cigarette Smoking
Other Individual Risk Factors for Tobacco Use
A Note on the Definition of Initiation
Patterns of Use and Progression of Nicotine Dependence
Age of Initiation and Smoking Intensity
Age of Initiation and Continued Smoking
Tobacco Cessation Among Adolescents and Young Adults
3 THE DEVELOPMENTAL AND ENVIRONMENTAL CONTEXT OF ADOLESCENT AND YOUNG ADULT TOBACCO USE
Cognitive, Psychosocial, and Biological Development in Adolescents and Young Adults
Biological Development of Adolescents and Young Adults
Tobacco-Related Decision Making by Adolescents and Young Adults
Tobacco Industry Targeting Adolescents and Young Adults
4 THE EFFECTS OF TOBACCO USE ON HEALTH
Time Horizon for the Health Effects of Cigarette Smoking
Intermediate-Term Effects on Morbidity
Maternal/Fetal and Infancy Health Effects
Impact of Cigarette Smoking on Mortality
Increased Susceptibility to Infectious Lung Diseases
Impact of Exposure to Secondhand Smoke on Mortality
5 RESTRICTIONS ON YOUTH ACCESS TO TOBACCO PRODUCTS
Youth Tobacco Access Laws in the United States
Federal Youth Tobacco Access Laws
State and Local Youth Access Laws
Enforcement of Youth Access Laws
Enforcing Restrictions Against Licensed Retailers
Enforcing Restrictions Against Internet Sellers
Enforcing Restrictions Against Non-Licensed Sellers and Social Distributors
Sources of Cigarettes for Underage Individuals
6 EVIDENCE ON THE EFFECTS OF YOUTH ACCESS RESTRICTIONS
The Impact of Enacting or Raising the Minimum Legal Age to Purchase Tobacco Products
A Logic Model for Predicting the Effects of an MLA
Declarative Effects and Deterrent Effects of Legal Restrictions
Reducing Availability by Increasing Search-Time Costs
Effects of Retailer Interventions on Access to and Use of Tobacco
Effect of Retail Enforcement and Other Interventions on Retailer Compliance
Relationship Between Retail Interventions and Underage Tobacco Use
Relationship Between Retail Interventions and Perceived Availability
Underage Access Restrictions in the Context of Other Tobacco Control Policies
Multiple Statewide Retailer Interventions and Underage Tobacco Consumption
Comprehensive Tobacco Control Policies and Underage Tobacco Consumption
Tobacco Purchase, Use, and Possession Laws
7 THE EFFECT ON TOBACCO USE OF RAISING THE MINIMUM AGE OF LEGAL ACCESS TO TOBACCO PRODUCTS
Adolescents Less Than 15 Years of Age
Adolescents 15 to 17 Years of Age
Young Adults 18 to 20 Years of Age
Young Adults 21 to 24 Years of Age
Estimated Initiation Effect Sizes
Effects of Raising the MLA on Smoking Initiation
8 HEALTH BENEFITS OF RAISING THE MINIMUM AGE OF LEGAL ACCESS TO TOBACCO PRODUCTS
Implications of Raising the Minimum Age of Legal Access to Tobacco Products on Health
9 OTHER CONSIDERATIONS FOR POLICY MAKERS
National or State Enactment of MLA
Effects of Other Tobacco Control Policies
Scope and Enforcement of MLA Restrictions
Enforcement Against Social Sources
Black Market Supply to Adolescents and Young Adults
Enforcement of PUP Restrictions
Adolescent Development and the MLA for Tobacco
Possible Public Health Effects of New Tobacco Products
Possible Effects of Raising the Tobacco MLA on Use of Alcohol and Other Drugs
A State and Local Laws on the Minimum Age of Legal Access to Tobacco Products
B State Laws—Tobacco Transfers to Minors
C State Laws—Tobacco Purchase–Use–Possession by Minors
