The objective of this report is to predict what the health consequences would be of raising the minimum age of legal access to tobacco products (MLA) to 19, 21, or 25. As discussed in Chapter 5, few jurisdictions, states, or localities in this country have undertaken such changes, and no other country has done so. None of the state and local initiatives has been followed by a rigorous evaluation published in the peer-reviewed literature. Because a review and synthesis of existing empirical literature cannot answer the question at hand, the committee drew on a comprehensive review of the relevant scientific literature, on its collective expertise, and on models of population-level smoking behavior to predict changes in adolescent and young adult initiation attributable to raising the MLA and to project the impact of these changes on the prevalence of use and on health outcomes.
Using conservative assumptions about the enforcement of the MLA increases, the committee concluded that raising the MLA will likely decrease initiation of tobacco use by adolescents and young adults and thereby, over time, reduce adult prevalence, leading to longer and healthier lives for those who would have otherwise used tobacco. More specifically, the modeling analysis concluded that raising the MLA, particularly to ages 21 and 25, would lead to substantial reductions in smoking prevalence and thereby prevent considerable numbers of smoking-attributable deaths, including lung cancer deaths, and poor maternal and child health outcomes. However, the committee has greater uncertainty about the magnitude of the effects of raising the MLA to age 25 rather than to 19 or 21. The results suggest a range of potential population health benefits that depend on
a number of informed assumptions regarding enforcement practices and behavioral responses to the policy change by retailers and other potential sources of tobacco products and by underage individuals in different age and gender groups.
The purpose of this chapter is to help policy makers translate the committee’s findings and conclusions into the policy context. First, the chapter highlights a key constraint arising from the committee’s charge: Its quantitative estimates and projections relate to the nation as a whole, while the traditional responsibility for enacting and enforcing the MLA lies with states and localities. Second, the chapter revisits several policy assumptions that were explicitly made by the committee (or that are built into the simulation models) as a basis for its estimates of the effects of raising the MLA on adolescent and young adult initiation. These assumptions relate to the scope and enforcement of the MLA policy and to the status of other tobacco control policies. Reviewing them is important because it will enable the policy maker to consider the possible effects of different assumptions. Third, the chapter discusses the possible policy implications of increasing scientific knowledge regarding adolescent development. Finally, the chapter identifies two factors of possible public health relevance that were not taken into account in making the estimates and projections described in the report. The more important of these factors is the possible impact of the marketing and use of new tobacco products, most notably electronic nicotine delivery systems (ENDS). The other is the possible impact of raising the MLA for tobacco use on the use of alcohol or other drugs.
Traditionally, political responsibility for setting the MLA for tobacco products has rested with the states and, depending on state constitutional arrangements, with local governments. However, since 1992 the federal government has played an increasingly significant role. The Family Smoking Prevention and Tobacco Control Act (hereafter referred to as the Tobacco Control Act), enacted by Congress in 2009, directed the Food and Drug Administration (FDA) to revive its 1996 Tobacco Rule, which prescribed a federal MLA of 18. At the same time, however, Congress precluded FDA from raising the MLA without congressional action. In effect, the Tobacco Control Act sets a “floor” of 18 while allowing states and localities to raise the age if they choose to do so. Hence, unless Congress acts to raise the age on a national basis or delegates authority to FDA to do so, one might expect a patchwork of different MLAs in different states and localities, as existed for alcohol for many decades, rather than a uniform MLA across all of the 51 jurisdictions.
It is important to emphasize that the simulations described in Chapters 7 and 8 model a situation in which increases in the MLA would be adopted and implemented on a nationwide basis. However, a state-by-state implementation is more likely. Nationwide implementation would occur only if Congress raises—or authorizes FDA to raise—the national MLA or if every state raises the MLA. To the extent that states choose not to raise the MLA, the effects estimated in Chapters 7 and 8 are not likely to be realized. In addition, to the extent that people who are underage in a high-MLA state could cross state borders to purchase in a low-MLA state, the effects estimated in Chapter 8 may be somewhat optimistic, particularly for small states surrounded by many low-MLA neighbors.
Even if Congress does not choose to set a national MLA higher than 18, there are other mechanisms through which universal or near universal adoption might be motivated. For example, Congress could provide incentives for states to do so by making the level of funding under federal grants contingent on the state raising the MLA. It could do this based on the approach used in the Synar Amendment (up to 40 percent of a state’s substance abuse prevention block grant funding is contingent on enforcing the state’s MLA) by simply defining underage purchasers under the Synar program as persons under 19, 21, or 25 as the case may be. Alternatively, Congress can use an approach similar to that taken in the National Minimum Drinking Age Act of 1984,1 which penalized states that did not ban the purchase and public possession of alcoholic beverages under age 21 by reducing their annual federal highway appropriations by 10 percent. By 1995 all 50 states and the District of Columbia were in compliance, thanks to this strong incentive. Although the highway appropriation may not be seen as the most appropriate type of leverage for tobacco policy, federal funds related to public health may be viewed as more suitable for this purpose.
In sum, Congress could decide to raise the MLA at the national level, to provide federal funding incentives for the states to do so, or to leave the matter entirely to the states or local jurisdictions. In the absence of a national MLA, however, the national public health impact of raising the MLA for tobacco would be dependent, first and foremost, on the degree to which local and state governments take up this policy.
Both simulation models predict the potential effects on future initiation of increasing the MLA. The SimSmoke model also includes modules for
1 The National Minimum Drinking Age Act of 1984, Public Law 98-363. 98th Cong. (July 17, 1984). 23 U.S.C. § 158.
modeling the effects of other tobacco control policies: taxation, smoke-free air, marketing restrictions, health warnings, media campaigns, and cessation treatment policies. Tobacco control policies are effective; they reduce tobacco use and hence decrease the adverse health outcomes associated with use. The effects of these policies are modeled as changes in the initiation and cessation of smoking. The effects of past policies are incorporated into the initiation and cessation rates in future years. While the models in general have the capability to project future changes in policies, the models as used here assume that all current policies other than the MLA will remain in effect at their current rates and that no new policies will be implemented. This assumption is useful because it isolates the effects of raising the MLA from other potential policy changes in the modeling of the effects of nationwide implementation. However, a significant change, one way or the other, in the intensity and effectiveness of tobacco control policies in the country as a whole could alter the figures projected by the models for prevalence and health outcomes presented in Chapters 7 and 8.
In this connection, it is important to emphasize that there are significant variations in the strength and efficacy of existing state and local tobacco control programs. These variations reflect differences in the number and intensity of tobacco control activities and in the resources allocated to support them. A comprehensive approach to tobacco control integrates “educational, clinical, regulatory, economic, and social strategies” (CDC, 2014, p. 6). Specifically, such an approach includes activities targeted at preventing initiation of tobacco use, reducing tobacco use and tobacco-related diseases, promoting cessation, and reducing exposure to secondhand smoke, combined with mass media campaigns and community mobilization efforts (CDC, 2014; HHS, 2000). Comprehensive, multifaceted strategies have been shown to effectively reduce tobacco use among adolescents (Farrelly et al., 2013; Kuiper et al., 2005; Laugesen and Swinburn, 2000; Luke et al., 2000; Tauras et al., 2005; Wakefield and Chaloupka, 2000), young adults (Farrelly et al., 2014; Kuiper et al., 2005; Laugesen and Swinburn, 2000; Pierce et al., 2009), and adults (Farrelly et al., 2008; Kuiper et al., 2005; Laugesen and Swinburn, 2000; Stillman et al., 2003; Zaza et al., 2005), as well as to reduce tobacco-related death and disease (Jemal et al., 2003; Kuiper et al., 2005; Laugesen and Swinburn, 2000). Moreover, in a review of comprehensive state-level tobacco control programs, Wakefield and Chaloupka (2000) found that states were able to substantially reduce teenage smoking despite differences in the specific program components that the states used. On the other hand, comprehensive statewide tobacco control programs that lacked optimal funding failed to achieve the full magnitude of their potential effect, despite achieving substantial reductions in tobacco use (Farrelly et al., 2008; Tauras et al., 2005). States and localities that have more comprehensive and intensive tobacco control activities
and that devote more resources to support these activities are likely to have a lower prevalence of tobacco use than states and localities with weaker tobacco control programs.
As noted above, the national projections in Chapters 7 and 8 are grounded in models that essentially aggregate each state’s tobacco control activities, whether they are strong or weak. To the extent that policy makers in individual states want to try to derive state-based estimates from the findings of national modeling exercise, they will have to take into account whether the existing level of tobacco control activity in their state is comparable to the investment (and intensity of activity) in the “average” state. If it is much weaker, the extrapolation from the modeling used in this report may not be suitable. Similarly, if a state is among the nation’s leaders in the tobacco control, the reduction in prevalence and in morbidity and mortality may be greater.
Before undertaking the task of estimating the effects of raising the MLA on adolescent and young adult initiation, the committee agreed on certain key assumptions about the scope and enforcement of the MLA (51 jurisdictions aggregated nationally). First, the committee assumed that current levels of enforcement and retailer compliance with the MLA restrictions will be sustained for all underage purchasers, including those 18 or older but under the new MLA, if the MLA is raised. Second, the committee assumed that existing bans on noncommercial distribution of tobacco by friends, proxy purchasers, and other “social sources” will continue to be weakly enforced whether or not the MLA is raised and that these sources will continue to provide substantial, though incomplete, substitution for retail purchases for newly underage buyers. Third, the committee assumed that the proportion of underage users who purchase tobacco on the illicit commercial market will remain small. Finally, the committee assumed that sanctions will continue to be directed primarily toward retailers and will not be enforced against underage users on a significant scale. The committee revisits these assumptions here.
Federal support for youth access enforcement, together with funding incentives, has significantly strengthened state enforcement of youth access policies and has thereby curtailed retail availability to underage persons. The committee has assumed that the current levels of enforcement and penalties for violators will continue, creating a credible threat of punishment sufficient to sustain current levels of compliance. In addition, the committee
assumes that the deterrent threat will be the same for selling to every underage purchaser, regardless of where the MLA line is drawn.
It is possible, of course, that the intensity of enforcement could be significantly increased against all underage users, in which case the committee’s estimates in Chapter 7 about the impact of raising the MLA on the adolescent and young adult initiation rates might be too conservative. On the other hand, it is also possible that increasing the MLA into the years of “adulthood” could generate a backlash and weaken public support for enforcing the law. As emphasized in Chapter 6, curtailing retail access depends on active enforcement and retailer compliance. Those conditions could be undermined if the MLA is set too high. Concerns about under-enforcement would be particularly pronounced if the MLA were set at age 25, and for this reason the committee is relatively more confident about the assumption that current enforcement intensity is more likely to be maintained if the age is increased to 19 or 21 than if it is set at 25. (This is one of the reasons why the range between the lower and upper scenarios is broader in the analysis of the MLA 25 policy option.)
If current levels of enforcement intensity are to be sustained and extended to the older ages, another key question is whether doing so will require a significant increase in current funding for enforcement. Recall that the 1992 Synar Amendment to the Alcohol, Drug Abuse and Mental Health Administration Reorganization Act2 was designed to incentivize states to enact, enforce, and continuously evaluate laws that prohibit the sale and distribution of tobacco products to individuals under age 18. As discussed in Chapters 1 and 5, states are required to follow specific guidelines for random compliance inspections, surveillance, and reporting as a condition of their receipt of federal Substance Abuse Prevention and Treatment block grant funding. Failure to comply with Synar regulations could result in the withholding of up to 40 percent of block grant funds.
The language of the Synar Amendment focuses specifically on restricting access to tobacco products among persons under age 18. Because the amendment incentivizes states to enforce and track compliance with tobacco purchase laws only for adolescents under age 18, it is not clear whether additional resources would be required to extend significant enforcement activities to individuals above age 18. Ongoing surveillance and the associated random inspections/compliance checks are essential, not only for policy evaluation but also as a strong incentive for retailers and distributors to comply with the law. Extending the training and surveillance systems in place for the Synar Amendment to ensure compliance with an MLA of 19 or above might require additional financial and human resource invest-
2 ADAMHA Reorganization Act of 1992, Public Law 102-321. 102nd Cong. (July 10, 1992).
ments. Compliance checks must be done with age-appropriate confederates (e.g., 20-year-olds cannot be used for compliance checks for Synar reporting, and under-18 purchasers are not appropriate for surveillance regarding enforcement among 18- to 20-year-olds).
For an MLA of 21, local enforcement activities might dovetail with those for alcohol, and assigning responsibility to the same agency, as some states have already done, might actually reduce the costs of enforcement, particularly given the overlap of licensees.
The committee understands that the relevant agencies in New York State and New York City have reached an agreement that facilitates the enforcement of the city’s new Tobacco 21 law without increasing the cost of enforcement. The New York City Department of Consumer Affairs (DCA) enforces the city’s Tobacco 21 law with funding from the state Department of Health. Their agreement requires DCA to perform compliance checks with adolescents ages 16 and 17 in compliance with state and federal laws prohibiting tobacco sales to adolescents under age 18. The state will then punish violators detected during these inspections. In addition, DCA will employ a small team of young adults ages 18 to 20 to assess compliance with the city’s MLA of 21, and will also punish violators.3 The agreement also requires DCA to verify that tobacco retailers post required minimum age signage, perform age verification, and comply with other point-of-sale restrictions. Because New York City’s Tobacco 21 law is more stringent than both state and federal laws, New York State has agreed that DCA will inspect for city Tobacco 21 signs (as opposed to state signs for MLA 18) and to check that retailers ask for proof of age using photo identification for customers who look under 30 years old (as opposed to state law requiring age verification for customers who look under age 26) (NYCDOHMH, 2014).
In addition to the intensity of enforcement and retailers’ perceived risk of getting caught, the severity of the penalty for violation would also play a role in policy effectiveness. For example, in Hawaii County, failure to post signage regarding the MLA 21 policy results in a $500 fine, and any person who sells or distributes tobacco products to a person under age 21 is subject to up to a $2,000 fine. Similarly, the penalties associated with New York City’s recent Tobacco 21 law include a $500 fine for failure to post required signage, a $1,000 fine for the first sales violation to someone ages 18 to 20 or any other violation in the same day, and a $2,000 fine for the second and any subsequent violation within 3 years. In addition, a second violation may result in the revocation of the retail tobacco license. Although the committee is not aware of any systematic data regarding the severity of
3 Personal communication, K. Munn, New York State Department of Health, October 14, 2014.
penalties imposed on violators, it seems likely that the imposition of penalties at this level, particularly the loss of the tobacco license or, as in some states, a lottery license, can achieve meaningful deterrence as long as there is a credible threat of detection for a violation.
As discussed in Chapter 6, cigarettes obtained from friends, family members or fellow smokers, or from proxy buyers are very good substitutes for the same product bought directly from a retail outlet. So if direct sales become unavailable through effective enforcement efforts, underage users will likely continue to substitute cigarettes obtained from these other sources. Although existing bans on noncommercial distribution of tobacco by friends, proxy purchasers, and other “social sources” are weakly enforced, the committee has concluded that access to social sources does not fully substitute for convenient access to retail purchases because, as economic theory suggests, the use of social sources is more costly. It requires additional time and effort, in addition to money, for someone to obtain cigarettes indirectly instead of purchasing them directly from a store. As such, forcing underage smokers to find and use indirect sources raises their costs of obtaining tobacco products, which in turn is likely to reduce their consumption. It is these additional costs that account for the reduction in underage use attributable to youth access restrictions, especially when smoking is reduced among the members of social networks to which the underage smoker has ready access. The committee has estimated that raising the MLA to ages 19, 21, or 25 will reduce tobacco use by secondary school students who lack ready access to social networks of older youth.
That said, the committee expects that social sources, especially proxy purchases, will remain the primary sources of tobacco for underage persons, and it has been realistic about the high level of continuing availability to adolescents and young adults who are in the workforce or in college environments. Our estimates in this respect are predicated on relatively conservative assumptions. Although access to social sources could be reduced significantly if the laws prohibiting transfers to underage persons were aggressively enforced, the committee does not expect such a radical change in enforcement policy in the foreseeable future, especially under a higher MLA, because of likely public resistance. However, if a state or locality decided to ramp up the threat of detection and punishment against social sources and to sustain this policy, the impact on youth consumption could be greater than the committee has projected.
As noted in Chapter 5, a 2015 National Research Council report (NRC, 2015) concluded that a sizable illegal market in untaxed tobacco and cross-border shipments from low-tax states to high-tax states is emerging. (See also Joossens and Raw, 2012; Shelley et al., 2007.) Cigarettes are fairly compact and are not highly perishable. A day’s supply weighs about an ounce, which means that black market operators could smuggle nontrivial quantities in the trunk of a car or other small spaces. Under a policy regime that significantly hindered social sources and proxy buyers, it is theoretically possible that a true black market serving underage smokers could emerge (with entrepreneurs organizing their activities to target underage consumers). Nonetheless, it seems quite unlikely that enforcement of the MLA restrictions against social sources and proxy buyers of tobacco will be intensified so substantially as to create underage demand for black market tobacco products. Also, it is difficult for a true black market to emerge when everyone over a certain age is a legitimate purchaser (as has been the experience with alcohol). As such, the committee thinks it highly unlikely that raising the MLA will create a black market with “street dealers” and associated violence, the way that prohibiting an entire product class for all ages (e.g., marijuana) can do and has done. If this supposition proves to be erroneous, the policy significance of an emerging black market in tobacco on the streets of our communities goes way beyond the limited task undertaken here.
As noted in Chapter 5, bans against underage purchase–use–possession (PUP) restrictions are common. Active enforcement of sanctions for PUP violations has rarely been attempted and, in the committee’s judgment, is unlikely to occur on a significant scale in the foreseeable future. However, this is not to say that the bans have no instrumental effect; indeed, they empower parents and schools to demand compliance and impose discipline. If raising the MLA was to be accompanied by greater PUP enforcement against underage users, then initiation rates could be reduced more than the committee has estimated. The committee did not attempt to quantify the effects of increased PUP law enforcement because there is so little basis in either the deterrence literature or the tobacco youth access literature for doing so.
Whether laws banning selling tobacco to minors should be accompanied by penalties against the underage purchasers themselves has been debated for a more than a quarter of a century, ever since preventing adolescent and young adult smoking emerged as a key component of tobacco
control in the early 1990s. Tobacco control advocates have typically concentrated their attention on the retailers and distributers who provide the tobacco rather than on the buyers themselves (Jason et al., 2007; Wakefield and Giovino, 2003). In addition to making enforcement easier, concentrating policy efforts on the sellers also focuses the moral responsibility for preventing youth access to tobacco products on the retailers and industry distributors rather than on the minors themselves (Craig and Boris, 2007; Forster and Wolfson, 1998).
The case against punishing underage users of tobacco was put forcefully in Growing Up Tobacco Free:
Imposing penalties on minors for buying, possessing, or using tobacco products is controversial. At least 21 states currently prohibit smoking and the use of tobacco products by minors. Proponents of these penalties argue that they may have some deterrent value, and that the failure to make possession illegal sends a mixed message, reinforcing the idea that tobacco use is a trivial infraction. However, the Committee believes that penalizing minors is an unwise and ineffective strategy. Criminal sanctions or delinquency adjudications are grossly disproportionate to the seriousness of the offense and would not be sought by prosecutors or imposed by judges. Even if the offense were punishable with a civil fine, like a traffic ticket, the penalty would rarely be enforced. Because lack of enforcement would erode whatever deterrent effect the law might otherwise achieve, the only remaining rationale for such a prohibition is a symbolic one: the failure to make tobacco use an offense would somehow imply that tobacco use is not harmful or that it is socially acceptable. In the Committee’s view, such speculative fears are groundless—social disapprobation is (or should be) strongly communicated by the laws on distribution, by warning labels, and by all of the other policies outlined in this report. Young people will not miss the point simply because their disapproved conduct is not against the law. Furthermore, purely symbolic prohibitions—laws that are not meant to be enforced—are harmful because they undermine respect for the law. Finally, imposing legal penalties on the underage purchaser also impedes the use of underage buyers to monitor retailer compliance with youth access restrictions. The need to obtain waivers unnecessarily increases the cost of enforcement. (IOM, 1994, pp. 222–223)
Notwithstanding the argument set forth in the 1994 IOM report, most states have prescribed penalties for underage purchasers, and some tobacco control advocates have argued that youth access restrictions would be more effective if sanctions against underage purchasers were prescribed and enforced. First, their argument goes, PUP laws signal strong social disapproval by making acquisition and use of tobacco punishable acts (the declarative effect). Under this view, a law that penalizes retailers who sell
tobacco products but does not penalize the underage individuals for purchasing, possessing, or using the product is sending a “mixed message,” thereby undermining the social norms against tobacco use that tobacco policy makers are trying to instill among young adults in work environments, school settings, and other public and private places. Second, PUP proponents contend, penalties against the underage purchaser would have a significant deterrent effect on purchase and would also make it easier to deter underage proxy sellers. Penalties against underage alcohol users appear to have been enforced to a greater extent than penalties for underage tobacco users and may have functioned to some extent as a deterrent to the purchase and public transport or use of alcohol. For example, some states have implemented so-called brown jug laws under which businesses that sell alcohol are allowed to report underage purchase/use and to receive the fine payments from offenders (IOM and NRC, 2004).
This argument reflects very different views about the effects on PUP laws on underage smoking than those set forth in Growing Up Tobacco Free as well as a different perspective on the potential disadvantages and the costs of punishing young people for this sort of minor transgression. There are few rigorous studies regarding the effects of PUP laws on underage use, mainly because the laws are so rarely enforced, and the limited evidence is mixed. It seems likely, in the committee’s view, that meaningful enforcement of PUP sanctions against underage persons for purchasing, possessing, or using tobacco products would deter tobacco use by some underage persons, most likely those who are at least risk for becoming addicted. However, the PUP laws on the books in 47 U.S. jurisdictions are essentially unenforced. Under these circumstances, the operative policy is to capture the declarative effects of making the behavior illegal and empowering parents and schools to enforce it without incurring the costs of having to impose legal punishment. The committee assumes that this will be the operative policy in the foreseeable future, and its estimates reflect this conservative assumption.
In accordance with the committee’s charge, this report addresses the “public health implications” of raising the MLA for tobacco products. However, federal, state, and local lawmakers will likely take into account factors other than public health benefits, including the economic interests of tobacco retailers and other businesses that profit from tobacco use. Legislators also will likely give some weight to arguments by and on behalf of young adults that they should be entitled to make their own decisions about whether to use tobacco products, especially in light of the fact that the “age of majority” for many legal purposes is 18 in all but four states (JRank, 2014). This argument may be grounded in a deeper concern about the role
of government, especially in the realm of public health, and these ethical concerns about the “nanny state” may affect not only the level of political support for proposals to raise the MLA4 but also the level of community willingness to enforce a higher MLA if it is enacted. Naturally the strength of these concerns is likely to increase as the proposed MLA is raised from 19 to 21 to 25, all the more so when the policy lever is an outright prohibition rather than an excise tax or a public smoking restriction, which would limit use without banning it completely. A lack of public support could erode the potential public health benefits of raising the MLA.
The policy judgment regarding where to draw the line for the MLA involves a burgeoning scientific literature on adolescent development on which the Supreme Court has recently relied to explain why the Constitution mandates differential treatment of adolescents in the context of criminal punishment (Bonnie and Scott, 2013). That body of research, reviewed in the National Research Council’s report Reforming Juvenile Justice: A Developmental Approach (2013) and summarized in Chapter 3, documents various distinctive features of adolescent judgment as compared with adults, including a heightened sensitivity to rewards, lower impulse control, and tendencies to take risks—especially when in the presence of peers—and to discount the long-term consequences of actions. These behavioral tendencies are rooted in the different pace of maturation between the brain’s motivational and reward systems and the systems in the brain that are responsible for self-regulation and cognitive control. These developmental factors, along with adolescents’ vulnerability to the rewarding effects of nicotine and their risk of addiction, are widely thought to justify policies that curtail access to tobacco products by teenagers (IOM, 1994, 2007; IOM and NRC, 2011). It is noteworthy that John Stuart Mill’s justly famous defense of the anti-paternalism principle in his essay On Liberty (1859) acknowledged that the individual’s sovereign control over self-regarding choices applies only to persons “in the maturity of their faculties.” Indeed, these same concerns about adolescent vulnerability and immature judgment have been invoked to justify non-prohibitory efforts to curtail smoking by addicted adults. As explained in Ending the Tobacco Problem in 2007:
It can also be argued that paternalism in this context is a justified response to irremediable deficiencies in smokers’ capacity to successfully exercise self-interested decision making about whether they should continue to smoke. Although the committee’s blueprint need not rest on this argument, many committee members do find elements of it convincing, and that is
4 A recent publication indicates that more than 70 percent of adults surveyed support raising the age of sale of tobacco products to 21 years of age; majority support is seen across smoking status, geographic region, race, sex, education, and age (Winickoff et al., 2015).
why we summarize it here. The argument runs as follows: (1) Virtually all addicted adults begin smoking (and probably become addicted) while they are adolescents, before they have developed the capacity to exercise mature judgment about whether or not to become a smoker; (2) the preferences expressed when people begin to smoke, which tend to ignore long-term health risks, are inconsistent with the health-oriented preferences they later come to have, and they soon regret the decision to have become a smoker; and (3) once smokers begin to be concerned about the health dangers of smoking, their judgment is often distorted by optimism bias (“the harms will happen to other people, not to me”), thereby weakening their motivation to quit. (IOM, 2007, p. 150)
Although adolescents’ vulnerability to addiction and immaturity of judgment support an underage access restriction, these developmental concerns do not resolve the policy question about the specific age at which the line should be drawn. The argument against raising the MLA above 18 is predicated on the assumption that adolescents older than 17 are mature enough to make their own decisions about what is in their best interests. However, experts on developmental psychology and neuroscience (e.g., IOM and NRC, 2014; Steinberg, 2012) and also specialists in family and adolescent and young adult policy (Goldfarb, 2014; Hamilton, 2012; Scott, 2013) have called attention to the evidence that capacities related to mature judgment, especially judgment in emotionally charged situations or in situations in which peer influence plays are role, are still developing into the early 20s. (See also Chapter 3.) Authorities on adolescent development generally agree that the period of development that is typically labeled adolescence stretches from the onset of puberty into the early 20s (Steinberg, 2012). Many young people in their late teens and early 20s may also still be at elevated risk, developmentally speaking, to becoming addicted to nicotine.
A review of age-specific public policies demonstrates that policy judgments about where to draw age lines relating to adulthood are highly contextual, ranging from ages 14 to 16 (medical decision making) to age 21 (the purchase, use, and possession of alcohol and firearms, fiduciary appointments, and most professional occupational licenses).5 In short, a balance needs to be struck between the personal interest of young adults in making their own choices and society’s legitimate concerns about protecting the public health and protecting young people from decisions they may later regret (IOM, 2007; IOM and NRC, 2004). None of this is to say that the line should be drawn based solely on developmental science; it is only
5 Although not directly relevant in the present context, it is worth noting that the legally relevant age of eligibility for various types of parental and social support in young adulthood is often around 25 or 26 (IOM and NRC, 2014).
to say that 18 is not the only developmentally plausible place to draw the line. The so-called age of majority functions as a default, and every state sets the legal age for certain activities higher or lower for different policy purposes. In short, state legislators will likely continue to draw the line in different places in different policy contexts, and tobacco will be no exception (Bonnie and Scott, 2013; Hamilton, 2010; Steinberg, 2012).
One inevitable comparison in any discussion of the MLA for tobacco is the 21-year-old MLA for alcohol in all states. The developmental justification for such a comparison is fairly strong in light of the addictive properties of these drugs and the long-term consequences of initiating use during adolescence. However, the intoxicating properties of alcohol are also associated with harm to other persons, especially in relation to driving and aggression, and not only with harm to oneself. The likely counterargument is that the public health burden of tobacco use exceeds the toll associated with any other self-regarding behavior or with the use of any other legal product, making a case for “tobacco exceptionalism” in public health policy (Collin, 2012; Malone and Warner, 2012). Whether this argument is sufficient to trump otherwise strong commitments to individual choice is being played out in the policy arena.
The prevalence of use of electronic nicotine delivery systems among adolescents and young adults appears to be increasing substantially (see Chapter 2; Arrazola et al., 2013; Wadley and Bronson, 2014). ENDS include electronic cigarettes (e-cigarettes), e-hookahs, and other vapor emitting devices. FDA has begun the process of deeming these products to be “tobacco products” under the Tobacco Control Act and thereby bringing them within the agency’s regulatory jurisdiction. States have also been gradually including these products in youth access statutes. The committee assumes that FDA will eventually regulate these products, that they will be subject to the MLA in all states, and that the committee’s findings regarding enforcement of the MLA will apply to ENDS and other novel products. It is also important to emphasize that the simulation models used in Chapters 7 and 8 are calibrated to project cigarette use and related outcomes and do not include the public health effects of use of other tobacco products.
The question of greatest relevance to the committee’s task is how the use of ENDS or other novel tobacco products is likely to affect the public health impact of increasing the MLA. Assessing this impact is difficult, given the relatively recent introduction of these products and the lack of detailed data on the patterns of ENDS use over time, its relation to cigarette use, and its health effects. Nevertheless, it is possible to speculate in
Preliminarily, it should be emphasized that even if increasing ENDS use has no effect on current patterns of initiation of cigarette use, it is likely to affect the prevalence of cigarette use over the long term. The challenge in evaluating its impact is that the net effect on conventional cigarette use could be in either direction. For example, it is plausible that some persons already using conventional cigarettes may quit using cigarettes and instead switch to ENDS. In this scenario, there is likely a public health benefit in that early data suggest that, while not harm free, ENDS are probably less harmful than conventional cigarettes (Bhatnagar et al., 2014; Farsalinos and Polosa, 2014; Grana et al., 2014). However, it is also plausible that some persons already using conventional tobacco cigarettes may become dual users of conventional cigarettes and ENDS (Bhatnagar et al., 2014; Dutra and Glantz, 2014; Grana et al., 2014; Pearson et al., 2012; Regan et al., 2013) because it costs less, helps the user reduce conventional cigarette consumption, or serves as a “bridge” for nicotine use during times when smoking conventional cigarettes is prohibited or inconvenient. Emergence of this “dual use” scenario may increase the public health harm attributable to tobacco use if it increases nicotine dependence (due to increased consumption of nicotine), making smoking cessation more difficult, or otherwise prolongs conventional cigarette smoking. While these scenarios are postulated to have no effect on the initiation of cigarette use and are therefore unaffected by raising the MLA, they would affect the quantitative estimates of health benefits attributable to raising the purchase age by reducing the estimated benefits in the first scenario (of increased conventional cigarette cessation) and increasing them under the latter scenario (of increased nicotine dependence and prolonged smoking).
The question of greatest relevance to this report is whether and how use of ENDS will affect initiation of cigarette use. Broadly speaking, there are three possibilities. One scenario is that initiation of ENDS use will reduce initiation of cigarette use; that is, some portion of adolescents and young adults who otherwise would have initiated cigarette use will not do so, becoming ENDS users instead. Under this scenario, there may be net public health benefits over the long term, but some portion of those benefits would be attributable to the initiation of ENDS, not to the raising of the MLA. A second possibility is that initiation of ENDS would delay conventional tobacco use, as adolescents and young adults who begin with ENDS switch to conventional cigarettes at a later time, due in part to nicotine dependence and to the relatively lower levels of nicotine delivery from ENDS compared to conventional cigarettes. This scenario, involving the possibility of ENDS serving as a gateway to conventional cigarettes, would be particularly wor-
risome because it would increase the prevalence of cigarette use, possibly offsetting some portion (if not all) of the public health gains of raising the MLA. Finally, as more recent data suggest (Wills et al., 2015), it is possible that some of those who have never considered using conventional tobacco products will initiate with ENDS and only use ENDS. In that case, the net public health effect would be entirely attributable to the yet unknown health effects of ENDS use.
All three of these patterns and trajectories of tobacco use—as well as other variations—are likely to emerge, and the committee has no basis for estimating the proportions of adolescents and young adults that will take each path, much less the net effect of ENDS use on initiation of cigarette use. What can be said, then, about the possible effects of raising the MLA for ENDS use on the likelihood of these scenarios? For this purpose, the committee assumes that the MLA will be increased for all tobacco products, including ENDS, and that the intensity of enforcement will be the same for all products. The committee sees no reason to believe that the effects of the legal norm and its enforcement on retailer compliance, retail availability, or access to social sources would differ materially for ENDS compared with other tobacco products. Given the evidence that adolescents who currently initiate tobacco use with ENDS rather than with conventional tobacco products are younger (Wills et al., 2015), the main effect of raising the MLA for ENDS will likely be to reduce the number of adolescents who initiate tobacco use with ENDS. That may translate into reduced initiation of cigarette use for some, but it also may translate into delayed initiation of cigarette use for others, including some proportion who would not have otherwise used conventional cigarettes. Presumably FDA and state policy makers will take these possibilities into account in setting the MLA and will carefully monitor the promotion and use of ENDS, especially by adolescents and young adults.
In summarizing the estimated health effects of raising the tobacco MLA presented in Chapter 8, the committee has not taken into account the possibility that reducing adolescent and young adult tobacco use could affect the use of alcohol, marijuana, or other illegal drugs and thus has ignored the substantial mortality and morbidity associated with use of those substances. However, it is possible that raising the MLA for tobacco could have indirect effects on the use and abuse of other substances, either by increasing their use (and thereby having a negative effect on public health that might offset some of the effects of reduced tobacco use) or by decreasing their use (and thereby augmenting the public health benefit of reducing
tobacco use). Because tobacco use is correlated with the use of many other substances, it could be important to consider the indirect effects of reducing tobacco use on the use of other substances, but definitive statements are difficult to make since the associations need not be causal. The mere fact that people who smoke today have greater rates of abuse or dependence on other substances is not sufficient to infer that an intervention that reduces smoking—such as raising the MLA—would necessarily reduce rates of abuse or dependence on that second substance. There is, however, some literature examining the effects of tobacco control interventions on the use of other substances.
The empirical literature on spillover effects of tobacco policies on alcohol use and abuse is mixed. Picone et al. (2004) found that smoking bans reduce alcohol consumption in older adult females. Gallet and Eastman (2007) obtained a similar but more general result, but Hahn et al. (2010) found no such effect. Young-Wolff et al. (2014) reported that increasing tobacco taxes was associated with modest to moderate reductions in alcohol use in vulnerable groups. McKee and colleagues, in a series of three studies (Kasza et al., 2012; McKee et al., 2009; Young-Wolff et al., 2013), found evidence for the proposition that smoking bans reduce alcohol use and related problems. However, Bernat et al. (2013) did not observe a decline in alcohol-related vehicle accidents when analyzing California and New York’s statewide smoke-free policies.
There is also a modest literature investigating whether tobacco and alcohol are “substitutes” or “complements” in the economic sense of these terms. Although some studies find that cigarettes are substitutes for either alcohol in general (Decker and Schwartz, 2000) or liquor in particular (Goel and Morey, 1995), a more common finding is that they are instead complements (e.g., Bask and Melkersson, 2004; Cameron and Williams, 2001; Jones, 1989; Pierani and Tiezzi, 2009; Tauchmann et al., 2013; Zhao and Harris, 2004); that is, they enhance each other’s value to a user, and a decrease in the use of one is likely to be associated with a decrease in the use of the other. Thus, the research would suggest that interventions that reduce tobacco use will not increase alcohol use. A study by Hughes (1993) found that smoking cessation treatment among adults does not increase alcohol intake, even among former alcohol abusers.
In theory, tobacco control policies could have indirect effects on the consumption of illicit drugs. However, the literature on this subject is quite sparse and mostly limited to effects on marijuana use. A few studies, such as Cameron and Williams (2001), Chaloupka et al. (1999), and Zhao and Harris (2004), find “complementarity” between tobacco and marijuana; that is, when cigarette prices go up, marijuana use declines. However, Cameron and Williams (2001) found that increases in tobacco prices did not affect cannabis use.
A conceptually separate issue concerns how changes in marijuana policy might affect tobacco use and, hence, the effects of raising the MLA on tobacco use. Marijuana policy is in a state of flux, and there is considerable overlap between the populations who use marijuana and those who use tobacco. Thus, changes in marijuana policy might spill over to affect tobacco use, and vice versa. It is extremely challenging to estimate legalization’s effects on marijuana use (Kilmer et al., 2010), let alone its spillover effects on the use of other substances, including whether any spillover effects would enhance or undermine the value of raising the MLA for tobacco. This, however, does not imply that any such effects would be small. If marijuana and tobacco were substitutes, increased marijuana use might lead to lower tobacco use. As noted above, however, what little literature exists on the subject suggests that marijuana and tobacco are more likely to be complements, not substitutes.
Furthermore, although the overlap in North America has tended to be by user (with marijuana smokers more likely than others to smoke tobacco and vice versa), in Europe it is quite common to mix tobacco and marijuana in the same cigarette (UNODC, 2006), as also occurs already in the United States with “blunts.” Hence, it is plausible that what adolescents and young adults primarily construe as “marijuana use” might become the vehicle for first exposure to nicotine. Also, the relaxation of marijuana laws has been accompanied by a proliferation of modalities of use, including vaporization as opposed to combustion. It is conceivable that a proliferation of vaporizer pens or other devices acquired initially for marijuana use might facilitate the uptake of consumption of nicotine via ENDS or increase the social acceptability of “vaping.”
In sum, it seems plausible that to the extent that raising the MLA reduces tobacco use, it might have some beneficial spillover in the form of indirect effects on the use of and harm from alcohol and, potentially, marijuana. And it seems plausible that changes in marijuana policy and patterns of use could modulate the effects of raising the MLA on tobacco use. However, the existing empirical literature does not allow estimating a specific magnitude or even a potential range of estimates of those effects in the population overall, let alone among adolescents and young adults specifically.
The committee was charged with assessing the potential public health implications of raising the minimum age of legal access to tobacco products. Studies investigating the effects of setting or raising the MLA for tobacco are sparse. In order to carry out its charge, the committee undertook a thorough review of the available evidence related to tobacco use by ado-
lescents and young adults, the effects of raising the MLA for alcohol, and enforcement of the existing MLA restrictions for tobacco products. This evidence provided a solid foundation for the critical phase of the committee’s work—using its collective expert judgment to estimate the effects of raising the MLA on initiation rates at various ages. Using these estimates as inputs, the committee commissioned new modeling studies of aggregate smoking behavior with which to project likely population-level outcomes of changes in the MLA. The most important assumptions required for these estimates have been discussed in this chapter, as have been additional policy-relevant considerations.
Among the key assumptions are relative stability in the intensity of tobacco control activities and the continuation of the MLA enforcement at existing levels. These are relatively conservative assumptions, and the public health benefits could be greater if tobacco control policies and the MLA enforcement were substantially strengthened. It is important to recognize, however, that public health gains also have to be weighed against the costs and other social consequences of enforcing more restrictive MLA policies.
It is also important to emphasize that the committee’s modeling estimates are based on nationwide adoption of the increased MLA, although public health benefits of that magnitude will occur only if Congress facilitates federal action or if states with a substantial portion of the nation’s population raise the MLA. Over the short term, at least, the projected public health benefits will need to be translated into state-by-state estimates.
Although the full benefits of preventing initiation of tobacco use will take decades to accrue, some direct health benefits, including those from reduced secondhand smoke exposure, will be immediate. Perhaps the greatest uncertainty in the committee’s assessment is the currently unpredictable effects of the marketing and use of electronic nicotine delivery systems and other novel tobacco products. However, in the absence of transformative changes in the tobacco market, social norms and attitudes, or the epidemiology of tobacco use, the committee is reasonably confident that raising the MLA will reduce tobacco initiation, particularly among adolescents 15 to 17 years of age, will improve health across the life span, and will save lives.
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