Increasing the minimum age of legal access to tobacco products will prevent or delay tobacco use by adolescents and young adults, particularly those ages 15 to 17, says a new report from the Institute of Medicine.

The committee that conducted the study included Rafael Meza, assistant professor of epidemiology at the University of Michigan’s School of Public Health, and Patrick O’Malley, research professor at the U-M Institute for Social Research.

The team estimated the likely reduction in tobacco-use initiation that would be achieved by raising the minimum age of legal access (MLA) to tobacco products to 19, 21 or 25 years old. They used two tobacco-use simulation models to quantify the accompanying public health outcomes.

Raising the MLA to age 21 likely will have a substantially greater impact on reducing the initiation of tobacco use—defined as having smoked 100 cigarettes—than raising it to 19. However, the added effect of raising the minimum age beyond age 21 to age 25 would probably be considerably smaller, the report says.

Underage users rely primarily on social sources—friends and relatives—to get tobacco, and there is little evidence that these individuals are obtaining tobacco from the illegal commercial market. Between ages 15 and 17, mobility increases with driving privileges, and social networks and potential sources of tobacco start to increase as some adolescents take on part-time jobs with co-workers who may be over the MLA.

Therefore, increasing the MLA to 19 may not change social sources substantially for this age group, but raising the MLA to 21 is likely to have a considerable impact on initiation, the study suggests.

Over the past 50 years, tobacco control efforts in the U.S. have led to an estimated 8 million fewer premature deaths. Tobacco use continues to significantly affect public health, however, and more than 40 million Americans still smoke.

Although the Family Smoking Prevention and Tobacco Control Act of 2009 granted the U.S. 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, 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 U.S., which vary considerably. Although most states currently set the MLA at 18, four states (Alabama, Alaska, New Jersey, Utah) set it at 19, 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,” said committee chair 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.”

 

The committee emphasized that policy decisions about the MLA should consider other factors in addition to projected health outcomes. One of those factors is the relative maturity of adolescents and young adults. 

Of the 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.

If the MLA were raised now, the report says that 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, the report says that if the MLA were raised now to age 21 nationwide, for the cohort of people born between 2000 and 2019, 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.

“These are considerable long-term health benefits that would accumulate throughout the lifetime of these individuals in addition to short-term and intermediate effects,” U-M’s Meza said.

Although reductions in smoking-related deaths following an increased MLA will not be observed for at least 30 years, some direct health benefits, including those from reduced exposures to secondhand smoke, will be immediate. An increase in the MLA for tobacco products likely will 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,” Meza said.

The committee noted that the recent increase in use of hookahs and electronic nicotine delivery systems, such as e-cigarettes, by adolescents and young adults could have a substantial effect on the use of cigarettes and other tobacco products, but it is too early to make informed predictions about these effects.

“By assessing the public health implications of raising the minimum age for accessing tobacco products, this report aims to provide the scientific guidance that states and localities need when evaluating new policies to achieve the ultimate goal—the reduction and eventual elimination of tobacco use by children and youth,” said Victor Dzau, president of the Institute of Medicine.

The study was sponsored by the FDA.