Tobacco 21: A Step in the Right Direction

cheryl_healtonOur Guest Blogger today is Dr. Cheryl Healton, Dean of Global Public Health at NYU and Professor of Public Policy at the Robert F. Wagner School of Public Service.  She weighs in on the proposed legislation to raise the minimum legal sale age for tobacco and related products from 18 to 21:

Each year in the US, 425,000 young people start to smoke. Of these, an estimated one- third will ultimately die from a tobacco-related cause. For the most recent year on which we have data, 44.7 percent of high schools students had at least tried a cigarette and over 18 percent were already current tobacco users.

candy flavored cigarsDespite the good news that youth smoking has declined sharply since 1998, the mix of tobacco products used has broadened considerably and now includes small cigars (many of which are flavored with candy-like additives )–and in 2011, nearly one in five twelfth graders reported using them.

The tobacco industry spends over $8 billion a year marketing its product in the US alone—many of these funds are used to support point of purchase marketing including the provision of steep discounts on product to facilitate initiation.

Almost 90 percent of daily smokers started smoking by age 18 and 99 percent begin by age 26. The tobacco industry has ramped up its marketing targeting youth over age 18 and there is a shift occurring in age of initiation with more youth becoming established smokers in the young adult years.

Tobacco addiction is no longer an equal opportunity health problem—it disproportionately impacts lower income groups and minorities. Those especially targeted by the industry including African Americans, Asian Americans, Latinos, Native Americans and the LGBT population.

Among those aged 18-22, almost 39 percent not enrolled in college smoke versus 24 percent enrolled in college.

NYC has been on the public health forefront by implementing evidence-based policies to reduce tobacco use. These have of course included clear air laws-both indoor and out; price increases and graphic public education.

All three strategies have resulted in NYC now having one of the lowest smoking rates of among US cities.  This new proposal too is evidence-based. Like the important increase in drinking age which occurred decades ago in response to the negative effects of reducing the drinking age, an increase in the age for the legal purchase of tobacco products to 21 will have positive effects. It will reduce consumption by youth, will likely avert tens of thousands of youth becoming addicted to nicotine and save many New Yorkers from suffering the health consequences of tobacco use.

According to Dr. Jon Winikcoff, Harvard pediatrician and tobacco expert, only 2.10 percent of tobacco sales are to those under 21, but that small initial market share leads to 80-90 percent of sales to lifetime smokers. If you get to age 21 without smoking, you presently only have about a 3 percent chance of ever becoming a smoker.

This policy will also save New Yorkers billions from health-related medicaid costs paid through taxes because over time fewer people with become ill with costly tobacco-related chronic conditions.

Three studies are very relevant–two from the United Kingdom evaluated the impact on smoking by youth of an increase in the legal age from 16 to 18 finding a significant reduction in tobacco use as a result of the age of purchase change. One study was based in schools and another was conducted in households—they cross-validate each other.

A second study from California UC-Urvine modeled the potential effects of an increase in age of purchase to 21 and concluded smoking could result in a drop of 82 percent in youth smoking from 13.3 to 2.4 percent. The model was based on the assumption that the age of initiation would shift to higher ages and conform to the known rates of initiation for any given age. This shift upward in age of initiation reduces smoking because after age 16 rates of initiation fall through age 20 and then initiation becomes rare. The authors projected health care savings under this scenario of 24 billion over 50 years.

Strong and growing scientific evidence demonstrates that the decision making area of the brain is not fully developed among those under age 21; and, therefore, they are not making an “informed decision” to smoke but rather responding to the relentless advertising by the tobacco industry and emulating their parents and friends only to regret it later when they find quitting smoking is for more challenging than starting to smoke.

With the proposed State legislation, NYS can become the first State to increase the legal age for purchase of tobacco to 21. The sponsors of this bill are to be applauded for taking this progressive step, one that is their right under the Family Smoking Prevention Act of 2009.

They will hopefully lead the way—as New York often does—in forging a new progressive front aimed at eradicating youth tobacco use once and for all and thus with it the roots of the lifelong addiction youth initiation sets in motion.

The tobacco epidemic cost 100 million lives over the last 1 00 years and is projected by the World Health Organization to cost a BILLION more lives this century—this step is one in the right direction—one that will reduce this wholly unacceptable toll.