Increasing the minimum age of legal access (MLA) to tobacco products will prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan, says a new report from the Institute of Medicine. The committee that conducted the study estimated the likely reduction in tobacco-use initiation that would be achieved by raising the MLA for tobacco products to either 19 years old, 21 years old, or 25 years, and used two tobacco-use simulation models to quantify the accompanying public health outcomes.

Raising the MLA to tobacco products to 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.

Over the past 50 years, tobacco control efforts in the U.S. have led to an estimated 8 million fewer premature deaths. However, tobacco use continues to significantly affect public health, 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 FDA from establishing a nationwide MLA for tobacco products above 18 years of age. In response to congressional direction, FDA asked the IOM 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, and 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 J. Bonnie, Harrison Foundation Professor of Medicine and Law and director of the Institute of Law, Psychiatry, and Public Policy at the University of Virginia in Charlottesville. “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 approximately 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.

Cigarette smoking is causally associated with a broad spectrum of adverse health effects, such as diabetes, impaired lung function, coronary heart disease, and numerous cancers, which cause suffering, diminished quality of life, and premature death. 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 approximately 249,000 fewer premature deaths, 45,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost.

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 pre-term births, 438,000 fewer cases of low birth weight, and roughly 4,000 fewer sudden infant death cases among mothers age 15 to 49.

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.

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The study was sponsored by the U.S. Food and Drug Administration. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

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National Academy of Sciences

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INSTITUTE OF MEDICINE Board on Population Health and Public Health Practice

Committee on the Public Health Implications of Raising the Minimum Age for

Purchasing Tobacco Products

Richard J. Bonnie, L.L.B.1 (chair)
Harrison Foundation Professor of Medicine and Law,
Professor of Psychiatry and Neurobehavioral Sciences, and
Director, Institute of Law, Psychiatry, and Public Policy
University of Virginia
Charlottesville

Anthony Alberg, Ph.D.
Blatt Ness Distinguished Endowed Chair in Oncology,
Professor of Public Health Sciences, and
Interim Director, Hollings Cancer Center
Medical University of South Carolina
Charleston

Regina M. Benjamin, M.D., M.B.A.1
Former U.S. Surgeon General, and
NOLA.com/Times Picayune Endowed Chair in Public Health Sciences
Xavier University of Louisiana
New Orleans

Jonathan P. Caulkins, M.S., Ph.D.2
H. Guyford Stever Professorship of Operations Research and Public Policy
Heinz School of Public Policy and Management
Carnegie Mellon University
Pittsburgh

Bonnie L. Halpern-Felsher, Ph.D.
Professor, Department of Pediatrics,
Director of Research, and
Associate Director of Adolescent Medicine Fellowship Program
Division of Adolescent Medicine
Stanford University
Stanford, Calif.

Swannie Jett, Dr.PH., M.Sc.
Executive Director
Seminole County
Florida Department of Health
Sanford

Harlan Juster, Ph.D.
Director
Bureau of Tobacco Control
New York State Department of Health
Albany

Jonathan Klein, M.D., M.P.H.
Associate Executive Director
Julius B. Richmond Center of Excellence
American Academy of Pediatrics
Elk Grove Village, Ill.

Paula M. Lantz, Ph.D., M.A.1
Professor and Chair
Department of Health Policy and Management
School of Public Health
Milken Institute
George Washington University
Washington, D.C.

Robin Mermelstein, Ph.D.
Professor of Psychology and Director
Institute for Health Research and Policy
University of Illinois
Chicago

Rafael Meza, Ph.D.
Assistant Professor
Department of Epidemiology
University of Michigan
Ann Arbor

Patrick M. O’Malley, Ph.D.
Research Scientist and Program Director
Survey Research Center
Institute for Social Research
University of Michigan
Ann Arbor

Kimberly M. Thompson, M.S., Sc.D.
Professor of Preventive Medicine and Global Health
College of Medicine
University of Central Florida, and
President
Kid Risk Inc.
Orlando