US: Raising the legal age for tobacco sales to 21 could prevent more than half a million premature deaths

A recent study[1] published in JAMA Health Forum and conducted by the Yale School of Medicine highlights the significant public health impact of “Tobacco 21” (T21) policies. These policies, which raise the legal age for tobacco sales to 21, could prevent more than 500,000 premature deaths in the United States.

T21 policies aim to reduce smoking initiation among youth by limiting their access to tobacco products. Raising the legal age could also limit initiation through peer influence, which often results in adolescents sharing tobacco. This peer influence is particularly important because youth under 21 have relatively little contact with older people.

The study in question sought to quantify the potential benefits of age-of-sale policies in terms of reducing premature mortality. The researchers used statistical models to estimate the impact of T21 policies on smoking prevalence and associated mortality. They took into account a variety of factors, including current youth smoking rates, consumption trends, and demographic data.

More than half a million premature deaths prevented

The study used a simulation model using state-specific data. Examining T21 policy adoption in all 50 states and the District of Columbia, the researchers quantified potential health benefits under three scenarios: local (municipal) T21 policies, state and local T21 policies, and a combination of federal, state, and local T21 policies.

The study estimates that full implementation of T21 laws at the local, state and federal levels could prevent up to 526,000 premature deaths from smoking in the United States and gain 13.3 million years of life by 2100. This figure includes deaths from diseases such as lung cancer, cardiovascular disease and respiratory illnesses.

Geographic disparities in policy impact

The analysis found large disparities based on population size, smoking trends, and state and local enforcement. States with higher smoking prevalence should see relatively greater benefits. States that have been engaged in these policies for decades are particularly likely to see benefits in terms of averted premature mortality.

California, which adopted statewide T21 laws early, could prevent nearly 27,000 premature deaths by 2100. This finding underscores the importance of early implementation, as the state policy preceded the federal T21 law by several years, the authors say.

Kentucky, where smoking rates are higher, demonstrated significant potential benefits despite later implementation. The study estimates that 15,000 premature deaths could be prevented. In Massachusetts, where local T21 policies covered more than 70,000 residents before the state law was passed in 2018, 8,000 deaths would be prevented by 2100. This reflects the effects of this public policy being rolled out at the municipal level even before the law was more widely implemented at the state level.

In contrast, Wisconsin, which has no state or local T21 policy, stands to gain from implementing federal T21 laws, which could prevent 10,000 premature deaths, according to modeling.

Strengthen controls and enforce the measure at local and state levels

According to the study authors, consistent enforcement at the federal, state, and local levels is essential to maximize the impact of T21 policies. States that lack strong state or local laws, such as Montana or Wisconsin, should prioritize adopting and implementing comprehensive T21 policies to align with federal standards. To that end, the authors recommend greater collaboration between federal agencies and state governments to close coverage gaps. They also call on the Food and Drug Administration (FDA) to increase the frequency and scope of compliance inspections at tobacco retailers. They also call on federal and state agencies to apply more dissuasive penalties to retailers that violate the laws. Currently, penalties are limited to 345$ even for repeat violations.

The authors caution that T21 laws must be part of a more comprehensive tobacco control strategy that includes smoking cessation programs, increased taxation of tobacco and nicotine products, and restrictions on marketing and advertising targeting youth.

More and more countries around the world are implementing this measure to increase the age of sale of tobacco products. In Europe, Ireland is set to approve legislation that will increase the minimum age of sale from 18 to 21. This measure is part of the goal of achieving a tobacco-free generation by 2025 in the country.[2]In France, the National Committee against Smoking also recommends this measure.

©Tobacco Free Generation

AE

[1] Tam J, Crippen A, Friedman A, et al. US Tobacco 21 Policies and Potential Mortality Reductions by State. JAMA Health Forum. 2024;5(12):e244445. doi:10.1001/jamahealthforum.2024.4445

[2] Generation without tobacco, Ireland: bill banning the sale of tobacco before the age of 21 submitted to the Council of Ministers, published June 29, 2024, accessed December 30, 2024