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1. Health Policy. 2018 Aug;122(8):929-935. Public support for tobacco control policies: The role of the protection of children against tobacco. Kuijpers TG(1), Willemsen MC(2), Kunst AE(3).

INTRODUCTION: In many countries, health advocates aim to increase public support

for tobacco control policies by framing these policies in terms of child

protection. We examined whether support for the protection of children is indeed

associated with support for tobacco control policies, even among smokers,

opponents of state intervention and opponents of a governmental role in tobacco control.

METHODS: We used a survey on a representative sample of Dutch adults of 18 years

and older (n = 1631). The survey measured respondents' support for banning

tobacco displays, raising the age of sale for tobacco to 21 years and limiting

tobacco sales to specialized shops. Regression analyses were done to assess the

association with respondents' support for the protection of children against

tobacco. In further analyses, subgroup interactions were added.

RESULTS: Respondents' support for the protection of children against tobacco with

legislation was positively related to support for all three policies.

Associations were weaker for smokers (except for raising the age of sale) but

similar for opponents of state intervention and opponents of a governmental role

in tobacco control.

CONCLUSION: This is the first paper to empirically support the idea that

emphasizing the need to protect children against tobacco enhances support for

tobacco control policies. This 'child effect' is effective in all segments of the

population, albeit somewhat weaker among smokers.

PMID: 29859650 [Indexed for MEDLINE]

2. Prev Chronic Dis. 2017 Nov 16;14:E112. Should the Legal Age for Tobacco Be Raised? Results From a National Sample of Adolescents. Kowitt SD(1)(2), Schmidt AM(3)(2), Myers AE(3)(4), Goldstein AO(2)(5).

Raising the minimum age of legal access to tobacco products may reduce smoking

initiation and save lives. In a national telephone survey (2014-2015), US

adolescents aged 13 to 17 years (N = 1,125; response rate, 66%) were asked about

raising the age of legal access to tobacco products and randomized to hear one of

3 ages (19, 20, or 21 y). Most adolescents, across all US regions, favored

raising the minimum age of legal access to 19 (75.7%), 20 (80.6%), or 21 (76.4%).

These supportive attitudes may be useful to tobacco prevention and control

practitioners who seek to reduce tobacco use among adolescents. PMCID: PMC5695643

PMID: 29144895 [Indexed for MEDLINE]

3. Am J Public Health. 2017 Sep;107(9):1401-1405. Minimum Age of Sale for Tobacco Products and Electronic Cigarettes: Ethical Acceptability of US "Tobacco 21 Laws". Morain SR(1), Malek J(1).

Several US jurisdictions have recently passed laws that raise the minimum age of

sale for tobacco products and electronic cigarettes to 21 years (Tobacco 21

laws). Although these laws have been demonstrated to be an effective means to

reduce youth smoking initiation, their passage and potential expansion have

provoked controversy. Critics have objected to these laws, claiming that they

unduly intrude on individual freedom and that they irrationally and

paternalistically restrict the freedom of those aged 18 to 20 years, who were

previously able to legally purchase tobacco products. We have examined the

ethical acceptability of Tobacco 21 laws. First, we have described ethical

support for such a restriction grounded in its public health benefit. We have

then offered arguments that raise doubts about the soundness of critics'

objections to these regulations and described an additional ethical justification

arising from concern about preventing harm to others. On the basis of this

analysis, we conclude that Tobacco 21 laws are ethically justifiable. PMID: 28727531 [Indexed for MEDLINE]

4. Pediatrics. 2017 Jan;139(1). pii: e20162216. The Tobacco 21 Movement and Electronic Nicotine Delivery System Use Among Youth. Meernik C(1), Baker HM(2), Lee JG(3), Goldstein AO(4)(2).

DOI: 10.1542/peds.2016-2216

PMID: 27940513 [Indexed for MEDLINE]

5. Tob Control. 2016 Oct;25(Suppl 1):i6-i9. Success in the city: the road to implementation of Tobacco 21 and Sensible Tobacco Enforcement in New York City. Moreland-Russell S(1), Combs T(1), Schroth K(2), Luke D(1).

New York City, a leader in municipal tobacco control in the USA, furthered its

goal of reducing the community's burden of tobacco use in 2014 by implementing

Sensible Tobacco Enforcement and Tobacco 21. These policies are intended to

restrict youth access and eliminate sources of cheap tobacco. Strong

partnerships, substantial local data and support from the public and elected

officials were key in overcoming many challenges and ensuring these policies were

signed into law.

PMCID: PMC5099222

PMID: 27697942 [Indexed for MEDLINE]

6. Ann Am Thorac Soc. 2016 Dec;13(12):2115-2118. Tobacco 21: An Important Public Policy to Protect Our Youth. Farber HJ(1), Pakhale S(2), Neptune ER(3); American Thoracic Society Tobacco

Action Committee.

An important approach to reduce youth tobacco use is the adoption of regulations

to prohibit tobacco product sale to individuals younger than 21 years, termed

Tobacco 21. In the United States, close to 90% of current smokers started smoking

before the age of 18 years, and 99% before age 26 years. Earlier age of tobacco

use initiation is associated with lower rates of smoking cessation. Increasing

minimum age to purchase has been shown to reduce tobacco product use among youth.

The critical determinant is likely the loss of social sources of tobacco

products. Enforcement activities are important for age-of-purchase laws to be

effective. Raising the minimum legal age to purchase tobacco products to 21 years

is highly supported among both the smoking and nonsmoking public. Tobacco sales

to those younger than 21 years account for just 2% of total tobacco sales, yet

produce 90% of new smokers. The short-term effect on small business of raising

the minimum age to purchase would be minimal. Small businesses will have time to

adapt to the decrease in tobacco sales as fewer youth grow up nicotine addicted.

Raising the minimum age to purchase of tobacco and nicotine products to 21 years,

combined with enforcement of those restrictions, will help protect future

generations from a lifetime of tobacco dependence and associated morbidity. These

regulations should apply to all tobacco products, including electronic nicotine

delivery systems. Respiratory health care providers should educate their local,

state, and federal policy makers on the importance of Tobacco 21. PMID: 27689306 [Indexed for MEDLINE]

7. Am J Bioeth. 2016 Jul;16(7):26-8. Tobacco 21 Laws: Withdrawing Short-Term Freedom to Enable Long-Term Autonomy. Morain SR(1).

PMID: 27292844 [Indexed for MEDLINE]

8. Public Health Rep. 2016 Mar-Apr;131(2):378-81. Raising the Tobacco Sales Age to 21: Surveying the Legal Landscape. Berman ML(1).

PMCID: PMC4765989 [Available on 2017-03-01]

PMID: 26957675 [Indexed for MEDLINE]

9. Tob Control. 2016 Nov;25(6):624-627. Retailer compliance with tobacco control laws in New York City before and after raising the minimum legal purchase age to 21. Silver D(1), Macinko J(2), Giorgio M(1), Bae JY(3), Jimenez G(3).

OBJECTIVES: New York City (NYC) is the first large city to increase the legal

minimum age for possessing tobacco products from 18 to 21 (Tobacco 21) and

establish a minimum price law to reduce smoking rates among youth. However,

retailer compliance with these regulations is unknown.

METHODS: Youthful investigators purchased cigarettes pre and post-Tobacco 21

implementation in 92 NYC neighbourhoods. Investigators recorded whether their ID

was checked, the pack's purchase price, and observed compliance with additional

regulations. Multivariable OLS and Poisson regression models assess pre and post

Tobacco 21 compliance with ID checks and purchase prices, controlling for

retailer type, location and compliance with other laws.

RESULTS: Retailer compliance with ID checks declined from 71% to 62% (p<0.004)

between periods, and holding constant other factors, compliance with ID checks

and sales at legal prices declined significantly after the laws changed. Compared

to chain stores, independent retailers had significantly lower compliance rates (p<0.01).

CONCLUSIONS: Several aspects of tobacco control appear to have deteriorated in

NYC. Greater attention to monitoring retailer compliance with all tobacco

regulations will be important for Tobacco 21 laws to be effective in reducing

youth access to tobacco products.

PMID: 26585707 [Indexed for MEDLINE]

10. Tob Control. 2016 May;25(3):355-9. Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Kessel Schneider S(1), Buka SL(2), Dash K(1), Winickoff JP(3), O'Donnell L(1).

OBJECTIVE: Raising the tobacco sales age to 21 has gained support as a promising

strategy to reduce youth cigarette access, but there is little direct evidence of

its impact on adolescent smoking. Using regional youth survey data, we compared

youth smoking trends in Needham, Massachusetts--which raised the minimum purchase

age in 2005--with those of 16 surrounding communities.

METHODS: The MetroWest Adolescent Health Survey is a biennial census survey of

high school youth in communities west of Boston; over 16,000 students

participated at each of four time points from 2006 to 2012. Using these pooled

cross-section data, we used generalised estimating equation models to compare

trends in current cigarette smoking and cigarette purchases in Needham relative

to 16 comparison communities without similar ordinances. To determine whether

trends were specific to tobacco, we also examined trends in youth alcohol use

over the same time period.

RESULTS: From 2006 to 2010, the decrease in 30-day smoking in Needham (from 13%

to 7%) was significantly greater than in the comparison communities (from 15% to

12%; p<.001). This larger decline was consistent for both genders, Caucasian and

non-Caucasian youth, and grades 10, 11 and 12. Cigarette purchases among current

smokers also declined significantly more in Needham than in the comparison

communities during this time. In contrast, there were no comparable differences

for current alcohol use.

CONCLUSIONS: Our results suggest that raising the minimum sales age to 21 for

tobacco contributes to a greater decline in youth smoking relative to communities

that did not pass this ordinance. These findings support local community-level

action to raise the tobacco sales age to 21. PMID: 26071428 [Indexed for MEDLINE]

11. Tob Control. 2016 May;25(3):284-8. Public support for raising the age of sale for tobacco to 21 in the United States. Winickoff JP(1), McMillen R(2), Tanski S(3), Wilson K(4), Gottlieb M(5), Crane R(6).

OBJECTIVES: The vast majority of tobacco users began before the age of 21.

Raising the tobacco sales age to 21 has the potential to reduce tobacco use

initiation and progression to regular smoking. Our objective was to assess the

level of public support nationally for 'Tobacco 21' initiatives in the USA.

METHODS: The Social Climate Survey of Tobacco Control, a cross-sectional

dual-frame survey representing national probability samples of adults was

administered in 2013. Respondents were asked to state their agreement level with,

'The age to buy tobacco should be raised to 21.'

RESULTS: Of 3245 respondents, 70.5% support raising the age to buy tobacco to 21.

The majority of adults in every demographic and smoking status category supported

raising the tobacco sales age to 21. In multivariable analyses, support was

highest among never smokers, females, African-Americans and older adults.

CONCLUSIONS: This national study demonstrates broad public support for raising

the sales age of tobacco to 21 and will help facilitate wide dissemination of

initiatives to increase the legal purchase age at national, state and local

levels. Increasing public awareness about the susceptibility and rapid addiction

of youth to nicotine may further increase public support for raising the tobacco

sale age to 21. PMID: 25701856 [Indexed for MEDLINE]

12. Tob Control. 2016 Mar;25(2):174-80. Multiple tobacco product use among US adolescents and young adults. Soneji S(1), Sargent J(1), Tanski S(2).

OBJECTIVE: To assess the extent to which multiple tobacco product use among

adolescents and young adults falls outside current Food and Drug Administration

(FDA) regulatory authority.

METHODS: We conducted a web-based survey of 1596 16-26-year-olds to assess use of

11 types of tobacco products. We ascertained current (past 30 days) tobacco

product use among 927 respondents who ever used tobacco. Combustible tobacco

products included cigarettes, cigars (little filtered, cigarillos, premium) and

hookah; non-combustible tobacco products included chew, dip, dissolvables,

e-cigarettes, snuff and snus. We then fitted an ordinal logistic regression model

to assess demographic and behavioural associations with higher levels of current

tobacco product use (single, dual and multiple product use).

RESULTS: Among 448 current tobacco users, 54% were single product users, 25% dual

users and 21% multiple users. The largest single use category was cigarettes

(49%), followed by hookah (23%), little filtered cigars (17%) and e-cigarettes

(5%). Most dual and multiple product users smoked cigarettes, along with little

filtered cigars, hookah and e-cigarettes. Forty-six per cent of current single,

84% of dual and 85% of multiple tobacco product users consumed a tobacco product

outside FDA regulatory authority. In multivariable analysis, the adjusted risk of

multiple tobacco use was higher for males, first use of a non-combustible tobacco

product, high sensation seeking respondents and declined for each additional year

of age that tobacco initiation was delayed.

CONCLUSIONS: Nearly half of current adolescent and young adult tobacco users in

this study engaged in dual and multiple tobacco product use; the majority of them

used products that fall outside current FDA regulatory authority. This study

supports FDA deeming of these products and their incorporation into the national

media campaign to address youth tobacco use. PMCID: PMC4547881

PMID: 25361744 [Indexed for MEDLINE]

13. Am J Public Health. 2014 Nov;104(11):e18-21. Retail impact of raising tobacco sales age to 21 years.

Winickoff JP(1), Hartman L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR.

The majority of tobacco use emerges in individuals before they reach 21 years of

age, and many adult distributors of tobacco to youths are young adults aged

between 18 and 20 years. Raising the tobacco sales minimum age to 21 years across

the United States would decrease tobacco retailer and industry sales by

approximately 2% but could contribute to a substantial reduction in the

prevalence of youths' tobacco use and dependency by limiting access.

PMCID: PMC4202948

PMID: 25211755 [Indexed for MEDLINE]

14. N Engl J Med. 2014 Jan 23;370(4):295-7. Tobacco 21--an idea whose time has come.

Winickoff JP(1), Gottlieb M, Mello MM.

PMID: 24401021 [Indexed for MEDLINE]

1. MMWR Morb Mortal Wkly Rep. 2014 Dec 12;63(49):1145-50. State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems--United States, November 2014. Marynak K, Holmes CB, King BA, Promoff G, Bunnell R, McAfee T; Centers for Disease Control and Prevention (CDC).

Electronic nicotine delivery systems (ENDS), including electronic cigarettes

(e-cigarettes) and other devices such as electronic hookahs, electronic cigars,

and vape pens, are battery-powered devices capable of delivering aerosolized

nicotine and additives to the user. Experimentation with and current use of

e-cigarettes has risen sharply among youths and adults in the United States.

Youth access to and use of ENDS is of particular concern given the potential

adverse effects of nicotine on adolescent brain development. Additionally, ENDS

use in public indoor areas might passively expose bystanders (e.g., children,

pregnant women, and other nontobacco users) to nicotine and other potentially

harmful constituents. ENDS use could have the potential to renormalize tobacco

use and complicate enforcement of smoke-free policies. State governments can

regulate the sales of ENDS and their use in indoor areas where nonusers might be

involuntarily exposed to secondhand aerosol. To learn the current status of state

laws regulating the sales and use of ENDS, CDC assessed state laws that prohibit

ENDS sales to minors and laws that include ENDS use in conventional smoking

prohibitions in indoor areas of private worksites, restaurants, and bars.

Findings indicate that as of November 30, 2014, 40 states prohibited ENDS sales

to minors, but only three states prohibited ENDS use in private worksites,

restaurants, and bars. Of the 40 states that prohibited ENDS sales to minors, 21

did not prohibit ENDS use or conventional smoking in private worksites,

restaurants, and bars. Three states had no statewide laws prohibiting ENDS sales

to minors and no statewide laws prohibiting ENDS use or conventional smoking in

private worksites, restaurants, and bars. According to the Surgeon General, ENDS

have the potential for public health harm or public health benefit. The

possibility of public health benefit from ENDS could arise only if 1) current

smokers use these devices to switch completely from combustible tobacco products

and 2) the availability and use of combustible tobacco products are rapidly

reduced. Therefore, when addressing potential public health harms associated with

ENDS, it is important to simultaneously uphold and accelerate strategies found by

the Surgeon General to prevent and reduce combustible tobacco use, including

tobacco price increases, comprehensive smoke-free laws, high-impact media

campaigns, barrier-free cessation treatment and services, and comprehensive

statewide tobacco control programs. PMCID: PMC4584536 PMID: 25503916 [Indexed for MEDLINE]

2. Nicotine Tob Res. 1999;1 Suppl 2:S93-7. Youth access to tobacco. Rigotti NA(1).

To start smoking, young people need a supply of tobacco products. Reducing youth

access to tobacco is a new approach to preventing tobacco use that has been a

focus of federal, state, and local tobacco control efforts over the past decade.

All 50 states ban tobacco sales to minors, but compliance is poor because laws

are not enforced. Consequently, young people have little trouble obtaining

tobacco products. Commercial sources of tobacco (stores and vending machines) are

important for underage smokers, who often purchase their own cigarettes. Underage

youths also obtain tobacco from noncommercial sources such as friends, relatives,

older adolescents, and adults. Educating retailers about tobacco sales laws has

not produced long-term improvement in their compliance. Active enforcement of

tobacco sales laws changes retailer behavior, but whether this reduces young

people's access to tobacco or their tobacco use is not clear. The effectiveness

of new local, state, and federal actions that aim to reduce youth access to

tobacco remains to be determined. Can enforcing tobacco sales laws reduce young

people's access to tobacco? If so, will this prevent or delay the onset of their

tobacco use? How will youths' sources of tobacco change as commercial sources are

restricted? What are the social (noncommercial) sources of tobacco for minors and

how can youths' access to tobacco from these sources be reduced? What is the

impact of the new federal policies aimed at reducing youth access to tobacco? Do

new state and local laws that ban youth possession or use of tobacco have a net

positive or negative impact on youth attitudes, access to tobacco, or tobacco

use? What is the relative effectiveness and cost-effectiveness of efforts to

reduce the supply of tobacco compared to those that aim to reduce demand for

tobacco? Will either work alone or are both necessary to achieve reductions in

youth smoking? PMID: 11768192 [Indexed for MEDLINE]

3. Tob Control. 2016 May;25(3):289-94. Compliance with minimum price and legal age for cigarette purchase laws: evidence from NYC in advance of raising purchase age to 21. Silver D(1), Bae JY(1), Jimenez G(1), Macinko J(1).

BACKGROUND: New York City (NYC) raised the minimum purchase age for cigarettes

from 18 to 21 on 1 August 2014. The new law is intended to decrease current

smoking rates and smoking initiation among the city's youth. Assessment of

compliance with existing cigarette sales and tax laws could aid in determining

what may be needed for successful implementation of the city's new law.

PURPOSE: To assess compliance with minimum sales price and purchase age laws in

NYC, before change in law.

METHODS: Ten trained field investigators purchased cigarettes from different

types of retailers throughout all five NYC boroughs, resulting in 421 purchases.

Investigators noted whether they were asked for identification and the price of

their purchase. Multivariable logistic and Ordinary Least Squares regression

techniques were used to assess predictors of retailer compliance with sales price

and minimum purchase age laws.

RESULTS: In 29% of purchases, investigators did not have to produce

identification (p<0.05) to purchase cigarettes. Only 3.1% of sales were at prices

lower than the minimum sales price. City borough was significantly associated

with purchase without identification (p<0.001) and mean sales price (p<0.024).

Vendor type (independent vs chain) was significantly related to investigators

being able to purchase cigarettes without identification (p<0.001).

CONCLUSIONS: Variation in compliance with existing laws suggests that more active

monitoring of compliance with the new minimum legal purchase age will be required

in order to realise the new law's public health potential. PMID: 25673327

4. Tob Control. 2018 May;27(3):258-260. The effects of tobacco control policies on retailer sales to minors in the USA, 2015. Dai H(1)(2)(3), Hao J(4).

BACKGROUND: Under the 2009 Family Smoking Prevention and Tobacco Control Act, the

Food and Drug Administration (FDA) has been routinely inspecting tobacco

retailers' compliance with under-age sales laws. We seek to identify factors

associated with Retail Violation Rate for sale to minors (RVRm).

METHODS: We collected the tobacco retailer inspection data for 2015 from the FDA

compliance check database. RVRm was calculated at the census tract level and

overlaid with tobacco regulations and youth smoking prevalence at the state

level. Multi-level spatial analysis was performed to examine the impacts of

tobacco jurisdiction variations, youth smoking rates and neighbourhood social

characteristics on RVRm.

RESULTS: A total of 136 816 compliance checks involving minors conducted by the

FDA in 2015 were analysed. A higher RVRm was associated with higher youth smoking

prevalence (aRR=1.04, p<0.0001). Tobacco regulations show significant

relationships with RVRm. For every one dollar increase in cigarette tax per pack,

the likelihood of retail violations was reduced by 2% (aRR=0.98, p=0.03). For

every 10% increase in tobacco prevention spending towards Centers for Disease

Control recommended funding targets, the likelihood of retail violations was

reduced by 1% (aRR=0.99, p=0.01). RVRm increased in states that enacted stronger

smoke-free air policies (aRR=1.08, p<0.0001).

CONCLUSION: We observed associations of tobacco regulations and neighbourhood

social characteristics with tobacco retailers' compliance with under-age sales

laws. This study provides evidence to support stronger tobacco regulations and

control policies in reducing youth access to tobacco products. PMID: 28219976 [Indexed for MEDLINE]

5. Tob Control. 2015 Mar;24(e1):e10-3. Public opinions on tax and retail-based tobacco control strategies.

Farley SM(1), Coady MH(1), Mandel-Ricci J(1), Waddell EN(1), Chan C(1), Kilgore EA(1), Kansagra SM(1).

BACKGROUND: While tobacco taxes and smoke-free air regulations have significantly

decreased tobacco use, tobacco-related illness accounts for hundreds of thousands

of annual deaths. Experts are considering additional strategies to further reduce

tobacco consumption.

METHODS: We investigated smokers' (n=2118) and non-smokers' (n=2210) opinions on

existing and theoretical strategies, including tax and retailer-based strategies

in New York City, across three cross-sectional surveys.

RESULTS: Compared with smokers, non-smokers were significantly more likely

(p<0.05) to favour all tobacco control strategies. Overall, 25% of smokers

surveyed favoured increasing taxes on cigarettes, climbing to 60% if taxes were

used to fund healthcare programmes. Among non-smokers, 72% favoured raising

taxes, increasing to 83% if taxes were used to fund healthcare programmes. 54% of

non-smoking New Yorkers favoured limiting the number of tobacco retail licences,

as did 30% of smokers. The most popular retail-based strategies were raising the

minimum age to purchase cigarettes from 18 to 21, with 60% of smokers and 69% of

non-smokers in favour, and prohibiting retailers near schools from selling

tobacco, with 51% of smokers and 69% of non-smokers in favour. Keeping tobacco

products out of customers' view, prohibiting tobacco companies from paying

retailers to display or advertise tobacco products and prohibiting price

promotions were favoured by more than half of non-smokers surveyed, and almost

half of smokers.

CONCLUSIONS: While the support level varied between smokers and non-smokers,

price and retail-based tobacco control strategies were consistently supported by

the public, providing useful information for jurisdictions examining emerging

tobacco control strategies. PMID: 24365700 [Indexed for MEDLINE]

6. Tob Control. 2016 Oct;25(Suppl 1):i44-i51. Tobacco retail policy landscape: a longitudinal survey of US states. Luke DA(1), Sorg AA(1), Combs T(1), Robichaux CB(1), Moreland-Russell S(1), Ribisl KM(2), Henriksen L(3).

BACKGROUND: There are ∼380 000 tobacco retailers in the USA, where the largest

tobacco companies spend almost $9 billion a year to promote their products. No

systematic survey has been conducted of state-level activities to regulate the

retail environment, thus little is known about what policies are being planned,

proposed or implemented.

METHODS: This longitudinal study is the first US survey of state tobacco control

programmes (TCPs) about retail policy activities. Surveyed in 2012 and 2014,

programme managers (n=46) reported activities in multiple domains: e-cigarettes,

retailer density and licensing, non-tax price increases, product placement,

advertising and promotion, health warnings and other approaches. Policy

activities were reported in one of five levels: no formal activity, planning or

advocating, policy was proposed, policy was enacted or policy was implemented.

Overall and domain-specific activity scores were calculated for each state.

RESULTS: The average retail policy activity almost doubled between 2012 and 2014.

States with the largest increase in scores included: Minnesota, which established

a fee-based tobacco retail licensing system and banned self-service for

e-cigarettes and all other tobacco products (OTP); Oregon, Kansas and Maine, all

of which banned self-service for OTP; and West Virginia, which banned some types

of flavoured OTP.

CONCLUSIONS: Retail policy activities in US states increased dramatically in a

short time. Given what is known about the impact of the retail environment on

tobacco use by youth and adults, state and local TCPs may want diversify policy

priorities by implementing retail policies alongside tax and smoke-free air laws.

PMCID: PMC5099223 PMID: 27697947 [Indexed for MEDLINE]

7. Health Policy. 2007 Mar;80(3):378-91. Limiting youth access to tobacco: comparing the long-term health impacts of increasing cigarette excise taxes and raising the legal smoking age to 21 in the

United States. Ahmad S(1), Billimek J.

Although many states in the US have raised cigarette excise taxes in recent

years, the size of these increases have been fairly modest (resulting in a 15%

increase in the per pack purchase price), and their impact on adult smoking

prevalence is likely insufficient to meet Healthy People 2010 objectives. This

paper presents the results of a 75-year dynamic simulation model comparing the

long-term health benefits to society of various levels of tax increase to a

viable alternative: limiting youth access to cigarettes by raising the legal

purchase age to 21. If youth smoking initiation is delayed as assumed in the

model, increasing the smoking age would have a minimal immediate effect on adult

smoking prevalence and population health, but would affect a large drop in youth

smoking prevalence from 22% to under 9% for the 15-17-year-old age group in 7

years (by 2010)-better than the result of raising taxes to increase the purchase

price of cigarettes by 100%. Reducing youth initiation by enforcing a higher

smoking age would reduce adult smoking prevalence in the long-term (75 years in

the future) to 13.6% (comparable to a 40% tax-induced price increase), and would

produce a cumulative gain of 109 million QALYs (comparable to a 20% price

increase). If the political climate continues to favor only moderate cigarette

excise tax increases, raising the smoking age should be considered to reduce the

health burden of smoking on society. The health benefits of large tax increases,

however, would be greater and would accrue faster than raising the minimum legal

purchase age for cigarettes. PMID: 16698112 [Indexed for MEDLINE]

8. Health Policy. 2018 Aug;122(8):929-935. Public support for tobacco control policies: The role of the protection of children against tobacco. Kuijpers TG(1), Willemsen MC(2), Kunst AE(3).