States, cities raising their minimum age for tobacco sales to 21: Protecting youth
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* Lindsey Wahowiak

New measures that can protect health and prevent potential smokers from lighting up are catching fire across the country. At the center of that work is a tactic that is growing in popularity: reevaluating the age at which consumers can purchase tobacco.

On June 9, California became the second state to restrict the sale of tobacco products to those 21 years old and up, an increase from its former 18-and-up law. For the first time, the state included electronic cigarettes and other vaping products in its definition of tobacco products as well. The restrictions were signed into law by Gov. Jerry Brown on May 4.

The law is making waves, as the state has 240,000 people ages 18 to 20 who smoke, said April Roeseler, MSPH, branch chief of the California Tobacco Control Program with the California Department of Public Health. And 34,000 people die each year from smoking-related diseases in the state.

A 2014 U.S. surgeon general report, “The Health Consequences of Smoking: 50 Years of Progress,” showed that 98 percent of U.S. smokers started smoking by age 26, and 87 percent started before they turned 18. The report suggested several measures, such as increasing taxes on tobacco products, to keep them out of young people’s hands. With substantial science on its side, the 21-and-up movement is picking up steam.

To ready California’s 34,000 licensed tobacco retailers for the restrictions, the department created and distributed educational materials, including an ID checking guide, a fact sheet, window clings and other signage. Roeseler said that while retailers had many questions about the restrictions at first, the new law is easier to enforce than the previous 18-and-up law: Drivers’ licenses for those under 21 are vertical, so they are easy to spot.

“In California, the ID checking just got so much simpler,” Roeseler told *The Nation’s Health.* “We are harmonizing this law with the alcohol product laws. They already know how to check for alcohol.”

California’s law is not the first of its kind: Hawaii enacted the first statewide 21-and-up tobacco law on Jan. 1. Spurred by evidence that such measures can help stem youth smoking, more than 170 municipalities nationwide have already enacted similar laws as of July.

Needham, Massachusetts, was the first city in the U.S. to raise its tobacco purchasing age to 21, gradually from 2005 to 2008. In subsequent youth risk behavior studies, researchers found that the city’s teen smoking rates dropped by 50 percent, said Rob Crane, MD, president of the Preventing Tobacco Addiction Foundation, authors of the Tobacco 21 project.

“Others had dropped some (over the same time period), but Needham just jumped off the page,” Crane, an APHA member, told *The Nation’s Health.* “There was a two-thirds reduction in kids who smoked every day.”

Once the results of Needham’s increase were published, other localities started to enact their own laws. In Massachusetts, more than 100 cities and towns, including Boston, have raised their tobacco purchasing age to 21. Other major cities, including New York City, Cleveland, Chicago and Kansas City, Missouri, have done the same. Massachusetts is considering a state-wide increase, and legislation has been passed by New Jersey legislative bodies.

Even though the national legal tobacco purchasing age is 18 — thus not allowing most teens to use the products —21-and-up laws protect younger teens, according to a 2015 Institute of Medicine report. “Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products” concluded that the increase has the greatest impact on teens ages 15 to 17.

“The parts of the brain most responsible for decision making, impulse control, sensation seeking and susceptibility to peer pressure continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine,” the report said. “In addition, the majority of underage users rely on social sources, like family and friends, to get tobacco.”

John Schachter, director of state communications at the Campaign for Tobacco-Free Kids, said eliminating the chance of youth getting tobacco products from their friends can “really make an impact.”

“If we can keep you from smoking when you’re a kid, then the odds are incredibly high that you will never smoke,” Schachter told *The Nation’s Health.*

The numbers add up: According to the IOM report, if the minimum legal age were raised to 21 nationally, estimates show there would be 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer and 4.2 million fewer years of life lost for people born between 2000 and 2019.

Public health is taking a strong stance in making sure increased tobacco purchasing age laws are enforced. In Boston, the city’s board of health enacted its 21-and-up tobacco regulation in December. Nikysha Harding, MPH, director of the Boston Public Health Commission’s Tobacco Prevention and Control Program, and three regulators work to enforce the regulation, as well as Boston’s smoke-free workplace regulations. For the city’s 21-and-up regulation, Harding’s team had 60 days to educate retailers, via mailings and educational visits to the city’s 830 tobacco retailers, before it started to do compliance inspections, for both signage and actual sales of the products, she told *The Nation’s Health.*

Part of strong enforcement is knowing what to look out for, said Margaret Reid, RN, MPA, director of the Division of Healthy Homes and Community Supports with the Boston Public Health Commission. Boston started regulating e-cigarettes in 2011, but while those are gaining in popularity across the country — and in Boston, where 5 to 6 percent of teens report using the products — the city’s youth are more likely to buy small, flavored cigars, at 21 percent.

Nationally, nearly twice as many teens report using e-cigarettes than those who report using cigarettes, according to the Centers for Disease Control and Prevention. But 73 percent of high schoolers and 56 percent of middle schoolers who had used a tobacco product in the past 30 days had used a flavored one.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/46/6/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/46/6/1.2/F1)

A smoke shop in lower Manhattan displays a sign in June declaring New York City’s tobacco restrictions. States and cities are passing laws and regulations that prevent people younger than 21 from buying tobacco products.

Photo courtesy Stephanie Vallejo

“The biggest impact would be if we got rid of the cigars,” Reid told *The Nation’s Health.* “At the same time we passed the 21 law, we passed a flavor regulation.”

The California Department of Public Health is working on a similar program to help retailers comply with the state’s new law, including age-of-sale warning signs, window clings for shops and tipsheets to help clerks check identification.

Public health’s enforcement of 21-and-up regulations are more than advocates walking the walk — they are opportunities to promote efforts supported by the public. June research from the University of North Carolina at Chapel Hill and East Carolina University showed that most adults support increasing the minimum legal age for tobacco product sales, and that most support increasing the age to 21, rather than 19 or 20.

“It’s surprisingly well received by local politicians and thought leaders” as well as voters, Crane told *The Nation’s Health.* “The public both understands and supports 21. It’s not a difficult sell.”

For more on 21-and-up tobacco laws and regulations, visit [www.tobacco21.org](http://www.tobacco21.org). For more on APHA’s tobacco advocacy and other resources, visit [www.apha.org/tobacco](http://www.apha.org/tobacco).

*   Copyright The Nation’s Health, American Public Health Association