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Clinical AND Health Affairs
<br />JANUARY/FEBRUARY 2017 | MINNESOTA MEDICINE | 37
<br />3. Mitka M. FDA exercises new authority to regulate
<br />tobacco products, but some limits remain. JAMA.
<br />2009;302(19):2078, 2080-1.
<br />4. IOM (Institute of Medicine). Public Health
<br />Implications of Raising the Minimum Age of Legal
<br />Access to Tobacco Products. Washington, DC: The
<br />National Academies Press; 2015.
<br />5. Lenk KM, Toomey TL, Shi Q, Erickson D, Forester
<br />JL. Do sources of cigarettes among adolescents vary
<br />by age over time? J Child and Adolesc Subst Abuse.
<br />2014;23(2):137-143.
<br />6. Centers for Disease Control and Prevention.
<br />Cigarette smoking among adults—United States,
<br />1992, and changes in the definition of current
<br />cigarette smoking. MMWR Morb Mortal Wkly Rep.
<br />1994;43(19):342–6.
<br />7. Bernat DH, Klein EG, Forester JL. Smoking initia-
<br />tion during young adulthood: A longitudinal study
<br />of a population-based cohort. J Adolesc Health.
<br />2012;51(5):497-502.
<br />8. Forster J, Poupart J, Rhodes K, et al. Cigarette
<br />smoking among urban American Indian adults —
<br />Hennepin and Ramsey Counties, Minnesota, 2011.
<br />MMWR Morb Mortal Wkly Rep. 2016;65(21):534–7.
<br />9. Substance Abuse and Mental Health Services
<br />Administration. Tobacco sales to youth. Available
<br />at: http://store.samhsa.gov/shin/content//SYNAR-14/
<br />SYNAR-14.pdf. Accessed September 1, 2016.
<br />10. Silver D, Macinko J, Giorgio M, Bae JY, Jimenez G.
<br />Retailer compliance with tobacco control laws in New
<br />York City before and after raising the minimum legal
<br />purchase age to 21. Tob Control. 2015 Nov 19. pii:
<br />tobaccocontrol-2015-052547. [Epub ahead of print]
<br />11. Increasing the Sale Age for Tobacco Products to
<br />21. Campaign for Tobacco Free Kids. Available at:
<br />www.tobaccofreekids.org/what_we_do/state_local/
<br />sales_21. Accessed October 1, 2016.
<br />12. Farley SM, Coady MH, Mandel-Ricci J, et al. Public
<br />opinions on tax and retail-based tobacco control strat-
<br />egies. Tob Control. 2015 Mar;24(e1):e10-3.
<br />13. Winickoff JP, McMillen R, Tanski S, Wilson K,
<br />Gottlieb M, Crane R. Public support for raising the
<br />age of sale for tobacco to 21 in the United States.
<br />Tob Control. 2016 May;25(3):284-8.
<br />14. King BA, Jama AO, Marynak KL, Promoff GR.
<br />Attitudes toward raising the minimum age of sale
<br />for tobacco among U.S. adults. Am J Prev Med.
<br />2015;49(4):583-8.
<br />15. Vuolo M, Kelly BC, Kadowaki J. Independent and
<br />interactive effects of smoking bans and tobacco taxes
<br />on a cohort of US young adults. Am J Public Health.
<br />2016;106(2):374–80.
<br />16. Gielen AC, Green LW. The impact of policy, envi-
<br />ronmental, and educational interventions: a synthesis
<br />of the evidence from two public health success sto-
<br />ries. Health Educ Behav. 2015;42(1S):20S-34S.
<br />strongly to smoking bans than to other
<br />types of tobacco control15 in part because
<br />a ban is an unambiguous anti-tobacco
<br />message that indirectly influences social
<br />norms, creating a social environment
<br />that discourages health-risk behavior.16
<br />Put differently, the effects of Tobacco 21
<br />policy would extend into the future as new
<br />cohorts of young people do not start using
<br />tobacco.
<br />Our analysis considered only cigarette
<br />smoking; but a Tobacco 21 policy would
<br />apply to all tobacco products. Whether the
<br />effects of raising the purchasing age to 21
<br />would be similar across all demographic
<br />and racial/ethnic groups is not known.
<br />Similar to the IOM, we did not adjust the
<br />Minnesota estimate for any variation by
<br />demographics other than age. This ques-
<br />tion should be examined when there is
<br />sufficient data on communities that have
<br />implemented the policy.
<br />Conclusion
<br />Raising the minimum sale age for tobacco
<br />to 21 would prevent the uptake of smoking
<br />among youth and young adults, subse-
<br />quently reducing smoking prevalence over
<br />time. Applying national estimates from the
<br />2015 IOM report to Minnesota, we found
<br />that implementing a Tobacco 21 policy
<br />could have a marked impact on smok-
<br />ing initiation among Minnesota’s young
<br />people. Tobacco 21 should be considered
<br />an effective strategy for reducing smok-
<br />ing initiation. Preventing smoking among
<br />youth remains a primary focus for reduc-
<br />ing morbidity and mortality as well as pro-
<br />moting health across the lifespan. MM
<br />Raymond Boyle is director of research programs
<br />for ClearWay Minnesota. John Kingsbury and
<br />Michael Parks are research scientists for the
<br />Minnesota Department of Health.
<br />REFERENCES
<br />1. Boyle RG, Amato MS, Rode P, Kinney AM, St.
<br />Claire AW, Taylor K. Tobacco use among Minnesota
<br />adults, 2014. Am J Health Behav. 2015;39(5):674-9.
<br />2. Johnston LD, O’Malley PM, Miech RA, Bachman
<br />JG, Schulenberg JE. Monitoring the Future National
<br />Survey Results on Drug Use, 1975-2015: Overview,
<br />key findings on adolescent drug use. Ann Arbor:
<br />Institute for Social Research, The University of
<br />Michigan. 2016. Available at: www.monitoringthefu-
<br />ture.org/pubs/monographs/mtf-overview2015.pdf.
<br />Accessed September 3, 2016.
<br />Of those who finished high school with-
<br />out initiating smoking, 10,368 will begin
<br />smoking between ages 18 and 21. Under a
<br />Tobacco 21 policy, 1,555 fewer young peo-
<br />ple would start smoking after high school.
<br />Overall, 3,355 fewer young people would
<br />start smoking in this cohort of youth if a
<br />Tobacco 21 policy were in effect (see Fig-
<br />ure). In other words, increasing the sale
<br />age to 21 would increase the proportion
<br />of nonsmokers in a cohort of 15-year-olds
<br />from 76% to 80%.
<br />Discussion
<br />Increasing the sale age to purchase tobacco
<br />products from 18 to 21 would have a posi-
<br />tive effect on Minnesota, where tobacco
<br />use remains popular among young adults.1
<br />Given that almost 95% of smokers start
<br />smoking by age 21, raising the age of sale
<br />to 21 years would prevent the vast majority
<br />of young people from becoming addicted
<br />to the nicotine in tobacco.
<br />At least 200 localities in 14 states have
<br />raised the minimum legal sale age for
<br />tobacco products to 21 years.11 Notably,
<br />Hawaii was the first state (2015) followed
<br />by California (2016), and New York City
<br />(2013) is the largest city to adopt a To-
<br />bacco 21 policy. This policy has broad
<br />support and is viewed positively by both
<br />smokers and nonsmokers. In New York
<br />City, 60% of smokers and 69% of non-
<br />smokers have supported the age increase.12
<br />In a national sample of adults, 70.5% sup-
<br />ported the increase.13 And in an online
<br />survey, 77.5% of never smokers and 70%
<br />of current smokers either strongly favored
<br />or somewhat favored raising the legal pur-
<br />chasing age to 21.14
<br />We acknowledge that some young
<br />people will begin using tobacco at a later
<br />age. The amount is unknown; but even if
<br />5% eventually take up smoking, this would
<br />not diminish the overall effect of Tobacco
<br />21 policy. In addition, while we have
<br />highlighted how Tobacco 21 would inhibit
<br />more than 3,300 youth from initiating
<br />smoking, it is important to note the policy
<br />could have additional and more indirect
<br />benefits. Youth tend to respond more
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