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a special susceptibility to even
<br />experimental tobacco use.
<br />1 Low
<br />minimum sales age laws exploit
<br />that susceptibility to addict youths
<br />to cigarettes for life, with relatively
<br />few cigarettes. Meanwhile, raising
<br />the sales age would appear likely
<br />to have a significant effect on
<br />current tobacco use rates among
<br />youths, decreasing the chances of
<br />a person ever becoming tobacco
<br />dependent. By some estimates,
<br />raising the tobacco sales age to 21
<br />years would reduce tobacco use
<br />prevalence by 55% for 15- to
<br />17-year-old adolescents within
<br />7 years.
<br />16
<br />In 2005, Needham, Massachu-
<br />setts, was the first town in the
<br />country to implement the law to
<br />raise the tobacco sales age to 21
<br />years. Following the implementa-
<br />tion of the law, the Youth Risk
<br />Behavior Surveillance System
<br />and Metro West Health Founda-
<br />tions’Adolescent Health survey
<br />data showed a 47% reduction in
<br />Needham high-school smoking
<br />rate in the 4 years (2006---2010)
<br />after the legislation was imple-
<br />mented.17 Of note, no tobacco re-
<br />tailers have gone out of business in
<br />Needham since implementation.
<br />LIMITATIONS
<br />Although we have not spe-
<br />cifically accounted for other non-
<br />cigarette tobacco or smokeless
<br />tobacco sales, we have accounted
<br />for any tobacco that is smoked and
<br />self-reported as a cigarette, the
<br />form that has the highest disease
<br />burden. According to the Centers
<br />for Disease Control and Preven-
<br />tion’s Morbidity and Mortality
<br />Weekly Report, about 90% of all
<br />combustible tobacco consumption
<br />is cigarettes among adult smokers.
<br />18
<br />In addition, 2012 National Youth
<br />Tobacco Survey data indicate that
<br />the majority of tobacco consump-
<br />tion remains cigarettes, and high-
<br />school students in the young adult
<br />age range (>17 years) are 3 times
<br />more likely to smoke cigarettes
<br />daily than use any other combina-
<br />tion of cigars, bidis, and cigarillos
<br />on a daily basis.
<br />Adult versus youth smokeless
<br />tobacco use rates and amount
<br />consumed are much harder to
<br />quantify and we intentionally ex-
<br />cluded these to avoid reporting
<br />bias. In addition, the US retail
<br />cigarette market is more than 30
<br />times greater than the smokeless
<br />tobacco market, making any adult
<br />versus youth consumption dis-
<br />crepancy unlikely to change our
<br />overall estimate of the tobacco
<br />sales impact.
<br />19
<br />CONCLUSIONS
<br />Overall, a small percentage
<br />of total tobacco sales (2%) is at-
<br />tributed to those younger than
<br />21years, yet most lifetime tobacco
<br />users start smoking before the
<br />age of 21 years. Early tobacco
<br />initiation during young adulthood
<br />comes with a high probability of
<br />addiction, progression to daily
<br />smoking, and heavier tobacco use
<br />in adulthood, and has long-term
<br />harmful health consequences.
<br />Action on this critical issue of raising
<br />the minimum tobacco sales age to
<br />21 years across the United States
<br />has excellent public health and
<br />ethical rationales, and costs almost
<br />nothing to implement through
<br />existing regulatory frameworks.j
<br />About the Authors
<br />Jonathan P. Winickoff, Minghua L. Chen,
<br />and Emara Nabi-Burza are with the
<br />Center for Child and Adolescent Health
<br />Research and Policy, Division of General
<br />Academic Pediatrics, Massachusetts
<br />General Hospital for Children, Boston.
<br />Lester Hartman is with Westwood/
<br />Mansfield Pediatrics, Westwood, MA.
<br />Mark Gottlieb is with the Public Health
<br />Advocacy Institute, Northeastern Univer-
<br />sity School of Law, Boston. Joseph R.
<br />DiFranza is with the Department of Family
<br />Medicine and Community Health, Univer-
<br />sity of Massachusetts Medical School,
<br />Worcester, MA.
<br />CorrespondenceshouldbesenttoJonathan
<br />P. Winickoff, MD, MPH, Center for Child
<br />and Adolescent Health Research and Policy,
<br />Division of General Academic Pediatrics,
<br />MassachusettsGeneralHospitalforChildren,
<br />15th Floor, Suite 1542A, 100 Cambridge
<br />St, Boston, MA 02114 (e-mail: jwinickoff@
<br />partners.org). Reprints can be ordered at
<br />http://www.ajph.orgbyclickingthe “Reprints”
<br />link.
<br />This article was accepted June 26,
<br />2014.
<br />Contributors
<br />J. P. Winickoff originated and designed
<br />this study, drafted the article and revised
<br />it, and takes full responsibility for the
<br />final submission. L. Hartman, M. Gottlieb,
<br />E. Nabi-Burza, and J. R. DiFranza made
<br />substantial intellectual contributions to
<br />the conceptualization and design of the
<br />study, and to editing the article. M. L.
<br />Chen advised on and conducted data
<br />analyses, and participated in the inter-
<br />pretation of results. All authors approved
<br />the final article as submitted.
<br />Acknowledgments
<br />This study was supported by the Na-
<br />tional Institutes of Health, National
<br />Cancer Institute grant R01-CA127127
<br />(J. P. Winickoff) and 2R01-CA087571
<br />(M. Gottlieb), the National Institute on
<br />Drug Abuse, and the Agency for Health-
<br />care Research and Quality.
<br />Note.The funders had no role in the
<br />design or conduct of the study, analysis
<br />and interpretation of the data, or prepa-
<br />ration, review and approval of the article.
<br />HumanParticipantProtection
<br />This study was exempt from institutional
<br />review board approval because it is a
<br />secondary data analysis of a publicly
<br />available data set.
<br />References
<br />1. DiFranza JR, Wellman R, Mermelstein
<br />R, et al. The natural history and diagnosis
<br />of nicotine addiction.Curr Pediatr Rev.
<br />2011;7:88---96.
<br />2. Zhan W, Dierker LC, Rose JS, Selya
<br />A, Mermelstein RJ. The natural course of
<br />nicotine dependence symptoms among
<br />adolescent smokers.Nicotine Tob Res.
<br />2012;14(12):1445---1452.
<br />3. Taioli E, Wynder EL. Effect of
<br />the age at which smoking begins on
<br />frequency of smoking in adulthood.
<br />N Engl J Med. 1991;325(13):968---969.
<br />4. US Department of Health and
<br />Human Services. Preventing tobacco use
<br />TABLE 2—Average Cigarette Consumption by Age for Current Smokers and Percentage of 18- to 20-Year-Old Smokers as a Percentage
<br />of Total Adult Cigarette Consumption: 2011 National Health Interview Survey, United States
<br />Variable
<br />All Participants Aged ‡18 Years,
<br />Mean of No.
<br />Participants Aged
<br />18–20 Years
<br />Participants
<br />Aged ‡21 Years
<br />Participants Aged 18–20 Years,
<br />% of Total Sample
<br />Average daily cigarette consumption per smoker 12.38 8.57 12.50
<br />Average annual cigarette consumption per smoker 4520.28 3131.62 4564.16
<br />No. of current smokers 6138 188 3.06
<br />Total no. of cigarettes smoked in 2011 27745475 588745 2.12
<br />Note. Current smokers included both daily and nondaily users, and lifetime consumption of greater than 100 cigarettes. The same size was n=33014 participants, including n=6138 current
<br />smokers; 18.6% of the population reported lifetime use of greater than 100 cigarettes and some level of current use.
<br />PUBLIC HEALTH POLICY BRIEFS
<br />e20 |Public Health Policy Briefs |Peer Reviewed |Winickoff et al.American Journal of Public Health |November 2014, Vol 104, No. 11
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