Article Text
PDF
Statistics from Altmetric.com
Introduction
In 2015, the US Institute of Medicine (IOM) concluded that raising the minimum legal sales age for tobacco products to 21 nationally would result in 223 000 fewer premature deaths, 50 000 fewer deaths from lung cancer and 4.2 million fewer years of life lost for individuals born between 2000 and 2019.1 Despite the IOM’s findings, no federal policy has been enacted, leaving inherent gaps in coverage between and within the states of USA. State and local ‘Tobacco 21’ policies could close the gaps, however significant barriers have included lawsuits leading to delayed policy implementation, governors and mayors vetoing policies, and state-imposed pre-emption of local authority (in 20 states).2 3 Gaps in coverage may exacerbate inequities in access to tobacco products in areas where the burden of tobacco-related illness is greatest, such as the southern states of USA.4 5 For the first time, this research estimates how many youth are and are not protected by Tobacco 21, separately for ages 18–20 (who have previously been able to purchase tobacco) and ages 15–17 (for whom the policy presumably restricts access through social sources).
Methods
Policy data were obtained in January 2019 from the Campaign for Tobacco-Free Kids, who maintains comprehensive policy data from regional advocacy directors as well as reports from press and technical partners.6 Data on pre-emption laws were obtained from the US Centers for Disease Control and Prevention.7
Merging the Tobacco 21 policy data to population data from the American Community Survey 2012–2016 required creating a crosswalk for jurisdictions. We used Census 2010 block and Census 2012–2016 block group data for population estimates in jurisdictions where county policies applied only to unincorporated areas (Illinois, Kansas, Mississippi, Missouri), and where Tobacco 21 communities were not classified as a Census Designated Place (Barrington, Rhode Island). We report the number and per cent of residents (ages 18–20 and 15–17) covered by Tobacco 21 for the entire USA, and by state and Census region.
Results
Overall, 9.7 million (72.1%) residents ages 18–20 were not yet covered by a Tobacco 21 policy in 2018 (figure 1). As of January 2019, six state policies (California, Hawaii, Maine, Massachusetts, New Jersey, Oregon) and the District of Columbia protected 2.6 million residents aged 18–20 and an additional 144 local ordinances in 16 states without state policies protected 1.1 million residents aged 18–20. Gaps in policy coverage were 40.4% in the West, 45.1% in the Northeast, 84.2% in the Midwest and 97.9% in the South. Among states with any local Tobacco 21 policies but no statewide policy, New York covered the largest proportion of residents aged 18–20 (71.1%); Arkansas, Alaska, Arizona, Colorado and Mississippi covered the smallest proportion (<1%). State pre-emption of local age restriction policies jeopardises the coverage of 5.5 million residents aged 18–20 across 20 states. An online appendix summarises state-level data by age group (15–17 and 18–20).
Supplemental material
Tobacco 21 policy coverage across the USA (January 2019). Grey dots indicate the number of residents aged 18–20 and green areas indicate where state and local tobacco 21 exist.
Discussion
The vast majority of US residents aged 18–20 were not covered by a Tobacco 21 policy as of January 2019. The largest gaps in coverage exist in the South, where adult tobacco use is higher than the national average (26.0% vs 24.2% in 2017),8 and a greater proportion of cancer deaths are attributed to smoking.9
A nationwide Tobacco 21 policy, as adopted in countries such as Japan, Thailand and Uzbekistan,10 would close gaps in coverage. National coverage would make evasions through cross-border purchases across state lines or on tribal lands impossible (limiting concerns to international borders, internet sales and identifying illegal sellers). In addition to reducing regional/state inequity in smoking-related morbidity and mortality, coverage could also extend to sales of tobacco products to US Active Duty Military personnel and retailers on American Indian/Alaskan Native tribal lands, thus potentially impacting the higher smoking rates among these populations.11 12 However, a national policy that pre-empts state and local authorities from passing further restrictions on the retail environment for tobacco or other local tobacco control measures could severely inhibit these jurisdictions from making progressive-advances towards ‘endgame’ goals, such as further increasing age restrictions.13 Effectiveness also at least partially depends on whether a policy is implemented in an environment with sufficient funding for education of retailers and monitoring of retailer compliance, as well as cessation services for smokers impacted by the policy.14 Currently, only the US Congress has the federal authority to set a minimum legal sales age for tobacco; it is also possible for Congress to incentivise states to raise purchasing ages to 21, as they have done with alcohol purchasing policies in 1984.
Future research on the coverage of Tobacco 21 policies in the USA could estimate the impact that gaps in coverage have on exacerbating inequities in morbidity and mortality, both across states and regions as well as sociodemographic variables. Studies could also address the extent to which gaps in Tobacco 21 mirror gaps in other tobacco control policies, such as weaker smoke-free air policies, lower taxes or below-average tobacco control spending.
Footnotes
Contributors ECL had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: ECL, LH. Acquisition, analysis or interpretation of data: All authors. Drafting of the manuscript: ECL, AR, LH, MM. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: ECL, NCS, AR. Obtained funding: LH. Supervision: LH.
Funding This work is supported by NIH grant P01-CA225597 from the National Cancer Institute. ECL was supported by NIH grant T32-HL007034 from the National Heart, Lung and Blood Institute.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.