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Abstract
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.
- End game
- Public opinion
- Prevention
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Tobacco is the leading cause of preventable disease and death in the USA.1 Almost all adult tobacco users started before the age of 21 and the majority of those begin during the high school years.2 Initiating cigarette smoking during adolescence rather than in early adulthood is more likely to lead to addiction and daily smoking.2 ,3 Moreover, many adults who purchase cigarettes for distribution to minors are under 21.4 High school students are less likely to have 21-year-olds than 18-year-olds in their social circles, suggesting reduced opportunities to access tobacco from older buyers.5 Raising the age of sale for tobacco has the potential to break this distribution cycle by reducing minors’ ability to buy from other high school students.
Although this approach may reduce tobacco sales in the long term, raising the age of sale would have a minimal initial impact on sales and overall tobacco tax revenue. A very small percentage of total tobacco sales, perhaps as little at 2% are attributed to the 18–20-year-old age group6 yet almost 90% of smokers in the USA began smoking before the age of 21.2
In recognition of the opportunity to prevent the majority of future tobacco use, the American Medical Association passed a 1986 resolution supporting raising the age of sale to 21, equal to that of alcohol. Efforts to achieve an age of tobacco sale of 21 were not successful at any level of government until Needham, Massachusetts, USA passed and enforced a minimum age of tobacco sale (‘tobacco 21’) regulation in 2005. Over the next 5 years, the high school smoking rate in Needham dropped by 47%, much more rapidly than a comparison group of 16 surrounding communities. Public health advocates have followed Needham's example in 2013 and 2014, succeeding in raising the age of sale of tobacco products to 21 in 33 cities and towns in Massachusetts, New York City, Suffolk County New York, USA, as well as the Big Island of Hawaii. Outside of the US, only Sri Lanka and Kuwait have raised the minimum age to 21 and Japan has raised it to 20. The WHO Framework Convention on Tobacco Control supports measures to prohibit the sales of tobacco products to persons under the age for minors as set by national law or 18, but does not specifically address raising the age beyond 18.7
With the exception of polls conducted in various states, no published studies exist about levels of public support for raising the age of sale to 21. Understanding what the public believes about this regulatory action will provide important political context as different local and state governments begin to consider these policy initiatives. Using a nationally representative sample, we examined overall levels of support for raising the age of sale to 21 as well as how levels of support varied by smoking status, sex, race, education and geographic region. We included these demographic predictors in order to determine whether support for this policy was stronger among some populations than others. Specifically, our research has found several issues for which smokers, white adults, males, adults with lower levels of education demonstrate lower levels of support for tobacco control policies.8–10 We also looked at levels of support among the critical 18–20-year-old demographic, the group who would be directly affected by such regulations.
Methods
Data presented in this study are from the nationally representative Social Climate Survey of Tobacco Control (SCS-TC), an annual cross-sectional survey dating from 2000 to the present. This survey applied a random-digit-dialing (RDD) sample frame of households with landline telephones from 2000 through 2009. However, wireless substitution of cell phones for landlines continues to increase, and 38% of US adults are currently wireless only.11 To address this increasing source of non-coverage bias, we added an additional probability-based internet panel frame to the SCS-TC in 2010. We continued to use an RDD frame to maintain compatibility with the SCS-TC from the previous 10 years. As recommended by guidelines for dual frame surveys, weighting adjustments were made for conditions in which these frames overlap and a respondent could be represented in both frames.12
Data from this study are from the cross-sectional dual-frame surveys representing national probability samples of adults administered to both frames from October to December 2013. The RDD frame included households with listed and unlisted landline telephones; five attempts were made to contact those selected adults who were not home. The Survey Research Laboratory at Mississippi State University's Social Science Research Center administered the surveys via computer-assisted telephone interviews to respondents in this frame. The probability-based panel frame included an online survey administered to a randomly selected sample from a nationally representative research panel.13 ,14 This panel is based on a sampling frame which includes both listed and unlisted numbers, those without a landline telephone and does not accept self-selected volunteers,13 ,14 and provides sample coverage for 99% of US households.15 The Institutional Review Board (IRB) at Mississippi State University approved this study, and informed verbal consent was obtained and the IRB provided a waiver of documentation of the written consent process. Data were weighted to adjust for age, race, gender and region, as well as frame overlap among internet panel respondents who also had a landline telephone and were therefore also eligible for the RDD frame. Specific details of the weighting of the merged frames had been provided in previous research.16
Age of sale for tobacco and other attitudes
Respondents were presented with the following statement, ‘The age to buy tobacco should be raised to 21,’ and then asked if they strongly agree, agree, disagree or strongly disagree with this statement. In order to simplify the interpretation of results, respondents who reported strongly agree or agree were coded as supportive of raising the age of sales for tobacco products; those who reported disagree or strongly disagree were coded as unsupportive. Four items assessed beliefs about cigarette experimentation and addiction. Respondents indicated whether they strongly agree, agree, disagree or strongly disagree with the following statements; (1) experimenting with cigarettes is a part of growing up, (2) it is important that adolescents and young adults never experiment with tobacco, (3) people can become addicted to nicotine even after smoking just a few cigarettes and (4) even one dose of nicotine or smoking one cigarette can change brain chemistry. In order to simplify the interpretation of results, respondents who reported strongly agree or agree were coded as supportive of raising the age of sales for tobacco products; those who reported disagree or strongly disagree were coded as unsupportive.
Cigarette smoking status and age of first use
Respondents were asked, ‘Have you smoked at least 100 cigarettes in your entire life?’ Respondents who reported that they had were then asked, ‘Do you now smoke cigarettes every day, some days, or not at all?’ Respondents who reported that they have smoked at least 100 cigarettes and now smoke every day or some days were categorised as current smokers. Current smokers were asked about when they started smoking regularly: ‘How old were you when you first started smoking fairly regularly?’
Analyses
Data for overall and subpopulation support for raising the age of sales for tobacco products were examined. We used bivariate χ2 analyses and multivariable logistic regression to explore demographic factors associated with support for raising the age of sale to 21 years of age. Non-responses to specific items were treated as system missing data and excluded from analyses.
Results
Sample characteristics
Table 1 shows the demographic characteristics of the overall sample. In the RDD frame, of 1689 eligible respondents contacted, 1552 completed surveys (completion rate, 91.9%). For the internet panel frame, 2667 panellists were randomly drawn from the probability panel; 1693 responded to the invitation, yielding a final stage completion rate of 63.5%.17 The total sample consisted of 3245 US adults. Length of time on the panel for the internet panel frame ranged from 0.12 to 13.97 years, with a median length of time on the panel of 2.16 years.
Sample characteristics
Support for raising age of sale for tobacco to 21
The majority of adults support raising the age of sale for tobacco to 21 (70.5%). Support did not differ across the RDD and panel frames. This majority support persisted across smoking status, geographic region, race, sex, education and age—including adults aged 18–20 (see table 2). However, χ2 analyses revealed that support did vary across demographic characteristics and attitudes about cigarettes and addiction. Support was stronger among non-smokers, adults living outside of the West Census region, older adults and females.
Support for raising the age of sales to 21 years of age
Although adults with lower levels of education have higher rates of smoking,18 these adults demonstrated higher levels of support for raising the age of sale to 21. Rates of support also varied by race with over 80% of blacks surveyed in support of raising the tobacco sales age. Support was also higher among adults who recognised the risks of youth experimenting with cigarettes and addiction.
Among smokers in the sample (n=457), there was majority support across all age groups of smoking initiation, however, the highest level of support (67%) was reported by smokers who initiated smoking between the ages of 18 and 20 (n=100). Conversely, adult smokers currently 18–20 years of age demonstrated the lowest support (n=14). Although the number of smokers aged 18–20 was low, this was the only demographic category for which a majority did not support this policy. Only one of the 14 smokers between the ages of 18 and 20 supported raising the age of sale to 21.
In multivariable analyses, support was found to be higher among never smokers, females, African-Americans and older adults (see table 3). Support was also higher among adults agreeing that it is important that adolescents and young adults never experiment with tobacco, that people could become addicted to nicotine even after smoking just a few cigarettes, and even one dose of nicotine or smoking one cigarette can change brain chemistry.
Logistic regression
Discussion
In this study we demonstrated strong majority support across numerous demographic categories, including those age 18–20 who would be directly impacted by this regulation. Notably, support was found among smokers themselves, who often regret that they ever began smoking.19 We also found higher support in adults with lower levels of education, a population that has substantially higher rates of smoking. Overall, African-Americans, a group that suffers disproportionately from diseases caused by tobacco,20–22 demonstrated the highest support for raising the age of sale.
Perhaps the most intriguing findings involve the 18–20 year olds—the cohort that would be directly impacted by this policy. The majority of these young adults supported raising the age of sale for tobacco. However, level of support was lower than that of other age groups; and 18–20 year old smokers did not support this policy. Despite this lack of support among young adult smokers, those smokers who had initiated smoking between 18 and 20 demonstrated the highest level of support among smokers. It is possible that older smokers have come to regret that they were able to purchase tobacco at a young age.
Policymakers interested in enacting regulations to raise the age of sale for tobacco can use these data to protect public health with the firm knowledge of majority support for their actions. Our data suggest that increasing public awareness about the addictive potential of even just a few cigarettes might increase support for raising the tobacco sales age. Although denormalising tobacco experimentation as part of growing up might theoretically bolster support for increasing the tobacco sales age to 21, attitudes about experimentation were not predictive of support in these logistic regression analyses.
Despite strong public support for this initiative, there remain objections from tobacco retailers and the tobacco industry. Most of these industry objections lack credibility on close scrutiny. One widely promulgated argument involves immediate loss of revenue, lost sales tax revenue for states and municipalities and job loss. However, the short-term costs are likely to be quite small, as tobacco sales to people between the ages of 18 and 20 only account for 2–3% of all tobacco sales.6 It should be noted that when Needham raised the tobacco age of sale to 21, none of the 12 tobacco retailers in the town went out of business. Although sales would decrease over time as the overall prevalence of adult tobacco use declined, businesses would have ample time to address a gradual change to their tobacco business.6 Concerns about enforcement and associated costs are also raised. However, current Food and Drug Administration policy requires retailers to check the ID of anyone attempting to purchase tobacco who appears to be under the age of 27. The agency conducts enforcement actions in every state and lists retailers that fail to check the ID of tobacco purchasers under the age of 27.23 Raising the minimum age for sales of tobacco to be consistent with alcohol could actually reduce the retailer's burden. In many states, driver's licenses for those under 21 look different than for those over 21. In addition, the Synar Amendment, which requires states to establish and enforce laws prohibiting the sale of tobacco to minors, provides states with substantial federal block grants tied to enforcing existing state youth access laws and requiring compliance checks for tobacco sales.24 Local compliance testing protocols can easily be modified to measure tobacco 21 compliance rates.
One frequently expressed objection to raising the age of sale of tobacco involves violation of the Equal Protection Clause of the US Constitution for young adults old enough to vote and provide military service. However, US courts have generally supported age restrictions that are rationally related to a legitimate government interest, such as protecting public health and preventing youth access to tobacco.25–28 Reducing youth access to tobacco will put fewer youth at risk for lifelong nicotine dependence partly because the developing brain appears to be especially susceptible to rapid addiction.2 Furthermore, legal precedents abound for age restrictions for young adults. The sale of alcohol, participation in casino gambling in most states, purchase of recreational marijuana in the states where it is legal, and application for a license to carry a handgun are each restricted to adults 21 years of age and older. The marketplace also often restricts car rentals to adults 25 and older and many hotels also have age restrictions. These facts and precedents make legal challenges unlikely to be successful.
This study has at least two limitations. First, we designed our dual frame methodology to reduce the potential for sample bias associated with either RDD or internet panel samples alone, but we still cannot eliminate the potential for non-coverage bias. Also, the use of the internet panel raises some concern about the representativeness of the sample. However, several studies demonstrate that this probability-based panel can produce results similar to well-designed RDD surveys29 ,30 and our use of this dual frame methodology produced estimates for current smoking that did not differ from those of several large, government surveys of US adults.16 We examined the validity of this dual-frame approach to reduce non-coverage bias in tobacco surveys in a previous study.16 We assessed the comparability of self-reported smoking prevalence estimates from our 2010 dual-frame survey with those from the 2010 National Health Interview Survey (NHIS) and the 2009–2010 National Health and Nutrition Examination Survey (NHANES). These are both large-scale national surveys and serve as the principal sources of information about tobacco use in the US population. We found that our estimates of self-reported smoking were within the CIs of those from both the NHIS and NHANES. This finding applied to overall estimates and those for gender, race and age.
Second, these data are self-report, and we could not verify that responses concerning age and cigarette smoking were not misrepresented. Studies comparing self-reported and biochemically assessed cigarette smoking, however, have supported the validity of self-reported cigarette smoking.31
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.
What this paper adds
This is the first paper to describe the level of public support nationally for raising the tobacco sales age to 21.
Findings demonstrate that the majority of adults in every demographic and smoking status category supported raising the tobacco sales age to 21.
Demonstrated 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.
References
Footnotes
Correction notice This article has been corrected since it was published Online First. The middle initial for author ‘Jonathan G Winickoff’ has been corrected from G to P. On page 3, an addition was made to the sentence ‘Our data suggest that increasing public awareness about the addictive potential of even just a few cigarettes might increase support for raising the tobacco sales age.’
Twitter Follow Mark Gottlieb at @MisterGottlieb and Rob Crane at @tobacco21
Contributors RM and JGW were responsible for drafting of the manuscript and for data analysis. All authors participated in the conceptual development, the study design, the writing and editing of the article. All authors read and approved the final manuscript.
Funding This work was supported by the Flight Attendant Medical Research Institute grant number 052302, Legacy grant number 6033, and the National Cancer Institute grant number R01-CA127127. The information, views and opinions contained herein are those of the authors and do not necessarily reflect the views and opinions of these organisations.
Competing interests None.
Ethics approval Institutional Review Board of Mississippi State University.
Provenance and peer review Not commissioned; externally peer reviewed.