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Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
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Public Health Implications of
Raising the Minimum Age
of Legal Access to
Tobacco Products

Committee on the Public Health Implications of
Raising the Minimum Age for Purchasing Tobacco Products

Board on Population Health and Public Health Practice

Richard J. Bonnie, Kathleen Stratton, and Leslie Y. Kwan, Editors

INSTITUTE OF MEDICINE
             OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract/Grant No. HHSF22301031T between the National Academy of Sciences and the Department of Health and Human Services: Food and Drug Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.

International Standard Book Number 13: 978-0-309-31624-8
International Standard Book Number-10: 0-309-31624-3
Library of Congress Catalog Card Number: 2015942038

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Suggested citation: IOM (Institute of Medicine). 2015. Public health implications of raising the minimum age of legal access to tobacco products. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

Knowing is not enough; we must apply.
Willing is not enough; we must do.
”      

                                                        —Goethe

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INSTITUTE OF MEDICINE
       OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

COMMITTEE ON THE PUBLIC HEALTH
IMPLICATIONS OF RAISING THE MINIMUM AGE
FOR PURCHASING TOBACCO PRODUCTS

RICHARD J. BONNIE (Chair), Harrison Foundation Professor of Medicine and Law, Professor of Psychiatry and Neurobehavioral Sciences, Director of the Institute of Law, Psychiatry, and Public Policy, University of Virginia

ANTHONY J. ALBERG, Blatt Ness Distinguished Endowed Chair in Oncology, Professor, Public Health Sciences, Interim Director of Hollings Cancer Center, Medical University of South Carolina

REGINA BENJAMIN, NOLA.com/Times Picayune Endowed Chair in Public Health Sciences, Xavier University, New Orleans

JONATHAN CAULKINS, Professor, Operations Research and Public Health Policy, Heinz College of Public Policy and Management, Operations Research Department, Carnegie Mellon University

BONNIE HALPERN-FELSHER, Professor, Department of Pediatrics, Director of Research, Associate Director of Adolescent Medicine Fellowship Program, Division of Adolescent Medicine, Stanford University

SWANNIE JETT, Executive Director, Florida Department of Health in Seminole County

HARLAN JUSTER, Director, Bureau of Tobacco Control, New York State Department of Health

JONATHAN D. KLEIN, Associate Executive Director, Julius B. Richmond Center of Excellence for Children and Secondhand Smoke, American Academy of Pediatrics

PAULA M. LANTZ, Professor and Chair, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University

ROBIN MERMELSTEIN, Director of the Institute for Health Research and Policy, Professor of Psychology, Clinical Professor of Community Health Sciences, School of Public Health, University of Illinois, Chicago

RAFAEL MEZA, Assistant Professor, Department of Epidemiology, University of Michigan

PATRICK O’MALLEY, Research Professor, Institute for Social Research, University of Michigan

KIMBERLY THOMPSON, Professor of Preventive Medicine and Global Health, University of Central Florida College of Medicine, President, Kid Risk, Inc.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

Consultants

THEODORE R. HOLFORD, Susan Dwight Bliss Professor of Public Health (Biostatistics) and Professor of Statistics, Yale School of Medicine, Yale University

DAVID T. LEVY, Professor, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center

MARIA RODITIS, Postdoctoral Research Fellow, Adolescent Medicine, Division of Adolescent Medicine, Department of Pediatrics, Stanford University

IOM Staff

KATHLEEN STRATTON, Study Director

LESLIE Y. KWAN, Research Associate

BETTINA RITTER, Research Assistant

ANNA MARTIN, Senior Program Assistant

DORIS ROMERO, Financial Associate

ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

ANNETTE M. BACHAND, Colorado State University

SANJAY BASU, Stanford Prevention Research Center

CHRISTINE DELNEVO, Rutgers School of Public Health

EDWARD EHLINGER, Minnesota Department of Health

MICHAEL P. ERIKSEN, Georgia State University

THOMAS J. GLYNN, Stanford University and American Cancer Society

STEVEN A. SCHROEDER, University of California, San Francisco

JOSHUA M. SHARFSTEIN, Maryland Department of Health and Mental Hygiene

LAURENCE STEINBERG, Temple University

JENNIFER IRVIN VIDRINE, University of Texas MD Anderson Cancer Center

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

KENNETH W. WACHTER, University of California, Berkeley

ALEXANDER C. WAGENAAR, University of Florida

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by SUSAN J. CURRY, University of Iowa, and RONALD S. BROOKMEYER, University of California, Los Angeles. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

Preface

The Surgeon General’s clarion call in 1964 for “appropriate remedial action” to address the hazards of smoking is often credited with having launched the nation’s public health campaign against cigarettes. Effective federal action was impeded for more than three decades by a symbolic congressional action in 1965 mandating weak package warnings and then by the regressive decision by Congress in 1969 to preempt the states from regulating tobacco advertising “based on smoking and health.” The 1969 legislation also banned tobacco advertising on television and thereby erased the country’s first major tobacco control initiative—the hugely significant ruling by the Federal Communications Commission that broadcasters who aired tobacco advertisements were required by the agency’s fairness doctrine to make time available for antismoking messages.

Attention then shifted to the states, largely driven by a grassroots movement for public smoking restrictions. The campaign was given major boosts by an important Surgeon General report emphasizing the addictive properties of nicotine (1988) and an Environmental Protection Agency report on the environmental hazards of tobacco smoke (1992). Another key building block of contemporary tobacco control was the initiative aiming to reduce youth smoking spearheaded by Congressman Mike Synar in 1992. The Synar Amendment requires states to enact and enforce youth access restrictions or else forfeit 40 percent of their block grants for substance abuse prevention and treatment. Within 2 years, the Synar Amendment was followed by two major reports by the Surgeon General and by the Institute of Medicine (IOM) on preventing the onset of nicotine addiction in adolescents and by a rhetorically and politically important initiative by Food and

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

Drug Administration (FDA) Commissioner David Kessler characterizing nicotine addiction as a “pediatric disease.” Despite some dissension within the ranks of tobacco control advocacy, preventing youth initiation took its place as one of the core strategic components of tobacco control.

The campaign against secondhand tobacco smoke and the new focus on child protection and the prevention of addiction played pivotal roles in the gradual evolution of public support for aggressive tobacco control in the 1990s. The cause of tobacco control was also fundamentally accelerated by the emerging evidence that cigarettes have been engineered to be addictive and by the public distaste for industry advertising campaigns that seemed so obviously targeted at children and adolescents. In 1995, as the policy context for tobacco control rapidly evolved, FDA announced its innovative initiative to declare jurisdiction over cigarettes as “nicotine delivery devices” and its intention to develop a new rule aiming to reduce youth smoking. FDA’s proposed rule included limitations on advertising and promotion as well as federal restrictions on youth access. Although the age of access in FDA’s regulation was 18, the agency considered setting the minimum age at 21. Whatever the reasoning within FDA may have been, the consensus within the IOM committee that authored the 1994 report on youth smoking was that setting the age at 21 was too large a leap for reform in a political and social context in which existing youth access restrictions were largely unenforced and cigarettes were easily available to children old enough to put coins in a vending machine.

FDA’s Tobacco Rule was proposed in 1995, promulgated in 1996, and invalidated by the Supreme Court in 2000. However, momentum for aggressive tobacco control continued to build throughout this period. The state attorney generals’ lawsuits against the tobacco companies to recover Medicaid costs attributable to smoking—and the accompanying disclosures of industry documents—led to the Master Settlement Agreement in 1998 and to aborted negotiations regarding federal tobacco regulation. Meanwhile, social norms toward smoking have been transformed, prevalence has gradually declined, more reports on tobacco have been issued by the IOM and by Surgeons General, and the Family Smoking Prevention and Tobacco Control Act was enacted in 2009. Tobacco advocates have begun to focus on the “end game” for cigarette smoking.

It is in this context that Congress directed FDA in the Tobacco Control Act to commission a report on the public health implications of raising the minimum age of legal access to tobacco products. Many states and localities are considering proposals to raise the age, and some have already done so. In light of the extraordinary momentum achieved by tobacco control advocacy over the past three decades, talking about raising the age of youth access may seem anticlimactic. However, cigarette smoking is a stubborn and costly public health problem, and the tobacco industry is resourceful

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

and creative. Adult prevalence remains about 18 percent, and smoking-related deaths approach 480,000 per year.

Although initiation rates have been dropping in recent years, history shows that they can reverse course just as easily. And investments in tobacco control tend to erode whenever the economy weakens. The development and marketing of new products is a wild card in the epidemiology of tobacco use. E-cigarettes and modified-risk tobacco products may eventually reduce the prevalence of cigarette smoking, but it is also possible that these products could serve as starter products for people who would not otherwise have begun smoking cigarettes and could also reduce incentives for cessation by addicted smokers who otherwise would have quit. Bringing these products within FDA’s regulatory jurisdiction is imperative.

Vigilance is always advisable in tobacco control. It is prudent for federal policy makers and state and local authorities to strengthen all policies aimed at reducing the initiation of smoking, including the design and enforcement of youth access restrictions. The minimum age of legal access to tobacco products was set at 18 by the states more than two decades ago in response to federal incentives and is now required by federal law. However, states and localities remain free to raise the age. By assessing the public health implications of raising the minimum age, this report aims to provide the scientific guidance the states and localities need. In return, I urge states and localities that decide to raise the age to make sure that the necessary data are collected to evaluate the new policy in achieving its ultimate goal—the reduction and eventual elimination of tobacco use by children and youth.

Richard J. Bonnie, Chair
Committee on the Public Health
Implications of Raising the Minimum
Age for Purchasing Tobacco Products

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
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Acknowledgments

The committee would like to express its sincere gratitude to the many people who contributed time and expertise in the development of this report. The work would not have been possible without the support of our sponsor, the Center for Tobacco Products of the Food and Drug Administration.

The committee would also like to acknowledge several consultants who contributed to this study. First and foremost, the committee extends its immense gratitude to Theodore R. Holford (Yale University) and David T. Levy (Georgetown University Medical Center), whose development, knowledge, and application of the Yale Lung Cancer/Cancer Intervention and Surveillance Modeling Network and SimSmoke models were integral to the deliberations of the committee and contributed significantly to the quality of the report. We thank them for their patience, expertise, and many hours of hard work. The committee is also grateful to Maria Roditis (Stanford University), who provided consultation and editorial support on draft materials on adolescent and young adult development, and Robert Pool for his assistance in editing the report.

Many individuals volunteered significant time and effort to address and educate the committee during our information-gathering meetings (see Appendix E for the names of these speakers). We are grateful to each of them for sharing their expertise and responding to our questions. The committee would like to add special thanks to Neal Benowitz (University of California, San Francisco) for his additional consultation and technical review of material on developmental neurobiology and neurological response to nicotine.

The committee also expresses its deep appreciation to the staff of the

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
×

Institute of Medicine and the National Academies for their invaluable assistance on this study. We thank the National Academies Research Center staff for their diligent help with research and references. We are grateful for the leadership of Rose Marie Martinez, senior board director of the Board on Population Health and Public Health Practice, and for the energetic and resourceful contributions of research associate Leslie Kwan, research assistant Bettina Ritter, and senior program assistant Anna Martin. Finally, we extend special thanks to study director Kathleen Stratton, whose wisdom and guidance throughout the study process were indispensable.

Suggested Citation:"Front Matter." Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. doi: 10.17226/18997.
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