Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products (2015) / Chapter Skim
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7 The Effect on Tobacco Use of Raising the Minimum Age of Legal Access to Tobacco Products
7 The Effect on Tobacco Use of Raising the Minimum Age of Legal Access to Tobacco Products
Pages 193-218
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From page 193... ...
are well established approaches for estimating the likely impact of changes in tobacco control policies on population-level smoking initiation and prevalence, and on population health outcomes. The next chapter (Chapter 8)
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The committee considered the likely magnitude of changes in initiation effects that each of the three policy options under consideration (raising the MLA to 19, 21, or 25 years of age) would have on the different age segments and arrived at ordered, categorical estimates labeled as "small," "medium," or "large." Third, once consensus about the magnitude of the effect at each age segment and policy option combination was reached, the committee attached numeric ranges to each of the magnitude estimate descriptors.
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From page 195... ...
of tobacco products will remain essentially as they are now, and no new efforts will be made to en force the MLA restrictions against noncommercial or social sources who provide tobacco products to underage users. • Sanctions will be directed as they are now, primarily toward retailers and not toward individual users.
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From page 196... ...
The committee based its estimates on an understanding of factors that are most relevant to achieving the threshold of 100 cigarettes for initiation, the data about which come from the National Health Interview Survey and are used in the simulation models in Chapter 8. The committee considered factors that operate both directly on tobacco use, such as access to tobacco products, and factors that operate more indirectly or distally, such as changes in biological vulnerability to the effects of nicotine with age or changes in social norms that indirectly affect motives for use.
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From page 197... ...
Although 19-year-olds may still be in high schools and thus potentially influence those under 15, it is far less likely that 21-year-olds are in the same social networks. Increasing the MLA from 21 to 25, however, is not likely to achieve any additional notable reductions in social sources for those under 15 than what is achieved with the 21-year-old MLA policy.
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From page 198... ...
Adolescents' social networks and potential social sources of tobacco start to grow as some take on formal, part-time jobs with coworkers who may be over the MLA. Changing the MLA for tobacco to 19 may not change social sources substantially for these adolescents, but the committee expects
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The committee expects the effects of increasing the MLA to 21 or 25 on the initiation rates of 19- and 20-year-olds will be similar to the effects on 18-year-olds. This expectation of increased effect is due primarily to the increased social distancing expected when the MLA is raised to 21 or 25, but it also takes into account the benefits of the additional maturing of executive functions, the decreased sensitivity to the rewarding properties of nicotine, the additional social norms proscribing tobacco use, and the decreased social value of tobacco and motives for its use as individuals enter the workforce or parenthood.
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The changes in the MLA are likely to have an effect of further moving social norms and attitudes toward discouraging tobacco use and making it less appealing. These social normative changes may help to reduce rebound effects.
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Conclusion 7-1: Increasing the minimum age of legal access to tobacco products will likely prevent or delay initiation of tobacco use by ado lescents and young adults. Conclusion 7-2: Although changes in the minimum age of legal access to tobacco products will directly pertain to individuals who are age 18 or older, the largest proportionate reduction in the initiation of tobacco use will likely occur among adolescents 15 to 17 years old.
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202 MINIMUM AGE OF LEGAL ACCESS TO TOBACCO PRODUCTS TABLE 7-1 Committee Estimates Regarding Effects on Initiation Reduction in Initiation by Age Group MLA 19 MLA 21 MLA 25 Reduction in initiation for adolescents under age 15 small medium medium Reduction in initiation for adolescents ages 15–17 small large large Reduction in initiation for young adults age 18 small medium medium Reduction in initiation for young adults ages 19–20 n/a medium medium Reduction in initiation for young adults ages 21–24 n/a n/a small
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From page 203... ...
Changes in the MLA will increase the MLA 21 will begin to change access to negative social consequences of tobacco tobacco products from social sources, much use; adolescents at this age are most more so than MLA 19. MLA 25 will have likely to get tobacco from social sources, only modest additional changes to social including from coworkers above the MLA.
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ESTIMATED INITIATION EFFECT SIZES As described above, the committee used a consensus process to arrive at estimates for changes in initiation rates. As shown above in Table 7-1, the committee decided on three qualitative descriptors, labeled small, medium, and large.
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. Table 7-2 summarizes the committee's estimates for percent reductions in initiation rates and potential rebound effects for the different age groupings assuming a change in the MLA to 19, 21, or 25 years of age, referred to as MLA 19, MLA 21, or MLA 25, respectively.
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206 TABLE 7-2 Committee Estimates Regarding Effects on Initiation with Qualitative Descriptors and Numeric Estimates MLA 19 MLA 21 MLA 25 Qualitative Numeric Qualitative Numeric Qualitative Numeric Reduction in Initiation by Age Group Descriptor Estimate Descriptor Estimate Descriptor Estimate Reduction in initiation for adolescents under age 15 small 5% medium 15% medium 15% Reduction in initiation for adolescents ages 15–17 small 10% large 25% large 30% Reduction in initiation for young adults age 18 small 10% medium 15% medium 20% Reduction in initiation for young adults ages 19–20 n/a n/a medium 15% medium 20% Reduction in initiation for young adults ages 21–24 n/a n/a n/a n/a small 5%
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These ranges do not represent bounds or a measure of uncertainty in a classical statistical sense. Rather, these values reflect ranges that the committee deemed plausible as described in the text.
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Using the smoking initiation estimates developed by the committee as inputs, the model was used to assess the potential effects of raising the MLA on U.S. smoking patterns by birth cohort and calendar year and the corresponding smoking-attributable mortality, life expectancy, and lung cancer deaths, using lung cancer projections from the CISNET Yale Lung Cancer Model (Holford et al., 2012)
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. Smoking Prevalence The models estimate the impact of reduced and delayed initiation on future annual U.S.
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To characterize the incremental impacts of policy changes that are predicted by the model, the committee subtracted the outcome result for the baseline or status quo policy from the outcome result for the new MLA policy and then divided by the baseline outcome result, thus expressing the change as a percentage. Both models project the baseline smoking prevalence in the United States from 2015 to 2100 assuming that smoking initiation and cessation rates will remain the same in all future years, but they do so in different ways and at different levels.
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Smoking prevalence (%) 20 16 12 8 6 8 2020 2060 2100 2020 2060 2100 Year Year FIGURE 7-2 CISNET model-projected smoking prevalence for the three mid-MLA scenarios for adults (18+)
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Table 7-4 shows a comparison between the two models of the projected adult smoking prevalence and the absolute percentage reductions in prevalence versus the status quo for selected years. The ranges in percentage
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MLA/Outcome 2020 2040 2060 2080 2100 SQ (status quo) SimSmoke prevalence 15.7 13.1 12.7 12.7 12.7 CISNET prevalence 15.2 10.4 9.1 8.8 8.7 MLA 19 SimSmoke prevalence 15.7 12.9 12.4 12.3 12.3 reduction versus SQ 0.4% 1.8% 2.7% 3.0% 3.0% (0.2, 0.6)
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Finding 7-2: The models predict that raising the minimum age of legal access to tobacco products would lead to additional reductions beyond the status quo in smoking prevalence based on reasonably conservative assumptions about the potential reductions in smoking initiation rates. Finding 7-3: Raising the minimum age of legal access to tobacco prod ucts to 21 or 25 years would lead to larger reductions in smoking prevalence than the status quo or an increase of the MLA to 19.
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From page 215... ...
An important consideration for the committee is whether a change in the MLA would differentially affect high-risk populations with initiation rates that vary significantly from the national averages considered in this report, including the rates contained in the modeling. One possibility is that groups with higher-than-average initiation rates would remain relatively resistant to tobacco control interventions and the effect would be smaller in those populations, widening the equity gap.
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2012. Reducing tobacco use and second hand smoke exposure: Interventions to increase the unit price for tobacco products.
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Under review. The role of tobacco control policies in reducing US smoking prevalence from 1965-2012: Results from the SimSmoke Tobacco Policy Simulation Model.
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From page 218... ...
2008. Population tobacco control interventions and their effects on social inequalities in smoking: Systematic review.
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