The Need to Increase The Tobacco Use Age to 21

Introduction

People originally began to chew and smoke tobacco for cultural and religious ceremonies. It was not until 1602, when an anonymous English author penned the first account to link tobacco to bad health (Cancer Council NSW, 2013). Fast forward more than four centuries, and tobacco is now the leading cause of preventable death in the country with almost 500,000 premature deaths a year; in fact, the Surgeon General (2014) estimated that continuing down this road would lead to the lives of 5.6 million youth. These staggering facts are part of the catalyst that has led to a nationwide movement to prevent our young adults from succumbing to those numbers. As tempting as it is to simply enact stricter policies, it is crucial to understand how this issue has risen to the main stage, taking possible consequences into consideration, as well as not losing sight of the main problem at hand.

Stakeholders

The Family Smoking Prevention and Tobacco Control Act (2009) gave the Food and Drug Administration oversight of all tobacco products. The FDA set the minimum age for sale of all tobacco products at 18, but “preserved the authority of state, local, and tribal governments,” which allowed them to set the minimum age of sale within their areas of governance. An Act Raising The Minimum Age To Purchase Tobacco And Vapor Products (CT HB06764) was introduced on January 29, 2019 by Representatives Mary Mushinsky and Joshua Elliot. It was referred to the Joint Committee on Public Health, and its status is still pending. The push for this legislation comes as no surprise, given the ongoing debate across the country and the triumph of similar legislation in towns like Hartford, Bridgeport, South Windsor, Southington, Wallingford, Trumbull and Milford. Although Connecticut’s actions are fairly recent, this movement started nearly 15 years ago in 2005 when Needham, MA became the first community to raise their tobacco purchase age to 21. As of today, there are twelve states and more than 450 localities that have raised the tobacco age to 21; some major cities such as New York City, Boston, Washington, D.C., and Chicago are already onboard.

Overview

The decision to raise the minimum age to purchase tobacco is not as clear cut as one would expect. There are many factors to consider, including ethical, social, and economical factors. Raising the minimum age possibly encroaches on individuals’ rights. Eighteen year olds can vote, have to pay taxes, and are tried and sentenced as adults if they commit a crime. For this piece of legislation, lawmakers have to consider whether it is morally conscious to send an 18 year old off to fight our nation’s wars but prohibit them from buying a pack of cigarettes. On the other hand, they are especially susceptible to social and environmental influences; the vast majority of adolescent smokers receive their first cigarette from a peer. These peer influences promote smoking as an enticing activity and further motivates adolescents to use tobacco. Furthermore, it reinforces the perception that tobacco use is contributable to a positive and successful social life, which is a strong and dangerous bias to encounter during one’s adolescence. Additionally, it is widely known that the tobacco industry has heavily targeted communities of color in their mass marketing. Flavored tobacco products have been heavily promoted to specific minority populations and many cigarettes “use tribal icons and logos to attract non-Hispanic American Indian/Alaska natives”. As a result, these populations use tobacco products more than the general population and this policy would directly affect minorities and people of color. For this policy to be effective, tobacco control efforts would put a spotlight on these communities, which will surely bring up racial and socioeconomic tensions. In addition, there are economic burdens – something that one might not think that smoking a cigarette was attributable to. The nation pays a great magnitude of financial costs due to smoking. In the General Surgeon’s report (2014) the financial burden was estimated to be upwards of $285 billion per year; this includes annual costs of direct medical care of adults caused by smoking, productivity losses from premature death, the value of lost productivity due to premature deaths caused by exposure to secondhand smoke.

Policy Impact

There has been a decline in cigarette sales over the last decade, making this an opportune moment to get this movement off its feet. Nonetheless, there is opposition to the policy that must be addressed before any conclusions. One of the biggest tradeoffs of this policy is an issue that was mentioned earlier: individual rights. Many have countered asking how it is just to take away the right to purchase tobacco from an individual who can vote and serve our nation. But the rationale is within the policy; this would prohibit 18 year olds from purchasing tobacco products, not from using them. There would be no ramifications for an 18 year old who is smoking a cigarette on a park bench. It would simply limit youth access to tobacco while their brain development matures more fully, as a Minnesota Department of Health advisory on nicotine (2017) showed the harmful effects of the substance on the developing brain. This can be aligned with our alcohol purchase laws, where alcohol is not as addictive as tobacco nor does it kill as many youth per year, yet the minimum age has been set at 21. Lawmakers, public health experts, and the general public must all acknowledge that minors will manage to get their hands on substances they cannot legally purchase themselves – this policy is merely a strategic tactic to prevent adolescents from falling down a slippery path. Economically, it is brought up that the change will adversely impact the profits of small businesses, such as convenience stores. Few products generate the magnitude and consistency of profits as tobacco does, due to its addictive nature. Not only could this policy hurt small businesses, but doubling down on the purchase age could push the young clientele towards non-standard methods of obtaining tobacco products. According to the Centers of Disease Control and Prevention’s report (2015), the illicit tobacco trade is worth anywhere from $2.95 billion to $6.92 billion – about 8-21% of the total tobacco trade. Raising the legal age to buy tobacco could motivate young adults to gravitate towards these markets.

Nursing Role

Tobacco has led to insurmountable costs spent on healthcare, which comes as no surprise. As health care practitioners, it is more than likely that we will encounter a patient with a history of tobacco use. The sad reality is that by the time the patient is in our hands, it may be too late. Nicotine is a dangerous substance that has a long list of negative effects to the human body. “Beyond causing addiction, it activates multiple biologic pathways that are relevant to fetal growth and development, immune function, the cardiovascular system, the CNS, and carcinogenesis” (US General Surgeon, 2014). One of the most significant health effects is that addiction to nicotine keeps young people smoking longer, causing increased physical damage. The US General Surgeon’s report (2014) concluded that:

Active smoking is now casually associated with age-related macular degeneration, diabetes, colorectal cancer, liver cancer, adverse health outcomes in cancer patients and survivors, tuberculosis, erectile dysfunction, orofacial clefts in infants, ectopic pregnancy, rheumatoid arthritis, inflammation, and impaired immune function. In addition, exposure to secondhand smoke has now been casually associated with an increased risk for stroke. 

Nurses and health practitioners can only stand to benefit from the passing of this policy. As caretakers, we are devoted and strive to provide our patients with the highest quality of life. The negative effects of tobacco products are all too known and significant to be able to oppose this law in any sense. Ending the tobacco epidemic is essential to our work to increase the life expectancy and quality of life of all Americans, and raising the minimum age is the first step. Not only will this help our patients reduce their healthcare costs, it will provide a clear path to making their health their top priority.

Conclusion

Every day over 2,000 kids under the age of 18 become daily smokers; eventually, one in three will die as result. These numbers are alarming enough to persuade anyone that we should be doing everything we can to prevent young people from smoking so they can lead long, fulfilling lives. Increasing the tobacco age to 21 will help achieve these goals, as documented by communities that have already enacted the law. Needham showed nearly a 50% drop in high schoolers who were smoking and Chicago reported that more than a third of their 18-20 year olds stopped smoking. While these initial numbers are promising, it is important to not let it deter from the overall goal. Simply changing the laws will not keep tobacco out of the hands of young people.