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PUBLIC HEALTH

Current Policies and Public Perceptions Concerning Raising the Legal Sale Age of Tobacco Products from 18 to 21 Years of Age: A

Daryn Papenfuse

Date of Award Spring 5-2-2018

Degree Type Thesis

Degree Name Master of (MPH)

Department Health Sciences

First Advisor Jodi Brookins-Fisher, PhD

Second Advisor Leah Rutkowski, MA

Abstract

TITLE: Current Policies and Public Perceptions Concerning Raising the Legal Sale Age of Tobacco Products from 18 to 21 Years of Age: A Literature Review By Daryn Papenfuse

INTRODUCTION: In the United States today, and for decades past, tobacco use has been the leading cause of chronic disease and death. Youth who initiate smoking in adolescence are at a greater risk of becoming addicted to tobacco as adults (United States Department of Health and Human Services, 2014). Nationwide, in 2015, the Centers for Disease Control and Prevention Youth Risk Behavior Survey (YRBS) indicated that 32.5% of students reported having ever tried a cigarette and 6.6% of those that did were 13 years of age or younger (Kann et al.,2016). While current shows that the prevalence rates of current youth tobacco smoking have been steadily decreasing since 1991 (27.5% to 10.8%), there is evidence that indicates upward trends

This Thesis is brought to you for free and by the Public Health Program at Central Michigan University. It has been accepted for inclusion in Public Health Theses by an authorized administrator of the Master of Public Health Program at Central Michigan University. For more information, please contact [email protected].

PUBLIC HEALTH THESIS

of youth using electronic cigarettes and other tobacco products such as hookah are on the rise (Kann et al.,2016).

METHODS: A thorough search of the databases PubMed, CINAHL, and Medline was conducted via the Google search engine. Relevant articles that were published between the years 2001-2018 were kept. Keywords and phrases that were searched included: “Youth Tobacco Law, T-21, Tobacco 21, Public Perceptions of Tobacco 21, and “Current US Policy surrounding Tobacco 21”. The systematic review process was informed further through a search of for relevant articles during the selected range of date. No (material produced outside of the traditional routes of academic ) was used for this review. Assistance with database searches for relevant articles was provided by Robin Sabo, health sciences subject librarian at Central Michigan University

RESULTS: Raising the legal purchase age of tobacco to 21 years old has shown some promising effects on the reduction of smoking in the places that have implemented it so far. Research shows that many of today’s youths obtain their tobacco products from individuals that are under the age of 21 years (Winickoff et al., 2014). High school students are much more likely to include individuals that are 18 years of age within their daily social circles than are individuals that are 21 years of age, as many high school seniors nationwide turn 18 years old prior to graduating (Ahmad & Billimek, 2007). One of the most noticeable benefits observed from Tobacco 21 laws that have already passed is that it places legal purchasers beyond the social groups of most middle school and high school students. This significantly reduces the transfer to tobacco from student-to-student. This disruption is particularly important, as individuals who get addicted to nicotine at an early age tend to exhibit heavier consumption and stronger addiction compared to others who developed their addiction later in life (Berman, 2016).

CONCLUSION: Tremendous strides have been made in reducing the impact of tobacco on our youth. Today, the U.S. is experiencing the lowest rates of traditional smoking in over two decades (Kann, 2016). However, the work is far from done. Emerging trends like electronic cigarettes and “vaping,” represent a new frontier for the tobacco industry to gain a foothold and secure its next generation of addicts.

Recommended Citation Papenfuse, D. (2018). Current Policies and Public Perceptions Concerning Raising the Legal Sale Age of Tobacco Products from 18 to 21 Years of Age: A Literature Review (Unpublished master’s thesis). Central Michigan University, Mount Pleasant, MI. https://www.cmich.edu/colleges/CHP/hp_academics/health_sciences/MPH/Pages/Research.aspx

This Thesis is brought to you for free and open access by the Public Health Program at Central Michigan University. It has been accepted for inclusion in Public Health Theses by an authorized administrator of the Master of Public Health Program at Central Michigan University. For more information, please contact [email protected]. P a g e | 1

Current Policies and Public Perceptions Concerning Raising the Legal Sale Age of Tobacco Products from 18 to 21 Years of Age – A Literature Review Daryn Papenfuse

P a g e | 2

Introduction

In the United States today, and for decades past, tobacco use has been the leading cause of chronic disease and death. Youth who initiate smoking in adolescence are at a greater risk of becoming addicted to tobacco as adults

(United States Department of Health and Human Services, 2014). Nationwide, in 2015, the Centers for Disease

Control and Prevention Youth Risk Behavior Survey (YRBS) indicated that 32.5% of students reported having ever tried a cigarette and 6.6% of those that did were 13 years of age or younger (Kann et al.,2016). While current research shows that the prevalence rates of current youth tobacco smoking have been steadily decreasing since 1991

(27.5% to 10.8%), there is evidence that indicates upward trends of youth using electronic cigarettes and other tobacco products such as hookah are on the rise (Kann et al.,2016).

We know that most adults who are currently addicted to cigarettes became daily smokers before the age of

18 years old (United States Department of Health and Human Services, 2012). Additionally, the earlier a person becomes addicted to cigarettes, the longer that individual is exposed to the hundreds of chemicals known to cause harm. In 2014, the United States Surgeon General reported concern regarding studies that indicated potential long- term negative effects on cognitive functions due to nicotine exposure at a young age, when the vast majority of brain development occurs (USDHHS, 2014).

Having poor health during the childhood and adolescent years often leads to lasting negative financial and health-related impacts in adulthood (Case, Fertig, & Paxson, 2005). While certainly beneficial, focusing most of the preventative effort on expanding access to health care services, as has been done in the past, is not enough to achieve a lasting positive impact. To truly make a permanent change, new policies designed with the intention to protect our youth must be designed and passed into law (Case & Paxson, 2006).

One such policy that is gaining momentum across the United States is the Tobacco 21 (T21) Initiative. T21 is a national campaign that seeks to raise the legal sale age for all tobacco products from 18 to 21 years of age. The campaign was initiated by, and is currently sustained through, the Preventing Tobacco Addiction Foundation

(PTAF), a nonprofit organization that was established in 1996 (Preventing Tobacco Addiction Foundation,

2016).This article will review and analyze peer-reviewed publications concerning current T21 policies as well as its public acceptance across the United States. P a g e | 3

Methods

A thorough search of the databases PubMed, CINAHL, and Medline was conducted via the Google search engine. Relevant articles that were published between the years 2001-2018 were kept. Keywords and phrases that were searched included: “Youth Tobacco Law, T-21, Tobacco 21, Public Perceptions of Tobacco 21, and “Current

US Policy surrounding Tobacco 21”. The systematic review process was informed further through a search of

Google Scholar for relevant articles during the selected range of date. No grey literature (material produced outside of the traditional routes of ) was used for this review. Assistance with database searches for relevant articles was provided by Robin Sabo, health sciences subject librarian at Central Michigan University.

Inclusion Criteria

Original articles, published in the U.S. in the English language, and covering the above-mentioned keywords and phrases were considered for this review. The methods sections and titles and abstracts were thoroughly screened for their respective eligibility. The citations that were selected were organized into two groups:

. Primary, qualified for further synthesis and potential inclusion

. Not relevant enough, discard from study

Primary citations were organized, and full-text articles were further reviewed. If deemed appropriate and relevant, findings were included in this article. A total of 38 articles were selected and 19 met the criteria for inclusion in the review.

Results

Raising the legal purchase age of tobacco to 21 years old has shown some promising effects on the reduction of smoking in the places that have implemented it so far. Research shows that many of today’s youths obtain their tobacco products from individuals that are under the age of 21 years (Winickoff et al., 2014). High school students are much more likely to include individuals that are 18 years of age within their daily social circles than are individuals that are 21 years of age, as many high school seniors nationwide turn 18 years old prior to graduating (Ahmad & Billimek, 2007). One of the most noticeable benefits observed from Tobacco 21 laws that have already passed is that it places legal purchasers beyond the social groups of most middle school and high school students. This significantly reduces the transfer to tobacco from student-to-student. This disruption is P a g e | 4 particularly important, as individuals who get addicted to nicotine at an early age tend to exhibit heavier consumption and stronger addiction compared to others who developed their addiction later in life (Berman, 2016).

Current Tobacco 21 Policy Development in the United States

In 2015, the Institute of Medicine released a report on the potential benefits to public health if the age to legally access tobacco products was raised. They found that an overall 12% reduction in the current smoking rate would be observed as a result of such a policy change (Institute of Medicine, 2015). Past government support for a policy that would raise the legal age of tobacco from the current age of 18 to 21 years of age has been minimal until recent. In fact, prior to 2005, the only official support for such legislation was from the American Medical

Association (AMA) when they passed a resolution in 1986 in support of raising the sale age to 21 years (Apollonio

& Glantz, 2016).

In 2005, Needham Massachusetts, a suburb of Boston, became the first municipality in America to pass and actively enforce a policy of not selling tobacco products to anyone under the age of 21 years. The results that followed were nothing short of eye-opening. From 2006 to 2010, youth tobacco use in Needham decreased from

13% to 7%, a nearly 50% difference (Schneider, Buka, Dash, Winickoff & O’Donnell, 2015). The surrounding cities were studied, and results were contrasted to Needham and it was found that rates of tobacco use declined at a much more modest rate from 15% to 12 percent. The success in Needham served as a catalyst for the T21 movement and paved the way for many other community stakeholders across the nation to begin considering this approach

(Schneider, et al., 2015).

From 2015-2017, five states (Hawaii, California, New Jersey, Maine, Oregon) raised the legal age of purchase from 18 to 21 years of age (See Map 1 below). During those years and since, the Tobacco 21 initiative has been adopted by over 300 cities in 19 states. Most recently, the city council in Akron, Ohio voted to adopt T21, making them the third major city in Ohio to do so, behind Columbus and Cleveland (Preventing Tobacco Addiction

Foundation, 2018). P a g e | 5

Support for raising the legal sale of purchase for tobacco products from 18 to 21 years crosses party lines. A survey into the matter found that 58.3% of Democrats and 58.0% of Republicans were directly in favor of implementing the policy (Preventing Tobacco Addiction Foundation, 2004).

Current T-21 Public Perceptions and Support

Public support for the T21 initiative has been measured at the state level from poll distribution, as well as, at the national level. One study conducted by the Office on Smoking and Health at the Centers for Disease Control and Prevention analyzed data gathered from a 2014 internet survey of American adults at least 18 years of age or older and found that nearly three quarters of survey participants were in support of T21 with seven out of 10 current smokers also indicating their support (King, Jama, Marynak & Promoff, G, 2015). Researchers at the American

Academy of Pediatrics reported similar findings when they analyzed the results of the Social Climate Survey of

Tobacco Control in 2013. Out of nearly 3,300 respondents, seven in 10 (70.5%) were in favor of raising the age of tobacco purchase to 21 years (Winickoff, McMillen, Tarski, Wilson, Gottlieb & Crane, 2016).

One study of 4,880 individuals living in the U.S. asked about willingness to support raising the legal age to purchase tobacco, as well as the specific age of legal sale those surveyed would be willing to support. Results showed that most people surveyed (66.3%) supported increasing the minimum age of tobacco sale, even in areas P a g e | 6

where raising the age limit would seem to be less popular. Women, non-white adults, Latinos, and non-smokers

were the most supportive of the changes (Lee et al., 2016).

Potential Future Obstacles

As of the writing of this review, there has not been any attempts at litigation by the tobacco industry

concerning raising the purchase age to 21 years, as states and local authorities have the legal right to do so in most

cases. Absence of a lawsuit is due in part to the fact that Tobacco 21 does not regulate advertising (deemed free

speech), but rather the commercial exchange, which is not protected by the First Amendment. One concern of those

advocating for T21 legislation is “express preemption,” which is when state laws can deny local governments the

authority to regulate in certain areas. Essentially it is an enforcement of a chain of command system if the state so

Figure 1 State Express Preemption Expressly Not Preempted No Clause chooses to enact such a law. Federal government can preempt state governments Alabama X Alaska X Arizona X from passing laws while state governments can preempt local municipalities Arkansas X California X Colorado X (Lewis, 2008). Connecticut X Deleware X Florida X Georgia X To date, there are 19 states in which local municipalities are prevented Hawaii X Idaho X Illinois X Indiana X from passing T21 legislation based on express preemption clauses (See Figure 1). Iowa X Kansas X Kentucky X This law depends on the state, and advocates for Tobacco 21 need to be aware Louisiana X Maine X Maryland X that this law is open to interpretation. So far, local jurisdictions have been the Massachusetts X Michigan X Minnesota X primary target of advocates for T21. This is largely due to the reality that local Mississippi X Missouri X Montana X Nebraska X politicians are not swayed to the same degree by the tobacco industry. It is Nevada X New Hampshire X New Jersey X possible, however, that as the T21 initiative continues to gain more momentum, New Mexico X New York X North Carolina X and the tobacco industry lobby will focus the bulk of their efforts on getting North Dakota X Ohio X Oklahoma X express preemption clauses passed in the remaining 31 states. Advocates of Oregon X Pennsylvania X Rhode Island X Tobacco 21 need to be prepared for this eventual challenge and be aware of local South Carolina X South Dakota X Tennessee X Texas X and state laws before beginning the lengthy process of passing T21 legislation in Utah X Vermont X Virginia X their local jurisdictions (Berman, 2016). Washington X West Virginia X Wisconsin X Wyoming X

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Areas for Future Research

Despite its recent surge in momentum, the Tobacco 21 movement is still a relatively new and emerging concept. Support from the general population has been fairly well documented in the previously discussed national surveys. Very little is known, however, about the support (or lack thereof) of government officials this represents a significant gap in literature. Health officers in charge of local and district health departments, public school superintendents, and other public administrators play a crucial role in the development of policies that protect their respective communities from the harms of tobacco (Winnail & Bartee, 2002). To bolster more support for T21, it would be beneficial to the movement if there were information concerning the level of support these, and other, officials have for such legislation.

One other area where research is lacking exists is in the formal evaluation of the movement in states that have passed T21 legislation. Hawaii and California have both maintained T21 laws in effect for a few years and data related to current youth smoking rates in those states should be analyzed for any emerging trends. Although still relatively new, some benefits could potentially be gained from beginning the evaluation process to determine if the movement has brought about any significant changes to their rates of youth using tobacco.

Conclusion

Tremendous strides have been made in reducing the impact of tobacco on our youth. Today, the U.S. is experiencing the lowest rates of traditional smoking in over two decades (Kann, 2016). However, the work is far from done. Emerging trends like electronic cigarettes and “vaping,” represent a new frontier for the tobacco industry to gain a foothold and secure its next generation of addicts.

In combination with other common-sense legislation, like raising taxes and establishing limits to advertising, the Tobacco 21 movement seeks to further the downward trend in youth smoking rates with the ultimate goal of eliminating tobacco use altogether by moving the main source of tobacco away from the social circles of students in primary school. The movement has passed in five states and hundreds of cities.

There also appears to be great public support for T21 from a wide segment of the United States with little interference from the tobacco industry so far. T21 is largely being considered the next logical option by many municipalities. As momentum continues to grow in states and local municipalities across the country, it can be P a g e | 8 expected that the tobacco lobby will begin to pay closer attention and devote their powerful lobbying efforts to influence states without preemptive clauses to pass them. To further the support for T21, advocates could greatly benefit from research conducted on elected and other public officials, such as health officers and public school superintendents, as well as the benefits obtained from passed legislation thus far.

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References Ahmad, S., & Billimek, J. (2007). Limiting youth access to tobacco: comparing the long-term health impacts

Of increasing cigarette excise taxes and raising the legal smoking age to 21 in the United States. Health Policy. 10.1016. Retrieved on 2/21/2018 from: https://www.ncbi.nlm.nih.gov/pubmed/16698112 Apollonio, D. E., & Glantz, S. A. (2016). Minimum ages of legal access for tobacco in the United States from

1863 to 2015. Amer Journal of Pub Health. Vol 206, No. 7. Retrieved on 2/11/2018 from:

https://www.ncbi.nlm.nih.gov/pubmed/27196658

Berman, Micah (2016). Raising the tobacco sales age to 21: surveying the legal landscape. Public Health Rep

131 (2). Retrieved on 4/1/2018 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765989/

Case, A., Fertig, A., & Paxson, C. (2005). The lasting impact of childhood health and circumstance. Journal

Of Health Economics 24 (2005) 365-389. Retrieved on 2/18/2018 from:

https://www.princeton.edu/~accase/downloads/The_Lasting_Impact_of_Childhood_Health_an

d_Circumstance.pdf

Case, A. & Paxson, C. (2006). Children’s health and social mobility. The Future of Children, Volume 16,

Number 2, pp. 151-173. Retrieved on 2/17/2018 from:

https://www.ncbi.nlm.nih.gov/pubmed/17036550

Institute of Medicine. (2015). Public health implications of raising the minimum age of legal access to tobacco

products. National Academies Press. Retrieved on 3/21/2018 from: https://www.ncbi.nlm.nih.gov/

pmc/articles/PMC4765989/#B5

Kann, L., McManus, T., Harris, WA., Shanklin, S. L., Flint, K.H., Hawkins, J., Queen, B., Lowry, R., Olsen, E.,...

Zaza, S. (2016). Youth risk behavior surveillance – United States, 2015. MMWR Surveill Summ 2016; 65

(No. 22-6): 1-174. Retrieved

on 3/18/2018 from: http://dx.doi.org/10.15585/mmwr.ss6506a1

King, B. A., Jama, A. O., Marynak, K. L., & Promoff, G. R. (2015). Attitudes toward raising the legal age of Tobacco sales: policy support and trust in government, 2014-2015, U.S. Am J Prev Med. 49 (4): 583-588. Retrieved on 2/21/2018 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4575862/ Lee, J., Boynton, M., Richardson, A., Jarman, K., Ranney, L., & Goldstein, A. (2016). Raising the legal age

Of tobacco sales: policy support and trust in government, 2014-2015, U.S. Am J Prev Med 2016

51(6): 910-915. Retrieved on 2/17/2018 from: https://www.ncbi.nlm.nih.gov/pubmed/27263

P a g e | 10

Lewis, A., G. (2008) Federal preemption of state and local laws: state and local effort to impose sanctions on Employers of unauthorized aliens. Advance Seminar of State Attorneys General. Columbia Law. Retrieved on 3/12/2018 from: http://web.law.columbia.edu/sites/default/files/microsites/career- services/Federal%20Preemption%20of%20State%20and%20Local%20Laws.pdf Preventing Tobacco Addiction Foundation. (2018). State-by-state: tobacco 21. Retrieved on 4/15/2018 from: https://tobacco21.org/preventing-tobacco-addiction-foundation. Preventing Tobacco Addiction Foundation. (2016). About us: tobacco 21. Retrieved on 3/23/2018 from: https://tobacco21.org/preventing-tobacco-addiction-foundation. Preventing Tobacco Addiction Foundation. (2004). The case for tobacco 21. Retrieved on 3/23/2015 from: http://www.tobacco21.org/ california/thecase.asp. Schneider, S. K., Buka, S. L., Dash, K., Winickoff, J. P., & O’Donnell, L. (2015). Community reductions in

Youth smoking after raising the minimum tobacco sales age to 21. Tob Control 2016; 25:355-339

Retrieved on 2/13/2018 from: http://tobaccocontrol.bmj.com/content/25/3/355

U.S. Department of Health and Human Services. (2012). Preventing tobacco use among youth and young

adults: a report of the surgeon general. Retrieved on 2/9/2018 from:

fhttps://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html

U.S. Department of Health and Human Services (2014). The health consequences of smoking – 50 years of

Progress: a report of the surgeon general. Atlanta: U.S. Department of Health and Human Services

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health

Promotion, Office on Smoking and Health. Retrieved on 3/11/2018 from: http://www.surgeongeneral.gov/

Library/reports/50-years-of-progress/?_ga=1.85329114.252217801.1464102713.

Winickoff, J., Hartman, L., Chen, M., Gottlieb, M., Nabi-Burza, E., DiFranza, J. (2014) Retail impact of

Raising tobacco sales age to 21 years. Am J Public Health 104(11): e18-e21. Retrieved on 2/22/

2018 from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202948/

Winickoff, J., McMillen, R., Tanski, S., Wilson, K., Gottlieb, M., & Crane, R. (2016). Public support for raising

The age of sale for tobacco to 21 in the United States. Tob Control 2016; 25: 284-288.

Retrieved on 1/29/2018 from: http://tobaccocontrol.bmj.com/content/25/3/284

Winnail, S. & Bartee, R. (2002). How can primary concerns of school district superintendents guide school health efforts? Journal of School Health. 10.1111/j.1746-1561.2002. Retrieved on 3/28/2018 from: http: https://www.mendeley.com/viewer/?fileId=65a07318-e75c-dff5-4e69- 4ec75c65f199&documentId=8c3d4f24-7c5c-371e-8093-93bf8f0cd44