New research reveals greater impact of Tobacco 21 policy

In 2020, the federal minimum age for purchasing tobacco products was officially raised from 18 to 21, as an increasing number of states and localities across the country moved to raise the age of purchase for tobacco products to protect the health of young adults.

One factor behind this change was a 2015 report by the National Academy of Medicine (NAM) that found that the federal Tobacco 21 (T21) law could prevent as many as 249,000 deaths by 2100.

A new study led by Yale researchers with the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group has found that the NAM report grossly underestimated the number of prevented deaths. The findings significantly strengthen the potential impact of the T21 Act and provide important new information for future state and local policy discussions regarding tobacco regulation and public health.

The modeling study estimates that comprehensive enforcement of local, state and federal T21 laws could prevent up to 526,000 premature smoking-related deaths across the United States and add 13.3 million years of life by the year 2100. The findings are more than double the estimates reported in the NAM report.

The Yale study was published in the JAMA Health Forum on December 20, the fifth anniversary of the signing of the US T21 Act.

The researchers said the lower NAM forecast was likely due to the fact that the report based its estimate on U.S. data, which was available when only 30 municipalities adopted policies raising the age of sale for tobacco products. The NAM report also did not take into account each state’s smoking and mortality rates, population size, or policy implementation timeline – factors that influence policy outcomes.

For comparison, the CISNET modeling study included comprehensive state-level data on smoking patterns, mortality, and T21 policy implementation at the local, state, and federal levels. This detailed data, in addition to rigorous evidence on the effects of the T21 policy, was used as input to simulation models developed for each of the 50 states and the District of Columbia. Because changes in smoking behavior will take decades to translate into disease and death, simulation models have been used to understand the potential long-term effects of smoking prevention policies.

The study found that among the 50 states, New York and Massachusetts ranked first in reducing relative mortality due to early and widespread adoption of T21 policies at the local level. Hawaii, the first state to implement T21, also saw a greater decline in relative mortality compared to states that were slower to implement the law.

We felt it was important to quantify the benefits of Tobacco 21 policies and give credit where credit is due. Local communities and states that pushed tobacco policies 21 early on reaped these benefits in the future. Our models use real political data to reflect this.”

Jamie Tam, assistant professor of public health (health policy) at the Yale School of Public Health and lead author of the study

Simulation results varied widely by state and reflected geographic disparities, where less healthy states such as Ohio – which have higher mortality rates and lower life expectancy – stand to gain more from T21 policies than healthier states such as California, which already have relatively low smoking rate. Eight states currently do not have their own state T21 laws and instead rely solely on federal enforcement.

To help inform states and localities about changes in tobacco sales regulations, the CISNET team designed a policy simulation model called the Tobacco Control Policy (TCP) tool. The free interactive website allows users to compare smoking and mortality outcomes in the baseline scenario with those in a specific policy scenario. The previous version of the TCP tool used T21 policy effects from the NAM report, while the new version now relies on actual T21 policy data and state-specific simulations.

The study also included Alyssa Crippen, Abigail Friedman and Theodore R. Holford, all of the Yale School of Public Health, as well as experts from the British Columbia Cancer Research Institute, the University of Michigan, Georgetown University and Preventing Tobacco Addiction Foundation/Tobacco 21. #