While “some 6 million [deaths] globally every year and 400,000 in the United States” are tobacco-related, the best way to reduce these statistics is unclear. Currently, nearly 50 million Americans continue to use some form of tobacco. A couple important ideas are discussed in a few recent perspective articles:
- NEJM 2014; 370: 293-4
- NEJM 2014; 370: 295-7 bit.ly/P6LiF4
- NEJM 2014; 370: 297-9
In my view, the most promising idea is “Tobacco 21.” Starting in May, in New York City, it will be illegal to sell tobacco products and electronic cigarettes to persons younger than 21 years of age. While the FDA set a national minimum of age 18 years, states and localities can set a higher age.
Although there are those who decry the ‘nanny state’ interfering in adults who are capable of enlisting in the army, there are compelling arguments to ignore these nihilists.
- In 2005, Needham, Massachusetts became the first town with a Tobacco 21 statute. What has happened? Youth smoking rate has fallen by nearly half to 6.7% (previously 12.9%). The surrounding communities have a rate of 12.4% (previously 14.9%). Thus, the rate of decline was nearly triple. This counters the notion that most of these youths will purchase in adjacent areas.
- 80% of adult smokers began smoking daily before 20 years of age. In addition, “90% of persons who purchase cigarettes for distribution to minors are under 21.” Thus, Tobacco 21 could make a big dent in a minor’s ability to buy from other students/youths. Furthermore, 90% of U.S. adults smokers have indicated that “if they had to it over again, they would not have started.”
- The “adolescent brain has a heightened susceptibility to the addictive qualities of nicotine.” Also, adolescents are more impulsive and risk takers which increase the likelihood that they would discount the potential consequences of tobacco experimentation.
- Checking age of purchasers is already needed for anyone “who appears younger than 27.” Thus, this does not increase regulatory burdens significantly.
Even though Tobacco 21 is the most logical next step in reducing the dangers of tobacco, a much more visible and controversial measure has been ENDs or electronic nicotine delivery systems. E-cigarettes have been widely advertised. The opponents of e-cigarettes object because they have the potential to diminish the stigma of smoking and serve as a gateway product, leading to more smoking (JAMA 2013; 310: 685-6).
On the other hand, advocates suggest that “the majority of e-cigarette users treat them as cessation aides.” Ultimately, these products will improve health only if it helps reduce use of combustible products.
Bottomline: Tobacco 21 has the best potential to reduce the mortality and morbidity of smoking, but ongoing efforts with warning labels, tax increases, clean-indoor policies, cessation programs, and public-service campaigns need to continue.
From NEJM twitter feed: Listen now to audio interview w/ TobaccoFreeKids’ Matthew Myers on efforts to reduce, eliminate, prevent smoking. http://nej.md/LKTV7F
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