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April 7th, 2015:

Raising Buying Age for Tobacco Could Mean Fewer Smokers

If someone makes it through high school without smoking, it is unlikely that he or she will ever start.

In 2005, the Boston suburb of Needham tried a new tactic to reduce youth tobacco use: the town raised the legal age for purchasing tobacco from 18 to 21. The results were dramatic – tobacco use among high school students dropped almost in half, and Needham’s decline in high school smoking rates far outpaced the surrounding suburbs.

In the past two years, communities around the country have begun to follow Needham’s lead. To date, more than 50 communities in seven states have raised their tobacco sales age to 21, including New York City in 2014. And the momentum keeps growing. And at least 10 state legislatures (including Hawaii) are now considering Tobacco 21 legislation.

Earlier this month, the Institute of Medicine (IOM), which is part of the National Academy of Sciences, released a 335-page report detailing the benefits of raising the tobacco sales age to 21, which would match the minimum age for purchasing alcohol.

Of all the options for addressing tobacco use, why are Tobacco 21 policies catching on? Why do they work?

Tobacco Use Is a ‘Pediatric Epidemic’

Think about the people you know who smoke. How many of them smoked their first cigarette before age 21? How many of them wish they had never smoked that first cigarette? The likely answer to both of these questions is: all of them.

The U.S. Surgeon General has referred to tobacco use as a “pediatric epidemic,” because it almost always begins in youth. Indeed, despite all we know about the harms of tobacco, it is still the case that one in four high school seniors is a smoker and youth tobacco rates have barely budged over the past decade.

Of those who begin smoking as youth, 80 percent will smoke into adulthood, and one-half of all adult smokers will die prematurely from tobacco-related diseases.

The flip side of tobacco use being a “pediatric epidemic” is that the likelihood of starting to smoke declines markedly with age. The older you are, the less likely you are to start smoking. Although the tobacco industry has been increasingly targeting college-age students with its marketing, it remains the case that if someone makes it through high school without smoking, it is unlikely that he or she will ever start.

The tobacco industry has recognized this for years. In a 1982 memo, a researcher from the tobacco company R J Reynolds stated: “If a man has never smoked by age 18, the odds are three-to-one he never will. By age 21, the odds are twenty-to-one.”

Why Do Tobacco 21 Policies Work?

Tobacco 21 policies are effective because they make it much more difficult for middle and high school students to access tobacco. This is because youth tobacco experimentation and use is driven by legal tobacco sales, not by illegal ones.

Today, at least in most places, 18- and 19-year-olds can legally purchase tobacco products and then supply them to younger kids (who, at least in the early stages of smoking, only use cigarettes occasionally). Raising the minimum age to 21 puts legal purchasers outside the social circle of most high school students.

Of course, raising the tobacco sales age to 21 will not keep all high school students from finding ways to access tobacco products, but the experience in Needham suggests it will significantly reduce the amount of youth tobacco use.

Given the scope of the problem – more than 3,800 kids under the age of 18 start smoking every day – the public health benefits could be enormous. Using conservative assumptions, the IOM study concluded that a nationwide Tobacco 21 policy would avoid nearly 250,000 premature deaths among those born between 2000 and 2019. Other public health benefits, such as a reduction in low birth weight and pre-term births, would be far more immediate.

We also now know that a legal age of 18 for tobacco is out of touch with what the scientific evidence says about adolescent brain development. As discussed in the recent book The Teenage Brain, brains do not fully mature until people reach their early 20s (and possibly later).

For a still-developing brain, exposure to nicotine causes long-term neurological harm; in essence, the addiction to nicotine gets hard-wired into the developing brain. This leads to a stronger nicotine addiction and makes it much more difficult to quit later on. For this reason, the recent explosion in youth e-cigarette use is deeply troubling, and Tobacco 21 policies should also include e-cigarettes, hookahs and other products that deliver nicotine.

18 Is Not a Magic Number

Federal law prohibits the FDA from raising the tobacco sales age above 18; only Congress can do that for the nation as a whole – and it’s hard for Congress to get anything done these days. But every state and most communities have the legal authority to adopt Tobacco 21 laws, which is exactly what they are starting to do.

The opposition to this emerging movement (primarily tobacco companies and tobacco retailers) chants “old enough to vote, old enough to smoke.” But tobacco use is not a right or a privilege; it is an addictive and deadly activity. For the overwhelming majority of smokers, tobacco use is not in fact an “adult choice;” it is the result of an addiction that began when they were in high school or younger, and one that they are trying hard to kick.

There is nothing natural or unchangeable about a minimum age of 18. In traditional British common law, the “age of majority” (adulthood) was 21. In the U.S., the voting age was not lowered from 21 to 18 until 1971, but soon thereafter states began raising their drinking age from 18 to 21 when they realized that teens were disproportionately responsible for drunk driving accidents.

More recently, states that have sanctioned the legal use of marijuana – a drug far less deadly than tobacco – have set 21 as the minimum age. In short, it has long been the case that there are different minimum ages at different times and for different purposes.

Something We Can Agree On

Because no one (except for tobacco companies) wants the next generation to smoke, raising the minimum age to 21 is one tobacco control policy that nearly everyone can agree upon. It’s no surprise then, that a recently published study found that more than seven in 10 adults favored increasing the tobacco sales age to 21, including strong majorities in every demographic category (including current smokers and 18-20 year olds). This is the rare policy measure that is bipartisan, popular, and effective.

What are we waiting for?

Michael Bloomberg fights big tobacco in Uruguay

Michael Bloomberg is a man on a mission. This, of course, isn’t the first “noble cause” he’s latched on to but the “evil” of tobacco is something he feels particularly strongly about.

In co-operation with the Bill and Melinda Gates Foundation, Mr Bloomberg has just launched a multi-million dollar fund to help smaller countries fight legal battles with tobacco companies, among them the small South American country of Uruguay.

Uruguay has considerably fewer smokers than Michael Bloomberg’s usual backyard of New York but this country of just three million people has become an unlikely battleground between anti-smoking campaigners and big tobacco. Its government is embroiled in a long running and expensive legal battle with the cigarette industry over its anti-smoking laws.

And the former Democrat, come Republican, come Independent once touted as a potential presidential nominee has stepped into fray.

“We are in this to help countries that can’t afford to defend themselves against an industry which will try to kill a billion people this century,” Bloomberg tells me, pulling no punches in his New York headquarters.

“If that isn’t a noble cause I don’t know what is. You can talk about saving society but you have to translate that into action.”

“There’s nothing else I will do that will save as many people,” Michael Bloomberg told me

Smoking in the developing world

Although tobacco consumption is falling in the west, the opposite is true in the developing world. That’s why Gates and Bloomberg have set up this fund.

In Uruguay itself the proof of the pudding is in the eating, so to speak. A country, which used to have the highest smoking rates in Latin America, is witnessing tobacco consumption decline rapidly. Silvina Echarte, from the Health Ministry’s dedicated anti-tobacco strategy group, says this is all down to new, aggressive laws.

“We have numbers, we have scientific evidence saying that these kind of policies and the enforcement of these kind of policies have been effective,” says Echarte.

Those laws include directives which mandate that 80% of a packet must be covered in health warnings and there’s a complete ban on tobacco advertising and promotion.

Most egregiously, say the tobacco manufacturers, a company cannot sell more than a single variation of the same brand: Marlboro Red and Marlboro Light, for example.

That legislation goes too far say the cigarette companies and that’s why the test case between the tobacco giant, Phillip Morris International (PMI) and the government is seen as so important; the right of an individual country to pursue its own aggressive health policies against the commercial freedoms of the cigarette companies.

Uruguay used to have the highest smoking rates in South America

Tobacco is, of course, a perfectly legal product and is sold around the world. Where it can advertise, Phillip Morris’ marketing and promotional ads are clever and well produced; urging smokers “not to be a maybe”, to try something different.

‘We do not target kids’

Health campaigners say the industry deliberately targets young people. That allegation is emphatically denied by PMI.

Cigarette companies don’t often give interviews to the media, perhaps feeling – with some justification – that they’re always portrayed as the villain in the piece. But on this occasion, PMI did agree to speak to me at their international headquarters in Lausanne, Switzerland.

Senior Vice President and Chief Legal Counsel Marc Firestone categorically denied those accusations of trying to “pull in” young, would-be smokers.

“We do not target kids, that is not our audience,” Firestone tells me. “We do seek to maintain brand loyalty among existing adult smokers and there are many who prefer our brands and those who don’t currently prefer we would like them to switch to our brands.”

Firestone rejects the suggestion that Uruguay is being deliberately “targeted” by the cigarette industry as part of a broader strategy to scare off smaller countries perhaps contemplating similar legislation. His accusation is that Uruguay’s laws breach existing trade agreements.

Uruguayan cigarette packaging already features anti-smoking adverts

“We had to withdraw seven of our 12 brands and obviously that disrupts our ability to compete in the marketplace with lawful products. So that’s why I say the regulation itself is highly unusual,” says the man from PMI.

‘It’s going to be a big fight’

Michael Bloomberg may be a champion of the capitalist system and made his own fortune in the free market but the tobacco companies’ arguments don’t wash with him.

“There’s nothing else I will do that will save as many people,” Bloomberg tells me. “It’s going to be a big fight. You’ve got to do something about these companies. You can’t just sell something that if used as advertised will kill people.”

Michael Bloomberg has made himself unpopular before with his campaigns against the gun lobby and global warming but you get the distinct impression that it’s his money and he’ll spend it as he wants on the issues he cares about.

Shrewsbury shopkeeper may stub out cigarette sales altogether after law change

A newsagent may stop selling cigarettes after new regulations banning the display of tobacco made it “more trouble than it’s worth”.

Ron Miller, of Castle News, Castle Gates, Shrewsbury, said a ban on displaying tobacco in small shops, which came into force yesterday, has made life difficult for traders.

He said: “It makes work a lot more difficult for us.

“Sales often go up when people are told they cannot do something. It just makes things for difficult for shopkeepers.

“I am seriously considering getting rid of them altogether.

“They are more trouble than they are worth.

“The cigarette market isn’t a big one for us now. I am going to concentrate on other things rather than tobacco.”

The ban has been welcomed by campaign group Action on Smoking and Health (Ash), but criticised by shopkeeper group the Tobacco Retailers’ Alliance and other retailers.

And the news has been met with mixed reaction by other Shropshire newsagents.

George Walker, manager of Claremont News in Claremont Street, Shrewsbury, said: “I think it is a bit unnecessary.

“I don’t think it will deter people. It is an added burden and just a scheme to make the Government look good.”

John Vine, who owns Newsworld in Sandford Avenue, Church Stretton, said: “We have had ours in a month and we are selling as many now as we did before the display changed.

“Ninety per cent of our customers are regulars who come in for their tobacco and haven’t stopped coming in because of the new display.

“So I don’t think it will make any difference – it certainly has not with us.”

Ramandeet Jarhal, director of Wilbrahams News in Shrewsbury Street, Whitchurch, said: “I think it is a good thing.

“It can be annoying for the retailer having to keep opening and closing the doors but I think it will probably deter more people from smoking.”

Hazel Cheeseman, director of policy at Ash, said the changes were vital to stop children smoking at an early age.

She said: “Two-thirds of smokers start before the age of 18, so it is vital that everything is done to put tobacco out of sight to protect future generations.

“The display ban in small shops will work hand in hand with standardised packs, which will be introduced in May 2016, to further protect children.”

Warning images on cigarette packets ‘raise young adults’ knowledge about harms of smoking’

A new study suggests a combination of health warning images and text on cigarette packets is more likely to drive a greater appreciation of the dangers of smoking among young adults than text warnings alone.

Researchers found that graphic health warning labels on cigarette packets - like these from the Brazilian Health Ministry - are more effective for increasing knowledge about the health consequences of smoking. Image credit: Public domain via Wikimedia Commons

Researchers found that graphic health warning labels on cigarette packets – like these from the Brazilian Health Ministry – are more effective for increasing knowledge about the health consequences of smoking.
Image credit: Public domain via Wikimedia Commons

Study authors Renee E. Magnan, PhD, of Washington State University, and Linda D. Cameron, PhD, of the University of California-Merced, publish their findings in the Annals of Behavioral Medicine.

As part of the 2009 Family Smoking Prevention and Tobacco Control Act, the US Food and Drug Administration (FDA) published a final rule in 2011 requiring tobacco companies to include color graphics on cigarette packets warning consumers of the negative health implications of smoking.

In August 2012, however, this rule was overturned by the government after it was challenged by several tobacco companies, who claimed such graphic warnings would violate the tobacco industry’s right to free speech.

Though this decision was upturned by the US supreme court in 2013, giving the FDA the go-ahead for enforcing graphic warnings on cigarette packets, it is unclear when – or if – it will happen.

Numerous studies have suggested that graphic health warnings on cigarette packets – such as those showing smokers dying in hospital beds and diseased body parts – are more like to help smokers quit the habit than text-only warnings. According to Magnan and Cameron, however, few studies have investigated how much adults learn from these warnings.

Graphic warning labels raise understanding, worry of smoking health consequences

To find out, the researchers surveyed two groups of smoking and nonsmoking adults aged 18-25 – some of whom had been recruited through a national website survey service, and some of whom took part in the survey as part of an undergraduate psychology course.

Fast facts about smoking

Almost 18% of Americans aged 18 and over currently smoke cigarettes
Cigarette smoking is the leading cause of preventable death in the US, responsible for more than 480,000 deaths annually
Men are more likely to be current cigarette smokers than women.

All participants were shown a variety of health warning labels on cigarette packets stating the negative consequences of smoking – such as lung cancer, heart disease, stroke and eye disease – either through text or a combination of text and images.

Subjects were then asked to rate how much each warning label influenced their understanding of the health consequences of smoking, whether it increased their knowledge of smoking-related health conditions, whether it evoked worry, and whether it discouraged them from smoking.

The results of the survey revealed that participants in both groups reported greater understanding and knowledge of the health implications of smoking from warning labels containing both images and text than text-only warning labels, as well as greater worry about health consequences and greater discouragement from the habit.

The researchers found that only two labels containing both images and text – one depicting impotence though a limp cigarette in an individual’s hand, and one depicting prolonged illness through an IV needle in a person’s skin – produced the same levels of understanding as their corresponding text-only labels.

Magnan and Cameron say their findings indicate that creating more informative health warning labels on cigarette packets through the use of images may cause people to worry about the health consequences of smoking and may even encourage them to quit.

Magnan adds:

“Although this is a preliminary investigation, from a policy perspective, these outcomes suggest that focusing on deriving greater understanding and knowledge from such labels may have more impact in terms of both motivational and emotional responses.

Importantly, however, these labels are only a small piece of what should be a larger campaign to educate the public on the dangers of smoking.”
Last month, Medical News Today reported on the release of the fifth edition of The Tobacco Atlas, in which experts claim the tobacco industry is using a “well-resourced array of tactics” to prevent global tobacco control.

Written by Honor Whiteman

FDA questions evidence for lower-risk tobacco product

WASHINGTON (AP) — U.S. health regulators have questions about the data submitted by tobacco maker Swedish Match in its bid to become the first company to market a smokeless tobacco product as less harmful than cigarettes.

Food and Drug Administration scientists say they have “concerns” about how the company studied its snus tobacco product and its proposal to modify cancer warning language on the packaging.

Snus are teabag-like pouches or loose tobacco that users stick between their cheek and gum to absorb nicotine. They are popular in Scandinavian countries and are part of a growing smokeless tobacco market in the U.S.

The FDA has scheduled a two-day meeting to review Swedish Match’s data intended to show that snus do not carry the same risks of mouth cancer, gum disease and tooth loss as other tobacco products.

In an application filed in June, Swedish Match, whose North American headquarters is in Richmond, Virginia, proposed a new warning emphasizing that snus are less risky than smoking: “No tobacco product is safe but this product presents substantially lower risks to health than cigarettes.”

But in a scientific review posted Tuesday, FDA staff question whether that language “adequately reflects the health risks of using snus.”

Swedish Match also wants FDA clearance to remove a warning about mouth cancer from its product. But agency staffers note that the studies submitted by the company may have underestimated cases of mouth cancer as users quit using snus.

Among other changes, Swedish Match wants the FDA to permit dropping another warning that smokeless tobacco products can cause gum disease and tooth loss. But regulators note a number of shortcomings with the company studies of that issue, including small populations that were often made up of adolescents and young adults. Additionally regulators say the company “does not provide an argument as to why it is biologically plausible that effects of snus on gum disease and tooth loss would be significantly different from other smokeless tobacco products.”

The agency will ask an advisory panel to weigh in on these and other issues. The FDA is not required to follow the advice of the group, which is composed of outside experts specializing in tobacco control, public health and cancer care.

The advisory panel’s review and FDA’s ultimate action on the application are being closely watched by both the public health community and tobacco companies, which are looking for new products to sell as they face declining cigarette demand due to tax increases, health concerns, smoking bans and social stigma.

Under a 2009 law, the FDA was given authority to evaluate tobacco products for their health risks and approve ones that could be marketed as safer than others. The agency has received 17 applications for such products, according to an agency spokeswoman, but none has been given the OK yet. Ten are currently pending review. Agency officials have previously noted that some tobacco products could pose less of a health risk to users than smoking.

CDC targets LGBTs with Tips From Former Smokers Campaign

This month CDC is launching its 4th annual wave of the popular and effective “Tips From Former Smokers ( Tips )” campaign, with its largest ever LGBT media outreach component. CDC is promoting Tips ads to LGBT communities across the country to supplement exposure to ads airing nationally.

“LGBT people spend an estimated $7.9 billion dollars each year on smoking, yet we still think of it as a personal choice; it’s time we realize we smoke at such high rates because of systematic targeting by the tobacco industry” said Dr. Scout, the Director of LGBT HealthLink. “We’re deeply pleased CDC is doing this level of marketing to reach the LGBT population, because the tobacco industry has been doing it for a long time.”

The Tips campaign has spurred an estimated 1.64 million Americans to make a cessation attempt. New information from the Surgeon General’s 50th anniversary report on tobacco ( #SGR50 ) not only acknowledges the disproportionate impact of smoking on the LGBT communities, but also links tobacco use to higher rates of additional cancers and for the first time, diabetes as well. This integration of LGBT communities into tobacco control programming has become more routine every year. The Acting Surgeon General made statements specific to the LGBT impact upon release of last years’ report, and prior Tips campaign ads and media buys have had a measure of activity tailored to the LGBT population. This year’s campaign has the most extensive LGBT media buy to date. CDC’s Office on Smoking and Health has long funded an LGBT tobacco disparity network, currently LGBT HealthLink. This is one of eight disparity networks that serve to provide CDC and their state grantees resources to assist reaching populations disproportionately impacted by tobacco and cancer.

“We’re incredibly pleased with the federal outreach to LGBT communities and states are reaching out more as well. When you call 1-800-QUITNOW you’re very likely to be asked if you’re LGBT, because we urged it; you’re very likely to get a counselor who is trained in LGBT cultural competency, because we provided the training; and in some states you’ll even see locally tailored outreach campaigns too,” notes Dr. Scout.

“LGBT communities smoke at rates that are about 50% higher than their heterosexual/straight counterparts. CDC is very concerned about this elevated smoking rate and committed to making sure tobacco control campaigns like Tips really do help reduce that disproportionate burden on LGBT communities,” said Tim McAfee, M.D., M.P.H., senior medical officer in CDC’s Office on Smoking and Health.

LGBT tailored Tips ads will run from now through Pride month and into mid-August in a variety of regional, national and digital media sites, as well as on social media. Access electronic versions of the ads, as well as videos, podcasts, and LGBT smoking facts at: .