What is the relationship between raising the minimum legal sales age of tobacco above 20 and cigarette smoking? A systematic review

Abstract

Objectives To determine whether raising the minimum legal sales age of tobacco (MLSA) to 20 or above is associated with reduced prevalence of smoking compared to an MLSA set at 18 or below through systematic review. Design Following a pre-registered protocol on PROSPERO (ref: CRD42022347604), six databases were searched for studies that assessed the association between MLSAs of 20 and above and tobacco smoking or tobacco sales. Assessments on e-cigarettes were excluded. Two reviewers independently extracted study data and used ROBINS-I to assess the risk of bias. Narrative methods were used to synthesise findings. Setting Global, with no language restrictions. Subjects Children and young people aged 11-20. Main outcome measures Current cigarette smoking and cigarette sales. Results 19 studies were reviewed, from which 26 effect estimates were extracted. All studies evaluated Tobacco 21 laws in the United States. Just under half of estimates found a statistically significant association with reduced current cigarette smoking or sales, just over half found no statistically significant association and one estimate found an association with increased cigarette smoking. The positive association appeared to be stronger for older age groups, those from a Hispanic/Latinx background and those with lower education. The degree of study bias was variable. Conclusions There is evidence that raising the MLSA for tobacco to 21 reduces cigarette sales and current cigarette smoking amongst those aged 11-20. It may have the potential to reduce health inequalities. Further research beyond the United States would support generalisability to other settings.

Perceptions of children and young people in England on the smokefree generation policy: a focus group study

“…Participants living in areas of higher deprivation were all very aware of shops in their area who sold underage tobacco and e-cigarette products, referring to this phenomenon with an apparent sense of resignation. Raising the age of sale of tobacco to both 18 [47] and 21 [6] have been associated with reducing socioeconomic health inequalities. Governments introducing SFG policies should direct resources for enforcement and communication into areas with high youth smoking rates and lower adherence with existing age-of-sale laws in order to have the greatest impact on health inequalities.…”

“…It found the introduction of Tobacco 21 was likely to reduce smoking rates, particularly for older school-aged groups and those aged 18-20. [6] However, there were differential effects by place of implementation. For example, impact of the policy was less clear for the state of California[7–9] which had issues with enforcement of the law immediately after implementation and several special exemptions.…”