Increasing the legal age for tobacco purchase should be combined with other measures to reduce smoking rates in young people

Achieving a smokefree generation—defined as smoking rates below 5% across all groups in society—is a key public health goal, but not one that can be achieved simply by continuing with existing measures. [1] Helping existing smokers to quit remains essential, but the most vital element is to stop young people from starting to smoke in the first place.

Most smokers start during childhood, hundreds in the UK each day, and two thirds of those who try smoking will go on to become regular smokers. [2,3] In this context, the proposal from the All Party Parliamentary Group (APPG) on Smoking and Health to increase the legal age for tobacco purchase from 18 to 21 is welcome. This change would make it harder for children to obtain cigarettes and, importantly, would take legal purchase of cigarettes beyond school age.

Smoking is a contagious habit, transmitted by peers—the higher the proportion of a child’s friends who smoke, the more likely they are themselves to smoke. [4] The age increase will protect younger children from exposure to older pupils in school who smoke and whose behaviour they may want to imitate. The gap will also remove a potential source of supply within schools. [5]

The tobacco industry fears this policy. Philip Morris has stated that raising the legal minimum age for cigarette purchase to 21 could “gut” their key young adult market of 17 to 20 year olds. [6] When the UK increased the legal age for tobacco purchase from 16 to 18 in 2007, this was associated with a fall in youth smoking rates, an effect which a further increase would be expected to replicate. [7] The change in the legal age is feasible, and already in place in six US states.

Importantly, the age increase is only one in a raft of measures the APPG proposes. A “polluter pays” levy, set to raise a fixed amount from the tobacco manufacturers of around £150m (€173m; $198m) per year, will help to pay for a revitalised, evidence based set of tobacco control policies. This could include supporting the proposed introduction of a retail licensing scheme for tobacco products.

Currently, anyone is allowed to sell tobacco. Licensing would help to limit underage sales and make it easier to ban sales from those who break the law. The current restrictions on retail display have been associated with a fall in the proportion of children who smoke buying cigarettes in shops. However, the difficulty obtaining cigarettes in shops reported by those who do buy them is no greater than in previous surveys. [8] This highlights the need, in addition to licensing, for more effective enforcement which a levy could help to fund.

Other measures include further increases in taxes to reduce affordability, particularly for hand rolled tobacco; restoring spending on mass media education campaigns back to 2008 levels; supporting regional tobacco control bodies that have had a substantial impact; and the inclusion of government mandated pack inserts to support quitting.

Polling data show that these measures are popular with the public, and as healthcare professionals we should be advocating for them. [9] Ministers should seize the opportunity to deliver a healthy legacy.

Nicholas S Hopkinson, Reader in Respiratory Medicine, National Heart and Lung Institute, Imperial College London.

Competing interests: NH is the medical director of the British Lung Foundation and chair of the board of ASH

References:

1. Department of Health (UK). Towards a Smokefree Generation. A Tobacco Control Plan for England. https://wwwgovuk/government/publications/towards-a-smoke-free-generation-tobacco-control-plan-for-england (accessed 9th August 2017) 2017
2. Hopkinson NS, Lester-George A, Ormiston-Smith N, et al. Child uptake of smoking by area across the UK. Thorax 2014;69(9):873-5. doi: 10.1136/thoraxjnl-2013-204379 [published Online First: 2013/12/07]
3. Birge M, Duffy S, Miler JA, et al. What Proportion of People Who Try One Cigarette Become Daily Smokers? A Meta-Analysis of Representative Surveys. Nicotine & Tobacco Research 2017:ntx243-ntx43. doi: 10.1093/ntr/ntx243
4. Laverty AA, Filippidis FT, Taylor-Robinson D, et al. Smoking uptake in UK children: analysis of the UK Millennium Cohort Study. Thorax 2018:thoraxjnl-2018-212254. doi: 10.1136/thoraxjnl-2018-212254
5. Health and Social Care Information Centre. Smoking, Drinking and Drug Use Among Young People in England – 2014 http://www.hscic.gov.uk/catalogue/PUB17879 (accessed 23/6/16), 2015.
6. Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. The National Academies Press 2015:http://www.iom.edu/Reports/2015/TobaccoMinimumAgeReport.aspx.
7. Millett C, Lee JT, Gibbons DC, et al. Increasing the age for the legal purchase of tobacco in England: impacts on socio-economic disparities in youth smoking. Thorax 2011;66(10):862-65. doi: 10.1136/thx.2010.154963
8. Laverty AA, Vamos EP, Millett C, et al. Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England. Tobacco Control 2018 doi: 10.1136/tobaccocontrol-2018-054511
9. All Party Parliamentary Group on Smoking and Health. Delivering the vision of a ‘Smokefree Generation’ The APPG on Smoking and Health submission to the Prevention Green Paper. http://ashorguk/wp-content/uploads/2019/02/2019-APPG-reportpdf 2019