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Raising the Smoking Age to 21 Saves Lives

San Francisco is the latest city to raise the legal cigarette smoking age from 18 to 21.

03.03.16 5:30 PM ET

It’s about to get harder for teenagers to smoke in San Francisco.

This week, the San Francisco Board of Supervisors voted unanimously to raise the legal age to buy cigarettes and other tobacco products to 21. The change will become effective at the beginning of June. With this new law, the City by the Bay will join several others, including New York City and Boston, as well as the entire state of Hawaii.

These laws are aimed at keeping new smokers from initiating the habit. Nearly 90 percent of smokers started before age 18, so raising the legal age of purchase is meant to keep young people from trying it in the first place. Given that older peers often provide cigarettes to underage smokers, laws such as San Francisco’s may make that harder to accomplish. High school seniors will still be a few years away from being able to buy smokes for their sophomore friends.

A study last year conducted by the Institute of Medicine (PDF) offered this striking conclusion: Raising the minimum age of purchase for tobacco products to 21 would result in 4.2 million fewer years of life lost due to smoking-related reasons for those born in the first two decades after 2000. They project that raising the smoking age now would result in a 3 percent decline in future adult smokers if it were to go up to 19, 12 percent if bumped to 21, and 16 percent if raised all the way to 25.

However, because most of the benefit would derive from disrupting the connection between younger prospective smokers and of-age friends, increasing the age to 25 would have diminishing returns for potential new smokers in the 15-17 year age range.

It’s worth noting, however, that this conclusion rests on raising the legal age to buy cigarettes nationwide. It’s too early to tell what the effect of more localized efforts like San Francisco’s will be. Also worth noting is that cigarette smoking by American teenagers has been in decline over the past several decades. Even with the current cut-off for most of the nation at 18, trends are already heading in an encouraging direction.

To what degree raising the legal smoking age will move this trend is difficult to assess, particularly when it comes to measures that affect only one particular area. The most obvious comparison is with alcohol, where the age limit to purchase was raised nationwide in 1984. Raising the legal limit to 21 did result in a significant drop in drinking among 18- to 20-year-olds in the years that followed. Though it rose again by the late 1990s, adolescent alcohol use also continues to decline.

Speaking on a purely intuitive level, I suspect that the effectiveness of laws raising the smoking age will vary based on the area they cover. It’s far too soon to have any data to back this up, but my guess is that Hawaii’s will be among the more successful. It takes a far more motivated 19-year-old to hop a flight from Honolulu than to get on board the BART, after all.

Yet even seeing the data from the Institute of Medicine, and lauding the goal of decreasing youth smoking wholeheartedly, I still find myself pausing before joining the chorus praising these new laws. I’ll admit, it’s a bit of an uncomfortable feeling to be out of alignment with the American Academy of Pediatrics (of which I am a member), which supports a nationwide increase in smoking age to 21. But as much as I value efforts to increase public health, I also value letting people make their own decisions for themselves, even if I think those decisions are awful. It’s for similar reasons that I dissent from the Academy’s position on legalizing marijuana use for adults, as well.

I think smoking is the absolute worst. Even smoking in small amounts is terrible for you. Whenever I ask my teenage patients if they smoke (and I ask routinely at every well visit), those who say they do are told to make an effort to stop as promptly as possible.

Having said that, though, and knowing I’m likely to get intense push-back from my pediatrician friends on social media, I still think grown-ups should have the choice to do what they may with and to their own bodies. If we allow 18-year-olds to vote, consent to their own cardiothoracic surgeries, and parachute into war zones, I just can’t force myself to say I think they shouldn’t have the freedom to choose something I really wish they wouldn’t. (I am entirely OK with toughening penalties for providing tobacco to minors, however.)

Unscientific as I concede my observations to be, I think it’s worth noting that far more of my patients admit drinking alcohol and smoking marijuana than smoke cigarettes. Even the majority of those who ingest some other substance I wish they wouldn’t seem to find tobacco revolting. Though hardly likely to get published in Lancet, the evidence I encounter in my own office suggests that efforts already in place to curb teen smoking are having a good effect.

However, those who put a premium on reducing it even further are likely to disagree with my position, and I certainly respect their perspective. The available data are encouraging with regard to the likely impact raising the smoking age will have on advancing that goal, and it’s a goal I sincerely want advanced. I’d just prefer to achieve it by continuing to convince as many teenagers as possible that it’s a gross habit to pick up in the first place.