An Increase in the Tobacco Age-of-Sale to 21: For Debate in Europe.

A debate on the adoption of a tobacco age-of-sale of 21 in Europe has not occurred, with the recent exception of the United Kingdom. The current legally set age of 18 years is proving to be inadequate as adolescents continue to access cigarettes. Tobacco 21 laws have the potential to further limit access to cigarettes by minors. We believe that soon the time will be ripe for this discussion to spread throughout Europe, specifically among countries that have adopted a smoke-free generation movement.

Introduction

Age-of-sale laws aim to limit access to commercial sources of cigarettes by minors, and thereby prevent smoking initiation. Many countries have a legally set age of 18 years, but this is proving to be inadequate as adolescents continue to access cigarettes.[1] One way is via proxy purchases; adolescents ask acquaintances or strangers over the age of 18—often young people under 21—to buy cigarettes for them.[1]

Increasing the legal age-of-sale to 21 may be able to optimize the effect of age-of-sale laws by limiting access to cigarettes via proxy buyers between 18 and 20 years old.[2] It is likely to have the largest effect among adolescents aged 15–17 as they are least likely to have friends or acquaintances above the age of 21.[2] This is the age group in which most people start smoking.

An increasing number of countries and localities, mostly in the United States, have adopted an age-of-sale of 21 (referred to as “Tobacco 21”). Needham, Massachusetts was the first town in the United States to adopt a Tobacco 21 law in 2005. Since then, more and more localities have followed suit. Currently, 440 localities and 7 states in the United States have an age-of-sale of 21.[3] Despite the rapid diffusion of policy adoption in the United States, Tobacco 21 has not yet gained popularity in other parts of the world. In Europe, a tobacco age-of-sale of 21 is not on the political agenda of the European Commission nor of most European countries, according to policy documents and minutes from European Union (EU) expert meetings with national representatives.[4] The United Kingdom is an exception, as it is currently considering a tobacco sales age of 21.[5] This situation raises the question whether the discussion on future adoption of Tobacco 21 laws has the potential to spread throughout Europe.

Effectiveness of Tobacco 21

Evidence on the effectiveness of an age-of-sale increase to 21 on adolescent smoking is limited. To date, only three studies in the United States have evaluated the effectiveness, of which two showed favorable results.[6,7] A stronger decrease in 30-day adolescent smoking was found following the implementation of an age-of-sale of 21 in Needham (after a 5-year follow-up) from 13% to 7% compared to 15% to 12% in control communities.[6] The percentage of youth under 18 purchasing cigarettes from stores also decreased in Needham from 18.4% to 11.6% compared to 19.4% to 19.0% in control communities.[6] A study evaluating the increase to 21 in New York City also found a decrease in tobacco use, although it was smaller than in control communities.[7] A comparison between USA states found 39% lower odds of monthly or established smoking among 18–20 year old in states with tobacco-21 laws.[8] Other studies in the United States have looked at public support and awareness of the law among adolescents and retailers following the ban, which were both found to be high.[9,10] Further effectiveness studies are currently being conducted, eg on trends in smoking behaviour among young people in US localities that increased the legal age-of-sale.

Policy Adoption in Europe

Age-of-sale laws were first proposed at a European level in the 2003 Recommendation by the European Commission (Recommendation 2003/54/EC, not legally binding), which focused on measures to reduce cigarettes supply to young people.[11] Article 16 of the World Health Organization Framework Convention for Tobacco Control, which is legally binding and has been signed and ratified by all European countries, requires countries to prohibit the sale of tobacco products to minors but does not specify an exact age limit.

Scandinavian countries had an age-of-sale of 16 since the 1970s and were among the first to adopt a tobacco age-of-sale of 18 years old between 1995 and 1997.[12] This was followed by a number of Eastern-European countries that adopted an age-of-sale of 18 years between 2002 and 2004 with no prior age-of-sale in place. In addition, Ireland also increased its age-of-sale from 16 to 18 in 2002.[12] Between 2006 and 2009, many countries followed suit including Denmark, France, Portugal, Spain, England, and Scotland.[12] The Netherlands adopted an age-of-sale of 18 in 2014.[12] Belgium and Austria are the only two European countries with a current age of 16.[12]

Differences in Starting Points US and EU

There are three main factors that give Europe a different starting point than the United States, and which may influence the likelihood of Tobacco 21 adoption in Europe in the near future.

First, in the United States, policies regarding age-of-sale can be introduced at the local level. The US Food and Drug Administration (at the federal level) is not authorized to increase the legal sales age over the age of 18. Adoption of Tobacco 21 laws instead started at the municipal level—primarily put into motion by pressure groups—and was followed by a few states.[13] In Europe, the opportunities to adopt new laws at the municipal level are more restricted, and adoption would therefore directly need to take place at the national level (similar to the state level in the United States).[14] Countries may therefore be more dependent on political parties in place at the national level, and their willingness to adopt new measures.[14]

Second, although both the United States and Europe have legal ages of adulthood of 18 years old, they differ with regard to drinking ages. For the past 25 years, the United States has had a legal alcohol age-of-sale of 21, which is often used as a strong argument for increasing the age-of-sale for tobacco.[15] In Europe, most countries have a legal purchasing age for alcohol and tobacco of 18 years old, with three countries having a legal age between 16 and 17, and five countries having a legal age dependent on alcohol content.[16] An alcohol age-of-sale higher than 18 years old is only found Sweden, which does not allow beverages with more than 3.5% alcohol to be sold to those under 20 years old. An increase of the tobacco age-of-sale to 21 may lead to a discrepancy between tobacco and alcohol, if the alcohol age-of-sale remains 18. This may dominate and frustrate a public debate on tobacco age-of-sale of 21.

Third, public support for Tobacco 21 appears to be low when compared to other tobacco control policies targeting young people. In the Netherlands, public support figures from a general population survey from 2014 found 84.1% supported a smoking ban in cars with children, 85.3% supported smoking bans at secondary schools, whereas 47.4% supported an increase in the age-of-sale to 21.[17] In Germany, 43.1% supported an increase from 18 to 21 in 2016.[18] These figures are still relatively low and are therefore not yet conducive to public debate.

Future Perspectives for Europe

Although the adoption of an age-of-sale of 21 is currently not a “hot topic” in Europe, there may be potential for a debate in various countries. A driving factor may be the smoke-free generation movement in Scotland, Ireland, Finland, France, the Netherlands, and other countries. The aim of this movement is to reduce the adolescent smoking prevalence under 5% within the next 15–20 years.[19] To reach this goal, these countries are adopting more and more restrictive policies that may influence youth smoking initiation such as point-of-sale display bans, plain packaging, and smoke-free playgrounds.[19] For example, the United Kingdom has recently adopted plain packaging and a smoking ban in cars with minors. The UK government is currently considering a sales age of 21 as a next step in its strategy to protect youth against smoking.[5]

If countries such as the United Kingdom were to adopt an age-of-sale of 21 years old as a step toward a smoke-free generation, then this may instigate a new policy diffusion process for this policy in Europe. National tobacco advocacy groups in Europe are often influenced by examples set by English-speaking countries such as the United Kingdom.[14] However, the timing of past policy adoption differed greatly between European countries.[20] If the policy in question is not covered by EU regulations then adoption will be dependent on national factors. Policy diffusion of Tobacco 21 laws may therefore not progress uniformly across countries.[20]

For the diffusion of Tobacco 21 laws to Europe, there may need to be more evidence on the effectiveness of the laws on smoking prevalence, eg from studies on trends in youth smoking and related behaviour around the time of implementation of Tobacco 21 laws.[14] If found to be effective in the European/UK setting, it may persuade policy makers from other countries to adopt this measure and provide strong arguments against pushback from the tobacco industry.[21]

Conclusion

A debate on the adoption of a tobacco age-of-sale of 21 in Europe has not occurred, with the recent exception of the United Kingdom. We believe that soon the time will be ripe for this discussion to spread throughout Europe, specifically among countries that have adopted a smoke-free generation movement.

Funding

This study is part of the SILNE-R project, which received funding from the European Commission (EC), Horizon2020 program, Call PHC6-2014, under Grant Agreement n°635056.

Conflict of Interests

There are no conflicts of interest.