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Deakin Health Economics (DHE) was commissioned by the Minderoo Foundation in early March 2018 to conduct systematic reviews on existing and potential impact of raising the legal age for smoking from 18 to 21 (Tobacco 21), product flavouring, and e-cigarettes on youth smoking rates. This document provides a summary of the full report together with appendices.

An overview of the literature review methods is at Appendix Two. Data extraction tables are available on request.

The differentiation between the legal age at which a person can purchase tobacco and the legal age that a person can smoke is made in some countries or local areas, but not in others. Though the age of smoking in many jurisdictions is 18 years, nearly half of current smokers become regular daily smokers before age 18 and approximately 95 percent of adult smokers began smoking before they were 21. As legal access to and use of cigarettes becomes more difficult, sources from peers, family, and carers become more important. In an attempt to reduce peer and family sources, there is a strong policy push in the US to raise the minimum legal age (MLA) for purchasing tobacco products to 21. The first Tobacco 21 law was adopted in the local town of Needham, near Boston, Massachusetts in 2005. By 2013, seven other localities had joined Needham, as well as the state of Hawaii (2013). Three years later, another 125 localities had followed suit. New York City (2014) and California (2016) followed more recently. Singapore has implemented a graduated approach to Tobacco 21, with the age for purchasing cigarettes rising to 19 in 2019, 20 in 2020 and 21 years in 2021.

Our review focused on three topics: (1) the impact of tobacco flavouring products on public health, (2) the public response to potential future bans on flavourings in tobacco products, and (3) the impact of banning flavouring tobacco products on smoking behaviours and smoking rates.

The results of our literature review suggests a number of pre-conditions for effective policy action on Tobacco 21. These include a strong need for action, community support, and respected advocates, a scientific case for action, and a clear policy design. A strong case for action can be made based on: (1) the threat posed by tobacco company targeting of adolescents and young adults, (2) the danger that hard won gains in reducing smoking prevalence will be lost, (3) the vulnerability of young brains to the effects of nicotine and nicotine addiction, and (4) the accepted role of government in controlling access to harmful substances. Quantitative social research conducted in some Australian states in 2017 suggests strong community support for policy action to raise the minimum age for smoking. Respected non-government organisations have also indicated their support, including the Cancer Council, the Australian Medical Association, the Medical Oncology Group of Australia, and the Private Cancer Physicians of Australia. Careful thought would need to be given as to how all community groups in Australia, particularly minority groups, would be engaged to support policy action.

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