Impact of Raising Smoking Age Was Underestimated, Yale Researchers Find

A study by Yale School of Medicine researchers estimates that raising the age for tobacco sales to 21 could avert more than 525,000 deaths, more than double prior estimates.

In 2020, the federal minimum age for buying tobacco products was officially raised from 18 to 21 as an increasing number of states and localities across the country sought to raise the age for tobacco purchases to protect the health of young adults.  One of the driving factors behind the change, according to Yale officials was a 2015 report from the National Academy of Medicine (NAM) that found that a federal Tobacco 21 (T21) law could prevent as many as 249,000 deaths through the year 2100.

Now, a new study led by Yale researchers with the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group has determined that the NAM report grossly underestimated the number of averted deaths.

The findings significantly amplify the potential impact of the T21 law and provide important new information for future state and local policy discussions surrounding tobacco regulation and public health. The Yale study was published in JAMA Health Forum on December 20, 2024, the fifth anniversary of the signing of the U.S. T21 law.

The modeling study estimates that comprehensive enforcement of local, state, and federal T21 laws could result in up to 526,000 premature smoking-attributable deaths being averted across the United States and 13.3 million life-years gained through 2100. The findings more than double the estimate provided in the NAM report.

The CISNET modeling study, by comparison, incorporated comprehensive state data on smoking patterns, mortality, and T21 policy implementation at the local, state, and federal levels. These detailed data, in addition to rigorous evidence on the effects of T21 policies, were used as inputs for simulation models developed for each of the 50 states and the District of Columbia. Because it takes decades before changes in smoking behavior translate into disease and deaths, simulation models were used to understand the potential long-term effects of smoking prevention policies.

Among the 50 states, New York and Massachusetts were top ranked in relative mortality reductions for their early and widespread adoption of T21 policies at the local level, the study found. Hawaii, as the first state to implement T21, also had higher relative mortality reductions compared to states that were slower to implement the law.

“We felt it was important to quantify the benefits of Tobacco 21 policies and to give credit where it’s due,” Dr. Jamie Tam, PhD, assistant professor of public health (health policy) at the Yale School of Public Health and the study’s lead author, explained. “Local communities and states that pushed for Tobacco 21 policies early on reap those benefits down the road. Our models use real-world policy data to reflect that.”

Other collaborators on the study included Alyssa Crippen, PhD, Abigail Friedman, PhD, and Theodore R. Holford, PhD, all from the Yale School of Public Health, as well as experts from British Columbia Cancer Research Institute, University of Michigan, Georgetown University, and the Preventing Tobacco Addiction Foundation/Tobacco 21.

News of the study was first reported on the website of the Yale School of Medicine.