Age Restrictions on Smoking, Drinking and Driving

State legislatures have been lobbied in a coordinated effort, called Tobacco 21 (here), to raise the minimum age for tobacco sales from 18 to 21 years.  Hawaii, California and the District of Columbia have adopted the higher age limit, but numerous city and county ordinances have been passed.

As an advocate of tobacco harm reduction, I strongly oppose any tobacco use by teenagers.  However, I am unconvinced that implementing a smoking ban for those under 21 is an effective strategy.

One of the arguments for Tobacco 21 is that the same age limit has reduced teenage drinking.  The National Minimum Drinking Age Act was passed in 1984.  By 1988, all states prohibited alcohol purchase by those under 21.  The impact on underage drinking is debatable.  It has been on the decline for many years, but rates remain disturbingly high (here). 

The chart above shows past-month (i.e., current) cigarette smoking, marijuana use, alcohol consumption and binge drinking (5 or more drinks on one occasion) among 16-17, 18-20 and 21-25 year olds in the 2014 National Survey on Drug Use and Health.  Despite almost 30 years of Alcohol 21 across the county, nearly a quarter of 16-17 year-olds and 44% of 18-20 year-olds were currently drinking, compared with 11% and 24% who were smoking.  In addition, a majority of drinkers were binging.  In 2014, recreational marijuana wasn’t legal for anyone, yet 15% of 16-17 year-olds and 21% of 18-20 year-olds were using that drug. 

We can also compare these figures with those from 10 years earlier.  Here are the changes in current use from 2004:

Percentage Change From 2004 to 2014 in Prevalence of Youth and Young Adults Who Currently Smoke, Toke, Drink or Binge Drink
Age (yrs)	Smoke	Toke(%)	Drink	Binge Drink
16-17	-51	+6	-28	-41
18-20	-36	+17	-14	-23
21-25	-25	+25	+4	-1

With Alcohol 21 in force for almost 30 years, drinking and binge drinking declined moderately among 16-17 year olds.  But smoking saw the steepest declines in all age groups, even in the absence of a ban for 18-20 year-olds.

Alcohol 21 and Tobacco 21 laws are promoted to save lives.  In the case of smoking, the lives saved are far in the future, as smoking generally takes a toll in advanced age.  With alcohol, the lives saved are primarily from traffic accidents.  With or without alcohol, traffic accidents are the number one killer of youth and young adults (age 16-24 years), with about 7,000 deaths each year (here).  Legislators seeking immediate life-saving impact should consider further age-restricted driving licenses. 

The Human Toll of Anti-Tobacco Extremism

This is a tale of two tobacco users and the very different medical advice they received.

• In 2005, two physicians and a dentist published a report in the American Journal of Psychiatry (reference here):

“Ms. A, a 52-year-old woman with schizoaffective disorder, bipolar type, started smoking shortly after her first psychotic episode at age 19 and, on average, smoked about 1½ packs per day for 33 years. She had attempted to quit using pharmacotherapy, nicotine gum, or patches in combination with cessation classes. Both gum and patch treatments were ineffective since they did not control her craving for cigarettes.

“Her motivation to quit was strong because of the sequelae of smoking: bronchitis, isolation from others, and destabilization of her psychiatric illness from frequently awakening to smoke. Her brother with a bipolar disorder had experienced severe burns over most of his body and died secondary to a fire caused by his smoking. For her, smoking had become a constant reminder of his suffering, which led to nightmares and further isolation. She was afraid to jeopardize the health and safety of others.

“One year ago, she was cross-titrated over a 1-week period to oral pouches. Since that time, she has not resumed smoking, and her psychiatric and medical symptoms have stabilized. Before her cessation of smoking, she lived an isolated existence. Now she resides with and cares for her parents. For Ms. A, ceasing to smoke was a life-changing event.” 

• A disabled veteran with post-traumatic stress disorder sent me this email:

“My doctor has been pounding me regarding mouth cancer and me dipping. I have good oral hygiene, but she insists I will get cancer. I now find myself worrying sick every time I have a wrinkled gum, or cut from a chip....etc.

“Please give me advice.

“Should I be concerned and quit dipping and switch to a vape or gum??  It is about to drive my wife nuts, it seems I’m always looking at my mouth now, and the doctor has her convinced too that I’m at a 4 times more likely [to get mouth cancer] than a non dipper.  Your input to ease my mind please.  I do not have a laptop, but saw your book.  Can’t read it on the phone.  So thought I’d ask.  My grandfather, right here in Kentucky smoked Pall Mall nonfilter cigs for 65 years...he died from a bleeding stomach ulcer caused by aspirin... I NEED TRUTH AND PEACE OF MIND. So I don’t become ocd more than I am since she gave my wife all these statistics.  I’d rather hear the blunt truth.

“Should I be worried?

“I’m 41, dip a can in a day and half, have dipped for 17 years since I went in the Army. I have high BP...(according to them) 140/84..

“Appreciate it very much if you would kindly respond.”

I asked the writer to put me in contact with his physician, so that I could provide her with factual information and resources for the benefit of all her patients.

These stories are polar opposites, but equally poignant.  Doctors in 2005 successfully switched a patient with severe mental problems from cigarettes to smokeless tobacco, citing two of my studies (here and here) as the scientific basis for their humane and “life-changing” guidance.  In 2017, a misinformed physician tormented a disabled veteran about smokeless tobacco’s negligible mouth cancer risk (here).     

Too many doctors cause unnecessary suffering among tobacco users and their families.  Their actions are influenced by the misguided crusade against smokeless tobacco conducted by many government agencies and prohibitionist organizations.  This harmful disinformation effort must end.