Congratulations to the Hawaii Legislature for being a leader in health by approving a bill to raise the legal age for smoking to 21.

This commentary is in response to Dr. Kathleen Kozak’s column on May 4, acknowledging that raising the age for smoking would save lives and money. However, she outlines dusty old arguments used by the tobacco industry to weaken protections for public health. This is surprising given Dr. Kozak’s usual measured and thoughtful approach to addressing health issues in the Health Beat column and her Hawaii Public Radio weekly program.

As a pediatrician at Kapiolani Medical Center for Women and Children and medical director of the HEALTHY Tobacco and Nicotine Cessation Program, I see the consequences of early initiation of tobacco and nicotine use. I care for many children suffering from secondhand smoke, as well as young people who start tobacco use and remain addicted to nicotine for their lifetimes.

No Smoking sign

Chad Blair/Civil Beat

On a daily basis, I see newborn infants, children, adolescents and young adults adversely affected by tobacco exposure. Effects include low birth weight, increased respiratory infections in children, and asthma exacerbation in all age groups. I support raising the legal smoking age to 21 because it will clearly save lives, decrease addiction, reduce everyone’s collective heath care costs, and protect our keiki.

There is plenty of data to support the following:

Smoking is deadly. This fact has been known for decades. Smoking kills more people than alcohol, AIDS, car accidents, illegal drugs, murders and suicides combined. Approximately 480,000 people in the U.S., including 1,400 in Hawaii, die each year from smoking or exposure to secondhand smoke. Of all the kids who become new smokers each year, almost a third will die from smoking.

Smoking costs all of us, even nonsmokers. Not only is the habit itself expensive for users, but the cost to all of us is astronomical. Every year, tobacco use results in $132 billion of health care costs in the U.S., including $526 million in Hawaii. Hawaii families pay $834 per household in additional tax burden from smoking-caused government expenditures. Smoking-caused productivity losses in our state are estimated at $387.3 million a year.

I support raising the legal smoking age to 21 because it will clearly save lives, decrease addiction, reduce everyone’s collective heath care costs, and protect our keiki.

Nicotine addiction starts early but lasts a lifetime. Do you remember making impulsive decisions when you were younger that you later regretted? Starting smoking is a decision that many regret but are unable quit due to the highly addictive nature of nicotine. The young adult brain is not fully developed at age 18 to 21. Impulsivity and risk-taking is higher, while the reward centers of the brain are more susceptible to the effects of nicotine. Tobacco companies have known about this for many years and specifically target young adults under age 21 as their brain chemistry makes them more likely to become addicted to nicotine.

According to the U.S. Surgeon General, 95 percent of all adult smokers start smoking before the age of 21. Three out of four teen smokers continue to smoke into adulthood, even if they intend to quit. A study published in the American Journal of Preventive Medicine concludes that nicotine exposure during adolescence has multiple adverse health consequences, including impacting the development of the cerebral cortex and hippocampus. This study recommends that sales of all nicotine products be restricted until at least 21 years of age.

According to the Institute of Medicine report released earlier this year, if the age to purchase tobacco products was raised to 21 nationwide, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019. Predicted smoking prevalence would fall from 17.8 percent to an estimated 12 percent.

Nicotine addiction is promoted with large amounts of corporate funds. Tobacco corporations spend more than $9 billion a year in marketing their products in the U.S., with $27.4 million spent in the state of Hawaii. This includes large amounts of money spent on lobbyists and attorneys to combat any legislation involving tobacco and nicotine control.

E-cigarettes are often used for initiation of nicotine use in young people. E-cigarettes are not at all FDA approved and the aerosol that is emitted contains nicotine, ultra-fine particles and toxic chemicals such as formaldehyde, lead, nickel, and acetaldehyde, all of which are known to cause cancer, birth defects and other reproductive harm. E-cigarettes are not regulated by the U.S. Food and Drug Administration (FDA). To date, no e-cigarette manufacturer has submitted their product to the FDA for review to become an approved cessation device because the purpose of these products is not to cease smoking, but to replace one nicotine delivery device with another.

Youth use of e-cigarettes is growing at an alarming rate, especially in Hawaii where teen use is twice as high as the national average. E-cigarette youth usage tripled (18 percent) among Hawaii high school students and quadrupled (8 percent) among Hawaii middle school students. Raising the legal age to 21 will help keep tobacco and e-cigarettes out of schools, where younger teens often obtain these products from peers who are 18 years old.

An independent poll conducted in 2014 found that more than seven out of 10 Hawaii residents support a law raising the age of sale of tobacco products to 21 and Hawaii is not alone in considering this policy. More than 62 cities and counties in the U.S. (including Hawaii County and New York City) have raised the legal age to purchase tobacco products to 21.

Limiting access to these deadly products is the least we can do to help save lives. Tobacco companies have been proven to aim their marketing and advertising to children and young adults. By reducing access to tobacco for those under 21, we improve the health outcomes overall, and prevent the start of lifelong addiction to tobacco and nicotine for many young people.

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About the Author

  • Bryan Mih
    Dr. Bryan Mih is an assistant professor of pediatrics at the John A. Burns School of Medicine and a pediatrician at Kapiolani Medical Center for Women and Children (KMCWC) in the Pediatric Clinic and Term Nursery. He is the medical director and principal investigator for HEALTHY Tobacco and Nicotine Cessation Program at KMCWC. He is an active member of the American Academy of Pediatrics, a former board member of the Hawaii chapter, and is involved with the provisional section on tobacco control. He also serves on the board of Hawaii Public Health Institute (Coalition for a Tobacco-Free Hawaii is a program of the Institute).