THE IMPACT OF ENACTING OR RAISING THE MINIMUM LEGAL AGE TO PURCHASE TOBACCO PRODUCTS

Only a small number of studies have examined the effects of enacting or raising an MLA on underage tobacco use. All of these studies have come from international experience: one from Finland (Rimpela and Rainio, 2004) and two from the United Kingdom (Fidler and West, 2010; Millett et al., 2011).² All of the studies that investigated the effect of the policy on tobacco use reported decreases in underage smoking prevalence.

Rimpela and Rainio (2004) examined the effect in Finland of enacting an MLA of 16 in 1977 and increasing it to 18 in 1995. Adolescent tobacco outcomes were assessed using a biennial, nationally representative postal survey of adolescents (ages 12, 14, 16, and 18) for 1977–2003 as well as an annual postal survey of eighth and ninth graders (ages 14–16) for 1996–2003. Following implementation of the original MLA legislation in 1977, there was a significant—but small and short-term—decrease both in tobacco purchases from commercial sources and in tobacco use. After the MLA increased to 18 in 1995, there was no immediate effect on tobacco use. However, after a 2000 revision of the MLA policy requiring tobacco retailers to develop and implement an enforcement plan to prevent sales to underage persons, experimental smoking and later daily smoking decreased significantly among adolescents ages 14 and 16 (i.e., those targeted by the policy). Only experimental smoking decreased among 12-year-old adolescents, but the sample was too small for the daily smoking category. There was no change in either experimental or daily smoking observed among those ages 18 and older (i.e., those not targeted by the policy). In addition, Rimpela and Rainio (2004) found that purchases from commercial sources decreased, while obtaining tobacco from social sources (i.e., purchasing or being given tobacco from relatives, friends, or strangers) increased. Consistent with that finding, the frequency with which 18-year-olds, of legal age, also reported purchasing tobacco for friends was greater in 1999 than it had been in the 1970s. There were also changes in perceived access to tobacco: The proportion of adolescents reporting that it was rather difficult or very difficult to purchase tobacco was higher after the MLA increase, but the proportion of students reporting that it was very easy or fairly easy to purchase tobacco from commercial sources nevertheless remained high (72 percent in 2002–2003). In sum, these findings suggest that, among adolescents, raising the MLA decreased the amount of tobacco available from commercial sources, increased difficulty of obtaining tobacco, and reduced tobacco use despite adolescents having continued access to social sources.

Fidler and West (2010) assessed the effects on smoking prevalence of an increase in MLA from 16 to 18 in 2007 in England and Wales. Smoking outcomes were assessed using data from monthly cross-sectional household surveys of a representative sample of adults ages 16 and older. Following the 2007 increase in the MLA, smoking prevalence decreased significantly among all ages. This decline occurred against the background of a larger societal trend of an overall decrease in smoking prevalence, but the greatest percentage decrease during this period was seen among those of ages 16–17 (a 7.1 percent decrease) compared to those 18 and older (2.4 percent decrease), suggesting that raising the MLA did indeed decrease smoking prevalence beyond secular trends. Moreover, smoking prevalence was significantly higher among those 18 and over, and this difference in prevalence by age was significantly greater after the MLA increase than it had been before, suggesting that the MLA increase was successful in at least delaying initiation.

Millett and colleagues (2011) examined the effects of the same 2007 legislation that Fidler and West studied, but they looked at it in England, Scotland, and Wales, among younger ages (11–15) and by socioeconomic status (SES). Smoking outcomes were assessed using data from a national school-based survey of students in grades 7 to 11 from 2003 to 2008, excluding 2007, the year of the MLA increase. The effect of the policy on socioeconomic smoking disparities was assessed by comparing students who were eligible for free school meals (a proxy measure for low SES because eligibility for free school meals is assessed using parental employment and income) with those not eligible. The study found that the MLA increase was associated with a significant reduction in regular smoking among all adolescents, with no differences found between those eligible and ineligible for free school meals. The study also assessed the effects of raising the MLA on perceived access to tobacco from retailers. After the MLA increase, the proportion of students who smoked regularly and perceived that purchasing cigarettes from a shop was difficult did not increase among those eligible for free school meals, but it did increase significantly among those not eligible. At the same time, the percentage of students reporting that purchasing cigarettes from a shop was easy did not change from before the MLA increase to afterwards. These findings suggest that increasing the MLA decreased tobacco use overall and that the decrease was neutral with respect to SES.

LESSONS FROM ALCOHOL

Given the paucity of directly relevant data from prior experience with raising the minimum age for tobacco, the committee recognized the opportunity to look at similar domains, most obviously alcohol, to see what lessons might be learned. The United States had direct experience with raising the minimum legal drinking age (MLDA) for alcohol from roughly 18 (with some variation across states) to a national standard of 21 years of age, and that experience came recently enough that the country has not changed dramatically in the interim but long enough ago for there to be an extensive literature evaluating its consequences. Furthermore, different states implemented the change at different times, resulting in a stronger basis for causal inference than if all had acted simultaneously.

Tobacco is, of course, different from alcohol in myriad ways. Tobacco products are psychoactive, but they are not intoxicants. Alcohol has been embedded within human culture for millennia, whereas modern, mass-produced tobacco products (namely, cigarettes) are, comparatively speaking, a relatively recent phenomenon. And, of course, the mechanism of consumption, the neural pathways triggered, the patterns of use and cessation, and various other specific details differ in a variety of ways. So one could hardly observe a point estimate of the reduction in alcohol use following the raising of the MLDA for alcohol and imagine that same number would necessarily be a best estimate for the corresponding reduction one might expect from increasing the MLA for tobacco products.

Nevertheless, there are obvious similarities between the two products, their legal status, and their industries' practices. Both are dependence-inducing substances that are legal for adults but subject to legal and social constraints on underage use. Both are relatively inexpensive and widely used by both adults and underage users. Both cause very large numbers of premature deaths. Both are marketed aggressively by industries that have, at least in some product classes, a high degree of market concentration. (Beer and cigarettes have higher degrees of market concentration than do wine or cigars.³) And, as is being considered with tobacco, the MLDA for alcohol was increased to 21—not to other ages and, particularly, not to higher ages.

In brief, the experience with raising the MLDA for alcohol is highly suggestive with respect to the prospects that raising the MLA for tobacco will appreciably reduce smoking rates. Kypri et al. (2006, p. 126) go so far as to say, “No traffic safety policy, with the possible exception of motorcycle safety helmet laws, has more evidence for its effectiveness than do the minimum legal drinking age laws.”

Of course, underage drinking still occurs, and it seems clear that if the MLA for tobacco is increased, there will still be some tobacco use by those under the legal age. Indeed, it would be unreasonable to expect that raising the MLA could completely eliminate all underage use. However, if the question is simply whether raising the MLA will noticeably reduce the use and use-related harms of tobacco among youth, then the academic literature evaluating the alcohol experience indicates that there will indeed be substantial benefits (e.g., Dejong and Blanchette, 2014; McCartt et al., 2010; Wagenaar and Toomey, 2002).

It is worth briefly mentioning the historical context. Following the repeal of national alcohol prohibition in 1933, MLDAs were set by the states, typically at 21. In the early 1970s, 29 states lowered their MLDAs to 18, 19, or 20. In response to increasing highway traffic fatalities, some states reversed course, and then in 1984 Congress passed the National Minimum Drinking Age Act (NMDAA). The NMDAA does not prescribe an MLDA of 21. Rather it encourages states to raise their MLDA to 21 by withholding a percentage of federal highway dollars if they fail to do so. By 1988 all states and the District of Columbia had an MLDA of 21.

By some measures, alcohol MLDAs are enforced fairly aggressively. For example, it is common for mere possession of alcohol to be an offense (known as a “minor in possession”). The severity of sanction for such offenses varies by state but can include fines and the loss of one's driver's license. Likewise, social host ordinances can lead to severe penalties for other individuals (not just businesses) who provide alcohol to underage drinkers. On the other hand, in many states parents are allowed to provide alcohol to their children. So comparisons between the intensity of the enforcement of alcohol MLDAs and the intensity of enforcement of either current or potential future tobacco MLAs are not straightforward, but on the whole, the severity of sanctions for the alcohol equivalent of purchase–use–possession (PUP) laws for tobacco may be greater than what might be contemplated under at least some scenarios involving raising the MLA for tobacco products.

The literature evaluating the effects of changing the MLDA for alcohol is large. DeJong and Blanchette (2014), McCartt et al. (2010), and Wagenaar and Toomey (2002) offer useful reviews. The trends that are observed in aggregate descriptive statistics are consistent with the idea that raising the MLDA has an effect on alcohol use. Specifically, the rates of drinking and binge drinking among those under 21 have been in sustained long-term decline since the MLA was raised, the death rates of 18- to 20-year-olds in nighttime driving accidents have fallen, and the rates of problem alcohol use are lower in the United States than they are in Europe, where drinking ages are lower. However, such correlations could be coincidental. The more persuasive comparisons involve looking at neighboring birth cohorts who reached an MLDA just before versus after the MLDA changed and looking at patterns of use by people who are just a little younger versus just a little older than a given MLDA (Carpenter and Dobkin, 2011). For example, the rates of binge drinking are appreciably higher for 21-year-olds than for 20-year-olds (SAMHSA, 2009).

A number of these studies have found that raising the MLDA for alcohol reduced consumption and consumption-related harms, with the estimate of nearly 1,000 premature deaths prevented per year being a typical number. Other studies have found no statistically significant effect (perhaps from a lack of statistical power), and a few outliers have found that consumption increased. For example, Wagenaar and Toomey (2002) reported that of 33 high-quality empirical analyses for which consumption was the outcome measure, 11 found that raising the MLDA decreased consumption, and only one found the opposite. The proportion of studies finding a favorable effect on traffic crashes was even greater (DeJong and Blanchette, 2014). An illustrative study, conducted by Shults et al. (2001), found that raising the MLDA reduced fatal and nonfatal crashes by 16 percent. Other studies identified less obvious outcomes. For example, Birckmayer and Hemenway (1999) estimated that raising the MLDA reduces teen suicide and, conversely, that lowering it from 21 back to 18 could lead to approximately 125 additional suicides per year among 18- to 20-year-olds.

DeJong and Blanchette's (2014) review includes international comparisons. Notably, New Zealand reduced its MLDA from 20 to 18 in 1999, and Huckle and Parker (2014) and Kypri et al. (2006) reported that this led to significantly more alcohol-related crashes among 15- to 19-year-olds. Conover and Scrimgeour (2013) found similar effects on alcohol-related hospitalizations among those newly eligible to purchase alcohol. International studies on the direct effect of MLDA on alcohol consumption come to comparable conclusions. The 2004 report by the National Academies on underage drinking (IOM and NRC, 2004) found that lower drinking ages in European countries were associated with higher rates of drinking, problem drinking, and drinking by underage individuals, despite common conceptions that underage users drink less in Europe.

The experience with alcohol also suggests that raising the MLDA may even affect patterns of consumption for people who are over the new MLDA (Norberg et al., 2009). For example, Plunk et al. (2013) argue that the ability to purchase alcohol before age 21 increases rates of binge drinking later in life, although the overall drinking frequency is not changed because the increase in binge drinking is accompanied by a reduction in non-heavy drinking. O'Malley and Wagenaar (1991), as reported in DeJong and Blanchette (2014), found that high school seniors and recent high school graduates drank less when the MLDA was 21 and that they also drank less throughout their early 20s, after they had reached the legal age.

A LOGIC MODEL FOR PREDICTING THE EFFECTS OF AN MLA

In light of the dearth of literature on the question of interest—whether raising the MLA for tobacco would reduce underage use—and acknowledging the indirect analogy of the U.S. experience with alcohol, the committee next focused on the scientific literature bearing on the effects of enforcing the existing MLA and other retailer interventions on underage access to and use of tobacco. In order to organize and interpret this literature, the committee developed a logic model to examine whether and to what extent laws restricting the commercial retail availability of tobacco products to underage persons, and MLA laws in particular, have the potential to reduce underage tobacco use. This logic model (see Figure 6-1), which draws on bodies of research on legal deterrence and behavioral economics, details the behavioral mechanisms by which an MLA policy is expected to reduce underage tobacco use. According to the most simplified form of the model, an MLA policy is expected to affect the behavior of potential users and distributors by declaring social norms and by deterring illegal behavior. Deterrence depends on an expectation among sellers that the law will be enforced. Enforcement is expected to increase retailer compliance with the MLA law. High levels of retailer compliance are expected to reduce retail tobacco availability to underage individuals, which in turn is expected to reduce underage tobacco use. The logic model is described in more detail below.

FIGURE 6-1

Simplified logic model of the effects of prescribing and enforcing a minimum age of legal access to tobacco products.

Declarative Effects and Deterrent Effects of Legal Restrictions

An MLA law can affect the behavior of tobacco retailers (and other sellers) in two ways. First, it may have a “declarative” effect on both retailers and potential underage users because they are disposed to comply with legal norms or because enactment of the law affects their beliefs and attitudes toward tobacco use by minors (Bonnie, 1982; IOM and NRC, 2004). Second, the law and its anticipated enforcement may deter potential violators from using or selling tobacco by communicating a credible threat of detection and punishment for violations. The variables that are expected to affect the likelihood of a violation by the targeted population are the probability of detection, the severity of the expected punishment (a function of the prescribed punishment and the probability of its imposition), and the swiftness with which the penalty is imposed. “General deterrence” refers to the effect of the perceived threat of enforcement and punishment on the target population of potential sellers or users. “Specific deterrence” refers to the effect of the imposition of sanctions on detected violators. Figure 6-2 shows a somewhat expanded view of the logic model detailing these enforcement mechanisms.

FIGURE 6-2

Expanded view of the logic model detailing enforcement mechanisms.

Deterrence will not occur unless potential violators perceive a credible threat of detection and punishment (hereafter, “enforcement”). Accordingly, any MLA law will need to be actively enforced using random compliance checks to maintain the retailers' perception that there is a significant risk that an illegal sale will be detected. The compliance checks are expected to have a “specific” deterrent effect on tobacco retailers caught selling to underage individuals, increasing the likelihood of future compliance by these retailers. In addition, an awareness of the possibility of such checks is expected to deter violations by the entire population of retailers who believe themselves to be at risk of compliance checks (“general deterrence”). If MLA laws achieve high rates of compliance (through the combined effect of declaring the legal norm and enforcing it), tobacco availability to underage consumers from commercial retail sources will likely be reduced. If these effects were complete, underage users would not be able to obtain tobacco from retailers. However, the more likely scenario is that enforcement increases the number of compliant retailers (or clerks) and increases the “search-time” costs incurred by underage users who are looking for a noncompliant retailer (or clerk).

Measures of Availability

To assess the overall effect of MLA laws and their enforcement on use, tobacco availability as a mediating variable can be assessed in two ways. First, it can be assessed as the “observed availability” measured as the number of noncompliant retailers (or rates of violations) within a specified area. Second, it can be measured as “perceived availability,” a subjective measure of how easy or difficult it is for underage users to get cigarettes, which is also a reflection of an underage individual's willingness to seek out tobacco products and take up smoking. Presumably, “perceived availability” bears some relationship to the perceived difficulty of accessing tobacco from retail sources, which might be a function of the observed availability; whatever its relationship with observed availability, however, reducing the perceived availability itself may also serve as a mechanism that decreases demand, deterring underage users from purchasing and using tobacco. This includes deterring underage individuals from taking up or escalating smoking as well as increasing likelihood of quitting. In addition to this pathway through perceived availability, there is also likely to be a direct effect of the MLA policy on underage tobacco use through the declarative effect of enacting and enforcing the higher MLA as well as through any effects of enforcement against users. Because social sources are another principal means of accessing tobacco, the impact of restricting retail access on the use of social sources and the corresponding implications for the success of an MLA policy also must be considered. Figure 6-3 illustrates the complete logic model, including pathways through these various measures of availability.

FIGURE 6-3

Complete logic model of the effects of prescribing and enforcing a minimum age of legal access to tobacco products.

EFFECTS OF RETAILER INTERVENTIONS ON ACCESS TO AND USE OF TOBACCO

Within the framework of the logic model, this section reviews the scientific literature bearing on the effects of retailer interventions on underage access to and use of tobacco. The first subsection summarizes studies that assess the impact of enforcement activities on retailer compliance. Even if the number of noncompliant stores (or unsuccessful purchase attempts) is reduced, the question remains whether increased retailer compliance has a discernible impact on the availability of tobacco to underage users and, if so, whether it reduces underage use. The next two subsections summarize studies addressing these two questions. The section closes with methodological observations.

UNDERAGE ACCESS RESTRICTIONS IN THE CONTEXT OF OTHER TOBACCO CONTROL POLICIES

It is unlikely that any revised MLA laws will be aggressively enforced in isolation, so examining the MLA laws and their enforcement in the context of other tobacco control policies can help elucidate their likely effects in circumstances that more closely resemble the likely real world scenarios in which an MLA increase would be implemented. In particular, investigating the effect of the MLA laws in this way may help explain some of the observed variations in community-level natural experiments. Studies in these small localities may not account for the contributions of other concurrent tobacco control programs at the state and national levels (e.g., smoke-free policies, excise taxes and price, mass media campaigns), and they also may be subject to spillover effects from neighboring jurisdictions, in particular, smuggling.⁵ The following section reviews the evidence on MLA retailer interventions in the context of other youth access restrictions, followed by other, general tobacco control programs.

TOBACCO PURCHASE, USE, AND POSSESSION LAWS

Although the focus of this analysis is on sales restrictions, it is also important to consider the effects of supplementing bans on distribution and sales with laws targeting underage tobacco PUP. As noted in Chapter 5, the laws of 44 states and the District of Columbia penalize underage individuals for purchasing, using, or possessing tobacco products, typically by civil fines or community service. Proponents of the laws argue that PUP laws are another effective strategy for deterring underage tobacco use (e.g., Jason et al., 2009b; Lazovich et al., 2007; Livingood et al., 2001), while critics argue that PUP laws shift blame from retailers and tobacco industry marketing and advertising practices toward adolescents and young adults and, furthermore, that PUP laws may actually increase the desirability of tobacco as an aspirational, adult product, further enticing adolescents to use tobacco (e.g., Wakefield and Giovino, 2003). Opponents of PUP laws also suggest that enforcement would be difficult, expensive, and therefore realistically infeasible (Tworek et al., 2011). The IOM's report Growing Up Tobacco Free (1994) elaborated on this, arguing that PUP laws lacking enforcement would only serve as a symbolic deterrent, which would be unlikely to deter tobacco use any more than laws punishing sellers, while also undermining respect for the law.

There is currently no systematic surveillance of PUP laws, and thus there is little information about either the extent to which they are enforced or their efficacy. The only available data on statewide enforcement that the committee was able to locate (Rogers et al., 2008) come from California, an aggressive tobacco control state, and the data show that, in 2007, 76 percent of youth access enforcement agencies across the state indicated that they did not “often” or “very often” issue citations to minors for PUP violations. Additionally, the average number of citations issued in the past 12 months across all 249 enforcement agencies statewide was 24.1 citations, or an average of two per agency per month. Similarly, qualitative studies also suggest that PUP laws are seldom enforced. Two studies using key informant interviews with individuals responsible for enforcing PUP laws (e.g., mayors, police officers, and school officials) found that PUP laws are poorly enforced and that only a small number of citations are issued (Hrywna et al., 2004); they also found that there was little knowledge about PUP enforcement, that active enforcement of PUP laws was not a priority, and that even when they were enforced, the enforcement was inconsistent (Hahn et al., 2007). Indeed, any widely violated and under-enforced prohibition is likely to be plagued by selective enforcement, and PUP laws are no exception. For example, Gottlieb et al. (2004) found differential enforcement of PUP laws, such that African-American and Hispanic students had a significantly greater probability of receiving a citation than white students.

Despite lax enforcement efforts, limited empirical data suggest that active enforcement of PUP laws in addition to active enforcement of youth tobacco sales restrictions may be effective at reducing tobacco sales to underage persons and, ultimately, at reducing underage tobacco consumption. Most of these findings come from a series of studies conducted by Jason and colleagues in a convenience sample of small, suburban towns in Illinois, which may not be representative of the rest of the state or the country as a whole. They found that active enforcement of PUP laws in addition to sales restrictions is associated with reduced tobacco sales to underage users (Jason et al., 2003); decreased observed and perceived adolescent tobacco use (Jason et al., 2009a); slower increases in the rate of smoking compared to enforcing sales restrictions alone (Jason et al., 2008); reduced smoking, both among whites only (Jason et al., 2003) and, alternately, among all groups (Jason et al., 2007c); lowered rates of heavy smoking (Jason et al., 2009b); reduced use of other drugs (Jason et al., 2010), and reduced crime rates (Jason et al., 2000). They also found that underage individuals who were fined for PUP violations were more likely to reduce tobacco use or quit than those who participated in tobacco prevention education programs (Jason et al., 2007b). Additionally, fines had a bigger effect than education on changing parental and adolescent attitudes toward tobacco use (Jason et al., 2007b). Finally, Jason and colleagues also found that the presence of PUP laws facilitated the uptake of smoke-free policies (Jason et al., 2007a). Studies by other researchers have further supported these findings, including studies demonstrating that actively enforcing PUP laws may be effective at reducing underage tobacco use (Gottlieb et al., 2004; Lazovich et al., 2007; Livingood et al., 2001) and increasing adolescent smoking cessation (Langer and Warheit, 2000). Moreover, Gottlieb et al. (2004) found that the threat of driver's license suspension as a penalty for PUP violations reduced smoking intentions among adolescent ever-daily smokers (but not ever or experimental smokers), suggesting a general deterrent effect. At the same time, having received a citation was associated with reduced smoking intentions in only some of the schools sampled, thus showing mixed findings with respect to specific deterrence.

On the other hand, two analyses also examined PUP laws in the context of other youth access restrictions, and neither found that they decreased adolescent smoking. Ross and Chaloupka (2001) found that punishing minors for the use or possession of cigarettes increased the number of cigarettes adolescents smoked, while Tworek and colleagues (2010) found no association between PUP laws and any measure of adolescent smoking cessation.

In sum, there continues to be some controversy about the relative advantages and disadvantages of implementing PUP laws for tobacco. Although a small number of observational studies of PUP interventions suggest that they can contribute to the reduction of underage tobacco use if enforced, there is scant evidence of enforcement. Moreover, the few existing studies also suggest that, when enforced, the laws are selectively applied and that minority populations may carry a disproportionate burden of PUP violations.

Finding 6-5: Enforcement of purchase–use–possession laws is a controversial strategy for reducing underage tobacco use. Although a small number of studies suggest that enforcing these laws, in combination with strategies that limit retail tobacco sales, can reduce use, they also raise concerns about fair enforcement.

SUMMARY

This chapter reviewed the existing evidence on the effects of raising the minimum legal age to purchase tobacco products, in particular the effect on underage tobacco use. No published evidence is yet available on the effects of raising the MLA to 21 in any of the localities in the United States that have done so. Limited international evidence suggests that raising the MLA from 16 to 18 in countries that already had an actively enforced MLA can be implemented successfully to reduce the availability of retail tobacco to newly underage persons and thereby reduce underage tobacco use. Experience with raising the minimum legal drinking age for alcohol in the United States from 18 to 21 is instructive for tobacco control, in that it has led to reductions in the use of alcohol and concomitant harms, such as motor vehicle accidents in the underage population, although it also demonstrates that the prevalence of underage drinking remains high.

In light of the dearth of direct evidence on the effects of raising the MLA for tobacco, the committee focused its attention on the substantial body of literature on the effects of enforcing the MLA restrictions that have already existed in the United States for more than two decades. This literature suggests that the MLA policies that are actively enforced and supported by other retailer interventions will likely increase retailer compliance and thereby reduce retail tobacco availability to underage individuals. Furthermore, although increased retailer compliance is predictably accompanied by a corresponding increase in the use of social sources to obtain tobacco, this substitution of sources is likely to be incomplete, leading to decreased use, especially if the youth access policy is implemented in a robust comprehensive tobacco control context.

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Footnotes

1

Although Needham, Massachusetts, the first jurisdiction in the United States to raise the MLA to 21, has been cited as having seen significant declines in tobacco use and tobacco-related disease, there are no published data on these outcomes. In addition, the little available data that exist (EDC, 2010a,b; NPHD, 2008, 2012) have no baseline measurements and are confounded by the presence of other tobacco control measures that occurred in the town and throughout the state of Massachusetts at the same time the MLA was increased.

2

Another small qualitative study (Borland and Amos, 2009) examined attitudes about raising the MLA from 16 to 18 in Scotland among 16- to 17-year-old regular smokers who had dropped out of high school and were attending a work skills program. However, given the small sample size and sample characteristics, these findings are likely not generalizable to larger or different populations. This study also provides no findings on the effect of raising the MLA on either reducing sales to adolescents or reducing underage tobacco use.

3

The Centers for Disease Control and Prevention reports that the market share of the dominant cigar firms is mostly below 20 percent even for specific types of cigars, and different firms dominate those different segments, whereas three companies control nearly 85 percent of the cigarette market (CDC, 2014a).

4

In certain circumstances they may also increase the monetary cost (e.g., if only a subset of retail stores are willing to sell to underage customers, and that restriction makes it harder for youth to shop for the best prices, or when a youth enlists a proxy purchaser and the proxy purchase charges a fee for that service).

5

Indeed, adolescents achieve increasing mobility as they begin to drive, and implementation at the town or county level may have a smaller effect than state- or national-level implementation due to the potential smuggling of tobacco from neighboring jurisdictions where tobacco availability is higher. Lessons from the alcohol experience suggest precisely this: Lovenheim and Slemrod (2010) and Dejong and Blanchette (2014) examined the effect of a minimum legal drinking age on fatal traffic accidents when states were implementing an MLDA of 21 in a patchwork while the national MLDA remained 18. Their analysis of county-level data found no reduction in fatal traffic crashes involving youth in counties with an MLDA of 21 that were within 25 miles of a state with a lower minimum drinking age, but significant reductions in fatal traffic crashes involving youth in counties further from the state borders.