Intended for healthcare professionals


US set to raise smoking age to 21 and to fund gun violence research after 20 year freeze

BMJ 2019; 367 doi: (Published 20 December 2019) Cite this as: BMJ 2019;367:l7055
  1. Owen Dyer
  1. Montreal, Canada

The annual spending bill advancing through Congress this week1 will ban the sale of tobacco and vaping products to people aged under 21 across the United States, in an unexpected win for anti-smoking groups.

The omnibus bill, which sets the federal budget for the year ahead, will also allocate $25m (£18m; €21m) to study gun violence, ending a 23 year freeze on public funding of such research.

Legislators often tack unrelated amendments onto the spending bill, and these can become obstacles to its passage. But both parties are eager to rack up legislative wins as the election approaches and a series of swift compromises saw the bill sail through the House.

In the Senate, both parties have already said they will back it. That leaves only the president’s signature, which is expected to be a formality.

Anti-smoking groups have long pushed for the minimum age of legal access to be raised to 21, but only recently has legislators’ resistance started to crumble, as the tobacco industry itself began advocating the change.

Tobacco giant Altria and leading e-cigarette manufacturer Juul both say that they support the bill. The industry, its critics say, sees raising the minimum age as the least painful way to tackle the uproar over youth vaping.

“Juul and Altria have hijacked the matter for their own nefarious reasons as a shield to fight efforts to prohibit flavoured e-cigarettes,” said Matthew Myers of the Campaign for Tobacco-Free Kids. “It’s disappointing that the budget agreement gives these tobacco companies what they want without tackling the crisis caused by flavoured e-cigarettes.”

President Trump’s ban on flavoured e-cigarettes, announced and then retracted, is to go forward after all, according to insiders. But it will probably exempt brick and mortar retail outlets, where he fears the effect of job losses. The industry will argue that if flavoured devices can only be bought in physical stores, where staff will now be barred from selling to those under 21, there will be no need for a wider ban.

Industry lobbyists have pushed for state laws against sales to those younger than 21 in an effort to forestall municipal laws, which tend to be stricter than notoriously poorly enforced state public health laws. The policy is known in the industry as “pre-emption.”

The imminent federal tobacco 21 law may have started life as an attempt at pre-emption. An early version was sponsored by Senate majority leader Mitch McConnell of Kentucky, the second biggest tobacco producing state, and Senator Tim Kaine of Virginia, the third biggest producer. Both men are among the top Congressional recipients of tobacco industry donations.

Their bill required each state to pass its own tobacco 21 law before the federal act could take effect there, giving industry an opening to water down provisions at state level, where its lobbyists are strongest.

But in a clear victory for anti-smoking advocates, the House adopted and sent forward a different tobacco 21 law, without that loophole. The bill, which simply changes “18” to “21” in the existing law, will be operative and enforced within 270 days of its enactment.

The American Lung Association estimates that 94% of adult smokers had their first cigarette before turning 21. An Institute of Medicine panel concluded in 2015 that raising the national minimum age to 21 would ultimately reduce the number of smokers by 12%. It would prevent 50 000 lung cancer deaths and save 4.2 million years of life in the cohort born from 2000 to 2019, they estimated.2

Gun research resumes

The spending bill includes $25m for gun violence research, split evenly between the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). No meaningful gun research has been federally funded since the Dickey Amendment was passed in 1996.

That law banned the CDC from “advocating gun control.” Congress also subtracted $2.6m from the CDC budget, precisely the amount it had spent on gun research the year before.

The CDC had aroused the ire of the National Rifle Association with research published in the New England Journal of Medicine suggesting that gun ownership increased homicide risk in a household. In 2011, research published in the American Journal of Public Health led to a similar amendment being passed about the NIH.

In the wake of high profile gun massacres, Congress has come under increasing pressure —even from former congressman Jay Dickey—to resume funding. The laws against federal scientists advocating gun control remain in place, however.

Obamacare taxes eliminated

The spending bill also eliminates three taxes created by the Affordable Care Act of 2010 that were designed to cover its costs. These are an annual fee on insurance providers, an excise tax on high end employee health plans, and an excise tax on medical device makers. All three were deeply unpopular in Congress, even with many Democrats.

Trade unions, who often negotiate high quality health insurance for their members, have long opposed taxing such plans. Elizabeth Warren is a critic of the tax on device makers, many of whom are based in her home state of Massachusetts.

Without the taxes, Obamacare loses its unusual ability to pay its own way. The burden will add $390bn to the federal deficit over the next decade, the Congressional Research Service estimated.


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