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that could be a result of raising the MLA, the com- mittee commissioned the use of two established and complementary tobacco simulation models, SimSmoke and the Cancer Intervention and Sur- veillance Modeling Network smoking population model (CISNET). In using the models, the committee employed all available evidence and expert judgment to project outcomes. The committee also had to make assumptions with important implications. The models only address cigarette smoking, but the committee expects the MLA and relative effects on initiation to apply to all tobacco prod- ucts. In addition, the models project the effects of raising the MLA on the United States as a whole and do not take into account existing variations in tobacco use—such as by race or socioeconomic status—initiation rates, and tobacco control activ- ities. In addition, the rapidly changing landscape of tobacco products—for example, e-cigarettes— provides unknowns and could affect the future of tobacco product use in ways that the committee was unable to anticipate due to lack of evidence. Based on the modeling and backed up by the literature review, the committee concludes that raising the minimum age of legal access to tobacco products in the United States, particularly to ages 21 and 25, will likely lead to a substantial reduc- tion in smoking prevalence. If the MLA were raised now, the models projected that by the time today's teenagers were adults, there would be a 3 percent decrease in prevalence of tobacco use among those adults if the MLA were raised to 19, a 12 percent decrease if raised to 21, and a 16 per- 3 The parts of the brain most responsible for decision making, impulse control, sensation seeking, and susceptibility to peer pressure continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine and nicotine addiction. cent decrease if raised to 25. Given a decline in the initiation rates of tobacco use by adolescents and lower prevalence in the population, it follows that tobacco -related disease would also decrease in proportion to the reduction in tobacco use. It is generally known that smoking-related diseases like cancer and heart disease develop over decades, and there- fore, it could take many years to lower rates of these diseases; however, there could be imme- diate decreases in other tobacco -related health effects. The committee concludes that raising the MLA will likely immediately improve the health of adolescents and young adults by reducing the number of those with adverse physiological effects such as increased inflammation and impaired immune functioning caused by smoking, as these could potentially lead to negative health conse- quences, including increased hospitalizations and lessened capacity to heal wounds. Adverse maternal, fetal, and infant outcomes—includ- ing preterm births, low birth weight, and sudden infant death—will also probably decrease due to reduced tobacco exposure in mothers and infants. Raising the MLA will also lessen the population's exposure to secondhand smoke and its associated health effects, both now and in the future. Over time, the committee concludes that rais- ing the MLA will likely lead to substantial reduc- tions in smoking-related mortality, though results from the models suggest that these results will not be observed for at least 30 years, assuming that the MLA increase occurs now. The CISNET model