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Downloaded from http://tobaccocontrol.bmj.com/ on December 12, 2016 - Published by group.bmj.com 'Education Development Center, Inc, Waltham, Massachusetts, USA 2Department of Epidemiology, Brown University, Providence, Rhode Island, USA 3Harvard Medical School, Boston, Massachusetts, USA Correspondence to Shari Kessel Schneider, Education Development Center (EDC), Inc, 43 Foundry Ave, Waltham, MA 02453, USA; skschneider@edc.org Received 18 December 2014 Accepted 12 May 2015 Published Online First 12 June 2015 CrossMark To cite: Kessel Schneider S, Buka SL, Dash K, et al. Tob Control 2016;25:355-359. Community reductions in youth smoking after raising the monhum tobacco sales age to 21 Shari Kessel Schneider,' Stephen L Buka,2 Kim Dash,' Jonathan P Winickoff,3 Lydia O'Donnell' ABSTRACT Objective Raising the tobacco sales age to 21 has gained support as a promising strategy to reduce youth cigarette access, but there is little direct evidence of its impact on adolescent smoking. Using regional youth survey data, we compared youth smoking trends in Needham, Massachusetts—which raised the minimum purchase age in 2005—with those of 16 surrounding communities. Methods The MetroWest Adolescent Health Survey is a biennial census survey of high school youth in communities west of Boston; over 16 000 students participated at each of four time points from 2006 to 2012. Using these pooled cross-section data, we used generalised estimating equation models to compare trends in current cigarette smoking and cigarette purchases in Needham relative to 16 comparison communities without similar ordinances. To determine whether trends were specific to tobacco, we also examined trends in youth alcohol use over the same time period. Results From 2006 to 2010, the decrease in 30 -day smoking in Needham (from 13% to 7%) was significantly greater than in the comparison communities (from 15% to 12%; p<.001). This larger decline was consistent for both genders, Caucasian and non -Caucasian youth, and grades 10, 11 and 12. Cigarette purchases among current smokers also declined significantly more in Needham than in the comparison communities during this time. In contrast, there were no comparable differences for current alcohol use. Conclusions Our results suggest that raising the minimum sales age to 21 for tobacco contributes to a greater decline in youth smoking relative to communities that did not pass this ordinance. These findings support local community -level action to raise the tobacco sales age to 21. INTRODUCTION Raising the legal age of tobacco sales to 21 to reduce youth smoking has gained increasing support among prevention advocates' who are working to reduce youth smoking initiation as a primary means of preventing addiction later in life. Nearly 1 in 10 high school youth experiment with cigarettes before age 13, and 4% have smoked regularly.2 These youth who initiate smoking in adolescence are at greater risk of becoming addicted to tobacco as adults. 3 4 Conversely, research shows that the major- ity of adults who are addicted to cigarettes began smoking daily before age 18.4 In addition, many people who purchase cigar- ettes for minors are under 21 themselves.s This suggests that prohibiting young adults under 21 from purchasing cigarettes would reduce the number of legal buyers in adolescents' social circles, thereby disrupting the supply of cigarettes to adolescents. Given that youth attitudes towards smoking, such as perceived risk and disapproval of smoking, have levelled off or lessened since 2007,6 reducing access to cigarettes is an important pre- vention strategy. A recent report by the Institute of Medicine sug- gests that raising the minimum age of legal access to tobacco to 21 would result in a 12% decrease in the prevalence of tobacco use among today's teen- agers once they become adults.7 Another simula- tion of the impact of raising the legal smoking age to 21 in the USA suggests that adolescent smoking would be reduced by more than half in 7 years.8 There is broad public support for this effort, with 70% of adults in support of raising the minimum sales age to 21, including a majority of adults in all demographic and smoking status categories.9 Despite these promising projections, there is little direct evidence that raising the minimum purchase age for tobacco would lead to a decline in youth smoking. In April of 2005, Needham, Massachusetts became the first town in the USA to raise the minimum tobacco sales age to 21; it was not adopted elsewhere in the USA until 2012 (DJ Wilson, Director, Massachusetts Municipal Association Tobacco Control Technical Assistance Program, personal com- munication, 7 November 2014.). In this paper, we use data from the MetroWest Adolescent Health Survey (MWAHS) to compare youth smoking trends from 2006 to 2012 in Needham with 16 surrounding communities that did not pass this ordinance. To the best of our knowledge, this is the first study to examine trends in the actual prevalence of smoking associated with raising the minimum sales age. We examined: (1) whether smoking declined more in Needham than in the nearby communities; and (2) whether the effect was specific to tobacco or if similar patterns were also found for alcohol. METHODS The MWAHS is a school-based census of youth in 25 communities in the Boston metropolitan area served by the MetroWest Health Foundation, having the primary goal of informing local preven- tion efforts. It has been administered biennially since fall, 2006 to students in grades 9-12. Of the 26 public high schools in the region served by the foundation, 18 began the survey in 2006. Of these, 17 high schools participated in all four surveys (2006, 2008, 2010 and 2012) and are included in this analysis. Student participation rates ranged from 88.8% to 89.6% over the four surveys, and the number of participants ranged from 16 385 to BMJ Kessel Schneider S, etal. Tob Control 2016;25:355-359. doi:10.1136/tobaccocontrol-2014-052207 355