Cigarette smoking is the leading cause of preventable disease and death in the United States — every year, it’s responsible for 480,000 deaths. While smoking is on the decline in the United States, more than 2,500 young people smoke their first cigarette each day. In fact, 9 in 10 adults who smoke say they tried their first cigarette before age 18; and nearly all tried their first cigarette by young adulthood.
In 2015, an Institute of Medicine (IOM) report projected that if the United States immediately raised the minimum legal sales age (MLA) for tobacco products from 18 to 21, there would be approximately 223,000 fewer premature deaths for those born between 2000 and 2019.
Soon after the release of the IOM report, Hawai‘i became the first state to pass a “Tobacco 21” bill. The law, Act 122, increased the MLA for selling, possessing, buying, or using tobacco products, including e-cigarettes. It created penalties for selling tobacco products illegally and fines and community service for buying, possessing, or using them illegally.
Partnering to Inform Change
Lila Johnson is the Program Manager for the Hawai‘i State Department of Health Tobacco Prevention and Education Program (TPEP). When asked how Hawai‘i passed Tobacco 21, she says the timing of the IOM report was great — but it was only a piece of the puzzle. Public support for Tobacco 21 was at 77%. “And we could not have succeeded without working hand-in-hand with our coalition partners in the tobacco control community,” she says. “They were critical for generating public support and grassroots mobilization, especially to get Hawaii’s youth involved in our campaign.”
The Campaign for Tobacco-Free Kids, a nonprofit that works nationally and locally to reduce tobacco use, provided advice and resources for the initiative. It created “21 Reasons to Raise the Age” brochures with tear-off petitions for distribution in Hawai‘i public schools. And its Kick Butts Day, a national event where young people speak out against tobacco, was key to the campaign.
For Kick Butts Day on March 15, 2015, the Coalition for Tobacco-Free Hawai‘i organized a youth rally at the state capitol in Honolulu. The Coalition brought youth from all across the state to attend the rally, turn in their “21 Reasons” petitions, and meet with their legislators. The youth wore T-shirts with key messages in support of Tobacco 21.
“It was really powerful to have these young people — the generation that will be impacted the most — travel to the capitol and meet with decision makers,” Johnson says. The bill moved through the legislature very quickly: it was introduced in January 2015, passed in April, and signed into law by Hawaii’s governor, David Ige, in June.
Prevention Among Young People Is Key
Johnson says that policy changes like Tobacco 21 laws are essential to tobacco use prevention in Hawai‘i. “Our program is about changing the environment and social norms around smoking,” she explains. “We’re making it harder to access tobacco products and harder to smoke them — inside or outside.”
For example, Hawai‘i has prohibited tobacco smoking and e-cigarette use in all enclosed worksites, including restaurants, bars, and nightclubs. All state parks and most county beaches are now smoke free. The state also bans self-service tobacco displays, which reduces access and lowers the likelihood that tobacco products (especially flavored ones) will be presented near candy and food.
Raising the MLA for tobacco products was an important addition to these efforts because it makes it more difficult for young people to buy cigarettes — or to get others to buy them. “A lot of young smokers have used older peers to get cigarettes for them,” says Johnson.
Since the state raised the MLA for tobacco from 18 to 21, current cigarette smoking in Hawai’i declined from 15.3% in 2015 to 12.0% in 2016 for people age 18 to 24. However, this decline could be the result of multiple factors, and further research is underway to determine the independent impact of the MLA law.
Continuing Efforts in Tobacco Control
Building on the success of the Tobacco 21 law, TPEP is continuing its efforts in Honolulu County to prohibit smoking in vehicles when a minor is present. And for next year’s state legislative session, the tobacco control advocates hope to regulate and tax e-cigarettes in order to both inhibit youth initiation and monitor compliance.
“This is important because, while rates of cigarette smoking have gone down, e-cigarette use rose among Hawaii’s youth,” Johnson says. The number of Hawai‘i public high school students who reported trying e-cigarettes jumped from 5% in 2011 to 22% in 2015.
While there’s always more that can be done, Johnson says Hawai‘i is proud of its tobacco prevention work — and she’s confident they’re making a difference. “The potential for these efforts to save lives down the road is really gratifying.”