What Does Tobacco 21 Mean for Adolescent Tobacco Use?

We’ve come a long way from the Joe Camel commercials I remember watching as a kid on TV. As a culture, we’ve become a lot less tobacco friendly. Indoor smoking bans, stricter advertising restrictions (meaning no more cartoon characters advertising cigarettes), and other policies have been enacted to curb tobacco use across the country. Despite these changes, teen smoking is still a big problem.

In 2015, the Institute of Medicine reported that raising the legal age for using tobacco products from 18 years to 21 years would significantly decrease, delay, or differ adolescent tobacco use [1]. Just last month Congress decided to test this prediction by passing House Resolution 1865 – Further Consolidated Appropriations Act, 2020 which was subsequently signed into law by President Trump. This spending package includes an amendment to the Federal Food, Drug, and Cosmetic Act, raising the minimum age for purchase of tobacco products to 21 years [2]. This certainly signals a bipartisan effort to curb adolescent tobacco use, but only time will tell the lasting impact of this and other new policies.

Despite laws existing to restrict tobacco sales to adults, there is limited evidence of interventions able to achieve high levels of adherence with these laws [3]. In fact, a majority of smokers endorse first using tobacco products before being of age. While the is ample evidence that exposure to tobacco advertising is related to youth picking up smoking, there are no randomized clinical trials (RCTs) that assess the effectiveness of different advertising restrictions or bans on adolescent tobacco use [4]. What percentage of potential under-age smokers are deterred by age restrictions? What effect would increasing the tobacco tax have on youth sales? What effect could flavor restrictions have on youth smoking? One approach to better understand the health effects of possible tobacco legislation could be to incorporate RCTs into this new law’s implementation.

Last year the Nobel Memorial Prize in Economics was awarded to three researcher who used RCTs to better understand the effects of economic policies on people’s lives [5]. This approach to policy interventions has allowed developmental economists inform legislation aimed at alleviating poverty and its negative externalities. Using these same standards to assess the efficacy of policies aimed at preventing youth tobacco use could have a lasting impact on the health of our nation.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.


  1. Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015 Jul. https://www.ncbi.nlm.nih.gov/pubmed/26269869
  2. R.1865 – Further Consolidated Appropriations Act, 2020 (Subtitle E, Section 603: Minimum age of sale of tobacco products) https://www.congress.gov/bill/116th-congress/house-bill/1865/text#toc-H1CB3CAE840AA412285E15A86531C8446
  3. Stead LF, Lancaster T. Interventions for preventing tobacco sales to minors. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001497. DOI: 10.1002/14651858.CD001497.pub2. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001497.pub2/information
  4. Lovato C, Watts A, Stead LF. Impact of tobacco advertising and promotion on increasing adolescent smoking behaviours. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD003439. DOI: 10.1002/14651858.CD003439.pub2. (Page 1, 12) https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003439.pub2/abstract
  5. The Prize in Economic Sciences 2019. https://www.nobelprize.org/prizes/economic-sciences/2019/press-release/

Pharmacological Smoking Cessation Aides And Cardiovascular Safety

Pharmacological smoking cessation therapies have had their challenges. For example, varenicline previously had a US Food and Drug Administration black box warning regarding neuropsychiatric risks.

The EAGLES study, published 2016, was an industry sponsored, randomized, placebo-controlled trial of nicotine, varenicline, and bupropion that sought to address the neuropsychiatric risk profile of these medications.1 They randomized participants with and without known psychiatric comorbidities to these medications and found that these agents were not associated with an increased risk of neuropsychiatric adverse events. Further, the study found varenicline to be more effective than nicotine, bupropion, and placebo for smoking cessation.

The FDA black box warning for varenicline was removed. However, concerns regarding the cardiovascular safety persisted. Apart from abundant observational data on this topic, there have been several randomized trials as well. For example, in 2015, a randomized clinical trial of varenicline versus placebo for patients hospitalized with acute coronary syndrome demonstrated efficacy for cessation and did not raise a safety signal.2

Further, a secondary analysis of the EAGLES study regarding cardiovascular safety was recently published.3 They compared rates of major adverse cardiovascular events, and changes in blood pressure and heart rate, among participants randomized to placebo, varenicline, bupropion, and nicotine replacement. They found very low rates of major cardiovascular events and did not find differences between drugs. Of course, these were not patients with recent or significant cardiovascular comorbidities, so the results do not generalize beyond the general population of smokers.

There is thus mounting evidence for both the psychiatric and cardiovascular safety of pharmacological smoking cessation therapies. While it can be argued that an adequately powered safety trial in patients in acute and/or significant cardiovascular disease has yet to be performed, it may nonetheless be time to create gold standard cessation programs for patients with cardiovascular disease. It may be premature, however, to do the same for patients with cerebrovascular disease – more evidence may be needed.


  1. Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016:387;2507-2520.
  2. Eisenberg MJ, Windle SB, Roy N, et al. Varenicline for Smoking Cessation in Hospitalized Patients With Acute Coronary Syndrome. Circulation. 2015:137; https://doi.org/10.1161/CIRCULATIONAHA.115.019634.
  3. Benowitz NL, Pipe A, West R, et al. Cardiovascular Safety of Varenicline, Bupropion, and Nicotine Patch in SmokersA Randomized Clinical Trial. JAMA Internal Medicine. 2018; doi:10.1001/jamainternmed.2018.0397.

Neal Parikh Headshot

Neal S. Parikh, MD, earned his MD from Weill Cornell Medical College and completed residency training in neurology at the same institution. He is now an NIH T32 neuro-epidemiology and vascular neurology fellow at New York-Presbyterian Hospital/Columbia University Medical Center. He tweets @NealSParikhMD and contributes to Blogging Stroke as a blogger.