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In the summer of 2015, the National Academy of Medicine issued a report on the potential impact of raising the legal age of purchasing tobacco. The message was simple. Raising the minimum age of purchase for tobacco products from 18 to 21, according to the report, was likely over time to decrease the prevalence of adult tobacco use in the United States by 12 percent and reduce mortality associated with tobacco illness by 10%.
If true, this would have massive implications for public health. Smoking is the single biggest cause of preventable death and disease in the nation. A 12 percent decrease in use, for kids born between 2000 and 2019, would translate to some 220,000 fewer premature deaths in their adulthood. 50,000 fewer people in this cohort would die from lung cancer, and an estimated 4.2 million fewer years of life would be lost overall. The reduction in use among women would also likely lead to a significant reduction in pre-term birth.
In Texas, the effect of the report was profound. A group of public health champions, led by the Campaign for Tobacco-Free Kids and The University of Texas MD Anderson Center, began organizing around the goal of changing state policy. Ultimately more than 100 organizations came together as the Texas 21 coalition. The work culminated in 2019 in the passage of Senate Bill 21 (SB 21), which will raise the minimum age of purchase of tobacco products in Texas from 18 to 21 for everyone except military personnel. On September 1, when it goes into effect, Texas will become the 18th state in the nation to pass such legislation. The ban includes e-cigarettes and other forms of tobacco.
“It was not an obvious or easy victory,” says Mark Moreno, Vice President of Government Relations at MD Anderson. “Texas is a conservative state, and its legislature is generally skeptical of government intervention in personal decision making. We had to do a lot of work helping key members and then ultimately the larger body really understand the evidence base and significant health and economic benefits behind the policy.”
The Texas 21 coalition also had to contend with opposition from the traditional tobacco industry as well as from the increasingly well-resourced e-cigarette manufacturing and retail industries.
The education effort, in which MD Anderson faculty played a key role, focused on two key points: the opportunity for the state to protect youth, and the long terms economic benefits to the state in reducing the health toll of tobacco use. There was hard evidence from other states that raising the age did, in fact, reduce initiation among youth. And a study from the Texas Department of State Health Services estimated that the state could save more than $400 million in health care costs over just five years, and billions over the long term.
The coalition also highlighted broad public support for making it illegal to sell tobacco to 18-21-year-olds. A 2016 poll found that almost 70 percent of Texans, including more than 65% of Republicans and more than 60% of smokers, supported such a shift.
By the start of the 85th legislative session, in January 2017, the coalition was bolstered by two key legislative champions, both of whom were well-regarded and influential Republicans: Representative John Zerwas in the House and Senator Joan Huffman in the Senate. The Zerwas-sponsored bill, HB1908, made it out of committee in the House but wasn’t passed by the full membership.
“The primary opposition was from industry and from the vape community,” said Moreno. “That pushback was really strong in 2017. There was also opposition from libertarian-minded legislators.”
Disappointed, but also encouraged by the broad support, the coalition continued its work in the interim. In the next 18 months, before the start of the 86th legislature, the political landscape tilted further in the direction of passage. Lieutenant Governor Dan Patrick announced that the reintroduced legislation would be on his list of priority bills. Other influential legislators signed on as active supporters. Public support increased, with one poll showing more than 80 percent of Texans in favor of raising the age. Perhaps the key shift came from the traditional tobacco companies. The industry went from actively opposing to actively supporting raising the age.
“Altria, which is the parent company of Philip Morris and owns a large stake in the e-cigarette company Juul, may have seen the writing on the wall,” said Sean Griffin, Associate Vice Chancellor for Governmental Relations and Health Affairs for The University of Texas System. “They understand the growing support for measures to prevent youth smoking, and want to be good corporate citizens. Some say they support this legislation to avoid more stringent regulations related to flavors. In either case, the only organized group who came out against it this time around were the independently owned and operated vape shops.”
By the time the legislative session began, the momentum behind passage was considerable. The only substantial tension that arose, over the course of the session, had to do with the military exemption. Initial versions of the bill didn’t include any exemptions. A version that looked like it was headed toward passage exempted only active duty military. The bill that was finally passed and signed by the governor exempted all military personnel.
Although there was some disappointment among advocates regarding the scope of the exemption, the number of 18-21-year olds exempted is likely to be very small, and the general mood is elation.
“This has significant implications for protecting Texas youth and improving public health,” said Moreno. “This bold action by state leaders and the Legislature will save thousands of lives in future generations.”