During the Vietnam War, when the voting age nationwide was lowered to age 18, twenty-nine states also lowered the minimum legal drinking age (MLDA) to 18, 19, or 20. Following this change, those states saw sharp increases in traffic fatalities among 18- to 20-year-old drivers, and many states responded by raising their drinking age to 21. But young people could still often travel across borders to drink in neighboring states where lower MLDAs remained in effect. Based on data from the Department of Transportation, organizations such as Mothers Against Drunk Driving (MADD), Parent-Teacher Associations (PTA), and ultimately President Ronald Reagan’s National Commission on Drunk Driving advocated for congressional legislation that would withhold federal highway construction funds from states that did not make it illegal to sell alcohol to persons under age 21. In 1984 President Reagan signed the law into effect, and by 1988, all states had raised the drinking age to 21. In 1995, President Bill Clinton signed additional legislation withholding highway funds from states that did not pass laws making it illegal for persons under age 21 to drive with any measurable blood alcohol level. By 1998, all states had adopted such laws.
The positive public health impact of these laws has been striking. From 1982 to 2016, binge drinking in the past two weeks declined from 41 percent to 16 percent among high school seniors. During this same time period, alcohol-related traffic deaths in ages 16-20 nationwide declined from 5,244 to 1,060—far surpassing the decline in deaths in traffic crashes in this age group where alcohol was not involved. In addition, national comparisons of adults through surveys and through death certificates have found that persons who grew up in states where it was legal to drink under age 21 were more likely as adults to meet alcohol and drug abuse and dependence criteria, and to die from liver cirrhosis, other liver diseases, and oral cancer.
Research suggests similar benefits could be seen by increasing the age of sale of tobacco products from 18 to 21. Like alcohol, tobacco use is a serious health hazard, causing disease and death from cancer, cardiovascular disease, pulmonary disease, and other causes. Adolescents and young adults are especially vulnerable to the effects of nicotine, including addiction and harm to the developing adolescent brain. National data show that about 90 percent of adult cigarette smokers tried their first cigarette before age 18. While less than half of adult smokers (46%) become daily smokers before age 18, four in five do so before they turn 21. Delaying the age when young people first experiment with or begin using tobacco regularly may reduce the risk that they will become addicted smokers.
In 2005, Needham, Massachusetts became the first jurisdiction to raise the age of sale for tobacco products to 21 years. As of January 2018, five states, the District of Columbia, and 290 cities and counties across 19 states have raised the minimum age of sale for tobacco products to 21 years, and many more are considering doing so. A 2015 report (from the Institute of Medicine) now the National Academy of Medicine) projected that if the minimum age of sale for tobacco products were raised to 21 years nationwide, tobacco use would decrease by 12 percent by the time today’s teenagers are adults, and smoking-related deaths would decrease by 10 percent. Smoking would be reduced by 25 percent among 15- to 17-year-olds and 15 percent among 18- to 20-year-olds. It is estimated that, nationwide, this action could prevent 223,000 deaths among people born between 2000 and 2019. This would include 50,000 fewer deaths from lung cancer—the nation’s leading cause of cancer death.
The experience with alcohol also shows that effective policy measures go well beyond legal age minimums. For example, studies have linked reduced drinking and related problems to implementation of zero-tolerance laws and higher alcohol prices. New research suggests that traffic deaths involving underage drinking drivers can be reduced by implementing: laws mandating license forfeiture on being caught using, purchasing, or possessing alcohol (referred to as use/lose laws); laws holding party holders liable for alcohol-related injuries (referred to as social host liability laws); laws allowing someone failing a sobriety test to be charged with possession (referred to as internal possession laws); graduated licensing; laws requiring bartenders to be at least 21; or restrictions on young drivers driving at night each. Research has also found that effects of the passage of MLDA 21 are strengthened by enforcement through compliance checks, monitoring and penalizing alcohol sales to underage or underage-appearing persons, sobriety checkpoints, and wider enforcement of drinking-and-driving and responsible-alcohol-beverage-service laws. (For additional information on these policies and their effectiveness see Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, https://addiction.surgeongeneral.gov/ ).
Similarly, effective measures to reduce tobacco use go well beyond raising the legal age of sale of tobacco products. Evidence-based policies in use around the world include significant tobacco tax and price increases, comprehensive smoke-free policies, comprehensive bans on tobacco industry marketing activities, prominent pictorial health warning labels on tobacco products, and population-wide tobacco cessation programs.
Prevention of substance use and its consequences goes beyond educating young people about the harms to their health and safety. Laws and other policy-level interventions make a huge impact, and thus need to be leveraged as part of a comprehensive public-health approach to reducing underage drinking and smoking by adolescents and young adults. NIH continues to conduct and fund research to understand how we can better prevent use of alcohol and tobacco products in our nation’s youth, because protecting the health of the next generation is a goal that all can agree on.