Monday, February 11, 2019

We Need Tobacco 21 Legislation Now

By Sid Roberts, MD
Lufkin Radiation Oncologist
Member, Texas Medical Association 

Editor's Note: This article was originally published Feb. 10 at The Lufkin Daily News and on Dr. Roberts' blog.

Who knew that candy apple, bubble gum, cherry cola, marshmallow, orange soda, s’mores, chocolate and taffy were literally so addictive?

Every one of those flavors — and thousands more — are available in e-cigarettes today. Tobacco and e-cigarette use — seductively called vaping — are increasingly sucking our youth into a lifetime quicksand of addiction with health and financial costs certain to follow.

A coalition of many partners, including the American Cancer Society Cancer Action Network, American Heart Association, American Lung Association in Texas, Texas Medical Association, Texas Hospital Association and numerous health systems throughout the state, have come together as Texas 21 to save lives by preventing tobacco use. One simple legislative change that Texas 21 supports can impact hundreds of thousands of lives down the line: raising the age to buy tobacco products to 21.

Almost all smokers start before age 21. In Texas alone, more than 10,000 kids become daily smokers every year. Lest you think raising the age to buy tobacco products to 21 is a radical idea, six states have already done so, as well as hundreds of cities across the country (including San Antonio in 2018). In fact, more than a quarter of the nation is covered by such T21 legislation.

My home county — Angelina County in Deep East Texas — has the dubious distinction of ranking dead last in Texas for health behaviors according to the Robert Wood Johnson Foundation (accessible online at Our higher-than-average adult smoking rate is a major factor in that determination. If we are to change the health behaviors of an entire county, we must address some factors more globally. Smoking is one of them.

In Texas alone, more than 10,000 kids become daily
smokers every year. 
Raising the smoking age to 21 will not have a big economic impact on retailers, as only 2 percent of U.S. cigarette sales go to those under age 21. But the long-term impact on our taxes, of which too much goes to smoking-caused health care, will be significant. In Texas, Medicaid costs caused by smoking amount to almost $2 billion annually. Total annual health care costs in Texas directly caused by smoking reach nearly $9 billion. If fewer kids start smoking, we will — over time — see a significant decrease in smoking-related expenditures. Not to mention that our kids will enjoy longer and healthier lives.

Our children are so vulnerable to influence when they are in their early teens. On average, kids in the U.S. try smoking for the first time before they are 14 years old. They get their first cigarettes from older teens. Most high school seniors can legally buy cigarettes before they graduate high school, because the legal age to purchase currently is 18. This gives younger teens easy access to nicotine and tobacco through their peers.

States and cities that have enacted T21 legislation have seen a significant drop in youth smoking initiation. The Institute of Medicine (now the Health and Medicine Division of the National Academy of Medicine) notes that raising the tobacco sale age will not only significantly reduce the number of adolescents and young adults who start smoking, it will reduce smoking-caused deaths and immediately improve the health of adolescents, young adults and young mothers who would be deterred from smoking, as well as their children.

It’s not just about cigarette smoking, though. E-cigarettes must be included in any T21 legislation. The tobacco industry, seeing overall declines in U.S. smoking rates, cleverly (and sinisterly) purchased e-cigarette companies and began refining and marketing these nicotine delivery systems to our kids. Vaping became mainstream.

The power of the tobacco industry to addict people to nicotine is evident in the fact that e-cigarette company Juul — in which tobacco giant Altria owns a large stake — has grown quickly to be worth as much as $38 billion by some estimates. Juul’s annual revenue is said to be $2 billion. Addicting teens with flavors like mango, creme brulee and mint has resulted in more kids using electronic cigarettes than regular cigarettes. In fact, e-cigarette use among youth is now considered to be an epidemic.

Juul and other vaping devices are not toys. Evidence continues to build that for young people, using e-cigarettes increases the likelihood of smoking cigarettes. Some of the chemicals in e-cigarettes are harmful as well. And the effects of nicotine on developing brains are not fully known. Especially worrisome is evidence that nicotine can cause impaired brain development, especially of the prefrontal cortex, which affects judgment and impulse control.

To flavor a highly addictive chemical and sell it to children is not only sinister and dangerous; it is appallingly profitable for the very tobacco companies who have been driving up our health care costs killing us with cancer, heart disease, COPD and many other illnesses for decades.

What can we do right now? Polls show nearly 70 percent of voters across party lines favor T21 legislation. More than half of voters strongly favor it. Sen. Joan Huffman and Rep. John Zerwas, who is a physician, have introduced Senate Bill 338 and House Bill 749 — both of which include e-cigarettes — to protect kids from tobacco addiction and save lives by raising the tobacco age in the state to 21.

This something we can all agree on. Let’s pass T21 legislation in Texas this session.

Dr. Sid Roberts is a radiation oncologist at the Temple Cancer Center in Lufkin. He can be reached at Previous columns may be found at

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