Health Policy$ense

The Effect of Vaping Minimum Age Laws on Teen Smoking and Birth Outcomes

New evidence of substitution effect

Public health advocates have been concerned about rising e-cigarette use (“vaping”) among teens. For the first time in 2014, teens reported being more likely to use e-cigarettes than regular cigarettes. New Jersey implemented the first law restricting the purchase of e-cigarettes or other electronic nicotine delivery systems (ENDS) in 2010; almost all states followed suit in the following years, before the U.S. Food and Drug Administration banned the sale of e-cigarettes and other electronic nicotine delivery systems (ENDS) to youth under 18 in August 2016.

These laws may have increased the monetary and non-monetary (“hassle”) costs of purchasing e-cigarettes relative to cigarettes, which have longstanding minimum age purchase limits. Economists often use these relative changes in costs to explore if products are substitutes or complements. In a recent study in Preventive Medicine, my colleagues and I used this approach and found a concerning trend of teen cigarette smoking increasing when ENDS age purchasing restrictions were enacted. Age purchasing restrictions increased a teen’s regular cigarette use by 0.8 percentage points, but had no effect on cigar use, smokeless tobacco use, or marijuana use. In our latest study, recently released in the National Bureau of Economic Research working paper series, we find that e-cigarette age restrictions had an even larger impact on smoking of regular cigarettes by pregnant teens, increasing by 2.1 percentage points.

Despite this large increase in cigarette use, we found that the laws had little or no effect on birth outcomes, with a possible beneficial effect in reducing very premature birth and increasing Apgar 5 score. This is the first study linking e-cigarette policy to a health outcome, and it may come as a surprise, because the risks of smoking are considered much greater than the risks of vaping. The British government suggests that e-cigarettes may only have 5% of the risks of cigarettes for a general person.

However, this risk profile is not applicable to pregnant women, because nicotine is especially dangerous to fetal outcomes and e-cigarettes often contain nicotine. These purchasing laws may have reduced overall nicotine exposure if some people quit vaping altogether in response. This suggests that the laws were effective in reducing overall nicotine exposure from both smoking and vaping combined, even if smoking rates increased. But the long-term health implications of the increase in smoking rates need to be considered. Pregnant women are especially motivated to quit smoking, although there is not enough evidence to recommend e-cigarettes as a smoking cessation tool. Our findings suggest that e-cigarettes may not be a safe smoking cessation device for pregnant women.  

A minimum purchase age of at least 18 is now the law of the land for both cigarettes and e-cigarettes. A number of states and municipalities are increasing their minimum purchasing age for both cigarettes and vaping products to 21, a policy recently endorsed in a New England Journal of Medicine editorial. Without commenting on the merits of raising the cigarette minimum purchasing age to 21, results from our studies suggest it would be better from a public health standpoint to keep the minimum purchase age for e-cigarettes and other ENDS at 18. Having a tiered minimum purchasing age based on product risk, similar to a tiered approach previously used in some states for beer and liquor, provides an incentive for older teen smokers to reduce their smoking by switching to vaping products.  

Michael Pesko is a health economist and an Assistant Professor in the Department of Healthcare Policy and Research at Weill Cornell Medical College. He has received pilot grant funding from the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH).