Getting to Tobacco 21: an all-policy consensus is needed to reduce unintended consequences

Thompson et al. (2018) remind us that the World Health Organization Ottawa Charter, published almost four decades ago, was the blueprint for health promotors and policymakers to build policies and create supportive environments to promote the health and well-being of communities and societies (World Health Organization, 1986). The relevance of this strategy continues in the 21st century if we are to achieve the goal of the tobacco endgame—a tobacco-free world (Malone et al., 2014). Moving us toward this destination has been the Framework Convention on Tobacco Control (FCTC) treaty, adopted by 182 countries globally and celebrating its 20th anniversary (World Health Organization, 2003); however, the tobacco endgame demands thinking that goes beyond it (Daube and Maddox, 2021).

A current debate for tobacco control seeks to move beyond Article 16 of FCTC and is anchored on increasing the age for legal sales by retailers from 18 to 21 years as a disincentive. It seems a laudable activity, given all that is known about the harmful effects of smoking (Nuyts et al., 2018; WHO, 2021; RCPI, 2022; Cox et al., 2023). The European Respiratory Society Tobacco Control Committee (ERSTCC) statement confirms that Tobacco 21 is an ‘important milestone in the journey towards a tobacco-free generation’ (p.4), and they highlight four countries where this policy change exists (USA, Singapore, Sri Lanka, Kuwait), noting the forward-looking policymakers in New Zealand and the decision to ban sales to anyone born after 2009 (Cox et al., 2023). Critically, the ERSTCC statement notes the absence of any policymakers leading this change within the European Union (EU); however, the UK government is now at the forefront of European change with their recent announcement and ‘Stopping the Start’ plan to introduce legislation from 2027 banning the sale of cigarettes to anyone aged 14 years or younger (UK Government, 2023). This change supports the components of tobacco control strategies, and Tobacco 21 is another significant part of a comprehensive approach (Cox et al., 2023).

We know that increasing the age for legal sales decreases tobacco initiation in adolescents aged 15–17 years when introduced (RCPI, 2022; Cox et al., 2023). Support for raising the legal age to 21 for sales exists among smokers, with evidence from the UK, Ireland and Canada demonstrating that 60%–80% of people aged 15 years and older supported raising the legal age of sales to 21 (Cosgrave et al., 2023; Cox et al., 2023).

Policy and regulations have been instrumental in reducing tobacco consumption globally in support of the tobacco endgame, including legislative bans and policies limiting smoking indoors and in public places, placing warnings on packaging, using plain packaging, banning advertising on media, banning sponsorship and increasing prices (Frazer et al., 2016a; WHO, 2023). The impact of policy and legislative policy changes is reducing the harmful effects of smoking on health and well-being; however, barriers persist and meeting the targets of Sustainable Development Goals (SDGs) by 2030 is less likely given that 2040 is the target for Europe’s Cancer Plan to reduce smoking rates to 5%—10 years beyond the target of the UN SDGs to leave no one behind by 2030 (UN, 2015; EC, 2023). Similarly, the body of evidence increases confirming both improvements and challenges when implementing policies to ban smoking in specialist settings (including hospitals and prisons), especially for those living in low- and middle-income countries (Frazer et al., 2016b; Lyons et al., 2023; Mattson et al., 2023; Merrit et al., 2023). The tobacco endgame is thus a shifting narrative from the focus at an individual level and ‘the why people smoke’ to a systems focus lens’ supported by the newly formed Global Alliance for Tobacco Control (WHO, 2023), and in line with the societal-wide focus at the heart of the Ottawa Charter (WHO 1986; Thompson et al., 2018).

Despite the gains, smoking accounts for 8 million deaths annually (direct and indirect smoking), and the finances of tobacco manufacturers increased with a sustained uptick in sales of e-cigarettes as they diversified their portfolio of tobacco products (WHO, 2022; Statistica, 2023). Worldwide income from tobacco sales is reported at $941.10bn worldwide for 2023, with $270.20bn accounting for European sales (additional revenue from e-cigarettes is reported at $24.1 billion) (Statistica, 2023).

We know that the availability of cigarettes did not diminish during COVID-19, with evidence of increased smoking rates in homes placing many at risk (Xie et al., 2021). Those at risk are disadvantaged and marginalized due to inequitable structural and societal barriers (Malone, 2021; Smith et al., 2021; WHO, 2022). We know that an equity impact of tobacco control (reducing rates for those most disadvantaged) requires policymakers to increase prices and ensure targeted tobacco cessation practices (Malone, 2021; Smith et al., 2021; WHO, 2022). While Tobacco 21 seems ever more important for public health and policymakers, the unintended consequences of Brexit—the EU–UK withdrawal agreement in February 2020 on the availability of duty-free sales of tobacco products—remain an unchallenged component of tobacco control strategies (European Council of the European Union., 2023).

Throughout the pandemic, international trading policies and impacts altered due to Brexit, emphasizing complex real-world trade and security challenges for Northern Ireland (European Council of the European Union., 2023). An unforeseen consequence was opening the duty-free market, enabling sales of tobacco products at reduced prices within the EU when leaving the UK. In Ireland, the political debate focused on ensuring adherence to allowances and ignoring the lower age limit for legal sales—reported as 17 years (Oireachtas, 2023a), which seems to differ from the focus of a national survey in 2022, which sought public opinions on Ireland’s tobacco endgame initiatives including increasing age for sales to 21 years (Cosgrave et al., 2023). Border control documentation in the UK continues to confirm the legal age for tobacco allowances as 17 years (EU Your Europe., 2023; GOV.UK Border Force. , 2022). The unintended consequences of the Brexit Agreement include outdated information on customs policies and increased opportunity for duty-free market trading—an economic shot in the arm for tobacco companies, highlighting a commercial gain GOV.UK Border Force. (2022).

The rationale for Tobacco 21 is unmistakable, and it would seem consistent for country-level policies on the minimum age for selling tobacco products to include policies and regulations for duty-free purchases (RCPI, 2022; WHO, 2022; Cox et al., 2023). Currently, five countries are consistent in limiting the purchase of duty-free sales of tobacco products (including e-cigarettes) to people aged over 18 years (Sweden, Norway, Denmark, Australia) or 21 years (USA) (Cox et al., 2023). The majority of EU countries report the minimum age for sales as 17 years on websites listing regulations for duty-free selling allowances (EU Your Europe, 2023). Ireland has no legal minimum age for sales of e-cigarettes, for example, although changing policy and legislation are imminent (Oireachtas, 2023b).

The components of tobacco control policies have been well recognized since the adoption of the FCTC by the World Health Assembly in 2003 (WHO, 2003, 2021, 2023), underpinned by the Ottawa Charter (WHO, 1986). The ERSTCC statement presents a strong argument for the Tobacco 21 policy and EU leadership. The impetus to get to Tobacco 21 must be embedded at the macro level—in all national tobacco control policies. Tobacco 21 is not a destination—it is our clarion call supporting the wider tobacco endgame and a tobacco-free generation.

Conflict of Interest

K.F. holds the position of Associate Editor for Health Promotion International. K.F., D.C., P.K., C.K. have received funding for research relating to tobacco control from Irish national funding agencies.

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