Raising the Tobacco Sales Age to 21 in Texas
Impact on Health Care Costs
Background
The Food and Drug Administration (FDA) is granted broad authority over tobacco products by the Family Smoking and
Tobacco Control Act of 2009 (Act), but is prohibited from raising the minimum age above 18 at a federal level. The Act
required the FDA to convene a panel to examine the ramifications of raising minimum tobacco purchase age. The FDA
tasked the National Academy of Medicine (formerly called the Institute of Medicine, IOM) with investigating this issue.
The Academy completed its investigation and issued a report titled Public Health Implications of Raising the Minimum
Age of Legal Access to Tobacco Products in 2015. The report details the impacts of raising the age minimum to 19, 21,
and 25 years. The Academy concluded that relative to status quo projected decreases, raising the age minimum to 19 years
of age would result in a 3% additional decrease; raising the age minimum to 21 years, a 12% additional decrease; and
raising the age minimum to 25 years, a 15% additional decrease. Furthermore, the Academy concluded that the age group
most impacted by raising the minimum age limit would be 15 to 17 year olds for any of the 3 ages studied.
The findings from the 2014 Texas Youth Tobacco Survey conducted by the Public Policy Institute at Texas A&M
University are reflected below in Table 11.

Table 2 below shows the prevalence of tobacco use as reported by the Texas Behavioral Risk Factor Surveillance System
in 2012 and 2013. Nationally, there was a decrease in current smoking among adults from 18.9% in 2012 to 18.2% in
2013. In Texas, the decrease was from 18.2% in 2012 to 15.9%.

The Academy report argued that increasing the age for tobacco purchase will result in delayed use of such products,
which in turn will decrease the prevalence of users. From a health perspective, the impacts of decreased prevalence would
be short- and long-term. Reductions in tobacco-related diseases will take decades to realize, but there would be immediate
reduction in adverse physiological effects and poor infant health outcomes. The report stated that raising the minimum age
to 21 years would result in 200,000 fewer premature deaths and potentially millions of years of life gained for those born
between 2000 and 2019.
December, 2016

 There are many long term health benefits for considering tobacco use reduction policies, this analysis estimates the shortterm benefits, more specifically reductions in preterm birth (PTB) and low birth weight (LBW) infants and estimates the
health cost savings over a five year time period. These two health outcomes are included in the Academy report in the
model projection on the effects of raising the minimum age limit to 21 years of age.2
Cost Estimates
The cost estimates of raising the minimum age limit for purchasing tobacco products to 21 years of age in Texas has been
calculated using the following:
 Averting cases of pre-term births (PTBs) attributable to smoking
 Averting cases of low birth-weight births (LBWs) attributable to smoking
 Cost of treating PTBs and LBWs
 Tobacco tax revenue loss
This is a direct mathematical analysis using birth statistics for smoking-attributable diseases and projected incidence
reduction from the Academy report. Those results allowed us to project the total number of cases averted, which were
multiplied by the cost of treating each specific condition. The details of each number used in the calculation is sourced or
explained below.
Births per year
The Texas Department of State Health Services keeps historical data on the number of births3 in Texas. Trend analysis
was used to forecast live births in Texas from 2016 to 2019 based on live births from 2011 to 2015. From 2015 to 2019,
there are projected to be 2,088,533 live births and from 2020 to 2039 these are projected to be 10,095,042 live births.
Preterm births attributable to smoking
According to Texas Pregnancy Risk Assessment Monitoring System (PRAMS)4 2012 data book, the incidence of preterm
birth attributable to smoking among women of childbearing age was 2.4% in 2012. This latest data, released in May 2016,
will be used in this analysis for the period from 2015 to 2039.
Low Birth Weight cases attributable to smoking
Under the status quo, in 2012 the incidence rate of smoking-attributable LBW babies according to Texas PRAMS 2012
data book is about 4.3% among the total births for all the women of childbearing age.
Cases averted
 The Academy report on raising the minimum legal age of purchase to 21 years estimates that this policy will
reduce PTB by 4.3% over the first five years of the policy and 11.6% over the subsequent 20 years.
 The report also estimates that the policy will reduce LBW by 4.1% over the first five years and 10.7% over the
subsequent 20 years. (Refer to Table 2, 3a and 4a in Appendix)


The maternal smoking rate in Texas was 6.5% in 2012. The national maternal smoking rate was 10.2% and to
account for this difference, the reductions were multiplied by the ratio of the Texas maternal smoking rate (in
2012) over the national maternal smoking rate. Hence, these numbers were reduced by 6.5/10.2% in order to
better estimate the results for Texas assuming that the smoking rate remains constant for the entire period
of calculations. (Refer to Table 3b and 4b in Appendix)

Cost of treating conditions

According to FY 20155 data from the Texas Health and Human Services Commission (HHSC), Texas Medicaid
paid for more than half (53.2%) of all live births in Texas. Additionally, Texas Medicaid paid over $402 million
for newborns with prematurity and low birth weight. Care delivered in the neonatal intensive care unit (NICU) is
now the costliest episode of medical care for the non-elderly population. The Texas Medicaid average
December, 2016

 newborn cost for prematurity/low birth weight complications is $109,220. These figures are used in the model to
project cost savings.
Tobacco tax estimate
In fiscal note filed for SB 313 (83rd Legislature), it was estimated that loss in taxes for 5 years (2014-2018) would amount
to $97,147,000.

Results

Applying the results of the Academy’s model to Texas, in the first five years, this policy would prevent about
1,374 cases of PTB and 2,346 cases of LBW (Table 3b and 4b), leading to a total health care savings of around
$406,295,932 of which 53.2% ($216,149,4367) will be accrued by Texas Medicaid. The tobacco tax revenue lost
during this period would be approximately about $97,147,000.
Over 25 years, this policy would avert about 31,945 incidences of LBW and almost 19,283 (Table 3 and 4) cases
of LBW. This leads to savings of about $5,595,181,610 while again 53.2% ($2,976,636,616) would be saved by
Texas Medicaid.
References
1.
2.
3.
4.
5.

Texans and Tobacco.2015. Department of State Health Services. As required by Section 161.0901, Texas Health and Safety
Code.
IOM (Institute of Medicine). 2015. Public health implications of raising the minimum age of legal access to tobacco
products. Washington, DC: The National Academies Press. July 14, 2016.
https://www.dshs.texas.gov/chs/vstat/annrpts.shtm (Accessed on 7-13-2016)
http://www.dshs.texas.gov/mch/#PRAMS2 (Accessed on 7-13-2016)
Better Birth Outcomes: Presentation to the House Committee on Public Health (May 19, 2016)
http://www.dshs.texas.gov/legislative/default.shtm (accessed on 12-7-2016)

December, 2016

 Appendix
Table 1: Live births from 2011-2015 and Projected live births in Texas from 2016-2039
Year
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039

Live birth
377,274
382,438
387,110
399,766
403,385
410,860
417,815
424,770
431,725
438,680
445,635
452,590
459,545
466,500
473,455
480,410
487,365
494,320
501,275
508,230
515,185
522,140
529,095
536,050
543,005
549,960
556,915
563,870
570,825

December, 2016

 Table 2: Smoking Attributable to LBW, Pre-term Births Attributable to Smoking Cases, Texas 2012 PRAMS Data
2015–2019
2020–2039
Pre-term Birth (PTW)

50,125

242,281

Low Birth Weight (LBW)

89,808

434,087

Table 3a:Smoking Attributable to PTB Cases and Averted Cases by Period Under Each Policy Option
2015–2019

2020–2049

50,125

242,281

451

7,753

Averted percentage reduction

0.90%

3.20%

MLA 21

2,155

28,105

Averted percentage reduction

4.30%

11.60%

MLA 25

4,110

38,765

Averted percentage reduction

8.20%

16.00%

Status Quo
Minimum Legal Age (MLA) 19

Table 3b: Smoking Attributable to PTB Cases and Averted Cases by Period Under Each Policy Option (adjusted for Texas)
2015–2019

2020–2039

Status Quo

50,125

242,281

MLA 19
Adjusted rate of reduction

287
6.5/10.2 %

4,941
6.5/10.2 %

MLA 21
Adjusted rate of reduction

1,374
6.5/10.2 %

17,910
6.5/10.2 %

MLA 25
Adjusted rate of reduction

2,619
6.5/10.2 %

24,703
6.5/10.2 %

Table derived from Health Benefits of Raising the Minimum Age of Legal Access to Tobacco Products." Institute of
Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington,
DC: The National Academies Press, 2015. doi:10.17226/18997.

December, 2016

 Table 4a: Smoking Attributable to LBW Cases and Averted Cases by Period Under Each Policy Option
2015–2019

2020–2039

89,808

434,087

718

13,023

Averted percentage reduction

0.80%

3.00%

MLA 21

3,682

46,447

Averted percentage reduction

4.10%

10.70%

MLA 25

5,927

65,113

Averted percentage reduction

6.60%

15.00%

Status Quo
MLA 19

TABLE 4b: Smoking Attributable to LBW Cases and Averted Cases by Period Under Each Policy Option (adjusted for
Texas)
2015–2019

2020–2039

Status Quo

89,808

434,087

MLA 19
Adjusted rate of reduction

458
6.5/10.2 %

8,299
6.5/10.2 %

MLA 21
Adjusted rate of reduction

2,346
6.5/10.2 %

29,599
6.5/10.2 %

MLA 25
Adjusted rate of reduction

3,777
6.5/10.2 %

41,494
6.5/10.2 %

Table derived from Health Benefits of Raising the Minimum Age of Legal Access to Tobacco Products." Institute of
Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington,
DC: The National Academies Press, 2015. doi:10.17226/189

December, 2016

 Tables 5 and 6 summarize the reductions in smoking prevalence for selected years and health outcomes by 20-year
periods for MLA 21, showing the relative timing at which different benefits occur. The results illustrate the longer times
required for chronic outcomes compared to short-term outcomes.
TABLE 5: Reduction (percentage) in Smoking Prevalence for MLA 21 by Year
2020

2040

2060

2080

2100

Smoking prevalence—SimSmoke*

2.0%

8.3%

10.3%

11.2%

11.20%

Smoking prevalence—CISNET*

0.4%

6.4%

10.6%

11.9%

12.00%

Table derived from Health Benefits of Raising the Minimum Age of Legal Access to Tobacco Products." Institute of
Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington,
DC: The National Academies Press, 2015. doi:10.17226/189
* The 2015 report referenced above uses two tobacco simulation models, SimSmoke and the Cancer Intervention and Surveillance
Modeling Network smoking population model (CISNET), to predict the likely public health outcomes of raising the minimum age for
the purchase of tobacco products.

TABLE 6: Reduction (percentage) in Health Outcomes for MLA 21 by Period
2020–2039

2040–2059

2060–2079

2080–2099

Deaths prevented—SimSmoke

0.0%

0.8%

4.6%

9.9%

Deaths prevented—CISNET

0.0%

0.2%

2.6%

8.2%

Years of life lost—CISNET

0.0%

0.5%

4.3%

9.3%

Lung cancer deaths prevented

0.0%

0.3%

3.7%

10.5%

Low birth weight cases

10.8%

12.2%

12.2%

12.2%

Pre-term birth cases

11.6%

13.0%

13.0%

13.0%

Sudden infant death syndrome cases

16.0%

18.5%

18.5%

18.5%

Table derived from Health Benefits of Raising the Minimum Age of Legal Access to Tobacco Products." Institute of
Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington,
DC: The National Academies Press, 2015. doi:10.17226/189

December, 2016