SA Metro Health Director Colleen Bridger in October will present a formal recommendation to City Council to raise the legal age to purchase tobacco products in San Antonio from 18 to 21. She wants to implement the policy, referred to as “tobacco 21,” before the end of the year.

“When I look at public health ‘bang for the policy buck,’ tobacco 21 has significant public health effects,” Bridger said. “I want to focus on that.”

With tobacco 21, Bridger hopes that San Antonio will join 13 of the 40 largest cities in the United States in raising the legal age to purchase tobacco products to 21.

“When you look at what we haven’t yet achieved, [tobacco 21] is the single most important public health policy we can pass,” Bridger said.

The primary motivation for implementing the tobacco 21 policy, Bridger said, is research indicating that people are more likely to become addicted to substances if they begin using them before their brain is fully developed. She told the Rivard Report that the policy’s intention is to “decrease the access to tobacco products before the brain has developed into realizing they shouldn’t [use them].

“What we do know is that if you haven’t started smoking by 21 you are much less likely to start,” Bridger said.

Before a formal proposal takes place, Bridger plans to gauge community support for tobacco 21 through an online survey that limits how many times people can respond. The survey will be distributed through neighborhood and community organization email lists, including those of Speak Up SA and elected officials, as well as  Metro Health’s listserv. To participate in the survey, click here.

Bridger has relocated to Texas after working as the head of the Orange County Health Department in North Carolina.
Metro Health Director Colleen Bridger Credit: Hannah Whisenant / San Antonio Report

“My guess is that it will be a pretty high percentage who will say they are in favor of the proposed change of law,” Bridger said.

Research indicates that there is widespread support to raise the legal age for purchasing tobacco products to 21 across the country. The level of support ranged from nearly 60% in seven states in the Midwest to 73% in four Southern states. When asked if they supported raising the minimum age to 19, 20, or 21 for buying tobacco products, most respondents said that 21 would be the best age to change the policy to.

In 2016, Hawaii became the first state to raise the age to purchase tobacco products to 21. California followed shortly after.

If City Council decides to raise the legal age to 21, San Antonio will be the first city in Texas to do so.

Councilwoman Ana Sandoval (D7) told the Rivard Report that she commends Bridger for planning to bring a tobacco 21 proposal to City Council, noting that “studies have shown that young people who use tobacco products before age 21 are significantly more likely to become lifelong users, which puts them at a much greater risk [for] lung cancer and heart disease.”

According to a report published by the Robert Wood Johnson Foundation in 2016, the adult smoking rate in Bexar County was 13% in 2015, below the state average of 15%. According to the Department of State Health Services, Bexar County is projected to see 820 new cases of lung or bronchial cancer in 2017.

“[Bridger] is trying to save lives,” Sandoval said. “As chairwoman of the Community Health and Equity Committee, I pledge to give her proposal the study and attention it deserves.”

Policies that limit access, especially in the state of Texas, are often met with criticism from people who oppose the concept philosophically, arguing that a “nanny state” undermines people’s freedom of choice. Bridger said there may be individuals, businesses, and political leaders who oppose the proposed age change, but “if you ask the mom of an 18-year old, they wouldn’t want them to smoke.

“Unlike other tobacco control measures, like raising the cost, making it illegal to purchase a cigarette does not have adverse economic effects on people,” Bridger said. “Will it affect a retailer’s bottom line? Potentially yes.”

Some organizations have come out in favor of the tobacco 21 policy. In 2015, CVS removed tobacco products from its pharmacy locations. A study published in the American Journal of Public Health shows that removing tobacco products was associated with a significant decrease in overall cigarette purchasing, including at other retail locations.

CVS dropping tobacco products makes philosophical sense for a retailer promoting health and wellness. The published study stated that the decision amounted to a $2 billion loss in annual sales. Despite the decline in sales from tobacco products, a 2016 statement from President and CEO Larry Merlo said that revenues went up nearly 16%.

While a tobacco policy change’s potential effects on small businesses in San Antonio are currently unknown, there has been extensive research on the retail impact of raising the age to purchase tobacco products to 21.

The National Center for Biotechnology Information, part of the United States National Library of Medicine, reports that raising the tobacco sales minimum age to 21 years across the U.S. would decrease tobacco retailer and industry sales by approximately 2%, but could contribute to a substantial reduction in the prevalence of youth’s tobacco use and dependency by limiting access.

Bridger said that if City Council voted for tobacco 21, she would recommend a “soft launch” for three months before the law would fully go into effect. During that time “there would be no consequences, just reminders,” as businesses and consumers adjust to the policy change.

Guiding Bridger’s proposal is a national project called CityHealth, a bipartisan public policy effort out of the de Beaumont Foundation, which established a formal rating process to analyze active health policies in the 40 largest cities in the U.S. and assign either a gold, silver, or bronze medal as their overall rating.

The de Beaumont Foundation, whose mission is to strengthen and transform public health through improving the effectiveness of local state health departments, provided the funding for the CityHealth project, which is in its third year.

CityHealth began by completing a two-year assessment of how the nation’s 40 largest cities fare in nine categories of policy that affect community health, as established by a panel of community and health industry experts.

Shelley Hearne, the principal investigator with CityHealth, told the Rivard Report that her organization sets the criteria and gives categorical ratings, and cities can then use that information to inform policy.

“All we have done is a straightforward assessment of: does the city have this law, and if they do have it, how good is it against a gold standard,” Hearne said.

“We see this as the power of information and accountability. [We are] creating transparency,” Hearne said. “We tell cities, here is what others are doing, what you are doing, and its up to them how to fill in the blanks.”

Bridger told the Rivard Report that while tobacco 21 would elevate San Antonio to an overall bronze medal in 2017, the intention is to get the city to reach gold. In the meantime, she believes the City will need to spend at least two years improving policy to achieve silver, with healthy food procurement as the next point of focus.

Bridger admits that it will take a lot of work to get San Antonio to gold medal status. She looks at it with a long-range view, beginning with tobacco 21.

“This is my recommendation as the City’s health director,” Bridger said. “But I want to make sure that I have all the information that City Council will need before they are asked to make a decision.”

Roseanna Garza reports on health and bioscience for the San Antonio Report.