Age Restricted Location Policies: A Potential Strategy for Advancing the Tobacco Endgame

Tobacco use is responsible for more than 480 000 US deaths per year, making it the leading cause of preventable death for the country.¹ For the last decade, a popular topic of discussion among tobacco control researchers seeking to reduce tobacco-related morbidity and mortality has been “the tobacco endgame.” This term refers to the goal of phasing out the sale of commercial tobacco products to near-zero levels. Though once considered an idealistic goal, there is an emerging consensus that tobacco endgame scenarios could be achieved through a combination of continued implementation of established measures, complemented by new and innovative policies.^2–5 Age restricted location (ARL) policies are an innovative strategy that advances this goal.

ARL policies are regulations that would restrict the sale of all tobacco products to adult-only establishments. Specifically, under an ARL policy, tobacco could only be sold in stores like tobacco shops and vape shops that bar entry to those under the minimum age of sale (age 21 years in the United States). Tobacco retailers like convenience stores, dollar stores, gas stations, grocery stores, and pharmacies (which, collectively, constitute more than 80% of tobacco retailers^6,7) would no longer be permitted to sell tobacco, as they allow children and young people on their premises. An ARL policy would, in many ways, mirror how both cannabis (where legal) and liquor sales are restricted in many US states. And it could have a major impact on US tobacco retailer density, which is currently estimated at over 1.22 retailers per 1000 persons.⁸ This value goes up to 16.7 retailers per capita when examining historically marginalized areas, such as neighborhoods with a greater composition of racially or ethnically minoritized residents.⁸ To provide some global context, Finland reports 1.0 retailers per 1000 persons,⁹ Scotland 7.5 per 1000 persons,¹⁰ and New Zealand 1.6 per 1000 adults.¹¹

Support for ARL policies is motivated by the extensive literature indicating the role that tobacco retailers play in perpetuating the tobacco epidemic by providing ready access to tobacco products.^12,13 Retailers are also a major source of exposure to the tobacco industry’s marketing, with more than 50% of youths reporting frequent tobacco marketing exposures at retailers¹⁴ (marketing exposure has been found to promote tobacco initiation and inhibit cessation^15–18). Concerningly, these issues of access and marketing exposure are often greatest in historically marginalized communities, where there are, on average, both more retailers and more marketing per retailer.^19–24 There is, likewise, strong evidence that reducing access to tobacco retailers would reduce youth use and support people who use tobacco and want to quit.^25–27

Perhaps through growing attention on the tobacco retail environment, ARL policies have received more consideration in the literature over the last few years, often in the context of reviewing endgame policies.^28–32 But ARL policies are not just a hypothetical tobacco prevention strategy. Recently, the Netherlands became the first country in the world to enact an ARL policy.^33,34 The multiphase implementation plan was intended to be gradual. In 2022, cigarette vending machines (previously allowed outside, as free-standing entities) were banned. Beginning July 1, 2024, tobacco sales in grocery stores were prohibited. By 2032, sales of tobacco in gas stations and convenience stores also will be prohibited. With the Netherlands blazing a trail for ARL policies, it is an excellent time for other countries, including the United States, to follow suit.

WHAT COULD AN AGE RESTRICTED LOCATION POLICY DO?

Likely benefits of an ARL policy include the following.

• 1.Reducing tobacco initiation among youths and improving cessation among youths and adults. Research has established that greater tobacco retailer density is associated with greater youth tobacco use¹³ and fewer successful quit attempts among adults who smoke.^16,27 Conversely, policies that reduce access—such as restricting cigarette vending machines to adult-only facilities in the United States—is associated with reduced youth use.³⁵ Among youths aged 18 years and older who use tobacco, 56.4% purchase it directly from brick-and-mortar stores and 34.5% buy or borrow it from someone who made a purchase.³⁶ As previously stated, an ARL policy would prohibit the sale of tobacco products at an estimated 80% of existing US tobacco retailers. Thus, an ARL policy would drastically reduce the number and density of tobacco retailers, thereby reducing access to tobacco products. Further, retailers no longer selling tobacco would gradually remove their tobacco advertisements and promotions, thereby reducing exposure to tobacco marketing.
• 2.Reducing tobacco-related health disparities. Tobacco retailer density is typically greater in historically marginalized communities,^20–23,37 contributing to tobacco use disparities based on neighborhood income, racial and ethnic composition, and rurality^38–44 (which have, in turn, been linked to tobacco-related health disparities). Convenience stores and dollar stores are also more prevalent in historically marginalized communities.^7,45–47 For example, our work in Ohio found that, when we looked at the percentage of tobacco retailers that were convenience stores, the prevalence was 62.3% for urban areas with high prevalences of poverty and people of color, 60.1% for rural areas with a high prevalence of poverty, and only 52.6% for urban areas with low prevalences of poverty and people of color.⁷ As tobacco sales from these types of stores would be eliminated by an ARL policy, the policy may potentially have the greatest impact for individuals living in historically marginalized communities, rendering it an equity-enhancing policy.
• 3.Complementing existing age-of-sale policies. Tobacco 21 laws in the United States prohibit tobacco sales to people aged younger than 21 years but do not restrict where tobacco can be sold or who can enter such locations. Under an ARL policy, tobacco sales would only be allowed in retailers that prohibit individuals younger than 21 years from entering, thus reducing the potential for illegal sales to minors. Currently, noncompliance with Tobacco 21 (i.e., sales to minors) is poor in some locations⁴⁸ and would remain a concern under an ARL policy. However, with considerably fewer retailers selling tobacco, retailer inspections will become more manageable, allowing retailers with repeat violations to receive more attention. This, in turn, could contribute to improvements in Tobacco 21 enforcement.

FUTURE CONSIDERATIONS

As with any new policy, important considerations are warranted. Because ARL policies are so new, there is not yet rigorous evidence concerning their effectiveness. Evaluations of the ARL policy in the Netherlands⁴⁹ and of other jurisdictions that adopt ARL policies in the future will be eagerly anticipated. In the meantime, simulation studies that model changes to observed tobacco retailer density data may also answer important questions about how ARL policies might unfold in various social, legal, and geographic contexts. For example, an ARL policy might complement and enhance the impact of some tobacco policies, such as licensing law strategies,^50,51 but could conflict with other endgame approaches, such as pharmacy-only policies (that would permit tobacco sales only in pharmacies).⁵² It will also be important to determine how low tobacco retailer density must become to have a meaningful impact on tobacco use behavior.

Another important consideration is the drafting of the ARL policies themselves, which will need to be carefully written to avoid loopholes or unintended consequences. In the Netherlands, for example, there are concerns that, in response to their ARL policy, the number of specialist tobacco shops may increase.⁴⁹ To maximize the effectiveness of ARL policies, language can be added to limit the total number of licenses available for adult-only stores (e.g., caps on retail licenses); this could help prevent compensatory market responses such as new tobacco or vape shops opening—especially in historically marginalized areas. In addition, language can be added to prevent retailers from designating separate areas (“store within a store”) as adult-only; this lesson was learned in the United States, when retailers sought loopholes to local flavor bans with adult-only exemptions.^53–55

Meaningfully reducing tobacco-related morbidity and mortality and related inequities requires innovative policies. The time has come to seriously consider ARL policies as part of a tobacco endgame strategy. There will undoubtedly be challenges. In the United States, for example, there are 27 tobacco retailers for every one McDonald’s fast-food establishment (the nation’s largest fast-food chain),⁵⁶ and, on average, cigarettes generate more than $500 000 in annual sales for each convenience store (though far less in profit). Thus, tobacco retailers and tobacco companies more broadly would have a strong incentive to oppose ARL policies. But this is not an insurmountable obstacle. Economic analyses have found that US declines in cigarette sales have not negatively affected business; in fact, the number of retailers, revenues, and profits have risen⁵⁷ and are expected to continue rising, as money previously spent on tobacco shifts to other services or merchandise.⁵⁸ Moreover, the tobacco industry has been on notice for more than 60 years that they are selling an addictive and deadly product, and there is now strong public support for more aggressive tobacco policies.^3,59,60

When we envision a world nearing the end of commercial tobacco sales, what does that look like? An ARL policy depicts a feasible scenario: just a small number of stores where adults who are unable or unwilling to quit retain their ability to legally purchase tobacco products. In this world, the preponderance of tobacco sales and point-of-sale marketing will be muted, perhaps most drastically in historically marginalized communities. It is a scenario worth real consideration. Achieving it will require the concerted and coordinated efforts of many strategies, including the continued implementation of established prevention and cessation measures. But the incorporation of ARL policies could bring us closer to that endgame.