A new report suggests that raising the legal age for buying tobacco products to 21 nationwide would prevent or delay smoking by adolescents, leading to a substantial reduction in tobacco use and smoking-related illnesses and mortality.

Raising the legal age for buying tobacco products to 21 nationwide would likely prevent or delay smoking by adolescents and young adults, leading to a substantial overall reduction in tobacco use and fewer smoking-related illnesses and deaths, according to a report released this month by the Institute of Medicine (IOM), the health arm of the National Academies.

The 13-member expert panel convened by the IOM at the behest of the FDA concluded that raising the minimum age of legal access (MLA) to 21 would be a significant deterrent for young people, particularly those ages 15 to 17 who primarily rely on older teens for access to tobacco products. As fewer adolescents and young adults initiate tobacco use, the panel projected a steady decrease in overall prevalence of adult smoking over the coming decades. Under the status quo, smoking prevalence would decrease from about 18% now to 9% in 2100, whereas raising the age to 21 would result in an additional 12% decline.

“Ninety percent of smokers have tried cigarettes before age 19 and almost all have tried it before age 26,” said Committee Chair Richard Bonnie, professor of medicine and law at the University of Virginia School of Law in Charlottesville, during a press conference. “The earlier the age of onset, the greater the intensity and persistence of smoking beyond adolescence.”

Reductions in smoking-related mortality would be substantial but may not be observed for several decades, the report says. Modeling suggests that if the MLA were raised to 21 now, there would be 10.5% fewer deaths from lung cancer for those born between 2000 and 2019, compared with the status quo.

The report notes that adolescents are particularly susceptible to nicotine addiction because the areas of their brains related to decision-making and impulse control, among others, are still developing. Smoking among American teens has been declining since 1997, although at a slower pace since the mid-2000s, the report states. In 2012, 34% of Americans between ages 21 and 25 smoked, the highest percentage of any age group.

The FDA does not have the authority to raise the national MLA above age 18, but states and municipalities can adopt their own restrictions. Currently, four states have an MLA of 19 while some cities, including New York, NY, have increased it to 21. Two states—Washington and California—have introduced legislation to set it at 21 statewide.

Since no substantial data are yet available on the impact of the higher MLA, the committee considered studies showing that increasing the age restriction for alcohol has been effective. For example, since the National Minimum Drinking Age Act was passed in 1984, there has been a sustained long-term decline in binge drinking among those under 21 and fewer teens dying in nighttime car crashes.

“Of course, underage drinking still occurs, and it seems clear that if the MLA for tobacco is increased, there will still be some tobacco use by those under the legal age,” the committee wrote. “However, if the question is simply whether raising the MLA will noticeably reduce the use and use-related harms of tobacco among youth, then the academic literature evaluating the alcohol experience indicates that there will indeed be substantial benefits.”