SEC. 19P.3. SALE OR DISTRIBUTION OF TOBACCO PRODUCTS TO PERSONS AGED 18, 19, OR 20 PROHIBITED.

Tobacco use remains the leading cause of preventable death in the United States, killing more than 480,000 people each year. It is known to cause cancer, heart disease, and respiratory diseases, among other health disorders.

Each day, 700 children under the age of 18 become regular, daily smokers; and almost one-third will eventually die from smoking. If current trends continue, 5.6 million of today's youth will die prematurely from a smoking-related illness.

According to a 2014 Report by the United States Surgeon General, cigarette smoking today is even more dangerous than previously thought. Cigarette smoking has been linked to disease of nearly all organs of the body.

The adverse health effects of tobacco use are not limited to smoking. The National Cancer Institute and the International Agency for Research on Cancer report that use of smokeless tobacco causes oral, pancreatic, and esophageal cancer; and may also cause heart disease, gum disease, and oral lesions other than cancer, such as leukoplakia (precancerous white patches in the mouth).

Further, electronic cigarettes (also known as e-cigarettes) also present significant health risks. E-cigarettes contain nicotine, a highly addictive neurotoxin. Exposure to nicotine during adolescence can harm brain development and predispose youth to future tobacco use. In addition, electronic cigarette aerosol has been found to contain at least ten chemicals that are on California's Proposition 65 list of chemicals known to cause cancer, birth defects, or other reproductive harm.

In addition to the adverse health impacts of tobacco use, the treatment of tobacco-related diseases adds tremendous costs, in the billions of dollars, to this country's health care system. A 2014 report by the University of California, San Francisco estimated that in 2009, the cost of smoking in San Francisco amounted to over $380 million, including direct health care costs and indirect costs from lost productivity due to illness and premature death.

State law prohibits the sale of tobacco products to persons under the age of 18. In spite of the ban on sales to minors, and numerous other tobacco control policies implemented at the federal, state, and local levels, 63% of smokers in California start smoking by age 18. National data show that 95% of adult smokers begin smoking before they turn 21.

In San Francisco, almost 2.7% of middle school and 9.1% of high school students smoke. The highest rate of smoking is among San Francisco's young adults (ages 18-24), 15.8% of whom smoke.

State law also bans the sale of electronic cigarettes to minors. In spite off this ban, preliminary data of more than 430,000 middle and high school students from the California Healthy Kids Survey found that in 2013, 6.3% of 7th graders, 12.4% of 9th graders, and 14.3% of 11th graders had used e-cigarettes in the past 30 days. Among young adults (18 to 29 years old), e-cigarette use tripled in only one year, from 2.3% to 7.6%.

A 2005 study based on data from the California Tobacco Survey, a large, population-based telephone survey, found that 82% of adolescents who had ever smoked obtained their cigarettes from others, mostly friends. A substantial percentage (40.9%) of the people giving the cigarettes were 18 years or older, with most of them (31.3%) being 18, 19, or 20. Adolescents who were 16 or 17 were especially likely to get their cigarettes from persons aged 18 through 20.

In 2015, the Institute of Medicine, a division of the National Academies of Sciences, Engineering, and Medicine, concluded that raising the minimum legal sales age for tobacco products nationwide would reduce tobacco initiation, particularly among adolescents aged 15 through 17, improve health across the lifespan, and save lives; and that raising the minimum legal sales age for tobacco products nationwide to 21 would, over time, lead to a 12% decrease in the overall smoking rate.

The Institute of Medicine also has predicted that raising the minimum legal sales age for tobacco products nationwide to 21 would result in 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for people born in the United States between 2000 and 2019, and would result in near-immediate reductions in preterm births, low birth weight babies, and sudden infant death syndrome.

Raising the minimum age to purchase tobacco products is likely to have a similar effect as has raising the legal drinking age to 21, which has led to reduced alcohol use and dependence among persons under 21. This Article 19P will likely result in less smoking and tobacco use among San Franciscans under 18 and San Franciscans under 21, sparing people within both age groups from the ravages that develop over time from harmful and highly addictive tobacco products.