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Home My WebLink AboutNew England Journal of Medicine Article_2024T rhe NEW ENGLAND IOURNAL oJ MEDICINE l,aY ?o, 20.21 Toward a Tobacco-free Generation - A Birth Dat+Based Phaseout Approach Katharine Silbaugh, J.D., Lis Del Valle, 8.A., and Christopher Robertson, J.D., Ph.D. ease, disability, and death in the United States. espite decades ofpublic health efforts and advances in cessation treatments, smoking is still the leading cause of preventable dis- Union, the Philippines, Singapore, Malaysia, Australia, and Norway. In April 2024, a TFG bill in the United Kingdom cleared a major hurdle in Parliament when a flrst reading secured strong support. Whereas the Brookline bylaw ap plies to all nicotine pmducts, in- cluding combustible producs and e.cigarcttes (vapes), New Zealand's repealed law and the U.K. bill cover combustible tobacco prod- ucs only. This variation reflects ongoing public health discus- sion about the relative harm of vapes as compared with ciga- rettes. By including vapes in its TFG bylaw, Brookline targets a key driver of initiation ofnicotine use among adolescens. The World Health Organization considers tobacco use, which kills more thal 8 million people per year, one of the largest global public health threats.l In 2022, one fifth of U.S. aduls still regu- larly consumed tobacco products. Use often starts at an early age: Smoking kills more people in this country tlun HW, drug overdoses, dcohol use, motor vehicle crash- es, and firearm-related injuries combined. Governments world- wide have tried to reduce tobacco use. In a development that could signal a new direction for tobacco regulation, one U.S. town's policy aimed at creating a tobacco-free generation bas successfully with- stood legd challenge. The $aru, passed by Brookline, Massachusetts, gradually phases out commercial tobacco by ban- ning ttre sale of nicotine products to anyone born on or after Janu- ary 1, 2000 (one of us cospon- sored the bylaw). Eventually, no one wi.ll be old enough b puchase nicotine products. Tobacco retail- ers sued Brookline over the bylaw. A uaanimous March 2024 Massa- chusetts Supreme )udicial Court decision upholding the tobacco- free generation (fFG) bylaw may now boost its viability as a model for other local and stete govem- ments. In rcsponse to the ruling health boards in three other Massachusetts towns (Melrose, Stoneham, and Wakefield) voted to implement birth date-based phaseouts, and other municipal- ities have taken initial steps to- ward adopting this policy. The concept of a birth date- based phaseout of commercial tobacco has dnwn attention world- wide New Zealand passed a sim- ilar law in 2022, though a subse- quent change in government led to its repeal. The concept is un- der discussion in the European N EXCLJ raao r9O;2O NETM.OTC XAy rO, 2024 1a37 The New England Joumal of Medicin€ is productd by NEIM Cmup,6 division of rhe Massachuscns Mcdicsj Society. Downloaded fmm nejmorg otr March 10. 2m6. CopyriSht o 2024 Massachusetls Mcdical Society. All righ6 rEserved, includiag rhosc for tcxr and drt6 miniDg, AI Eaining, and similar technologies. ffi/1\tltrcGc \GAA PERSPECTIVE t}lat same year, 22.2% of U.S. middle and high school students reported ever having used tobacco products, according to the Centen for Disease Control and Preven- tion (CDC). Adolescents are par- ticularly affected by the smoking behaviors of young adults -people just above the minimum age for purchasing tobacco prod- ucts, who may serve as role mod- els or buyers for younger users.' Reducing the availability ofnico- tine to this young-adult group may reduce its attractiveness to teenagers. Smoking increases the risk of heart disease, stroke, lung can- cer, and diabetes, among other conditions. Secondhand smoke contributes to 41,000 deaths per year in the United States among people who don't smoke. A re- duction in smoking has long been among the most important goals for public health leaders. Nicotine is thought to be more addictive than other widely avail- able products, such as alcohol and cannabis. Nicotine binds to aetyl- choline receptors in the central nervous s,stem that stimulate the release of neuromodulators such as dopam.ine, which gives the user a feeling of pleasure.! There are several pharrnacologic approaches to helping people stop using nico- tine. But withdrawal symptoms -such as sleep problems, nausea, nicotine cravings, fatigue, irrita- bility, and depression - cause more than 75% of people r+'iro try to quit smoking without medical support to relapse within the first week.a Nicotine dependency is so sEong that people who stop using nicotine for 1 )rar still have a 35% chance of relapse at some Point in their lives.a Exposure to nico- dne can therefore be associated with lifelong harm. over the past six decades, the United States has seen many eF forts to reduce tobacco-related harrn The U.S. Surgeon General's report h 1964 linked smoking to lung cancer and hean disease, and in 1965 Congress required manu- ftcturers m add a werning label m cigerette packs. In 1970, Congess banned the advertising of ciga- rettes on television and radio. Be- ginning in 1992, stores were prohibited from selling tobacco products to people under 1Ii ryars of age. By 1998, a total of 46 states, the District of Columbia, and frve U-S. territories had sued tfu four largest U.S. tobacco com- panies. This lawsuit resulted in ttre Master Setdement Ageemeng which required companies m pay the states billions of dollars each year to compensate for taxpayer money used to fund health care for people who smoke In 2009, Congress banned fla- vored cigarettes (not including menthol-flavored cigarettes) and gave the Food and Drug Admin- istration (FDA) the authority to regulate the manufacturing, dis- tribution, and marketing of to- bacco products. In 2019, Congress passed legislation that tobacco producs could be sold only to people 21 years of age or older, znd n 2022, it gave the FDA the authority to regulate products containing nicotine from any source, including so-called syn- tletic nicotine.s State excise taxes on cigarette purchases are as higtt as $5.35 per pack in New York, with an additional $1.01 federal tax, but U.S. taxes remain sub- stantially lower than taxes in oth- er high-income countries. Not- withstand ing these efforts, tobacco use kills about 480,000 people ech year in the United States, ac- cording to the CDC. TOWARD A TOBACCO'FREE 6ENERATION Brookline's TFG bylaw, passed in 2020 when it applied to people who were too young to purchase tobacco products under state and federal law, represents a new approach to tobacco regulation. This approach doesn't afrect peo- ple who currently smoke, a fea- ture designed to humanely rec- ognize access concerns generated by nicotine addiction. Instead, ttre bylaw could eventually establish a generational firebreak against nicotine addiction, prwenting to- bacco purchases even as the cur- rent generation of young people ages. This approach could result in a steadily increasing propor- tion oftle population that cannot legally be sold tobacco products, thereby phasing out tobacco sales. Several tobacco retailers in Brookline filed a lawsuit against the town, arguing that the bylaw is preempted by state law and that it violates the guarantee of equal protection under tlte Mas- sachusetts constitution by dis- criminating against people born on or after ranuary 1, 2000. In March 2024, the Massachusetts Supreme Judicial Court unani- mously rejected these challenges, thereby paving the way for action by other Massachusetts munici- palities. Retailers had argued that Brookline's mbacco bylaw is pre- empted by the Massachusetts To- bacco Act, which males it illegal to sell mbacco products to anyone under 21 years of age. The Mas- sachusetts high court recognized that the Brookline bylaw leaves that sales restriction "untouched' and that the Tobacro Act express ly preserves a role for cities and towns in regulating tobacco. The court also rejected the suggestion t}rat the Brookline by- law requires a heightened level of 1a38 N ENGL., MEo 39o;2o NEJv.orG r.aY !o, 2o2lt The Nes/ England Joumal of M€dicire is poduc€d by NEIM Group, a division of the Massachus€tts Medical Soci€ty. Downloaded from n€jm.org on March 10,2026. Copyright O 2024 Massachusetts Medical Society- All rights reserved, including thoc€ for text ard dala mining. Al trainin8, and similar te.hnologies. PERSPECTIVE scrutiny under the state's equal- protection prwisioL Because the bylaw doesn't burden a funda- mental right, such as religious fteedom, or discriminate on the basis of a suspect classification, such as race or gender, it needs only to be "rationally related to tle furtherance of a legitimate state interest." The bylaw clearly meets this st ndard; it was dlaft ed to pretttrt health{€lated hams associated with tobacco use. Line drawing is routine and necessary in aly legislation. As other U.S. jurisdictions consider this approach, the Su- preme Judicial Court's decision could be an important precedenr The equd-protcction standnd in Massachusetts is similar m pro- ll An oudb inuwic,t nrrh tsEslo visions in\ Xorhorine SilbougL, ir ffiE the U.S. oyoilabte at NE)M.otg d1flff6 qoo.1iLr- tion and ottrer state constitutions. Unlike the Massachusetts legisle- ture, how€ver, some sate legisla- tures have aggressively limited their local gorcmmens' authoriry to enact public herlth meesur€s. In thes€ states, tlte power to mnsider a fiG law rests with the state leg- islature. Other states, including California have permitted loel innovation in tobacco control; cit- ies in those states could now choose to follou Bmokline's lead. Brookline's bylaw will have only a modest effect on public health as long as neighboring towns continue to permit tobac- co sales to people who have tumed 21. We believe the bylaw, and the court's decision, offer a proof of concept for birth date- based phaseout Iaws. other Mas- sachusetts towns have already shown an inclination to follow Brookline's lead. As more towns implement this policy, the Mas- sachusetts legislature and other states could be motiyated to adopt TOWARD A TOBACCO.FREE GENEFATION a birth date-based phaseout of commercial tobacco. Dilclo6uE formr proidcd by thc author6 ar. arril.bl. .l NE M.org. Froln thc Boston Univ.rsity School of Law (X.S., L.D.V., C.R.), and th! Boston Univcr- sit, School ofPublic Hcahh (C.R.) - both an Boston. This articlc w.s publish.d on Mq 25,2021, at NElM.org. l. WHO r€port on th€ globel tobacco epi- demic, 2023: protcct p€ople from tobacco smoke. Geneva, World Hralth organiz.- tion, ,uly 11, 2023 (http6rllwwir.who.intl publicatio!6/ilitemf9789240o77164). 2. Bertick ,. Drawidg on adolcoccnt p6y- chology to achicrc tob:cco-ftce pnentions. Public Hcelth Rlv 2022i43:16O4321.3. selby P, zapcnailo L. Tobacco addic- tion. N Engl, MEd 2021382345-54.{ ciuli.tti F, Filipponi A, RftctEDi G, ct al. Pharmacological approzch to sookiog ce$ation: an updat d rcvilw for daily clioi- cal practice. High Blood prcss Cardiovasc Prct 7UOi7.349-67. 5. A.ron DG, Wallec. C& Sinha MS. In- cludiDg c{igalctt 6 iD thc fDA rulc limiting ni€otin.. rA-tr'lA 2021;130:1129-30. ool: r0.1055/NE Mp21O3297 coptti h O tu2. ttdetl,tdtB t di@l tu \. Fair Allocation of GLP-I and Dual GLP-141P Receptor Agonists EzekielJ. Emanuel, Ph.D.,.Johan L Dellgren, 8.A., Matthew S. McCoy, Ph.D., and Govind Persad,J.D., Ph.D '-fr he percentage of U.S. adults J. with overweight or obesity now exceeds 709o, and more than 10% of adults have type 2 diabetes. These people are at in- creased risk for heart disease, stroke, cancer, and premature death. Glucagon-like peptide-l (GLP-1) receptor agonists, such as semaglutide, and dual GLP-1 and glucose-dependent insulino- tropic polypeptide (cIP) recepror agonists, such as tirzepatide, have been found to b€ effective for ueating obesity and diabetes, significantly reducing weight and the risk or predicted risk of ad- verse cardiovascular events. There is a global shortage ofthese med- ications that could last several years and raises questions about how limited supplies should be allocated. Belgium, Britain, and other countries have banned or discour- aged use of GLP-1 receptor ago- nists for weight loss to prioritize use for diabetes. No U,S. state ot fueml agency has released similar guidance, although some health plans have restricted use for obe- sity, and Medicare doesn't cover these or other drugs for weight loss. Consequently, in the United States, allocation of these drugs has been largely on a first-come, first*erred basis and has often de- pended on people's ability to pay, which has produced ncia.l, ethnic, and socioeconomic inequities.t We propose a fair-allocation framework drat enables evaluation of the ethics of current pracdces and could guide governments, professional societies, ald physi- cians in allocation decisions. This fiamework focuses on allocation within countries, although fair allocation among countries also requires ethical analysis., Fair allocation of scarce medi- N E|{GL' rrED a9O;2O NErM.Ox6 ra^y:ro,2o2a The Ne,, E gland Joumal of Medicine is produced by NEIM Group, a division of the Maslachuscus Medical society Downloaded f.oft nejm.org on March 10, 2026. 1839 Copyright G) 2024 Massachusetts Medical Socicty. All rights res€rved, includiag tho6c for taxt and dsta minint, Al training, and similer techtrotogics