A Community Data-Driven Policy Analysis Framework to Promote Tobacco 21 in the United States

Project Summary

Raising the minimum legal age of tobacco sales to 21 (T21) is among a small number of low-cost, population-level interventions that may significantly delay youth tobacco initiation and reduce smoking prevalence. The overarching goal of this study is to develop a community data-driven policy framework in order to 1) optimize the effects of T21 and 2) reduce policy-related health disparities.

Research Question(s)

  • Which factors (e.g., smoking prevalence, rural vs. urban, etc.) are associated with T21 policy promotion and adoption?
  • How do T21 policies impact youth tobacco use behaviors, both traditional and e-cigarettes? Are these impacts mitigated by age, sex, race/ethnicity, and SES; tobacco retailer density and retail compliance; and other related tobacco policies?
  • Will the impacts of T21 policies be larger for some subpopulations (e.g., Latinx)?


  • Inform states and localities on the best approaches for initiating and implementing T21 policies to reduce youth smoking and related health disparities.


Disparities in Tobacco 21 (T21) policy adoption, retail inspections, and retail compliance may limit the policy impact. Reducing tobacco-related health disparities requires a more unified approach to restricting youth access to tobacco products, with provision of resources and implementation of interventions in vulnerable communities.

  • This study found significant inequalities in the coverage of state/local T21 by geographic distribution, rurality, demographics, SES factors, and tobacco control policies. These findings add to the growing literature that state or local T21 policies were not uniformly adopted in the United States.
  • As of December 2019, T21 was more likely to be adopted in the Northeast (64.9%) and West regions (41.0%) than in the South (35.7%) and Midwest (30.1%).
  • It is promising to observe the narrowing racial disparity between T21 and non-T21 regions with high coverage for some racial/ethnic minority populations, including Hispanics/Latinos and Asians. However, the T21 policy coverage in areas with high proportions of Indigenous peoples persistently fell behind other racial/ethnic groups from 2015 to 2019.


Tobacco use (cigarettes, e-cigarettes, cigars, smokeless tobacco, and hookahs)


The researchers are using a quasi-experimental design with difference-in-difference analysis. A multi-level regression analysis and synthetic control method are used to examine youth behaviors in T21 and non-T21 (“control”) regions before and after the policy change.

hands breaking a cigarette in half
Grantee and Partner organizations

University of Nebraska Medical Center College of Public Health

Grant status
Principal investigators
Hongying (Daisy) Dai, PhD
Start date
Award amount
24 months

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