Explaining the Rapid Adoption of Tobacco 21 Policies in the United States

In this issue of AJPH, Reynolds et al. (p. 1540) describe the process of passing the first Tobacco 21 (T21) policy that raised the legal age for the sale of tobacco products to 21 years in Needham, Massachusetts, in 2003 and the subsequent spread of T21 policies across the United States. T21 policies have proliferated faster than any other retail tobacco control policy and the reasons behind their rise are worth examining because they may offer clues for promoting other worthy policies that have low adoption. We use diffusion of innovation¹ and multiple streams theories² to explain the rise of T21 policies.

Why has T21 spread so rapidly compared with other policies? At least 475 localities have passed T21, and 17 states have adopted the policy (two of which go in effect in 2020 or 2021).³ Not a single state has put in place other retail-focused policies such as minimum floor prices for tobacco products, bans on tobacco promotions, limits on tobacco retailer density, or banning menthol tobacco sales. Only one state, Massachusetts, has a ban on tobacco sales in pharmacies.

EXPLAINING POLICY SUCCESS

Diffusion of innovation theory describes how an idea or innovation spreads through a population or system.¹ The theory states that certain characteristics of the innovation, the adopters, and the system for which the innovation is intended increase the likelihood that the innovation is adopted and spread. Attributes of the innovation that affect the likelihood of adoption and diffusion include relative advantage, compatibility, complexity, observability, and trialability (Table 1).

TABLE 1—

Application of Diffusion of Innovation Theory to Tobacco 21

Factors Affecting Adoption and Spread	Description	Examples
Innovation
Relative advantage	Innovation is superior to what currently exists	Evidence of benefit from raising minimum legal age from 18 to 21 years in alcohol literature
		Peer-reviewed publications showing T21 policies reduce youth smoking
Compatibility	Innovation is consistent with values and norms	Local and national concern about youth smoking
		High level of public support of T21 policies
Complexity	Innovation is difficult to understand or use	Incremental change from T18 policy
Observability	Benefits of the innovation are apparent	Publication of T21 impacts in high-impact journals
		Articles about T21 published in newspapers and magazines
Trialability	Innovation can be tested before complete adoption	Implementation of T21 policy in one area served as a trial for other localities
Adopters: individual traits	Adopters are motivated and capable	Policy champions with medical backgrounds
		Champions consulted with a lawyer with expertise in tobacco control
		Developed clear and focused advocacy strategy
System readiness
Tension	Current situation is not tolerable	Local and national concern about youth access to tobacco and high youth smoking rates
Support and advocacy	Multiple organizations endorse the policy	Support from Campaign for Tobacco-Free Kids, Truth Initiative, American Academy of Pediatrics, and American Heart Association

Note. T21 = Tobacco 21.

Relative advantage describes the extent to which an innovation is superior to what already exists. Although the impact of T21 was unclear when the policy was first introduced in Needham, the change to 21 years made sense from a parallel evidence standpoint because raising the legal age for the sale of alcohol had proven health benefits.

A T21 policy was also highly compatible with the existing values of Needham and other locales. Reynolds et al. note that Needham previously supported progressive tobacco control policies, such as limiting smoking in restaurants and implementing smoke-free workplace legislation. Studies found that the US public and even the tobacco companies supported raising the age of tobacco sales.⁴ T21 is perceived as having low complexity because existing policies regulating and enforcing the legal age of sale of tobacco at 18 years were already in place.

T21 policies have had a high level of observability because results of the MetroWest Adolescent Health Survey showed a 49% reduction in youth smoking after the T21 policy. These results and others have been shared in high-impact journals such as the New England Journal of Medicine. Implementation of T21 policies across the United States was covered in the New York Times, Washington Post, and Time. T21 could be considered to have a low level of trialability, or the ability for an innovation to be tested before adoption, unless implementation of a T21 policy in one locality is considered a trial for another potential adopter.

In addition to the characteristics of the innovation, diffusion of innovation theory suggests that T21 was more likely to be widely implemented if the adopters were capable and motivated. Needham Board of Health members with doctoral degrees in medicine and microbiology were champions of the policy when it was first enacted in Needham. Policy champions have been strategic. They consulted with a lawyer with expertise in tobacco control, developed an advocacy strategy that included writing op-eds and gathering media coverage, and kept the focus of T21 on protecting youths, which is difficult to argue against regardless of political affiliation. As local T21 policies spread, statewide T21 legislation was planned. Adoption of tobacco control policies, first at the local level and then advocating implementation at state and national levels, is a proven and effective strategy in tobacco control.

Finally, system readiness is another critical factor in innovation adoption and spread. An innovation is more likely to be adopted if the current situation is intolerable. In the 1990s there were concerns in Needham that students were smoking. Illegal sales to minors were also a problem nationwide. In response, organizations such as the Campaign for Tobacco-Free Kids, Truth Initiative, the American Academy of Pediatrics, and the American Heart Association have endorsed T21 policies.

Another framework used to explain policy passage is Kingdon’s multiple streams theory, which states that policy change is most likely when there is a “window of opportunity” and the 3 “streams” (problem, policy, and politics) align.² Policy change is most likely when a problem is documented, a policy solution is available, and policymakers have the opportunity and are motivated to pursue that policy. With T21, the three streams were in alignment. Youth smoking rates were high (problem), T21 was a legally viable solution (policy), and Massachusetts had a strong state tobacco control program and policymakers were supportive of T21, as were powerful public health advocacy organizations (politics). It was fairly easy for politicians to pursue this highly supported policy in Massachusetts and then in other states, such as California and Hawaii, which also had a history of supporting tobacco control efforts.

What distinguishes T21 from other retail-focused policies that have not been adopted so widely? T21 differs most from other retail-focused policies in being less complex and highly observable. T21 is simply an incremental change from a T18 policy. In addition, the public can easily understand a T21 policy, whereas other tobacco control policies, such as a retailer density policy, are more difficult to conceptualize and viewed as antibusiness. There has also been less visibility for other retail-focused policies among the public. The success of the T21 policy suggests that retail-focused policies could be framed as improving existing policies. In addition, obtaining press coverage is important for increasing observability. Press coverage may also help bring attention to the problem and increase the political will needed for the three “streams” in Kingdon’s theory to align.

NEXT STEPS

Despite its rapid adoption to date, the local and state T21 passage trajectory will likely decelerate. Twenty states preempt local age restriction policies.⁵ In other words, local jurisdictions in 40% of US states are prohibited from passing local T21 policies. In addition, jurisdictions that had enough political will to pass T21 policies already had lower smoking rates and strong tobacco control policies in place.⁵ The South, which has high rates of smoking and a disproportionate burden of tobacco-related disease, has the lowest rates of T21 coverage.⁵

Given the slow adoption of T21 in the South and preemption challenges, the optimal solution is a national policy. Although the US Food and Drug Administration has authority over the sales and marketing of tobacco products, they are explicitly prohibited from raising the national tobacco sale age to 21 years. Therefore, a nationwide T21 policy will require Congress to pass legislation and the president to sign it.

CONCLUSION

Approximately 90% of adult smokers report first using cigarettes before they were aged 19 years.⁶ Research suggests that raising the minimum legal sale age to 21 years in the United States would reduce adolescent smoking by half in seven years.⁷ In the absence of a national policy, state tobacco control programs and local advocates should work together to continue the spread of T21 policies across the United States.