Background: In early 2018, the American Lung Association worked with the Research & Evaluation Group at Public Health Management Corporation (R&E Group) to develop a survey to gauge voter attitudes in Pennsylvania about raising the minimum legal age of sale for tobacco from 18 to 21.

Methods: The Tobacco 21 survey instrument was administered as an anonymous, un-incentivized, in-app poll. Data from 3,016 registered Pennsylvania voters who voted in the 2016 general election were collected from February to April 2018. Respondents were asked to provide demographic and tobacco use characteristics and to respond to the key question: Would you favor or oppose a statewide law that would raise the legal age for tobacco sales from 18 to 21? Following data collection, survey results were weighted by population demographics. All findings described are based on weighted data.

Results: There is widespread support in Pennsylvania among all surveyed demographic groups for raising the minimum legal age of sale for tobacco from 18 to 21. Overall, 68.4 percent of Pennsylvania voters favor or strongly favor the change. Groups with the highest levels of support include 65+ voters, women, former and never smokers, and Democrats. Upon cross-tabulation, groups most commonly opposing the change include current smokers ages 18-24. Survey results are being used to train statewide advocates and educate decision-makers on the importance of Tobacco 21 through collateral material development, in-person and online education opportunities, legislative visits, and social media campaigns.

Conclusions: In-app polling is a new and promising methodology that leverages existing segmentation infrastructure on smartphone apps. Representative samples on specific questions can be replicated in other states to inform public health efforts. Understanding point-in-time stance of varied demographic groups can inform messaging, advocate recruitment, outreach and education efforts, and myth-busting action.

Background. Emerging “Tobacco21” policies provide protection to reduce youth access to tobacco by more than merely raising the minimum legal sales age (MLSA) to 21. Many of these policies include advancements in elements including mandated compliance checks, higher age verification, and steeper penalties on noncompliant retailers. The purpose of this policy analysis was to examine regulator strengths and gaps in state and local Tobacco21 policies.

Methods. A team of tobacco control policy experts, attorneys, and researchers developed a tool that assessed components of Tobacco21 policies, such as age verification, signage, compliance/inspection enforcement plans; tobacco retail license, violations and penalties; and public education. Using this tool, two coders reviewed all state and local Tobacco21 policies passed from 2005 to 2018. Coding discrepancies were discussed until consensus was reached, then a third coder reviewed for triangulation. Frequencies for policies components and ‘added measures’ (e.g., flavor bans) were reported for state and local policies.

Results. No state currently provides model policy language for all components; however, some local policies may provide a model for state and federal regulations. Several local policies included additional measures, such as bans on flavors, tobacco vending machines, and self-service displays. Added measures appeared to recieve greater community support when included with Tobacco21 legislation. However, several state and local policies included components not recommended for MLSA legislation (e.g., military exemptions).

Conclusions. Localities considering a Tobacco21 policy should use best practices language (e.g., comprehensive tobacco definition, penalty structure for the retailer, education). Also, those seeking to pass a Tobacco21 policies may include additional restrictions (e.g., flavors, menthol within both cigarettes and e-cigarettes, and comprehensive smoke-free environments) that may be met with greater acceptance when included with the Tobacco21 policy. Those with existing Tobacco21 policies could use the FDA’s regulatory announcement as an opportunity to amend and strength policy language.

Ninety-five percent of smokers begin before the age of 21. An emerging policy, predicted to reduce the smoking rate, lung cancer deaths and prevent youth access, is called Tobacco 21. As of today, 6 states and over 450 cities throughout the US have adopted this policy. The Texas legislature considered this policy during the 2017 session, but the bill stopped progressing through the House due to legislative deadlines. The city of San Antonio pursued this policy, with successful passage in January of 2018 and implementation in October 2018.

The coalition has been working to educate law makers and elected officials on this youth prevention policy since 2016. The coalition is now a collective group of 75 supportive organizations from a variety of sectors such as healthcare, academic, prevention, business, government and community organizations.

Strategic activities were conducted between the 2017 and 2019 legislative sessions; including targeted outreach and education to reach conservative districts on the details of raising the minimum sale age of tobacco products to 21. Key conservative legislative members were secured to champion this policy in both the House and Senate. Conservative messaging and fact sheets were created to address the evidence, public health impacts, discuss myths and solutions for passing this policy; such as, including electronic smoking devices to combat the e-cigarette epidemic among Texas youth; including military installations. Strong public opinion data was collected to enhance the campaign strategy. Effective media outreach (social, online paid, earned) strategies were integrated throughout the two years of the campaign.

The Texas legislative session ends in May 2019, and the coalition is hopeful for a positive outcome. No matter the outcome, the coalition would like to share successful strategies and lessons learned for public health advocates working in conservative southern states, and/or on tobacco control policies.

In 2016, a Tobacco 21 local ordinance was passed for St. Louis County. Recently, an amendment to this ordinance was proposed to include the prohibition of possessing tobacco products or electronic smoking devices for anyone under the age of 21. While rising rates of e cigarette use, which have the potential to lead to later cigarette use among youth, necessitate continued preventative measures to curb youth tobacco use and access, punitive measures for youth possession are not the way to address this. In order to address why possession, use, and purchase (PUP) laws are not an appropriate prevention and control method and provide alternative recommendations, St. Louis County Department of Public Health (DPH) implemented a multifaceted educational and advocacy approach.

By engaging local partners on the issue and writing a policy brief which outlined the purpose of PUP laws, how they could be applied inequitably across racial groups in St. Louis, and alternative recommendations based on local enforcement data, lessons learned since the implementation of T21, and other evidence based sources, an updated amendment was submitted by a community group. This amendment was written on the recommendations from community partners and recommendations from the policy brief. The amendment focuses on non-criminal measures for possession infractions, such as education, and includes stricter punitive measurements for retailers selling tobacco products to individuals under 21.

When engaging in policy matters, it is important to bring in relevant partners in the process. They have the ability to bring voice, attention, and expertise to the issue. Furthermore, synthesizing both local data and broader evidence based information in a digestible manner is important to ensure that informed decisions are being made. By using these methods, local public health departments can be effective advocates. This is particularly relevant when it is necessary to advocate for underserved populations. Making sure that racial equity concerns were voiced in the brief is an important way to be intentional about addressing issues of health equity in policy. Addressing health equity is relevant to any policy and likely to the majority of health departments. Explicitly discussing it in a policy brief is a way to make this issue more tangible and bring it to the forefront of any policy discussion.