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State and regional gaps in coverage of ‘Tobacco 21’ policies
  1. Eric Craig Leas1,
  2. Nina Schliecher2,
  3. Amanda Recinos3,
  4. Margaret Mahoney4,
  5. Lisa Henriksen5
  1. 1 Division of Global Health, Family and Preventive Medicine, University of California: San Diego, La Jolla, California, USA
  2. 2 Stanford Prevention Research Center, Stanford University, Stanford, California, USA
  3. 3 GreenInfo Network, Oakland, California, USA
  4. 4 Minneapolis, Minnesota, USA
  5. 5 Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA
  1. Correspondence to Dr Eric Craig Leas, Division of Global Health, Family and Preventive Medicine, University of California: San Diego, La Jolla, CA 94304-1334, USA; ecleas{at}

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In 2015, the US Institute of Medicine (IOM) concluded that raising the minimum legal sales age for tobacco products to 21 nationally 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 individuals born between 2000 and 2019.1 Despite the IOM’s findings, no federal policy has been enacted, leaving inherent gaps in coverage between and within the states of USA. State and local ‘Tobacco 21’ policies could close the gaps, however significant barriers have included lawsuits leading to delayed policy implementation, governors and mayors vetoing policies, and state-imposed pre-emption of local authority (in 20 states).2 3 Gaps in coverage may exacerbate inequities in access to tobacco products in areas where the burden of tobacco-related illness is greatest, such as the southern states of USA.4 5 For the first time, this research estimates how many youth are and are not protected by Tobacco 21, separately for ages 18–20 (who have previously been able to purchase tobacco) and ages 15–17 (for whom the policy presumably restricts access through social sources).


Policy data were obtained in January 2019 from the …

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  • Contributors ECL had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: ECL, LH. Acquisition, analysis or interpretation of data: All authors. Drafting of the manuscript: ECL, AR, LH, MM. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: ECL, NCS, AR. Obtained funding: LH. Supervision: LH.

  • Funding This work is supported by NIH grant P01-CA225597 from the National Cancer Institute. ECL was supported by NIH grant T32-HL007034 from the National Heart, Lung and Blood Institute.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.