Introduction

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).