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Tobacco 21

State: OH Type: Promising Practice Year: 2019

Summit County Public Health (SCPH) is the local health district serving people of Summit County, Ohio. The mission of SCPH is to protect and advance the health of the entire community through its policies, programs and activities that protect the safety, health and well-being of the people in Summit County. Summit County is comprised of nine townships, nine villages and thirteen cities. As of 2015, it consisted of 541,968 persons, making it the 4th largest county in Ohio. The largest proportion of residents are between the ages of 45 and 64 years (28.4%). This group is closely followed by those who are 18 to 34 years of age (21.7%), those under 18 years of age (21.5%) and those 65 and older (16.7%).

Tobacco use contributes to many of Ohio and Summit County's greatest health challenges, including cardiovascular disease, cancer and infant mortality. In addition, tobacco use is a cost driver for Medicaid and employers. Tobacco use by youth under age 18 is a serious problem in Summit County and throughout the nation. Those who begin using tobacco products at an early age run a significant risk of being lifelong tobacco users. Just 2% of tobacco sales (those to individuals under 21) produce 90% of new smokers. More than one-third (37%) of high school students and 16% of middle school students who smoked said they could purchase tobacco at a store, restaurant, or bar. Another 25% say they were able to give money to someone else to buy tobacco for them. Underage kids commonly obtain tobacco from those in their social circle who can legally purchase it (ages 18-20).

In the past year, SCPH has pursued passage of T21 legislation in local municipalities to raise the minimum purchase age of tobacco products from 18 to 21. T21 laws reduce minors' access to tobacco products and prevent kids from becoming lifelong smokers. The immediate goal of this practice is to enact T21 legislation in all Summit County municipalities. The ultimate goal is to reduce youth smoking rates, reduce access to tobacco products, improve health outcomes, and to create a generation of healthy adults in Summit County.

SCPH began holding initial meetings with representatives from local jurisdictions to assess their openness to pursuing T21 legislation. Simultaneously, SCPH Board of Health began the process of determining logistics for enforcement, including setting the fee structure and planning inspection protocols. SCPH developed educational materials, identified community champions and began meeting with city councils. Since October 1, 2018, there have been 119 compliance checks in the jurisdictions with T21 laws. Thirty percent of businesses failed but are now working with SCPH to offer education and training to their staff to ensure future compliance.

Since April 2018, SCPH has facilitated the passage of T21 legislation in six communities. Almost half of all Summit County residents (49%) and 20% of smokers live in jurisdictions covered by T21 laws. The first city to pass T21 legislation, Akron, holds the highest percentage of heavy smokers (9 or more packs a week). Additionally, there are seven communities who are in progress of considering T21.

Summit County is the process of meeting the immediate objective of passing T21 legislation in all of Summit County municipalities. Long term objectives will be measured over time through ongoing monitoring of tobacco use trends.

Political will and community partnerships have been the foundation for success in passing T21 legislation in six municipalities. A variety of community partners from different sectors, city council members, parents, students and school administrators all provided support for T21 passage. This community effort, supported by local data and a growing body of strong supporting evidence, helped to convince local legislators of the potential positive impact of T21 on the health of their communities.

Nationally, T21 legislation has reduced youth tobacco use in the communities that have adopted it. Needham, Massachusetts showed a 48% drop in high school smoking rates after policy implementation. Chicago also saw a 36% decrease in 18-20 year olds that currently smoked. Although it is too early to measure the effects of T21 in Summit County, this strong evidence-basis gives us hope that it will have a positive impact. Because SCPH is conducting the Youth Risk Behavior Survey (YRBS) in most Summit County schools, we will be able to closely measure T21's effectiveness in reducing youth access to tobacco. Long term reduction in tobacco use will have positive impact on chronic disease rates, health care costs and individual and community wellness.

www.scph.org/T21


Tobacco use contributes to many of Ohio and Summit County's greatest health challenges, including cardiovascular disease, cancer and infant mortality. In addition, tobacco use is a cost driver for Medicaid and employers. Ohio ranks in the bottom half of states for all tobacco-related metrics in the 2017 Health Value Dashboard released by the Health Policy Institute of Ohio. Tobacco use by youth under age 18 is a serious problem in Summit County and throughout the nation. Those who begin using tobacco products at an early age run a significant risk of being lifelong tobacco users. Just 2% of tobacco sales (those to individuals under 21) produce 90% of new smokers. Providing tobacco to minors is both illegal and very easy to do. More than one-third (37%) of high school students and 16% of middle school students who smoked said they could purchase tobacco at a store, public event, or a  restaurant, bar, or club or bar. Another 25% say they were able to give money to someone else to buy tobacco for them. Underage kids commonly obtain tobacco from those in their social circle who can legally purchase it (ages 18-20). 

The target population for this promising practice is youth under the age of 21. Particularly we are focusing on the geographic locations with the highest rates of youth tobacco use. Since April 2018, SCPH has facilitated the passage of T21 legislation in six communities. Almost half of all Summit County residents (49%) and 20% of smokers live in jurisdictions covered by T21 laws.

Traditionally, public health has approached the health issue of tobacco use through delivery of programs, such as tobacco cessation services, directly to smokers. Though this can be an effective way to get individuals to quit smoking, a more sweeping and cost-effective approach may be innovative policy changes to prevent people from starting to smoke in the first place. T21 policies, a new practice to the field of public health, are beginning to achieve this. Currently, 6 states have enacted T21 laws, covering a population of over 90,000,000 individuals.

SCPH consulted The Guide to Community Preventative services to create this model practice. The positive impact of T21 policies is supported by strong evidence. An Institute of Medicine report predicted that raising the minimum age of sale of tobacco products would result in an over 15% reduction in smoking initiation rates among youth under age 21. Needham, Massachusetts showed a 48% drop in high school smoking rates after policy implementation, a significant decline relative to comparison communities. In the year after implementation, Chicago found a 36% decrease in 18-20 year olds that reported currently smoking cigarettes. In California, statewide retailer violation rates to under 18 year-olds decreased from 10.3% to 5.7% since implementation of T21.

The immediate goal of this practice is to enact T21 legislation in all Summit County municipalities. The ultimate goal is to reduce youth smoking rates, reduce access to tobacco products, improve health outcomes, and to create a generation of healthy adults in Summit County.

SCPH began holding initial meetings with representatives from local jurisdictions to assess their openness to pursuing T21 legislation. Simultaneously, SCPH Board of Health began the process of determining logistics for enforcement, including setting the fee structure and planning inspection protocols. SCPH developed educational materials, identified community champions and began meeting with city councils. Internally, several different SCPH divisions worked together to plan for implementation. Senior management and Population Health staff worked on facilitating passage of T21 legislation through advocacy and partnerships with local jurisdictions. Simultaneously, an internal committee of representatives from Population Health and Environmental Health worked to establish protocols and plans for enforcement.

The criteria used to determine which jurisdictions to target first included those with the highest smoking rates. SCPH also targeted jurisdictions which we felt would be most willing to enact T21 legislation.

A variety of community partners from different sectors, city council members, parents, students and school administrators all provided support for T21 passage.  SCPH obtained letters of support from three local hospital systems, The American Cancer Society, The American Heart Association and the American Lung Association.  SCPH manages a multi-sector community coalition that was instrumental in the passage of T21 legislation. 

In-kind costs necessary for start-up included the staff time necessary for planning and advocacy. Additionally, SCPH spent roughly $5,000 on print and marketing materials to inform the public about the change in policy within the city of Akron and advertise cessation resources for those who would no longer be able to legally purchase tobacco products. However, by implementing a license fee for tobacco retailers and imposing fines for violators, we believe these startup and operational costs can be offset, making T21 sustainable into the future. 


Although it is too early to measure the effects of T21 in Summit County, this strong evidence-basis gives us hope that it will have a positive impact. Because SCPH is conducting the Youth Risk Behavior Survey (YRBS) in most Summit County schools, we will be able to closely measure T21's effectiveness in reducing youth access to tobacco. Since April 2018, SCPH has facilitated the passage of T21 legislation in six communities. Almost half of all Summit County residents (49%) and 20% of smokers live in jurisdictions covered by T21 laws. The first city to pass T21 legislation, Akron, holds the highest percentage of heavy smokers (9 or more packs a week). Additionally, there are seven communities who are in progress of considering T21. Approximately 70,000 individuals under 21 are now covered by T21 in Summit County. This represents 51.4% of the total population of individuals under 21. Performance measures include youth tobacco use and access as measured by the YRBS, number of communities with T21 legislation, process measures related to enforcement activites and compliance, and ultimately health outcomes for those jurisdictions with T21 compares to those without. 




Through the process of both passage of T21 legislation and implementation of policy enforcement, SCPH has learned that close internal and community collaboration is vital to success and sustainability. Initial passage of the legislation will not be the the only collaboration with local jurisdictions, but their buy-in and continued commitment will be necessary to maintaining momentum. This team approach encourages retailers to commit to ensuring compliance with the law. 

For T21 laws to be effective, they must be adequately enforced. Police departments are currently responsible for enforcing tobacco sales laws in jurisdictions without T21, and they simply lack the time or resources to conduct frequent compliance checks. By granting authority to local health departments to enforce T21 laws, we have learned that we can conduct compliance checks with much more frequency. Additionally, by requiring tobacco retailers to pay SCPH licensing fees and impose fines when retailers violate the law, this program can financially support itself without additional community investment. 

We plan to continue to work closely with our community partners, city governments and retail partners to ensure that T21 continues to be an effective tool for improving the wellbeing of our communities. 

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