Geographical distribution and social determinants of Tobacco 21 policy adoption and retail inspections in the United States, 2015–2019

hands breaking a cigarette in half

This study evaluates multiple factors associated with Tobacco 21 (T21) policy adoption in the U.S. from 2015 to 2019 before the nationwide adoption of T21 to identify disparities between regions that adopted the policy and those that did not. Authors further used the proxy measure of the FDA retail inspections to inform potentially differential enforcement of T21 laws by region and other ecological factors.

  • This study found significant inequalities in the coverage of state/local T21 by geographic distribution, rurality, demographics, SES factors, and tobacco control policies. These findings add to the growing literature that state or local T21 policies were not uniformly adopted in the United States.
  • As of December 2019, T21 was more likely to be adopted in the Northeast (64.9%) and West regions (41.0%) than in the South (35.7%) and Midwest (30.1%).
  • It is promising to observe the narrowing racial disparity between T21 and non-T21 regions with high coverage for some racial/ethnic minority populations, including Hispanics/Latinos and Asians. However, the T21 policy coverage in areas with high proportions of American Indians persistently fell behind other racial/ethnic groups from 2015 to 2019.

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