Raise Tobacco Sales Age To 21

Susi Worden & Sami Albalawi

Central Michigan University
HSC 419
Jodi Brookins-Fisher
December 10th, 2015

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Statement of the problem
The use of tobacco is the prime cause of avoidable deaths in the United States, and is
estimated to cause about 480,000 preventable deaths per year. Extensive use of tobacco and its
products is reported in teenagers and young adults who are under 21 years of age. According to
Corey et al. (2014), millions of young adults are exposed to tobacco and its products through oral
absorption or inhalation. The impact of chronic exposure to tobacco, especially during brain
development, is a primary concern because it might have permanent negative consequences
(Winickoff et al., 2014). It was reported by the Institute of Medicine that the majority of smokers
(about 90%) began smoking before they reached the age of 21 years.
Selling tobacco to young adults under the age of 21 makes them vulnerable to addiction
(Winickoff et al. 2014), and exposes them to life-threatening illnesses such as lung cancer (Neff
et al 2014). Each day, about 700 children aged 18 and below become regular smokers and
approximately one third of them will be victims of smoking illnesses in the future (Knox 2015).
A solution to the problem is to increase the minimum legal age of selling tobacco and its
products to persons whose age is 21 and above. By raising the legal tobacco sales age to 21
years, the number of new smokers among youth and young adults each year will be reduced,
leading to an overall reduction in the number of smokers nationwide. According to an extensive
report done on the subject by the Institute of Medicine (IOM, 2015), raising the sales age could
eventually lower the number of smokers by as much as 12 percent, which could lead to 223,000
fewer premature deaths.
The program will succeed because it will be difficult for retailers to sell tobacco to
teenagers and young adults without confirming their age. It will also be more difficult for high
schoolers to get cigarettes illegally from older students, since they are far less likely to be around

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21-year-olds than 18-year-olds. The program will also succeed because of the wide range of
support the idea will most likely receive. A CDC report showed the strategy of raising age limit
is supported across the United States (King, Jama, Marynak, & Promoff, 2015). In fact, 70% of
adults and seven in 10 smokers across the country support the program (Knox, 2015). By
increasing awareness of the benefits this strategy will have on the health of the nation and the
nations youth, and providing the means to advocate for this cause, this program will have a
tremendous impact on communities and eventually on the country as a whole.

Literature Review
According to Brewer et al. (2012), the use of tobacco products often begins during
adolescence and gradually develops into adulthood. Therefore, current adolescent tobacco users
face the risk of continuing the use of tobacco into adulthood. According to the CDC (2015), the
younger a person is when they adopt the use of tobacco, the higher the risk they get of becoming
tobacco consumers during their adulthood.
In the teenage age group, the use of tobacco products attract popularity in the different
flavors attached to the tobacco products (Winickoff et al., 2014). The prevention of tobacco use
among people below 21 years does not only call for the prevention of access to the flavored
tobacco products, but also all other forms of tobacco (Corey et al., 2015). Several strategies have
been proposed in different states in the United States. The best strategy appeared to be the
restriction of sales of both flavored and unflavored tobacco products to these age groups.
The restriction of sales attracts controversy as it does applause. While experts and
analysts argue that the restriction of use is the best way, the major players in the tobacco industry
argue that restrictions would cause more harm than good to their businesses (McLaughlin et al.,

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2014). However, additional strategies were proposed, which included increasing the prices of
tobacco products. These strategies are successful mostly in areas of poor social class.
According to past researchers, application of barriers has proven to be a successful way
in term of fighting the effects of additional problems related to early usage of these substances.
For example, the lessons and benefits for the increase of minimum drinking age to 21 years is
demonstrated through legislation (Kessel Schneider et al., 2015). The plan to raise the minimum
age of tobacco to 21 years would be an approach that helps addressing the public health
problems related to addiction and use of tobacco products.
Preventing youth from beginning the use of any tobacco products is important. Also, it
plays a central role in the improvement of the addiction and prevalence of all the tobacco-related
complications (James, Chen, and Sheu, 2007). The strategies require a healthy approach from
society and the social education for the need to limit the use of tobacco from early ages.
Goals and Objectives
Goal: Decrease smoking among those under the age of 21 years.
Administrative Objectives
-

Develop a tool kit by the beginning of 2015 for National Eta Sigma Gamma (ESG)

members to use in advocating for raising tobacco sales age.

Within one month of tool kit completion, send tool kit to all National Eta Sigma Gamma

for distribution to local chapters.

Each ESG chapter will form an advocacy committee by holding elections for a committee

leader, and taking volunteers to form the rest of the committee.

Committee members will research and choose a local city council meeting to attend
within two weeks of formation of committee.

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-

The ESG advocacy committee will organize a community forum to take place before the
end of the semester.

Learning Objectives
-

Within six months, 50% of Eta Sigma Gamma members will be able to give three reasons

why the tobacco sales age should be raised.

After receiving the tool kit, Eta Sigma Gamma would be able to state the financial

benefits of raising tobacco sales age.

Within one month of committee formation, members will begin advocacy activities.
Members of committees will practice proper speaking procedures for local city council
meetings.

Behavioral Objectives
-

Within one month of the formation of advocacy committees, members will begin a letter
writing campaign to legislators, encouraging them to advocate for raising tobacco sales

age in their areas.

Within six months this committee will create an awareness program for the city in their
area.

Environmental Objectives
-

Within one month of receiving the information, half of all Eta Sigma Gamma chapters

will have formed committees to advocate for raising tobacco sales age.
After formation of the committees, ESG members will research and reach out to potential
partners, such as high school principals/school boards, health care providers, and health
insurance providers for collaboration.

Pre-Programming Administrative Strategies

Gaining Support from Stakeholders

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There are various organizations and individuals who are stakeholders. Some of these
include local business leaders and employers, local advocates, policy makers, chambers of
commerce, representatives, and other businesses and local associations. Additionally, social
clubs, hospitals, health care facilities, professional groups, state officials, school boards, and
colleges and universities are potential shareholders. Eta Sigma Gamma members will show the
benefits of increasing the minimum age for tobacco sales, the value and effectiveness of the
policy to these individuals. Involving the local legislators will be of utmost value because they
are the ones who will help making and passing the ordinance/law.
The identified stakeholders shall be involved directly in the campaign planning and
designing phases as a way of gaining their interest and retaining their support. Involving college
and other education institution boards and authorities can be of value because they service the
population of youth below 21 years.
If the change in law is successful, it will benefit the stakeholders because it will save the
lives and health of their youth. Schools and colleges, for example, prohibit the use of tobacco in
their environments and the law that supports these rules will make their work easier. It expands
their grounds for taking legal actions against the violators. The local businesses that sell tobacco
products will be convinced to participate because it will be demonstrated to them how little of
their sales in tobacco products actually come from the 18-20 year age group. Examples of
businesses from other counties that have implemented similar ordinances will be shown to
business orders to demonstrate how little their sales will actually be affected. In addition to this,
they will also be shown how raising the tobacco sales age to 21 years will make checking IDs
easier since it will be the same whether someone is purchasing alcohol, tobacco, or both.
Policies to Be Addressed

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The Family Smoking Prevention and Tobacco Control act of June 22, 2009 that gave the
Food and Drug Administration (FDA) the power to control tobacco use in products, aids in the
current policy development (HHS, 2015). The law gave the FDA the authority to supervise the
manufacturing and sale of products containing tobacco. An essential part of the law is it controls
the sale of tobacco to teenagers aged below 18 years (HHS, 2015). Retailers who violate the rule
by selling to minors risk fines. Additionally, educational institutions have policies that prohibit
the use of tobacco in their environment. If the policies are enforced with the proposed changes,
millions of lives could be saved from the health issues that result as an impact of using tobacco.
Some institutions, however, prohibit tobacco use inside buildings, but allow outdoor smoking
which can prevent this policys developmental success. All of these policies together will help in
changing the proposed policy into law.
Marketing Strategies
The product will be the advocacy toolkit that will first be distributed to Eta Sigma
Gamma members, and then ESG will distribute the toolkit to interested stakeholders. Eta Sigma
Gamma and the stakeholders will then use the toolkit to influence legislation for a change in law.
The price of the program will be minimal. Internet and university resources, such as
websites and paper supplies, will be utilized and should mostly be free. If ESG members can
reserve a room at their local university, the location (place) for their meetings and for the
community forum should also be free.
Promoting the advocacy toolkit will first be done through the National Eta Sigma Gamma
website and newsletter. Here different chapters will be able to learn about it and decide if their
chapter would like to utilize this as one of their projects. ESG chapters will then promote the
toolkit to their local stakeholders by talking about it at a city council meeting, and have it

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available for distribution at their community forum. They will advertise for their community
forum through flyers, the local newspaper, their university, and social media sites such as
Facebook.
Administrative Strategies
Personnel Requirements
For each ESG chapter that decides to use the advocacy tool kit, there will need to be on
elected committee leader, and 3-5 extra volunteers to make up the committee. The leaders and
members of the committee will not be paid as they will be doing this as part of their ESG
activities. Their duties will include studying the information in the packet in order to inform
themselves on basic advocacy skills and the benefits of raising the minimum tobacco purchase
age. Other duties will include researching potential partners in their particular area, such as high
school principals and school boards, health care providers, the mayor, and city council. They
should then contact these potential partners and invite them to a community forum that ESG
members will also organize.
After this, their task will be learning and practicing how to write letters/emails to policy
makers and local authorities. They should follow this up with a letter writing campaign, and ask
some of their local partners to put their signatures on the letters they have written. The toolkit
will come with a basic survey intended to gauge local awareness and support of raising the
tobacco sales age. Distribution of the survey that comes in the toolkit and analysis of the date
collected from the survey will also be tasks committee members will be responsible for.
Budget
There will be no FTE costs as Eta Sigma Gamma is an honorary society and participation
in this project will be voluntary. The tool kits will be available online, and as there are a plethora

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of online resources, there will be no costs associated with the toolkit. If ESG chapters need to
print out their tool kits, they can use the resources of printer, ink, and paper at whatever
university they are associated. Their committee meeting locations will also be provided by their
university, and the meeting for the community forum will be in a room reserved for free at the
university. One possible cost would be if local chapters decide to have coffee/drinks/snacks at
their community forums as an incentive, but they could first try to find out if a local business
would be willing to provide this for free in exchange for advertising. If not, ESG has project
grants that chapters have the opportunity to apply for that would more than cover this cost.

++++++++++++++++++++Intervention Strategies

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The intervention strategies for this program will begin with the development of the
advocacy toolkit for raising the minimum tobacco purchase age, which will then be distributed to
Eta Sigma Gamma chapters. Once individual ESG chapters have received the toolkit, they will
conduct several advocacy projects to increase awareness of the benefits of raising the age, and to
hopefully influence local policy to officially make 21 the minimum legal age for purchasing
tobacco products.
A toolkit will need to be developed and include a fact sheet on the harm of tobacco in the
youth population, as well as the benefits of raising the tobacco sales age. It should also include a
sample survey asking simple questions about awareness of the possible benefits of raising the
sales age and questions that could gauge the general opinion on this issue. An informational sheet
on how to correctly write a letter to a state representative or local person of authority, as well as a
sample letter, should also be in the toolkit.
The toolkit will be emailed to the president/board of National Eta Sigma Gamma, who after
reviewing it will place it on the national ESG website so each individual chapter is able to easily
access it. The availability of the toolkit will be announced in the ESG newsletter to all members,
and displayed on the welcome page of the website to ensure chapter presidents and members are
aware.
Eta Sigma Gamma chapters that choose to utilize the toolkit for an advocacy project should
present the idea at their first general meeting. Members will vote on whether or not to take on the
project after learning about what it will entail. Should the chapters choose to do the project, they

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will need to hold elections for a committee leader at their next general meeting. Once a
committee leader has been elected, a sign-up sheet will be passed around so that ESG members
can volunteer to be on the advocacy committee. There should be at least 3-5 members on the
committee in addition to the committee leader.
Advocacy committee members will each receive one copy of the toolkit. The committee
should hold a special meeting to go over the packet and study and discuss the contents and
information. Once members have familiarized themselves with the toolkit, they should begin
distributing the sample survey in order to find out information about their specific communitys
opinions on the subject of raising tobacco sales age. Once survey information has been collected,
members of the committee should analyze the data to determine current viewpoints in their area.
The committee leader and one or two other members should research local city council
meetings in their area to find one on a date that they can attend. Those attending should review
the part of the toolkit on speaking at a city council meeting, and do research on procedures for
speaking at their own specific city council. At the meeting, the member who will be speaking
should present the issue to the city council according to the directions found in the toolkit.
Committee members should also be researching potential partners in the area who are
respected in the community and who would be willing to advocate for raising the minimum
tobacco sales age. Parents, business owners, teachers, students, and health professionals would
all be possible partners. They should also see if there is anyone who has had success in the past
at changing local policy, and if possible consult with them and see what helped them to be
successful.

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Two to three other members should be given the task of writing a letter addressed to those
who have the power to chance policy, such as state legislators, local city council members and
the mayor, as well as local boards of health. Following the guidelines in the toolkit, and their
own understanding of their particular community, these committee members will draft a letter to
be reviewed by other members of their committee, and general members of ESG.
The committees other task will be to organize a community forum on the topic. They
should be working on this within one week of committee formation and hold brief committee
meetings every week or every other week to discuss progress. They should invite key decision
makers in the community to this forum, such as members of city council, high school
administrators, and health care providers. They should also place an announcement in the local
newspaper advertising the forum to the public. They should also try to get some parents, high
schoolers and college students to attend. The advocacy committee could seek out space at their
university that is available for such activities. They could also try to get a local company, such as
Starbucks or Biggby, to sponsor the event by donating coffee and snacks.
The committee should find someone to lead the forum, such as a teacher, parent, business
owner, or some leader in the community. The forum should encourage discussion of the topic to
create awareness and raise support for raising the minimum age to purchase tobacco. All
committee member should be present at the forum. One committee member should speak for the
committee, and should encourage those attending to continue to advocate for this issue. Copies
of the toolkit could be available for people to look at and take home, and attendees will be given
the opportunity to add their names/signatures to the letter that Eta Sigma Gamma will be sending
to their local policy-makers. They will also encourage citizens to write letters of their own.

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Theory
The Community Readiness Model (CRM) is the theory that will help guide the
implementation of the program and increase the communitys readiness and support the program.
The following details the interventions employed in each of the nine stages to support the
program.
No Awareness
At this stage, only few people in the community realize that selling tobacco to teenagers
and young adults is harmful. However, it is not a concern to the leadership and most people in
the community. The few members who understand the importance of raising tobacco sales age to
21 years will be used as influencers and working with them will raise the awareness.
Denial
At this stage, few members recognize the dangers of selling tobacco to persons aged 21
and below, but the whole community feels nothing should be done because it is not their
problem. Therefore, the focus of this stage is to create awareness that shows the problem exists
and the community can do something about it. The survey distributed will help to gauge the level
of community awareness and local opinions on raising the sales age.
Vague Awareness

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The previous two stages have helped create a general feeling that there is a problem and
actions must to be taken. It is important to identify community leaders who will help in term of
creating the community teams. Researching and reaching out to possible local partners in the
community will help with future plans of community forums and creating advocates who are
leaders in the community.
Preplanning
At this level, a significant number of community members understand that there is a
problem and they have heard something about the local efforts. The community teams will start
raising awareness by using strategies to start the changes. Also, the teams will gather information
about tobacco use, explore the existing policies, and bring on the major community leaders. At
this point committee members will attend the local city council meeting to speak on the subject
and begin to raise awareness in the community. They will talk about the upcoming community
forum. They will also create flyers to distribute to local businesses and schools, and make an
announcement in the local papers about the upcoming forum.
Preparation
The majority of the community members are aware of the local efforts, and effective
leadership will be important in term of improving the current efforts. The community forum will
be run by a local leader, and will help to pick out more potential partners and leaders. It will also
further create awareness and support for raising the tobacco sales age.
Initiation

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At this stage, local leadership will play an important part in the development and
implementation of new efforts. Also, leaders and community members will acknowledge that it is
their responsibility to fight tobacco sales. The community will find resources that will keep the
program going for a long period of time. Additionally, the community teams and leadership will
work to pass policies and conduct training to get professionals. Also, conducting interviews with
consumers will help identify the gaps and how to improve the policy.
Stabilization
The community members have sufficient knowledge about the local efforts such as the
purpose of the program and the target audience. The goal of the interventions at this stage is to
keep and maintain their efforts. It will be necessary to plan for community events so community
members can attend and cooperate to do their part. Positive comments from the consumers will
be supportive and will increase the interest for the program.
Confirmation and Expansion
Activities at this stage will focus on gathering data that evaluates the success of the
advocacy program, and analyzing and distributing that data to other communities who may be
interested in doing something similar.
Professionalism
The interventions in the last stage focus on keeping the community active. The committee
should use the data collected from evaluations to make any necessary improvements to their
advocacy efforts.
Evaluation

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Process Evaluation
ESG members involved from each chapter could fill out a post-project evaluation (kind
of like a course evaluation) that would be used to determine if the toolkit was useful, what other
documents or tools might be useful, what they wished they had done differently, and whether or
not they thought the project was effective.
Impact Evaluation
The survey on awareness and public opinion originally given out before the advocacy
project began could be distributed once again to the community. This would allow committee
members to see how the project affected the local communitys awareness and opinions.
Outcome Evaluation
The first achievement to demonstrate outcome evaluation would be passage of a city
ordinance. Since this is the first nationwide advocacy effort by Eta Sigma Gamma, they would
want to determine the breadth and depth of all chapter efforts on this advocacy issue. National
Eta Sigma Gamma could work with local chapters to make follow up contact through phone calls
or emails with local partners and leaders to see if they have or are going to continue to advocate
for raising the minimum tobacco age. If they sent advocacy letters to their state representatives,
they could also follow up with them to see if they would support the issue if it came to changing
state policy.

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References
Brewer, H., Kulik, K., Klingaman, L., Deutschlander, S. and Black, C. (2012). Teenagers' Use of
Tobacco and Their Perceptions of Tobacco Control Initiatives. Journal of Drug Education,
42(3), pp.255-266.
CDC, (2015). 7 in 10 students who currently use tobacco used a flavored product. CDC U.S.
Department of Health and Human Services.
Corey, C., Ambrose, B., Apelberg, B. and King, B. (2015). Flavored Tobacco Product Use
Among Middle and High School Students United States, 2014. MMWR. Morbidity and
Mortality Weekly Report, 64(38), pp.1066-1070.
James, D., Chen, W. and Sheu, J. (2007). Type of Tobacco Product Used: Are There Differences
between University and Community College Students?. Journal of Drug Education, 37(4),
pp.379-392.
Kessel Schneider, S., Buka, S., Dash, K., Winickoff, J. and O'Donnell, L. (2015). Community
reductions in youth smoking after raising the minimum tobacco sales age to 21. Tobacco
Control.
King, B. A., Jama, A. O., Marynak, K. L., and Promoff, G. R. (2015). Attitudes toward Raising
the Minimum Age of Sale for Tobacco among U.S. Adults. American Journal of
Preventative Medicine, 49(4), pp. 583-588.

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Knox, B. (2015, September, 10). Increasing the Minimum Legal Sale Age for Tobacco Products
to 21. Campaign for Tobacco-Free Kids.
McLaughlin, I., Pearson, A., Laird-Metke, E. and Ribisl, K. (2014). Reducing Tobacco Use and
Access Through Strengthened Minimum Price Laws. Am J Public Health, 104(10), pp.18441850.
Neff, L., Arrazola, R., Caraballo, R., Corey, C., Cox, S., King, B., Choiniere, C. and Husten, C.
(2015). Frequency of Tobacco Use Among Middle and High School Students United
States, 2014. MMWR. Morbidity and Mortality Weekly Report, 64(38), pp.1061-1065.
Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products.
(2015, March). In Institute of Medicine.
U.S. Department of Health and Human Services, (2015). Tobacco Laws and Policies. Retrieved
November 15, 2015, from http://betobaccofree.hhs.gov/laws/
Winickoff, J., Hartman, L., Chen, M., Gottlieb, M., Nabi-Burza, E. and DiFranza, J. (2014).
Retail Impact of Raising Tobacco Sales Age to 21 Years. American Journal of Public Health,
104(11), pp.18-21.