i

TOBACCO 21: Policy 

Evaluation for Comprehensive 

Tobacco Control Programs
Acknowledgements

This guidance was developed by the Centers for Disease 

Control and Prevention’s Office on Smoking and Health (OSH) 

and RTI International to serve as a technical resource to help 

inform effective policy evaluation and implementation by state 

tobacco prevention and control programs. 

The following individuals from the Centers for Disease 

Control and Prevention, Office on Smoking and Health 

(OSH) helped contribute to the preparation of this 

publication:

Rene Lavinghouze, MA, Health Scientist

Nicole Kuiper, MPH, Health Scientist

Rebecca Fils-Aime, MPH, Evaluation Fellow

Megan Cotter, MPH, Evaluation Fellow

Tamara Crawford, DBH, MPH, ORISE Fellow

Yessica Gomez, MPH, Health Scientist

Nikki Hawkins, PhD, Lead Health Scientist

Monica Cornelius, PhD, MPH, Associate Service Fellow

Briana Oliver, MPH, ORISE Fellow

Cross-division workgroup members: Pamela Lemos, Sarah 

R. Lewis, Michael Tynan, and MaryBeth Welton

The following partners also contributed to the preparation 

of this publication: 

Missouri University and the Missouri Department of Health 

and Senior Resources

California Department of Public Health

Hawaii State Department of Health 

New York City Department of Health and Mental Hygiene 

Maine Department of Health and Human Services

A special thanks to RTI International for their contribution 

to the publication.
Purpose 

The Centers for Disease Control and Prevention’s Office on 

Smoking and Health developed this guide to help state, local, 

territorial, and tribal health departments plan and implement 

evaluation of the federal law to raise the minimum legal sales 

age (MLSA) for tobacco products to 21 years (herein referred 

to as the T21 law). Guidance in this document can also support 

evaluation of state, local, territorial, and tribal T21 laws that 

may mirror or are more stringent than the federal T21 law 

(broadly referred to as T21 policies in this document).

On December 20, 2019, the Federal Food, Drug, and Cosmetic 

Act was amended to raise the MLSA for tobacco products 

from 18 to 21 years, effective immediately. The Food and Drug 

Administration (FDA) has 180 days to adopt a final rule for 

implementation and enforcement. Regulatory and enforcement 

elements for the national T21 law are unfolding and may have 

implications for the guidance provided in this document. Prior 

to the enactment of the national T21 law, nineteen states 

had already passed legislation to raise the MLSA for tobacco 

products to 21 years. This guide includes examples from Hawaii 

and California, the first two states to implement state T21 laws.

The evaluation approaches described in this guide can help 

assess the effects and impact of T21 laws to help advance the 

goals of the National Tobacco Control Program (NTCP) and to 

support NTCP awardee efforts in the following areas:

● Preventing initiation of tobacco use

● Eliminating nonsmokers’ exposure to secondhand smoke

● Promoting quitting among adults and youth

● Identifying and eliminating tobacco-related disparities

Audience

The primary audiences for this guide consist of planners, 

program managers, and evaluators of state tobacco control 

programs. Users are encouraged to adapt the tools and 

resources in this guidance to meet program evaluation needs. 

Accessible Version

https://www.cdc.gov/tobacco/stateandcommunity/tobacco_

control_programs/surveillance_evaluation/tobacco-21-policyevaluation/index.html.
Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Planning for Policy Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Step 1: Engaging Stakeholders .

Step 2: Describing the Policy Being Evaluated .

Step 3: Focusing the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Evaluating Policy Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Evaluating Policy Implementation .

Evaluating Policy Impact .

Steps 4-5: Gathering Credible Evidence and Justifying Conclusions . . . . . . . . . . . . . . . . . . . . . . 14

Step 6: Applying Policy Evaluation Results . 

Appendix: Accessible Explanations of Figures . 

References . 

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figures and Tables

Figure 1. Generic T21 Logic Model 

Figure 2. California State T21 Policy Logic Model 

Figure 3. Hawaii State T21 Policy Logic Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Figure 4. Evaluation Planning and Implementation Flow 

Table 1. Examples of T21 Policy Stakeholders 

Table 2. Evaluation Planning Matrix – T21 Policy Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Table 3: Types of Information Disseminated from Policy Evaluation Results . 

Suggested Citation: Tobacco 21: Policy Evaluation for Comprehensive Tobacco Control Programs. Atlanta, 

Georgia: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and 

Health Promotion, Office on Smoking and Health, 2020.
1

Introduction 

Tobacco use is the leading cause of preventable 

and premature death in the United States (USDHHS, 

2014).1 Nearly all tobacco use begins during youth 

and young adulthood (USDHHS, 2012). People who 

begin smoking at a young age are more likely to 

become addicted, to progress to daily smoking, 

and to smoke more heavily in adulthood (USDHHS, 

2012). In addition, the use of nicotine by adolescents 

and young adults can harm the developing brain, 

including the parts of the brain that control attention, 

learning, mood, and impulse control (USDHSS, 2016). 

Policies to increase the MLSA for tobacco products 

have been shown to contribute to reductions in 

tobacco use and dependence among youth (Institute 

of Medicine, 2015). Increasing the MLSA for tobacco 

to 21 years could reduce the likelihood of high school 

students legally purchasing tobacco products for 

themselves, other students, and underage friends, 

thus reducing the secondary risks of harm on youth 

brain development and early addiction. 

According to the Institute of Medicine’s 2015 report 

(Institute of Medicine, 2015), once the MLSA for 

tobacco products increases to 21 years nationally, it is 

projected that:

● Tobacco use will decrease by 12 percent by the time 

today’s teenagers become adults; smoking-related 

deaths will decrease by 10 percent.

● Smoking initiation will be reduced by 25 percent 

for 15–17-year-olds and by 15 percent for 

18–20-year-olds.

● Nationwide, 223,000 premature deaths will be 

prevented among people born between 2000 

and 2019, including 50,000 fewer deaths from 

lung cancer.

On December 20, 2019, the Federal Food, Drug, and 

Cosmetic Act was amended to reflect a change in the 

MLSA for tobacco products from 18 to 21 years of age, 

effective immediately. Prior to the enactment of the 

national T21 law, nineteen states had passed T21 laws: 

Arkansas, California, Connecticut, Delaware, Hawaii, 

Illinois, Maine, Maryland, Massachusetts, New Jersey, 

New York, Ohio, Oregon, Pennsylvania, Texas, Utah, 

Vermont, Virginia, and Washington. Guam and Palau 

had also raised the MLSA for tobacco products to 21 

years. Many cities adopted city-wide T21 laws as well, 

such as New York, Washington D.C., Chicago, and St. 

Louis (Counter Tobacco, 2019). 

Policy evaluation can help inform program efforts 

by identifying potential gaps or deficiencies within 

the policy, and the effects that those gaps can have 

on the policy’s implementation or intended impact. 

Furthermore, policy evaluation can help assess 

support and compliance with the implemented policy, 

demonstrate the value of the policy, and can help 

inform the evidence for future policies at the state, 

local, territorial, tribal, and national levels. It also can 

provide accountability for resources appropriated. 

Evaluating the impact of the federal T21 law within a 

specific jurisdiction can help answer questions about 

impact in various domains, for example:

● To what extent does the policy prevent initiation?

● How does the policy affect youth access to 

tobacco products?

● How does the policy affect social norms on 

tobacco use?

● What is the economic impact of the policy? 

Additionally, tobacco control programs can consider 

examining whether differences exist between T21 

laws enacted in their jurisdictions and the national 

T21 law and the extent to which different provisions 

affect the implementation and effects of the law.

1

“Tobacco” in this document refers specifically to the use of manufactured, commercial tobacco products and not the sacred and traditional use of 

tobacco by American Indians and other groups.
2

Planning for Policy Evaluation 

Step 1: Engaging Stakeholders

In identifying and engaging potential stakeholders for 

evaluating tobacco control policies, it is important to 

include participants from sectors in addition to those 

that are customarily involved in evaluation efforts. 

Promising groups include those involved in the policy 

implementation and enforcement. Federal, academic, 

or national health organization partners represent 

stakeholders that may have an interest in evaluation 

of the T21 law. Examples of these and other potential 

stakeholders are shown in Table 1. 

Table 1. Examples of T21 Policy Stakeholders

Stakeholder Categories Examples of Stakeholders

Policy Experts National/state/local/territorial/tribal legislators and staff

National/state/local/territorial/tribal tobacco prevention and control program staff 

Relevant enforcement agency staff (e.g., Department of Health, Attorney General’s Office, alcohol and 

tobacco boards, state enforcement agencies)

State/national/local nonprofit organizations (e.g., American Cancer Society, American Heart 

Association, American Lung Association, Campaign for Tobacco-Free Kids, Public Health Law Center)

Evaluation Experts State, federal, academic, or contract evaluation research partners

Agency evaluation staff

Subject Matter Experts State/local/territorial/tribal department of health and tobacco prevention and control program staff, 

SAMHSA-funded (Synar compliance) staff

Legal support partners (e.g., legal technical assistance centers)

State/national nonprofit organizations (e.g., Campaign for Tobacco-Free Kids, American Cancer Society, 

American Heart Association, American Lung Association, American Academy of Pediatrics, youth 

organizations)

Local substance abuse agencies, local arms of the state alcohol and tobacco agency

University research partners

National Network representatives (e.g., National LGBT Cancer Network, National African American 

Tobacco Prevention Network)

State and local partners of National Networks

Implementers Inspection or enforcement agency staff (e.g., Department of Health, SAMHSA-funded staff such as 

Synar compliance staff, Alcohol and Tobacco boards/agencies, local law enforcement)

Local enforcement agency staff (Department of Finance, Office of Consumer Affairs)

City/county boards/workgroups responsible for enforcing laws

Local advocates, coalition members, mobilized stakeholders

Mayor’s staff responsible for implementing new laws

Attorney General’s Office

Military stakeholders

Tribal stakeholders

Business associations, retailers selling tobacco (engaged only in the context of implementation-related 

outcomes and only as appropriate)
Step 2: Describing the Policy Being Evaluated

Evaluation of a T21 law requires a clear understanding 

of the policy. Stakeholders and evaluators should 

understand the policy content, including provisions, 

implementation, and enforcement guidance. FDA’s 

guidance regarding the federal T21 law continues to 

emerge. Several key policy components are likely to 

affect implementation and enforcement and thus the 

evaluation. These components are highlighted below:

● Policy definitions (e.g., tobacco products covered)

● Enforcement authority

● Penalty schedule

● Dates for when the policy is effective and active 

enforcement begins. 

Understanding the policy and its intended effects 

enables evaluators to graphically display the theorized 

pathways of change in a logic model. The logic model 

should be tailored to the policy components and a 

specific jurisdiction’s evaluation priorities. A generic 

logic model that can be tailored to meet diverse 

evaluation needs is shown in Figure 1. In addition to 

standard logical model components, such as policyrelated inputs, activities, outputs and outcomes 

(CDC, 2008), environmental context and unintended 

consequences are important considerations that also 

should be tailored. 

Figure 1. Generic T21 Logic Model 

INPUTS ACTIVITIES

Policy 

development 

process

OUTPUTS

Ads placed

Earned media

Press releases

SHORT-TERM 

OUTCOMES

Increased awareness 

and understanding 

of T21 policy 

(general public, 

retailers)

INTERMEDIATE 

OUTCOMES

Increased support for 

T21 Policy

LONG-TERM 

OUTCOMES

Reduced initiation of 

tobacco use among 

individuals under 21 

years

Model T21 Policy

Funding

Partners

Networks

Surveillance & 

Monitoring Systems

Cessation Resources

Evaluation staff time 

and effort

Finalize policy 

components

Develop media 

campaign

Develop and 

distribute 

communications 

materials 

Develop and 

distribute 

signage

Train 

enforcement 

personnel; 

conduct 

inspections

Communication 

materials developed

Education sessions 

held

Signage distributed 

Inspections protocol

Compliance checks 

conducted

Increased 

enforcement activity 

related to T21

Increased negative 

social norms around 

underage tobacco 

use

Increased 

compliance with T21 

policy

Decreased 

availability 

of tobacco 

products to 

individuals <21

Decreased sales 

of tobacco 

products

Reduced tobacco use 

prevalence among 

individuals under 21 

years 

Reduced tobaccorelated morbidity 

and mortality

Unintended Consequences

y Increase in illicit sales (e.g., adults purchasing for minors outside the store)

y Diminished political will for other evidence-based retail policies (e.g., flavored 

sales restrictions)

y Reduced opportunities for implementation

Environmental Context

Rates of tobacco use, state/local tobacco control funding, existing state/local tobacco policy landscape, tobacco and e-cigarette industry spending neighborhood 

demographics, retail density, proximity to exempted areas (e.g., tribal, military) or borders with non-covered areas (other localities, states).
Evaluation of logic models specific to T21 policies 

passed in California (Figure 2) and Hawaii (Figure 3) 

illustrate state-specific tailoring of a generic logic 

model. California’s model was designed to support 

process and outcome evaluations. The California 

T21 policy specified that “any person, firm, or 

corporation” who sells or gives away tobacco products 

is accountable for violating the policy and included an 

exemption for active duty military personnel (Cal. Bus. 

& Prof. Code § 22958)

Figure 2. California State T21 Policy Logic Model 

INPUTS 

ACTIVITIES OUTPUTS SHORT-TERM

OUTCOMES

INTERMEDIATE

OUTCOMES

LONG-TERM

OUTCOMES

y Distribute new age-of-sale 

warning signs to all CA 

tobacco retailers

y Develop and disseminate 

materials to educate retailers 

about increased age of sale 

and effective employee 

training

y Administer and promote 

a statewide tobacco use 

quitline to general public 

and 18-20-year-old tobacco 

users

y Display ads at point of sale 

to educate public about 

increased age of sale and 

quitline

y Conduct enforcementrelated compliance checks 

of tobacco sales to minors 

under 21

y Educate American Indian 

communities about tobacco 

age of sale disparity

y Warning signs posted at 

100% of tobacco retailers

y Educational materials and 

training tools distributed to 

retailers

y Operational quitline 

promoted to diverse 

populations and 18-20-yearold tobacco users

y Advertisements notifying 

public about new law and 

quitline displayed at tobacco 

retailers

y Demand letters issued to 

violating retailers through 

compliance checks of 

tobacco sales to minors 

under 21

y Educational materials 

for American Indian 

communities

y Increase awareness and 

support for new age-of-sale 

law among the general 

public and 18-20-year-olds

y Increased perception among 

youth that tobacco is difficult 

to obtain

y Increased awareness of new 

age of sale among retailers

y Increased competence of 

retailers to comply with the 

new age of sale law

y Increased compliance with 

new age-of-sale law

y Increased awareness of 

dangers of young adult 

smoking

y Increased call volume to 

quitline from diverse callers 

and 18-20-year-old tobacco 

users

y Increased awareness among 

American Indian leaders 

about disparity in age of sale 

and health consequences

y Decreased illegal sales of 

tobacco to youth under 18 

and young adults ages 18-20

y Decreased ability for minors 

under age 21 to obtain 

tobacco products

y Decreased sales of tobacco 

products

y Decreased susceptibility 

to experimentation with 

tobacco products

y Increased quit attempts 

among tobacco users age 

18-20

y Increased quit attempts 

among all tobacco users

y Increased number of tribal 

compacts or tribal policies 

with age of sale as 21

y Increased age of tobacco use 

initiation

y Decreased tobacco use 

initiation

y Decreased tobacco use 

prevalence among young 

adults ages 18-20

y Decreased youth and adult 

tobacco use prevalence

y Decreased tobacco 

consumption

y Decreased exposure to 

secondhand smoke/toxic 

aerosol

y Decreased tobacco-related 

morbidity and mortality

y Minimized tobacco-related 

disparities among American 

Indian population

Environmental Context

State excise tax rates, rates of tobacco use, national media campaigns, state tobacco control funding, utilization of statewide quitline, tobacco cessation insurance coverage, 

tobacco and e-cigarette industry spending

Note: “Tobacco products” include electronic smoking devices”; “smoking” includes smoking tobacco and vaping electronic smoking devices; “smoke-free” and “secondhand smoke” 

include tobacco smoke and toxic aerosol emitted from electronic smoking devices; and “thirdhand smoke” includes residue from tobacco

Statewide Tobacco 21 Implementation Plan, Surveillance of Tobacco-Related Attitudes and Behaviors, Surveillance of Tobacco Sales to Minors, Statewide Tobacco 

Cessation Quitline

The Hawaii T21 policy held “any person”—including 

the retailer making an illegal sale and the underage 

individual attempting to purchase a tobacco product—

accountable for violating the policy (Figure 3; Haw. Rev. 

Stat. Ann. § 712-1258). It specified that persons under 

age 21 years in violation of the policy are subject to a 

$10 fine for the first offense and a $50 fine or 48–72 

hours of community service for subsequent offenses. 

Hawaii did not explicitly exempt the military; the 

Army, Marines, and Navy indicated that they would 

voluntarily follow Hawaii’s T21 policy.2

2

 For more information: Army, http://governor.hawaii.gov/newsroom/usag-news-release-army-to-comply-with-hawaii-tobacco-law/; Marines, http://

www.marines.mil/News/Messages/Messages-Display/Article/897646/notice-of-hawaii-raising-smoking-age-to-21-effective-1-january-2016/; Navy, 

http://www.navy.mil/submit/display.asp?story_id=92572
Figure 3. Hawaii State T21 Policy Logic Model

INPUTS

Policy:

Tobacco 21 Legislation

Funding:

CDC Funds

Coalition Funds

Partners:

Dept. of Health/TPEP

Coalition for a TobaccoFree Hawaii (Coalition)

CDC OSH

Campaign for TobaccoFree Kids (CFTFK)

Cancer Center

Univ. of Hawaii (Public 

Health Studies; Campus 

Police; Student Affairs)

Dept. of Education (DOE)

Hawaii Police Dept. (HPD)

Networks:

Military Base 

Commanders

Legislators

Attorney General’s Office

Youth Coalitions

Tourism & Hospitality

Retailers & Grocers

Chamber of Commerce

Tax Commissioner’s Office

HPPUD?/ADAD?

Surveillance & Monitoring 

Systems:

HYTS (Spring 2015)

YRBS (Spring 2015)

BRFSS (e-cig module in 

2016)

SYNAR

State Inspections of 

Tobacco Retailers

Coalition’s Public Opinion 

Polling

Cessation Resources:

Quitline

ACTIVITIES

Enact State Law as of 

1/1/16

Develop and distribute 

educational materials

Educate key audiences

y Military base 

commanders

y University staff/

students

y Public school teachers 

& administrators

y Youth & young adults 

< 21

y Merchants

y ENDS retailers

Create enforcement 

infrastructure 

y In schools 

y In universities

y On military bases

y With general public

y With visitors/tourists

Train enforcement 

personnel in various 

sectors

Create & distribute 

signage

y In schools

y In retail 

establishments

y In point of sale 

locations

Create & distribute media 

campaign

Promote cessation 

resources

Broaden and conduct 

underage enforcement 

activities 

Monitor and evaluate

y Conduct periodic 

surveillance efforts

y Conduct focus groups 

on Quitline users

y Research vape shops’ 

product lines

y Monitor tobacco 

revenue

OUTPUTS

# audience-tailored fact 

sheets developed (e.g., 

military, POS locations) & 

distributed

# education / training 

sessions held by group

# meetings convened 

to discuss Tobacco 

21 implementation 

& enforcement (e.g., 

military, univ. campus 

security)

# and type of tobaccorelated policy revisions / 

procedures developed and 

disseminated

y ENDS-use at 

universities

y military base tobacco 

policies for personnel 

<21

y ENDS as drug 

paraphernalia in 

schools

y tobacco possession in 

schools

y public possession

# / type signage 

developed and distributed 

(e.g., schools, retail 

establishments, point of 

sale locations)

# calls to Quitline (tobacco 

and ENDS by age)

# ads in #/type of venues 

(featuring Quitline tag)

# newsletter stories by 

audience

# press releases by 

audience (e.g., tourism, 

grocers)

#/type of direct mass 

mailings

Revised protocols & 

contracts (e.g., SYNAR, 

state inspections)

# focus groups & 

participants (e.g., ENDS 

cessation)

Monthly tobacco sales 

revenue data/reports

#/type surveys conducted 

& #/type of respondents

# reports produced

SHORT-TERM 

OUTCOMES

Increased awareness 

and understanding of 

law (e.g., general public, 

tourists)

Increased military base 

policies’ consistency with 

state law

Increased awareness of 

location-specific policies 

around tobacco & ENDS 

(e.g., universities, schools, 

military bases)

Increased enforcement

Decreased commercial 

supply of tobacco/

nicotine to minors

Decreased social supply 

of tobacco/nicotine to 

minors

y Decreased intentions 

to start smoking/using 

ENDS

y Decreased intentions 

to product switch

Increased quit intentions 

Increased understanding 

about attitudes and 

knowledge of tobacco/

ENDS users

Increased understanding of unintended effects (e.g., 

negative economic impacts, illicit market)

INTERMEDIATE 

OUTCOMES

Increased favorable public 

opinion of law (attitudes 

& beliefs)

Increased compliance 

with law

Decreased tobacco & 

ENDS sales to persons 

<21

Increased favorable social 

norms around underage 

smoking (descriptive, 

injunctive, subjective)

y Decreased smoking /

ENDS use initiation

y Decreased product 

switching

y Decreased conversion 

from occasional to 

daily use

y Increased calls to 

Quitline from persons 

<21

y Increased quit 

attempts by underage 

smokers/ENDS 

consumers

LONG-TERM 

OUTCOMES

Decreased smoking /ENDS 

use prevalence among 

minors (& military)

Increased sustained 

cessation among minors 

Improved health

y Decreased tobacco/

nicotine exposure 

among minors

y Decreased health 

effects b/c of smoking/

ENDS use

Decreased health 

disparities (e.g., tobacco/

nicotine access, use, 

and health and social 

consequences)

Improved economic 

return on investment 

(ROI)
6

Below are several types of evaluation studies that 

state or local tobacco control programs can conduct to 

understand the process and outcome of a T21 policy. 

Public Support. These studies use focus groups and/

or surveys to assess public awareness of and support 

for a T21 policy. Public awareness/support studies can 

be used formatively to shape implementation or to 

document baseline public awareness and support for 

the policy and to measure changes over time. 

Retailer Implementation. Telephone-based or inperson surveys of tobacco product retailers can be used 

to monitor implementation issues and unintended 

consequences (e.g., increases in purchases made 

on behalf of, or with the intent to sell to, underage 

consumers), as well as retailer support for or concerns 

about the policy.

Retailer Compliance. Assessments of T21 policy 

compliance by tobacco product retailers often rely on 

data gathered by the agency charged with enforcing 

the T21 policy, for example, tobacco purchase 

compliance checks. Such checks can be conducted by 

various agencies, depending on the jurisdiction, and 

may be part of routine retailer inspections for other 

purposes (e.g., FDA compliance, Synar compliance, 

state compliance). Data from compliance checks can 

be used to document policy compliance rates (i.e., 

proportion of retailers in a jurisdiction found to be 

in compliance with the policy), implementation of 

the enforcement regime, and/or types of venues and 

geographic regions that are more or less compliant 

with the T21 policy. This information can inform 

resource allocations for targeted retailer education, 

outreach, and enforcement efforts.

Behavior of Underage Youth and Young Adults.

Questions on behavioral outcomes (e.g., reported ease 

of access to tobacco products; ever or current use of 

tobacco products; quit attempts) can be developed for 

existing state- or locality-based surveys of youth and 

young adults within the jurisdiction being evaluated. 

Studies of behavioral outcomes are most effective if 

they include data from before and after the T21 policy 

goes into effect. 

Economic Impact. These studies use economic data to 

assess the cost-benefit of a T21 policy on retailers and 

other stakeholders. For example, a study on the costeffectiveness of raising the MLSA to 21 in California 

used simulation models to generate estimates of 

benefits and costs (Ahmad, 2005). Substantial declines 

in youth initiation over 50 years with no net cost and 

a significant gain in quality adjusted life years were 

reported (Ahmad, 2005). Additionally, Ali et al. assessed 

the association between raising the MLSA to 21 with 

monthly sales of cigarette packs in California and 

Hawaii using difference-in-differences methods. Preand post- implementation estimates were obtained. 

The results showed that T21 policies were associated 

with a 13% reduction in cigarette pack sales in 

California and 18% reduction in cigarette pack sales 

in Hawaii (Ali, 2019). The costs, benefits, and methods 

included in these and similar studies may provide 

information that is helpful when planning studies of 

economic impact.
7

Step 3: Focusing the Evaluation 

Planning and implementing a T21 policy evaluation 

rely on having clearly articulated objectives and a 

sound plan for collecting and analyzing data. This 

section covers example evaluation questions across the 

domains of public awareness, compliance, health, and 

economic impact. Evaluation questions are organized 

by evaluation stage (Figure 4).

Content evaluation explores the process of 

identifying the problem and developing the policy.

Implementation evaluation explores the 

policy enactment and implementation, including 

enforcement. 

Impact evaluation examines the policy’s impact on 

the intended short-, intermediate- and long-term 

outcomes, as laid out in the policy logic model.

Figure 4. Evaluation Planning and Implementation Flow

Evaluating Policy Content 

Evaluation of policy content is often included as 

a preliminary step of a comprehensive evaluation 

because it helps the evaluator properly interpret 

implementation and impact evaluation. Content 

evaluation of any policy, including T21 laws, takes an 

in-depth look at the policy’s strengths and weaknesses 

when compared with a model policy. For example, 

national tobacco control organizations created 

guidelines for a strong MLSA policy and developed 

model language (see below). 

According to these organizations (Public Health Law 

Center, 2019), “A strong tobacco minimum legal sales 

age (MLSA) 21 ordinance will:

● Define tobacco products to include current and 

future tobacco products, including e-cigarettes.

● Prohibit the sale of tobacco products to persons 

under the age of 21.

● Require the tobacco retailer or their employer to 

verify the age of the purchaser prior to the sale.

● Require tobacco retailers to post signs stating that 

sales to persons under the age of 21 are prohibited.

● Designate an enforcement agency and establish a 

clear enforcement protocol.

● Create a tobacco retail licensing program if 

the jurisdiction has the authority to do so under 

state law.

● Dedicate funding to fully cover enforcement costs, 

either through licensing fees or as a provision in a 

state statute or local ordinance.

● Provide authority for the state, county, or 

municipality to inspect tobacco retailers for 

compliance with MLSA 21 and a mandated 

minimum number of annual compliance checks for 

every tobacco retail establishment.

● Provide penalties focused on the tobacco retailer, 

or licensee rather than the youth purchaser or the 

non-management employee. This would mean 

eliminating Purchase, Use, and Possession (PUP) 

penalties where they exist in current tobacco sales 

laws or polices.

Problem 

Identification

Content Evaluation

Policy

Analysis

Strategy and Policy 

Development

Policy 

Enactment

Implementation 

Evaluation

Impact

Evaluation

Policy 

Implementation
8

● Establish a civil penalty structure for violations 

rather than a criminal penalty structure to avoid 

unintended consequences that disproportionately 

impact marginalized communities and undermine 

the public health benefits of the policy.

● Where state legislation is pursued, ensure that 

local jurisdictions have the authority to enact more 

stringent regulations for tobacco products than 

state or federal law.”

Nineteen states and over 540 localities passed T21 

laws prior to the passage of the federal law, and two 

additional states have enacted T21 laws since passage 

of the federal law (Campaign for Tobacco-Free Kids, 

2020). Jurisdictions may continue to adopt their own 

MLSAs for tobacco products to help bolster compliance 

with the federal T21 requirements or to raise the MLSA 

higher than 21 years. If a state, local, territorial, or tribal 

law is not as strong as federal law, retailers still must 

comply with the federal law. Differences among 

these policies may be relevant for assessing and 

comparing the strengths of the various laws as well 

as any other relevant, existing state or local policy 

elements that are still being enforced. This can help 

inform future MLSA policy development, as well as 

other retail-oriented policies.

Examples of specific questions for a T21 policy content 

evaluation are listed below:

● Is there support for the policy components?

Is there opposition?

● Is the policy consistent with gold standard policies? 

● Are enforcement activities, retailer education, and 

penalties delineated?

● How are key components defined in the policy (e.g., 

tobacco products, restrictions, and signage)? 

● Did economic considerations or interests strengthen 

or weaken the policy?

● Does the policy state the evidence about the expected 

economic impact?

● If there are multiple local policies, how do they differ 

along these key components?

● How did local education efforts affect policy adoption 

at the local level?

Evaluating Policy Implementation 

A T21 implementation evaluation explores the 

activities involved in communicating about the 

policy, policy monitoring, and policy enforcement. 

For example, an implementation evaluation may 

examine media and other communications efforts (e.g., 

distributing signage) about the policy to the public 

and retailers. Implementation also covers the training, 

protocol development, and activities related to retailer 

inspections that make up compliance monitoring. 

For the federal T21 law, the FDA has not yet issued its 

final regulation, but has said that its enforcement will 

generally be carried out using the same process as 

when the federal MLSA was 18, and that it has begun 

using older underage persons in its compliance checks. 

(FDA, 2020). 

Implementation evaluation questions could include:

● Were education activities conducted, including 

addressing any concerns? Were they well-received?

● Were education efforts effective at increasing 

awareness of the policy? 

● Were compliance checks performed according to the 

policy, or if not, how were they performed?

● Are there geographic pockets of retailers who are 

non-compliant? 

● Were the right stakeholders involved in 

implementation? 

● Was the policy implemented uniformly across states?

As part of an evaluation of policy implementation, 

evaluators should examine all aspects of the policy. 

This includes the activities, actions, and the multiple 

perspectives for raising the MLSA for tobacco products 

to 21 years (for an expanded discussion, see Morian 

& Malek, 2017). A comprehensive evaluation will 

address all viewpoints by providing evidence of the 

policy’s impact and equipping policymakers and 

implementers with available data to mitigate any 

unintended consequences. 

Evaluating Policy Impact 

T21 policy impact evaluations can explore a variety 

of topics including changes in policy awareness and 

support, enforcement activities and compliance, 

retail sales, and underage tobacco access and use. 
9

Comprehensive impact evaluations intend to answer 

questions about whether the policy is having its 

intended effect, such as: 

● How has public and retailer support for the policy 

changed since its enactment?

● Did T21 policy enactment affect public or 

decision-maker support for other evidence-based 

tobacco control policies?

● Did negative social norms about underage tobacco

 use change?

● Has retailer non-compliance changed over time as 

enforcement activities have continued?

● Did quitline call volume change?

● Did young adult tobacco use change?

● Did retail tobacco product sales change?

● Did cessation activity of underage youth or young

 adults change?

● Did retailer revenues and employment change after 

the policy went into effect?

Impact evaluations can employ quantitative and 

qualitative methods and a variety of data sources, 

including focus groups; public opinion polls; surveys of 

adults, youth, and retailers; enforcement agency reports; 

and retail sales data.

Table 2 presents example evaluation questions, study 

designs, indicators, and data sources for evaluation of 

T21 policy content, implementation, and impact.

Table 2. Evaluation Planning Matrix – T21 Policy Evaluation 

PUBLIC AND RETAILER SUPPORT

Content Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

Is there support for the 

elements of the policy under 

consideration (e.g., penalties)?

Qualitative (content analysis of 

news media)

Quantitative (analysis of opinion 

poll/survey data)

Level of support for specific 

policy components

News media

Survey or opinion poll

Is there opposition to any of the 

elements?

Qualitative (content analysis of 

legislative history, testimony, 

news media)

Expressions of opposition in 

legislative history, news media

Legislative history 

News media

Is the policy consistent with 

gold standard policies?

Qualitative (analysis of policy 

language, model policy 

language)

Presence of policy content in 

alignment with gold standard

Legal documents; published 

and grey literature

Does the policy apply to 

more products than the federal 

law?

Qualitative (analysis of policy 

language)

Presence of definitions Legal documents 

Implementation Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

Were efforts made to educate 

the public, retailers, decision 

makers, or other stakeholders 

about the policy?

Qualitative (analysis of 

administrative records, 

stakeholder interviews, 

focus groups)

Number and types of 

communication with 

stakeholders (e.g., in-person 

meetings, phone calls, emails, 

press releases, educational 

materials distributed)

Administrative records, press 

releases, stakeholder websites, 

stakeholder interviews, focus 

groups

Telephone or in-person retailer 

interviews
10

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

Were efforts made to address 

or alleviate concerns about 

the policy? Were efforts well 

received?

Qualitative (analysis of 

stakeholder interviews, 

focus groups)

Quantitative (analysis of opinion 

poll/survey data)

Number and types of 

communication with 

stakeholders (e.g., in-person 

meetings, phone calls, emails, 

press releases, educational 

materials distributed)

Public awareness of outreach

Percent of public who felt 

concerns were addressed

Stakeholder interviews, focus 

groups, newspaper coverage

Opinion poll data

Impact Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

How has public support 

changed since the policy 

was enacted? 

Qualitative (focus groups, 

content analysis of news media)

Quantitative (time-series)

Level of community awareness 

Level of support for T21 policy

Level of support for policies, and 

for enforcement of policies, to 

decrease availability of tobacco 

to young people

Focus groups (before and after 

policy enactment)

Adult tobacco survey, public 

opinion polls, news media 

Did policy enactment 

change support for other 

policies to prevent initiation of 

tobacco use?

Quantitative (time-series) Level of support for other 

tobacco use initiation policies

Public opinion polls

Did negative social 

norms about underage tobacco 

use change?

Quantitative (time-series) Level of support for norms 

about underage tobacco use

Adult tobacco survey, public 

opinion polls

COMPLIANCE

Content Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

Are retailer, public education 

and enforcement activities 

explicitly referenced, delegated, 

and funded in the policy?

Qualitative (analysis of policy 

language)

Presence of policy components 

relevant to education and 

enforcement

Legal documents

Were penalties for noncompliance specified in 

the policy for retailers and 

customers? Are the penalties 

evidence-based?

Qualitative (analysis of policy 

language, literature)

Presence of T21 penalties

Evidence from the literature 

supporting T21 penalties

Legal documents, grey and 

published literature
11

Implementation Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

To what extent were the public 

and businesses aware of the 

policy? 

Qualitative (analysis of 

stakeholder interviews, focus 

group data)

Quantitative summary analysis

Knowledge of specific policy 

components

Stakeholder interviews 

(including retailers)

Focus groups

Public opinion polls

To what extent were compliance 

checks and enforcement actions 

performed according to the 

policy?

Qualitative (analysis of 

stakeholder interviews)

Quantitative summary analysis 

(post-intervention)

Description of compliance 

checks in alignment with policy

Documentation of compliance 

checks

Stakeholder interviews 

(including retailers)

Enforcement data

Are there pockets of noncompliance that need additional 

enforcement?

Quantitative summary analysis 

(post-intervention)

Number of T21 violations by 

geographic area, store type

Enforcement data

Impact Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

Has non-compliance changed 

over time as enforcement 

activities have continued?

Quantitative (post-intervention 

time series)

Number of violations as 

proportion of inspections

Enforcement data

How does observed retailer 

compliance compare to other 

states or localities without their 

own T21 policies? 

Quantitative (post-intervention 

time series; strengthened with 

comparison)

Number of violations as 

proportion of inspections

Enforcement data

Has reported retail access 

changed for youth under 18? 

Have reported usual sources 

for tobacco changed for youth 

under 18? 

Quantitative (time-series, 

strengthened with comparison)

Proportion of young people 

who report having purchased a 

tobacco product from a retailer 

in the previous 30 days 

Proportion of youth who report 

that they were refused sale of 

tobacco products because of 

their age during the previous 

30 days

Locations where youth 

purchased cigarettes

Youth tobacco survey

YOUTH BEHAVIOR

Content

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

Is policy consistent with 

evidence base to eliminate 

harms to health and not 

increase disparities among 

population groups?

Qualitative (literature review) Evidence supporting policy 

content regarding health and 

disparities

Grey and published literature
12

Implementation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

To what extent was policy 

enacted uniformly in all 

communities affected by the 

policy?

Quantitative summary analysis 

(post-intervention)

Qualitative (stakeholder 

interviews)

Proportion of stores inspected 

in affected jurisdiction(s)

Perception of uniform 

implementation

Number of people affected

Enforcement data

Stakeholder interviews

Impact Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

How did quitline call volume 

change as a function of the 

policy? 

Quantitative, time-series Number of quitline calls (per 

week/month)

Quitline data

How did rates of youth tobacco 

use change as a function of the 

policy?

Quantitative (time-series, 

strengthened with comparison)

Proportion of young people 

who have never tried smoking 

or using any other tobacco 

products 

Proportion of young people 

who have smoked or used some 

type of tobacco product at least 

1 day during the previous 30 

days

Youth tobacco survey

How did rates of young adult 

tobacco use change as a 

function of the policy?

Quantitative (time-series, 

strengthened with comparison)

Cigarettes: Proportion of adults 

aged 18-24 years old who have 

smoked at least 100 cigarettes 

in their lifetime and who now 

report smoking cigarettes every 

day or some days

Other tobacco products: 

Proportion of adults who have 

ever used a given tobacco 

product in their lifetime and 

who now report using the 

product every day or some days

Adult tobacco survey

How did overall tobacco 

consumption change as a 

function of the policy? 

Quantitative (time-series, 

strengthened with comparison)

Retail unit sales of tobacco 

products

Retail scanner data

How did rates of tobacco use 

cessation actions (quit attempts, 

quits) by young adults change 

as a function of the policy?

Quantitative (time-series, 

strengthened with comparison)

Proportion of tobacco users 

who stopped using a tobacco 

product for 24 hours in a quit 

attempt

Proportion of former tobacco 

users who last used tobacco 6 

months to 1 year ago

Proportion of former tobacco 

users who have sustained 

abstinence from tobacco use for 

6 months or longer

Adult tobacco survey
13

ECONOMIC IMPACT

Content

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

To what extent did economic 

considerations or interests 

strengthen or weaken the 

policy?

Qualitative (content analysis of 

legislative history, testimony)

Evidence of economic 

considerations in legislative 

history

Legislative history

Did the policy state the 

evidence about the expected 

economic impact?

Qualitative (content analysis of 

legislative history, testimony)

Presence of economic impact 

considerations in policy 

language

Legislative history

Implementation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

How did events or activities 

in surrounding jurisdictions 

impact policy implementation 

(e.g., such that these may have 

encouraged or discouraged 

cross-border sales by young 

people)?

Qualitative (content analysis of 

stakeholder interviews, legal 

documents)

Quantitative (time-series, 

adjacent jurisdictions)

Summary of policy and/or 

environmental context of 

surrounding jurisdiction(s)

Retail unit sales of tobacco 

products

Stakeholder interviews, legal/

news documents, scanner data

Impact Evaluation

Example Evaluation 

Questions

Example Evaluation 

Designs

Example Meaningful 

Indicators Example Data Source

How did retailer revenues and 

employment change after the 

policy was enacted, all other 

factors being equal?

Qualitative (review of tax, sales, 

revenue information)

Quantitative (time series, 

post-implementation)

Retailer revenue/tax filings for 

tobacco product sales

Perception of employment and 

economic impact after policy 

enacted

Number of retail stores

Tax receipts, sales revenue data, 

retailer survey
14

Steps 4-5: Gathering Credible Evidence and Justifying Conclusions 

In addition to the standard considerations around 

data selection and analyses, the logistical, social, 

and political context of T21 policies should also be 

considered carefully when planning an evaluation. 

When looking at state, local, and territorial or tribe-level 

policies, the logistical and contextual considerations 

below can vary significantly between policies. While 

the national T21 law may dissipate much of the 

variability among state, local, territorial, or tribal laws, 

it will still be important to understand how the law is 

structured, the environmental context in which it is 

taking place, as well as the historical context, which 

will vary between jurisdictions.

Compliance Checks: In addition to compliance 

activities conducted to enforce state, local, territorial, 

or tribal T21 laws, compliance checks for the federal 

T21 law occur at both state and federal levels. The 

Synar Amendment to the Alcohol, Drug Abuse, and 

Mental Health Administration Reorganization Act 

of 1992 requires states to enact and enforce laws 

prohibiting the sale or distribution of tobacco products 

to individuals under the age of 18 years to be eligible 

to receive substance abuse funding (Substance Abuse 

and Mental Health Administration, 2017). Under the 

Synar Amendment and other T21 laws enacted prior 

to the national T21 law, compliance was assessed by 

using underage decoys to determine if retailers were 

selling to underage persons. When the national T21 law 

was enacted, the Synar Amendment was also updated 

to reflect the new MLSA of 21. The federal agency that 

administers the Synar program has not yet provided 

guidance for states to conduct those compliance 

checks, and FDA has not yet finalized its regulations 

related to federal enforcement of the federal law.

Baseline Data Collection: States or jurisdictions 

should consider collecting baseline information 

when using pre-post designs to evaluate T21 policies. 

However, the rapid nature in which the national 

T21 law was passed presents challenges for having 

baseline data. This makes it difficult to measure 

changes in public opinion over time and, thus, policy 

impact. In such cases, existing data sources may offer 

opportunities for estimating baseline rates. Examples 

include, examining previous tobacco use among 

16-17-year-old survey respondents, underage retail 

sales rates from Synar inspections, data collected 

related to more locally based T21 policies prior to the 

national T21 law, and retail scanner sales data (which 

is typically available retrospectively for several years). 

If information was not previously collected, a prepost comparison will not be possible. However, other 

designs could be used to assess impact. 

Comparative Assessments: When baseline measures 

are impossible to obtain, quasi-experimental designs 

using comparison groups could be helpful, since this 

design allows for comparisons of samples similar in 

all aspects except for the characteristic of interest. 

For example, this design can be used to assess how 

contextual factors and variation in enforcement and 

compliance can have an impact on policy outcomes 

and impact (Coly & Parry, 2017). 

Environmental Context: As with any policy 

evaluation, policies, campaigns, initiatives, or other 

environmental changes concurrent to the policy 

under review must be considered when designing 

and analyzing a T21 evaluation. This attention to 

the environmental context is especially important 

given that point-of-sale campaigns, increases in 

tobacco taxes, and other strategies may be enacted 

independent of T21 policies. Evaluators should consider 

both new and existing tobacco control policies 

and other interventions that may contribute to the 

outcomes being measured. In addition, evaluators can 

use evaluation designs that maximally control sources 

of invalidity (Campbell & Stanley, 1966).
15

Step 6: Applying Policy Evaluation Results 

T21 policy evaluation results can be useful for stakeholders at multiple levels. Evaluation results can be used to 

inform ongoing national, state, and local implementation and enforcement, assess the level of public awareness 

and support for the policy, and provide meaningful indicators of success for stakeholders and the public. 

Some examples of how evaluation findings can be used by various audiences, are highlighted below (Table 3).

Table 3: Types of Information Disseminated from Policy Evaluation Results

Evaluation Findings Type of Information to be Disseminated

Content/implementation 

evaluation results

Potential enforcement gaps to inform policy/enforcement modifications

Impact evaluation results Policy outcomes and the effect on the population, including intended and unintended effects 

Lessons Learned Recommendations for future T21 and other retail policy implementation and evaluation

Evaluators should consider tailoring communication of evaluation findings to the needs and interests of different 

stakeholders, while packaging the evaluation results in a manner that is appropriate for the type of stakeholder. 

For example, a report describing policy impact may be of interest to T21 implementers, enforcement agencies, 

and policy and evaluation experts. Scientific manuscripts detailing the methods to evaluate the policy and the 

findings may be of greater interest to policy and subject matter experts. Similarly, “lessons learned” reports and 

straightforward documents or publications describing recommendations for implementation may be a better fit 

for staff members in jurisdictions that exhibit problems with effective implementation of the T21 law.
16

Appendix: Accessible Explanations of Figures 

Figure 1 Generic T21 logic model. Evaluators can 

use this model as a guide and tailor it to best fit 

the evaluation needs of each state and jurisdiction. 

Provided are examples of points to include in a 

T21 logic model. This model covers six categories: 

inputs, activities, and outputs, as well as short-term, 

intermediate, and long-term outcomes. The inputs 

for this T21 model are the T21 law, funding, partners, 

networks, surveillance and monitoring systems, 

cessation resources, and the evaluation of staff 

efforts and time. Activities for this model can involve 

policy development and finalizing its components, 

development and distribution of media campaigns, 

communication materials and signage, and training 

personnel on enforcement and inspections. Outputs 

can include advertisements and press releases, 

educational sessions for the T21 law, signage 

distribution, inspection protocols, and compliance 

checks. Short-term outcomes in this model can 

encompass increased awareness and understanding of 

T21 law, as well as increased enforcement of activities 

related to the law. Intermediate outcomes can be an 

increase in support for T21 law, increased change in 

social norms for underage tobacco use, increased 

compliance with T21 law, decreased availability of 

tobacco products to youth under 21, and decreased 

sales of tobacco products. Long-term outcomes 

can include reduction of the following: tobacco use 

initiation, tobacco use prevalence, and tobacco-related 

morbidity and mortality for youth under 21. This 

logic model also covers sections for both unintended 

consequences and an environmental context that 

gives states and jurisdictions an opportunity to discuss 

specific issues related to implementation of the T21 law 

in their area. (Page 3)

Figure 2 California’s T21 logic model. It uses six 

categories: inputs, activities, and outputs, as well as 

short-term, intermediate, and long-term outcomes. 

California’s inputs are the statewide implementation 

of their T21 law and cessation quitline, as well as 

surveillance of the public’s attitudes/behaviors of 

the law and surveillance of tobacco sales to youth. 

Activities in this model involve distributing warning 

signs and educational materials to retailers and 

employees about T21 law, promoting quitline to 

youth tobacco users, educating the public about T21 

law and quitline, conducting compliance checks, and 

educating American Indian communities about age of 

sale disparity. Outputs in this model include warning 

signs posted in all tobacco retailers, distribution of 

training materials to retailers, promotion of quitline 

to underage tobacco users, advertisements notifying 

the public of T21 law, demand letters to retailers 

who violate the law, and educational materials to 

American Indian communities. Short-term outcomes 

in this model cover increased awareness and support 

for the T21 law among the public and underage 

tobacco users, increased perception among youth 

that tobacco use is dangerous and difficult to obtain, 

increased awareness of and compliance with T21 law 

among retailers, increased call volume to quitline 

for tobacco users, and increased awareness among 

American Indians of disparity in age of sale and health 

consequences. Intermediate outcomes in this model 

include decreased illegal sales and ability to obtain 

tobacco products for youth under 21, decreased 

sales of tobacco products, decreased susceptibility to 

experimentation of tobacco products, increased quit 

attempts for all tobacco users, and increased number 

of tribal compacts or policies with age of sale as 21. 

Long-term outcomes for this model involve increased 

age of tobacco use initiation, decreased tobacco use 

initiation and tobacco use prevalence for youth and 

adults, decreased tobacco consumption, decreased 

exposure to secondhand smoke/toxic aerosol, 

decreased tobacco-related morbidity and mortality, 

and minimized tobacco-related disparities among 

American Indian population. California utilized the 

environmental context section and highlighted state 

excise tax rates, rates of tobacco use, national media 

campaigns, state tobacco control funding, utilization 

of quitline services including cessation insurance 

coverage, and spending on tobacco products. They 

also make note that references to tobacco products 

and use include that of e-cigarettes and other 

electronic smoking devices. (Page 4)

Figure 3 Hawaii’s T21 logic model. This model covers 

six categories: inputs, activities, and outputs, as well 

as short-term, intermediate, and long-term outcomes. 

The inputs for Hawaii’s logic model are as follows: T21 

law, funding from CDC and other coalitions, external 

partnerships with public health departments and 

organizations, state-based networks like military bases 

and youth coalitions, surveillance and monitoring 
17

systems (HYTS, YRBS, BRFSS, SYNAR, etc.), and 

cessation quitline services. Activities in Hawaii’s logic 

model involve enacting the T21 law, developing and 

distributing educational materials, educating the 

public and those who work with youth about the T21 

law, creating enforcement infrastructure, training 

enforcement personnel, creating and distributing 

signage and media campaigns, promotion of cessation 

resources, broadening underage enforcement 

activities, and monitoring the following: evaluation, 

research, and surveillance efforts on quitline users 

and sales of tobacco products. The outputs for 

Hawaii’s model include fact sheets tailored to every 

audience about the law, training sessions to discuss 

implementation and enforcement of the T21 law, 

dissemination plan for tobacco-related procedures, 

development and distribution of signage, number 

of calls to quitline, advertisements to promote the 

T21 law and quitline services, revised protocols and 

contracts, and focus groups. Short-term outcomes 

for this model cover increased awareness and 

understanding of T21 law, increased consistency 

between tobacco-related military policies and T21 law, 

increased enforcement, decreased commercial supply 

of tobacco products to minors, decreased intention 

to start smoking or switch to a different product, 

increased quit intentions, and increased understanding 

about the attitudes of tobacco users. Intermediate 

outcomes include increased favorable public opinion 

and compliance of T21 law, decreased tobacco product 

sales to persons under 21 years, increased change in 

social norms around underage smoking, decreased 

smoking initiation and tobacco product switching, 

decreased daily smoking, and increased calls to 

cessation resources and quit attempts for youth under 

21. Long-term outcomes in the model encompass 

decreasing tobacco use prevalence among minors and 

military, increased sustained cessation for youth under 

21, decreased tobacco product exposure among youth, 

decreased health effects of tobacco use, decreased 

tobacco-related health disparities, and improved 

economic return on investment. Hawaii also provided 

a space to discuss an increased need to understand 

the unintended consequences when a T21 law is 

implemented. (Page 5)

Figure 4 Evaluation Planning and Implementation Flow. 

The flow starts with content evaluation, which occurs 

during the policy identification, policy analysis, and 

strategy and development steps. The flow then moves 

to implementation evaluation, which occurs with policy 

enactment step. The flow ends with impact evaluation, 

which occurs with implementation step. (Page 7)

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