Centers for Disease Control and Prevention, Office on Smoking and Health

Summary of Scientific Evidence: 

Raising the Minimum Legal Sales Age for Tobacco Products 

February 2021 

This information is provided for educational purposes. It is not provided for or against any specific legislative 

proposal; is not intended to be used as testimony; and is not intended to act as an endorsement or appearance of 

endorsement of any specific entity or proposal. 

The Public Health Burden of Tobacco Product Use

• The burden of disease and death from tobacco product use in the United States is

overwhelmingly caused by cigarettes and other combustible tobacco products.1

o Every year in the United States, approximately 480,0000 deaths and over $300 billion in

healthcare and lost productivity costs are attributable to cigarette smoking.2,3

o For every person who dies from smoking in the United States, at least 30 people live with

a serious smoking-related illness.4

o Worldwide, tobacco product use and secondhand smoke exposure cause over 8 million

deaths per year.5

o Cigarette smoking causes diseases of almost every organ of the human body, including

cancer, stroke, Type 2 diabetes, and chronic obstructive pulmonary disease (COPD).6

Smoking causes cancer of the lung, esophagus, larynx, mouth, throat, kidney, bladder,

liver, pancreas, stomach, cervix, colon, and rectum.7,8,9

o Even occasional or intermittent cigarette smoking still causes considerable harm.10

Occasional or intermittent smoking is associated with increased risk for cardiovascular

disease, lung and other cancers, and lower respiratory tract infections.11,12

• No tobacco product is harmless.

o Smokeless tobacco product use causes cancers of the mouth, esophagus, and pancreas; is

associated with diseases of the mouth; and may increase the risk for death from heart

disease and stroke.

13,14,15

o Additional research is still needed regarding the health effects of using e-cigarettes and

other emerging tobacco products, such as heated tobacco products. However, the current

evidence shows that the aerosol that e-cigarette users breathe from the device and exhale

can contain harmful and potentially harmful substances, including heavy metals like lead,

volatile organic compounds, and cancer-causing agents.16

o Studies of secondhand emissions from heated tobacco products suggest that the products

expose both users and bystanders to some of the same chemicals found in cigarette

smoke, although at lower levels than cigarette smoke.17

• Nicotine is a highly addictive drug found in tobacco products.18

o As with drugs such as cocaine and heroin, nicotine activates the brain’s reward circuits

and reinforces repeated nicotine exposure.19

o Nicotine also increases the risk of cardiovascular, respiratory, and gastrointestinal

disorders; decreases immune response; negatively impacts reproductive health; has acute

toxicity at high-enough doses; and increases the risk for the development of smokingrelated disease.20,21,22

• Nicotine is a health danger for pregnant women and their developing babies.23

• Youth and young adults are especially vulnerable to the harmful effects of nicotine.24,25
 

 

 

 

o Nicotine exposure can harm the developing brain, which continues to develop into the 

mid-20s. Specifically, using nicotine in adolescence and young adulthood can harm the 

prefrontal cortex, or the part of the brain that controls attention, learning, mood, and 

impulse control.26 

o Each time a new memory is created or a new skill is learned, stronger connections – or 

synapses – are built between brain cells. Young people’s brains build synapses faster than 

adult brains. Nicotine changes the way these synapses are formed.27 

o The findings of a recent study suggest that starting smoking regularly at age 18 to 20 was 

associated with higher odds of nicotine dependence and lower odds of smoking cessation 

than starting at age 21 or older.28 

o Using nicotine in adolescence and young adulthood may also increase risk for future 

addiction to other drugs.29 

The Problem of Tobacco Product Use Initiation 

• Almost all smokers begin smoking as youth or young adults, and focusing on preventing 

youth and young adult initiation is a critical component to addressing the tobacco epidemic.30 

• The U.S. Surgeon General has reported that “earlier age of onset of smoking marks the 

beginning of the exposure to the many harmful components of smoking. This is during an age 

range when growth is not complete and susceptibility to the damaging effects of tobacco 

smoke may be enhanced.”31 

• In addition, an earlier age of initiation extends the potential duration of smoking throughout 

the lifespan. For the major chronic diseases caused by smoking, the epidemiologic evidence 

indicates that risk rises progressively with increasing duration of smoking; indeed, for lung 

cancer, the risk rises more steeply with the duration of smoking than with the number of 

cigarettes smoked per day.32,33 

• According to the Surgeon General, “if smoking persists at the current rate among young 

adults in this country, 5.6 million of today’s Americans younger than 18 years of age are 

projected to die prematurely from a smoking-related illness.”34 

• Each day in the United States, about 1,600 youth under age 18 try their first cigarette.35 

Nearly 9 out of 10 adult cigarette smokers who smoke daily first try smoking by age 18,36 

and 99% first try smoking by age 26.37 Therefore, after age 25, almost no smokers began 

smoking or transitioned to daily smoking.38 

Youth and Young Adults’ Current Use of Tobacco Products 

• It is important to consider how younger populations use tobacco products when addressing 

youth and young adult initiation. 

o The use of multiple tobacco products is quite common among youth and young 

adults.39 Youth may be switching between products for a number of different reasons, 

including pricing, marketing, or other factors.

40 

o However, switching between combusted tobacco products such as cigarettes and 

cigars, continuing to smoke while using non-combusted products such as smokeless 

tobacco or e-cigarettes, or cutting down smoking does not meaningfully reduce the 

health risks associated with tobacco product use.41,42 The only way to fully reduce the 

health risks associated with smoking is to quit smoking completely.43 The use of any 

tobacco product—including e-cigarettes—is unsafe for youth and young adults.44 

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• Since 2011, the United States has seen declines in youth use of combustible tobacco 

products.45,46 In 2020, however, 1.6% of middle school students and 4.6% of high school 

students reported current (past 30 day) use of cigarettes and 1.5% of middle school students 

and 5.0% of high school students reported current use of cigars.

47,48 

• Although considerable progress has been made in reducing cigarette smoking among U.S. 

adults and youth,49 the tobacco product landscape continues to evolve to includes a variety of 

tobacco products, including smoked, smokeless, and electronic products, such as ecigarettes.50 

• E-cigarettes have been the most commonly used tobacco product among U.S. youth since 

2014.51 

o In 2020, 19.6% of U.S. high school students and 4.7% of U.S. middle school students 

– a total of 3.6 million youth – reported current use (use in the past 30 days) of ecigarettes.52 Among these students reporting current use of e-cigarettes, more than 1 

in 5 high school students and nearly 1 in 10 middle school students reported using 

these products daily.53 

o In recent years, patterns of e-cigarette use have driven patterns of overall tobacco 

product use among U.S. youth.54 E-cigarettes may expose a new generation of young 

people to nicotine addiction and might lead to sustained tobacco use.55,56,57 

o E-cigarette use is higher among younger adults than older adults; in 2018; current ecigarette use was 7.6% among adults aged 18-24, compared to 4.3% among those 

aged 25-44, 2.1% among those aged 45-64, and 0.8% among those aged 65 years or 

older.58 

Youth Vulnerability to Tobacco Marketing 

• Adolescents are highly vulnerable to tobacco industry marketing, smoking imagery in 

movies, and peer influence, and are not able to fully appreciate the health risks they face in 

the future.59 

• Furthermore, the tobacco industry has also explicitly targeted youth and young adults.60 

o Internal tobacco industry documents emphasize the industry’s desire to increase 

consumption within these target markets in order to obtain “replacement smokers,” 

and thus, remain profitable.61,62 

o In 2006, U.S. District Court Judge Gladys Kessler concluded that, regarding the 

tobacco industry’s marketing practices, “from the 1950s to the present, different 

defendants, at different times and using different methods, have intentionally 

marketed to young people under the age of twenty-one in order to recruit 

‘replacement smokers’ to ensure the economic future of the tobacco industry.”63 

o In 2014, the Surgeon General stated that “the root cause of the smoking epidemic is 

also evident: the tobacco industry aggressively markets and promotes lethal and 

addictive products, and continues to recruit youth and young adults as new consumers 

of these products.”64 

o In 2016, the U.S. Surgeon General concluded that e-cigarettes are marketed by 

promoting flavors and using a wide variety of media channels and approaches that 

have been used in the past for marketing conventional tobacco products to youth and 

young adults.65 

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Potential Public Health Impact of Raising the Minimum Legal Sales Age 

• A robust strategy that combines strategies with a well-established evidence base, such as 

comprehensive smoke-free laws and pricing strategies, as well as newer strategies such as 

laws raising the minimum legal sales age (MLSA) to 21 years, can help prevent and reduce 

tobacco product use among U.S. youth.66,67 

• In March 2015, the Institute of Medicine (now known as the National Academy of Medicine) 

issued a report, Public Health Implications of Raising the Minimum Age of Legal Access to 

Tobacco Products. The report was compiled by a committee of experts in the epidemiology 

of tobacco product use and tobacco product risks, adolescent and young adult development, 

risk behaviors and perceptions, public policy modeling, and public health policy, law, and 

practice. The report modeled the likely public health outcomes of raising the MLSA to 19 

years, 21 years, and 25 years, taking into consideration the developmental stages during 

which adolescents and young adults are more vulnerable to the adverse effects of nicotine.68 

o The Institute of Medicine report found that, overall, increasing the MLSA will likely 

prevent or delay initiation of tobacco use by adolescents and young adults, and that 

the age group most impacted by this prevention and delay of initiation will be those 

age 15 to 17 years. 

o The report also concluded that raising the MLSA would likely lead to substantial 

reductions in smoking prevalence as well as in smoking-related mortality.69 

o Specifically, the report predicted that, over time, adult cigarette smoking prevalence 

would decline by about 12% and smoking-related deaths would decline by over 10% 

if the MLSA for tobacco products were raised to 21.70 The report also predicted that, 

over that same timeframe, adult smoking prevalence would decline by nearly 16% 

and smoking-related deaths would decline by over 14% if the MLSA for tobacco 

products were raised to 25.71 

• A more recent study examined the potential impact of raising the MLSA to 21 years on 

young adults who are likely to smoke. 

o Specifically, it estimated that raising the MLSA to 21 years would reduce the odds of 

cigarette smoking by 39% among 18- to 20-year-olds who had ever tried smoking or 

using an e-cigarette.72 

o It also found that, among 18- to 20-year-olds who had close friends who smoked or 

used e-cigarettes at age 16, raising the MLSA to 21 would decrease their odds of 

becoming established smokers by 46%.73 Thus, it is expected that this policy would 

have a magnified effect among young people who have peers who smoke or use ecigarettes. 

• A comprehensive strategy to prevent youth smoking includes restricting the supply of 

cigarettes to minors, which includes both commercial (e.g., from stores or vending machines) 

and social supply chains (e.g., borrowing, buying, or stealing from other youth or adults). 74,75 

o Addressing the commercial supply requires taking appropriate steps to prevent illegal 

sales in the retail environment; educating merchants, youth, and young adults; and 

actively enforcing MLSA laws.76,77,78,79 

o However, raising the MLSA could also help eliminate the social supply—especially 

in high schools, where 18-year-old seniors are often a supply source for tobacco 

products for their younger counterparts.80 Older youth are also more likely to succeed 

in purchasing tobacco products and, thus, raising the MLSA to 21 years could reduce 

the likelihood that youth can access tobacco products and provide them to younger 

peers.81 

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• A recent study also modeled how raising the MLSA for tobacco products to 21 years of age 

would impact national retail tobacco sales.82 

o The study found that if such a policy were implemented nationwide, the maximum 

immediate loss of sales would be just 2% of the total cigarette sales in the United 

States.83 As the lower tobacco-use cohort aged, small businesses would be able to 

adjust to the resulting changed market conditions.84 

o Furthermore, the study noted that retailers are already required under federal rules to 

check the ID of anyone who appears to be younger than 27 years seeking to purchase 

tobacco, so an age 21 requirement would place no additional compliance burden on 

retail staff.85 The researchers concluded that, overall, the potential of this approach to 

reduce smoking and prevent disease outweighs the temporary cost of lost sales.86 

• In addition, setting the MLSA for tobacco products to 21 years will harmonize tobacco and 

alcohol sales, which would streamline enforcement.87 

• In addition to enforcement considerations, the science related to alcohol is also available for 

consideration in the context of MLSA. For example, overall, the scientific literature related to 

alcohol indicates that higher minimum legal sales ages improve health outcomes—especially in 

preventing youth and young adult use.88 

• Specifically, the Task Force on Community Preventive Services recommends implementing and 

maintaining an age 21 minimum legal drinking age based on strong evidence of their 

effectiveness.89 Evidence indicates that age 21 minimum legal drinking age laws result in lower 

levels of alcohol consumption—both among young adults 21 years of age and older, as well as 

those less than 21 years of age– and reduce alcohol-attributable harms, including motor vehicle 

crashes.90 The Task Force also recommends enhanced enforcement of these laws.91 

What States and Localities Have Done 

• On December 20, 2019, the Federal Food, Drug, and Cosmetic Act was amended to raise the 

federal MLSA for tobacco products from 18 to 21 years. This legislation became effective 

immediately and made it illegal for a retailer to sell any tobacco product - including cigarettes, 

cigars, and e-cigarettes - to anyone under 21 years.92 

• The new federal MLSA applies to all retail establishments and persons with no exceptions. It 

applies to retailers in all states, the District of Columbia (D.C.), five U.S. territories, and on tribal 

lands.93 

• Prior to this change in federal law, 19 states, 2 territories (Guam and Palau), and D.C. had 

already enacted legislation raising their MLSA for tobacco products to 21 years.94 At least 

540 localities had also raised their MLSA to 21 years, with the first such policy being 

implemented in 2005.95,96 

• Jurisdictions can enforce their MLSA laws and impose penalties for violations of those laws. 

If a jurisdiction’s laws are not as strong as the federal MLSA law, however, retailers still 

must comply with the federal law.97,98 

• There is no mandate that states, localities, and territories increase their MLSA to 21 years to 

conform to federal law.

99,100 However, many states have done so to enable them to receive 

federal grants to address substance use, which are conditioned on prohibiting tobacco product 

sales to underage persons.101,102 

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• In addition, many states have also raised their MLSA to complement federal enforcement 

activities with respect to the new federal prohibition on sales to individuals who are between 

18 and 20 years old, because federal enforcement agents do not do compliance checks in 

every store each year.

103,104,105 

• As of December 31, 2020, an additional ten states have raised their MLSA for tobacco 

products to 21 years.106 

• The federal MLSA law does not preclude state, local, tribal, or territorial laws that further 

restrict the sale of tobacco products; jurisdictions can enact sales prohibitions that are more 

restrictive than the federal law, including raising the MLSA for tobacco products above 21 

years.107,108 

• The specific impact of recently enacted local policies that raise the MLSA for tobacco 

products is still being evaluated. However, there are some initial data supporting the earlier 

studies that projected declines in tobacco product use. 

o In 2005, Needham, Massachusetts, was the first town in the country to raise the 

MLSA to 21 years.109 Surveillance data reveal a 47% reduction in the Needham highschool smoking rate over four years after implementation, likely attributable, in part, 

to this local policy approach.110 

o In 2015, Hawaii became the first state to raise the MLSA for tobacco to 21.111 After 

Hawaii raised its MLSA to 21, it observed a sales decrease in cigarettes, cigars, and 

cigarillos. 112 An evaluation of its policy also suggested that it may help to reduce 

sales of cigarette and large cigar products most preferred by U.S. youth and young 

adults.113 

o Another evaluation of both Hawaii’s and California’s MLSA laws suggested that 

cigarette sales declined by about 18% and 13%, respectively, when compared to states 

that did not raise their MLSAs, indicating that these types of laws may reduce tobacco 

product sales and consumption.114 

o Oregon raised its MLSA to 21 years effective January 1, 2018. An evaluation of the 

law, which consisted of cross-sectional surveys of youth and young adults before and 

after the law, found that initiation of tobacco product use decreased significantly 

among tobacco users aged 13-17 years (from 34% to 25%) and aged 18-20 years 

(from 23%-18%) following the law’s implementation.

115 

o A study of cigarette sales in select U.S. cities suggested that MLSAs of 21 years 

likely reduced sales of brands popular with young people under the age of 21.116 

o A study of smoking prevalence among 18- to 20-year old people living in urban areas 

throughout the United States suggested that local laws setting an MLSA of 21 years 

reduced smoking prevalence among people in this age group.117 

Public Support for Increasing the Minimum Legal Sales Age 

• Studies indicate broad support among U.S. adults for increasing the MLSA. 

• Generally, approximately three-quarters of U.S. adults favor raising the minimum tobacco 

age of sale to 21 years of age.118,119 This includes seven out of ten adult cigarette smokers.120 

• Additionally, a recent evaluation of the California law suggests that high awareness and 

support for the law may have contributed to reducing illegal tobacco sales to young people 

and achieving widespread retailer knowledge of, and conformity with, the new law.121 

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Summary 

• Given that almost all adult daily smokers first start smoking before the age of 26, preventing 

youth and young adults from trying their first tobacco products, and reducing the number of 

youth and young adults that transition to become regular, daily tobacco product users into 

adulthood, are two key components to ending the tobacco epidemic. 

• Youth and young adults are especially vulnerable to the deadly chemicals in tobacco, nicotine 

dependence and addiction, and the heavy marketing used to sell tobacco products, including 

e-cigarettes. 

• An emerging body of scientific evidence suggests that raising the MLSA for tobacco 

products appears to be a promising and important component of a comprehensive approach to 

tobacco prevention and control. It also has the shorter-term benefit of reducing young 

people’s exposure to the harmful, addictive effects of nicotine—especially during this 

vulnerable period of brain development. 

References 

1 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

2 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

3 Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. Annual healthcare spending attributable to cigarette smoking: 

an update. Am J Prev Med. 2015;48(3):326-333. 4 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 5 World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017. World Health Organization, 2017. 6 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

7 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

8 U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis 

for Smoking-Attributable Disease: A Report of the Surgeon General. U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office 

on Smoking and Health, 2010.

9 U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 10 Schane RE, Ling PM, Glantz SA. Health effects of light and intermittent smoking: a review. Circulation 

2010;121(13):1518-22. 11 Schane RE, Ling PM, Glantz SA. Health effects of light and intermittent smoking: a review. Circulation 

2010;121(13):1518-22. 12 Inoue-Choi M, Christensen CH, Rostron BL, et al. Dose-response association of low-intensity and nondaily smoking with 

mortality in the United States. JAMA Netw Open. 2020;3(6):e206436. 13 World Health Organization. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 89: 

Smokeless Tobacco and Some Tobacco-Specific N-Nitrosamines. World Health Organization, International Agency for 

Research on Cancer, 2007. 14 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

7 
 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 15 Piano MR, Benowitz NL, Fitzgerald GA, Corbridge S, Heath J, Hahn E, et al. Impact of smokeless tobacco products on 

cardiovascular disease: implications for policy, prevention, and treatment: A policy statement from the American Heart 

Association. Circulation 2010;122(15):1520–44. 16 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

17 Simonavicius E, McNeill A, Shahab L, et al. Heat-not-burn tobacco products: a systematic literature review. Tob Control 

2019;28:582-94. 18 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

19 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

20 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

21 Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A. Harmful effects of nicotine. Indian J Med Paediatr Oncol. 

2015;36(1):24-31. 22 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

23 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

24 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

25 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. 26 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

27 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

28 Ali FRM, Agaku IT, Sharapova SR, Reimels EA, Homa DM. Onset of regular smoking before age 21 and subsequent 

nicotine dependence and cessation behavior among US adult smokers. Prev Chronic Dis 2020;17:E06. doi: 

http://dx.doi.org/10.5888/pcd17.190176

29 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016. 30 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

31 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

32 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

33 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

8 
 

 

 

 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

34 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

35 Substance Abuse and Mental Health Services Administration. 2018 National Survey on Drug Use and Health. Annual 

Detailed Tables. Substance Abuse and Mental Health Data Archive. Available at: http://www.samhsa.gov/data/report/2018-

nsduh-annual-national-report 36 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

37 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

38 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

39 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

40 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 41 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

42 Goniewicz ML, Smith DM, Edwards KC, et al. Comparison of nicotine and toxicant exposure in users of electronic 

cigarettes and combustible cigarettes. JAMA Netw Open. 2018;1(8):e185937. 43 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

44 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

45 Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students— 

United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2019;68:157-64. 46 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 47 Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students— 

United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2019;68:157-64. 48 Gentzke AS, Wang TW, Jamal A, et al. Vital signs: tobacco product use among middle and high school students — United 

States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1881-88. 

49 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 50 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

51 Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students— 

United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2019;68:157-64. 52 Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA. E-cigarette use among middle and high school students — 

United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(37):1310-12. doi: 

http://dx.doi.org/10.15585/mmwr.mm6937e1

53 Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA. E-cigarette use among middle and high school students — 

United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(37):1310-12. doi: 

http://dx.doi.org/10.15585/mmwr.mm6937e1 

9 
 

 

 

54 Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students— 

United States, 2011–2018. MMWR Morb Mortal Wkly Rep. 2019;68:157-64. 55 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

56 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

57 U.S. Department of Health and Human Services. Surgeon General’s Advisory on E-cigarette Use Among Youth, 2018. 

Available at: https://e-cigarettes.surgeongeneral.gov/documents/surgeon-generals-advisory-on-e-cigarette-use-among-youth2018.pdf

58 Creamer MR, Wang TW, Babb S, et al. Tobacco product use and cessation indicators among adults — United States, 2018. 

MMWR Morb Mortal Wkly Rep. 2019;68:1013-19. 

59 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

60 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 61 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

62 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

63 U.S. v. Phillip Morris USA, Inc., et al. No 99-CV-02496GK (U.S. Dist. Ct., D.C.), Final Opinion, p. 972, August 17, 2006. 64 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

65 U.S. Department of Health and Human Services. E-cigarette Use Among Youth and Young Adults: A Report of the Surgeon 

General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for 

Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016.

66 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

67 Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. 

National Academies Press, 2015. 68 Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. 

National Academies Press, 2015. 

69 Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. 

National Academies Press, 2015. 

70 Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. 

National Academies Press, 2015. 

71 Institute of Medicine. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. 

National Academies Press, 2015. 

72 Friedman AS, Buckell J, Sindelar JL. Tobacco‐21 laws and young adult smoking: quasi‐experimental evidence. Addiction 

2019;114:1816-23. doi: https://doi.org/10.1111/add.14653 73 Friedman AS, Buckell J, Sindelar JL. Tobacco‐21 laws and young adult smoking: quasi‐experimental evidence. Addiction 

2019;114:1816-23. doi: https://doi.org/10.1111/add.14653 74 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of 

the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

75 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

76 U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A 

10 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.

77 U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A 

Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

78 Dai H, Chaney L, Ellerbeck E, Friggeri R, White N, Catley D. Youth knowledge of Tobacco 21 and its association with 

intention to use tobacco. Nicotine & Tob Research 2021;23(2):341-48. doi: https://doi.org/10.1093/ntr/ntaa149 79 Levinson AH, Lee JGL, Jason LA, DiFranza JR. Asking for identification and retail tobacco sales to minors. Pediatrics 

2020;145(5):e20193253.doi: https://doi.org/10.1542/peds.2019-3253 80 DiFranza JR, Coleman M. Sources of tobacco for youths in communities with strong enforcement of youth access laws. 

Tob Control 2001;10(4):323-28. 81 DiFranza JR, Coleman M. Sources of tobacco for youths in communities with strong enforcement of youth access laws. 

Tob Control 2001;10(4):323-28. 82 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising tobacco 

sales age to 21 years. Am J Public Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 83 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising tobacco 

sales age to 21 years. Am J Public Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 84 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising tobacco 

sales age to 21 years. Am J Public Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 85 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising tobacco 

sales age to 21 years. Am J Public Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 86 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising tobacco 

sales age to 21 years. Am J Public Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 87 Winickoff JP, McMillen R, Tanski S, et al. Public support for raising the age of sale for tobacco to 21 in the United States. 

Tob Control 2016;25(3):284-88. 88 Centers for Disease Control and Prevention. Age 21 Minimum Legal Drinking Age Fact Sheet. Accessed October 19, 2020. 

Available at: http://www.cdc.gov/alcohol/fact-sheets/mlda.htm 

89 Shults RA, Elder RW, Sleet DA, et al. Reviews of evidence regarding interventions to reduce alcohol-impaired driving. Am 

J Prev Med. 2001;21(4S):66–8. 

90 O’Malley PM, Wagenaar AC. Effects of minimum drinking age laws on alcohol use, related behaviors, and traffic crash 

involvement among American youth: 1976–1987. J Stud Alcohol and Drugs 1991;52:478-91. 

91 Elder RW, Lawrence B, Janes G, Brewer RD, Tommey TL, Hingson RW, Naimi TS, Wing SG, Fielding J. Enhanced 

enforcement of laws prohibiting sale of alcohol to minors: systematic review of effectiveness for reducing sales and underage 

drinking. Transportation Research Circular. E-C123. 2007;E-C123:181-88. Available at: 

http://www.trb.org/Publications/Blurbs/159420.aspx

92 U.S. Food & Drug Administration. Tobacco 21. Accessed January 29, 2021. https://www.fda.gov/tobacco-products/retailsales-tobacco-products/tobacco-21

93 U.S. Food & Drug Administration. Tobacco 21. Accessed January 29, 2021. https://www.fda.gov/tobacco-products/retailsales-tobacco-products/tobacco-21

94 CDC State Tobacco Activities Tracking and Evaluation (STATE) System. CDC STATE System Tobacco Legislation – 

Youth Access. Accessed October 19, 2020. https://www.cdc.gov/STATESystem/ 

95 Campaign for Tobacco-Free Kids. States and Localities That Have Raised the Minimum Legal Sale Age for Tobacco 

Products to 21. Accessed December 9, 2020. 

https://www.tobaccofreekids.org/assets/content/what_we_do/state_local_issues/sales_21/states_localities_MLSA_21.pdf

96 Winickoff JP, Hartman L, Minghua LL, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising 

tobacco sales age to 21 years. Am J Pub Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 97 Public Health Law Center. The New Federal Tobacco-21 Law: What it Means for State, Local, and Tribal Governments, 

January 15, 2020. Accessed October 19, 2020. https://publichealthlawcenter.org/blogs/2020-01-07/new-federal-tobacco-21-

law-what-it-means-state-local-and-tribal-governments

98 Marynak K, Mahoney M, Williams KS, Tynan MA, Reimels E, King BA. State and territorial laws prohibiting sales of 

tobacco products to persons aged <21 years — United States, December 20, 2019. MMWR Morb Mortal Wkly Rep. 

2020;69(7):189-92. doi: http://dx.doi.org/10.15585/mmwr.mm6907a3 99 Public Health Law Center. The New Federal Tobacco-21 Law: What it Means for State, Local, and Tribal Governments, 

January 15, 2020. Accessed October 19, 2020. https://publichealthlawcenter.org/blogs/2020-01-07/new-federal-tobacco-21-

law-what-it-means-state-local-and-tribal-governments 100 Marynak K, Mahoney M, Williams KS, Tynan MA, Reimels E, King BA. State and territorial laws prohibiting sales of 

11 
 

 

 

 

 

 

 

 

 

 

tobacco products to persons aged <21 years — United States, December 20, 2019. MMWR Morb Mortal Wkly Rep. 

2020;69(7):189-92. doi: http://dx.doi.org/10.15585/mmwr.mm6907a3 101 Public Health Law Center. The New Federal Tobacco-21 Law: What it Means for State, Local, and Tribal Governments, 

January 15, 2020. Accessed October 19, 2020. https://publichealthlawcenter.org/blogs/2020-01-07/new-federal-tobacco-21-

law-what-it-means-state-local-and-tribal-governments 102 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Revision 

to Guidance, June 12, 2020. Available at: https://www.samhsa.gov/sites/default/files/synar-guidance-tobacco-21.pdf 103 Public Health Law Center. The New Federal Tobacco-21 Law: What it Means for State, Local, and Tribal Governments, 

January 15, 2020. Accessed October 19, 2020. https://publichealthlawcenter.org/blogs/2020-01-07/new-federal-tobacco-21-

law-what-it-means-state-local-and-tribal-governments 104 Marynak K, Mahoney M, Williams KS, Tynan MA, Reimels E, King BA. State and territorial laws prohibiting sales of 

tobacco products to persons aged <21 years — United States, December 20, 2019. MMWR Morb Mortal Wkly Rep. 

2020;69(7):189-92. doi: http://dx.doi.org/10.15585/mmwr.mm6907a3 105 Lee JG, Shook-Sa BE, Bowling JM, Ribisl KM. Comparison of sampling strategies for tobacco retailer inspections to 

maximize coverage in vulnerable areas and minimize cost. Nicotine & Tob Research 2017;20(11):1353-8. doi: 

https://doi.org/10.1093/ntr/ntx149

106 CDC State Tobacco Activities Tracking and Evaluation (STATE) System. CDC STATE System Tobacco Legislation – 

Youth Access. Accessed October 19, 2020. https://www.cdc.gov/STATESystem/ 107 Public Health Law Center. The New Federal Tobacco-21 Law: What it Means for State, Local, and Tribal Governments, 

January 15, 2020. Accessed October 19, 2020. https://publichealthlawcenter.org/blogs/2020-01-07/new-federal-tobacco-21-

law-what-it-means-state-local-and-tribal-governments 108 Marynak K, Mahoney M, Williams KS, Tynan MA, Reimels E, King BA. State and territorial laws prohibiting sales of 

tobacco products to persons aged <21 years. — United States, December 20, 2019. MMWR Morb Mortal Wkly Rep. 

2020;69(7):189-92. doi: http://dx.doi.org/10.15585/mmwr.mm6907a3 

109 Winickoff JP, Hartman L, Minghua LL, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising 

tobacco sales age to 21 years. Am J Pub Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 110 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising 

tobacco sales age to 21 years. Am J Pub Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 111 Campaign for Tobacco-Free Kids. States and Localities That Have Raised the Minimum Legal Sale Age for Tobacco 

Products to 21. Accessed December 9, 2020. 

https://www.tobaccofreekids.org/assets/content/what_we_do/state_local_issues/sales_21/states_localities_MLSA_21.pdf

112 Glover-Kudon R, Gammon DG, Rogers T, et al. Cigarette and cigar sales in Hawaii before and after implementation of a 

Tobacco 21 Law. Tob Control 2021;30(1):98-102. doi: https://doi.org/10.1136/tobaccocontrol-2019-055248 113 Glover-Kudon R, Gammon DG, Rogers T, et al. Cigarette and cigar sales in Hawaii before and after implementation of a 

Tobacco 21 Law. Tob Control 2021;30(1):98-102. doi: https://doi.org/10.1136/tobaccocontrol-2019-055248 114 Ali FRM, Rice K, Fang X, et al. Tobacco 21 policies in California and Hawaii and sales of cigarette packs: a differencein-differences analysis. Tob Control 2020;29(5):588-92. 115 Oregon Health Authority. Oregon’s Tobacco 21 Law: Impact Evaluation. May 2019. Available at: 

https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/TOBACCOPREVENTION/Documents/Oregon-Tobacco-21-

Impact-Evaluation-Report.pdf 116 Liber AC, Xue Z, Cahn Z, Drope J, Stoklosa M. Tobacco 21 adoption decreased sales of cigarette brands purchased by 

young people: a translation of population health survey data to gain insight into market data for policy analysis. Tob Control 

2020. Epub ahead of print. doi: https://doi.org/10.1136/tobaccocontrol-2020-055932 117 Friedman AS, Wu RJ. Do local tobacco-21 laws reduce smoking among 18 to 20-year olds? Nicotine & Tob Research 

2020;22(7):1195-1201. doi: https://doi.org/10.1093/ntr/ntz123 118 Winickoff JP, Hartman L, Minghua L, Chen ML, Gottlieb M, Nabi-Burza E, DiFranza JR. Retail impact of raising 

tobacco sales age to 21 years. Am J Public Health 2014;104(11):e18-e21. doi: 10.2105/AJPH.2014.302174 

119 King BA, Jama AO, Marynak KL, Promoff GR. Attitudes toward raising the minimum age of sale for tobacco among U.S. 

adults. Am J Prev Med. 2015;49(4):583-8. 120 King BA, Jama AO, Marynak KL, Promoff GR. Attitudes toward raising the minimum age of sale for tobacco among U.S. 

adults. Am J Prev Med. 2015;49(4):583-8. 121 Zhang X, Vuong TD, Andersen-Rodgers E, et al. Evaluation of California’s ‘Tobacco 21’ law. Tob Control 2018;27:656-

62. 

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