Background: Multiple strategies have been utilized in attempts to decrease the prevalence of youth tobacco use. One strategy, raising the minimum legal sale age (MLSA) of tobacco products to 21, known as Tobacco 21, has recently gained popularity. Tobacco 21 legislation targets youth tobacco use by obstructing two main sources of youth tobacco products: stores and older friends. Although these sources are the most common for youth across the nation, regional differences have not been explored. Further, youth perspectives about raising the tobacco MLSA have not been considered. Youth may help identify potential challenges to implementing tobacco control measures, as well as suggest alternatives for intervention, thus helping to shape successful tobacco control policies.

Study Aim: This study aimed to 1) examine youth perspectives on raising the tobacco minimum legal sale age to 21 and 2) identify common sources of tobacco products among middle and high school students living in rural, low-income Appalachian communities.

Methods: A cross-sectional survey about perceptions and use of tobacco products was conducted with students in the Appalachian regions of Kentucky and North Carolina (N=426). Questions were asked concerning perspectives on the effect of Tobacco 21 implementation. Descriptive statistics characterized participants by Tobacco 21 perspectives. Participants were given the opportunity to further expand upon their opinions in an open-ended format.

Results: The majority (58.7%) of participants responded that the same number of youth would use tobacco if the legal purchase age were raised, followed by responses that fewer would use (28.9%) and more would use (12.4%). Significant differences emerged based on tobacco use status (p<.05), friends’ tobacco use (p<.001), and whether participants identified family members as sources of youth tobacco products (p=.047). When given the opportunity to expand upon their views concerning the implementation of Tobacco 21 laws in their communities, many respondents cited poor enforcement of tobacco MLSAs at stores, continued access to tobacco products from family members and friends, and the overall abundance of tobacco in their communities as potential barriers to the successful implementation.

Conclusion: Fewer than one-third of participants believed that Tobacco 21 legislation would succeed in reducing the prevalence of youth tobacco use. Perspectives on the effect of Tobacco 21 legislation were related to personal tobacco use, exposure to tobacco users, and beliefs that family members provide tobacco products to youth. Open-ended responses identify potential obstacles in implementing Tobacco 21 legislation in Appalachia. Future research should attempt to include youth perspectives when designing and implementing tobacco control policies and examine family members as sources of tobacco products for youth.

Key Take Away Points

  • Over half of the participants believed that implementing Tobacco 21 legislation would result in no change in youth tobacco use.
  • Fewer than one-third of participants thought that this legislation would reduce youth tobacco use.
  • Most of these rural youth suggested that increasing the purchase age would not impact youth access to tobacco in their communities.

Author Biography

Lindsay K. Tompkins is pursuing a doctoral degree in Epidemiology and Population Health at the University of Louisville. She holds an MS in Epidemiology and her research interests center in vulnerable populations. Her work examines tobacco perceptions and use as well as exposure to environmental toxins. Clara G. Sears received her MS in Epidemiology and PhD in Epidemiology and Population Health from the University of Louisville’s School of Public Health and Information Sciences. Her expertise includes tobacco control, especially among youth and other vulnerable populations, and environmental pollution effects. Joy L. Hart is Professor of Communication at the University of Louisville. Her research examines health communication, environmental communication, and organizational communication. In particular, her research agenda focuses on message production and interpretation and links to healthy workplaces, lifestyles, and communities. Kandi L. Walker is Professor of Communication at the University of Louisville. Her areas of expertise include health communication and interpersonal communication. Her work explores the intersection between health and interpersonal communication by examining how people perceive the social world surrounding health issues. Alexander S. Lee holds an MPH with a concentration in Biostatistics and an MS in Physiology and Biophysics from the University of Louisville. He is interested in tobacco control, health care, and hospital data management, and he currently works as a health care consultant. Aruni Bhatnagar is Professor of Medicine at the University of Louisville. He currently serves as the Director of the Diabetes and Obesity Center and as a senior member of the Institute of Molecular Cardiology. His research is centered in environmental cardiology, focusing on the effects environmental pollutants have on cardiovascular health.


Data collection for the research reported in this work was supported by grant number P50HL120163 from the National Heart, Lung, and Blood Institute (NHLBI) and FDA Center for Tobacco Products (CTP). Data analysis and manuscript preparation were supported by the Department of Communication at the University of Louisville. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the Food and Drug Administration, or the University of Louisville. We extend thanks to the middle and high school students who participated in this research and the schools that hosted our research team. We also thank Courteney Smith and Allison Siu for assistance with data collection, Shesh Rai for assistance with data analysis, and Rose Marie Robertson for support of this work.