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Clinical AND Health Affairs JANUARY/FEBRUARY 2017 | MINNESOTA MEDICINE | 35 Raising the Minimum Legal Sale Age for Tobacco to 21 The Estimated Effect for Minnesota BY RAYMOND G. BOYLE, PHD, JOHN H. KINGSBURY, PHD, AND MICHAEL J. PARKS, PHD A campaign to raise the minimum legal sale age for tobacco products from 18 to 21 years known as Tobacco 21 is having a nationwide impact, with at least 200 localities in 14 states having already implemented a Tobacco 21 policy. A 2015 report from the Institute of Medicine (IOM) estimated the effects of such policy on cigarette use at the national level; however, little is known about the expected effects for individual states. The purpose of this study was to consider the effect on smoking initiation in Minnesota if the minimum sale age were 21 in 2015. Estimates from the Minnesota Adolescent Community Cohort and Minnesota Adult Tobacco Survey were used to calculate the uptake of smoking in a hypothetical cohort of Minnesota adolescents 15 to 20 years of age. Expected reductions in initiation in the IOM report were used to calculate the effects of Tobacco 21 policy on smoking uptake in this cohort. Results revealed that raising the sale age to 21 in 2015 would prevent 3,355 young Minnesotans from starting to smoke. Minnesota addresses tobacco use through a comprehensive ap- proach that includes coordinating smoke-free policies, promoting norma- tive changes in the social acceptability of tobacco use, establishing and expanding the reach of cessation programs, keeping the price of tobacco high and preventing young people from initiating tobacco use. The overall effect of these actions has been a 35% reduction in cigarette smoking in Minnesota since 1999;1 however, tobacco use remains popular among young adults in Minnesota and nationally.1,2 The persistence of tobacco use among young adults, coupled with an evolving marketplace that includes new flavored products (eg, flavored cigars and cigaril- los) and new delivery methods (eg, elec- tronic cigarettes), has led to a desire for increased regulation of tobacco. In 2009 the U.S. Congress granted authority to the Food and Drug Administration (FDA) through the Family Smoking Prevention and Tobacco Control Act to regulate the manufacture, distribution and marketing of tobacco products.3 Although this law prohibited the FDA from increasing beyond age 18 the na- tional minimum sale age for tobacco prod- ucts, state and local governments are able to raise the minimum sale age for tobacco. In addition, the law required a study of the health implications of a higher minimum age of legal access. The Institute of Medi- cine (IOM), now the National Academy of Medicine, conducted the study using national data to consider the effects of dif- ferent minimum purchase ages (19, 21 or 25 years) and examine multiple outcomes, including preventing young people from starting and encouraging current smokers to quit smoking, and the health benefits from reduced smoking because of an in- creased purchase age. Nationally, increas- ing the purchase age to 21 would result in approximately 223,000 fewer premature deaths and 50,000 fewer deaths from lung cancer.4 Adolescents younger than age 18 fre- quently obtain tobacco from social sources who are older than 18 but younger than 21.5 If tobacco could not be sold to 18- to 20-year-olds, they would be far less likely to provide tobacco to younger teens. By age 21, young adults are likely to have friends older than high-school age and, therefore, less likely to provide tobacco to minors. The IOM’s 2015 report is particularly important because it provides scientific guidance for state and local governments as they seek to protect public health. Al- though the report provided novel informa- tion on the expected effects of Tobacco 21 policy on a national level, it provided little