In 2016, Cleveland City Council passed a policy to raise the legal age to purchase tobacco products in the city from 18 to 21. Today, the legislation—known as Tobacco 21—is in effect and, according to research by Case Western Reserve University’s Prevention Research Center for Healthy Neighborhoods (PRCHN), is already creating a healthier future for Clevelanders.
Led by Erika Trapl, director of the PRCHN and associate professor in the Department of Population and Quantitative Health Sciences, the researchers conducted a study looking at tobacco rates in high school students from 2013 to 2019 to evaluate the effectiveness of the policy. The study used data collected from the Youth Risk Behavior Survey (YRBS), a survey given every other year to middle and high schoolers in Cuyahoga County to track risky behaviors and potential protective factors over time.
PRCHN was uniquely positioned to conduct the study as the center’s work was instrumental in helping push Cleveland’s Tobacco 21 legislation forward. In fact, Trapl chaired the committee that brought the legislation forward to city council in 2015 and was lead author on the study published in JAMA Network Open.
“I hope we recognize that policy can be a strong lever for public health,” she said. “And in this case, this policy was developed (by) and came from the community.”
To better understand the impact of the legislation and the study’s findings, we sat down with Trapl to discuss her team’s work.
Answers have been lightly edited for length and clarity.
How did this study come about and what made your team want to look into the impact of the legislation?
Being part of the committee, we were on the front end of this, we needed to figure out how to evaluate this because no other city that has adopted this policy has been able to figure out how it works, if it works or what impact it has.
We already collected data and we used our YRBS data to inform city council about youth tobacco use and why we think there’s an imperative to protect youth, so the best way to show impact is to keep using that data and look at change over time to see if rates are coming down that we might be able to attribute at least partially to the policy.
It felt important to be able to use the data that we had to inform our community about how impactful that policy was and see if we still needed to do more and also celebrate the success of that.
What do you think these results will show about the future health of Clevelanders and youth, more specifically?
Cleveland continues to look at how to strengthen that policy because, even though we have state and federal policy, what’s really important with policy is enforcement. And the state and the federal government don’t have the resources to enforce this policy across the over 500 tobacco retailers in the city of Cleveland. So we continue to look at ways to reinforce this locally.
But with the success that we’ve seen in the decline in tobacco use among kids, what that really translates into is fewer adult smokers in the city of Cleveland in the future and a reduction in tobacco-related disparities in disease.
We hope that some of the impact of tobacco on those diseases is lessened because we have reduced the number of kids who start. One of the reasons Tobacco 21 is really important is because very few adult smokers begin smoking after the age of 21. Most smokers start early during adolescence, and the adolescent brain is more sensitive to becoming dependent on nicotine, so the addiction starts much more quickly for kids. That’s why we see over 90% of adult smokers are people who started when they were teenagers and just could not quit and continued smoking.
The hope is that, if we’re reducing initiation and use right now among kids and driving that down as far as we can, then we’re reducing the number of adults smokers that we have in the community and driving down the cost of those diseases in our community.
Because it’s something that is so future-driven, was this policy hard to sell?
No, because we really saw this as a way to protect our kids and invest in our children and our community. The other thing that our data allows us to do is say there are this many fewer thousands of children using tobacco in our Cleveland high schools in 2021 than there were in 2015 before we passed that legislation. We can actually equate it to the number of kids who did not start smoking, who are not currently smoking.
What’s it like seeing this data after having played such an important role in Cleveland’s legislation passing?
As scientists, we all hope to see the impact of the work that we do and usually in policy, it takes a bit of time. This has been incredibly rewarding, not just for me and my team at [PRCHN] but also for all the partners that we’ve worked with on this legislation since 2013. Our goal was to have a positive impact and protect the health of the children who live in the city of Cleveland. And amazingly right within just four years, really we saw it, even within two years of this policy, we saw fewer kids smoking.
That’s a big deal. And it’s a big deal, not just to celebrate that success, but to realize, we can take that energy and bring it to the next policy and to the next issue that we need to address to improve the health of kids in Cleveland and Cleveland residents.
Do you have any plans to expand upon this research at all?
Yes, and no. I’m curious to see what the state and federal impact is, and I hope it remains the same and certainly my team aims to continue to monitor tobacco use. We will likely shift our focus to the pending legislation on the ban of all flavored tobacco products, because that is pending nationally with the US Food and Drug Administration Center for tobacco products. They proposed a rule a couple of months ago to ban menthol cigarettes, which would have a huge impact within the African American adult community—particularly here in Cleveland—but also to ban flavored cigars, which are the most common of any tobacco product among all youth in the city of Cleveland.
Our work is moving now into flavors as really the next avenue to reduce youth initiation. We hope to encourage local adoption of flavor policy.
What do you think the impact of your findings will be?
Locally, I hope it reassures those of us in Cleveland who are involved in policy change that we can make policy change, that policy change can be impactful and we can see that change on actual people’s lives.
The second would be recognizing that we can develop equitable policies that can and should protect us from predatory companies.