2. Materials and Methods
3.1.1. Policy Diffusion
3.1.2. Policy Entrepreneurs
3.1.3. The Rise of the E-Cigarette/Vaping Epidemic
3.2.1. Industry Influence
3.2.2. Low Ranking among Legislative Priorities
3.2.3. Controversy over Bill Language
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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|National advocacy *||26||(33%)|
|Health department staff||12||(15%)|
|Policy Diffusion||Policy Entrepreneurs||E-cigarette Epidemic||Tobacco Industry Influence||Lack of Priority||Bill Language Controversy|
|N/A||Legislators||Legislators were starting to see signs of the e-cigarette epidemic.||Industry influenced legislators through campaign contributions and quid pro arrangements.||N/A||Health advocates unsuccessfully lobbied against military exemption.|
They were willing to withdraw support if preemption was in the bill.
|Minimal local traction, primarily one high profile city.||Legislators||Minimal local traction, primarily one high profile city. N/A|
Influenced by NY, HI, CA passing T21.
|Industry publicly testified against the bill.||N/A||N/A|
|Extensive local traction; 80% of municipalities passed. |
Friendly competition with NYC passing.
|Physicians and Legislators||Surge of JUUL use alarmed legislators and school administrators.||Industry posed public opposition through public hearings and advertisements.||Health advocacy groups focused on flavor bans.|
Legislators seen as removed from realities of youth smoking.
|Advocates fought the inclusion of preemption in the final bill but were unsuccessful.|
|N/A||Legislators||Legislators were motivated to prevent addiction and JUUL use.||Bill was strongly supported by Industry, and some evidence that they wrote it and proposed it to legislators at the last minute to minimize opportunity for opposition.||Clean Indoor Air policy was the priority for tobacco advocates at the time T21 was introduced.||Since the bill was introduced at the end of legislative session, advocates had little time to fight the weakest elements of the bill and were unsuccessful in having them removed from the final bill.|
|Local traction in one influential city contributed momentum to other local action and the state bill.|
Encouraged by growing number of states passing T21, including nearby NY and MA.
|Physician and Legislators||Increasing use of e-cigarettes by youth in schools could no longer be ignored by legislators.||Industry lobbied against the T21 bill.||N/A||Advocates fought against instituting penalties for possession and purchase and were ultimately unsuccessful.|
|No local traction.|
Legislators were influenced by a handful of other states that had passed.
|Physicians and Legislators||Vaping epidemic alarmed the public and increased news media attention, which influenced legislators.||Industry lobbied extensively in support of weak legislation.||There were competing demands for the attention of health advocacy groups and legislators, notably the opioid epidemic.||Advocates fought the inclusion of preemption and military exemption but failed to keep them out of the final bill.|
|Local traction in one influential city was viewed as litmus test for state bill.|
Legislators motivated by the sense of T21 being a nationwide movement.
|Legislators||The rise in vaping created more political will; legislators were influenced by increased calls from concerned constituents.||Industry lobbied against T21 and promoted messaging about e-cigarettes as harm reduction.||N/A||Some advocates withdrew support for T21 in the end because law included preemption, military exemption, and weak retailer penalty structure.|
|Local traction in two influential cities created momentum for other local action and the state bill.||Legislators||The increase in youth vaping along with calls from constituents motivated legislators.||Industry was first in opposition but changed position and negotiated with legislators.||N/A||N/A|
|Local traction in the capital contributed to statewide momentum.|
Also priding itself as a progressive state, so followed lead of HI passing.
|Legislators||Local traction in the capital contributed to statewide momentum.|
Also priding itself as a progressive state, so followed lead of HI passing.
Concerns about increased e-cigarette use among high schoolers increased legislative support.
|Industry was initially in opposition and purportedly funded legislators to oppose the bills. Later in the campaign, industry switched positions and provided support for T21.||Tobacco control advocates were initially prioritizing other policies (e.g., taxation, smoke free air laws and fully funded tobacco program).||Advocates unsuccessfully fought the inclusion of preemption in the final bill, as well as a military exemption.|
|Industry supported T21 and played a role in promoting a weak bill.||Legislators||Local traction in two influential cities created momentum and rationale for the state bill.||Statements from the FDA and CDC declaring an epidemic attracted attention from legislators.||N/A||Advocates unsuccessfully fought several elements of the weak bill, including preemption, military exemption, grandfathering, and PUP penalties.|
|Facilitators||Policy Diffusion||“And I think there was a lot of concern among state legislators that we were going to have just a very non-uniform policy, that certain cities would be at the current age of 19 and other cities would start passing their own Tobacco 21 regulations, and I think there were some in our legislature who didn’t want those different policies. They didn’t want to have different policies across the state.” (UT, National advocacy)|
“But the interesting part is – what I discovered about Massachusetts – I don’t think they care so much about what the percentage of the population is under a [T21] regulation; they cared about the percent of towns, and things didn’t move as well statewide until we had 50 percent of the towns, which means we had to go into eastern Mass – western Mass, as well, and kind of get people. And the philosophy was get any town, no matter how big or how small.” (MA, Regional advocacy)
“Well, and I also think there’s kind of always the healthy competition between states. I work both in Washington and Oregon, and any time you have one of those states that passes a policy that’s well received that’s supported by both sides of the aisle, I think the legislators on the other side of the state line will take a look at that. And Hawaii’s just across the ocean a couple thousand miles. So, I think it was also part of some growing momentum that was happening around the Pacific Northwest at the time as well.” (WA, National advocacy)
|“And what they [physician champions] were doing was with their white coats, it was incredibly powerful, and they were getting into the communities we hadn’t been in in a while, that we hadn’t been able to move a tobacco agenda forward in.” (MA, Health departments)|
“[W]e also had really, really great champions...Our attorney general is an unapologetic Democrat. And so, working with somebody like [Republican] Representative, who I would say, probably disagrees with us on 80 percent of everything else, but when it came to healthcare issues, he was just incredible. And I – that has a lot to do with it...I think that that was just very, very helpful.” (WA, Policymaker)
“We had the Republicans carry the bill in both chambers and I think we have some Democratic lawmakers that have been tobacco control champions for a long time but they understand that having a Republican carry the goal is likely to be a more effective strategy...And so, having Republicans carry the bill...help[ed] work behind the scene as well as other Republicans also.” (TX, National Advocacy)
|Rise of E-cigarette Epidemic||“I think the teen vaping thing, the epidemic – it was alarming and it freaked people out…I bought a JUUL device and took it to the capitol and I was showing it to these people. And I was like, one in five kids in Arkansas are smoking this. It’s not healthy. It’s nicotine. They get hooked on it. And I had all the facts and stuff, and then you have the surgeon general’s warning – not only was that surgeon general warning a big deal, but it also created it where it put this JUUL-ing teen epidemic on their radar.” (AR, National advocacy) |
“We also had stories coming out from principals and administrators about bags and bags of e-cigarettes they had confiscated from students. They were using them in classes, in the hallways. They were using them in bathrooms. And the administrators and parents were really having a hard time figuring out how to keep these things out of schools because there is a lot of – it’s almost like students started using e-cigarettes and posting on Snapchat. Using them in the most risqué places. So, using them in classrooms and kind of getting those cool cred points with their friends for doing things like that. And so, it really has become part of the culture in a lot of our middle and high schools. And so, I think those kinds of stories definitely helped our legislators understand the urgency of addressing this problem.” (WA, National advocacy)
“And that was, I think, also a very powerful message to have young people talk about what they were seeing in their high schools, having their bathrooms closed because people are using it so much, or saying – telling the stories about their friends who were getting these products from their brothers and sisters and using them and having to see them struggle with that. And so, I think youth involvement...was incredibly important, I think, for the decision makers and lawmakers to hear kids tell them what they’re seeing.” (CT, National advocacy)
|Challenges||Tobacco Industry Influence||“I think Altria was trying to get in front... they’re pushing this weak bill across the nation and I think they were just trying to look like they were doing good for the youth as it related to tobacco products.” (VA, Health Departments)|
“I would definitely say it was the e-cigarette industry and the influence of the tobacco industry just in general. I mean they hired – I think we counted maybe 30, maybe 40 tobacco lobbyists in 2017. So if they have money, they have the influence to hire a lot of people to try to kill the bills that we’re trying to push forward.” (TX, National advocacy)
“Well, I would say [one of the biggest challenges was] the industry, at every turn… and then, certainly, I would say JUUL. The tobacco industry, JUUL and the local vape industry. Because they are well funded. They have a lot of resources. And really, up until this last year, they were heavy, heavy opposition...[T]hey would never oppose in the hearings. They are busy working legislators. They can make hefty contributions.” (WA, Regional advocacy)
|Lack of Priority||“[A]s an evidence-based organization, we only take positions on policies after we have data and research...And when it came to Tobacco 21, we could assume that it would help, but we don’t operate on assumptions…[T]he Institute of Medicine report came out shortly after our legislative session ended. And that gave ACS CAN and some of other national advocacy partners the data and the research that we needed to really take a position of support on Tobacco 21….[T]he first year of the campaign, we were not supportive. Second year, it was one of our top legislative priorities.” (WA, National advocacy)|
“We would have much preferred to strengthen our clean air legislation and create more comprehensive clean indoor air policies across the state prior to Tobacco 21 being able to successful as we saw it.” (VA, Health departments)
“[I]n the northeast where we’ve made a lot of progress [in tobacco control], people felt like we had done enough, and did we really need to do this? So the sense of urgency at times wasn’t – was a factor [and] a barrier for us.” (MA, Policymaker).
|Controversy over Bill Language||“We ended up having to put in a military exemption, not because anybody liked it or – the bill authors didn’t even support it – but the governor’s office was threatening to potentially veto the bill if it didn’t have a military exemption in it.” (TX, National advocacy)|
“I’ll say the final product was something that we didn’t support at all and we had problems with it prior to that, but – and the final product had a lot of challenges with it including there was a military exemption in the final product and new tobacco sales – the preemption of tobacco sales laws that was added to the bill, too. And I mean, from the [Organization’s] perspective we testified a few times in committee on some of the weaknesses in the bill. We – and we otherwise worked with – talked with legislators and also worked closely with our partners as well, too.” (AR, Regional advocacy)
“[T]hat was yet another concern about the bill, was that it exempted the military. And I think, to a large extent, the – our advocacy groups, they wanted to kill the whole bill...And I’m like, you’re not gonna kill it, the governor supports it...it is clearly getting traction – bipartisan traction, you’re not going to be able to kill it, it’s not gonna happen, let’s at least move it from an F to a D by fighting the military exemption... They did not agree with my recommendation. They continued to fight the whole bill.” (VA, Health Department)
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