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Challenges and Lessons Learned from Advocating for a CommunityLevel Student Led Tobacco 21 Policy InitiativeMallory Ohneck, Nicole McKenzie, Karen Teeple, Claire Copa,Amy Thompson, & Tavis GlassmanAbstractNearly all lifelong smokers start as children or young adults, and the tobacco industry targetsthese specific age groups. A key public health effort to limit the use of tobacco products by peopleunder the age of 21 years is the promotion of the “Tobacco 21” initiative. This initiative promotesand supports efforts to establish bills and ordinances across the country, which authorizes an increasein minimum legal sale age for tobacco products and electronic cigarettes to 21 years. To date, theselaws stop short of making possession of tobacco and tobacco products by persons under 21 a crime,placing the direct responsibility on retailers under penalty of civil fines. Public Health advocates fromthe Toledo, Ohio community have engaged policymakers and community stakeholders to adopt a localTobacco 21 ordinance. This case study describes the steps students and citizens took to advocate for alocal ordinance and describes the challenges and lessons learned from this initiative.IntroductionTobacco is a major risk factor for premature death and chronic illness and is the leading cause ofpreventable deaths in the United States (Centers for Disease Control and Prevention [CDC], 2018; U.S.Department of Health and Human Services, 2014). Tobacco use is known to cause cancer, heart disease,and respiratory diseases, among other health disorders (CDC, 2018). According to the CDC (2018), if*Mallory Ohneck, MPH, CHES , GraduateResearch Assistant, The University ofToledo, 2801 W. Bancroft Street Mailstop119, Toledo, OH 43606; Email: Mallory.Rinckey@rockets.utoledo.eduNicole McKenzie, MHA, RRT, AssistantProfessor, Respiratory Care , TheUniversity of Toledo, 2801 West BancroftStreet Mailstop 119, Toledo, OH 43606;Email: Nicole.Mckenzie@utoledo.eduKaren Teeple, B.S, CTTS, CPST, 4612 285thStreet, Toledo, OH 43611; Email: Karen.Teeple@rockets.utoledo.eduClaire Copa, MA, CTRS, Graduate ResearchAssistant; The University of Toledo, 2801W. Bancroft Street Mailstop 119, Toledo,OH 43606; Email:26Claire.Copa@rockets.utoledo.eduAmy Thompson, PhD, CHES , FESG, ViceProvost of Faculty Affairs The University ofToledo, 2801 West Bancroft Street Mailstop119, Toledo, OH 43606; Email:Amy.Thompson4@utoledo.eduTavis Glassman, PhD, MPH, MSEd, MCHES ,CCPH, Professor Health Education/PublicHealth, The University of Toledo, 2801West Bancroft Street Mailstop 119, Toledo,OH 43606; Email:Tavis.Glassman@utoledo.edu*Corresponding AuthorThe Health EducatorFall 2019, Vol. 51, No. 1

the prevalence of smoking continues at thecurrent rate, 5.6 million youth under the age of18 will die early from a smoking-related illness.Delaying the age when youth first experimentwith tobacco products may reduce the risk ofadolescents transitioning to a daily adult smoker(Institute of Medicine [IOM], 2015; Schneider,Buka, Dash, Winickoff, and O’Donnell, 2016).Youth are susceptible to the addictive effects ofnicotine, and human brains continue to developthrough the age of 25 (IOM, 2015; Feinstein,Richter, and Foster, 2012). From an addictionperspective, the cerebral cortex, the area of thebrain responsible for decision making, impulsecontrol, sensation seeking, and susceptibility topeer pressure is vulnerable to nicotine duringadolescence and early adulthood (IOM, 2015;Feinstein et al., 2012). Thus, local/state policiesor ordinances called Tobacco 21 aim to limitthe sale and distribution of cigarettes, tobaccoproducts, e-cigarettes, and liquid nicotine toindividuals under the age of 21 years old. Thesepolicies minimize tobacco accessibility to minors,as many young adult smokers (18 to 21-yearolds) serve as a social resource for acquisitionof tobacco (IOM, 2015; Schneider et al., 2016).Combating the tobacco epidemic, particularlyyouth smoking, by advocating for policy change,is a direct effort to create environments conduciveto healthier behaviors. While there have beenseveral articles published that show the impact ofTobacco 21 laws on the reduction in adolescenttobacco use, there is a dearth of research on thesteps used to pass such a law or lessons learned(Schneider et al., 2016; Moreland-Russell,Combs, Schroth, and Luke, 2016; IOM, 2015).Tobacco 21 Policies in the United StatesIn 2005, the first community to increasethe minimum sale age of tobacco and nicotineproducts was Needham, Massachusetts. Thetobacco smoking rate for past 30-day use amongthe high school students in Needham decreasedfrom 12.9% in 2006 to 5.5% in 2012 (Schneideret al., 2016). In effect, the law blocked the socialsources that provided the Needham youth withFall 2019, Vol. 51, No. 1tobacco products. To date, there are over 475cities and 18 states that have adopted a Tobacco21 ordinance (Preventing Tobacco AddictionFoundation, 2019). Before Ohio passed astatewide policy, 24 cities adopted the Tobacco21 ordinance, but none in the northwest cornerof the state (Preventing Tobacco AddictionFoundation, 2019). Due to the advocacy effortstaking place throughout the state, in July 2019,Ohio’s governor passed Tobacco 21 legislationto take effect in October 2019 (FY 2020-2021Operating Budget, 2019).Tobacco 21 Policies in Toledo, OhioAdvocacy for Tobacco 21 in Toledo beganas a classroom assignment at the University ofToledo in a graduate-level public health coursein 2015. The assignment required researchingTobacco 21 and talking to one city council memberto learn advocacy skills and how local policies arepassed. The project continued after the semesterended and grew the collaborative effort to includemany dedicated public health students, includingthe university’s Eta Sigma Gamma chapter,faculty members, and community public healthprofessionals and enact this important publichealth policy. Figure 1 provides a chronologyof the steps implemented as a part of the ToledoTobacco 21 initiative.Student responsibilities included creatingan advocacy packet to use during meetingswith city council members, collecting letters ofsupport, and writing opinion editorials for localnewspapers. Materials were created during onesemester and updated or amended throughout thecampaign. Individual meetings with city councilpresidents and members, chiefs of staff, cityadministrators, and community members werethe starting point for advocacy using the materialscreated by students. Students and facultyadvocated with policymakers to implement aTobacco 21 ordinance. The Toledo efforts beganwith students collecting background informationand organizing a plan, later forming an integralpartnership with the Toledo-Lucas County HealthDepartment in March 2017.The Health Educator27

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The advocacy approaches used in thisstudy are unique including: 1) the communityadvocacy efforts were student driven - Universityof Toledo students and local high school studentswere leaders; 2) Holding city council meetingsat a local high school to involve youth in theadvocacy efforts; 3) Students worked alongsidethe local health department and led the initiative;4) Students were the spokespeople for most ofthe media advocacy; 5) Students collected datafrom the community regarding local supportfor the Tobacco 21 that was used to advocatefor passaging the law; 6) Students planned,implemented and evaluated a Tobacco 21 Summitwhere they invited local officials and communitystakeholders to attend and participate; and 7)Students successfully advocated for the passageof a Student Government Resolution to supportTobacco 21. This case study informs universityhealth education/public health faculty or localeducators on how to plan and implement aTobacco 21 policy in the community. This study,presented as a commentary of advocacy strategies,shares information from lessons learned and didnot entail human subjects.Strategies for SuccessThroughout the initiative, students workedwith faculty members to develop successfulstrategies. The Tobacco 21 advocacy team usedevidence from the literature and learned by trialand error the most effective strategies in creatingchange (Gielen and Green, 2015). Studentsadapted initiative tactics based on the changingpolitical and social landscape within the Toledocommunity. By being organized and strategizingahead of time, students advanced the initiative bymobilizing public health advocates, communitymembers, and the media. Below is a list of keystrategies for a successful advocacy initiative.Identify a Consistent Point PersonThe advocacy initiative had a student as aconsistent point person in the community to helporganize and schedule meetings and send updatesFall 2019, Vol. 51, No. 1to community partners. This student point personkept a record of meetings and contacted citycouncil to schedule meetings. The point personalso kept the initiative moving forward when newstudents became engaged in advocacy.Develop PartnershipsThe second strategy was buildingpartnerships with public health agencies andorganizations. The partners provided letters ofsupport, testimony at city council meetings,and professional guidance. The partnersinvolved include: Preventing Tobacco AddictionFoundation, the previous Northwest OhioTobacco Prevention Coalition, the HealthyYouth and Family Coalition, Eta Sigma GammaIota Chapter, the University of Toledo StudentOrganization Students for Drug Free Policy, andthe Toledo-Lucas County Health Department.Secure Grant FundingNext, students wrote a successful grantproposal under the guidance of faculty to anOhio agency, the Prevention Action Alliance(previously the Drug Free Action Alliance), toimplement a social norms marketing campaign.A doctoral health education student developedthree billboard social norm message designs andundergraduate and graduate Eta Sigma GammaIota Chapter students assisted with testing themessages by using central intercept interviewswith the target audience through an onlinequestionnaire and in-person interviews. Basedon the feedback from message testing, a graphicdesign artist made revisions. The final messagewas displayed on nine billboards for four weeksacross the Greater Toledo Area with 4,634,124impressions.Engage the CommunityStudents and faculty organized communityforums to raise awareness, educate, and advocatefor Tobacco 21 in the community. The firstcommunity forum, attended by 65 people,included employees of local health agencies andstudents. The second forum was held to strategizeThe Health Educator29