Columbus is the 14th largest city in the U.S. and capital of Ohio with a population of approximately 850,000 residents. Columbus is a diverse community representing many ethnicities and a wide range of household incomes.
Studies have shown that more than 95% of addicted smokers start before the age of 21 and the developing teenage brain is vulnerable to the effects of nicotine. It has been found that the primary sources of tobacco for underage smokers are their 18 to 20 year old peers; social circles for teens do not typically include those who are 21 and older. By increasing the sales age of tobacco, vape, and paraphernalia products to 21, accessibility of these products in the teen population is greatly reduced.
The goal of the City of Columbus Tobacco 21 program is to protect health and improve lives of our youth by restricting their access to tobacco products which may prevent their tobacco use and reducing their likelihood of becoming addicted. The objectives are to implement an annual license for retailers, require a sign at points of sale to educate consumers about the law, conduct inspections, and utilize enforcement to achieve compliance. By educating the public and regulating the retailer, the program is comprehensive and effective in preventing tobacco sales to underage youth.
Columbus City Council passed the Tobacco 21 ordinance and the Board of Health passed a new city health code which gave Columbus Public Health the authority and mechanism to regulate retailers through licensing and impose civil fines through enforcement when there is non-compliance. The Tobacco 21 law prohibits tobacco sales, inclusive of all products and paraphernalia, including hookah, e-cigarettes, pipes, and rolling papers to anyone under the age of 21.
Key requirements include:
· Tobacco, vape, and paraphernalia sales are restricted to individuals 21 and over at traditional retail facilities and temporary events.
· Retailers are required to obtain an annual Retail Tobacco and Paraphernalia Sales License.
· ID checks are mandated for all tobacco and paraphernalia sales up to age 30.
· CPH approved signage that states all sales are prohibited to those under the age of 21 shall be posted at all points of sales and on display cases.
· Vending machines are prohibited in all venues for the sale of tobacco, vape, and paraphernalia.
· Inspections consist of two parts: an underage consumer will attempt a purchase and sign compliance is verified.
· A civil fine of $500 will be issued for a 1st violation. Second and subsequent violations within 2 years of the 1st violation will be issued a civil fine of $1,000 per violation.
· In addition to the civil fines administered by the health department, criminal offenses related to underage sales are enforceable by local law enforcement.
· Fines will be deposited into a Tobacco Enforcement and Education Fund administered by the department.
Tobacco 21 regulated products:
· Electronic smoking devices including, but not limited to: e-cigarettes, e-cigars, e-pipes, vape pens, and e-hookah.
· Product paraphernalia including, but not limited to: pipes and rolling papers.
· Tobacco products including, but not limited to: any product that is made from or derived from tobacco and is intended for human consumption, or is likely to be consumed using a method such as smoking, chewing, inhaling, or ingestion.
· Tobacco products including, but not limited to: cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, snus, electronic smoking devices, filters, rolling papers, pipes, and liquids, with or without nicotine, used in electronic smoking devices.
The department has successfully implemented all components of the Tobacco 21 program. A database of retailers was established and all have been successfully licensed and provided mandated signs. Proper placement of signs is verified by sanitarians who conduct annual inspections. By using college students as underage-buyers, an annual underage-buy component was created and has been successfully utilized to identify retailers who allow underage sales.
During initial underage-buy attempts at facilities, it was determined that 66% of retailers were compliant with the new law. Currently, the department is conducting a second round of underage-buy attempts and data collected so far indicates that 78% of retailers who initially violated the law are now compliant with preventing sales to underage youth. By preventing the sale of tobacco products to youth under 21, we believe that our objectives are being met.
Internal collaboration among department colleagues and multiple external partnerships led to the success of the practices that support the City of Columbus Tobacco 21 program. In addition, principles of continuous quality improvement were utilized throughout the process which has contributed to the efficiency and effectiveness of the program.
Statement of the public health issue
Each year, tobacco kills over 480,000 people in the United States and smoking is the leading cause of preventable deaths in the U.S. It kills more people than alcohol, AIDS, car crashes, illegal drugs, murders, and suicides combined. (Source: Tobacco Free Kids, The Toll of Tobacco in the United States 2015 https: //www.tobaccofreekids.org/problem/toll-us)
While smoking rates have declined in the United States, e-cigarette use has significantly increased since 2014, threatening to undo public health efforts. FDA Commissioner Scott Gottlieb has called youth use of e-cigarettes an epidemic and indicated that youth e-cigarette use has increased by 78% from last year. (Source: FDA Press Announcement November 2018)
What target population is affected by problem?
Using 2016 demographic data, there are approximately 236,906 youth in the City of Columbus between the ages of 0-20 of these, 117,135 youth are between the ages of 10-20. The City of Columbus Tobacco 21 program targets youth under the age of 21 by restricting sales of tobacco products, vape products, and paraphernalia to only those who are 21 and over. Therefore, approximately 28% of the general population is directly impacted by the Tobacco 21 program in the City of Columbus. In addition, there are currently 812 retailers that are licensed and regulated through the Tobacco 21 program.
Why is the current/proposed practice better? Is it new to the field of public health?
The Environmental Health Division of Columbus Public Health is a leader in both the national environmental health community and the State of Ohio. The Columbus City Council wanted to explore adopting a comprehensive Tobacco 21 program with a strong enforcement component to improve the health of residents by reducing tobacco use among youth in the community. There are several other municipalities with a Tobacco 21 ordinance in the state, however, the City of Columbus Tobacco 21 program is the only program with an extensive enforcement mechanism and the program is believed to be the largest and most comprehensive program in the country. Tobacco 21 laws across the country have shown to be an important step in protecting the health and safety of youth.
Columbus Public Health contracted with The Ohio State University College of Public Health and is anxiously awaiting results from researchers who are currently utilizing several sets of data to evaluate the effectiveness and impact of the Tobacco 21 program in the City of Columbus. Utilizing data from the Buckeye Teen Health Study, analyses are being conducted to examine smoking-related behaviors among 14-19 year old males prior to and after implementation of the Tobacco 21 program. The Ohio State University College of Public Health will review rates of compliance with different types of facilities located throughout the City and evaluate awareness and understanding of the Tobacco 21 law by facility clerks. Clerks at regulated retail locations will be interviewed onsite by researchers to assess knowledge about the Tobacco 21 law as well as perceived barriers to compliance.
Traditionally, the department has addressed tobacco use in the community through education and cessation programs. The Tobacco 21 program in the City of Columbus was the first program in the city to address tobacco use through a pro-active means by regulating sales to underage youth. Rather than being a reactive initiative with existing smokers, Tobacco 21 is a program that prevents youth from becoming new smokers in the community.
While Tobacco 21 is not a new public health initiative in the country, it is relatively new in the state of Ohio.
The City of Columbus Tobacco 21 program is unique because it is housed within the Environmental Health division of the department. While it is not a conventional Environmental Health program, the program excels within the division because it utilizes the same regulatory measures and principles used with traditional environmental health programs. Enforcement measures for the Columbus Tobacco 21 program include: an annual licensing component, yearly sanitarian inspections for proper sign placement, ongoing underage buy attempts to identify facilities with underage sales, civil penalty fines imposed by the department, criminal penalties by law enforcement, and potential loss and/or denial of a Tobacco 21 license for repeat offenses for up to five years preventing all sales. In implementing these measures, the Columbus Tobacco 21 program has been able to monitor and achieve continual increased compliance with its retailers. By combining strong enforcement procedures with the principles of Tobacco 21, the City of Columbus Tobacco 21 program is able to be highly effective in preventing underage sales of tobacco products, vape products, and paraphernalia to youth throughout the city.
Tobacco 21, raising the age from 18 to 21 for tobacco, vape, and paraphernalia sales, is an evidence based practice. Tobacco 21 is a national movement which is rapidly spreading across the country as a new way to address tobacco use. According to the Preventing Tobacco Addiction Foundation, over 360 cities and counties in 22 states have implemented Tobacco 21 policies. For example, Preventing Tobacco Addiction Foundation states, In the year after implementation, Chicago found a 36% decrease in 18-20 year olds that reported currently smoking cigarettes.” According to the Tobacco21.org website, approximately 90,019,195 people are covered by Tobacco 21 laws across the country.
Goals and objectives of practice:
The goals and objectives of the City of Columbus Tobacco 21 program are to prevent sales to youth under the age of 21 by utilizing a multi-faceted enforcement mechanism which includes an annual licensing requirement to regulate retailers and a mandatory sign component that educates consumers about the law. Therefore, the overall objective is to enforce retail point of sale restrictions and levy penalties to discourage the sale of regulated products to those under 21 years of age.
What did you do to achieve the goals and objectives? Steps taken to implement the program:
At Columbus Public Health, we sought expansion of our educational outreach by using direct methods to reach impacted operators. Specifically, during the first six months, we did not actively enforce any of the new law requirements. Instead, outreach workers and sanitarians visited over 900 prospective facilities to provide on-site education to operators about the requirements. In addition, staff provided and assisted operators with placement of the required signage. After the education phase, buy attempts began at facilities and operators who sold to our underage buyers received a warning letter regarding penalties for underage sales and an opportunity for additional education sponsored by the department about the new law. Subsequent underage sales at facilities resulted in increasing fines being levied against facilities. The progressive enforcement resulted in increased compliance with the additional buy attempts indicating that operators were performing ID checks and no longer selling regulated products to individuals under age. Additionally, sign inspections were completed by sanitarians to verify that signs were properly placed within facilities.
Any criteria for who was selected to receive the practice?
The overall program objective was to enforce retail point of sale restrictions and levy penalties against licensed facilities to prevent the sale of regulated products to those under 21 years of age. The focus was on retailers of regulated products including brick and mortar facilities, temporary events, and locations with incidental sales of regulated products such as bars that sold cigarettes and cigars to consumers from behind the counter. Extensive education was completed with hookah lounges in The Ohio State University campus area and in areas of the city with large student and/or ethnic populations. In addition, the law prevented vending machines from being used to dispense regulated product without carding or oversight. Over 30 vending machines were identified throughout the city and staff worked with operators to eliminate the vending machines at all venues. These measures further restricted access to regulated products throughout the city.
What was the timeframe for the practice?
The ordinance giving authority for the program was effective March 2017 and the program start-up began immediately. The program implemented the following schedule:
Introductory Letters (April 2017):
Developed comprehensive Tobacco 21 database which includes tobacco retailers, vape shops, paraphernalia retailers, and hookah facilities
Letter sent to all licensees & food facility corporate owners
Enclosures: FAQ document & two adhesive signs
Sanitarian Outreach – Food Licensed Facilities (May 2017 – September 2017):
Conducted Just-In-Time training for staff about T21 educational outreach visits
Outreach visits conducted during routine inspections of all food facilities eligible for T21 licensing
Sanitarians distributed FAQ document, compliance letter, and helped operators with placement of signs
Over 9000 signs were distributed to facilities throughout the city
Outreach for Facilities – Non-Licensed Facilities (July 2017 – August 2017):
Conducted interviews and hired two part-time outreach workers
Outreach visits completed by outreach workers and program manager
Staff distributed FAQ document, compliance letter, and helped operators with placement of signs
Over 9000 signs were distributed to facilities throughout the city
Discussed application process and licensing with new licensees
T21 education and materials provided to the public at the Columbus Public Health Farmers' Markets
Resident Outreach/Education (August 2017 – December 2017):
Goal: to introduce the new T21 law to the community, especially those directly impacted (18-20 years old); the public needed to be informed to comply with the law
Audience: general public, ages 15-25, and secondary audience, ages 18-20, in City of Columbus
Tactics and Timeline:
Google Mobile ads & Facebook advertising
Bench ads & COTA ads
Google Search & Display ads
Early ID Checks (August 2017 – September 2017):
Conducted early ID checks to verify compliance with the new law
Piloted anonymity skills for underage buy attempts in the field
Initial Licensing (August 2017 – September 2017):
Created comprehensive Retail Tobacco and Paraphernalia Sales License application
Applications sent in August and September for licensing
Facilities submitted applications with supporting documents and a $150 license fee
Cigarette Dealer's Licenses and Vendor's Licenses ensured accurate ownership records for future enforcement actions
Challenges included expired Cigarette Dealer's Licenses, inaccurate Vendor's Licenses, incomplete applications, and late submittals
Licenses issued early and valid until September 30, 2018
Licensing for facilities with change of ownership and new facilities was ongoing throughout the year
Enforcement (October 2017 – Current):
Completed initial underage buy attempts for licensees
Each initial underage buy attempt was completed by a pair of outreach workers (the underage buyer” is not permitted to possess the purchased products after the sale)
Advisory letters were sent to licensees and corporate entity statutory agents for each initial failed buy attempt
Monthly educational sessions are offered at Columbus Public Health to provide further assistance with compliance
Second round buy attempts with outreach workers and a sanitarian have begun for facilities who failed the first buy attempt
$500 civil penalty letters and invoices have been sent to facilities who fail the second buy attempt
$500 fines have been collected for failed second buy attempts
Third round buy attempts with outreach workers and a sanitarian have begun for facilities who failed the second buy attempt
$1000 fines have been collected for failed third round buy attempts
Multiple appeal hearings regarding assessed fines have been held at the department and the department has won each appeal hearing
· Facilities that fail a 3rd round buy attempt will receive notice that their license status is under review
· After a failed 3rd round buy attempt, Columbus Public Health will notify Columbus Police Department of illegal sales witnessed by a sanitarian
Narratives are maintained for each buy attempt for potential enforcement proceedings
Sanitarian inspections for proper placement of signs is ongoing for each licensed facility
Partnerships have been created with outside agencies to assist with enforcement/licensing issues
Temporary Event Licenses (May 2018 – Current):
· Created a Temporary Retail Tobacco and Paraphernalia Sales License application
· Application, FAQ, and introductory letter sent to event coordinators for early licensing of temporary event vendors
· Temporary applications are submitted with supporting documents and a $50 license fee
· Cigarette Dealer's Licenses and Vendor's Licenses ensure accurate ownership records for future enforcement action(s)
· Licensed multiple temporary event vendors throughout the 2018 licensing year and all vendors were 100% compliant
· Licensing for temporary event vendors continues to be ongoing for future events
Were other stakeholders involved? What was their role in the planning and implementation process? What does the LHD do to foster collaboration with community stakeholders? Describe the relationship and how it furthers the practice goals:
Columbus Public Health worked with stakeholders from multiple disciplines including The Ohio State University College of Public Health, the Preventing Tobacco Addiction Foundation, and the American Heart Association to craft the new Tobacco 21 city ordinances prior to passage by City Council. In addition, stakeholders associated with our licensed operators were invited to a meeting hosted by the department to discuss specifics of the new health code and concerns regarding implementation of Tobacco 21 in the City of Columbus. Stakeholders in attendance at the meeting included the Ohio Grocers Association, the American Heart Association, and the Ohio Vapor Trade Association. Input and concerns from the stakeholders were considered and reviewed during the passage of the City Codes and the new Health Code.
Any start-up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise provide an estimate of start-up costs/ budget breakdown:
Columbus Public Health did not receive any initial money other than City of Columbus funds to implement the Tobacco 21 program. The initial startup was covered as a > $150k allocation for two staff positions. All other expenses i.e. sign printing, mailing, office materials were allocated at > $10k.
Goals and objectives of the Tobacco 21 program are to prevent sales to youth under the age of 21 by utilizing a multi-faceted enforcement mechanism including: an annual licensing requirement to regulate retailers, ongoing underage buy attempts at facilities using college students as secret shoppers”, and a mandatory sign component that educates consumers about the law.
The City of Columbus Tobacco 21 program has implemented and achieved the program's objectives. Retailers have been successfully licensed and procedures have been developed to address licensee ownership changes and identify new facilities. During the 1st licensing year, each facility received an underage buy attempt with 66% of the facilities being compliant with the new law. Facilities which failed initial underage buy attempts are receiving ongoing additional buy attempts that result in the imposition of civil fines. Compliance continues to increase with the facilities who failed initial buy attempts. Regarding 2nd round buy attempts for failed facilities, 102 of 185 facilities who initially sold underage are now in compliance and have successfully passed additional underage buy attempts. With the additional buy attempts, compliance with preventing underage sales among all licensees has increased from 66% to 78%. While several retailers have challenged civil fines, the department has successfully won each appeal hearing. Sign inspections were completed by staff and facilities were in compliance or brought in to compliance at the time of inspection with the program's requirements.
Evaluation of practices is ongoing and the principles of CQI are continually used to increase efficiency and effectiveness within the program. Standard operating procedures are being drafted, however; developing innovative strategies to increase compliance among retailers continues to be a priority. All data is directly collected by staff in the program. Information is entered into department software and spreadsheets to assess trends among the data. Performance measures include ensuring that each licensee receives at least one buy attempt and one sign inspection during the licensing year. Success in the program is defined by minimizing underage sales within the facilities and at temporary events. In addition, staff ensure that signs are properly placed at points of sale and on all display cases.
The City of Columbus Tobacco 21 program has been presented nationwide during the past year at both the annual National Environmental Health Association conference and at a multi-state conference with Kentucky and Indiana this past fall. It has been used as a model Tobacco 21 program by multiple jurisdictions throughout the state of Ohio. In addition, it was reviewed by Hartford, CT as they implemented their Tobacco 21 program and it was recognized as a model Tobacco 21 program for adoption of Tobacco 21 in Pima County, AZ and the City of Tucson.
Please enter the sustainability of your practice
The program utilizes a licensing model imposing annual license fees for each retail location. The annual license fee is set at an amount to sustain routine program activities. Monetary fines support enforcement activity with fine amounts set at an amount expected to supplement the costs associated with the program. The resultant fines help cover the expense of recalcitrant retailers, to pay for enforcement appeal hearings, and other enforcement activity associated with non-compliance.
Lessons learned in relation to practice
As with any new program, initial start-up required commitment of resources for program design including staff time to create guidance, templates for correspondence, a data base of facilities, and to establish a program implementation timeline. Without an existing example to reference for anticipated program costs, the fees were based primarily on estimated staffing needs, which was determined to be one full time program manager and one full time sanitarian position, and allocated hours for part-time undercover buyers. Costs were divisible by the number of licensable facilities; Columbus has approximately 812 retailers. It was found that staffing needs were greater during the initial phases of establishing the program, during the annual licensing month, and then, later during the phase when buy attempts were being conducted at all facilities. It was found that with activities occurring in the field it was difficult to maintain other activities such as appeal hearings and licensing in the office, and supplemental staff were utilized from other programs within the division. It was found that a trained clerical staff person is essential as the licensing of facilities is year-round due to new facilities needing a first license, and ownership changes requiring issuance of a new license.
Did you do a cost benefit analysis? If so, describe.
Columbus Public Health has not conducted a cost benefit analysis for the program operations. The expectations were that the estimates for implementation would cover the entire cost of the program. We found that during start-up, costs were higher due to the need for additional staff time. A full cost analysis is planned for all components of the program. Another issue with setting the license fee is that there are limits to what the market will bear since retailers, some who currently pay for an additional annual county license for cigarette sales, then need to pay for the additional annual Columbus Tobacco 21 license. This means that review of costs is essential for sustainability and will require that program costs be contained since the license fee, at least initially, may not cover program expenses. Looking at the community health benefits, it is expected that the value in the program encompasses further restricting access to nicotine products and prevention of resultant life-long addictions and associated health care costs. This analysis would be at least five years into the implementation and would focus on any reductions in adult smokers in Columbus.
Is there sufficient stakeholder commitment to sustain the practice? Describe sustainability plans:
Columbus has provided a national model for restricting the sale of tobacco, vape, and paraphernalia to those under the age of 21. This is due to the program's active enforcement mechanisms and commitment to compliance that is not provided by many other municipalities and even statewide programs throughout the country. The City of Columbus Tobacco 21 program has already partnered and expanded its program to another local jurisdiction (City of Worthington). The program holds monthly open training sessions about the new law for local retailers in addition to continuing on-site training for facilities. The ongoing education initiative provides new retailers with an on-site consult at the retail operation to assist retailers one-on-one with placement of tobacco sales restriction signs and education about the law's requirements. We continue to maintain active communication with our stakeholders and community partners regarding their roles with this important community health initiative.