Abstract
INTRODUCTION: All 50 states have e-cigarette minimum legal sales age (MLSA) policies. In 2019, national tobacco control organizations released a model MLSA policy providing guidance on how tobacco policies should be structured to effectively prevent underage sales. We explored state e-cigarette MLSA implementation in relation to the model policy. METHODS: Key informant (KI) interviews were conducted with state personnel involved in MLSA implementation from a purposive sample of states. Informants were asked about policy components, implementation facilitators, challenges, and processes, based on Bullock's determinants of policy implementation framework. Interviews were coded by framework domains and analyzed for themes related to implementing model policy components. Key components included product definitions, age restrictions, licensure, funding, education, preemption, ID verification, signage, enforcement agency and protocols, compliance checks, penalties, and prosecution. RESULTS: Between April 2023 and July 2024, 24 MLSA interviews were conducted with 32 KIs from 23 states, yielding 4589 coded passages. KIs reported engaging with model policy components during the implementation process, though states varied in their alignment with the model's recommendations, with areas of more common deviation including penalty structures, whether clerks or retailers were penalized, and required compliance checks. Several implementation factors absent from the model also emerged as important, including online sales, license transfer, "decoy buy" products, complaint-driven compliance checks, and product disposal. CONCLUSION: States' e-cigarette MLSA policy implementation experiences in relation to model policy recommendations identified areas where states could improve (eg, penalties) and novel issues (eg, online sales) whose implementation is worthy of ongoing attention. IMPLICATIONS: Insights from the state MLSA implementation experiences should inform advocates, bureaucrats, and elected officials about potential solutions to implementation barriers for e-cigarette MLSA. Findings highlight implementation facilitators and identify existing model policy components that may be improved in future guidance. Key elements for revising state policies and/or the model include shifting penalties from clerks to retailers, setting a minimum number of compliance checks, coordinating compliance programs, reconsidering criminal penalty structures, regulating online sales, preventing illegitimate license transfers, establishing complaint-driven enforcement, and requiring the inclusion of e-cigarette products in a minimum percentage of decoy buys.