Despite the recent push for Tobacco 21 legislation in the US and the national adoption of Tobacco 21, there is a paucity of data on the process of policy adoption. To explore the key factors that served as facilitators or challenges to the passage of state T21 laws that apply to the sale of all tobacco products to anyone under 21 years of age, we conducted a comparative, cross-case study in ten states that adopted Tobacco 21 between 2016 and 2019. Stakeholders from selected states were identified via snowball sampling, and interviews were conducted from November 2018 to March 2020. Three primary factors emerged as facilitators to the passage of state T21 laws: (1) increased attention on e-cigarettes as the product driving an overall increase in youth tobacco use and depiction of an "e-cigarette epidemic", (2) having at least one influential policy entrepreneur or champion, and (3) traction from other states or local municipalities passing T21 legislation. Challenges to T21's success included (1) influence of the tobacco industry, (2) the bill's low ranking among legislative priorities, and (3) controversy among advocates and policymakers over bill language. As e-cigarette rates spiked, T21 bills became legislative priorities, traction from other successful efforts mounted, and ultimately, the tobacco industry flipped from opposing to supporting T21 laws. Despite these favorable headwinds, advocates struggled increasingly to pass bills with ideal policy language.
Keywords: e-cigarettes; health behavior; policy; tobacco.