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Clinical AND Health Affairs information about the expected effects at a state level. The purpose of this study was to con- sider the effects on smoking initiation in Minnesota if the legal minimum sale age for tobacco products were 21. The specific goal was to calculate how many young people ages 15 to 20 years would not start smoking if the assumptions from the IOM report were applied to Minnesota. Methods and Assumptions Age groups: The 2015 IOM report exam- ined effects among specific age groups: under 15 years, 15- to 17-year-olds and 18- to 20 -year-olds. In this analysis, we limited the consideration to ages 15 and older. Initiation rate: Cohort studies that fol- low participants over time provide the best estimates of smoking initiation. The Min- nesota Adolescent Community Cohort (MACC) study was a population -based study of Minnesota youth ages 12 to 16 in 2000 who were followed until 2008. In 2003, approximately 19% of the cohort reported smoking in the previous month.' Smoking among Minnesota high school students has fallen to about 10% since 2003. Therefore, in this analysis we used 10% as the estimate of smoking initiation among youth 15 to 17 years of age. In a later analysis of the MACC data, 16% of the cohort who did not start smoking in high school took up smoking (smoked in the past month) between the ages of 18 and 21.' This estimate of smok- ing uptake is consistent with the preva- lence of smoking among young adults in the Minnesota Adult Tobacco Survey. For this analysis we used 16% as the estimate of 18- to 20 -year-olds who would initiate smoking. Estimated effects of Tobacco 21 policy: An increase in the minimum sale age is expected to apply to all commercial to- bacco products; however, for the purpose of estimating effects similar to those in the IOM report, the scope of this study was restricted to cigarette smoking. In addi- 36 1 MINNESOTA MEDICINE I JANUARY/FEBRUARY 2017 FIGURE Estimated Reduction in Youth Smokers with Implementation of Tobacco 21 Policy WITHOUT TOBACCO 21 POLICY 17,568 O WITH TOBACCO 21 POLICY 14,213 LJ_J10,368 co 7,200 8,813 � 5,400 z Ages 15 to 17 years Ages 18 to 20 years Combined Total POLICYAGE GROUPS AFFECTED BY TOBACCO 21 NUMBER NOT NUMBER WHO PROPORTION SMOKING IF COHORTAGE HAVE NOT WHO START NUMBER POLICYWERE (YEARS) SMOKED SMOKING SMOKING IN EFFECT 15 72,000 16 to 17 64,800 10% 7,200 1,800 18 to 20 54,432 16% 10,368 1,555 Note: The cohort size is 1 /5 of the census estimate of TOTAL: 3,355 Minnesota 15- to 19 -year-olds in 2015. tion, the expected reduction in smoking initiation is thought to vary by age. The ef- fect is expected to be larger among youth 15 to 17 years of age, with an expected re- duction in the uptake of smoking of 25%. Among those 18 to 20 years of age, the expected reduction is 15%.' Variation by demographic variables: Smoking rates vary substantially by popu- lation groups in Minnesota. For example, in 2014 the overall adult smoking rate was about 14%,' but within the urban Ameri- can Indian population the smoking rate was 59%.A There is a lack of literature on how smoking initiation would be affected in population groups with higher smoking rates if the sale age were increased. Thus, the estimate here is not adjusted by gender or other demographic variables (eg, race/ ethnicity, income). Enforcement. States are required to enact and enforce laws prohibiting the sale or distribution of tobacco products to in- dividuals younger than 18 years of age. A major assumption of Tobacco 21 policy is that the same level of current enforcement and retailer compliance would remain in effect. Although Minnesota has a high rate of retailer compliance with current law,'retailer cooperation has been lower in other places. For example, in New York City, compliance has fallen over time after Tobacco 21 policy was implemented." Calculation: In this analysis, we began with a cohort of Minnesota 15 -year-olds in 2015—approximately 72,000. We esti- mated the smoking initiation rate in two periods: during high school (ages 15 to 17 years) and after high school (ages 18 to 20 years). Next, the reduction in smoking was calculated for each period if the sale age for tobacco were raised to 21 in 2015. We assumed that the smoking uptake in high school and after high school would not change in future years. The difference is reported as the number of young people 15 to 20 years of age who would not have started smoking. Results In 2015, the Minnesota population of those 15 -year-olds was approximately 72,000. Of these, an estimated 7,200 will start smoking during their high school years. If the minimum legal sale age in 2015 were 21, an estimated 1,800 would not start smoking in high school.