Impact of tobacco retail licensing on youth smoking in Virginia: A system dynamics simulation approach

Importance: Virginia raised the minimum legal age of sale for tobacco from 18 to 21 (T21), effective July 1, 2019. Evaluating the potential policy effects of this new policy is crucial.Objectives: To simulate and predict the effects of different levels of TRL enforcement on youth cigarette use and the consequent health and economic impacts. Design: A system dynamics model (SDM) was developed. The model was parameterized, calibrated and validated based on empirical data: National Youth Risk Behavior Surveillance System (YRBSS), Behavioral Risk-Factor Surveillance System (BRFSS) of Virginia, and Youth Risk Behavior Survey (YRBS) Combined Datasets of Virginia. Setting: We considered four provisions: 1) All retailers are required to obtain a license to sell tobacco; 2) Retailers are required to pay an annual renewal fee; 3) Any violation of a local, state or federal tobacco law is considered a violation of the license; and 4) fines and penalties for violations, and suspension and revocation of the license. These provisions were used to define four enforcement levels: No licensing; Minimum TRL enforcement (provision 1 + one of the other three provisions); Moderate TRL enforcement (provision 1 + two of the other three provisions); Comprehensive TRL enforcement (all provisions). Our SDM simulated youth smoking status with 4 enforcement levels.Participants: Youth aged 13 to under 21 residing in Virginia.Main outcomes: Smoking prevalence. Results: The results suggested that youth smoking prevalence in Virginia would decrease by 1.09% by the end of 2031 under comprehensive TRL enforcement compared with no enforcement. Additionally, non-Hispanic White and Hispanic youth were more responsive than non-Hispanic AAs to the enforcement—the greatest yearly reduction in smoking prevalence was estimated to be 1.81% and 1.45%, respectively, under comprehensive TRL regulation. We estimate these prevalence reductions would save $124.96 million in direct life-long medical costs and 424 smoking-attributable deaths over the next 10 years.Conclusions and Relevance: TRL regulations could be an effective policy option to ensure and enhance the effects of the T21 law. Future studies should include more mechanisms and tobacco control methods in tobacco product use simulations.