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Chronic Disease Notes and Reports

CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 14 • Number 3 • Fall 2001

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Special Focus: Reducing Tobacco Use

The National Tobacco Control Program

CDC data show that if current trends continue, 5 million children alive today will die prematurely during adulthood of tobacco-related illnesses. According to Terry Pechacek, PhD, Associate Director for Science in CDC's Office on Smoking and Health (OSH), "Research has shown that in states with higher levels of investment in tobacco control programs, there is a greater impact on reducing tobacco use—and results are seen more quickly—than in states with lower funding levels." In fiscal year 2001, however, only seven states met or exceeded CDC's minimum recommendations for funding such programs.

"The question is, how many of the 5 million children are we going to save?" asked Dr. Pechacek. CDC's goal, he said, is to build a national tobacco control infrastructure. To do this, CDC will use the National Tobacco Control Program (NTCP), launched in May 1999, to bring various earlier federal initiative activities into one national program. In fiscal year 2000, the NTCP distributed $59 million for comprehensive tobacco control efforts in all 50 states, the District of Columbia, and seven U.S. territories. However, CDC and state investments are unlikely to eliminate the burden of tobacco use in the United States. Strategies must include social, economic, and regulatory measures, and funding from other federal sources.

Significant changes have occurred in states that have committed adequate resources to tobacco control, showing that it is possible to meet national goals for reducing tobacco use.

CDC data show that the burden of tobacco use in the states and territories varies widely; for example, state-specific smoking prevalence among adults varied more than twofold in 1999, ranging from a low of 13.9% in Utah to a high of 31.5% in Nevada. Current smoking prevalence among high school students ranged from 11.9% in Utah to 43.6% in South Dakota, more than a threefold difference. These differences mean that each state must develop a unique and targeted response to the problem of tobacco use within the broad framework of proven strategies.

Statewide programs have emerged as the new laboratory for developing and evaluating comprehensive plans to reduce tobacco use. Information from states that have already implemented comprehensive tobacco control programs shows that such programs are effective in preventing and reducing tobacco use. Findings from these states (California and Massachusetts, in particular) led to the development of CDC's Best Practices for Comprehensive Tobacco Control Programs, which describes nine essential elements that should be included in a comprehensive program:

Community programs to reduce tobacco use.

Chronic disease programs to reduce the burden of tobacco-related illness.

School programs.

Enforcement of tobacco control policies.

Statewide programs.

Countermarketing.

Cessation programs.

Surveillance and evaluation.

Administration and management.

The Best Practices document also includes recommendations for the appropriate level of funding for each component based on specific characteristics of each state. According to the U.S. Surgeon General, David Satcher, MD, PhD, "There are known strategies for reducing the burden of smoking-related diseases, but making the investment in these proven strategies remains a challenge."

State Efforts to Control Tobacco Use
Significant changes have occurred in states that have committed adequate resources to tobacco control, showing that it is possible to meet national goals for reducing tobacco use. Some states have passed legislation to raise cigarette taxes and fund comprehensive tobacco control efforts with the proceeds. In other cases, large monetary settlement payments from state Medicaid lawsuits against the tobacco industry are being used to fund major new statewide tobacco control programs.

In 1988, California was the first state to pass a citizen initiative to raise tobacco taxes and dedicate a portion of the revenue to tobacco prevention and education programs. (Massachusetts did the same in 1992, Arizona in 1994, and Oregon in 1996.) California is now starting to see the benefits of its sustained efforts. Between 1988 and 1997, the incidence rate of lung cancer among women declined by 4.8% in California while it increased by 13.2% in other U.S. regions. Another recent study concluded that the California program was associated with 33,300 fewer deaths from heart disease between 1989 and 1997 among women and men combined than would have been predicted if trends like those observed in the rest of the country had continued.

In Massachusetts, combining a cigarette tax hike with a statewide media campaign markedly reduced cigarette consumption in the state. Between 1992 and 1996, per capita cigarette consumption fell by 20% in Massachusetts, more than three times the rate of decline (6%) in the 48 states not having such a program.

Arizona's comprehensive program, started in 1996, placed an especially heavy emphasis on community-based efforts. As a result, adult smoking prevalence in Arizona declined by 21% between 1996 and 1999, and significant reductions were observed in both males and females, in young adults, and in the state's Hispanic populations.

Oregon increased cigarette excise taxes by 30 cents per pack and funded a comprehensive tobacco prevention and education program that reduced overall cigarette consumption by 11.3% between 1996 and 1998. Among adults, smoking prevalence declined 6.4% during this same time frame, representing 35,000 fewer smokers in the state. Despite a population increase of 2.7%, 25 million fewer cigarette packs were sold in Oregon in 1998 than were sold in 1996.

A study released in 1999 by CDC and Florida's Department of Health described how state efforts to reduce teen smoking resulted in a significant decline in smoking rates among middle and high school students in Florida between 1998 and 1999. Past-month smoking rates declined among middle schoolers from 18.5% to 15.0%, while rates among high school students dropped from 27.4% to 25.2%. This represents the largest annual reported decline in teen smoking rates in the United States since 1980. Current smokeless tobacco use also dropped significantly among middle school students, from 6.9% in 1998 to 4.9% in 1999.

CDC has been a long-time leader in the national effort to reduce tobacco use. Along with its many partners from a broad spectrum of professional and voluntary organizations, academic institutions, and local, state, and other federal agencies, CDC's National Tobacco Control Program provides scientific expertise and funding to support a comprehensive, broad-based approach with four main goals:

Preventing young people from starting to smoke.
Eliminating exposure to environmental tobacco smoke.
Promoting quitting.
Identifying and eliminating disparities in tobacco use among different population groups.

These four goals focus on groups at high risk of using tobacco—such as young people, racial and ethnic minority groups, blue-collar workers, people with low incomes, and women. Prevention activities are carried out through the following program components:

Community interventions are designed to influence societal organizations, systems, and networks and enable them to help people make behavior changes consistent with tobacco-free norms.
Countermarketing programs attempt to reduce pro-tobacco influences and promote pro-health messages through the use of media advocacy, media relations, counteradvertising, and efforts to reduce tobacco industry sponsorships and promotions and expose industry tactics.
Policy and regulation efforts include analyzing current policy and educating decision makers and the public about the importance and benefit of public health policies. Such policies may address clean indoor air, excise taxes, product regulation, insurance coverage for treatment and cessation assistance, and ingredient disclosure.
Surveillance and evaluation activities continuously monitor tobacco-use measures over time to guide program and policy direction and interventions. They also include point-in-time assessments to measure the effectiveness of programmatic, policy, and media efforts.

Other Tobacco Control Activities Are Still Needed
"We are encouraged by the fact that states are investing more for tobacco control than at any time in our history," CDC Director Jeffrey Koplan, MD, MPH, said. In fiscal year 2001, 45 states made a total investment in tobacco-use prevention and control programs of more than $883 million, or about $3.38 per person. "However," Dr. Koplan pointed out, "these investments are far exceeded by the $8.24 billion that tobacco companies spend each year to advertise and promote their products. They are outspending us by nearly 10 to 1."

Cover of publication: Investment in tobacco control, State highlights 2001

State investments in tobacco control are far exceeded by the $8.24 billion that tobacco companies spend each year to advertise and promote their products.

State investments alone are not enough to reduce the burden of tobacco use in the United States. "Healthy People 2010, the national action plan for improving the health of all Americans, sets forth 21 ambitious tobacco-related objectives, including cutting in half the rates of tobacco use among young people and adults," wrote Lawrence W. Green, DrPH, former Acting Director, OSH, in a foreword to a CDC report entitled Investment in Tobacco Control: State Highlights 2001. "Achieving these objectives will require a significant national commitment to implement a variety of strategies, including social, economic, and regulatory approaches— some of which can only be implemented by the federal government or by the private sector."

Dr. Green cited CDC's efforts as an example of the essential role of federal support, and he praised the American Legacy Foundation's national media campaign, upon which states can build and tailor messages specific to their populations, as an example of excellent private sector involvement. Other private partners in the national effort to reduce tobacco use are the American Cancer Society, the American Lung Association, the American Medical Association, the National Center for Tobacco-Free Kids, and the Robert Wood Johnson Foundation.

Tools to Inform State Programs
CDC's State Tobacco Activities Tracking and Evaluation (STATE) System is an Internet tool for public use that provides information to planners and policymakers and supports their efforts to develop and improve comprehensive tobacco control programs in their states. It is the first-ever electronic data warehouse of state-based tobacco information and was designed by OSH to provide consistent interpretation of the data and facilitate research. It combines many different data sources and gives users access to informative and comprehensive summaries of tobacco use in all 50 states and the District of Columbia. At the STATE Web site (http://www2.cdc.gov/nccdphp/osh/state), users can find up-to-date information and historical data on the prevalence of tobacco use, tobacco control laws, the health impact and costs associated with tobacco use, and tobacco agriculture and manufacturing.

The Youth Tobacco Survey (YTS), conducted by CDC in collaboration with most states, provides information about tobacco use among the nation's middle and high school students. First implemented in 1998 in Florida, Mississippi, and Texas, the YTS has grown to include data from 43 states and the District of Columbia. It has become a critical component of state surveillance and evaluation systems, and findings from the surveys are used to help guide the design, implementation, and evaluation of the youth components of comprehensive state tobacco control and prevention programs.

CDC's OSH also provided technical advice to the CDC Foundation as it conducted the first National Youth Tobacco Survey in 1999. This survey, funded by The American Legacy Foundation, provided the first- ever national data on tobacco use among middle school students. It was repeated during the spring of 2000.

The Need to Act Now

Tobacco use, particularly cigarette smoking, remains the number one cause of preventable disease and death in the United States.

Tobacco use, particularly cigarette smoking, remains the number one cause of preventable disease and death in the United States. Clearly, as shown in the few states that have done so, implementing adequately funded comprehensive statewide tobacco control programs can make a difference. Although our knowledge about tobacco control remains imperfect, according to Dr. Satcher's 2000 report on reducing tobacco use, we know more than enough to act now.

"It is clear that the major barrier to more rapid reductions in tobacco use is the effort of the tobacco industry to promote the use of tobacco products," Dr. Satcher said. "Our lack of greater progress in tobacco control is more the result of failure to implement proven strategies than it is the lack of knowledge about what to do." For more information about pro-grams that work, visit CDC's Web site at http://www.cdc.gov/tobacco or call 1/770/488-5705.

Five Key Documents on Tobacco Control

The CDC Community Guide staff is convening five state workshops to bring together public health decision makers, practitioners, and tobacco control advocates to help them better understand the importance of these key documents and how they complement each other and to assist in program and policy development. For more information, contact Bradford Myers at 1/770/488-8230.

Reducing Tobacco Use: A Report of the Surgeon General.
This report on smoking and health is the first to offer a composite review of the various methods used to reduce and prevent tobacco use. The topic is a new one in this series of reports, although previous reports have looked at aspects of such strategies. This report evaluates each of five major approaches to reducing tobacco use: educational, clinical, regulatory, economic, and comprehensive. Further, the report attempts to place the approaches in the larger context of tobacco control, providing a vision for the future of tobacco-use prevention and control based on these available tools. The report is clear in its overriding conclusion: Although our knowledge about tobacco control remains imperfect, we know more than enough to act now. Available on the Internet at www.cdc.gov/tobacco/sgr_tobacco_use.htm

The Guide to Community Preventive Services: Tobacco Use Prevention and Control.
This special supplement of the American Journal of Preventive Medicine was produced by the Task Force on Community Preventive Services with support from CDC's Office on Smoking and Health, the National Cancer Institute's Division of Cancer Control and Population Sciences, and the Division of Prevention Research and Analytic Methods in CDC's Epidemiology Program Office. This publication offers evidence-based recommendations on the most effective and cost-effective strategies within comprehensive tobacco control programs. The evidence on which the recommendations are based is clearly laid out, as are the methods used to establish that evidence base, allowing users to determine for themselves how best to apply the recommendations locally. In addition, another report summarizes guidelines on various aspects of tobacco-use prevention and control from different sources within the federal government and clearly lays out how they complement each other and can be used together to create a rational and comprehensive evidence-based tobacco policy. Available at www.thecommunityguide.org/home_f.html*

Treating Tobacco Use and Dependence: A Clinical Practice Guideline.
Studies have shown that 70% of current smokers would like to quit, and that among smokers who try to quit, those who have the support of their physician or other health care provider are the most successful. This Public Health Service report, aimed at practicing clinicians, contains evidence-based information about first- and second-line pharmacologic therapies and highlights new evidence about how telephone counseling can help patients quit. The guideline was developed by a consortium that included CDC, the Agency for Health Care Research and Quality, the Robert Wood Johnson Foundation, the University of Wisconsin Medical School's Center for Tobacco Research and Intervention, the National Cancer Institute, the National Institute on Drug Abuse, and the National Heart, Lung, and Blood Institute. In addition, more than 100 other organizations supported this effort. This guideline builds on a smoking cessation guideline first issued by the government in 1996 and concludes that tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions. It urges health care insurers and purchasers to include, as a covered benefit, the counseling and pharmacotherapeutic treatments identified in the report as effective and to pay clinicians for providing tobacco dependence treatment, just as they pay for treatment of other chronic conditions. Available at http://www.cdc.gov/tobacco/quit/guidline.htm

Best Practices for Comprehensive Tobacco Control Programs is an evidence-based guide to help states plan and establish effective programs to prevent and reduce tobacco use. The book identifies and describes the key elements for effective state tobacco control programs, including programs designed for communities, schools, and the entire state. Best Practices also addresses the significance of cessation programs, countermarketing, enforcement, surveillance and evaluation, and chronic disease programs for reducing the burden of tobacco-related diseases. Tobacco control program funding models for all 50 states and the District of Columbia are included. Available at www.cdc.gov/tobacco/bestprac.htm

Investment in Tobacco Control: State Highlights 2001 analyzes current investments in tobacco control, places these investments in the context of tobacco-use prevalence rates and health and economic consequences of tobacco use specific to each state, and compares current investments with the specific funding ranges contained in Best Practices. The report is the third State Highlights report released by CDC and for the first time provides a compilation of state investments in tobacco control and the funding source. Available at www.cdc.gov/tobacco/statehi/statehi_2001.htm

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* Links to non-Federal organizations are provided solely as a service to our users. Links do not constitute an endorsement of any organization by CDC or the Federal Government, and none should be inferred. The CDC is not responsible for the content of the individual organization Web pages found at this link.

Chronic Disease Notes & Reports is published by the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. The contents are in the public domain.
Director, Centers for Disease Control and Prevention Jeffrey P. Koplan, MD, MPH
Director, National Center for Chronic Disease Prevention and Health Promotion James S. Marks, MD, MPH
Managing Editor Teresa Ramsey
Staff Writers Linda Elsner, Helen McClintock, Valerie Johnson, Teresa Ramsey, Phyllis Moir, Diana Toomer
Contributing Writer Linda Orgain	Layout & Design Herman Surles	Copy Editor Diana Toomer
Address correspondence to Managing Editor, Chronic Disease Notes & Reports, Centers for Disease Control and Prevention, Mail Stop K–11, 4770 Buford Highway, NE, Atlanta, GA 30341-3717; 770/488-5050, fax 770/488-5095 E-mail: ccdinfo@cdc.gov NCCDPHP Internet Web site: www.cdc.gov/nccdphp

This page last reviewed August 10, 2004

United States Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion

CENTERS FOR DISEASE CONTROL AND PREVENTION Volume 14 • Number 3 • Fall 2001 Return to index of articles

CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 14 • Number 3 • Fall 2001

Return to index of articles