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Best Practices for
Comprehensive Tobacco
Control Programs, August 1999
Executive Summary
Tobacco use is the single
most preventable cause of death and disease in our society. Most people begin using
tobacco in early adolescence, typically by age 16; almost all first use occurs before high
school graduation. Annually, tobacco use causes more than 430,000 deaths and costs the
Nation approximately $50–$73 billion in medical expenses alone. Data from California
and Massachusetts have shown that implementing comprehensive tobacco control programs
produces substantial reductions in tobacco use.
The goal of
comprehensive tobacco control programs is to reduce disease, disability, and death related
to tobacco use by
- Preventing the initiation of tobacco use
among young people.
- Promoting quitting among young people and
adults.
- Eliminating nonsmokers’ exposure to
environmental tobacco smoke (ETS).
- Identifying and eliminating the
disparities related to tobacco use and its effects among different population groups.
In this guidance document,
CDC recommends that States establish tobacco control programs that are comprehensive,
sustainable, and accountable. This document draws upon “best practices”
determined by evidence-based analyses of comprehensive State tobacco control programs.
Evidence supporting the programmatic recommendations in this guidance document are of two
types. Recommendations for chronic disease programs to reduce the burden of
tobacco-related diseases, school programs, cessation programs, enforcement, and
counter-marketing program elements are based primarily upon published evidence-based
practices. Other program categories rely mainly upon the evidence of the efficacy of the
large-scale and sustained efforts of two States (California and Massachusetts) that have
been funding comprehensive tobacco prevention and control programs using State tobacco
excise taxes.
Based upon this
evidence, specific funding ranges and programmatic recommendations are provided. The local
analysis of each State’s priorities should shape decisions regarding funding
allocations for each recommended program component. The funding required for implementing
programs will vary depending on state characteristics, such as demographic factors,
tobacco use prevalence, and other factors. Although the type of supporting evidence for
each of the recommended nine program components differs, evidence supports the
implementation of some level of activity in each program area. In general, States
typically have selected a funding level around the middle of the recommended ranges.
Current allocations range from $2.50 to over $10; however, no State is currently
implementing all of the recommended program components fully. Approximate annual costs to
implement all of the recommended program components have been estimated to range from $7
to $20 per capita in smaller States (population under 3 million), $6 to $17 per capita in
medium-sized States (population 3 to 7 million), and $5 to $16 per capita in larger States
(population over 7 million).
The best practices
address nine components of comprehensive tobacco control programs:
I. Community Programs to Reduce
Tobacco Use (Base funding of $850,000–$1.2 million per year for State
personnel and resources; $0.70–$2.00 per capita per year for local governments and
organizations).
Local community programs cover a wide
range of prevention activities including engaging youth in developing and implementing
tobacco control interventions; developing partnerships with local organizations;
conducting educational programs for young people, parents, enforcement officials,
community and business leaders, health care providers, school personnel, and others; and
promoting governmental and voluntary policies to promote clean indoor air, restrict access
to tobacco products, provide coverage for treatment, and achieve other policy objectives.
In California and Massachusetts, local coalitions and programs have been instrumental in
achieving policy and program objectives. Program funding levels range from approximately
$1.00 per capita in California to over $2.50 per capita in Massachusetts.
II. Chronic Disease Programs to
Reduce the Burden of Tobacco-Related Diseases ($2.8 million–$4.1 million per
year).
Even if current tobacco use stopped, the
residual burden of disease among past users would cause disease for decades to come. As
part of a comprehensive tobacco control program, communities can focus attention directly
on tobacco-related diseases both to prevent them and to detect them early. The following
are examples of such disease programs and recommended funding levels:
- Cardiovascular disease prevention
($500,000 for core capacity and $1–$1.5 million for a comprehensive program).
- Asthma prevention (base funding of
$200,000–$300,000 and $600,000–$800,000 to support initiatives at the local
level).
- Oral health programs
($400,000–$700,000).
- Cancer registries ($75,000–$300,000).
III. School Programs
($500,000–$750,000 per year for personnel and resources to support individual school
districts; $4–$6 per student in grades K–12 for annual awards to school
districts).
School program activities include
implementing CDC’s Guidelines for School Health Programs to Prevent Tobacco Use
and Addiction, which call for tobacco-free policies, evidence-based curricula,
teacher training, parental involvement, and cessation services; implementing
evidence-based curricula identified through CDC’s Research to Classroom Project; and
linking school-based efforts with local community coalitions and statewide media and
educational campaigns. Oregon has developed a new funding model for school programs based
upon CDC’s guidelines and experience in California and Massachusetts. At an annual
funding level of approximately $1.60 per student, Oregon was able to provide grants to
approximately 30% of their school districts. Assuming 100% coverage of school districts
using a funding model similar to the Oregon model, $4–$6 per student in grades
K–12 should be budgeted.
IV. Enforcement
($150,000–$300,000 per year for interagency coordination; $0.43–$0.80 per capita
per year for enforcement programs).
Enforcement of tobacco control policies
enhances their efficacy by deterring violators and by sending a message to the public that
community leaders believe that these policies are important. The two primary policy areas
that require enforcement activity are restrictions on minors’ access to tobacco and
on smoking in public places. State efforts should be coordinated with Food and Drug
Administration (FDA) and Substance Abuse and Mental Health Services Administration
(SAMHSA) Federal programs. California and Massachusetts have addressed enforcement issues
as part of community program grants. Florida has taken a more centralized approach by
using State Alcoholic Beverage Control Officers to conduct compliance checks with locally
recruited youth in all regions of the State.
V. Statewide Programs
(Approximately $0.40–$1 per capita per year).
Statewide projects can increase the
capacity of local programs by providing technical assistance on evaluating programs,
promoting media advocacy, implementing smokefree policies, and reducing minors’
access to tobacco. Supporting organizations that have statewide access to racial, ethnic,
and diverse communities can help eliminate the disparities in tobacco use among the
State’s various population groups. Statewide and regional grants to organizations
representing cities, business and professional groups, law enforcement, and youth groups
inform their membership about tobacco control issues and encourage their participation in
local efforts. Both California and Massachusetts have awarded grants to statewide
organizations, businesses, and other partners that total about $0.40 to $1.00 per capita
per year.
VI. Counter-Marketing
($1–$3 per capita per year).
Counter-marketing attempts to counter
pro-tobacco influences and increase pro-health messages and influences throughout a State,
region, or local community. Counter-marketing consists of a wide range of efforts,
including paid television, radio, billboard, and print counter-advertising at the State
and local level; media advocacy and other public relations techniques using such tactics
as press releases, local events, and health promotion activities; and efforts to reduce or
replace tobacco industry sponsorship and promotions. Counter-marketing activities can
promote smoking cessation and decrease the likelihood of initiation. They also can have a
powerful influence on public support for tobacco control interventions and set a
supportive climate for school and community efforts. Counter-marketing campaigns are a
primary activity in all States with comprehensive tobacco control programs. With funding
levels ranging from less than $1.00 per capita up to almost $3.00 per capita, the
campaigns in California, Massachusetts, Arizona, and Florida have been trendsetters in
content and production quality.
VII. Cessation Programs
($1 per adult to identify and advise smokers about tobacco use; $2 per smoker to provide
brief counseling; and the cost of a full range of cessation services including
pharmaceutical aids, behavioral counseling, and follow up visits ($137.50 per served
smoker covered by private insurance; $275 per served smoker covered by publicly financed
insurance).
Strategies to help people quit smoking
can yield significant health and economic benefits. Effective cessation strategies include
brief advice by medical providers, counseling, and pharmacotherapy. In addition, system
changes (e.g., tobacco-use screening systems, clinician training, and insurance coverage
for proven treatments) are critical to the success of cessation interventions. State
action should include establishing population-based treatment programs such as telephone
cessation helplines; covering treatment of tobacco use under both public and private
insurance; and eliminating cost barriers to treatment for underserved populations,
particularly the uninsured. No State currently is fully implementing the Agency for Health
Care Policy and Research smoking cessation guidelines. Massachusetts and California are
implementing the basic recommended elements. The complete recommended program is being
implemented in several large health maintenance organizations around the country.
VIII. Surveillance and Evaluation
(10% of total annual program costs).
A surveillance and evaluation system
monitors program accountability for State policymakers and others responsible for fiscal
oversight. Surveillance is the monitoring of tobacco-related behaviors, attitudes, and
health outcomes at regular intervals of time. Program evaluation efforts build upon
surveillance systems by linking statewide and local program efforts to progress in
achieving intermediate and primary outcome objectives. Experience in California,
Massachusetts, and other States has demonstrated that the standard public health practice
guideline of devoting 10% of program resources to surveillance and evaluation is a sound
recommendation. State surveillance efforts should be coordinated with Federal tobacco
surveillance programs such as SAMHSA’s National Household Survey on Drug Abuse.
IX. Administration and Management
(5% of total annual program costs).
An effective tobacco control program
requires a strong management structure to facilitate coordination of program components,
involvement of multiple State agencies (e.g., health, education, and law enforcement) and
levels of local government, and partnership with statewide voluntary health organizations
and community groups. In addition, administration and management systems are required to
prepare and implement contracts and provide fiscal and program monitoring. Experience in
California and Massachusetts has demonstrated that at least 5% of program resources is
needed for adequate staffing and management structures.
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