3. 3
H
he perception of tobacco use has
changed with each progressing
generation in the United States.
We’ve shifted from a country
whose doctors “prescribed”
Lucky Strike brand cigarettes
to patients alongside their
antibiotic treatment, to a society in which system
changes are now equipping healthcare providers
with tools and knowledge about evidence-based
tobacco cessation practices. Before the hazardous
health effects of smoking were widely known and
accepted, cigarette companies were able to advertise
essentially regulation-free. From the late 1700s, the
companynowknownasLorillardTobaccoCompany
is credited with placing the very first tobacco
advertisement in the United States promoting their
snuff in a local New York newspaper.1
The 2009
Family Smoking Prevention and Tobacco Control
Act now gives the Food and Drug Administration
(FDA) the authority to regulate the manufacture,
distribution and marketing of tobacco products
to protect the public’s health.2
Cigarette smoking
and other tobacco use were socially acceptable
once upon a time – creating an era when smoking
and nonsmoking sections separated patrons in
trains, airplanes, office buildings and restaurants.
The regard for the health of nonsmokers was
not yet warranted above the common belief that
smoking was not hazardous. Today, public health
professionals and researchers in the United
States are offering a different objective and have
1. James, Randy. “Cigarette Advertising” (2009). Time Magazine.
Available at: http://www.time.com/time/magazine/article/
0,9171,1905530,00.html.
2. U.S. Food and Drug Administration Website. Family Smoking
Prevention and Tobacco Control Act, Public Law 111-31, 123 U.S.
Statutes at Large 1776 (2009). Available at: http://www.fda.gov/
TobaccoProducts/GuidanceComplianceRegulatoryInformation/
ucm246129.htm.
unequivocal evidence to substantiate that there is
no safe level of tobacco use, period.
The purpose of Strategizer 56 is to highlight the
statistically significant measures that amplify the
scientific conclusions regarding the harmful effects
of tobacco use, interventions that reduce access to
tobacco products and evidence-based models that
increase tobacco cessation.Tobacco use remains the
number one cause of preventable death in the United
States killing nearly 100 million worldwide in the
20th century. Contributing to more than 400,000
deaths per year, tobacco ranks higher in annual
deaths toAIDS, alcohol abuse, car accidents, illegal
drug abuse, murders, suicides and fires combined.
More than 13 percent of those deaths represent
men, women and children whose lives were lost
due to secondhand smoke exposure,3,4
meaning
they never even picked up a cigarette. The numbers
don’t lie and the advancements in science have put
public health advocates in a position to win the fight
against “Big Tobacco.” Grassroots experience and
evidence-based “change agents” have identified
3. McGinnis J, Foege WH. Actual Causes of Death in the United
States. Journal of American Medical Association 1993; 270:2207-12.
4. CDC. Smoking-Attributable Mortality, Years of Potential Life
Lost, and Productivity Losses—United States, 2000-2004.
Morbidity and Mortality Weekly Report 2008; 57(45):1226-8.
T Today, public health
professionals and researchers
in the United States are offering
a different objective and
have unequivocal evidence to
substantiate that there is no safe
level of tobacco use, period.
Introduction
Tobacco use is a major public health concern, ranking higher in annual deaths to AIDS,
alcohol abuse, car accidents, illegal drugs, murders, suicides and fires combined.
4. H
4
proven, cost-effective strategies that prevent youth
from starting, help current users quit and protect
everyone from secondhand smoke exposure.
Communities throughout the country have made
strong, sustainable strides in tobacco control
and some of those reviewed case studies will be
highlighted in this publication. According to the
2010 Annual Survey of Coalitions administered to
all CADCA coalitions, 59 percent of coalitions are
directly addressing tobacco use in their community,
35 percent of coalitions are addressing smoking
cessationand77percentofcoalitionrespondentsare
collecting data on tobacco use in their community.
Over 20 percent of CADCA coalitions surveyed
ranked tobacco use in their top three community
priorities.TheTask Force on Community Preventive
Services (TFCPS), an independent, non-federal,
unpaid body, appointed by the Director of the
Centers for Disease Control and Prevention (CDC),
developed the Guide to Community Preventive
Services. The Community Guide is a compilation of
all TFCPS reviews, findings, and recommendations
regarding community-based health promotion and
disease prevention programs, services, and policies
in high-priority topic areas. The TFCPS members
represent a broad range of research, practice, and
policy expertise in community preventive services,
public health, health promotion, and disease
prevention. The TFCPS, established in 1996 by the
U.S. Department of Health and Human Services
(HHS), provides evidence-based recommendations
about community preventive services, programs,
and policies that are effective in saving lives,
increasing longevity, and improving Americans’
quality of life.5
The data analysis, recommendations
and conclusions outlined in this publication will
be drawn from the Community Guide, the 2012
Report of the Surgeon General on Tobacco and the
2006 Robert Wood Johnson Foundation’s Series on
Health Policy: Tobacco Control Policy.
Tobacco Epidemic In the U.S.
Tobacco Epidemic: The Science
Tobacco use remains the largest cause of
preventable morbidity and mortality in the
United States. According to the CDC, tobacco is
recognized as a cause of multiple cancers, heart
disease, stroke, complications of pregnancy
and chronic obstructive pulmonary disease.6
It is
important to continue to encourage individuals to
adopt a tobacco-free lifestyle by choosing to avoid
all types of tobacco products: cigarettes, cigars,
cigarillos, smokeless tobacco, pipes and hookahs.
Every day, nearly 4,000 young people try their first
cigarette—approximately 1,000 of them become
addicted. More than 80 percent of adult cigarette
5. The Guide to Community Preventive Services website. Available
at: http://www.thecommunityguide.org/about/aboutTF.html.
6. CDC. Vital Signs: Current Cigarette Smoking among Adults
Aged >=18 Years—United States, 2005--2010. September 9, 2011,
MMWR 2011; Vol 60(35); 1207-1212. Retrieved from http://www.
cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm.
5. H
5
smokers began smoking before their 18th birthday.
Studies have shown that children of parents who
smoke are twice as likely to become smokers
themselves. High rates of smoking in the United
States expose more than 88 million people to
secondhand smoke on a regular basis.7
Tobacco Epidemic: The Face.
I am Marie and I began
smoking in high school with
my friends. It was the thing
to do and we thought it made
us look older. I smoked for
40 years, although I tried
several times to stop. I
would quit smoking for up
to nine months at a time,
but something—an issue at
work or a problem with the kids—would inevitably
trigger a relapse. Back when I was a key puncher
for a brokerage house in New York City, you could
smoke in the office. Even while I smoked, I would
encourage colleagues to walk and get exercise
during their lunch breaks. It was during these walks
that I felt something wasn’t right because my legs
would stiffen up. In 1993, I was diagnosed with
Buerger’s disease, a disorder linked to tobacco
use that causes blood vessels in the hands and
feet to become blocked and can result in infection
or gangrene. It took a year for the diagnosis to
be confirmed. I was taking painkillers every day
because of the excruciating pain. Over time, parts
of my body: feet, fingertips, and lower legs, were
amputated. And, when I was 45, I had a below-the-
knee amputation of my left leg. Then my fingers
began to go. In 2006, I finally quit smoking for
good with the help of (nicotine) patches. I wanted
to be able to see my grandchildren and great-
grandchildren grow.8
7. Dube SR, McClave A, James C, Caraballo R, Kaufmann R,
Pechacek T. Vital Signs: Current Cigarette Smoking Among Adults
Aged >=18 Years—United States, 2009. MMWR. September 10,
2010. 59(35); 1135-1140.
8. Office on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion. “Tips from Former
Smokers” Campaign. Available at: http://www.cdc.gov/tobacco/
campaign/tips/.
Tobacco Epidemic: Federal Response
It is stories like Marie’s that the federal
government is hoping to evoke action among
tobacco prevention advocates and the courage to
quit among smokers through the Tips from Former
Smokers initiative. Launched in March 2012
by the CDC, the campaign features real people
suffering as a result of smoking and exposure to
secondhand smoke. Their compelling stories send
a powerful message: Quit smoking now or better
yet—don’t start. Public health professionals have
taken a significant step to reduce tobacco use and
exposure from the deadly chemicals produced
from tobacco products to focus on keeping youth
and young adults from ever starting.9
However,
access to tobacco products is increasingly easier as
“Big Tobacco” continues to market new products
like snus, orbs, sticks, strips and other smokeless
tobacco products that resemble candy or mints,
making them more enticing for youth. The Tips
from Former Smokers initiative is a bold step to
prevent young people from starting to use tobacco
and helping those who smoke quit.
Recent milestones in President Obama’s
administration’s agenda include the passage of the
Family Smoking Prevention and Tobacco Control
Act, which gives the FDA authority to regulate
tobacco products to prevent use by minors.
According to the Director of the CDC, Thomas
R. Frieden, M.D., M.P.H., there is sound evidence
that supports the use of the types of hard-hitting
images and messages such as those featured in the
Tips from Former Smokers initiative to encourage
smokers to quit, to keep children from ever
beginning to smoke, and to drastically reduce the
harm caused by tobacco.10
9. Department of Health and Human Services. (2012). CDC Ad
Campaign Reveals Harsh Reality of Smoking-related Diseases:
“Tips from Former Smokers” shows real lives and bodies damaged
by tobacco [Press Release]. Retrieved from http://www.hhs.gov/
news/press/2012pres/03/20120315a.html.
10. Department of Health and Human Services. (2012). CDC Ad
Campaign Reveals Harsh Reality of Smoking-related Diseases:
6. H
6
Why DoYoung People Smoke?
It is important to understand why young people
begin using tobacco in order to present innovative
strategies at reducing use among this population.
According the 2012 Surgeon General Report on
Tobacco, youth progress from early cigarette trials
to intermittent use to regular use and dependence.
The factors that stimulate early cigarette trials may
be distinctly different from those that influence
progression and persistence. The Surgeon General’s
report goes on to suggest that the decision to smoke
by young people is a multi-determined behavior
– no one factor leads to their decision to smoke.
It is influenced by overlapping combinations of
biological, psychosocial, and environmental factors
that function as risk or protective measures.11
Adolescence is an impressionable period of one’s
life and a time that’s strongly encouraged to explore
and experience new things.
Community efforts must include the voice of teens
to promote peer-to-peer guidance and deterrence
from tobacco. Teen advocates against tobacco
are the industry’s worst enemy – state supported
resources provide young people with a platform to
invigorate new social norms that parallel healthy
lifestyle behaviors.
SOLUTIONS: How can communities help
keep teens and young adults tobacco-free?
• Change Social Norms
Create a world where seeing people smoke or
use other tobacco products is the exception, not
the norm (Ex. Establish tobacco-free city/
county ordinances; work with retailers to
remove tobacco displays).
“Tips from Former Smokers” shows real lives and bodies damaged
by tobacco [Press Release]. Retrieved from http://www.hhs.gov/
news/press/2012pres/03/20120315a.html.
11. Department of Health and Human Services (DHHS).
Preventing Tobacco Use among Youth and Young Adults: A Report
of the Surgeon General. Atlanta, GA: U.S. Department of Health
and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2012.
• Restrict Access
Take steps that make it harder for youth to use
tobacco, such as raising cigarette prices and
enforcing laws that prohibit the sale of tobacco
to children (Ex. Work with law enforcement
officials to perform routine compliance checks
at tobacco retail establishments).
• Limit the Influence
Further limit tobacco marketing that is likely
to be seen by young people (Ex. Encourage
local community event planners not to accept
tobacco sponsorship at state fairs, rodeos,
etc.).
• Limit Media Exposure
Limit youth exposure to smoking in movies
and other media (Ex. Support the efforts
spearheaded by the Campaign for Tobacco
Free Kids to change movie ratings that feature
characters using tobacco products).
• Promote Comprehensive Education
Educate young people and help them make
healthy choices (Ex. Recruit and train youth
leaders that can provide peer-to-peer
encouragement to be tobacco-free).
• Set the Example
Encourage young people to avoid tobacco use
by quitting and talking to them about why you
or someone you know quit (Ex. At every op-
portunity, be honest with young people about
your choices and how it has affected your life).
Using the Community Guide
Recommendations
In selecting and implementing interventions, it
is recommended that communities develop and
maintain a comprehensive, multifaceted strategy
to reduce exposure to environmental tobacco
smoke (ETS), reduce tobacco use initiation, and
increase tobacco use cessation. Improvements
in each category will contribute to reductions
7. H
7
in tobacco-related morbidity and mortality,
and success in one area may contribute to
improvements in the other areas as well. Although
theTFCPS has provided assessments for individual
interventions or intervention combinations,
comprehensive community efforts will require
the implementation of multiple interventions to
address tobacco use and exposure to ETS in diverse
settings and populations. The recommendations
provided in this report can assist communities in
assembling a comprehensive program consisting
of interventions with demonstrated evidence of
effectiveness. When selecting interventions to
meet local objectives, take into consideration
REDUCING TOBACCO USE INITIATION
Increasing the unit price of tobacco products: include legislation at the state
or national level to raise the product excise tax
Recommended
Mass media campaigns: mass media interventions of an extended duration,
using brief, recurring messages to inform and to motivate children and
adolescents to remain tobacco-free
Recommended; when combined
with other interventions
RESTRICTING MINORS’ ACCESS TO TOBACCO PRODUCTS
Increasing the unit price of tobacco products Strongly recommended
Community engagement with additional interventions Recommended
Community education about youth access to tobacco products when used alone Insufficient evidence; when used in
isolation of other interventions
Active enforcement of sales laws directed at retailers when used alone Insufficient evidence
Retailer education with reinforcement and information on health
consequences when used alone
Insufficient evidence
Retailer education without reinforcement when used alone Insufficient evidence
Laws directed at minors’ purchase, possession, or use of tobacco products
when used alone
Insufficient evidence
Sales laws directed at retailers when used alone Insufficient evidence
REDUCING EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE (ETS)
Smoking bans and restrictions: are policies and regulations that ban or limit
the consumption of tobacco products in designated areas.
Recommended; used alone or as
part of a multicomponent commu-
nity or workplace intervention
Community education to reduce exposure in the home: provides informa-
tion to parents, other occupants, and visitors to the home about the impor-
tance of reducing or eliminating ETS to protect nonsmoking adults and
children
Insufficient Evidence; insufficient
number of studies for assessing the
effectiveness of the intervention
DECREASING TOBACCO USE AMONG WORKERS
Smoke-free policies to reduce tobacco use Recommended
Incentives competitions Insufficient Evidence; when used
in isolation of other interventions
Incentives competitions when combined with additional interventions Recommended
INCREASING TOBACCO USE CESSATION
Smoking bans and restrictions Recommended
Community education to reduce exposure in the home Insufficient evidence
Table 1: Community Guide Recommendations
Source: The Guide to Community Preventive Services
8. H
8
whether your coalition has the necessary
resources, what other organizations or agencies
in your community are already doing, and current
ordinances or policies currently in place. The
TFCPS recommendations are based primarily on
the evidence of effectiveness of interventions as
implemented, evaluated, reported, and published.
A TFCPS finding of insufficient evidence does
not imply evidence of ineffectiveness of the
intervention, but does identify areas of uncertainty
and specific continuing research needs. In these
instances it should not be inferred that the targeted
outcomes are not important in a comprehensive
community effort.
Strategy I: Reducing
Tobacco Use Initiation
Tobacco use remains excessively high despite
nearly four decades of policies, regulations,
educational efforts and increasing information on
the negative health effects of tobacco use and the
positive health benefits of cessation. Tobacco use
initiation and the transition from experimentation
to addiction are not easy to prevent because they
occur primarily in adolescence, when individuals
are more susceptible to influences from family,
friends, peers, society and the tobacco industry that
encourage tobacco use. Children and adolescents
may perceive tobacco use to be normal peer
and adult behaviors, and often act on this belief
because tobacco products are readily available
and accessible.12
The main regularity in youth
smoking research observed by sociologists and
psychologists is that youth are more likely to smoke
if their parents, siblings and peers also smoke. Age
of onset of smoking is negatively correlated with
the amount smoked and the incidence of negative
health effects.13
12. Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to
Community Preventive Services: What Works to Promote Health?”
Part I: Changing Risk Behaviors and Addressing Environmental
Challenges. Oxford University Press. 2005. 3 - 79.
13. Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E.
(2006). Robert Wood Johnson Foundation Series on Health Policy:
Healthy People 2010 is an initiative introduced by
HHS in 2000 that provided science-based, 10-year
national objectives for improving the health of all
Americans. The following objectives related to
reducing tobacco use initiation were identified:
• Reduce cigarette smoking from 24 percent to 12
percent among adults;
• Reduce use of tobacco products from 40 percent
to 21 percent among adolescents; and
• Reduce initiation of tobacco use among children
and adolescents by 2010.14
The Community Guide recommends interventions
to reduce tobacco use initiation by preventing
or delaying experimentation with tobacco or
preventing the transition from experimentation
to regular use by increasing the price of tobacco
products, increasing frequency of mass media
education campaigns and reducing access to
tobacco products by minors. There are a variety
of interventions to restrict and reduce the supply
of tobacco products that minors can obtain from
commercial sources. These interventions include
components intended, in whole or in part, to
reduce the demand for tobacco products by
minors through efforts to educate and organize
the community and to change social norms about
the acceptability of tobacco use. The TRUTH
campaign, the largest national youth-focused
anti-tobacco education campaign, was designed
to engage teens by exposing “Big Tobacco’s”
marketing and manufacturing practices, and
to highlight the toll of tobacco in relevant and
innovative ways.
Tobacco Control Policy. “The Effects of Government Regulation on
Teenage Smoking,” 90, 94.
14. U.S. Department of Health and Human Services. Office of
Disease Prevention and Health Promotion. Healthy People 2010.
Washington, DC. 2000. Available at http://www.healthypeople.gov.
9. H
99
H
Case Study
Youth in Missouri and Minnesota Take Action to Reduce Tobacco Use
n Polk County, Mo., the community calls
“Smokebusters” to the table to disseminate
tobacco prevention messages from teens to
other teens to increase quit rates and reduce ini-
tiation. Smokebusters is a teen advocacy group
that educates schools and communities about the
effects of secondhand smoke and works to create
smoke-free environments. The training curriculum
is evidence-based and, when implemented, keeps
other students smoke-free.The teams are overseen
by members of the Advocates for Better
Communities (ABC) coalition, a drug and violence
prevention group and CADCA member, that began
more than 15 years ago with the Safe Drug Free
Schools Act. These teens are more than sideline
participants; Smokebusters actively approach
community leaders to safeguard Polk County
residents from secondhand smoke exposure. For
example, Smokebusters urged school administra-
tors to adopt smoke-free campus policies, and
upon agreement, used local tobacco prevention
funding to post “Respect the Smoke-free Campus”
signs to remind community members and
visitors. Additionally, when the Bolivar City
Council decided not to mandate a smoke-free
ordinance,theSmokebustersandABCworkedwith
individual area restaurants to establish smoke-free
workplace policies. Each participating restaurant
received free advertisement and recognition to
raise awareness of their support of healthy environ-
ments and smoke-free workplaces. Following this
attempt, a new mayor was elected – a cardiologist –
who agreed to designate smoking areas away
from youth at local parks and municipal building
entrances. ABC and Smokebusters continued to
educate Polk County health facility providers on
evidence-based cessation techniques that led to the
creation of smoking cessation courses offered at
the Health Center.
In Polk County, Minn., further north from Polk
County, Mo., teen coalition members are making
sure local retailers comply with the state law. The
law prohibits businesses from selling tobacco
products to people under 18 years old. The Polk
County ATOD Task Force Coalition, also a
CADCA member, gathered data from the 2008
Minnesota Youth Tobacco and Asthma Survey on
“Access to Cigarettes” and found that more than
three-fourths of high school smokers receive their
cigarettes from other people. The survey results
alsoshowedthat10percentofunderagehighschool
smokers admitted to purchasing products from
local stores. About one in five students reported
that they know where to purchase single cigarettes,
better known as “loosies.” Community members
formed the youth-led, adult-guided network, The
Minor League (TmL), to raise awareness about
the dangers of alcohol, tobacco and other drugs in
their respective schools and communities. Youth
partnered with local law enforcement as part of
the Tobacco Compliance Check Program that
monitors tobacco retailers in order to eliminate the
sale of tobacco products to minors. TmL members
have established a strong relationship with their
local law enforcement to keep them engaged in
the comprehensive tobacco control program and
maintain their support to create an environment in
which tobacco use is not a social norm. As a re-
sult of the TmL and law enforcement partnership,
fewer youth are able to purchase tobacco and retail
clerks are more likely to ask for identification.
I
10. H
10
TFCPS Recommendations:
✓ Tobacco Pricing Controls
(strongly recommended)
Interventions to increase the unit price for tobacco
products primarily include legislation at the
municipal, state or federal level to raise the excise
tax on tobacco products. In several states, excise
tax increases have resulted from successful state
ballot initiatives that snowball into increased calls
among state-sponsored quitlines. Although other
factors affect tobacco product pricing, excise
tax increases have historically resulted in an
equivalent or larger increase in tobacco product
prices.15
Excise taxes on tobacco products increase
the overall product cost and therefore make the
use of tobacco products less attractive to young
people with limited income and a variety of ways
to spend their money. A 10 percent price increase
on tobacco products results in an approximately
4 percent decrease in consumption of tobacco
products and an approximately 4 percent decrease
in smoking among adolescents and young adults.
Consequently, these price increases also reduce
tobacco use among adults; therefore protecting
adolescents and children from an environment
in which tobacco use is acceptable. Passage of
legislation or a statewide referendum is required
for an excise tax increase on tobacco products
and may, therefore, present a significant barrier
to implementation, although some states have
passed such legislation. Political opposition has
historically been well organized and funded at both
the federal and state levels. In the Series on Health
Policy: Tobacco Control Policy published by the
Robert Wood Johnson Foundation, the authors
presented a set of estimates that described the
impact of advertising ban policies on the demand
for cigarettes by teenagers in the United States and
15. Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to
Community Preventive Services: What Works to Promote Health?”
Part I: Changing Risk Behaviors and Addressing Environmental
Challenges. Oxford University Press. 2005. 3 - 79.
examined the extent to which federal excise tax
increases on cigarettes reduce teenage smoking.16
These authors suggest that cigarette smoking is, in
part, a habitual behavior that begins early in life
and that changes in teenage smoking behavior in
response to government regulatory actions could
have sustainable and substantial impact in the long
run.17
Therefore, communities shape and frame
the social norms that youth are most receptive to
in their most impressionable years. Policies help
to prohibit such accessibility to dangers, such as
tobacco, and prevent curiosity to experiment.
✓ Mass Media Education Campaigns
(recommended, when combined
with other interventions)
When used for an extended duration, mass media
education campaigns, combined with other
interventions, that disseminate brief, recurring
messages, such as the TRUTH campaign,
can motivate people to remain tobacco-free.
According to the TFCPS, mass media education
campaigns are effective in decreasing the number
of children and adolescents who use tobacco by
more than 2 percentage points. The Community
Guide recommends that mass media campaigns be
coordinated with additional interventions, such as
increases in tobacco product excise taxes, school-
based education, and other community-wide
educational activities. The content of mass media
campaigns designed to educate and motivate
children and adolescents to remain tobacco-
free vary, but two primary strategies prevail:
agenda setting and demand reduction education.
Agenda-setting messages increase awareness of
strategies used by the tobacco industry to promote
tobacco use, and attempt to facilitate changes in
16. Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E.
(2006). Robert Wood Johnson Foundation Series on Health Policy:
Tobacco Control Policy. “The Effect of Tobacco Advertising Bans
on Tobacco Consumption” 355-360.
17. Isaacs, Stephen L., Knickman, James R., Warner, Kenneth E.
(2006). Robert Wood Johnson Foundation Series on Health Policy:
Tobacco Control Policy. “Does Tobacco Advertising Target Young
People to Start Smoking?” 318-324.
11. H
11
both tobacco use behaviors and public tobacco
policies. Demand reduction education messages
provide information and support to young people
to help them decide to remain tobacco-free. A
comprehensive approach to reducing tobacco use
is imperative to begin the change process and
maintain positive outcomes over time. Mass media
education campaigns can also include messages
that contribute to reductions in tobacco use among
adults, although the message content, broadcast
times, and settings that reduce youth tobacco use
may not be as effective in reducing adult tobacco
use. The messages should be tailored for the
intended audience through the use of formative
research, by survey or focus group, for example.
Message content should be culturally appropriate
and respectful.The main barrier to implementation
of mass media campaigns is the cost of purchasing
advertising time. However, costs of developing
and test marketing messages can be offset by
cooperation between local and national tobacco
control programs.
What You Can Do in Your Community:
Strategy I: Reduce Tobacco Use Initiation
• Support legislation that increases product excise
tax and limits point of purchase promotions.
• Partner with high school and university
administrators to educate their students about
I.D. swiping (see page 13).
• Educate the public and policymakers about
the relationship between enforcing the law
prohibiting tobacco sales to minors and
preventing youth tobacco use and on the
importance of enforcing state law.
• Collaborate with your State Tobacco Control
Program to provide technical assistance to
local retailers on enforcing the tobacco sales
to minors law.
• Conduct compliance checks to ensure tobacco
retailers are not selling tobacco to minors.
Track and publicize retailer compliance.
Strategy II: Restricting
Minors’ Access to
Tobacco Products
Laws directed at retailers provide specific
regulation or restriction of the sale of tobacco
products to minors. These laws include licensing
requirements for tobacco retailers and bans or
restrictions on tobacco product vending machines
and self-service displays. The laws may include
additional conditions, such as requiring proof
of the purchaser’s age before selling tobacco,
displaying sales laws (such as warning signs
at the point of purchase), banning the sale of
single cigarettes, and restricting the age of the
seller. These laws may designate the method
of enforcement and establish the penalties and
the responsible parties for each violation (for
example, civil penalties directed at the retail owner
or license holder). A potential benefit of these
laws is that license requirements for the sale of
tobacco products enable communities to identify
commercial sources of tobacco. These laws also
provide support for additional interventions, such
as active enforcement of sales laws. Finally, self-
service display bans reduce or eliminate minors’
ability to obtain cigarettes by stealing them.18
Tobacco companies have always claimed that they
do not want adolescents to use their products.
However, for a tobacco company to be profitable
over the long term, it must compete successfully
for a share of the youth market to maintain a pool
of “replacement smokers.” The tobacco industry
has publicly supported laws that penalize youth for
possessing, using and purchasing tobacco products.
But, many of these laws have been criticized because
they ignore the responsibilities of the industry and
retailers.19
In a 1998 study by Forster and Wolfson,
18. Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to
Community Preventive Services: What Works to Promote Health?”
Part I: Changing Risk Behaviors and Addressing Environmental
Challenges. Oxford University Press. 2005. 3 - 79.
19. Department of Health and Human Services (DHHS).
Preventing Tobacco Use Among Youth and Young Adults: A Report
12. H
12
they found that the voluntary efforts exhibited by
tobacco manufacturers and retailer organizations to
educate and train retailers were aimed at pardoning
them from any responsibility for smoking by youth.
The idea was to focus the blame on minors who
attempt to purchase tobacco and clerks who sell it
to them. Further, a 2002 study of tobacco company
internal documents found that the industry used
its youth access programs only to gauge current
tobacco control efforts: “For monitoring purposes,
we fund our allies in the convenience store group to
regularly report ordinance introductions and assist
in campaigns to stop unreasonable measures…”
Internal documents also revealed that manufacturers
modified product design to enhance product appeal
to novice users. The design and packaging of
products was almost completely devoid of regulatory
controls with the exception of the small text warning
statements until the passing of the Tobacco Control
Act in 2009.20
FDA regulation of tobacco product
marketing presents an extraordinary opportunity for
the FDA to partner with established tobacco control
entities to identify and implement new ways for
preventing youth tobacco use and promoting youth
and adult cessation.21
Access Restrictions to Tobacco Products
Access to tobacco products by minors contributes
to the initiation and regular use of tobacco by
children and adolescents. First, it’s important
to identify where youth are accessing tobacco
products. Retailers who sell tobacco products to
minors (including vending machines in accessible
settings) constitute one avenue of access for
minors. Social sources (such as parents, family
and friends) provide another route of access
of the Surgeon General. Atlanta, GA: U.S. Department of Health
and Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2012.
20. U.S. Department of Justice
21. Orleans, C. Tracy, PhD, Mabry, Patricia L., PhD, Abrams,
David B., PhD. “Increasing Tobacco Cessation in America: A
Consumer Demand Perspective.” American Journal of Preventive
Medicine (2010) 38(3S): S303-S306.
for many minors. Illegal retailer sales to minors
provide tobacco products for distribution to other
minors, contributing to social access. Minors
obtain tobacco from commercial sources through
purchases from retailers (self-service displays or
requests for products held behind the counter),
vending machines, via mail or over the Internet,
through free product samples and theft from
retail sources. Overall, minors’ access reflects the
availability of tobacco products within the community,
the willingness of retailers to sell them and the efforts
of minors to obtain them. Interventions to reduce
access attempt to modify or to change one or more of
these factors, according to theTFCPS.22
Smokeless Tobacco: The New Frontier
Since 1970, smokeless tobacco has gone from a
product used primarily by older men to one used
predominantly by young men and boys. This trend
has been directly proportional to the increase in
smokeless tobacco promotions. The result? A new
generation of smokeless tobacco products thrives
in the current market. Youth using smokeless
tobacco who have not begun using cigarettes
for their nicotine dependence are more likely to
become regular cigarette smokers.23
New users of
smokeless tobacco—attracted to the product for a
variety of reasons—are most likely to begin with
products that are milder tasting, more flavored,
and/or easier to control in the mouth, according
to the U.S. Smokeless Tobacco Company (UST).
After a period of time, UST indicated that there is a
natural progression of product switching to brands
that are more full-bodied, less flavored, have more
concentrated “tobacco taste” than the entry brand.24
22. Zaza, Stephanie; Briss, Peter A.; Harris, Kate W. “The Guide to
Community Preventive Services: What Works to Promote Health?”
Part I: Changing Risk Behaviors and Addressing Environmental
Challenges. Oxford University Press. 2005. 3 - 79.
23. Tomar, S, “Is use of smokeless tobacco a risk factor for cigarette
smoking? The U.S. experience,” Nicotine Tobacco Research
5(4):561-569, August 2003.
24. “The Marketing of Nicotine Addiction by One Oral Snuff
Manufacturer,” Tobacco Control 4(1), Spring 1995.
13. H
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Smokeless tobacco products have been heavily
marketed to youth through sporting events like
auto racing and rodeos that are widely attended
by kids. The use of smokeless tobacco is prevalent
at such events and done in plain sight where
children can see and be exposed. Although the
Tobacco Master Settlement Agreement (MSA)
has limited UST’s ability to continue to support
brand-name sponsorships of events and teams
within states, UST continues to sponsor both
professional motorsports, and bull riding.25
Magazines like Sports Illustrated and Rolling
Stone with high youth readership have been targets
for tobacco industry product marketing.26
Even
after restrictions were placed on youth advertising
25. Morrison, MA, et al., “Under the Radar: Smokeless Tobacco
Advertising in Magazines With Substantial Youth Readership,”
American Journal of Public Health (AJPH) 98:543-548, 2008. See
also, Sports Illustrated, July 30, 2001 and Rolling Stone, July 5, 2001.
26. Massachusetts Department of Public Health, Smokeless
Tobacco Advertising Expenditures Before and After the
Smokeless Tobacco Master Settlement Agreement: A Report
of the Massachusetts Department of Public Health, May 2002,
http://archives.lib.state.ma.us/bitstream/handle/2452/49479/
ocm50878863.pdf.
by the Smokeless Tobacco Master Settlement
Agreement (established the same year as the
Tobacco Master Settlement Agreement), UST
continued to advertise in youth-oriented magazines
with a 161 percent increase in expenditures over a
four-year period.27
Tobacco companies have also
hired “spokesmodels” to attend venues and events
highly frequented by young college-aged adults
to swipe personal identification cards. “Swiping”
is a technique the tobacco industry uses to retain
personal information and mail free samples or
coupons directly to their potential customer’s
home. This marketing practice is tracked by the
number of coupons redeemed and the customer
continues to receive promotions tailored to the
products they prefer based on previous purchases.
27. U.S. Food and Drug Administration Website. Family Smoking
Prevention and Tobacco Control Act, Public Law 111-31, 123 U.S.
Statutes at Large 1776 (2009). Available at: http://www.fda.gov/
TobaccoProducts/GuidanceComplianceRegulatoryInformation/
ucm246129.htm.
14. H
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In a concentrated effort to combat the potential
damaging effects of increased smokeless tobacco
use among young people, tobacco companies must
prove the validity of any health claims to the U.S.
Food and Drug Administration before using them
in promotional materials under the Tobacco Control
Act. Additionally, any new tobacco products
(including smokeless) must go through independent
testing regarding either their inherent harmfulness
or their likely impact on overall tobacco use levels
or public health before entering the market.28
Currently, there are six types of spit tobacco on the
market: oral snuff, nasal snuff, snus, dissolvables,
loose leaf chew, and plug chew. According to a
study published in the November, 1998, Journal of
Adolescent Health, high school students who use
spit tobacco 20 to 30 days per month are nearly
four times more likely to currently use marijuana
than nonusers and almost three times more likely
to ever use cocaine or inhalants to get high. Heavy
smokeless tobacco users are almost 16 times more
likely than nonusers are to currently consume
alcohol, as well.29
As stated in the 2012 Surgeon
General’s Report on Tobacco, tobacco marketing is
a key factor in causing young people to start using
tobacco. The nicotine addiction keeps them using
it long after the experimental stage.30
New and
easy-to-use smokeless tobacco products like those
being piloted and marketed by the tobacco industry
provide youth with a gradual, progressive platform
to stronger forms of tobacco and higher levels
of nicotine. Additionally, the staggering effects
associated with dual use (smokeless and cigarettes)
28. Everett, S, et al., “Other Substance Use Among High School
Students Who Use Tobacco.” Journal of Adolescent Health,
November 1998.
29. Department of Health and Human Services (DHHS). Preventing
Tobacco Use Among Youth and Young Adults: A Report of the
Surgeon General. Atlanta, GA: U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention,
National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 2012.
30. Task Force on Community Preventive Services.
Recommendations Regarding Interventions to Reduce Tobacco Use
and Exposure to Environmental Tobacco Smoke. American Journal
of Preventive Medicine. (2001) 20(2S).
pave the way for the damaging effects of long-
term use and increase the chances of long-term
dependence. It becomes increasingly imperative
that communities pay attention to the irrefutable
scientific evidence outlined in the 2012 Surgeon
General’s Report on Tobacco and work to change
the indicators in their environment and deter early
childhood tobacco use.
What You Can Do in Your Community:
Strategy II: Restrict Minors’ Access to
Tobacco Products
• Develop a plan of action to implement a
tobacco point-of-purchase ordinance policy.
• Gather data on where smokeless tobacco
products and tobacco advertising are placed
in retail establishments to identify priority
communities; consider launching a pilot
project to test the plan of action.
• Educate the public and policymakers about the
role limiting point-of-purchase tobacco adver-
tising plays in preventing youth tobacco use.
• Conduct a survey to evaluate public support
for restricting point-of-purchase tobacco
advertising.
• Develop a local ordinance tracking system;
provide report to legislators at year-end to
keep them abreast of local conditions regard-
ing tobacco ordinances.
Strategy III: Reducing
Exposure to Environmental
Tobacco Smoke
Preventing tobacco use in children and adoles-
cents, reducing tobacco use in adults, and reducing
nonsmokers’ exposure to ETS are essential public
health objectives for communities. When the
TFCPS developed a report to present their recom-
mendations in the Community Guide, reducing
ETS exposure was identified as a primary goal for
communities given that tobacco use is the largest
preventable cause of premature death in the United
(continued on page 16)
15. H
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H
Case Study
The Tobacco Free Community Partnership and the
Partnership of Community Resources Curb Secondhand Smoke
utdoor spaces are just as vulnerable to
the damaging results of tobacco use as
indoor spaces. Local communities are
disseminating the evidence and discovering new
partnerships as they work to dispel the myths
associated with outdoor clean air restrictions.
People are just as susceptible to the dangers of
second and third-hand smoke outdoors as they
are indoors. Furthermore, tobacco litter found at
recreational parks, plazas and multi-unit dwellings
is costly to clean up and gives an unpleasant
impression to children and young adults.
CADCA member, the Tobacco Free Community
Partnership for Hampshire and Franklin counties
in Massachusetts has been an instrumental group
that educates tenants, private landlords and local
housing authorities about the health consequences
of secondhand smoke exposure in multi-unit
dwellings such as apartments, condominiums,
and other attached homes. After receiving pilot
project funding, the coalition gathered baseline
data on the level of knowledge and awareness of
smoke-free policies among property owners and
residents from five municipalities. The survey
data supported a smoke-free policy. The coalition
began working with the housing authority,
landlord associations, boards of health, the asthma
association, city planners, fire departments,
realtors and the Massachusetts Rental Housing
Association to establish smoke-free home policies.
The result of their collaborative work resulted in
the adoption of a smoke-free policy by four local
housing authorities.
In 2011, another CADCA member, the Partnership
of Community Resources Coalition in Nevada,
began a campaign to promote smoke-free
playground policies. To ensure that smoking in
parks wasn’t just their group’s perception, they
collected cigarette butts in parks throughout the
community with the StudentsTaking on Prevention
team to determine if smoking was actually a
problem. The group collected butts two weeks in a
row totaling 200 butts; it was the proof they needed
that smoking in parks was a problem in their
community.Thegrouporganizeddatatopreparefor
the upcoming Parks and Recreation Commission
presentation. Their request was approved by the
Parks and Recreation Commission to post “Young
Lungs at Work” and “Watch Your Butts” signs
in and around playground areas. The Parks and
Recreation Commission further supported the
Partnership of Community Resources Coalition to
go before the County Commissioners to gain their
approval, as well. The County Commissioners not
only approved the request, but also showed strong
interest in making all county facilities smoke-free.
Additionally, the County Commissioners requested
that youth attend their planning meetings to share
the information regarding the policies at the start
of each new school year. These steps and successes
led to increasing awareness among community
members about the dangers of secondhand smoke.
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16. H
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States. Their recommendations also suggest that
communities will be most successful in reducing
ETS if they maintain intervention strategies that
are comprehensive and multifaceted. Communities
should make consistent improvements to all of the
interventions highlighted; success in one area (e.g.
reduce tobacco use initiation) may contribute to
improvements in the other areas (e.g. reduce expo-
sure to ETS and increase tobacco use cessation).
The recommendations of theTFCPS outlined below
are designed to assist communities with developing
a comprehensive, strategic approach consisting of
interventions proven to be effective.
TFCPS Recommendations:
✓ Smoking bans and restrictions (strongly
recommended)
Smoking bans and restrictions are policies and
regulations that ban or limit the consumption
of tobacco products in designated areas. These
include private business and employer policies,
organization regulations, and government laws
and ordinances. Laws and ordinances can establish
minimum standards to protect workers in private-
sectorworkplaces,aswellasbanorrestrictsmoking
in public areas and workplaces. Smoking bans
and restrictions are strongly recommended on the
basis of strong scientific evidence that they reduce
exposure to ETS (1) in a wide range of workplace
settings and adult populations; (2) when applied at
different levels of scale, from individual businesses
to entire communities; and (3) whether used alone
or as part of a multicomponent community or
workplace intervention. In addition to evidence
of effectiveness in reducing workplace exposure
to ETS, several qualifying studies observed a
significant reduction in daily consumption of
cigarettes by workers subject to a smoking ban
or restriction. Some of the qualifying studies
that evaluated smoking bans observed increases
in tobacco use cessation and/or reductions in
tobacco use prevalence in their study populations.
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✓ Community education (insufficient evidence)
Community education provides information to
parents, other occupants, and visitors to the home
about the importance of reducing or eliminating
ETS to protect nonsmoking adults and children.
Education interventions attempt to motivate
household members to modify smoking habits
to reduce nonsmokers’ exposure to indoor ETS
(e.g. by establishing home policies restricting or
banning smoking) if they cannot quit entirely.
The TFCPS review identified only one qualifying
study of community-wide education interventions
including an ETS component, which is insufficient
for assessing the effectiveness of the intervention.
A recent review of efforts to reduce children’s
exposure to ETS reached a similar conclusion.31
What You Can Do in Your Community:
Strategy III: Reduce Exposure to
Environmental Tobacco Smoke
• Conduct an environmental scan to prepare a
plan of action to implement outdoor (e.g.
tobacco-free parks, sports facilities, beaches,
etc.) and multi-unit housing policies.
• Collaborate with community partners to
collect local data on distribution of free to-
bacco samples and gather data on tobacco
advertising near faith-based organizations,
school property and other child-focused
facilities.
• Collaborate with your State Tobacco Control
Program and other partners to improve
enforcement of current tobacco access
restrictions.
• Develop a tracking system to monitor
enforcement of tobacco access restrictions in
retail settings within communities through-
out the state and present the data using GIS
31. Dyann Matson Koffman, Jerry W. Lee, Joyce W. Hopp, and
Seth L. Emont (1998) The Impact of Including Incentives and
Competition in a Workplace Smoking Cessation Program on
Quit Rates. American Journal of Health Promotion: November/
December 1998, Vol. 13, No. 2, pp. 105-111.
Mapping, Photovoice, etc.
• Work with businesses and other organizations
to modify employer policies, regulations and
local ordinances to reduce ETS exposure.
• Provide businesses tobacco-free signage
prohibiting the use of tobacco products at their
establishments.
• Motivate household members to modify
smoking habits and establish tobacco-free
home policies.
Strategy IV: Increasing
Tobacco Use Cessation
The need for access and education about the use
of tobacco use cessation services and products
will become increasingly more necessary as
communities continue to establish policies
prohibiting its use. Reducing tobacco use is good
for everyone—smokers and nonsmokers. Our
environments have to shape better alternatives to
unhealthy decisions that are easier to make the first
time. Communities that create guided pathways
to evidence-based tobacco cessation treatment
options will witness long-term, sustainable
outcomes in the number of adults and youths
exposed to tobacco.
In 2009, the U.S. Congress enacted the largest
federal tax increase on tobacco products in the
nation’s history. Some 32 states and hundreds of
communities have enacted comprehensive smoke-
free laws since that time and the cost of tobacco
cessation decreased resulting in unprecedented,
national support for smokers’ quitting efforts. The
U.S. National Tobacco Cessation Collaborative
(NTCC) developed a supplement to the American
Journal of Preventive Medicine that aims to call
attention to the value of offering a consumer-
oriented perspective to population-level tobacco
cessation efforts.The NTCC suggests that if public
health efforts could increase consumer demand for
evidence-based tobacco cessation products and
services, then many more would attempt to quit,
and do so successfully. The authors suggest that
18. H
18
more work needs to be done within communities
to increase the demand for and use and reach of
evidence-based treatments and potentially spur the
wider adoption of policy changes that will make
these treatments affordable, accessible, and easier
to use.32
With the momentum created by the passage of
stricter laws prohibiting use and ground-breaking
national media education campaigns, the question
remains: Why are cessation rates so low while
tobacco use rates remain so high? Is the socio-
economic gap widening? Some experts suggest
that the links among public health policy changes
and policy and practice changes in the treatment
arena do not yield simultaneous advancements.
Expansions in treatment coverage, funding for
quitline promotion and staff and the fraction of
tobacco excise tax and MSA funds that have been
applied to tobacco prevention and treatment are
all modest adjustments. Community leaders have
to remain vigilant well after funding has been
dispersed and laws have been enacted to achieve
long-term, sustainable outcomes. This involves
educating local, state and federal lawmakers con-
sistently and engaging all levels and sectors of a
community when establishing new policies.
State-funded cessation quitlines, telephone-based
tobacco cessation services, is another intervention
strategy documented by a number of research
studies to be efficient and effective. Quitlines
are designed to help tobacco users quit through
a variety of services, counseling, medications,
information and self-help materials by setting
a quit date, designing a quit plan and achieving
permanent deliverance from nicotine addiction.
Quitline services can be tailored to an individual
tobacco user’s experience, tobacco use behavior
and motivations. Through the leadership of state
and federal governments, quitlines provide a
32. NAQC Issue Paper: Tobacco Cessation Quitlines: A Good
Investment to Save Lives, Decrease Direct Medical Costs and
Increase Productivity (January 2009) .
quick and easy service for tobacco users, require
no travel and are readily available in rural and
urban areas. Many factors including centralization
and service delivery by telephone contribute to
quitlines’ cost-effectiveness. Sustained funding
for quitlines could contribute to the overall decline
in tobacco use prevalence. In fiscal year 2006, a
total of 328,795 tobacco users called U.S. quitlines
to seek help. This number represents roughly
47 reporting state-funded quitlines. Additional
funding for services and promotions would help
increase the number of tobacco users who receive
quitline services.33
Community coalitions should
be aware of the services associated with their state-
funded quitline to better promote and increase the
level of understanding regarding those services.
Promoting the quitline services and success stories
through local mass media education campaigns is
another strong effort local communities should
engage in.
TheTFCPS evaluated a wide range of interventions
to increase cessation among tobacco product users.
Efforts to increase cessation include strategies to
33. Task Force on Community Preventive Services
Recommendations Regarding Interventions to Reduce Tobacco Use
and Exposure to Environmental Tobacco Smoke. American Journal
of Preventive Medicine. (2001) 20(2S).
(continued on page 20)
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Case Study
The Southern Coalfields Tobacco Prevention Coalition Network
(SCTPCN) Tackles Maternal Smoking Prevention
n a population alongside a stretch of
mountainous land dotted with surface mines
and underground coal mines, the McDowell
County residents in Southern West Virginia
represent a community in which half of the county’s
residents have not completed high school, a third
of the population lives below the poverty line, 35
percent of the adult population live without health
insurance, and the high prevalence of tobacco
use exacerbates the preventable morbidity and
mortality rates in the population. The smoking
during pregnancy rate was very high at 44 percent
and many of the tobacco users in this rural area
lacked access to evidence-based tobacco cessation
and prevention services. According to the 2000
National Vital Statistics Reports, between 12 and
20 percent of all pregnant women smoke. Similarly,
Barry County, a rural county in Michigan, reported
a 23 percent maternal smoking rate, which is much
higher than the state’s overall adult smoking rate.
Both communities found it difficult to reach their
high-risk population using traditional variables
and both utilized some out-of-the-box strategies
to render sustainable outcomes. The Southern
Coalfields Tobacco Prevention Coalition Network
(SCTPCN), a CADCA member, worked with the
West Virginia Chapter of the March of Dimes,
the McDowell County HOPE Coalition, Hands
of Hope Ministries, Women Infants and Children
(W.I.C.) Offices and Head Start centers to bring
access to specialized tobacco treatment services
and proper prenatal health education to the lowest
levels of baseline interventions. The community-
based workshops and home education sessions
taught pregnant mothers about the importance
of proper prenatal care with the main focus
on the necessity of a tobacco-free pregnancy.
Participating pregnant mothers and/or family
members were referred to group tobacco cessation
counseling services in their local community. To
increase the sustainability of the project’s impact,
local healthcare providers and social service
workers were trained by the American Legacy
Foundation in the implementation of BriefTobacco
Intervention (BTI) using the 5-A’s of Smoking
Cessation with pregnant smokers: Ask, Advise,
Assess, Assist and Arrange follow-up. Cessation
experts also advocate the use ofAAR Intervention,
which is Ask, Advise and Refer.
The Barry County Substance Abuse Task Force
(SATF), a partner of the the SCTPCN, hosted
workshops, conducted community presentations,
increased their earned media presence and
distributed educational materials to providers who
work with pregnant women and children. SATF
found that health professionals used a more skillful
approach with pregnant and parenting patients
about smoking behaviors and offered smoking
cessation resources. More healthcare providers are
voluntarily distributing cessation and educational
materials to their patients. As a result, calls to the
state quitline greatly increased.
Among those mothers in McDowell County who
had previously smoked, but reported recently
quitting smoking, almost half (48 percent)
indicated they quit after the tobacco education
received from the SCTPCN. Of those who quit,
36 percent were pregnant mothers and 64 percent
were post-partum mothers. Seventy-eight percent
of the social service providers and medical
providers ‘strongly agreed’ that they could list the
5-A’s and describe how they apply to individuals
who are unwilling and willing to quit after the
BTI training. The providers all agreed that they
could describe the harmful effects of tobacco use
and the risk of smoking during pregnancy and
breast feeding. Ninety-six percent of the mothers
reported having established a household smoke-
free policy as well as a smoke-free vehicle policy
(100 percent) during follow-up sessions.
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20. H
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increase the number of tobacco users who attempt
to quit, strategies to increase the frequency of
these cessation attempts, strategies to improve the
success rate of individual cessation attempts, and
strategies to achieve all of these goals.
TFCPS Recommendations:
✓ Increasing the unit price for tobacco
products (strongly recommended)
Interventions to increase the unit price of tobacco
products include state and federal legislation
raising the excise tax on these products. Although
other factors also affect tobacco product pricing,
excise tax increases historically have resulted in
equivalent or larger increases in tobacco product
prices. Interventions to increase the price of
tobacco products are strongly recommended by the
TFCPS based on strong evidence of effectiveness.
These interventions have been found to:
n Reduce population consumption of tobacco
products;
n Reduce tobacco use initiation (described in the
“Strategies to Reduce Tobacco Use Initiation”
page 8); and
n Increase tobacco cessation.
Excise tax increases demonstrated evidence of
effectiveness in a variety of populations and when
implemented at both the national and state levels.
✓ Community Education (insufficient evidence)
These community-wide interventions provide
tobacco product users with cessation information
and motivation to quit through the use of broadcast
and print media.TheTFCPS review of the available
evidence distinguished among three types of mass
media interventions (campaigns, cessation series,
and cessation contests) that differ in the duration,
intent, and intensity of the media messages.34
34. Task Force on Community Preventive Services.
Recommendations Regarding Interventions to Reduce Tobacco Use
and Exposure to Environmental Tobacco Smoke. American Journal
of Preventive Medicine. (2001) 20(2S).
What You Can Do in Your Community:
Strategy IV: Increase Tobacco Use Cessation
• Develop a survey to determine the number of
public and private healthcare systems that
document tobacco use as a vital sign and
deliver the 5A’s (Ask, Advise, Assist, Assess
and Arrange follow-up) or AAR (Ask, Advise
and Refer) interventions.
• Encourage adoption of tobacco-free policies
on healthcare system campuses by educating
and training health care providers on how to
implement provider reminder systems and
how to deliver the 5A’s or AAR intervention to
their patients.
• Implement a provider reminder system and the
5A’s or AAR interventions in the local health
units and at all clinics sponsored and/or
operated by the local city/county or state
Department of Health, including Women,
Infants and Children (WIC) and Family
Health Branch (Family Planning and Maternal
Child Health) Program.
• Collaborate with federally-qualified health
centers (FQHC) and local dental offices to
implement a provider reminder system and the
5A’s or AAR interventions.
• Incorporate provider reminder systems and
the 5A’s or AAR interventions into the
curriculum at the higher education institutions
training health care professionals, including
nurses,dentists,dentalhygienists,pharmacists,
respiratory therapists, optometrists, etc.
• Develop a plan to educate healthcare providers
about treating tobacco use and how to make
fax referrals to the State Tobacco Helpline
(1-800-QUIT-NOW).
• Work with local health care professionals to
include tobacco use prevention and cessation
information on all in-take forms at clinics,
hospitals and health centers.
21. H
21
Importance of Building
Community Partnerships
Relationship building may very well be one of the
single most important strategies coalitions can
consistently practice and render positive tobacco
prevention outcomes if maintained appropriately. It
is a way to leverage resources, maximize capacity
and sustain momentum around the tobacco-related
indicators identified in the community. CADCA
encourages coalitions to convene and combine tal-
ent and resources to address local alcohol, tobacco
and other drug issues by partnering with the fol-
lowing sectors: law enforcement, youth, parents,
businesses, media outlets, schools, youth serving
organizations, faith-based organizations, civic and
volunteer groups, health care professionals and
state, local or tribal agencies. Partnerships with
these sectors present an opportunity for recipro-
cated education whereas the sectors learn about
how a community coalition operates to reduce un-
healthy behaviors, such as tobacco use, and the co-
alition learns about these various sector operations
and how to thread evidence-based tobacco preven-
tion strategies into their organizational structure.
A large county in Kentucky, for example, has had
tremendous success in sustaining tobacco control
outcomes by diversifying their coalition member-
ship. Dottie Kraemer, Calloway County Alliance
for Substance Abuse Prevention Project Director
and CADCA member, stresses that the great les-
son for any and all staff serving on a coalition is
to remember who you serve and who really does
the work. “The stronger the individual partners,
the stronger the coalition, and thus the goals of the
community do get accomplished,” Kraemer said.
As community partners and agency staff get
to know one another, opportunities to share
resources within the coalition become apparent.
Neighborhoods benefit from an influx of new
contractual interactions with agencies, enhancing
the tobacco use cessation services offered and
provided in their communities. Many CADCA
coalitions have found that investing in the building
of new and trusting relationships with various sec-
tors of the community can produce strong positive
benefits – not just for the coalition and their target
audience, but for the surrounding neighborhoods
as well. These relationships change social norms.
Communities with strong, active relationships
become the leaders in their city and/or county for
other areas in their state and the benefits become
a domino effect. As a Community Transformation
Grant National Network recipient, CADCA
has formed partnerships with the International
Association of Chiefs of Police (IACP), National
Sheriffs’ Association (NSA), National District
Attorneys’ Association (NDAA) and Lions Clubs
International to disseminate tobacco-free living
strategies to their members and employees. We
recognize how the benefits of partnerships com-
pound when the national focus on tobacco issues
are supported and mimicked on the local level
– those relationships are designed to deepen and
enhance the local work coalitions are doing in
meaningful ways.
22. H
22
Local/State:
Asthma Specialty Clinics/Physicians
Big Brothers, Big Sisters Program
Boys and Girls Clubs of America
Boy Scouts/Girl Scouts
Chamber of Commerce
City/County Health Departments
Community Services Agencies for
hearing and visually impaired
Dental offices
District Attorney’s Office
Faith-based Organizations
Family Counseling Agencies
Fire Department
Greek fraternity and sorority local chapters
Grocery and convenience store managers
Homeless Shelter/Agencies
K-12 Schools
The Kiwanis Club
Local chapters of American Cancer Society
Local chapters of American Heart Association
Local chapters of American Lung Association
Parks and Recreation Agencies
Police Department
Pre-medicine, nursing and
dental college students
Restaurant managers/association
Sheriff’s Department
State Health Department
State tobacco control program
University and college campuses
Veterinary Pet Clinics/Associations
Women, infants and children (WIC) Program
YMCA/YWCA
Youth Family Service agencies
National:
American Cancer Society
American Heart Association
Americans for Nonsmokers’ Rights
American Lung Association
Campaign for Tobacco Free Kids
Centers for Disease Control and Prevention
Food and Drug Administration
Center for Tobacco Products
Legacy for Health
National Networks for Tobacco
Control and Prevention
Robert Wood Johnson Foundation
Smoking Cessation Leadership Center at
University of California, San Francisco
Partners to Consider:
23. H
23
he findings and recommendations
outlined here in Strategizer 56 offer
local communities a blueprint for
implementing successful tobacco prevention
interventions. The recommendations are designed
to provide community programs and leaders with
a succinct summary on the level of effectiveness
of interventions to curb the influence and change
the perception of tobacco use. It’s important
to note that the Community Guide reviews
suggest that effectiveness within each of the
noted strategic directions (cessation, initiation,
reducing secondhand smoke) demands a similar
comprehensive approach in the combination
and coordination of interventions. This task,
although challenging, is possible. Engaging the
range of community members and leaders to
actively contribute to the execution of the plan
can alleviate burn-out and a motivational plateau
among the coalition members. This publication
only features a summary of the conclusions and
recommendationsfromtheTFCPSoninterventions
to reduce the initiation of tobacco use, to increase
tobacco use cessation, and to reduce exposure
to environmental tobacco smoke. The evidence
provided grants local communities the opportunity
to expand the listed interventions in Table 1
(page 7) through interactive and innovative avenues
including social media and networking, guerilla
marketing techniques influenced by youth and
virtual platforms that tell the stories of tobacco
prevention champions, just to name a few. The
work of the TFCPS offers timely and appropriate
reviews for communities to use in order to track
positive changes that are complementary to the
Healthy People 2020 objectives in Table 2 (page 24).
This work supplements community education
opportunities with “call to action” tasks that
are effective, sustainable approaches to reduce
the exposure to environmental tobacco smoke.
Coalitions and others in the community should
recognize the power of bringing all types of people
and sectors to the table to tackle tobacco-related
issues.Tobacco use affects everyone – nonsmokers
and smokers alike. That’s why it’s important to
develop a comprehensive plan with a diversified
approach. Solving community problems can
never be mitigated to a one-size-fits-all model.
Coalitions can refer to these evidence-based
strategies outlined in this publication to guide their
local decisions, actions and evaluation measures,
while maintaining a focus on sustainability.
The information provided in this publication is,
therefore, designed to contribute in different ways,
to tobacco prevention and control efforts across
a range of audiences, settings, environmental
structures and situations.
T
Conclusion
24. H
24
TOBACCO USE
Reduce tobacco use by adults from 20.6% to 12%.
Reduce tobacco use by adolescents from 26% to 21%.
Reduce the initiation of tobacco use among children, adolescents, and young adults from 7.7% to 5.7%.
Increase smoking cessation attempts by adult smokers from 48.3% 80%.
Increase recent smoking cessation success by adult smokers from 6% to 8%.
Increase smoking cessation during pregnancy from 11.3% to 30%.
Increase smoking cessation attempts by adolescent smokers from 58.5% to 64%.
HEALTH SYSTEMS CHANGE
Increase comprehensive Medicaid insurance coverage of evidence-based treatment for nicotine dependency in
States and the District of Columbia from 6 states to 51 states (50 States and District of Columbia).
Increase tobacco screening in health care settings from 62.4 to 68.6%.
Increase tobacco cessation counseling in health care settings from 19.2% to 21.1%.
SOCIAL AND ENVIRONMENTAL CHANGES
Reduce the proportion of nonsmokers exposed to secondhand smoke from 52.2% to 47%.
Increase the proportion of persons covered by indoor worksite policies that prohibit smoking from 75.3% to 100%.
Establish laws in States, District of Columbia, Territories, and Tribes on smoke-free indoor air that prohibit
smoking in public places and worksites from 30 to 51 (50 States and District of Columbia).
Increase the proportion of smoke-free homes from 79.1% to 87%.
Increase tobacco-free environments in schools, including all school facilities, property, vehicles, and school
events to 100%.
Eliminate State laws that preempt stronger local tobacco control laws.
Increase the Federal and State tax on tobacco products.
Reduce the proportion of adolescents and young adults grades 6 through 12 who are exposed to tobacco
advertising and promotion.
Reduce the illegal sales rate to minors through enforcement of laws prohibiting the sale of tobacco products to
minors from 5 to 51 (50 States and District of Columbia).
(Developmental) Increase the number of States and the District of Columbia, Territories, and Tribes with
sustainable and comprehensive evidence-based tobacco control programs.
Table 2:
Healthy People 2020 Objectives: Tobacco Use
H
Source: Healthy People 2020
25. H
25
n Americans for Nonsmokers’ Rights (ANR):
ANR, formed in 1976, pursues efforts to enact
legislation to protect nonsmokers in the
workplace and enclosed public places.
http://www.no-smoke.org/
n Addiction Incorporated: A documentary that
tells the true story of Dr. Victor DeNoble, one
of the most important and influential
whistleblowers of all time.
http://www.addictionincorporated.com/
n CADCA Tobacco Initiatives Page: A library
of tobacco prevention and control resources,
such as toolkits, fact sheets and articles, to help
coalitions implement policy interventions to
reduce tobacco use in their communities.
http://www.cadca.org/tobacco
n Campaign for Tobacco Free Kids: Provides
community coalitions with advocacy tools for
public policies and fact sheets to help prevent
kids from smoking, help smokers quit and
protect everyone from secondhand smoke.
http://www.tobaccofreekids.org
n CDC Office on Smoking and Health: The
lead federal agency for comprehensive tobacco
prevention and control providing communities
with premiere facts, evidence-based articles and
practice-based strategies to reduce the harmful
effects of tobacco use.
http://www.cdc.gov/tobacco/index.htm
n ChangeLab Solutions (formerly Public
Health Law Policy): ChangeLab Solutions’
tobacco control attorneys provide advocates,
health professionals, government attorneys, and
elected officials with high-quality products and
services on tobacco control policies.
http://changelabsolutions.org/tobacco-control
n FDA Center of Tobacco Products: The Center
for Tobacco Products (CTP) oversees the
implementation of the Family Smoking
Prevention and Tobacco Control Act. Their
website features a host of tobacco product topics
(regulation, compliance, etc.), funding
opportunities, webinars, fact sheets on youth and
tobacco and resources for consumers; retailers;
manufacturers; researchers; health professionals
and state; local; tribal and territorial
governments.
http://www.fda.gov/tobaccoproducts/default.htm
n Guide to Community Preventive Services:
The Community Guide is a resource for
evidence-based Task Force recommendations
and findings about what works to improve
public health.
http://www.thecommunityguide.org/tobacco/
index.html
n Legacy for Health: Develops game-changing
public health campaigns and technical resources
to reduce tobacco use among young people and
adults.
http://www.legacyforhealth.org/aspen/
n Legacy Tobacco Documents: The Legacy
Tobacco Documents Library (LTDL) contains
more than 13 million documents created by
major tobacco companies related to their
advertising, manufacturing, marketing, sales,
and scientific research activities.
http://legacy.library.ucsf.edu/
H
Helpful Resources
26. H
2626
H
n National Networks for Tobacco Control:
In 2006, the Centers for Disease Control and
Prevention (CDC) Office on Smoking and
Health (OSH) funded six Networks to provide
leadership and expertise in the development of
policy related initiatives (including
environmental and systems change) and
utilization of proven or potentially promising
practices when available or appropriate.
• Asian Pacific Partners for Empowerment,
Advocacy, and Leadership (APPEAL)
• Break Free Alliance
• National African American Tobacco
Prevention Network (NAATPN)
• National Latino Tobacco Control Network
(NLTCN)
• National Native Network (NNN)
• The Network for LGBT Health Equity
http://www.tobaccopreventionnetworks.org/
site/c.ksJPKXPFJpH/b.2580071/k.BD53/
Home.htm
n North American Quitline Consortium:
The North American Quitline Consortium
(NAQC) is an international, non-profit
membership organization based in Oakland,
Calif. that seeks to promote evidence-based
quitline services across diverse communities
in North America.
http://www.naquitline.org/?page=mappage
n Quit Tobacco: Quit Tobacco—Make Everyone
Proud is an educational campaign for the U.S.
military, sponsored by the U.S. Department of
Defense.
http://youcanquit2.org/
n Robert Wood Johnson Foundation (RWJF):
RWJF provides public health professionals and
community coalitions with up-to-date
resources, such as publications and policy
briefs, to reduce tobacco use in their
communities to transform itself for the better.
http://www.rwjf.org/pr/topic.jsp?topicid=1030
n Smoking Cessation Leadership Center at
the University of California, San Francisco:
As a national program office of the RWJF,
SCLC provides coalitions with training and
research-based publications aimed to increase
smoking cessation rates and the number of
health professionals who help smokers quit.
http://smokingcessationleadership.ucsf.edu/
index.htm
1-877-509-3786
n State Tobacco Activities Tracking and
Evaluation System: The State Tobacco
Activities Tracking and Evaluation (STATE)
System is an interactive application that
houses and displays current and historical
state-level data on tobacco use prevention and
control.
www.cdc.gov/tobacco/statesystem
n Tobacco Control Network: A database
comprised of the tobacco control program
managers and additional staff from each state,
territory, and D.C.
http://www.ttac.org/tcn/index.html
n Tobacco Technical Assistance Consortium
(TTAC): The Tobacco Technical Assistance
Consortium (TTAC) builds and develops
highly effective tobacco control programs,
provides individualized technical assistance
and customized trainings to help communities
succeed in their tobacco control efforts.
http://www.ttac.org/
n Trinkets Trash: Trinkets and Trash (TT)
acts as a surveillance system that monitors,
collects, and documents tobacco products and
current tobacco industry marketing tactics.
http://www.trinketsandtrash.org/
28. H
28
About CADCA
Community Anti-Drug Coalitions of America (CADCA) is the nation’s
leading substance abuse prevention organization representing more than 5,000
community anti-drug coalitions across the country and internationally. CADCA’s
mission is to strengthen the capacity of community coalitions by providing
technical assistance and training, public policy and advocacy, media strategies
and marketing programs, conferences and special events.
This publication is part of CADCA’s Strategizer series. Strategizers offer concise,
proven solutions to issues facing coalitions. Designed to provide step-by-step
guidance, Strategizers range in topics from how to start a coalition, advocacy,
getting the faith community involved, youth programs, conducting evaluations
to reducing underage drinking, prescription drug abuse prevention, the myths
of marijuana, effective prevention strategies, and community mobilization. To
order copies, visit www.cadca.org or send an e-mail to editor@cadca.org.
To reproduce this publication, include the following citation: This Strategizer
was developed by Community Anti-Drug Coalitions of America (CADCA).
Published August 2012.
625 Slaters Lane
Suite 300
Alexandria, VA 22314
1-800-54-CADCA
www.cadca.org
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Twitter: @CADCA
www.youtube.com/CADCA09
