Improving Tobacco Control

The Problem

Tobacco use imposes a considerable burden on society, including disease, lives lost, health care costs, and economic costs resulting from lost productivity. Smoking is the leading cause of premature death and preventable disease in the United States and is responsible for about 480,000 premature deaths each year.

Smoking is a multi-billion dollar problem causing hundreds of thousands of premature deaths.

What Can Be Done?

Comprehensive tobacco control efforts save lives, improve health outcomes, and reduce health care and lost-productivity costs. To maximize health and economic benefits, CDC recommends investments in comprehensive statewide tobacco control programs that include the following components:

• State and community interventions  to prevent initiation of tobacco use, promote tobacco cessation, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities;
• Mass-reach health communication interventions  to raise awareness of the health effects of smoking and secondhand smoke exposure, promote tobacco cessation, and discourage tobacco use initiation;
• Cessation interventions  that expand insurance coverage for cessation treatments and use of these treatments, make tobacco-dependence treatment part of routine clinical care, and increase quitline capacity;
• Surveillance and evaluation  of attitudes, behaviors, and health outcomes to assess program effectiveness and impact over time; and
• Infrastructure, administration, and management  to achieve the capacity needed to sustain program effectiveness and efficiency and foster collaboration among state and local entities.

State Examples

California
Between 1989 and 2008, the California tobacco control program, which cost an estimated $2.4 billion, reduced health care expenditures statewide by an estimated $134 billion. California used a comprehensive approach to tobacco control efforts, including community interventions, smoke-free laws, tobacco tax increases, and media campaigns that included promotion of state cessation and quitline services. Between 1988 and 2010, the adult smoking rate in California fell from 22.7 percent to 11.9 percent. Since 1998, lung cancer incidence in California has been declining four times faster than in the rest of the United States.⁷

Arizona
Arizona’s tobacco control program has focused on preventing youth initiation of tobacco use.⁸ Between 1996 and 2004, the Arizona program, which cost $235 million, generated about $2 billion in health care cost savings.⁹

Florida
From 1998 to 2003, a comprehensive prevention program in Florida, anchored by an aggressive youth-oriented health communication campaign, reduced the preva¬lence of smoking among middle- and high-school students by 50 percent and 35 percent, respectively.¹⁰

New York
From 2001 to 2010, the New York State Tobacco Control Program reported declines in the preva¬lence of smoking among adults and youth that outpaced declines nationally.¹¹ As a result, smoking-attributable personal health care expen¬ditures in New York in 2010 were $4.1 billion less than they would have been had the prevalence of smoking remained at 2001 levels.⁸

Strategies for Improved Public Health

State and Community Interventions
Active, coordinated, state- and community-level interventions form the foundation of comprehensive tobacco control programs. These interventions mobilize communities to:

• Promote tobacco use cessation;
• Prevent tobacco use initiation;
• Eliminate secondhand smoke exposure; and
• Identify and eliminate tobacco-related disparities.

Mass-Reach Health Communication Interventions
Typically, the most effective state and community interventions are those that are combined with mass-reach health communication interventions. This involves strategic, culturally appropriate, and high-impact messages delivered through sustained and adequately funded campaigns and a variety of media, such as television, radio, print, Internet and social media, and local events.

Cessation Interventions
Comprehensive tobacco cessation activities can focus on three broad goals: 1) promoting health systems change to fully integrate tobacco-dependence treatment into routine clinical care; 2) expanding public and private insurance coverage of proven cessation treatments; and 3) supporting state quitline capacity.

Surveillance and Evaluation
Monitoring the achievement of program goals and evaluating implementation and outcomes increase efficiency and impact over time, demonstrate accountability, and provide credible information for programmatic decision making.

Infrastructure, Administration, and Management
To be effective, efficient, and sustainable, comprehensive tobacco control programs need to be appropriately resourced with adequate funding, staff, leadership, and support.

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² U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. 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, 2014.
³ Lightwood J, Glantz SA. The effect of the California tobacco control program on smoking prevalence, cigarette consumption, and healthcare costs: 1989-2008. PLoS One 2013; 8(2):e47145.

⁴ Richard P, West K, Ku L. The Return on Investment of a Medicaid Tobacco Cessation Program in Massachusetts. PLoS ONE 2012; 7(1): e29665. doi:10.1371/journal.pone.0029665.
⁵ McCallum, D. M. & Fosson, G. H. & Pisu, M. Making the Case for Medicaid Funding of Smoking Cessation Treatment Programs: An Application to State-Level Health Care Savings.” Journal of Health Care for the Poor and Underserved, vol. 25 no. 4, 2014, pp. 1922-1940. Project MUSE. doi:10.1353/hpu.2014.0171.
⁶ Athar, H., et al. Impact of Increasing Coverage for Select Smoking Cessation Therapies With no Out-of-Pocket Cost Among the Medicaid Population in Alabama, Georgia, and Maine. Journal of Public Health Management and Practice 2016. 22(1): 40-47.

⁷ Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2014. Atlanta: 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, 2014.
⁸ Meister JS. Designing an effective statewide tobacco control program—Arizona. Cancer 1998; 83(S12A): 2728–32, doi: 10.1002/(SICI) 1097-0142(19981215)83:12A+<2728::AID-CNCR13>3.0.CO; 2-3. Available at Wiley Online Library .
⁹ Lightwood J, Glantz S. Effect of the Arizona tobacco control program on cigarette consumption and healthcare expenditures. Soc Sci Med 2011; 72(2): 166–72, doi: 10.1016/j.socscimed.2010.11.015.
¹⁰ Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program. JAMA 2000; 284(6): 723–8.
¹¹ RTI International. 2011 Independent Evaluation Report of the New York Tobacco Control Program. Albany, NY: New York State Department of Health, 2011.