Tobacco Use: Comprehensive Tobacco Control Programs

Included studies consistently showed that comprehensive tobacco control programs reduce the prevalence of tobacco use among adults and young people, reduce tobacco product consumption, increase quitting, and contribute to reductions in tobacco-related diseases and deaths. Additionally, increases in program funding are associated with increases in program effectiveness.

Prevalence of Tobacco Use among Adults (22 studies)

• Overall median decrease of 3.9 percentage points (interquartile interval [IQI]: 5.6 to 2.6 percentage points; 16 studies); programs were implemented for a median of 9 years.
  • Studies from U.S. only: median decrease of 2.8 percentage points (IQI: 3.5 to 2.4 percentage points; 12 studies); programs were implemented for a median of 9 years.
• U.S. states with a comprehensive tobacco control program saw a median additional annual reduction of 0.46 percentage points compared to the rest of the country (IQI: 0.24 to 0.69 pct pts; 5 studies). Over time, the difference between state and national declines narrowed (2 studies).
• A county comprehensive tobacco control program in the U.S. reduced adult smoking prevalence by 6.3 percentage points over a period of 6 years (1 study).
• Self-reported exposure to multiple components of a U.S. state comprehensive tobacco control program was significantly associated with reductions in prevalence of adult smoking (1 study).

Cessation (8 studies)

• A country with a national comprehensive program saw an increased quit rate following program implementation (1 study).
• States and localities with comprehensive tobacco control programs saw greater increases in cessation rates in before-after comparisons (2 studies, 1 U.S. and 1 non-U.S.) and when compared to the rest of the country or localities without such programs (4 studies, all U.S.).
• A U.S. state with a comprehensive tobacco control program had similar cessation rates as the rest of the country (1 study).

Prevalence of Tobacco Use among Young People (<25 Years of Age) (14 studies)

• Overall median decrease of 4.6 percentage points (IQI: 8.4 to 1.1 percentage points; 10 studies); programs were implemented for a median of 8 years.
  • Studies from U.S. only: median decrease of 4.5 percentage points (IQI: 6.0 to 0.7 percentage points; 9 studies); programs were implemented for a median of 6 years.
• In three studies, U.S. states or localities with comprehensive tobacco control programs had greater reductions in smoking prevalence among young people than states or localities without such programs.
• In one study, self-reported exposure to multiple components of a U.S. state comprehensive tobacco control program was not associated with reductions in prevalence of smoking among young people.

Initiation (3 studies)

• Comprehensive tobacco control programs reduced initiation among adolescents (11-17 years old; 3 studies) but had little or no impact on initiation among young adults (18-25 years old; 2 studies).
  • U.S. states with comprehensive tobacco control programs had greater reductions in initiation among 11-15 year olds compared to rest of the country (1 study) and saw reductions in initiation among 12-17 year olds in before-after comparisons (2 studies).
  • U.S. states with comprehensive tobacco control programs had little or no impact on initiation among 16-22 year olds compared to the rest of the country (1 study) or among 18-26 year olds in a before-after comparison (1 study).

Tobacco Consumption (18 studies)

Cigarette Pack Sales (number of packs sold per month; 11 studies)

• Studies from U.S. only: median decrease of 12.7% (IQI: 20.8% to 5.5%; 7 studies); programs were implemented for a median of 4 years.
• In four studies, U.S. states with a comprehensive tobacco control program had a greater annual decline (2 studies) or greater overall decline (2 studies) in cigarette sales than the rest of the country.

Individual Daily Consumption (number of cigarettes consumed per day; 10 studies)

• Overall median decrease of 17.1% (IQI: 43.4% to 13.5%; 6 studies); programs were implemented for a median of 8 years.
  • Studies from U.S. only: median decrease of 23.7% (range: 54% to 12.3%; 5 studies); programs were implemented for a median of 8 years.
• U.S. states with comprehensive tobacco control programs showed greater reductions in daily consumption when compared to the rest of the country (2 studies) and with before-after comparisons (2 studies).

Exposure to Secondhand Smoke (4 studies)

Secondhand Smoke Exposure (2 studies)

• U.S. states with comprehensive tobacco control programs saw reductions in adults’ exposure to secondhand smoke at home or work ( 2.5 percentage points and -1.6 percentage points, respectively, 1 study), or overall ( 21.6 percentage points, 1 study) following program implementation.

Prevalence of Smoke-Free Homes (3 studies)

• U.S. states with comprehensive tobacco control programs saw increased number of households that adopted voluntary smoke-free rules by a median of 8.9 percentage points (range: 3.0 to 18.7 percentage points; 3 studies) following program implementation.

Tobacco-Related Diseases and Deaths (8 studies)

Morbidity (2 studies)

• U.S. states with comprehensive tobacco control programs saw reduced lung cancer incidence (1 study) and hospitalization due to tobacco-related diseases (1 study).

Mortality (6 studies)

• U.S. states with comprehensive tobacco control programs saw reduced lung cancer mortality (3 studies), smoking-attributable cancer mortality ( 18.4%; 1 study), and tobacco-related cardiovascular mortality (3 studies).

Tobacco-Related Disparities (10 studies)

Stratified Analyses by Race/Ethnicity (5 studies)

• Comprehensive tobacco control programs had similar effects across examined racial and ethnic groups for the following outcomes:
  • Reducing tobacco use prevalence among adults (3 studies) and young people (2 studies).
  • Reducing secondhand smoke exposure (1 study).

Stratified Analyses by Education (4 studies)

• Comprehensive tobacco control programs were effective across groups with different levels of educational attainment for the following outcomes:
  • Reducing tobacco use prevalence among adults (2 studies).
  • Reducing individual daily consumption (1 study).
  • Increasing cessation (2 studies).
• A national program reduced the odds of being a smoker for all groups, but groups with the lowest education attainment had the highest odds of being a smoker (1 study).

Stratified Analyses by Income/Socio-economic Status (SES) (3 studies)

• Comprehensive tobacco control programs were effective across groups with different income levels or SES for the following outcomes:
  • Reducing tobacco use prevalence among adults (1 study) and young people (1 study).
  • Reducing secondhand smoke exposure (1 study).
• A national program reduced smoking prevalence and increased cessation across all SES groups; the lowest SES group experienced the greatest increase in cessation (1 study).

Impact Due to Changes in Program Funding or Strength (18 studies)

In 16 studies, changes in tobacco use outcomes were evaluated in relationship to changes in comprehensive tobacco control program funding levels (some studies assessed more than one outcome)

• In 13 of 16 studies, increased program funding was associated with increased program impact, including:
  • Decreased tobacco use prevalence among adults (3 studies); no impact in 2 studies.
  • Increased sustained cessation among pregnant women after delivery but no impact on cessation during pregnancy (1 study).
  • Decreased tobacco use prevalence among young people (2 studies); no impact in 1 study.
  • Decreased tobacco use initiation (2 studies).
  • Increased cessation among young people (1 study).
  • Decreased cigarette pack sales (6 studies); no impact in 1 study.
  • Decreased individual daily consumption (1 study).

In two studies, changes in tobacco use outcomes were evaluated in relationship to program strength (presence or extent of implemented interventions and policies)

• Increased program strength were associated with the following outcomes (2 studies):
  • Decreased adult smoking prevalence (1 study); program strength measured as composite score of program funding, staff capacity, and policy and environment change as a result of the program.
  • Increased cessation (1 study); program strength measured as composite score of 6 tobacco control policies and interventions.

Twelve studies were included in the economic review (10 from the U.S. and 2 from Australia). Of the U.S. studies, 8 considered state comprehensive tobacco control programs and 2 examined data from the entire country. Estimates of cost-effectiveness were compared to a conservative cost-effectiveness threshold of $50,000 per quality-adjusted life year saved (QALYS). All monetary values are reported in 2012 U.S. dollars.

Economic evidence indicates that comprehensive tobacco control programs are cost-effective, and savings from averted healthcare costs exceed intervention costs.

• Healthcare costs averted (10 studies)
  • Estimates of healthcare costs averted varied substantially, mainly due to variations in the examined programs and differences in modeling practices used by researchers.
  • Values ranged from $34.9 million over 75 years in Australia (population in 2013: 23.1 million) to $141.1 billion over 20 years in California (population in 2013: 38.3 million).
• Cost-effectiveness estimates (3 studies)
  • Cost per QALY saved (2 studies)
    • $24/QALYS economic effect of a single year of state and national tobacco control programs for Australian population at $0.51 program cost per capita.
    • $857/QALYS economic effect of 15 years of state funding for tobacco control for US population at $1.21 annual per capita program cost.
  • Cost per life year saved: $5,629 (1 study).
• Cost-benefit estimates (9 studies)
  • Median benefit-to-cost ratio of 12:1 (IQI: 3:1 to 56:1).

• U.S. and non-U.S. settings
• National, state, city, and local scale programs
• Adults and young people
• Males and females
• All racial groups examined (African-American, non-Hispanic white, Asian/Pacific Islander, Hispanic)
• All SES groups (education attainment and income levels used as proxy)

• More research is needed to examine longitudinal associations between comprehensive tobacco control programs and changes in the presence and strength of tobacco control policies. It would also be useful to understand the relationships between specific comprehensive program components and policy changes.
• Funding levels vary widely for overall tobacco control programs and the specific components within them. More information is needed about the relationships between funding levels for specific components and overall comprehensive program effectiveness.
• In the U.S., state programs emphasize different goals for their comprehensive tobacco control programs (e.g., to increase the number of tobacco users who quit, reduce tobacco use among young people, or reduce exposures to secondhand tobacco smoke) and vary funding levels accordingly. More research is needed to examine how these differences modify overall program effectiveness.
• Research is needed to examine the effects of comprehensive tobacco control programs on use of combustible tobacco products other than cigarettes (e.g., cigars and cigarillos), and noncombustible nicotine delivery products (e.g., e-cigarettes and smokeless tobacco products). Future studies could compare changes in use based on the presence or funding levels of program interventions/components directed at products other than cigarettes. Studies could also examine the effects of comprehensive tobacco control programs on product substitution (i.e., switching from cigarettes to smokeless tobacco) among tobacco users who do not quit.
• Continued research is needed on the effectiveness of comprehensive tobacco control programs among subpopulations with high rates of tobacco use. It would also be useful to know more about the independent effectiveness of specific program components among these subpopulations.
• Continued economic research is needed to examine cost-effectiveness of comprehensive tobacco control programs. Studies could also examine cost-effectiveness for specific program components.
• Future economic research should assess changes in worker productivity (such as averted productivity losses attributable to reductions in tobacco use).

• Included studies assessed comprehensive tobacco control programs in the United States (55 studies), Australia (2 studies), Canada (1 study), France (1 study), Ireland (1 study) and nations within the European Union (1 study).
• Most of the U.S. studies evaluated comprehensive programs at the state level (48 studies from 10 states) with the remaining studies at the city (3 studies from New York City) and local or community level (4 studies from New York and Texas).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Tables – Effectiveness Review

Economic Review

Summary Evidence Table – Economic Review

Effectiveness Review

Sixty-one studies were included in this review, and 5 papers provided more information about included studies.

Adams EK, Markowitz S, Kannan V, Dietz PM, Tong VT, Malarcher AM. Reducing Prenatal Smoking: The Role of State Policies. American Journal of Preventive Medicine 2012;43(1):34-40.

Al-Delaimy WK, Pierce JP, Messer K, White MM, Trinidad DR, Gilpin EA. The California Tobacco Control Program’s effect on adult smokers: (2) Daily cigarette consumption levels. Tobacco Control 2007(2):91-5.

Bandi P, Remington PL, Moberg DP. Progress in reducing cigarette consumption: the Wisconsin tobacco control program, 2001-2003. WMJ 2006(5):45-9.

Barnoya J, Glantz S. Association of the California tobacco control program with declines in lung cancer incidence. Cancer Causes Control 2004(7):689-95.

Biener L, Harris JE, Hamilton W. Impact of the Massachusetts tobacco control programme: population based trend analysis. BMJ 2000(7257):351-4.

CDC. Cigarette smoking before and after an excise tax increase and an antismoking campaign–Massachusetts, 1990-1996. MMWR 1996(44):966-70.

CDC. Decline in cigarette consumption following implementation of a comprehensive tobacco prevention and education program-Oregon, 1996-1998. MMWR 1999(7):140-3.

CDC. Decline in smoking prevalence-New York City, 2002-2006. MMWR 2007;56(24):604-8.

CDC. Decrease in smoking prevalence-Minnesota, 1999-2010. MMWR 2011(5):138-41.

Chattopadhyay S, Pieper DR. Does spending more on tobacco control programs make economic sense? An incremental benefit-cost analysis using panel data. Contemporary Economic Policy 2012:30(3):430-47.

Chen X, Li G, Unger J, Liu X, Johnson CA. Secular trends in adolescent never smoking from 1990 to 1999 in California: an age-period-cohort analysis. AJPH 2003;93(12):2099-104.

Ciecierski CC, Chatterji P, Chaloupka FJ, Wechsler H. Do state expenditures on tobacco control programs decrease use of tobacco products among college students? Health Economics 2011;20(3):253-72.

Cowling D, Yang J. Smoking-attributable cancer mortality in California, 1979-2005. Tobacco Control 2010;19 Suppl 1:i62-i7.

Currie L, Blackman K, Clancy L, Levy D. The effect of tobacco control policies on smoking prevalence and smoking-attributable deaths in Ireland using the IrelandSS simulation model. Tobacco Control 2013;22(e1):e25-e32.

Dilley J, Rohde K, Dent C, Boysun M, Stark M, Reid T. Effective tobacco control in Washington State: a smart investment for healthy futures. Preventing Chronic Disease 2007;4(3):A65-A.

Dilley J, Harris J, Boysun M, Reid T. Program, policy, and price interventions for tobacco control: quantifying the return on investment of a state tobacco control program. AJPH 2012;102(2):e22-e8.

Farrelly MC, Pechacek TF, Chaloupka FJ. The impact of tobacco control program expenditures on aggregate cigarette sales: 1981-2000. J Health Econ 2003(5):843-59.

Farrelly MC, Pechacek TF, Thomas KY, Nelson D. The impact of tobacco control programs on adult smoking. AJPH 2008(2):304-9.

Farrelly MC, Loomis BR, Han B, et al. A Comprehensive Examination of the Influence of State Tobacco Control Programs and Policies on Youth Smoking. AJPH 2013;103(3):549-55.

Farrelly M, Arnold K, Juster H, Allen J. Quantifying the effect of changes in state-level adult smoking rates on youth smoking. Journal of Public Health Management and Practice 2014;20(2):E1-E6.

Farrelly M, Loomis B, Kuiper N, et al. Are tobacco control policies effective in reducing young adult smoking? Journal of Adolescent Health 2014;54(4):481-6.

Fichtenberg CM, Glantz SA. Association of the California Tobacco Control Program with Declines in Cigarette Consumption and Mortality from Heart Disease. New England Journal of Medicine 2000;343(24):1772-7.

Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003. AJPH 2005(6):1016-23.

Germain D, Durkin S, Scollo M, Wakefield M. The long-term decline of adult tobacco use in Victoria: changes in smoking initiation and quitting over a quarter of a century of tobacco control. Australian and New Zealand Journal of Public Health 2012;36(1):17-23.

Gilpin EA, Messer K, White MM, Pierce JP. What contributed to the major decline in per capita cigarette consumption during California’s comprehensive tobacco control programme? Tobacco Control 2006(4):308-16.

Jemal A, Thun M, Yu X, et al. Changes in smoking prevalence among U.S. adults by state and region: Estimates from the Tobacco Use Supplement to the Current Population Survey, 1992-2007. BMC Public Health 2011;11(1):512.

Kabir Z, Connolly GN, Clancy L, Jemal A, Koh HK. Reduced lung cancer deaths attributable to decreased tobacco use in Massachusetts. Cancer Causes Control 2007(8):833-8.

Kabir Z, Connolly GN, Clancy L, Koh HK, Capewell S. Coronary heart disease deaths and decreased smoking prevalence in Massachusetts, 1993-2003. AJPH 2008(8):1468-9.

Kilgore EA, Mandel-Ricci J, Johns M, et al. Making It Harder to Smoke and Easier to Quit: The Effect of 10 Years of Tobacco Control in New York City. AJPH 2014;104(6):e5-e8.

Launay M, Faou ALL, Sevilla-Dedieu C, Pitrou I, Gilbert F, Kovess-Masfety V. Prevalence of tobacco smoking in teachers following anti-smoking policies: Results from two French surveys (1999 and 2005). European Journal of Public Health 2010(2):151-6.

Levy DT, Romano E, Mumford E. The relationship of smoking cessation to sociodemographic characteristics, smoking intensity, and tobacco control policies. Nicotine Tob Res 2005(3):387-96.

Lieberman L, Diffley U, King S, et al. Local Tobacco Control: Application of the Essential Public Health Services Model in a County Health Department’s Efforts to Put It Out Rockland. AJPH 2013;103(11):1942-8.

Lightwood J, Glantz S. Effect of the Arizona tobacco control program on cigarette consumption and healthcare expenditures. Soc Sci Med 2011(2):166-72.

Lightwood J, Glantz S. The effect of the California tobacco control program on smoking prevalence, cigarette consumption, and healthcare costs: 1989-2008. PLoS ONE 2013;8(2):e47145-e.

Marlow ML. Tobacco control programs and tobacco consumption. Cato Journal 2006;26:573.

Marlow ML. Do Tobacco-Control Programs Lower Tobacco Consumption?: Evidence from California. Public Finance Review 2007;35(6):689-709.

Marlow ML. Effectiveness of Massachusetts’ comprehensive tobacco control program. Applied Economics 2012;44(3):373-85.

McAlister A, Morrison TC, Hu S, et al. Media and community campaign effects on adult tobacco use in Texas. J Health Commun 2004(2):95-109.

McAlister AL, Huang P, Ramirez AG. Settlement-funded tobacco control in Texas: 2000-2004 pilot project effects on cigarette smoking. Public Health Rep 2006(3):235-8.

Meshack AF, Hu S, Pallonen UE, McAlister AL, Gottlieb N, Huang P. Texas Tobacco Prevention Pilot Initiative: processes and effects. Health Educ Res 2004(6):657-68.

Messer K, Pierce JP. Changes in age trajectories of smoking experimentation during the California Tobacco Control Program. AJPH 2010(7):1298-306.

Messer K, Pierce JP, Zhu SH, et al. The California Tobacco Control Program. Tobacco Control 2007(2):85-90.

Miller LS, Max W, Sung H-Y, Rice D, Zaretsky M. Evaluation of the economic impact of California’s Tobacco Control Program: a dynamic model approach. Tobacco Control 2010;19(Suppl 1):i68-i76.

Morley C, Pratte M. State-level tobacco control and adult smoking rate in the United States: an ecological analysis of structural factors. Journal of Public Health Management and Practice 2013;19(6):E20-E7.

Murphy JM, Moreno SLd, Cummings KM, Hyland A, Mahoney MC. Changes in cigarette smoking, purchase patterns, and cessation-related behaviors among low-income smokers in New York State from 2002 to 2005. Journal of Public Health Management and Practice 2010(4):277-84.

Pierce JP, Gilpin EA, Emery SL, et al. Has the California Tobacco Control Program Reduced Smoking? JAMA 1998:893-9.

Pierce JP, Messer K, White MM, Kealey S, Cowling DW. Forty years of faster decline in cigarette smoking in California explains current lower lung cancer rates. Cancer Epidemiol Biomarkers Prev 2010(11):2801-10.

Pierce JP, White MM, Gilpin EA. Adolescent smoking decline during California’s tobacco control programme. Tobacco Control 2005(3):207-12.

Polednak AP. Trends in death rates from tobacco-related cardiovascular diseases in selected US states differing in tobacco-control efforts. Epidemiology 2009(4):542-6.

Reid J, Hammond D, Driezen P. Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use? Canadian Journal of Public Health 2010;101(1):73-8.

Rhoads J. The effect of comprehensive state tobacco control programs on adult cigarette smoking. Journal of Health Economics 2012;31(2):393-405.

Rigotti NA, Regan S, Majchrzak NE, Knight JR, Wechsler H. Tobacco use by Massachusetts public college students: long term effect of the Massachusetts Tobacco Control Program. Tobacco Control 2002:ii20-4.

Rohrbach LA, Howard-Pitney B, Unger JB, et al. Independent evaluation of the California Tobacco Control Program: relationships between program exposure and outcomes, 1996-1998. AJPH 2002(6):975-83.

Schaap MM, Kunst AE, Leinsalu M, et al. Effect of nationwide tobacco control policies on smoking cessation in high and low educated groups in 18 European countries. Tobacco Control 2008(4):248-55.

Siegel M, Mowery PD, Pechacek TP, et al. Trends in adult cigarette smoking in California compared with the rest of the United States, 1978-1994. AJPH 2000;90(3):372-9.

Soldz S, Clark TW, Stewart E, Celebucki C, Walker DK. Decreased youth tobacco use in Massachusetts 1996 to 1999: evidence of tobacco control effectiveness. Tobacco Control 2002:ii14-9.

Soldz S, Kreiner P, Clark TW, Krakow M. Tobacco use among Massachusetts youth: is tobacco control working? Prev Med 2000(4):287-95.

Tauras JA, Chaloupka FJ, Farrelly MC, et al. State Tobacco Control Spending and Youth Smoking. AJPH 2005;95(2):338-44.

Trinidad DR, Messer K, Gilpin EA, Al-Delaimy WK, White MM, Pierce JP. The California Tobacco Control Program’s effect on adult smokers: (3) Similar effects for African Americans across states. Tobacco Control 2007(2):96-100.

Weintraub JM, Hamilton WL. Trends in prevalence of current smoking, Massachusetts and states without tobacco control programmes, 1990 to 1999. Tobacco Control 2002:ii8-13.

White VM, Hayman J, Hill DJ. Can population-based tobacco-control policies change smoking behaviors of adolescents from all socio-economic groups? Findings from Australia: 1987-2005. Cancer Causes Control 2008(6):631-40.

Studies Providing Additional Information for Already Included Studies Implementation, Applicability, Generalizability (5 Studies)

CDC. Declines in lung cancer rates–California, 1988-1997. MMWR 2000;49(47):1066-9.

Coady M, Jasek J, Davis K, Kerker B, Kilgore E, Perl S. Changes in Smoking Prevalence and Number of Cigarettes Smoked Per Day Following the Implementation of a Comprehensive Tobacco Control Plan in New York City. J Urban Health 2012;89(5):802-8.

Gilpin EA, Pierce JP. The California Tobacco Control Program and potential harm reduction through reduced cigarette consumption in continuing smokers. Nicotine Tob Res 2002:S157-66.

Lightwood JM, Dinno A, Glantz SA. Effect of the California tobacco control program on personal health care expenditures. PLoS Med 2008(8):e178.

White VM, Warne CD, Spittal MJ, Durkin S, Purcell K, Wakefield MA. What impact have tobacco control policies, cigarette price and tobacco control program funding had on Australian adolescents. Addiction 2011;106:1493-502.

Economic Review

Carter R, Scollo M (2000) Economic evaluation of the National Tobacco Campaign. In: Hassard K, editor. Australia’s National Tobacco Campaign, Evaluation Report Volume Two. Canberra: Commonwealth Department of Health and Aged Care.

Chattopadhyay S, Pieper DR (2012) Does spending more on tobacco control programs make economic sense? An incremental benefit-cost analysis using panel data. Contemporary Economic Policy 30(3): 430-47.

Cutler DM, Gruber J, Hartman RS, Landrum MB, Newhouse JP, Rosenthal MB (2002) The economic impacts of the tobacco settlement. Journal of Policy Analysis and Management 21(1): 1-19.

Dilley J, Rohde K, Dent C, Boysun MJ, Stark MJ, Reid T (2007) Effective tobacco control in Washington State: a smart investment for healthy futures. Prev Chronic Dis [serial online]4(3).

Dilley JA, Harris JR, Boysun MJ, Reid TR (2012) Program, policy, and price interventions for tobacco control: quantifying the return on investment of a state tobacco control program. Am J Public Health 102(2): e22-8.

Hurley SF, Matthews JP (2008) Cost-effectiveness of the Australian National Tobacco Campaign. Tob Control 17:379-84.

Lightwood J, Glantz S (2011) Effect of the Arizona tobacco control program on cigarette consumption and healthcare expenditures. Soc Sci Med 72:166-72.

Lightwood J, Glantz SA (2013) The effect of the California tobacco control program on smoking prevalence, cigarette consumption, and healthcare costs: 1989-2008. PloS one 8(2):e47145.

Lightwood JM, Dinno A, Glantz SA (2008) Effect of the California tobacco control program on personal health care expenditures. PLoS Med 5(8): e178.

Max W, Sung HY, Lightwood J (2013) The impact of changes in tobacco control funding on healthcare expenditures in California, 2012-2016. Tob Control 22: e10-e15.

Miller LS, Max W, Sung HY, Rice D, Zaretsky M (2010) Evaluation of the economic impact of California’s Tobacco Control Program: a dynamic model approach. Tob Control 19(Suppl 1): i68-i76.

Rhoads JK (2012) The effect of comprehensive state tobacco control programs on adult cigarette smoking. Journal of Health Economics 31:393-405.

Implementation Resources

Rural Health Information Hub, Tobacco Control and Prevention Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of tobacco control and prevention programs in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• • Comprehensive Tobacco Control Programs

CDC’s High-Impact in 5 years initiative recommends population-based tobacco control interventions based on evidence they reduce smoking initiation and use among adults and youths within five years and have economic value.

Effectiveness Review

The following databases were searched for English-language papers that evaluated tobacco control interventions:

• • • • Cochrane library
      • EMBASE (OVID)
      • Medline (OVID)
      • OSH (CDC’s Office on Smoking & Health Database)
      • PsycINFO (OVID)
      • PubMed (NLM)
      • Sociological Abstracts (ProQuest)
      • Web of Science (Thomson)

The literature search covered all tobacco control interventions. For the review on comprehensive tobacco control programs, Community Guide staff screened search results twice to identify papers specific to this intervention.

Search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Following are the search strategies used in PubMed.

1. Tobacco Cessation Part 1

#1 (“quit”[title] or “quitting”[title] or “quit line”[title] or “quit lines”[title] or “quitline”[title] or “quitlines”[title] or “abstinence”[title] or “abstinent”[title] or “stop” [title] or “stopped”[title] or “stopping”[title] or “cessation”[title] or “telephone”[title] or “hotline”[title] or “hotlines”[title] or “telephone”[MeSH] or “hotlines”[MeSH])

#2 “Smoking”[MeSH] or “tobacco”[MeSH] or “tobacco, smokeless”[MeSH] or “tobacco use disorder”[MeSH] or cigar*[title] or tobacco*[title] or hookah*[title] or “hubble-bubble”[title] or “narghile”[title] or “shisha”[title] or “smokeless”[title] or “snuff”[title] or “snuffs”[title]

#3 (“waterpipe” or “waterpipes” or “water pipe” or “water pipes”) and (tobacco or smoking or smoke)

#4 (“pipe” or “pipes”) and (smoke or smoking or tobacco))

#5 “Tobacco use cessation”[MeSH] or “smoking cessation” or “tobacco cessation”

#6 #1 AND (#2 OR #3 OR #4)

#7 #6 OR #5

#8 #7 Filters: Publication date from 2011/01/01 to 2012/12/31; English

2. Tobacco Cessation Part 2

#1 telephone or telephones or quitline or quitlines or “quit line” or “quit lines” or helpline or helplines or “help line” or “help lines”

#2 Smoking

#3 #1 and #2

#4 #3 Filters: Publication date from 2011/01/01 to 2012/12/31; English

Combine Part 1 OR Part 2

3. Tobacco Youth Update Part 1

#1 Smoking[title] or tobacco[title] or cigar[title] or cigars[title] or cigarette[title] or cigarettes[title] or smoking/psychology[mesh] or smoking[mesh] or tobacco[mesh] or tobacco use disorder[mesh] or tobacco, smokeless[mesh]

#2 (initiation[title] or initiate[title] initiates[title] or initiated[title] or delay[title] or delays[title] or delayed[title] or uptake[title] or “take up'[title] or ‘taking up” [title] or begin[title] or begins[title] or beginning[title] or beginnings[title] or causality[title] or preventive[title] or grade[title] or grader[title] graders[title] or student[title] or students[title] or preteen[title] or preteens[title] or “pre-teen” [title] or “pre-teens” [title] or development[title] or prevalence[title] or discourage[title] or discouraged[title] or religious[title] or prevention[title] or preventing[title] or prevent[title] or prevents[title] or prevented[title] or school[title] or schools[title] or middle[title] or adolescent[title] or adolescents[title] or adolescence[title] or initial[title] or start[title] or starts[title] or started[title] or starting[title] or protective[title] or causation[title] or contributing[title] or contributed[title] or contribute[title] or contributes[title] or try[title] or trying[title] or “pre-contemplating”[title]or “pre-contemplation”[title] or precontemplating[title] or precontemplation[title] or contemplate[title] or contemplated[title] or contemplating[title] or precontemplated[title] or “pre-contemplated”[title] or gateway[title] or gateways[title] or avert[title] or averts[title] or averted[title] or never[title] or genetic[title] or genetics[title] or genetically[title] or onset[title] or “never smoker” [title] or “never smokers” [title] or program[title] or programs[title] or programming[title] or intervention[title] or interventions[title])

#3 (youth[title] or youths[title] or adolescent[title] or adolescents[title] or adolescence[title] or child[title] or children[title] or kid[title] or kids[title] or gradeschool[title] or gradeschools[title] or gradeschooler[title] or gradeschoolers[title] or “grade school”[title] or “grade schools”[title] or “grade schooler”[title] or “grade schoolers”[title] or “elementary school”[title] or “elementary schooler”[title] or “elementary schoolers” [title] or “high school”[title] or “high schools”[title] or “high schooler”[title] or “high schoolers”[title] or college[title] or colleges[title] or preteen[title] or preteens[title] or “pre-teen”[title] or “pre-teens”[title] or tween[title] or tweens[title or tweenage[title] or tweenager[title] or tweenagers[title] or young[title] or youngster[title] or youngsters[title])

#4 #1 and #2 AND #3

#5 (#1 and #2) AND (infant[MeSH] OR child[MeSH] OR adolescent[MeSH])

#6 #4 OR #5

#7 #6 Filters: Publication date from 2011/01/01 to 2012/12/31; English

4. Tobacco Youth Update Part 2

#1 “tobacco use prevention”

#2 (tobacco AND “sales to minors”)

#3 #1 OR #2

#4 #3 Filters: Publication date from 2011/01/01 to 2012/12/31; English

Combine PART 1 OR PART 2

Economic Review

No content is available for this section.

• • • • CDC’s Best Practices for Comprehensive Tobacco Control Programs (2014) offers detailed, state-specific program composition and funding recommendations.
      • Evidence indicates comprehensive tobacco control programs are effective independent of increases in tobacco product prices or adoption of smoke-free policies. All of these interventions are effective, important, and complementary elements of an overall strategy to reduce tobacco use and secondhand smoke exposure.
      • Increases in program funding are associated with increases in program effectiveness, with the greatest impact seen if programs are funded at CDC-recommended levels.
      • Comprehensive tobacco control programs are effective in U.S. and non-U.S. settings, at national, state, city, and local levels, across age groups, and for both females and males.
      • Comprehensive tobacco control programs are effective across diverse racial, ethnic, educational, and SES groups. CDC’s Best Practices for Comprehensive Tobacco Control Programs (2014) suggests program options to address population groups that have experienced persistently high rates of tobacco use and secondhand smoke exposure.
      • Community Preventive Services Task Force’s recommendations for program components can be found for quitlines and mass-reach health communication interventions. The Task Force recommends additional programs and policies to reduce tobacco use and secondhand smoke exposure.
      • A number of national organizations provide resources on program implementation and evaluation.
        • American Cancer Society
        • American Heart Association
        • American Lung Association
        • Americans for Nonsmokers’ Rights Foundation
        • Association of State and Territorial Health Officials
        • Campaign for Tobacco-Free Kids
        • National Association of County and City Health Officials
        • National Association of Local Boards of Health
        • North American Quitline Consortium
        • Robert Wood Johnson Foundation
        • Tobacco Control Legal Consortium
        • Tobacco Technical Assistance Consortium
        • Truth Initiative

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• • • • • Reduce current tobacco use in adults — TU‑01
        • Reduce current cigarette smoking in adults — TU‑02
        • Reduce current cigarette, cigar, and pipe smoking in adults — TU‑03
        • Reduce current tobacco use in adolescents — TU‑04
        • Reduce current cigarette smoking in adolescents — TU‑06
        • Reduce current cigar smoking in adolescents — TU‑07
        • Reduce current use of smokeless tobacco products among adolescents — TU‑08
        • Eliminate cigarette smoking initiation in adolescents and young adults — TU‑10
        • Increase past-year attempts to quit smoking in adults — TU‑11
        • Increase use of smoking cessation counseling and medication in adults who smoke — TU‑13
        • Increase successful quit attempts in adults who smoke — TU‑14
        • Increase the number of states, territories, and DC that prohibit smoking in worksites, restaurants, and bars — TU‑17
        • Eliminate policies in states, territories, and DC that preempt local tobacco control policies — TU‑20

Health Impact in 5 Years (HI-5)

HI-5 highlights community-wide approaches that have demonstrated 1) positive health impacts, 2) results within five years, and 3) cost effectiveness and/or cost savings over the lifetime of the population or earlier.

• • • • • • • Tobacco Control Interventions