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Reducing Tobacco Use and Secondhand Smoke Exposure: Comprehensive Tobacco Control Programs

Task Force Finding

The Community Preventive Services Task Force recommends comprehensive tobacco control programs based on strong evidence of effectiveness in reducing tobacco use and secondhand smoke exposure. Evidence indicates these 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. Economic evidence indicates that comprehensive tobacco control programs are cost-effective, and savings from averted healthcare costs exceed intervention costs.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

Comprehensive tobacco control programs are coordinated efforts to implement population-level interventions to reduce appeal and acceptability of tobacco use, increase tobacco use cessation, reduce secondhand smoke exposure, and prevent initiation of tobacco use among young people.

Programs combine and integrate evidence-based educational, clinical, regulatory, economic, and social strategies at local, state, or national levels.

Comprehensive tobacco control programs most often include administrative support, surveillance, evaluation, and program monitoring. In the United States, programs are typically organized and funded at the state level to provide a platform for effective implementation of the following components:

  • Assistance to community-based organizations and coalitions to pursue local programs and policies to reduce tobacco use and secondhand smoke exposure
  • Partnerships at local and state levels to engage health systems and providers, businesses, and public and private agencies and organizations, in an effort to broaden the reach and impact of tobacco control interventions
  • Mass-reach health communication interventions to inform individual and public attitudes about tobacco use and secondhand smoke
  • Cessation services, such as quitlines, to help tobacco users in their efforts to quit
  • Information and technical assistance to support the diffusion and adoption of evidence-based practices (e.g., smoke-free policies, affordable and accessible cessation services, increased tobacco product prices, and decreased tobacco product marketing and availability)

Some programs may have authority to implement policies directly, such as restrictions on tobacco product marketing and availability, and smoke-free policies.

About the Systematic Review

This Task Force finding is based on evidence from a review of 61 studies (search period through August 2014). Fifty-six studies evaluated program impact on cigarette use only. This review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to reducing tobacco use and secondhand smoke exposure.

Results

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.
Study Characteristics
  • 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).
Applicability

Based on results for different settings and populations, findings are applicable to the following:

  • 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)

Economic Evidence

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).

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion. The Community Guide does not conduct systematic reviews of implementation.

  • CDC's Best Practices for Comprehensive Tobacco Control Programs External Web Site Icon (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
    • Institute of Medicine
    • Legacy for Health (formerly American Legacy Foundation)
    • 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

References

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. Available at: https://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm External Web Site Icon

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Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Reducing tobacco use and secondhand smoke exposure: comprehensive tobacco control programs. www.thecommunityguide.org/tobacco/comprehensive.html. Last updated: MM/DD/YYYY.

Review completed: August 2014