Tobacco Use: Comprehensive Tobacco Control Programs

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) 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.

The full CPSTF Finding and Rationale Statement and supporting documents for Tobacco Use: Comprehensive Tobacco Control Programs are available in The Community Guide Collection on CDC Stacks.

Intervention

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 CPSTF 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.

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).

Summary of 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)

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.)

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

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 older teens and young adults (16-25 years old; 2 studies)

Tobacco Consumption (18 studies)

Cigarette Pack Sales: 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
Individual Daily Consumption: Overall median decrease of 17.1% (IQI: 43.4% to 13.5%; 6 studies); programs were implemented for a median of 8 years

Exposure to Secondhand Smoke (4 studies)

U.S. states with comprehensive tobacco control programs saw reductions in adults’ exposure to secondhand smoke at home or work and 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)

Tobacco-Related Diseases and Deaths (8 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)
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)

Comprehensive tobacco control programs had similar effects across examined racial and ethnic groups
- Reducing tobacco use prevalence among adults (3 studies) and young people (2 studies)
- Reducing secondhand smoke exposure (1 study)
Comprehensive tobacco control programs were effective across groups with different levels of educational attainment
- Reducing tobacco use prevalence among adults (2 studies)
- Reducing individual daily consumption (1 study)
- Increasing cessation (2 studies)
Comprehensive tobacco control programs were effective across groups with different income levels or SES
- Reducing tobacco use prevalence among adults (1 study) and young people (1 study)
- Reducing secondhand smoke exposure (1 study)

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

In 16 of 18 studies, changes in tobacco use outcomes were evaluated in relationship to changes in comprehensive tobacco control program funding levels

Summary of Economic Evidence

Twelve studies were included in the economic review (10 from the U.S. and 2 from Australia). Economic evidence indicates that comprehensive tobacco control programs are cost-effective, and savings from averted healthcare costs exceed intervention costs. All monetary values are reported in 2012 U.S. dollars.

Healthcare costs averted (10 studies): Values ranged from $34.9 million over 75 years in Australia to $141.1 billion over 20 years in California
Cost-effectiveness estimates (3 studies): Cost per QALY saved: $24/QALYS (1 study); $857/QALYS (1 study). 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)

Applicability

Results are applicable to:

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)

Evidence Gaps

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).

Implementation Considerations and Resources

CDC’s tobacco control resources offers program resources
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
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 across diverse racial, ethnic, educational, and SES groups
Community Preventive Services Task Force’s recommendations for program components can be found for quitlines and mass-reach health communication interventions

Crosswalks

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