ENDING THE
 

TOBACCO EPIDEMIC
 

Progress Toward
 

A Healthier Nation
 

ENDING THE TOBACCO EPIDEMIC
 

Progress Towards A Healthier Nation
 

August 2012
 
Suggested Citation: 

U.S. Department of Health and Human Services. Ending the Tobacco Epidemic: Progress 

Toward a Healthier Nation. Washington: U.S. Department of Health and Human Services, 

Office of the Assistant Secretary for Health, August 2012. 

To access this publication online, please go to http://www.hhs.gov/ash/initiatives/tobacco/. 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table of Contents 

Introduction 1
 

Tobacco Control High-Priority Performance Goal 2
 

Challenges: The Burden of Tobacco Use and Barriers to Progress 3
 

Setting the Stage for a New Tobacco Strategic Action Plan 5
 

American Recovery and Reinvestment Act 5
 

Children’s Health Insurance Program Reauthorization Act 5
 

Family Smoking Prevention and Tobacco Control Act 6
 

Prevent All Cigarette Trafficking Act 7
 

The Affordable Care Act 7
 

Confronting the Epidemic: Transforming Vision Into Action 8
 

Leading by Example: Leveraging HHS Systems and Resources
 

to Create a Society Free From Tobacco-Related Death and Disease 8
 

Improving the Public’s Health: Strengthening the Implementation
 

of Evidence-Based Interventions and Policies in States and Communities 10
 

Engaging the Public: Changing Social Norms Around Tobacco Use 18
 

Advancing Knowledge: Accelerating Research
 

to Expand the Science Base and Monitor Progress 20
 

Toward a Society Free From Tobacco-Related Death and Disease 25
 

Appendix A: Tracking Progress Toward the Healthy People Objectives 27
 

Adult Smoking Prevalence 27
 

Adolescent Tobacco Use 28
 

Smoking Initiation 29
 

Attempts to Quit 31
 

Exposure to Secondhand Smoke 32
 

Appendix B: List of Acronyms 33
 

References 34
 

Introduction 

The United States has made historic progress in combating the epidemic of tobacco-caused 

illness and death since the landmark 1964 Surgeon General’s Report on the health effects 

of cigarette smoking. Because of this, many mistakenly assume that future advances will be 

assured. In 2009, recognizing that declines in smoking prevalence had stalled, Secretary of 

Health and Human Services (HHS) Kathleen Sebelius directed HHS to develop a Department-wide strategic action plan for tobacco control to accelerate progress in combating the 

tobacco epidemic. A working group of public health experts across HHS was convened to 

develop Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. 

Department of Health and Human Services (hereafter referred to as the Strategic Action Plan, 

or the Plan) (U.S. Department of Health and Human Services, 2010a). 

Published in November 2010, the Strategic Action Plan mobilizes HHS tobacco control 

resources toward the bold vision of a society free from tobacco-related death and disease and 

provides a framework for coordinating tobacco control efforts across the Department and 

the nation. The Strategic Action Plan prescribes proven, practical, achievable actions that can 

be implemented at the federal, state, and community levels. It sets forth the most effective 

evidence-based and evidence-informed approaches that will enable HHS to build on recent 

legislative milestones, respond to the changing market for tobacco products, and promote 

robust tobacco control programs at the federal, state, and community levels. 

The Strategic Action Plan charts a framework designed to achieve four central tobacco-related 

objectives of Healthy People 2020 (U.S. Department of Health and Human Services, 2010b): 

•	 Reduce tobacco use by adults and adolescents 

•	 Reduce the initiation of tobacco use among children, adolescents, and young adults 

•	 Increase smoking cessation success by adult smokers 

•	 Reduce the proportion of nonsmokers exposed to secondhand smoke 

The Plan also directs that future activities focus on accomplishing specific objectives in four 

major action areas: 

•	 Leading by example 

•	 Improving the public’s health 

•	 Engaging the public 

•	 Advancing knowledge 

In 2011, a newly established HHS Tobacco Control Implementation Steering Committee 

comprising senior HHS leaders and tobacco control experts and chaired by Assistant 

Secretary for Health Howard K. Koh, MD, MPH, began monitoring the overall implementation of the Strategic Action Plan to ensure effective coordination and collaboration across 

the Department and with other federal agencies and to provide support to the Food and 

Drug Administration’s role of regulating tobacco products. The Steering Committee meets 

regularly to set priorities, develop plans for cross-agency implementation of strategic actions, 

and promote information exchange and collaboration. 

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This report, Ending the Tobacco Epidemic: Progress Toward a Healthier Nation, fulfills the 

recommendation put forth by the Strategic Action Plan for periodic reports that document 

progress in implementing the specific actions in the Plan and ultimately achieving the 

Healthy People 2020 objectives. 

Tobacco Control High-Priority Performance Goal 

In 2011, the Office of Management and Budget asked federal Departments to commit 

to ambitious goals that stimulate innovation. These priority goals would be attained within 

an 18- to 24-month time frame. 

The following tobacco control objective was selected as one of HHS’s priority goals: 

By December 31, 2013, reduce annual adults’ cigarette consumption in the United States from 

1,281 cigarettes per capita to 1,062 cigarettes per capita. This would represent a 17.1% decrease 

from the 2010 baseline of 1,281 cigarettes per capita. 

In the United States, per-capita cigarette consumption data, which reflect cigarettes legally 

purchased for domestic consumption, are available as far back as the late 1800s. Per-capita 

cigarette consumption is a key measure that has been used by researchers in the United States 

and other countries to objectively measure cigarette use and the impact of tobacco control 

over time. The Steering Committee is coordinating the actions necessary to achieve this goal, 

and data confirm that the priority goal intermediate target for 2011—1,232 cigarettes per 

capita—was achieved. 

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Challenges: The Burden of Tobacco Use 

and Barriers to Progress 

One hundred years ago, tobacco use was not a significant cause of illness or death in the 

United States. In fact, lung cancer was almost nonexistent a century ago; it now ranks as the 

leading cause of cancer death in the United States for both men and women, with more than 

80% caused by smoking (Centers for Disease Control and Prevention, 2008). 

Smoking kills an estimated 443,000 Americans each year, with 50,000 of these deaths from 

exposure to secondhand smoke (Centers for Disease Control and Prevention, 2008). Almost 

one in five adults smoke—45 million altogether—along with one in five high school seniors 

(U.S. Department of Health and Human Services, 2012a). Their prognosis is grim. Half 

of the adults who continue to smoke will die from smoking-related causes (Centers for 

Disease Control and Prevention, 2008). Many who comprise the other half will suffer from 

cancer, stroke, heart attack, and other serious tobacco-related diseases. Users of other tobacco 

products, such as smokeless tobacco and cigars, also suffer from significant adverse health 

consequences, such as cancer and heart disease. 

Nonsmoking Americans are also affected by tobacco use. Approximately 88 million nonsmokers, or 40% of the nonsmoking U.S. public, continue to be exposed to secondhand 

smoke (Centers for Disease Control and Prevention, 2010a). Because even brief exposure 

to secondhand smoke can be harmful, many nonsmokers are at risk of developing smokingrelated illnesses, and many will get sick or die prematurely from cancer or heart disease 

as a result (Centers for Disease Control and Prevention, 2008). 

Moreover, the financial burden imposed by cigarette smoking is enormous. Smoking-related 

illness in the United States costs $96 billion each year in medical costs and $97 billion in lost 

productivity due to premature mortality (Centers for Disease Control and Prevention, 2008), 

and the human toll on survivors and caregivers of individuals affected by tobacco-related 

illness is incalculable. 

In addition, there is a growing concern about new tobacco products being marketed to 

smokers and nonsmokers as alternatives for use in smoke-free environments. Dual use of cigarettes and smokeless tobacco can sustain tobacco addiction, encouraging continued tobacco 

use among smokers who might otherwise quit. And the marketing of smokeless tobacco and 

new purported reduced-risk products may increase overall tobacco use. Consumer misperceptions regarding the “safety” of the use of these products, independently and concurrently 

with smoking, pose an ongoing challenge to tobacco prevention and control efforts. 

The tobacco industry continues to aggressively promote tobacco use and fuel addiction 

among consumers. Cigarette manufacturers spend $9.94 billion each year, or $27 million 

each day, on advertising and promotions to attract new youthful users, retain current 

users, increase consumption, and generate favorable attitudes toward tobacco use and 

tobacco manufacturers. Of this amount, 72% is spent on providing discounts to make 

cigarettes more affordable, increasing initiation and consumption. Data also demonstrate that 

the depiction of cigarette smoking in movies continues to glamorize its use for young people 

and substantially increases smoking initiation by youth (U.S. Department of Health and 

Human Services, 2012a). 

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In response, the U.S. government, along with states and localities, has worked hard to reduce 

tobacco use over the last 50 years. The federal government has a) documented the lethal and 

addictive nature of tobacco products, b) supported state and community tobacco control 

efforts, c) required cigarette and smokeless tobacco products to carry warning labels, d) 

banned certain tobacco advertisements from television and radio, e) banned smoking from 

air travel, f) worked to educate the public about the lethal nature of secondhand smoke 

exposure, and g) supported education and research initiatives to prevent tobacco use and 

facilitate quitting. 

The United States has made historic progress in combatting tobacco-related death and 

disease. Since the release of the first Surgeon General’s Report on tobacco use in 1964, adult 

smoking rates in the United States have been cut in half (from 42.4% in 1965 to 20.9% 

in 2005). Despite this progress, tobacco use remains the leading cause of premature and 

preventable death in our society. The prevalence of current cigarette smoking among U.S. 

adults aged 18 years and older declined only slightly between 2005 and 2010—from 20.9% 

to 19.3%; however, even this small reduction in the smoking rate resulted in approximately 

3 million fewer smokers, which over time will avert as many as 1.5 million premature deaths 

(Centers for Disease Control and Prevention, 2011a). These efforts need to be expanded and 

sustained if we are to achieve our Healthy People 2020 objectives for tobacco use. 

4
Setting the Stage for a New Tobacco 

Strategic Action Plan 

To strengthen and accelerate the nation’s efforts to combat the tobacco epidemic, in 2009 

and 2010, President Obama signed into law five new measures that provide critical tools for 

protecting Americans from the dangers of tobacco. These laws individually and collectively 

provide historic new opportunities to ameliorate the harm caused by tobacco. They also set 

the stage for a new national strategic planning effort for tobacco control. As described here, 

these new laws have given federal agencies more authority and funding to a) restrict the sale, 

distribution, and promotion of cigarettes and smokeless tobacco to make them less accessible 

and attractive to youth; b) deter people from smoking; c) help people quit; d) reduce exposure 

to secondhand smoke; and e) promote an overall culture of health and prevention. In short, 

these laws form an essential foundation for the successful launch and implementation of the 

Strategic Action Plan. 

American Recovery and Reinvestment Act 

In February 2009, President Obama signed into law the American Recovery and Reinvestment 

Act (ARRA), also known as the Stimulus or Recovery Act. ARRA, an economic recovery 

package, invested $200 million to support local, state, and national tobacco prevention and 

control efforts, thus mitigating decreases in state tobacco control budgets. With this funding, 

HHS and the Centers for Disease Control and Prevention (CDC) launched the Communities 

Putting Prevention to Work (CPPW) program, which provided grants to help states, cities, 

counties, and tribes address the ongoing public health challenges; 22 grants addressed 

tobacco use specifically. 

Children’s Health Insurance Program Reauthorization Act 

In February 2009, President Obama signed into law the Children’s Health Insurance 

Program Reauthorization Act, which included an unprecedented 62-cent increase in the 

federal excise tax on cigarettes to $1.01 per pack. For every 10% increase in the price 

of tobacco products, consumption falls by approximately 4% overall, with a greater reduction 

among youth. This single act by Congress—increasing the price of cigarettes—is projected 

to prevent more than 2 million children from initiating smoking, cause more than one 

million adult smokers to quit, avert nearly 900,000 smoking-attributed deaths, and avoid 

$44.5 billion in long-term health care costs (Campaign for Tobacco-Free Kids, 2009). 

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Family Smoking Prevention and Tobacco Control Act 

In June 2009, President Obama signed into law the Family Smoking Prevention and Tobacco 

Control Act (hereafter referred to as the Tobacco Control Act), thereby granting the Food 

and Drug Administration (FDA) the authority to comprehensively regulate thousands 

of tobacco products for the first time in history. This law facilitated the creation of the Center 

for Tobacco Products (CTP) to regulate the manufacture, distribution, and marketing 

of tobacco products to protect public health. Recognizing that most new users of tobacco 

products are younger than 18 years of age—the minimum legal age to purchase these 

products nationally and in most states—and that many new users will become addicted 

before they are old enough to understand the risks, parts of the act focus on reducing use 

by youth. The Tobacco Control Act also requires that as of September 2012, cigarette 

packages have larger and bolder health warnings, including graphic images (implementation 

of this provision is currently enjoined by a pending lawsuit brought by tobacco companies). 

In addition, the Tobacco Control Act mandates that tobacco companies disclose harmful 

or potentially harmful constituents in their products. Similarly, it prohibits false or misleading 

labeling and advertising for tobacco products and requires the tobacco industry to submit 

an application to CTP for new products or products with modified risk claims. 

Importantly, the act gives CTP the authority to set standards for tobacco products that are 

appropriate for the protection of public health. Successful development of these standards 

will be informed by a strong science base. With support and guidance from FDA’s Tobacco 

Products Scientific Advisory Committee as well as from the Office of the Assistant Secretary 

for Health, CDC, the National Institutes of Health, and the Substance Abuse and Mental 

Health Services Administration, CTP is carefully researching what actions are appropriate for 

the protection of public health. 

Cigarette Prices and Cigarette Sales, United States, 1970-2010
Prevent All Cigarette Trafficking Act 

In March 2010, President Obama signed into law the Prevent All Cigarette Trafficking 

(PACT) Act to reduce the illegal sale and transport of cigarettes and other tobacco products. 

The PACT Act will reduce and prevent smoking by blocking access to underpriced and 

untaxed cigarettes and smokeless tobacco products. It will help curtail online and mail order 

sales to underage youth by requiring sellers to verify a customer’s age prior to sale by checking 

databases. The delivery service must also check the age and identification of the person 

accepting a package containing cigarettes or smokeless tobacco products. This law will help 

the government collect more than $5 billion a year in lost revenue from online and mail 

order cigarette sales (Quick, 2011). It also sets a new precedent by applying the same age 

verification and reporting requirements to online tobacco sellers in tribal lands, where 20% 

of all online tobacco sellers in the United States are located (Campaign for Tobacco-Free 

Kids, 2010). 

The Affordable Care Act 

In March 2010, President Obama signed into law the Patient Protection and Affordable Care 

Act (hereafter referred to as the Affordable Care Act). As part of its emphasis on prevention 

and health promotion, the law a) requires private insurance plans to cover tobacco cessation 

treatments, including medications that help people quit smoking; b) expands smoking 

cessation coverage for pregnant women who receive Medicaid; and c) provides Medicare 

beneficiaries with an annual wellness visit that includes personalized prevention plan 

services that may include referrals for tobacco cessation services. The Affordable Care Act also 

established the Prevention and Public Health Fund, which represents the most significant 

investment in U.S. history to scale up and promote effective public health and preventive 

measures, including programs to prevent and reduce tobacco use. Through this fund, the 

United States will invest mandated funds in prevention efforts every year (U.S. Department 

of Health and Human Services, 2012b). HHS distributed $500 million from the fund 

in fiscal year (FY) 2010, $750 million in FY 2011, and $1 billion in FY 2012 to target four 

priorities: community prevention, clinical prevention, public health infrastructure, and 

research and tracking. In addition, the Affordable Care Act created the National Prevention, 

Health Promotion, and Public Health Council (National Prevention Council) and called for 

the development of the National Prevention Strategy to realize the benefits of prevention 

for all Americans’ health. Tobacco control is one of the National Prevention Strategy’s key 

priorities. The National Prevention Council has identified specific areas in which prevention 

can be accelerated through the combined efforts of all 17 National Prevention Council 

departments. One of these areas is a commitment to increase tobacco-free environments 

within National Prevention Council departments and encourage partners to do so voluntarily, as appropriate. 

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Confronting the Epidemic: 

Transforming Vision Into Action 

In the year following publication of the Strategic Action Plan, HHS achieved measurable 

success in transforming goals into action. This section provides details about significant 

strides that have been made in all four major action areas. 

Leading by Example: Leveraging HHS Systems and Resources 

to Create a Society Free From Tobacco-Related Death and Disease 

One way for HHS to achieve its vision of change is to set a strong, clear example. HHS has 

now implemented its own model tobacco control policies to protect employees, contractors, 

and visitors against exposure to secondhand smoke; help employees quit tobacco use; and use 

federal programs to expand the delivery of tobacco control programs and cessation services 

to millions of Americans. HHS has also sought to create synergy by collaborating with other 

federal agencies, nongovernmental organizations, state and local leaders, business interests, 

and the international community in support of tobacco control and prevention initiatives. 

HHS Establishes a Tobacco-Free Campus 

In July 2011, HHS expanded its existing smoke-free policy to protect the health of its 

employees, contractors, and visitors by prohibiting the use of any tobacco products at all 

of its facilities under direct HHS control—within buildings as well as in outdoor spaces, 

parking lots, private vehicles on the premises, and government vehicles—regardless of location. The tobacco-free policy covers cigarettes, cigars, pipes, smokeless tobacco, e-cigarettes, 

and all other tobacco combustible and noncombustible products. As a key action step of the 

HHS Strategic Action Plan, this policy projects a positive, pro-health message and is intended 

to encourage similar policies in all workplaces. 

In addition to implementing its comprehensive tobacco-free campus policy, HHS is working 

to ensure that its conferences take place only in states and localities that have laws making 

private workplaces and restaurants smoke-free. The National Cancer Institute (NCI), National 

Institute on Drug Abuse (NIDA), Substance Abuse and Mental Health Services Administration 

(SAMHSA), and Centers for Disease Control and Prevention (CDC) have led the way, convening their events only in the 31 states and the many other cities and counties that currently 

have adopted laws making private workplaces and restaurants smoke-free (Centers for 

Disease Control and Prevention, 2011a). 

HHS Collaborates With the Office of Personnel Management to Help More 

Employees Become Tobacco-Free 

In addition to strengthening its own workplace policies, HHS is collaborating with other 

federal departments on tobacco control activities across the federal government. One 

notable success is that the Office of Personnel Management (OPM) now ensures that all 

federal employees have access to robust cessation treatments consistent with the 2008 U.S. 

Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence 

(Fiore et al., 2008). Specifically, with HHS support and technical guidance, OPM adopted 

a groundbreaking new policy: starting in 2011, it expanded tobacco cessation treatment 

coverage under the Federal Employee Health Benefits (FEHB) program for all current and 

retired full-time federal employees and their dependents. FEHB covers approximately 2 million federal employees, of whom an estimated 18% were smokers as of 2008–2009, as well as 

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6 million dependents and retirees whose smoking prevalence is unknown (U.S. Office of Personnel Management, 2012). As part of the new policy, FEHB plans now cover four annual 

telephone, group, or individual counseling sessions and access to all FDA-approved tobacco 

cessation medications. These services and medications require no copayments or coinsurance 

and are not subject to deductibles or annual or lifetime dollar limits. By providing these 

comprehensive tobacco cessation services without barriers, the federal government increases 

the productivity of its workers, protects both their health and that of their families, and also 

reduces the taxpayer dollars needed to treat tobacco-related illnesses in the future. Based on a 

recent survey of plans, OPM estimates that 100,000 tobacco users were prescribed cessation 

medications and/or had cessation counseling in the first year of the benefit. 

HHS Launches Initiative to Support the Adoption 

of Tobacco-Free Policies by Colleges and Universities 

In 2011, HHS created its Tobacco-Free College Campus Initiative to promote and support 

the adoption and implementation of tobacco-free policies at universities, colleges, and other 

institutions of higher learning across the United States. Advertising, marketing, and promotion of tobacco products have been strategically designed by the tobacco industry to attract 

young people. HHS has enlisted the participation of leaders at academic institutions with 

tobacco- or smoke-free campus policies to counter these efforts. Supported by HHS, these 

academic champions—themselves leading by example—planned multiple events for 2012, 

including education and training sessions at the National Conference on Tobacco or Health 

to take the tobacco-free academia message to their peers and prepare public health advocates 

and others to effectively promote tobacco- or smoke-free campus policies across the 

nation. Prior to the launch of this initiative, approximately 775 colleges and universities 

had implemented 100% smoke-free campus policies (American Nonsmokers’ Rights 

Foundation, 2012). Collectively, these institutions are accelerating the momentum for 

increasing the number of tobacco- and smoke-free campuses and the number of students, 

faculty, and staff covered nationwide. Also of note, the City University of New York (CUNY) 

garnered widespread attention in early 2011 when it adopted a smoke-free campus policy 

that applies to almost half a million students and more than 20,000 faculty across CUNY’s 

23 campuses (City University of New York, 2011). Their comprehensive policy takes effect 

in September 2012. 

Also, funds received from CDC’s Communities Putting Prevention to Work (CPPW) 

program have helped a number of academic institutions develop comprehensive tobaccoand smoke-free policies, including seven community colleges in Chicago, eight community 

colleges in St. Louis, and the CUNY system. 

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HHS Partners With Employers to Launch a Smoke-Free Worksite Challenge 

The benefits of employers going smoke-free are tremendous. The Task Force on Community 

Preventive Services concluded that smoke-free workplace policies are associated with a 6.4% 

increase in cessation and 3.4% decrease in tobacco use prevalence (Task Force on Community Preventive Services, 2012). Cessation has been shown to lead to reduced medical costs and 

increased worker productivity. Additionally, nonsmokers are no longer exposed to the hazards 

of secondhand smoke. 

In September 2011, at the United Nations High-level Meeting on the Prevention and Control of Non-communicable Diseases, HHS’s Assistant Secretary for Health introduced the 

Global Smoke-Free Worksite Challenge, a global multisector partnership comprising privatesector companies, nongovernmental organizations, and governments whose goal is to totally 

eliminate smoking and tobacco smoke at the worksite and ensure that every worker is protected from exposure to secondhand smoke. 

The Global Smoke-Free Worksite Challenge represents a collaboration among HHS, the 

American Cancer Society, the Campaign for Tobacco-Free Kids, Edelman, the Global Business Coalition on Health, Johnson & Johnson, the World Heart Federation, and the Mayo 

Clinic with support from the World Health Organization. The Global Smoke-Free Worksite 

Challenge is a 2011 Clinton Global Initiative “Commitment to Action.” The partnership 

has begun to work with governments, global corporations, hospitals, and nongovernmental 

organizations who are interested in committing to the challenge of becoming a 100% smokefree worksite. HHS has set a goal of recruiting six partner countries to participate by the end 

of 2012. 

Improving the Public’s Health: Strengthening the Implementation 

of Evidence-Based Interventions and Policies in States and Communities 

State and Local Initiatives Prevent Tobacco-Related Illness and Save Lives 

Much of the burden of tobacco-related illness can be reduced with approaches that incorporate 

proven, evidence-based, and affordable population-wide measures. 

Some of the most effective tobacco control programs start at a smaller scale as states and 

communities take action to reduce tobacco consumption and decrease health care costs. For 

example, in California, home to the nation’s longest-running tobacco control program, the 

adult smoking rate has declined by nearly 50%, with the number of cigarettes smoked per 

person decreasing by 67% since the state began its tobacco control program in 1988. During 

the program’s first 15 years, California saved $86 billion in health care costs by spending $1.8 

billion on tobacco control, resulting in a 50:1 return on investment (Lightwood, Dinno, 

& Glantz, 2008). Additionally, as a result of program-related reductions in smoking, lung 

cancer incidence has declined four times faster in California compared with the rest of the 

nation (Centers for Disease Control and Prevention, 2007). 

Based on this example and others, the federal government has supported state tobacco control 

programs for many years, with CDC recently also promoting grants for cities and counties 

to implement evidence-based tobacco control measures. 

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Through its National Tobacco Control Program (NTCP), CDC supports coordinated, 

evidence-based tobacco control efforts and interventions across the country to reduce 

tobacco use. CDC funds all 50 states, the District of Columbia, 8 U.S. territories, 8 tribal 

support centers, and 6 national networks. The funding leverages significant state investments 

to implement comprehensive, evidence-based tobacco control interventions and to reduce 

morbidity and mortality as well as tobacco-related disparities. 

In the last 2 years, HHS has used both the American Recovery and Reinvestment Act 

(ARRA) and the Prevention and Public Health Fund, created through the Affordable Care 

Act, to make important strategic investments in promoting public health prevention. These 

new opportunities invest in effective strategies to prevent tobacco-related death and disease. 

Federal Grants Build Healthier Communities: The HHS Communities Putting 

Prevention to Work and Community Transformation Grants Programs Combat Tobacco 

Use in Localities and States 

Treating cancer, lung and heart disease, and other chronic illnesses resulting from tobacco use 

is responsible for 8% of total health care expenditures in the United States—approximately 

$96 billion each year (Centers for Disease Control and Prevention, 2008). In contrast, studies have consistently demonstrated that relatively small investments in preventive health 

programs lead to enormous savings in future health care costs (Trust for America’s Health, 

2009). As previously noted, in 2009, HHS directed $200 million from ARRA to launch 

CPPW. CPPW provides resources to local communities to reduce tobacco use and obesity; 22 cities and counties received funds to implement evidence-based strategies to reduce 

tobacco use. Each community developed its own specific approach, designed to produce 

documented results and to be replicable in other localities and states. 

CPPW-funded tobacco control programs have provided tools, education, and information 

explaining the improvements in public health to be derived from the adoption of smokefree and tobacco-free policies for multiunit housing settings, college campuses, local school 

districts, and outdoor spaces and for implementing health care system changes related to 

tobacco use screening, documentation, and cessation treatment. 

CPPW Success Stories: Adoption of Tobacco-Free Policies 

in School Districts 

CPPW funds have supported efforts to make schools tobacco-free 

•	 Florence, SC – Four public school districts passed comprehensive tobacco-free policies, 

protecting 18,700 students and 2,500 staff in 30 schools 

•	 Archdiocese of Chicago – The Chicago Catholic schools adopted a tobacco-free campus 

policy in 137 schools, protecting an estimated 40,000 students and 2,500 faculty and staff 

•	 Cherokee Nation – All schools and child care facilities now prohibit tobacco use at all 

times in school buildings, on school grounds, in school vehicles, at school functions, and 

at offsite school events 

•	 St Louis, MO – Rockwood School District, the largest in St Louis County (with more 

than 25 schools, 22,500 students, and 3,300 employees), adopted a comprehensive 

tobacco-free policy 

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Cppw Success Stories: Adoption of Smoke-Free 

Multiunit Housing Policies 

CPPW funds have supported efforts of communities to adopt smoke-free housing policies and 

helped people find smoke-free homes 

•	 Boston, MA – In May 2011, seven multifamily housing providers implemented smokefree policies, directly affecting more than 3,000 affordable and market-rate units 

•	 Chicago, IL – By March 2012, four Chicago Housing Authority sites had implemented 

smoke-free housing policies, affecting 367 public units The Chicago Tobacco Prevention 

Project has 211 private housing units that are committed to going smoke-free, with an 

ultimate goal of 1,000 units going smoke-free 

•	 Santa Clara County, CA – The county adopted a policy requiring that all multiunit 

housing be smoke-free, including public housing This policy covers unincorporated areas 

of the county, and after full implementation will impact 1,328 existing units occupied 

by more than 3,300 residents 

Cppw Success Stories: Integration of Tobacco Use Screening, 

Documentation, and Cessation Treatment Referral Into 

Mental Health and Substance Abuse Treatment Facilities 

CPPW funds have supported efforts to enhance tobacco prevention and cessation efforts in mental 

health treatment settings 

•	 Austin, TX – The Seton Family of Hospitals, Central Health, and CommUnityCare 

Clinics implemented a screening protocol for assessing tobacco use and referring patients 

to cessation services and integrated this protocol into their electronic medical record 

systems This new policy reaches 1 8 million patients in 11 counties 

•	 State of Utah – The State Department of Health is facilitating staff training, resource 

development, and tobacco-free policies to reduce tobacco use among patients and staff 

at treatment centers 

•	 New York, NY – The New York Health Department provided training to help 44 Assertive 

Community Treatment teams and staff at 160 Supportive Housing units integrate tobacco 

dependence treatment into care given to clients with severe mental illness 

As part of CPPW, the Office of the Assistant Secretary for Health awarded grants to 10 

national organizations to support CPPW community outcomes. Included in these grants 

were three national organizations to support tobacco prevention and control outcomes in 18 

CPPW communities: the American Academy of Pediatrics, American Lung Association, and 

Society for Public Health Education. In the first year of the grant, these organizations provided more than 170 sessions of peer-to-peer technical assistance and 64 products, including 

issue briefs, Webinars, and roundtables. 

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To build on the successful CPPW effort, in September 2011, CDC awarded more than $100 

million in prevention funding through a new program called Community Transformation 

Grants (CTGs), funded by the Prevention and Public Health Fund. CTGs are now helping 

states, communities, and tribes across the nation implement tobacco control programs and 

other wellness initiatives that promote healthy lifestyles and reduce the incidence of preventable disease. Again, by financing proven prevention programs, the CTG program is improving 

not only public health but also the nation’s economic well-being (Centers for Disease 

Control and Prevention, 2011b). 

FDA Implements Regulations to Reduce Youth Access to Tobacco Products 

FDA contracts with states to conduct federal compliance check inspections of tobacco retailers. These retail inspections focus on ensuring compliance with the Tobacco Control Act and 

FDA regulations at retail locations. FDA awarded contracts to 15 states in 2010 and to 37 

states as well as the District of Columbia in 2011, infusing $33 million into these communities. These contracts enable FDA to conduct compliance check inspections at retail locations 

to ensure compliance with the law, including a) age and ID verification, b) requirements for 

labeling and advertising of smokeless tobacco products, c) restrictions on the sale of single 

cigarettes, d) a ban on certain candy- and fruit-flavored cigarettes, and e) prohibition of 

the use of self-service displays and vending machines in retail establishments where minors 

are present or permitted to enter. As of June 1, 2012, FDA has conducted almost 70,000 

retail inspections and issued nearly 3,000 warning letters to retailers, the majority of which 

include violations relating to selling tobacco to minors. Awarding additional contracts in 

2012, including contracts with territories, will facilitate FDA’s progress on its goal to contract 

with every state and U.S. territory to assist FDA with tobacco retail inspection efforts and 

ultimately reduce tobacco use among all Americans and particularly youth (Food and Drug 

Administration, 2012). 

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SAMHSA’s Synar Program Works to Reduce Youth Access to Tobacco 

SAMHSA implements the Synar program; the Synar amendment and its implementing 

regulation require the 50 states, District of Columbia, and 8 U.S. territories (as a condition 

of receipt of their full Substance Abuse Prevention and Treatment Block Grant awards) 

to enact and enforce state laws prohibiting tobacco sales to youth. FDA works closely with 

SAMHSA to ensure that these regulations work together with SAMHSA’s efforts to reduce 

youth access to tobacco under the Synar program to help reach the shared goal of reducing 

youth access to, and use of, tobacco products. In 2011, the average national retailer violation 

rate of tobacco sales to youth was 8.5%, the lowest level in the history of the program 

(Substance Abuse and Mental Health Services Administration, 2012). 

HHS Strategic Action Plan Helps People Quit 

HHS has implemented a coordinated Department-wide tobacco-use cessation strategy. 

This strategy includes increasing insurance coverage for cessation services, media and education on the benefits of quitting, and support for the national quitline network. 

Insurance coverage of services
 

to treat tobacco use signifi-
 Quitline Facts (McKay & Kesmodel, 2011) cantly reduces use of tobacco •	 In 2010, quitlines served approximately products. For example, in 478,000 smokers, including 170,000 2006, Massachusetts pro- Medicaid beneficiaries vided comprehensive tobacco cessation coverage for •	 State and federal quitline program funding 

all Medicaid beneficiaries. totaled $114 million in 2011 

Smoking prevalence among 

Medicaid enrollees dropped 

from 38% to 28%, reducing 

hospitalizations for cardiovascular events by nearly 50% (Land et al., 2010). Within 2 years, 

Massachusetts realized an estimated total savings of more than $10 million, representing 

a return on investment of $3 for every $1 spent. If this program were implemented in every 

state, it is estimated that the Medicaid program would save $2.4 billion within 5 years 

(Richard, West, & Ku, 2012). 

By making key modifications to agency policies, HHS has significantly increased direct 

assistance to consumers who want to quit using tobacco. 

The Health Resources and Services Administration (HRSA) is the primary federal agency for 

improving access to health care services for people who are uninsured, isolated, or medically 

vulnerable. As a result of the HHS Strategic Action Plan, HRSA has designated tobacco control as an agency priority. In 2011, HRSA began requiring all of its 1,100 Health Center Program grantees to report on measures for tobacco screening and cessation counseling. In order 

to improve clinical performance on these measures, HRSA has implemented several programs to support clinicians.The Center for Integrated Health Solutions, a joint SAMHSAHRSA cooperative agreement to integrate behavioral health and primary care, offered two 

national Webinars on tobacco cessation for health centers and community behavioral health 

centers. Area Health Education Centers that partner academic institutions with communitybased health care organizations provided educational activities addressing tobacco cessation 

and prevention services. The 340B Drug Pricing Program continues to provide discounted 

medications for tobacco cessation. 14
Medicare and Medicaid Expand Tobacco Cessation Coverage 

In August 2010, the Centers for Medicare & Medicaid Services, the federal agency that 

administers Medicare, Medicaid, and the Children’s Health Insurance Program, expanded its 

coverage of tobacco cessation counseling to include Medicare beneficiaries who use tobacco 

but who did not have signs or symptoms of tobacco-related disease. As a result of these 

changes and prior Medicare Part D legislation covering FDA-approved cessation pharmacotherapies, all Medicare patients now have coverage for tobacco cessation. 

Similarly, Medicaid coverage has been expanded to include full cessation support for pregnant women (pregnancy may be a period of high motivation for maternal smoking cessation), and it reimburses states for 50% of the cost of providing telephone quitline support 

to callers covered by Medicaid. As a result of the latter policy, over the next 10 years, 

approximately 2.5 million additional smokers are expected to use quitlines and related 

services (North American Quitline Consortium, 2010). Since this policy went into effect in 

June, 2011, six states (Maryland, Massachusetts, Louisiana, Montana, North Carolina, and 

Oklahoma) have executed a memorandum of understanding (MOU) with their state Medicaid agencies to obtain the federal match. Another four states (Arizona, California, Colorado, 

and Delaware) are close to having such MOUs in place. 

Quitlines Improve Access to Cessation 

Quitlines are an important cessation resource for lowering the burden of tobacco use in the 

United States. Quitlines provide telephone-based support to help tobacco users quit. This 

support includes counseling, medications, Web-based information, referral to community 

resources, and self-help materials. Research has found that quitlines are effective with diverse 

populations and have broad reach (Fiore et al., 2008). 

The National Network of Tobacco Cessation Quitlines, which is a collaborative effort 

between CDC, NCI, and states and which is funded through NTCP and states, makes free 

telephone cessation counseling available in the United States. Every state has its own quitline. CDC, through additional funds provided by the Affordable Care Act, provides funds to 

states to expand or enhance existing services. These enhanced services may include expanding hours of operation, offering services in additional languages, and providing callers with 

additional counseling sessions and free nicotine replacement therapy. Funding has also been 

used to promote state quitlines to increase the number of smokers reached, often with a focus 

on underserved populations with higher smoking rates. Most significantly, the 1-800-QUITNOW number was included in CDC’s national tobacco education campaign, Tips From 

Former Smokers. This provided a direct point of support for people to quit tobacco use. 

Innovative Mobile and Social Media Initiatives Make Quitting Easier 

HHS cessation promotion efforts include new innovations designed to reach larger audiences. 

Using a multiplatform strategy that includes mobile, Internet, and social media components, 

HHS is harnessing technology to deliver smoking cessation interventions broadly and inexpensively to both teens and adults. Participating in conversations and building a community 

is a way that social media tools, like Facebook and Twitter, can help HHS integrate social 

support into our interventions and remove barriers associated with traditional smoking 

cessation treatments. 

15
 

 

 

 

 

The Odds of Quitting 

•	 68 8% of smokers say they want to quit 

(Centers for Disease Control and 

Prevention, 2011c) 

•	 52 4% of smokers had made a quit 

attempt in the past year (Centers for 

Disease Control and Prevention, 2011c) 

•	 The average smoker makes multiple 

attempts before succeeding 

(Fiore et al , 2008) 

Building on the success of its 

existing cessation Web sites 

(www.smokefree.gov and 

www.women.smokefree. 

gov), NCI recently launched 

Smokefree Teen, a suite 

of mobile and online resources to help teen smokers quit. Smokefree Teen 

features a youth-oriented 

cessation Web site (www. 

teen.smokefree.gov) as well 

as tools to connect teens 

with cessation support via 

their mobile phones. Also, 

SmokefreeTXT is a free text message cessation service that provides encouragement, advice, 

and actionable behavioral strategies to teens trying to quit smoking. Teens can sign up to 

receive text messages timed around their quit date and to continue receiving them for up to 

6 weeks after they quit. Message content is targeted to the unique needs of teen smokers, and 

the bidirectional service allows teens to request real-time support when faced with common 

situational triggers, such as when they feel stressed and are tempted to smoke. Teens with 

iPhones can also download QuitStart, a mobile application that delivers cessation and mood 

management tips, tracks cravings, and monitors quit attempts. Along with the launch of 

these mobile tools, Smokefree Teen also unveiled a comprehensive social media strategy that 

includes an active presence on several social media pages: Twitter (@SmokefreeTeen), Facebook (www.facebook.com/SmokefreeTeen), and Tumblr (www.smokefreeteen.tumblr.com). 

In addition, to reach adult smokers, NCI has introduced several new mobile and social 

media tools as well. SmokefreeTXT includes a second message library that targets young 

adult smokers. As part of a broader social media outreach strategy, NCI’s Smokefree Women 

program created a Facebook group to connect women trying to quit smoking. More than 

2,500 users are participating, some through their mobile phones. In addition to evidencebased cessation tips, this virtual community provides women with ready access to the social 

support vital for quitting. 

NCI also launched an open-source library of smoking cessation messages that provides the 

foundation for an interactive text-based intervention for adult smokers called QuitNowTXT. 

The QuitNowTXT text messages, which offer tips, motivation, encouragement, and facts 

based on information tailored to the user’s response, are available at www.smokefree.gov/ 

hp.aspx. These mobile texting resources will be integrated into HHS’s comprehensive tobacco 

control strategy to further address the burden of tobacco use across our nation. 

At the United Nations High-level Meeting on the Prevention and Control of Non-communicable Diseases in September 2011, HHS launched a global public-private partnership to 

make the QuitNowTXT program available to other countries to reach adult tobacco users. 

Organizations committed to collaborating with HHS on this initiative include the mHealth 

Alliance (hosted by the United Nations Foundation), World Medical Association, Campaign 

for Tobacco-Free Kids, Johnson & Johnson, IBM, and the Center for Global Health at 

16
 

 

George Washington University. This initiative brings interested governments and organizations 

together to support mHealth/text-based demonstration projects using this new text messaging 

resource. The QuitNowTXT library is also now freely available on the mHealth Alliance’s 

HealthUnbound.org Web site. 

Pioneers for Smoking Cessation Campaign Addresses High-Risk Groups 

Those individuals suffering from mental illness or substance abuse disorders represent one of 

the most vulnerable and tobacco-dependent groups of people. Persons with mental illness are 

estimated to consume 44% of all cigarettes sold in the United States (Schroeder & Morris, 2010). 

The Connection Between Tobacco 

and Mental Illness and Substance 

Abuse 

•	 People attending substance abuse 

treatment show extremely high rates 

(77%) of smoking (Kelly et al , 2012) 

•	 75% of people with a severe or persistent 

mental illness are dependent on tobacco 

(American Psychiatric Association, 2006) 

In 2009, SAMHSA partnered 

with the Smoking Cessation 

Leadership Center (SCLC) at 

the University of California, 

San Francisco (with support 

from the Robert Wood 

Johnson Foundation and 

the American Legacy Foundation) to help facilities 

treating mental illness or 

addiction provide tobacco 

screening and cessation 

support to their patients. 

A related goal was to establish smoke-free environments in these facilities. The program seeks to close a gap created 20 

years ago when smoking was banned in hospitals but allowed to continue in psychiatric and 

drug treatment units. 

The first phase of the program mobilized consumer 

groups, rehabilitation centers, health care providers, and 

other stakeholders at the local level to create smoke-free 

environments and provide smoking cessation services. 

One hundred organizations, named Pioneers for Smoking 

Cessation, received small grants and technical assistance 

for their proposed activities through Webinars, a tollfree number, a dedicated e-mail list, and a catalogue 

of tools. 

Then, in 2010, SAMHSA launched the second phase 

of the program, awarding 25 Pioneers with additional 

funding to refine and expand their initiatives benefiting 

people with, or at elevated risk for, mental health or 

substance use disorders. 

Results indicate that 20 of the 25 Pioneers reported 

a decrease in tobacco use among clients and staff 

(Smoking Cessation Leadership Center, 2011). 

State Leadership 

Academies for 

Wellness and 

Smoking 

Cessation 

•	 Arizona 

•	 Arkansas 

•	 Maryland 

•	 New York 

•	 North Carolina 

•	 Oklahoma 

•	 Texas 

The training and education at facilities has resulted in a more than doubling of the number 

of patients being counseled to quit—from just over 20% to just over 50% in the first 

18 months of the program (Reyes, 2011). 17
In the fall of 2010, the collaboration of SAMHSA and SCLC continued with a new initiative, 

State Leadership Academies for Wellness and Smoking Cessation. The purpose of the Academies 

is to launch statewide partnerships among behavioral health providers, consumers, and other 

stakeholders to create and implement an action plan to reduce smoking prevalence among 

people with behavioral health conditions. 

Engaging the Public: Changing Social Norms Around Tobacco Use 

For the first time, the federal government is making substantial investments in national 

tobacco education campaigns. Both traditional media and new electronic media are increasing 

awareness of the dangers of tobacco use and promoting the resources available to help people 

quit. 

CDC Spearheads a National Tobacco Education Campaign 

In 2011, CDC launched a 12-week integrated advertising campaign pilot in several markets 

in the South and Southeast, where adult and youth smoking rates are among the highest in 

the country. Along with traditional media placement, the CDC campaign also included a 

substantial social media effort involving a Facebook fan page (www.facebook.com/cdctobaccofree), YouTube videos, sharable multimedia messages, and Twitter postings. The campaign 

achieved increases in smokers’ and nonsmokers’ awareness levels of the three television ads 

that ran during that period. It also yielded $2.54 in earned media for every $1.00 spent. 

On March 15, 2012, CDC launched a hard-hitting national ad campaign that depicted the 

harsh reality of illness and damage suffered as a result of smoking and exposure to secondhand smoke. The Tips From Former Smokers campaign profiled people who are living with 

the significant adverse health effects due to smoking, such as paralysis from stroke, lung removal, heart attack, asthma, stomas, and limb amputations. The advertisements underscored 

the immediate damage that smoking can cause to the body and featured people who experienced smoking-related diseases at a relatively young age. These hard-hitting ads helped people 

quit, saving lives and decreasing the huge economic burden caused by tobacco use. The ads 

were tagged with 1-800-QUIT-NOW, a toll-free number to access quit support across the 

country, or the www.smokefree.gov Web site, which provides free quitting information. 

The campaign’s paid advertisements and public service announcements delivered a mix of 

high-impact advertising via television, radio, newspapers, magazines, movie theaters, billboards, and Web and social media such as Facebook and Twitter. The campaign has generated 

almost 200,000 additional calls to 1-800-QUIT-NOW and more than 400,000 additional 

unique visitors to www.smokefree.gov. These numbers provide a powerful early indication 

that the 12-week campaign, which ended on June 10, is on track to surpass the goal of generating at least 500,000 quit attempts and 50,000 successful long-term quits. Further data 

detailing the number of quit attempts will be available later this year. Throughout the 

12-week campaign, more than 4,000 news stories with a total reach of 3.6 billion impressions 

and a publicity value exceeding $10.5 million have been generated. 

18
 

FDA Initiates the First of Multiple Public Education Campaigns 

FDA plans to launch multiple campaigns to educate the public about the constituents in 

tobacco products and the harms of tobacco use, to reduce initiation, and to encourage cessation. Integrated campaigns, including advertising, digital marketing, social media, and event 

marketing, will reach and engage teen and young adult audiences. Special emphasis will be 

directed toward at-risk and underserved populations with high prevalence levels of tobacco 

use. Each distinct campaign will utilize formative research to ensure that the messages educate in ways that are relevant and motivating to unique audiences, with a goal of providing 

accurate information so youth can effectively resist pressure to initiate tobacco use and adults 

are encouraged to try to quit. Also, each campaign will undergo rigorous evaluation to demonstrate its effectiveness. 

New Health Warning Labels Will Convey 

the Harms of Tobacco 

In 2009, four new health warnings were required for smokeless tobacco products. These health warnings now cover 30% 

of the two main surfaces of smokeless tobacco packages, and 

these warnings must comprise at least 20% of smokeless 

tobacco advertisements. In June 2011, FDA promulgated 

the historic final rule requiring cigarette packaging and advertisements nationwide to feature new warning statements 

accompanied by graphic images depicting the negative 

health consequences of smoking. This rule marked the first 

change to cigarette warnings in 25 years. FDA has developed 

nine warning label designs that educate consumers about 

the health risks of smoking. These warnings are designed to 

cover the top 50% of the front and back of cigarette packages and will occupy 20% of each cigarette advertisement. 

As noted earlier, a lawsuit by the tobacco industry has halted 

implementation of the cigarette labels. 

Studies in other countries have shown that exposure to larger health warnings and exposure 

to graphic health warnings increase awareness of the health risks of tobacco use. This 

increased awareness can also lead to an increased interest in quitting, prompting calls 

to quitlines and conversations with a doctor, and therefore increase the number of successful 

quit attempts. Such education also discourages nonsmokers from starting. Based on an 

extensive evidence base, FDA expects that the new cigarette warnings will decrease the 

number of smokers and result in lives saved, increased life expectancy, improved health, and 

reduced medical costs. Specifically, it is estimated that these warnings will result in 16,500 

fewer smokers each year, both by encouraging smokers to quit and by deterring nonsmokers 

from starting to smoke. Importantly, the monetized benefit of the health warnings is estimated to be more than $630 million per year over 20 years. Additional benefits of the rule, 

such as reduction in secondhand smoke exposure, will also occur but were not included in 

the monetized estimate. 

19
Advancing Knowledge: Accelerating Research to Expand the Science Base 

and Monitor Progress 

Scientists have known about the dangers of tobacco for decades, but the market for tobacco 

and nicotine-delivery products continues to evolve and diversify in unprecedented ways. 

To identify more effective methods to prevent youth and young adults from starting and to 

help addicted smokers quit, researchers continue to study the effects of tobacco use and the 

pathways to addiction. HHS also administers national surveys to monitor tobacco use and 

attitudes, understand emerging trends, and guide future efforts. In addition to this ongoing 

research, HHS has recently embarked on new efforts to advance knowledge, including updated reports from the Surgeon General, a new cohort study of tobacco users, and increased 

tobacco regulatory research. 

Surgeon General Reports on Tobacco 

The Surgeon General provides the public with information to help them lead healthier lives. 

For the last 50 years, a series of Surgeon General Reports on tobacco and health has raised 

national awareness about the harms of tobacco use and the measures necessary to address 

these harms. 

The 30th Surgeon General’s Report on tobacco and health, released in 2010, is entitled 

How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable 

Disease (U.S. Department of Health and Human Services, 2010c). It details the ways 

in which tobacco smoke damages the human body, with major findings including: 

•	 There is no safe level of exposure to tobacco smoke. Any exposure to tobacco 

smoke—even an occasional cigarette or exposure to secondhand smoke—is harmful. 

•	 Damage from tobacco smoke is immediate. 

•	 Smoking longer means more damage. 

•	 Cigarettes are designed for addiction. 

•	 There is no safe cigarette. 

•	 The only proven strategy for reducing the risk for tobacco-related disease and death 

is to never smoke, and if you do smoke, to quit. 

The report has achieved significant coverage since it was released: 

•	 Within 24 hours of its release, the report received media coverage in all parts of the 

country—in more than 2,000 television, radio, print, and online media outlets and 

amassing a publicity value of $3 million. 

•	 By year’s end, the report had generated more than $4.6 million in earned media and 

42 million media impressions. 

On March 8, 2012, Surgeon General Dr. Regina Benjamin released Preventing Tobacco Use 

Among Youth and Young Adults: A Report of the Surgeon General—the 31st tobacco-related 

Surgeon General’s Report issued since 1964. This report describes the epidemic of tobacco 

use among youth ages 12 through 17 and young adults ages 18 through 25, including the 

epidemiology, causes, and health effects of tobacco use and interventions proven to prevent it 

(U.S. Department of Health and Human Services, 2012a). Major findings include: 20
•	 Far too many young people are still using tobacco. More than 600,000 middle 

school students and 3 million high school students smoke cigarettes. Rates of decline 

for youth cigarette smoking have slowed in the last decade, and rates of decline for 

smokeless tobacco use have stalled completely. 

•	 Prevention efforts must include focus on young adults ages 18 through 25, too. 

Nearly 9 out of 10 smokers started smoking by age 18, and 99% started by age 26. 

Progression from occasional to daily smoking almost always occurs by age 26. 

•	 Tobacco use by youth and young adults causes both immediate and long-term 

damage. One of the most serious health effects is nicotine addiction, which prolongs 

tobacco use and can lead to severe health consequences. The younger youth are when 

they start using tobacco, the more likely they’ll become addicted. 

•	 Youth are vulnerable to social and environmental influences to use tobacco; messages 

and images that make tobacco use appealing to them are everywhere. 

•	 Tobacco companies spend more than a million dollars an hour in this country alone 

to market their products. This report concludes that tobacco product advertising and 

promotions still entice far too many young people to start using tobacco. 

•	 Comprehensive, sustained, multicomponent programs can cut youth tobacco use 

in half in 6 years. 

The report has achieved significant coverage since it was released: 

•	 In the first 2 weeks, more than 2,000 media outlets and 2,300 social media and 

Web sites covered the report. 

•	 Three months later, the report had generated approximately $6.69 million in earned 

media and 2.9 billion media impressions. 

On May 30th, Dr. Regina Benjamin, U.S. Surgeon General, announced the winners of a 

video contest she launched on March 15, 2012, in conjunction with the release of Preventing 

Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. At that time, she 

invited young Americans to develop original videos that featured one or more of the findings 

from the report. 

The contest—Tobacco: I’m Not Buying It—was hosted by CDC’s Office on Smoking and 

Health (OSH) and supported through Challenge.gov. Applicants were invited to submit 

videos in either English or Spanish in two age categories: youth (13–17 years) or young 

adult (18–25 years). This creative outlet encouraged applicants to express their views about 

this problem and share why they choose to be tobacco-free. To encourage participation in 

the contest, CDC/OSH announced the availability of up to four grand prizes (one for each 

category, both in English and in Spanish). Three runner-up prizes were also available for each 

category and language. Contestants were instructed to submit their content via the Challenge 

.gov Web site. 

21
 

 

 

CDC also publicly announced the winners and runners-up and promoted their videos 

through a variety of digital media (Web sites, YouTube, Facebook, Twitter), providing them 

with broader recognition and further publicizing the Surgeon General’s Report findings. 

On June 14, 2012, Dr. Benjamin and other public health officials joined youth in Seattle, 

Washington, to participate in a youth and tobacco town hall sponsored by HHS and FDA, 

in partnership with CDC, state and local public health authorities, and tobacco prevention professionals throughout the Pacific Northwest. This town hall brought together public 

health professionals; tobacco use prevention specialists; educators; advocates; policy makers; 

and most importantly, young people from around the Pacific Northwest to share information, tools, and best practices in tobacco use prevention. 

FDA and NIH Collaboration 

In October 2011, FDA and the National Institutes of Health (NIH) announced a joint 

national, prospective, longitudinal cohort study of tobacco users (and those at risk for 

tobacco product use) to monitor and assess their tobacco use and the health impacts of such 

use. The initiative, called the Population Assessment of Tobacco and Health (PATH) Study, 

represents the first large-scale FDA-NIH collaboration on tobacco regulatory research since 

Congress granted FDA the authority to regulate tobacco products under the Tobacco 

Control Act. Scientific experts at NIDA and FDA’s Center for Tobacco Products (CTP) will 

coordinate this effort, which will prospectively follow at least 60,000 people who are users 

of tobacco products and those at risk for tobacco product use ages 12 and older in the United 

States. The study will a) examine what makes people susceptible to tobacco product use; 

b) evaluate initiation and use patterns; c) study patterns of tobacco product cessation and 

relapse; d) evaluate the effects of regulatory changes on risk perceptions and other tobaccorelated attitudes; e) assess differences in attitudes, behaviors, and key health outcomes 

in racial/ethnic, gender, and age subgroups; and f) assess biomarkers of exposure and disease 

outcomes. 

By measuring and accurately 


reporting on behavioral and 
 The PATH Study 

health effects associated with “The launch of this study signals a major mile- tobacco product use in the stone in addressing one of the most significant United States, this study public health burdens of the 21st century The will play an important role results will strengthen FDA’s ability to fulfill in the development, imple­ our mission to make tobacco-related death and mentation, and evaluation of disease part of America’s past and will further tobacco product regulations guide us in targeting the most effective actions by FDA. to decrease the huge toll of tobacco use on our 

NIH and FDA have estab­ nation’s health ” 

lished an unprecedented re­ - FDA Commissioner Margaret A Hamburg search partnership to increase 

tobacco regulatory science 

knowledge and capabilities. 

This partnership has begun innovative research of the impact of how altering nicotine levels 

in tobacco products could affect the way people use tobacco products and become addicted. 

FDA and NIH are working to establish Tobacco Centers of Regulatory Science for research 

relevant to the Tobacco Control Act as well as funding research project grants and research 

training grants. 

22
In a workshop in February 2012, FDA met with research organizations to communicate 

its tobacco regulatory research priorities. FDA’s priorities for research include: 

•	 Expanding understanding of the diversity of tobacco products 

•	 Reducing addiction to tobacco products 

•	 Reducing toxicity and carcinogenicity of tobacco products and smoke 

•	 Continuing research of the adverse health consequences of tobacco use 

•	 Broadening understanding of communications about tobacco products 

•	 Increasing knowledge about tobacco product marketing 

•	 Furthering understanding of how economics and policies affect tobacco product use 

NIH Research 

A number of key NIH agencies are accelerating tobacco research as part of the HHS Strategic 

Action Plan. NIDA has made the development of addiction-related medications, including 

new smoking cessation medications, a top priority through its Translational Medications 

Avant-Garde Award for Medications Development. One of the 2011 awardees is developing 

and testing a novel vaccine that induces a strong immune response against nicotine without 

the need for chemical enhancers, which could result in a less expensive vaccine with fewer 

side effects. In addition, NIDA is embarking on a novel product development partnership 

to leverage the strength and resources of public, nonprofit, and private-sector entities to 

accelerate the development and production of effective smoking cessation medications at 

reasonable costs. 

NCI leads and collaborates on research related to the prevention, treatment, and control of 

tobacco use and tobacco-related cancers, employing basic and applied research in the biological, behavioral, social, and population sciences. Two fiscal year (FY) 2009 NCI funding 

initiatives include “Measures and Determinants of Smokeless Tobacco Use, Prevention, and 

Cessation” and “Improving Effectiveness of Smoking Cessation Interventions and Programs 

in Low-Income Adult Populations.” The goal of the smokeless tobacco initiative is to develop 

an evidence base to inform smokeless tobacco control efforts and develop effective ways to 

limit the spread and promote cessation of smokeless tobacco use. The long-term goal of the 

initiative is to facilitate a significant reduction in smoking prevalence among low-income 

adults, thereby reducing the excess disease burden of tobacco use within these groups and 

decreasing the prevalence of smoking the United States as a whole. 

Historically, states and communities have played an important role in implementing tobacco 

prevention and control policies and programs and in designing and implementing mass 

media campaigns. In FY 2012, NCI funded the State and Community Tobacco Control 

Research Initiative to support innovative research that will yield actionable findings for state 

and community tobacco control programs and practitioners. Research funded by this initiative is aimed at addressing understudied aspects of tobacco control policy and media interventions by targeting four high-priority research areas at the state and community levels in 

the United States: 1) secondhand smoke policies, 2) tobacco pricing policies, 3) mass media 

countermeasures and community social norms, and 4) tobacco industry practices as they 

relate to the preceding three items. This research initiative includes seven research project 

sites around the country and one coordinating center site. 23
CDC Research 

CDC has established a partnership with FDA to enhance tobacco-related surveys in the 

United States, including the recently conducted 2012 National Youth Tobacco Survey, 

which will provide the first round of data to evaluate the impact of CTP’s regulatory efforts 

on youth, and the companion National Adult Tobacco Survey, which will be conducted in 

the fall of 2012 and aid in evaluating the impact of CTP’s regulatory efforts on tobacco use 

among adults. 

CDC is currently expanding the Smoking-Attributable Mortality, Morbidity, and Economic 

Costs online application, which contains two distinct Internet-based computational programs to estimate the economic and disease impact of smoking on adults and infants, to 

include estimates for the international tobacco control community. In addition, CDC is 

updating it to include current smoking-attributable factors. 

In addition, FDA is funding CDC’s Tobacco Laboratory to conduct a number of specific 

analyses related to the Tobacco Control Act. CDC will develop and validate new, more 

robust methods for analyzing harmful and potentially harmful constituents (HPHC) in 

tobacco products and tobacco smoke. CDC will use its expertise to train staff in FDA’s Office 

of Regulatory Affairs Southeast Regional Laboratory to carry out analytical methods for compliance and enforcement testing. CDC’s laboratory is establishing baseline levels of HPHC 

in selected tobacco products and smoke in order to assess the overall risk and overall trends 

in delivery of HPHC. The laboratory is building off of its decades-long experience in developing new biomarkers of exposure to HPHC in order to more fully assess the exposure of 

users of tobacco products. In order to better understand the relationship of tobacco product 

design, additives, ingredients, HPHC, and exposure, the laboratory is measuring biomarkers of exposure in smoking participants of the National Health Examination and Nutrition 

Examination Survey. The laboratory will serve as the primary biomarker analysis laboratory 

for the PATH study in order to help develop the most effective regulatory actions and to 

evaluate the impact of FDA regulatory actions on exposure of users and nonusers of tobacco 

products. CDC also conducts quick-turnaround projects to address specific questions related 

to FDA regulations. 

SAMHSA Surveillance 

SAMHSA’S National Survey on Drug Use and Health collects data on tobacco use and its 

association with both the use of other substances and mental health disorders. Additionally, 

beginning in 2011, SAMHSA’s National Survey of Substance Abuse Treatment Services, 

which collects data from all private and public substance abuse treatment facilities in the 

United States, began collecting data on the extent of a facility’s smoking policy and whether 

the facility provides nicotine replacement and/or non-nicotine smoking cessation medications 

to its clients. 

24
Toward a Society Free From 

Tobacco-Related Death and Disease 

For more than a century, tobacco use has been a burden on American public health, causing 

decreased quality of life for tens of millions of Americans, almost half a million lost lives 

annually, and billions of dollars each year in medical expenses and lost productivity. 

Despite these challenges, the resolve among HHS and other public health authorities to end 

the tobacco epidemic is strong, and the potential to do so unprecedented. More than ever 

before, public attitudes, political will, and scientific evidence are converging to support this 

goal. 

A growing body of successful evidence-based tobacco control measures has added powerful 

new tools to stem tobacco use. HHS’s Strategic Action Plan to end the tobacco epidemic 

provides a critical framework to guide and coordinate this work. Already, as described in this 

publication, federal and state agencies, together with local communities, are hard at work on 

many fronts applying proven methods for reducing the burden of tobacco dependence in the 

United States. 

HHS has led the way by implementing the proven tobacco prevention and treatment 

interventions recommended in the Strategic Action Plan. The Plan demonstrates that HHS 

is making good on this historic opportunity to rekindle the momentum of previous decades 

and achieve the vision of a society free from tobacco-related death and disease. 

To sustain the recent progress, robust action by HHS and other stakeholders must continue. 

With a committed and concerted effort, HHS and other public and private-sector partners 

across the country can achieve the Healthy People objectives of preventing youth initiation 

and reducing the adult smoking rate, resulting in millions of fewer smokers in the United 

States. The path charted by that achievement will then set a powerful stage for continued 

progress and success toward the ultimate goal of eliminating tobacco-related illness and 

death. 

25
26
Appendix A: Tracking Progress Toward 

the Healthy People Objectives 

The Strategic Action Plan is framed around Healthy People goals and objectives. Released 

by HHS each decade since 1980, Healthy People establishes 10-year targets to guide national 

health promotion and disease prevention efforts. In December 2010, HHS launched Healthy 

People 2020 (U.S. Department of Health and Human Services, 2010b), the fourth generation 

of this initiative, building on a foundation of three decades of work. 

HHS adopted four Healthy People 2020 objectives as the key goals for its Strategic Action 

Plan (U.S. Department of Health and Human Services, 2010b): 

•	 Reduce tobacco use by adults and adolescents 

•	 Reduce the initiation of tobacco use among children, adolescents, and young adults 

•	 Increase smoking cessation success by adult smokers 

•	 Reduce the proportion of nonsmokers exposed to secondhand smoke 

HHS commits to tracking key outcomes noted below as part of these four objectives. 

Adult Smoking Prevalence 

Current overall smoking prevalence falls short of the Healthy People 2020 target of 12%. 

27
•	 As of 2010, nearly one-fifth of American adults smoke (Centers for Disease Control 

and Prevention, 2011a). 

•	 The percentage of adults who smoke has been declining for many years, with today’s 

smoking rate being less than half of what it was in the 1960s. However, the rate 

of decline has slowed in recent years (Centers for Disease Control and Prevention, 

2011a). 

Some adults smoke at much higher rates than others. For example, in 2010: 

•	 Non-Hispanic whites (21.0%) and blacks (20.6%) are far more likely to smoke than 

Hispanics (12.5%) and Asians (9.2%) (Centers for Disease Control and Prevention, 

2011a). 

•	 Among racial/ethnic groups, American Indians/Alaska Natives have the highest 

smoking rates (31.4%), but they have shown a large decrease in recent years (Centers 

for Disease Control and Prevention, 2011a). 

•	 People who did not finish high school (25.1%) and those with only a high school 

diploma (23.8%) smoked at more than twice the rate of those with an undergraduate 

college education (9.9%) (Centers for Disease Control and Prevention, 2011a). 

•	 Persons with chronic mental illness consume 44% of all cigarettes sold, reflecting 

both high prevalence and heavy smoking (Schroeder & Morris, 2010). 

•	 Cigarette smoking also varies widely by geographic area. For example, 9.1% of adults 

in Utah and 12.1% of adults in California smoked cigarettes, compared with 26.8% 

in West Virginia and 24.8% in Kentucky. Overall, smoking rates were highest in the 

Midwest (21.8%) and South (21.0%) and lowest in the West (15.9%) and Northeast 

(17.4%) (Centers for Disease Control and Prevention, 2011a). 

Adolescent Tobacco Use 

In 2011, about 23% of high school students reported current use of some type of tobacco 

product, and 18% smoked cigarettes. 

28
•	 The United States is not close to achieving the Healthy People 2020 targets for adolescent tobacco use (Centers for Disease Control and Prevention, 2010b). 

•	 Teen smoking rates increased dramatically through the mid-1990s, then dropped 

sharply. However, in recent years, the decline in prevalence has slowed (Centers for 

Disease Control and Prevention, 2010b). 

•	 Since gradually falling in the preceding decade, smokeless tobacco use has risen 

slightly since 2003 (Centers for Disease Control and Prevention, 2010b). 

As with adults, patterns of tobacco use by high school students vary by demographic group. 

For example, in 2009: 

•	 White high school students were more than twice as likely to smoke as black high 

school students. Hispanic high school students smoke more than black high school 

students (Centers for Disease Control and Prevention, 2010b). 

•	 Smokeless tobacco remains a predominantly male problem; usage rates for high 

school students were 13.4% for males compared to 2.3% for females (Centers for 

Disease Control and Prevention, 2010b). 

Smoking Initiation 

The vast majority of smokers start when they are adolescents or young adults. 

29
•	 The 2010 National Survey on Drug Use and Health estimated that 2.4 million 

people smoked a cigarette for the first time within the past 12 months (Substance 

Abuse and Mental Health Services Administration, 2011). 

•	 The rate of adolescent initiation has held fairly steady for the last decade. In 2010, 

5.8% of adolescents who had never smoked before smoked a cigarette for the first 

time (Substance Abuse and Mental Health Services Administration, 2011). 

•	 Among 18- to 25-year-olds, the rate of initiation has increased since 2002. In 2010, 

7.9% of the nonsmokers in this age group tried a cigarette for the first time 

(Substance Abuse and Mental Health Services Administration, 2011). 

30
Attempts to Quit 

Every year, almost half of the adult smokers in the United States try to quit. 

•	 The proportion of adult smokers who try to quit each year has increased slowly, at 

best, and the nation is far from the Healthy People 2020 objectives of 80% of adult 

smokers trying to quit each year (U.S. Department of Health and Human Services, 

2010b). 

31
Exposure to Secondhand Smoke 

The percentage of nonsmokers exposed to secondhand smoke has decreased dramatically 

since the early 1990s, owing to a combination of local, state, and federal smoke-free laws; 

workplace policies; and people deciding to make their homes smoke-free. The Healthy People 

2010 goal has been exceeded (U.S. Department of Health and Human Services, 2006). 

Despite the overall progress at reducing nonsmokers’ exposure to secondhand smoke, some 

groups remain disproportionally at risk. For example, in 2007–2008: 

•	 Children aged 3-11 years (53.6%) were more likely to be exposed to secondhand 

smoke than adults aged 20 years and older (36.7%) (Centers for Disease Control and 

Prevention, 2010a). 

•	 Black nonsmokers (55.9%) were exposed to secondhand smoke at much higher 

rates than whites (40.1%) or Hispanics (28.5%) (Centers for Disease Control and 

Prevention, 2010a). 

32
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix B: List of Acronyms 

ARRA American Recovery and Reinvestment Act 

CDC Centers for Disease Control and Prevention 

CPPW Communities Putting Prevention to Work 

CTG Community Transformation Grant 

CTP Center for Tobacco Products 

CUNY City University of New York 

FDA Food and Drug Administration 

FEHB Federal Employee Health Benefits 

FY Fiscal year 

HHS Department of Health and Human Services 

HPHC Harmful and potentially harmful constituents 

HRSA Health Resources and Services Administration 

MOU Memorandum of understanding 

NCI National Cancer Institute 

NHANES National Health and Nutrition Examination Survey 

NHIS National Health Interview Survey 

NIDA National Institute on Drug Abuse 

NIH National Institutes of Health 

NSDUH National Survey on Drug Use and Health 

NTCP National Tobacco Control Program 

OPM Office of Personnel Management 

OSH Office on Smoking and Health 

PACT Prevent All Cigarette Trafficking 

PATH Population Assessment of Tobacco and Health 

SAMHSA Substance Abuse and Mental Health Services Administration 

SCLC Smoking Cessation Leadership Center 

YRBSS Youth Risk Behavior Surveillance System 

33
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