Best 

Practices 

for Comprehensive 

Tobacco Control 

Programs 

2014 
Suggested Citation

Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control Programs—2014.

Atlanta: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health, 2014.

Ordering Information

To download or order copies of this report, go to 

www.cdc.gov/tobacco

or

to order single copies, 

call toll-free

1 (800) CDC-INFO

1 (800) 232-4636 
Best 

Practices 

for Comprehensive 

Tobacco Control 

Programs 

2014 
The following individuals from the 

Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and Health Promotion, 

Office on Smoking and Health (OSH), 

were primary contributors to the preparation of this publication: 

Brian King, PhD, MPH

Terry Pechacek, PhD

Peter Mariolis, PhD

The following OSH staff 

also contributed to the preparation of this publication:

Judy Ahearn, BS; Stephen Babb, MPH; Diane Beistle, BA; Rebecca Bunnell, PhD; Ralph Caraballo, PhD;

Shanta Dube, PhD, MPH; Monica Eischen, BS; Jami Fraze, PhD; Erika Fulmer, MHA; 

Bridgette Garrett, PhD, MS; Karen Gutierrez, BA; Carissa Holmes, MPH; David Homa, PhD, MPH; 

Brandon Kenemer, MPH; Rene Lavinghouze, MA; Allison MacNeil, MPH; Ann Malarcher, PhD, 

MSPH; Kristy Marynak, MPP; Timothy A. McAfee, MD, MPH; Sarah O’Leary, MPH, MA; 

Gabbi Promoff, MA; Robert Rodes, MS, MBA, MEd; Patti Seikus, MPH; Shawna Shields, MPH; 

Kisha Smith, MPH; Karla S. Sneegas, MPH; Xin Xu, PhD; and Lei Zhang, PhD. 

OSH also gratefully acknowledges 

the contributions provided by the following individuals:

David Abrams, PhD, Legacy; Rob Adsit, MEd, University of Wisconsin; Linda Bailey, MHS, JD, 

North American Quitline Consortium; Cathy Callaway, BS, American Cancer Society Cancer Action 

Network; Jennifer Cantrell, DrPH, MPA, Legacy; Thomas Carr, BA, American Lung Association; 

Julia Cartwright, BA, Legacy; Frank Chaloupka, PhD, University of Illinois–Chicago; K. Michael 

Cummings, PhD, MPH, Medical University of South Carolina; Marietta Dreher, BA, ClearWay 

Minnesota; Sherry Emery, PhD, MBA, University of Illinois–Chicago; Matthew Farrelly, PhD, RTI 

International; John Francis, MPH, MBA, CDC’s Division of Community Health; Karen Girard, 

MPA, Oregon Healthy Authority; Emma Goforth, MPH, Colorado Department of Public Health 

and Environment; Roy Hart, MPH, Mississippi State Department of Health; Sally Herndon, MPH, 

North Carolina Division of Public Health; Delmonte Jefferson, National African American Tobacco 

Prevention Network; Harlan Juster, PhD, New York State Department of Health; Pamela Ling, 

MD, MPH, University of California at San Francisco; Doug Luke, PhD, Washington University–St. 

Louis; Marc Manley, MD, MPH, University of Pittsburg Medical Center; Danny McGoldrick, PhD, 

Campaign for Tobacco-Free Kids; Jeannette Noltenius, PhD, MA, National Latino Tobacco Control 

Network; Sjonna Paulson, APR, Oklahoma Tobacco Settlement Endowment; Meg Riordan, PhD, 

Campaign for Tobacco-Free Kids; Todd Rogers, PhD, RTI International; April Roeseler, MSPH, 

BSN, California Department of Public Health; Mary Kate Salley, BA, Alere Wellbeing; Scout, 

PhD, National LGBT Tobacco Control Network; Chris Sherwin, BA, American Heart Association; 

Jennifer Singleterry, MA, American Lung Association; Madeline Solomon, MPH, Tobacco Technical 

Assistance Consortium; Jeff Soukup, BS, Nebraska Department of Health and Human Services; 

Colleen Stevens, MS, California Department of Public Health; Bob Vollinger, MSPH, 

National Cancer Institute; Donna Warner, MBA, MA, Multi-State Collaborative for Health 

Systems Change to Address Tobacco Use; Jeff Willett, PhD, Kansas Health Foundation; 

and David Willoughby, MA, ClearWay Minnesota. 
5

Table of Contents

Executive Summary .........................................................................................................................................................................................................................................................................................................................................................................................................................6

Introduction .................................................................................................................................................................................................................................................................................................................................................................................................................................................................9

Section A: Components of a Comprehensive Tobacco Control Program .........................................................................................................................17

I. State and Community Interventions ..............................................................................................................................................................................................................................................................................................18

II. Mass-Reach Health 

Communication Interventions .....................................................................................................................................................................................................................................................................................................................................30

III. Cessation Interventions ........................................................................................................................................................................................................................................................................................................................................................40

IV. Surveillance and Evaluation ...................................................................................................................................................................................................................................................................................................................................56

V. Infrastructure, Administration, and Management ........................................................................................................................................................................................................................64

Section B: Recommended Funding Levels for All 50 States and the District Of Columbia .......................71

Annual Total Funding Levels for State Programs .............................................................................................................................................................................................................................................72

Annual Per Capita Funding Levels for State Programs ................................................................................................................................................................................................................74

Section C: Recommended Funding Levels, by State .....................................................................................................................................................................................................................................77

Appendices ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................129

Appendix A: Funding Recommendation Formulations ................................................................................................................................................................................................130

Appendix B: Program and Policy Recommendations for 

Comprehensive Tobacco Control Programs .........................................................................................................................................................................................................................................................133

Appendix C: National Prevention Strategy Recommendations ........................................................................................................................................................136

Appendix D: Guidelines for Comprehensive Local Tobacco Control Programs ............................................................................138

Appendix E: Data Sources ...................................................................................................................................................................................................................................................................................................................................................139
6

Executive Summary 

Tobacco use is the single most preventable cause 

of disease, disability, and death in the United States. 

Nearly one-half million Americans still die prematurely 

from tobacco use each year, and more than 16 million 

Americans suffer from a disease caused by smoking. 

Despite these risks, approximately 42.1 million U.S. 

adults currently smoke cigarettes. And the harmful 

effects of smoking do not end with the smoker. 

Secondhand smoke exposure causes serious disease 

and death, and even brief exposure can be harmful 

to health. Each year, primarily because of exposure to 

secondhand smoke, an estimated 7,330 nonsmoking 

Americans die of lung cancer and more than 33,900 die 

of heart disease. Coupled with this enormous health 

toll is the significant economic burden. Economic costs 

attributable to smoking and exposure to secondhand 

smoke now approach $300 billion annually. 

F

ifty years have passed since the 1964 Surgeon General’s report on smoking and 

health concluded: “Cigarette smoking is a 

health hazard of sufficient importance in 

the United States to warrant appropriate remedial 

action.” There now is a robust evidence base for 

effective tobacco control interventions. Yet, despite 

this progress, the United States is not currently on 

track to achieve the Healthy People 2020 objective to reduce cigarette smoking among adults to 

12% or less by the year 2020. A 2007 Institute of 

Medicine (IOM) report presented a blueprint for 

action to “reduce smoking so substantially that it is 

no longer a public health problem for our nation.” 

The two-pronged strategy for achieving this goal 

includes: 1) strengthening and fully implementing currently proven tobacco control measures; 

and 2) changing the regulatory landscape to permit policy innovations. Foremost among the IOM 

recommendations is that each state should fund 

a comprehensive tobacco control program at the 

level that the Centers for Disease Control and Prevention (CDC) recommends.

Evidence-based, statewide tobacco control 

programs that are comprehensive, sustained, 

and accountable have been shown to reduce 

smoking rates, as well as tobacco-related diseases 

and deaths. A comprehensive statewide tobacco 

control program is a coordinated effort to establish 

smokefree policies and social norms, to promote 

and assist tobacco users to quit, and to prevent 

initiation of tobacco use. This comprehensive 

approach combines educational, clinical, regulatory, 

economic, and social strategies. Research has 

documented the effectiveness of laws and policies 

in a comprehensive tobacco control effort to 

protect the public from secondhand smoke 

exposure, promote cessation, and prevent initiation, 

including: increasing the unit price of tobacco 

products; implementing comprehensive smokefree 

laws that prohibit smoking in all indoor areas of 

worksites, restaurants, and bars, and encouraging 

smokefree private settings such as multiunit 

housing; providing insurance coverage of evidencebased tobacco cessation treatments; and limiting 

minors’ access to tobacco products. Additionally, 

research has shown greater effectiveness with 

multicomponent interventional efforts that integrate 

the implementation of programmatic and policy 

initiatives to influence social norms, systems, 

and networks.

CDC’s Best Practices for Comprehensive 

Tobacco Control Programs—2014 is an evidencebased guide to help states plan and establish 

comprehensive tobacco control programs. This 

edition updates Best Practices for Comprehensive 

Tobacco Control Programs—2007. The 2014 

edition describes an integrated programmatic 

structure for implementing interventions proven 

to be effective and provides the recommended 

level of state investment to reach these goals 

and to reduce tobacco use in each state. 

These individual components are most 

effective when they work together to produce 

the synergistic effects of a comprehensive 

statewide tobacco control program. On the 

basis of evidence of effectiveness documented 

in the scientific literature and the experiences 

of state and local programs, the most effective 

population-based approaches have been defined 

within the following overarching components. 
7

Executive Summary

I. State and Community Interventions 

State and community interventions include supporting 

and implementing programs and policies to influence 

societal organizations, systems, and networks that 

encourage and support individuals to make behavior 

choices consistent with tobacco-free norms. The social 

norm change model presumes that lasting change 

occurs through shifts in the social environment—initially 

or ultimately—at the grassroots level across local 

communities. State and community interventions unite 

a range of integrated activities, including local and 

statewide policies and programs, as well as initiatives to 

eliminate tobacco-related disparities. 

The most effective state and community 

interventions are those in which specific strategies for 

promoting tobacco use cessation, preventing tobacco 

use initiation, and eliminating exposure to secondhand 

smoke are combined with mass-reach health 

communication interventions and other initiatives to 

mobilize communities and to integrate these strategies 

into synergistic and multicomponent efforts. 

II. Mass-Reach Health Communication Interventions 

An effective state-level, mass-reach health 

communication intervention delivers strategic, culturally 

appropriate, and high-impact messages through 

sustained and adequately funded campaigns that are 

integrated into a comprehensive state tobacco control 

program. Typically, effective health communication 

interventions and countermarketing strategies employ 

a wide range of paid and earned media, including: 

television, radio, out-of-home (e.g., billboards, transit), 

print, and digital advertising at the state and local levels; 

promotion through public relations/earned media 

efforts, including press releases/conferences, social 

media, and local events; health promotion activities, 

such as working with health care professionals and other 

partners, promoting quitlines, and offering free nicotine 

replacement therapy; and efforts to reduce or replace 

tobacco industry sponsorship and promotions.

Innovations in health communication interventions 

include the ability to target and engage specific 

audiences through multiple communication channels, 

such as online video, mobile Web, and smartphone and 

tablet applications (apps). Social media platforms, such as 

Twitter and Facebook, have facilitated improvements in 

how messages are developed, fostered, and disseminated 

in order to better communicate with target audiences 

and allow for relevant, credible messages to be shared 

more broadly within the target audiences’ social circles.

III. Cessation Interventions 

Comprehensive state tobacco control program cessation 

activities can focus on three broad goals: (1) promoting 

health systems change; (2) expanding insurance coverage 

of proven cessation treatments; and (3) supporting state 

quitline capacity.

Health systems change involves institutionalizing 

cessation interventions in health care systems and 

seamlessly integrating these interventions into routine 

clinical care. These actions increase the likelihood that 

health care providers will consistently screen patients 

for tobacco use and intervene with patients who use 

tobacco, thus increasing cessation. Expanding cessation 

insurance coverage removes cost and administrative 

barriers that prevent smokers from accessing cessation 

counseling and medications, and increases the number of 

smokers who use evidence-based cessation treatments 

and who successfully quit. Expanding cessation insurance 

coverage also has the potential to reduce tobacco-related 

population disparities. 

Quitlines potentially have broad reach, are effective 

with and can be tailored to diverse populations, and 

increase quit rates. Because state quitline services are 

free, remove time and transportation barriers, and are 

confidential, they are one of the most accessible cessation 

resources. Optimally, quitline counseling should be made 

available to all tobacco users willing to access the service. 
8

Executive Summary

IV. Surveillance and Evaluation 

Surveillance is the process of continuously monitoring 

attitudes, behaviors, and health outcomes over time. 

Statewide surveillance is important for monitoring the 

achievement of overall program goals. Evaluation is 

used to assess the implementation and outcomes of a 

program, increase efficiency and impact over time, and 

demonstrate accountability. 

Publicly financed programs need to have 

accountability and demonstrate effectiveness, as well as 

have access to timely data that can be used for program 

improvement and decision making. 

Therefore, a critical infrastructural component of any 

comprehensive tobacco control program is a surveillance 

and evaluation system that can monitor and document 

key short-term, intermediate, and long-term outcomes 

within populations. Data from surveillance and 

evaluation systems can be used to inform program and 

policy directions, demonstrate program effectiveness, 

monitor progress on reducing health disparities, ensure 

accountability to those with fiscal oversight, and engage 

stakeholders.

V. Infrastructure, Administration, and Management 

A comprehensive tobacco control program requires 

considerable funding to implement. Therefore, a fully 

functioning infrastructure must be in place in order to 

achieve the capacity to implement effective interventions. 

Sufficient capacity is essential for program sustainability, 

efficacy, and efficiency, and it enables programs to plan 

their strategic efforts, provide strong leadership, and foster 

collaboration among the state and local tobacco control 

communities. 

An adequate number of skilled staff is also necessary 

to provide or facilitate program oversight, technical 

assistance, and training. 

The primary objectives of the recommended 

statewide comprehensive tobacco control program 

are to reduce tobacco use and the personal and 

societal burdens of tobacco-related disease and 

death. Research shows that the more states spend 

on comprehensive tobacco control programs, the 

greater the reductions in smoking. The longer 

states invest in such programs, the greater and 

quicker the impact. 

Implementing comprehensive tobacco control 

programs at the levels of investment outlined in this 

report would have a substantial impact. As a result, 

millions of fewer people in the United States would 

smoke and hundreds of thousands of premature 

tobacco-related deaths would be prevented. Longterm investments would have even greater effects. 

We know what works to effectively reduce 

tobacco use, and if we were to fully invest in 

and implement these proven strategies, we could 

significantly reduce the staggering toll that tobacco 

takes on our families and in our communities. We 

could accelerate the declines in cardiovascular 

mortality, reduce chronic obstructive pulmonary 

disease, and make lung cancer a rare disease. With 

sustained implementation of state tobacco control 

programs and policies, the Healthy People 2020

objective of reducing adult smoking prevalence 

to 12% or less by 2020 could be attainable. 
9

Introduction 

Burden of Tobacco Use

Tobacco use is the single most preventable cause 

of disease and death in the United States.1 The 

health consequences of tobacco use include 

heart disease, multiple types of cancer, pulmonary disease, adverse reproductive effects, and the 

exacerbation of chronic health conditions.1 Nearly 

one-half million Americans still die prematurely 

from tobacco use each year, and economic costs 

attributable to smoking and exposure to secondhand smoke now approach $300 billion annually.2

Despite these known health and financial burdens, 

approximately one in four American adults currently use some form of tobacco, with one in five 

smoking cigarettes.3,4

This public health problem is compounded 

by the fact that the harmful effects of tobacco use 

do not end with the user. Although substantial 

progress has been made in the adoption of 

comprehensive smokefree policies that prohibit 

smoking in all indoor areas of workplaces and 

public places, millions of Americans not protected 

by such policies remain susceptible to involuntary 

secondhand smoke exposure in these areas, as 

well as private settings such as multiunit housing.5,6

There is no risk-free level of secondhand smoke, 

and exposure can cause premature death and 

disease in nonsmoking adults and children.7,8

Nearly 90% of adult smokers begin smoking 

by the time they are 18 years of age.9 Although 

the prevalence of cigarette smoking among 

youth decreased significantly from the late 

1990s to 2003, the rate of decline has slowed in 

recent years.10 In 2012, approximately 6.7% of 

middle school students and 23.3% of high school 

students reported using a tobacco product within 

the past 30 days.11 Several factors may have 

contributed to this lack of continued decline, 

including smaller annual increases in the retail 

price of cigarettes, decreased exposure among 

youth to effective mass media tobacco control 

campaigns, and less funding for comprehensive 

statewide tobacco control programs.12

Additionally, actions by the tobacco industry, 

including substantial increases in expenditures 

on advertising and promotion at the point of sale, 

may also have played a role, especially given the 

industry’s history of deceptive advertising. In the 

2006 final opinion in United States v. Philip Morris, 

U.S. District Judge Gladys Kessler concluded that the 

major tobacco companies are adjudicated racketeers 

that had “mounted a coordinated, well-financed, 

sophisticated public relations campaign to attack 

and distort the scientific evidence demonstrating 

the relationship between smoking and disease.”13

Goals of Comprehensive 

Tobacco Control Programs

In 2007, the Institute of Medicine (IOM) released 

the report, Ending the Tobacco Problem: A Blueprint for the Nation, which outlined a two-pronged 

strategy for eliminating the burden of tobacco use 

in the United States.14 This strategy included: 1) 

strengthening and fully implementing traditional 

tobacco control measures; and 2) changing the regulatory landscape to permit policy innovations. 

The IOM Committee specifically concluded that 

there was compelling evidence that comprehensive state tobacco programs can achieve substantial 

reductions in tobacco use.14

The mission of comprehensive tobacco control 

programs is to reduce disease, disability, and 

death related to tobacco use. A comprehensive 

approach—one that optimizes synergy 

from applying a mix of educational, clinical, 

regulatory, economic, and social strategies—is 

the guiding principle for eliminating the health 

and economic burden of tobacco use.15,16

Goals for Comprehensive 

Tobacco Control Programs

 Prevent initiation among youth and young adults. 

 Promote quitting among adults and youth. 

 Eliminate exposure to secondhand smoke. 

 Identify and eliminate tobacco-related disparities 

among population groups. 
10

Introduction

Impact of Comprehensive 

Tobacco Control Programs

States that have made larger investments in comprehensive tobacco control programs have seen 

larger declines in cigarettes sales than the United 

States as a whole, and the prevalence of smoking among adults and youth has declined faster 

as spending for tobacco control programs has 

increased.17–19 For example, during 1998–2003, 

a comprehensive prevention program in Florida 

anchored by an aggressive youth-oriented health 

communications campaign reduced the prevalence of smoking among middle and high school 

students by 50% and 35%, respectively.20 Similarly, 

during 2001–2010, the New York State Tobacco 

Control Program reported declines in the prevalence of smoking among adults and youth in the 

state that outpaced declines nationally. As a result, 

smoking-attributable personal health care expenditures in New York in 2010 were $4.1 billion less 

than they would have been had the prevalence of 

smoking remained at 2001 levels.21

In addition to the beneficial impact of larger 

investments in comprehensive tobacco control 

programs on smoking rates, research also shows 

that the longer states invest in such programs, the 

greater and quicker the impact.16 For example, in 

California, the nation’s first and longest-running 

comprehensive state tobacco control program, 

the prevalence of smoking among adults declined 

from 22.7% in 1988 to 11.9% in 2010.22 Decreases in 

lung cancer incidence and the correlation between 

lung cancer incidence and quit ratios also provide 

compelling evidence of the value of sustained 

tobacco control efforts. Since 1998, lung cancer 

incidence in California has been declining four 

times faster than in the rest of the United States.23

National Initiatives to 

Support Comprehensive 

Tobacco Control Programs

A comprehensive approach to tobacco prevention 

and control requires coordination and collaboration across the federal government, across the 

nation, and within each state. The federal government has undertaken a number of important 

activities that provide a foundation for state action. 

For example, in 1999, the National Tobacco Control Program (NTCP) was launched, combining 

initiatives from the National Cancer Institute (NCI) 

and the Centers for Disease Control and Prevention (CDC) into one coordinated national program 

that CDC funds and manages.24 CDC funding is 

designed to support and leverage state funding for 

evidence-based interventions and to help states 

evaluate their program efforts. NTCP provides 

technical assistance and limited funding to all 50 

states, the District of Columbia, and seven territories, as well as Tribal Support Centers and National 

Networks of specific populations. 

Similarly, The National Network of Tobacco 

Cessation Quitlines was developed through 

a partnership among CDC, the NCI Cancer 

Information Service, the North American 

Quitline Consortium, and the states.25 This 

system provides callers from across the nation 

with a single, toll-free access point (1-800-QUIT 

NOW) that automatically routes them to their 

state’s telephone-based cessation services. 

In addition to these activities, several major 

advances were made in recent years through the 

enactment of national tobacco control legislation. 

Specifically, the 2009 Family Smoking Prevention 

and Tobacco Control Act gives the Food and 

Drug Administration authority to regulate the 

manufacture, distribution, and marketing of tobacco 

products.26 In addition, the Patient Protection 

and Affordable Care Act, as amended by the 

Health Care and Education Reconciliation Act and 

referred to collectively as the Affordable Care Act, 

provides expanded coverage for recommended 

clinical preventive services, including evidencebased smoking-cessation treatments, for many 

persons in the United States.27 Finally, the Children’s 

Health Insurance Program Reauthorization Act 

of 2009 raised the federal tax rate for cigarettes 

from $0.39 to $1.01 per pack.28 Increasing the 

price of tobacco products is the single most 

effective way to prevent initiation among 

nonsmokers and to reduce consumption.15,29

Scientific data about the extent of tobacco use, 

its impact, and effective interventions to reduce 

its use have been generated and disseminated 

by several federal agencies, including CDC, 

the National Institutes of Health (NIH), the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA), and the Agency for 

Healthcare Research and Quality. The federal 

government has also supported several national 

and state tobacco use surveys among adults 

and youth through the CDC (e.g. Behavioral 

Risk Factor Surveillance System, National 
11

Introduction

Health Interview Survey, Youth Risk Behavior 

Surveillance System, national and state Adult 

Tobacco Surveys, national and state Youth Tobacco 

Surveys), NIH (e.g. Tobacco Use Supplement to 

the Current Population Survey and Monitoring 

the Future), and SAMHSA (e.g. National Survey 

on Drug Use and Health). These surveys provide 

complementary data from various populations 

that are critical for surveillance and evaluation.

National partner organizations and many 

academic and research partners also play a 

critical role in tobacco prevention and 

control efforts. For example: 

















The American Cancer Society, American Heart 

Association, and American Lung Association 

provide strong national, state, and local 

advocacy leadership on tobacco control 

policy issues as well as community support 

The American Legacy Foundation’s truth® 

campaign reinforces state-based youth 

prevention efforts and has been independently 

associated with substantial declines in the 

prevalence of smoking among youth30

The Americans for Nonsmokers’ Rights 

Foundation provides technical assistance to 

states and localities as they engage in the 

process of implementing smokefree policies 

The Association of State and Territorial 

Health Officials, the National Association 

of County and City Health Officials, and 

the National Association of Local Boards of 

Health provide state and local health officials 

with support in developing and maintaining 

tobacco control policies and programs 

The Campaign for Tobacco-Free Kids 

provides legal, media, and research 

support to assist in promoting and 

implementing tobacco control policies 

The Robert Wood Johnson Foundation 

has supported research to document the 

effectiveness of policies and programs and also 

helps build tobacco control infrastructure 

The Tobacco Control Legal Consortium, 

a network of legal programs supporting 

tobacco control policy change, works 

to assist communities and increase legal 

resources available for tobacco control 

The Tobacco Technical Assistance 

Consortium supports the effectiveness of 

tobacco control programs by providing 

technical assistance to state and local 

programs, partners, and coalitions 

Although a number of critical efforts to curb 

tobacco use occur at the national level, state and 

local community action is essential to ensure the 

success of tobacco control interventions. Most 

funding for tobacco control interventions comes 

from the states.31 Furthermore, it is the policies, 

partnerships, and intervention activities that occur 

at the state and local levels that ultimately lead to 

social norm and behavior change. In acknowledging 

the essential and unique roles that states and 

communities play in tobacco control efforts, this 

report provides technical information and evidencebased benchmarks to assist states in designing 

comprehensive programs. Communities, in turn, 

support comprehensive programs by implementing 

evidence-based initiatives at the local level. 

For example, although the centralized quitline 

number and structure of the National Network 

of Tobacco Cessation Quitlines were established 

through partnerships at the national level, states 

still provide the foundation for this system by 

maintaining their quitline services and promoting 

their use through broadcast media. Communities 

can further promote this service through local 

channels, such as hospitals, health care systems, 

newspapers, and community organizations.

Implementing Best Practices 

for Comprehensive Tobacco 

Control Programs 

Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and 

accountable have been shown to reduce smoking rates as well as tobacco-related diseases and 

deaths. A comprehensive statewide tobacco control 

program is a coordinated effort to:

 Establish smokefree policies and social norms 

Promote cessation and assist tobacco 

users to quit 

Prevent initiation of tobacco use 

CDC’s Best Practices for Comprehensive 

Tobacco Control Programs—2014 is an evidencebased guide to help states plan and establish 

comprehensive tobacco control programs. CDC 

has prepared this report to help states organize 

their tobacco control program efforts into an 

integrated and effective structure that uses and 
12

Introduction

maximizes interventions proven to be effective 

and to operate at the scale that would be required 

to reach the Healthy People 2020 objective of 

reducing smoking to 12% or less by the year 2020. 

In 1999, CDC first published Best Practices 

for Comprehensive Tobacco Control Programs.

That report outlined the elements of an evidencebased state tobacco control program and 

provided a recommended state funding range 

to substantially reduce tobacco-related disease, 

disability, and death.32 Best Practices—1999

recommended that states invest a combined 

$1.6 to $4.2 billion annually in such programs. 

Subsequently, the recommendation was 

updated to $3.7 billion annually in 2007.16

After the 1999 report was published, overall 

funding for state tobacco control programs more 

than doubled, and states restructured their tobacco 

control programs to align with CDC’s goals and 

programmatic recommendations.16 To date, all 

50 states and the District of Columbia have state 

tobacco control programs that are funded through 

various revenue streams, including tobacco 

industry settlement payments, cigarette excise 

tax revenues, state general funds, the federal 

government, and nonprofit organizations.31

However, in 2011, only two states funded 

tobacco control programs at CDC-recommended 

levels, whereas 27 states funded at less than 25% of 

these levels.4 Many state programs have experienced 

and are facing substantial state government cuts 

to tobacco control funding, resulting in the nearelimination of tobacco control programs in 

those states.31 In 2010, states appropriated only 

2.4% of their state tobacco revenues for tobacco 

control. Reaching the Best Practices—2007

funding goal would have required an additional 

13.0% of tobacco revenues, or $3.1 billion of 

the $24 billion collected across all states.31

Investing in comprehensive tobacco control 

programs and implementing evidence-based 

interventions have been shown to reduce youth 

initiation, tobacco-related disease and death, 

and tobacco-related health care costs and lost 

productivity.14,16,32 These interventions include:









Increasing the price of tobacco products

Enacting comprehensive smokefree policies

Funding hard hitting mass-media campaigns 

Making cessation services fully 

accessible to tobacco users

Best Practices for Comprehensive Tobacco 

Control Programs—2014 updates the guidance 

provided in 2007, reflecting additional state 

experiences in implementing comprehensive 

tobacco control programs, new scientific literature, 

and changes in state populations, inflation, 

and the national tobacco control landscape. 

This report draws upon best practices 

determined by evidence-based analysis of state 

tobacco control programs and published evidence 

of effective tobacco control strategies. On the 

basis of this analysis, experience, and evidence, 

CDC recommends that states establish and sustain 

comprehensive tobacco control programs that 

contain the following overarching components. 

Overarching Components 

of Comprehensive Tobacco 

Control Programs 

 State and community interventions. 

 Mass-reach health communication interventions.

 Cessation interventions. 

 Surveillance and evaluation. 

 Infrastructure, administration, and management. 

This report describes an integrated budget 

structure for implementing interventions proven to 

be effective, and the minimum and recommended

state investment that would be required to reduce, 

and ultimately eliminate, tobacco use in each state. 

Information for each of these components includes:

 Justification for the program intervention

Considerations for achieving equity to 

reduce tobacco-related disparities

Budget recommendations for 

successful implementation

References to assist with implementation
13

Introduction

As with the funding guidance published in 2007, 

annual funding levels can vary within the lower 

and upper estimate provided for each state.16 The 

levels of annual investment for state and community 

interventions factor in multiple state-specific 

variables, such as the proportion of individuals 

within the state living at or below 200% of the 

poverty level, the proportion of the population that 

is a racial/ethnic minority, average wage rates for 

implementing public health programs, geographic 

size, and the state’s infrastructure as reflected by 

the number of local governmental health units. 

The 2014 funding formulas are provided 

in Appendix A of this report. On the basis of 

these different factors, the annual investment 

needed to implement the recommended program 

components of a comprehensive tobacco 

control program has been estimated to range 

from $7.41 to $10.53 per capita for all 50 states 

and the District of Columbia combined. 

The minimum and recommended funding 

levels presented in this report reflect the annual 

investment that each state can make in order to 

fully fund and sustain a comprehensive tobacco 

control program. The minimum funding level 

represents the lowest annual investment for 

attaining a comprehensive tobacco control program. 

The recommended funding level represents the 

annual level of investment for ensuring a fully 

funded and sustained comprehensive tobacco 

control program with resources sufficient to most 

effectively reduce tobacco use. These funding 

investment recommendations reflect, in aggregate, 

a nationally realistic level of investment. States 

that invest resources above the recommended 

level will accelerate their progress in eliminating 

tobacco use and reducing tobacco-related 

morbidity and mortality, and associated costs. 

It is important to note that additional 

investments are also required at the societal level 

in order to most effectively reduce tobacco use. 

For example, the enactment of the Affordable Care 

Act has presented significant new opportunities 

to institutionalize tobacco use screening and 

interventions and to increase access to evidencebased cessation treatments through expanded 

insurance coverage. These costs are important to 

consider for the purposes of addressing tobacco 

use but are not necessarily within the purview of 

state tobacco control program funding parameters. 

In fact, the new opportunities realized through 

the Affordable Care Act, along with other factors, 

contributed to a decline in the recommended 

state funding levels for cessation interventions in 

Best Practices for Comprehensive Tobacco Control 

Programs—2014.

Although each state’s analysis of their priorities 

can shape decisions about funding allocations 

for each recommended program component, it 

remains clear that more substantial investments 

in comprehensive state tobacco controls programs 

lead to quicker and greater declines in smoking 

rates and in smoking-related disease and death.17–19

This report provides evidence to support 

each of the five components of a comprehensive 

tobacco control program. While acknowledging the 

importance of the individual program components, 

it is critical to recognize why these individual 

components must work together to produce the 

synergistic effects of a comprehensive program. 

A comprehensive approach, with the combination 

and coordination of all five program components, 

has shown to be most effective at preventing 

tobacco use initiation and promoting cessation.33–35

Each day in the Unites States, the tobacco 

industry spends nearly $23 million to advertise 

and promote cigarettes.36 During the same period, 

more than 3,200 youth younger than 18 years of 

age smoke their first cigarette and another 2,100 

youth and young adults who are occasional smokers 

progress to become daily smokers.2 However, 

the tobacco use epidemic can be stopped by 

implementing the interventions that we know 

work. Full implementation of comprehensive 

tobacco control policies and evidence-based 

interventions at CDC-recommended funding levels 

would result in a substantial reduction in tobaccorelated morbidity and mortality and billions of 

dollars in savings from averted medical costs 

and lost productivity in the United States.2,16
14

Introduction

References

1. U.S. Department of Health and Human Services. 

The Health Consequences of Smoking: A Report of 

the Surgeon General. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2004.

2. U.S. Department of Health and Human Services. 

The Health Consequences of Smoking – 50 Years of 

Progress: A Report of the Surgeon General. Atlanta, GA: 

U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, 

Coordinating Center for Health Promotion, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2014.

3. King BA, Dube SR, Tynan MA. Current tobacco 

use among adults in the United States: findings 

from the national Adult Tobacco Survey. American 

Journal of Public Health 2012;102(11):e93–e100. 

4. Centers for Disease Control and Prevention. 

Current cigarette smoking among 

adults—United States, 2011. Morbidity and 

Mortality Weekly Report 2012;61(44):889–94.

5. Centers for Disease Control and Prevention. Vital 

signs: nonsmokers’ exposure to secondhand 

smoke—United States, 1999–2008. Morbidity 

and Mortality Weekly Report 2010;59(35):1141–6.

6. Centers for Disease Control and Prevention. State 

smoke-free laws for worksites, restaurants, and 

bars—United States, 2000–2010. Morbidity and 

Mortality Weekly Report 2011;60(15):472–5.

7. U.S. Department of Health and Human Services. 

The Health Consequences of Involuntary Exposure 

to Tobacco Smoke: A Report of the Surgeon General.

Atlanta: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, 

Coordinating Center for Health Promotion, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2006.

8. U.S. Department of Health and Human Services. 

How Tobacco Smoke Causes Disease: The Biology 

and Behavioral Basis for Smoking-Attributable 

Disease: A Report of the Surgeon General. Atlanta: 

U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2010. 

9. U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Youth and Young 

Adults. Atlanta: U.S. Department of Health and 

Human Services, Centers for Disease Control 

and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, 

Office on Smoking and Health, 2012.

10. Centers for Disease Control and Prevention. 

Cigarette use among high school students—United 

States, 1991–2009. Morbidity and Mortality 

Weekly Report 2010;59(26):797–801. 

11. Centers for Disease Control and Prevention. Tobacco 

product use among middle and high school 

students—United States, 2011 and 2012. Morbidity 

and Mortality Weekly Report 2013;62(45):893–7.

12. Centers for Disease Control and Prevention. 

Cigarette use among high school students—United 

States, 1991–2005. Morbidity and Mortality 

Weekly Report 2006;55(26):724–6.

13. U.S. v. Philip Morris, 449 F.Supp.2d 1. D.D.C. 2006.

14. Institute of Medicine. Ending the Tobacco 

Problem: A Blueprint for the Nation. Washington: 

National Academies Press, 2007. 

15. U.S. Department of Health and Human Services. 

Reducing Tobacco Use. A Report of the Surgeon 

General. Atlanta: U.S. Department of Health and 

Human Services, Centers for Disease Control 

and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, 

Office on Smoking and Health, 2000.

16. Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control 

Programs—October 2007. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2007. 

17. Farrelly MC, Pechacek TF, Chaloupka FJ. The 

impact of tobacco control program expenditures 

on aggregate cigarette sales: 1981–2000. Journal 

of Health Economics 2003;22(5):843–59.

18. Tauras JA, Chaloupka FJ, Farrelly MC, Giovino 

GA, Wakefield M, Johnston LD, O’Malley PM, 

Kloska DD, Pechacek TF. State tobacco control 

spending and youth smoking. American 

Journal of Public Health 2005;954(2):338–44.
15

Introduction

19. Farrelly MC, Pechacek TF, Thomas KY, 

Nelson D. The impact of tobacco control 

programs on adult smoking. American 

Journal of Public Health 2008;89(2):304–9. 

20. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. 

Changes in youth cigarette use and intentions 

following implementation of a tobacco control 

program. JAMA: the Journal of the American 

Medical Association 2000;284(6):723–8.

21. RTI International. 2011 Independent Evaluation Report 

of the New York Tobacco Control Program. Albany, 

NY: New York State Department of Health, 2011.

22. California Department of Public Health. 

Smoking prevalence among California adults, 

1984–2010; <http://www.cdph.ca.gov/Pages/NR11-

031SmokingChart.aspx>; accessed: December 2, 2013.

23. Centers for Disease Control and Prevention. Statespecific trends in lung cancer incidence and 

smoking—United States, 1999–2008. Morbidity 

and Mortality Weekly Report 2011;60(36):1243–7.

24. Centers for Disease Control and Prevention. 

National Tobacco Control Program; <http://

www.cdc.gov/tobacco/tobacco_control_

programs/ntcp/>; accessed: December 2, 2013.

25. U.S. Department of Health and Human 

Services. HHS Announces National Smoking 

Cessation Quitline Network; <http://archive.

hhs.gov/news/press/2004pres/20040203.

html>; accessed: December 2, 2013.

26. Family Smoking Prevention and Tobacco Control 

and Federal Retirement Reform. Public Law 111-31, 

U.S. Statutes at Large 123 (2009):1776; <http://www.

gpo.gov/fdsys/pkg/PLAW-111publ31/pdf/PLAW111publ31.pdf >; accessed: December 2, 2013.

27. Patient Protection and Affordable Care Act. Public Law 

111-148, U.S. Statutes at Large 124 (2010):119; <http://

www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/

PLAW-111publ148.pdf >; accessed: December 2, 2013.

28. Children’s Health Insurance Program Reauthorization 

Act of 2009. Public Law 111-3, U.S. Statutes at 

Large 123 (2009):8; <http://www.gpo.gov/

fdsys/pkg/PLAW-111publ3/pdf/PLAW-111publ3.

pdf>; accessed: December 2, 2013.

29. Centers for Disease Control and Prevention. 

Federal and state cigarette excise taxes—United 

States, 1995–2009. Morbidity and Mortality 

Weekly Report 2009;58(19):524–7. 

30. Farrelly MC, Davis KC, Haviland L, Messeri P, 

Healton CG. Evidence of a dose-response 

relationship between “truth” antismoking 

ads and youth smoking prevalence. American 

Journal of Public Health 2005;95(3):425–31.

31. Centers for Disease Control and Prevention. State 

tobacco revenues compared with tobacco control 

appropriations—United States, 1998–2010. Morbidity 

and Mortality Weekly Report 2012;61(20):370–4. 

32. Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control 

Programs—August 1999. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1999.

33. Zaza S, Briss PA, Harris KW, editors. The Guide to 

Community Preventive Services: What Works to Promote 

Health? New York: Oxford University Press, 2005.

34. Eriksen, M. Lessons learned from public health efforts 

and their relevance to preventing childhood obesity. 

In: Koplan JP, Liverman CT, Kraak VA, editors. Preventing 

Childhood Obesity: Health in the Balance. Washington: 

National Academy of Sciences; 2005:343–75.

35. National Cancer Institute. Greater Than the Sum: 

Systems Thinking in Tobacco Control. Tobacco Control 

Monograph No. 18. Bethesda (MD): U.S. Department 

of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer 

Institute, 2007. NIH Publication No. 06-6085.

36. Federal Trade Commission. Federal Trade 

Commission Cigarette Report for 2011; <http://

www.ftc.gov/os/2013/05/130521cigarettere

port.pdf>; accessed: December 2, 2013. 

17

Section A

Components of a Comprehensive 

Tobacco Control Program 
18

Section A: State and Community Interventions

I. State and Community Interventions 

Justification 

The history of successful public health practice 

has demonstrated that the active and coordinated involvement of a wide range of societal and 

community resources must be the foundation of 

sustained solutions to pervasive problems like 

tobacco use.1–8 In a review of evidence of population-wide tobacco prevention and control efforts, 

the Task Force on Community Preventive Services confirmed the importance of coordinated 

and combined intervention efforts.9 The strongest 

evidence demonstrating the effectiveness of many 

of the population-wide approaches that are most 

highly recommended by the Task Force on Community Preventive Services comes from studies in 

which specific strategies for smoking cessation, 

preventing tobacco use initiation, and eliminating 

exposure to secondhand smoke are combined with 

mass-media campaigns and efforts to mobilize 

communities and to integrate these strategies into 

synergistic and multicomponent efforts.9

Additionally, research has demonstrated the 

importance of community support and involvement 

at the grassroots level in implementing several 

of the most highly effective policy interventions, 

including increasing the unit price of tobacco 

products and creating smokefree public and private 

environments.3,4,6,10–12 Although knowledge is critical, 

communities must reinforce and support health.13

Example program and policy recommendations 

from the Task Force on Community Preventive 

Services, as well as the Healthy People 2020

policy goals for the nation, are provided in 

Appendix B. In addition, recommendations for 

tobacco-free living from the National Prevention 

Council are provided in Appendix C.

The policies, partnerships, and intervention 

activities that occur at the state and community 

levels will ultimately lead to social norm 

and behavior change nationwide. State and 

community coalitions are essential partnerships. 

For example, they can keep tobacco issues 

before the public, combat the tobacco industry, 

enhance community involvement and promote 

community buy-in and support, educate policy 

makers, and help to inform policy change. 

Social norm change influences behavior 

indirectly by creating social and legal climates in 

which harmful products and conduct become less 

desirable, acceptable, and attainable. The health 

impact pyramid provides a five-tier framework to 

improve health through different types of public 

health interventions, with greater improvements 

coming from activities focused on policy change 

that create a context in which the healthy options 

are easy to attain.6

 This community intervention 

model has now become a core element of statewide 

comprehensive tobacco control programs.3,4,10,14–16

Since the establishment of the California 

Tobacco Control Program in 1989, California has 

achieved an almost 50% decline in the prevalence 

of smoking among adults, from 22.7% in 1988 to 

11.9% in 2010; nearly one million lives saved from a 

combination of smokers who quit and young people who chose not to start; and improved health 

outcomes for Californians, with lung cancer declining nearly four times faster than in the rest of the 

nation.17 During fiscal years 1989–2008, the California Tobacco Control Program cost $2.4 billion 

and led to cumulative health care expenditure 

savings of $134 billion.18 The program uses a socialnorm-change approach to reduce the uptake and 

continued use of tobacco products. For example, 

the statewide media campaign frames the message, 

community-level projects provide education on evidence-based tobacco control policy interventions, 

and statewide projects build the capacity of community-level projects. The tobacco control program’s 

technical assistance is the engine powering social 

change across California by playing a key role in the 

education of evidence-based policy approaches to 

reduce tobacco use.19 State comprehensive tobacco 

control programs nationwide have the tools to 

match and even exceed California’s achievements. 

Tobacco control interventions can counter 

the aggressive and often misleading information 

spread by tobacco companies, which have been 

found in federal court to have deliberately deceived 

the public about the health effects of tobacco.20

In this context, it is particularly important that 

comprehensive statewide tobacco control programs 

coordinate community-level interventions that 

counter tobacco industry marketing and focus on:
19

Section A: State and Community Interventions

 Preventing initiation among youth and 

young adults 

Promoting quitting among adults and youth

Eliminating exposure to secondhand smoke

Identifying and eliminating tobacco-related 

disparities among population groups

Reducing tobacco use is particularly challenging 

because tobacco products are so heavily marketed. 

In 2011, tobacco companies spent more than $8 

billion, or nearly $23 million per day, to market 

cigarettes in the United States, mostly at the point 

of sale.21 In addition to these tobacco advertising 

and promotion efforts, both adults and youth 

have been, and continue to be, heavily exposed 

to images of smoking in the movies, other massmedia, social marketing, and digital and mobile 

technologies.22–26 For example, 35% of U.S. youth 

reported having seen tobacco advertisements on 

the Internet in 2008.7 Research has shown that there 

is a causal relationship between advertising and 

promotional efforts of the tobacco companies and 

the initiation and progression of tobacco use among 

young people;7 approximately one-third of underage 

experimentation with smoking can be attributed 

to tobacco industry advertising and promotion.7

As cigarette use declines, new tobacco 

products, such as noncombustible products, and 

nicotine delivery products, such as e-cigarettes, are 

also being introduced and marketed. Approximately 

one of five current smokers has used e-cigarettes.27

Additionally, e-cigarette experimentation and recent 

use doubled among U.S. middle and high school 

students during 2011–2012, resulting in an estimated 

1.78 million students having ever used e-cigarettes 

as of 2012.28 Coordinated implementation of a broad 

range of statewide and community programs and 

policies is important to ensuring that the continued 

marketing of cigarettes and other combustible 

products, as well as the new marketing and sale 

of emerging non-combustible products, does not 

prolong the harms caused by smoking. These 

programs and policies are best implemented along 

with mass media campaigns to influence societal 

organizations, systems, and networks that encourage 

and support individuals to make behavior choices 

consistent with tobacco-free norms.3,4,14,29,30

Community engagement is essential for 

meaningful change to occur in the way that tobacco 

products are marketed, sold, and used. The National 

Association of County and City Health Officials 

has developed guidelines for comprehensive local 

tobacco control programs (Appendix D).31 The 

CDC-recommended community-based model to 

produce durable changes in social norms is based 

on evidence that approaches with the greatest span 

(economic, regulatory, and comprehensive) and 

jurisdictional reach (number of people covered) 

will have the greatest population impact.3,4,14,29,30

Interventions to prevent tobacco use initiation 

and to encourage cessation among youth and 

young adults can reshape the environment so that 

it supports tobacco-free norms. Nearly 9 of 10 

smokers in the United States start smoking by the 

time they are 18 years old, and 99% start by the age 

of 26.7 Thus, intervening during adolescence and 

young adulthood is critical.32 Research has shown 

that increasing the unit price of tobacco products, 

comprehensive smokefree air laws, and state 

tobacco control programs are effective strategies 

for curbing youth and adult smoking.32 Community 

programs and school and college policies and 

interventions should be part of a comprehensive 

effort—coordinated and implemented in 

conjunction with efforts to create tobacco-free social 

norms, including increasing the unit price of tobacco 

products, sustaining anti-tobacco media campaigns, 

and making environments smokefree.7,9,22,33

Recommendations for Preventing 

Tobacco Use Among Youth9,34

 Increase the unit price of tobacco products.

Conduct mass-media education campaigns in 

combination with other community interventions.

Mobilize the community to restrict minors’ 

access to tobacco products in combination 

with additional interventions (stronger 

local laws directed at retailers, active 

enforcement of retailer sales laws, and 

retailer education with reinforcement). 

Most states fund community and statewide 

organizations to develop and maintain an 

infrastructure and to implement populationwide and specific programs. To achieve lasting 

changes, community and statewide organizations 

require funding to hire diverse staff, provide 

operating expenses, purchase or develop 

education materials and resources, conduct 

education and training programs, carry out 

communication and media advocacy campaigns, 

and recruit and maintain local partnerships.31
20

Section A: State and Community Interventions

Statewide Programs 

Statewide programs can deliver statewide programming such as mass media campaigns and 

enforcement efforts, and provide leadership and 

coordination of efforts related to state policies, 

laws, and regulations. Statewide programs also 

can provide the skills, resources, and information 

needed for coordinated and strategic implementation of effective community programs. For 

example, training local community coalitions about 

the legal and technical aspects of comprehensive 

smokefree policies and enforcement can be provided most efficiently through statewide partners 

who have experience in administering these services. In states where comprehensive smokefree 

policies have already been implemented, efforts 

to promote smokefree private environments, such 

as multiunit housing, may be considered. Direct 

funding provided to statewide organizations can 

be used to mobilize their organizational assets to 

strengthen statewide initiatives and community 

resources. 

For example, the New York Tobacco Control 

Program runs statewide media campaigns, 

develops and executes policy and regulatory 

initiatives, implements enforcement efforts, and 

funds organizations across the state to work 

in five modalities: community partnerships for 

tobacco control, youth action programs, school 

policy programs, cessation centers, and colleges 

for change programs. Community programs 

are structured in such a way that every county 

falls within the coverage area of a community 

partnership, a cessation center, and a school policy 

program. All community programs are charged 

with bringing about environmental change in 

multiple settings, including worksites, schools, 

licensed tobacco retailers, multiunit housing, and 

public spaces such as parks and beaches. These 

community actions complement and reinforce 

similar statewide action through three types of 

activities: use of paid and earned media to raise 

awareness and educate the community and key 

community members about the tobacco epidemic; 

education of government policy makers about the 

tobacco epidemic to build support for tobacco 

control policies; and education of organizational 

decision makers, including tobacco retailers, health 

care organizations, school boards, and community 

organizations, for policy changes and resolutions.35

It is important to note that careful attention 

must be paid to ensuring that public funds are 

appropriately used. Tracking and reporting on 

funding sources by activity is integral to ensure that 

public funds are not used for prohibited activities. 

CDC’s National Center for Chronic Disease 

Prevention and Health Promotion has developed 

four domains that can provide a framework for 

state tobacco prevention and control programs 

to collaborate with other state and community 

programs to address diseases for which tobacco 

is a major cause, including multiple cancers, 

heart disease and stroke, and chronic lung 

and respiratory diseases (See Figure 1).36
21

Section A: State and Community Interventions

Figure 1. Key domains for transforming the nation’s health and providing individuals with 

equitable opportunities to take charge of their health. 

Domain 1

Epidemiology and surveillance to gather, analyze, and disseminate 

data and information and conduct evaluation to inform, prioritize, 

deliver, and monitor programs and population health. 

Domain 3

Health system interventions to improve the effective delivery and use of 

clinical and other preventive services in order to prevent disease, detect diseases 

early, and reduce or eliminate risk factors and mitigate or manage complications. 

Domain 2

Environmental approaches that promote health and support 

and reinforce healthful behaviors statewide and in communities. 

Domain 4

Strategies to improve community-clinical linkages ensuring 

that communities support and clinics refer patients to programs 

that improve management of chronic conditions. 

Addressing evidence-based tobacco control strategies in the broader context of tobacco-related 

diseases is beneficial for four reasons:

 It is critical that interventions are 

implemented to alleviate the existing 

burden of tobacco-related disease.

The incorporation of tobacco prevention 

and cessation messages into broader 

public health activities ensures wider 

dissemination of tobacco control strategies.

Tobacco use in conjunction with other 

diseases and risk factors, such as sedentary 

lifestyle, poor diet, and diabetes, poses a 

greater combined risk and poorer prognosis 

for many chronic diseases than the sum 

of each individual degree of risk. 

 Educating the public about the broader context 

of tobacco-related diseases helps mobilize 

public support and action for tobacco control.

Each state’s financial, social, and 

demographic characteristics have a significant 

role in tobacco prevention and control efforts. 

Examples are provided in the following box.
22

Section A: State and Community Interventions

Examples of Statewide Efforts for Tobacco Prevention and Control 

 Supporting and/or facilitating tobacco prevention 

and control partnership and coalition development, 

as well as links to other related partnerships and 

coalitions (e.g., cancer control, cardiovascular disease, 

diabetes, asthma).

Establishing a strategic plan for comprehensive 

tobacco control with appropriate partners at the 

state and community levels.

Educating state leaders, decision-makers, and 

the public about the burden of tobacco use and 

evidence-based policy and other strategies to 

reduce this burden.

Engaging stakeholders and partners on 

approaches, such as message development 

and messengers, to reach populations with 

the greatest disparities in tobacco use.

 Collecting, disseminating, and analyzing state 

and community-specific data; developing and 

implementing culturally appropriate interventions 

with appropriate multicultural involvement; and 

making program adjustments as indicated.

Sponsoring community, regional, and statewide 

trainings, conferences, and technical assistance on 

best practices for effective tobacco use prevention 

and cessation programs.

Monitoring pro-tobacco influences to facilitate public 

discussion and debate among partners, decision 

makers, and other stakeholders at the state and 

community level.

Supporting community-level innovations in tobacco 

control that may enhance the public health impact 

of current state-level policies and disseminating 

successful interventions across communities.

Community Programs 

A “community” encompasses a diverse set of entities that reach across multiple sectors, including 

voluntary health agencies; civic, social, and recreational organizations; businesses and business 

associations; city and county governments; public health organizations; labor groups; health care 

systems and providers; health care professionals’ 

societies; schools and universities; faith organizations; and organizations for racial and ethnic 

minority groups.1–5,8,10

To counter aggressive pro-tobacco influences, 

communities are encouraged to change the 

knowledge, attitudes, and practices of tobacco 

users and nonusers and also engage in strategies to 

address the manner in which tobacco is promoted, 

the time, manner, and place in which tobacco is 

sold, and how and where tobacco is used.4,5,7

State and local governments play an 

integral role in achieving the goals of the Family 

Smoking Prevention and Tobacco Control Act 

(FSPTCA), which granted the Food and Drug 

Administration (FDA) the authority to regulate 

tobacco products.37 The FSPTCA permits states 

and local governments to impose specific bans or 

restrictions on the time, place, and manner—but 

not the content—of cigarette advertisements. 

States may adopt or continue to enforce 

requirements pertaining to tobacco products that 

are in addition to, or more stringent than, many 

requirements of the law. However, although the 

law preserves a substantial amount of the states’ 

authority to regulate tobacco products, some 

state and local requirements are preempted.37

Effective community programs involve and 

influence people in their daily environment.1,3–5,8,38

Therefore, community engagement and 

mobilization are essential to programs addressing 

tobacco control.39,40 Implementing strategies 

that can impact societal organizations, systems, 

and networks necessitates the involvement of 

community partners.1,2,4,7 Decreasing disparities in 

tobacco use occurs largely through engagement 

in evidence-based community interventions.
23

Section A: State and Community Interventions

Achieving Equity to Eliminate 

Tobacco-Related Disparities 

Reducing tobacco-related disparities is a critical 

component of a comprehensive tobacco control 

program.10,41 Tobacco-related disparities are differences that exist among population groups with 

regard to key tobacco-related indicators, including patterns, prevention, and treatment of tobacco 

use; the risk, incidence, morbidity, mortality, and 

burden of tobacco-related illness; and capacity, 

infrastructure, and access to resources; and second-hand smoke exposure.42

Identifying and eliminating tobacco-related 

disparities among population groups is one of 

the four goals for comprehensive state tobacco 

control programs. To ultimately eliminate 

tobacco-related disparities, tobacco control 

programs and policies must be implemented in 

a way that achieves equitable benefits for all.

Activities focused on achieving equity and 

eliminating tobacco-related disparities can help 

accelerate the decline in the prevalence of tobacco 

use and access to effective cessation treatments, 

thus alleviating the disproportionate health 

and economic burden experienced by some 

population subgroups.10 Tobacco-related disparities 

can affect population subgroups on the basis of 

certain factors, including but not limited to:43,44

 Age

 Disability / limitation 

 Educational attainment

 Geographic location (e.g., rural/urban) 

 Income 

 Mental health status

 Occupation 

 Race / ethnicity

 Sex 

 Sexual orientation and gender identity 

 Substance abuse conditions 

 Veteran and military status

It is important to use surveillance systems 

and other data collection systems to measure these 

types of characteristics within states and communities 

to help identify populations with tobacco-related 

disparities,45 and to engage members of affected 

communities in reducing and preventing tobacco use. 

 Providing funding to community-based organizations 

in order to strengthen the capacity of these groups to 

positively inform social norms regarding tobacco use 

and to build relationships among multiple sectors of 

the community, such as housing, education, business, 

planning, and transport.

Empowering local agencies to build community 

coalitions and partnerships that facilitate 

collaboration among programs in local governments, 

voluntary and civic organizations, and diverse 

community-based organizations.

Collaborating with partners and other programs to 

implement evidence-based interventions and build 

and sustain capacity through technical assistance 

and training.

Supporting community strategies or efforts to 

educate the public and media, not only about 

the health effects of tobacco use and exposure 

to secondhand smoke, but also about available 

cessation services.

 Promoting public discussion among partners, decision 

makers, and other stakeholders about tobacco-related 

health issues and pro-tobacco influences.

Establishing a community strategic plan of action that 

is consistent with the statewide strategic plan.

Ensuring that funding formulas for the local public 

health infrastructure provide grantees (e.g., local 

and county health departments, tribal organizations, 

nonprofit organizations) operating expenses 

commensurate with tobacco control program and 

evaluation efforts.

Ensuring that community grantees measure and 

evaluate social norm change outcomes (e.g., policy 

adoption, increased compliance) resulting from their 

interventions.

Ensuring that partners receiving funding for tobacco 

control from various entities work collaboratively. 

Examples of State Program Involvement in Community-Level Interventions 
24

Section A: State and Community Interventions

 Conduct surveillance to identify populations 

disproportionately affected by tobacco use.

 Partner with population groups and communitybased organizations that serve these populations 

experiencing tobacco-related disparities.

 Ensure that health equity is an integral part of state 

and community tobacco control strategic plans.

 Mitigate barriers to effective implementation 

of tobacco control interventions, such as 

enhancing access to cessation services for 

low-income or other communities.

 Fund organizations that can effectively reach, 

educate, and involve populations experiencing 

tobacco-related disparities.

 Provide culturally competent technical assistance 

and training to grantees and partners. 

In order to adequately identify and effectively 

eliminate tobacco-related disparities, state tobacco 

control programs must implement a number of 

tobacco prevention and control strategies, including establishing infrastructure and building 

capacity.42 These strategies are useful for guiding the development of policies and practices that 

reflect the principles of inclusion, cultural competency, and equity. Reaching the national goal of 

eliminating health disparities related to tobacco 

use will also require enhanced collection and 

This guidance is based upon information and 

experience derived from state practices, scientific studies, and input from external partners and 

experts in the field of tobacco control. The guidance highlights the presumed minimum capacity 

and infrastructure needed by state tobacco control 

programs to pursue a strategic plan with initiatives 

that will most effectively achieve equity in tobacco 

prevention and control through the identification 

and elimination of tobacco-related disparities.47

use of standardized data to correctly identify disparities in tobacco-related outcomes, including 

awareness and use of tobacco products, health 

outcomes, and program effectiveness.45,46 The 

use of oversampling, combining multiple years 

of data, and qualitative methods are often necessary to adequately assess these outcomes among 

some population groups.10 In addition, clear leadership, dedicated resources, and a commitment to 

inclusion are essential to develop and implement a 

strong strategic plan.42

Ending the Epidemic: A Tobacco Control 

Strategic Action Plan for the U.S. Department 

of Health and Human Services, which was 

published in 2010, called attention to the need 

to reduce tobacco-related disparities through 

specific interventions in locations serving high-risk 

populations, such as subsidized and public housing, 

substance abuse facilities, mental health facilities, 

correctional institutions, community health centers, 

federally qualified health centers, Ryan White 

clinics, rural health clinics, and critical 

access hospitals. 

 Create partnerships to maximize resources 

and reach of interventions.

 Integrate efforts to eliminate tobacco-related 

disparities in all chronic disease prevention areas.

 Identify and develop culturally competent 

materials and interventions.

 Educate partners and key decision makers 

about tobacco-related disparities.

 Reduce exposure to targeted tobacco industry 

advertising, promotion, and sponsorship.

 Obtain comprehensive Medicaid coverage 

for tobacco dependence treatments.

 Evaluate intervention efficacy and 

refine efforts as appropriate. 

Activities to Support Equity Achievement and Eliminate 

Tobacco-Related Disparities 

Strategies to Achieve Equity and Eliminate Tobacco-Related Disparities 
25

Section A: State and Community Interventions

Reducing the prevalence of tobacco use 

requires greater attention to populations 

carrying a disproportionate burden of use and 

dependence. One way to reach such groups 

is through efforts that directly affect those 

populations, including tobacco-free policies, 

quitline promotion, and counseling and 

cessation services.48 Following are examples 

from select states that have made such efforts.

In 2006, the Massachusetts Medicaid program 

expanded its cessation benefit by providing 

comprehensive coverage of tobacco cessation 

medications.49 More than 75,000 (37%) Medicaid 

subscribers used the benefit in the first two and a 

half years. The prevalence of smoking among the 

Medicaid population decreased from 38% to 28% 

during this period. Use of a comprehensive tobacco 

cessation benefit that includes pharmacotherapy was 

associated with a significant decrease in claims for 

hospitalizations for heart attacks and acute coronary 

heart disease. Annualized hospitalizations for these 

cardiovascular conditions among Medicaid smokers 

who used the benefit declined by almost half. Every 

dollar spent on the benefit was associated with $3.12 

in medical savings for cardiovascular conditions.49

In California, the California Smoker’s Helpline 

and the Asian Smokers Quitline provide cessation 

services and culturally appropriate information in 

multiple languages for different audiences. These 

focused tobacco cessation interventions, along with 

other elements, have led to significant reductions 

in smoking across ethnic groups in California. 

For instance, during 1990-2005, smoking rates 

among Asian men dropped from 20% to less than 

15%; among Hispanic men, from 22% to 16%; and 

among African American men, from 28% to 21%.50

Adults with any mental illness have a high 

prevalence of cigarette smoking.51 Moreover, 

sociodemographic variations in the prevalence 

of current smoking among persons with any 

mental illness resemble patterns in the overall 

population, and adult smokers with mental illness 

are less likely to quit than those smokers without 

mental illness. Accordingly, enhanced prevention 

and cessation efforts among persons with mental 

illness can further reduce smoking-related death 

and disease. For example, the New York tobacco 

control program has identified populations with 

chemical addictions or mental illness for specific 

intervention. To reach these populations, the state 

used strategies that included integrating tobacco 

dependence treatment into treatment protocols 

for mental illness or chemical dependency, 

promoting tobacco-free campuses for substance 

abuse and mental health facilities, and partnering 

with agencies representing each group.52

In 2013, the following national networks jointly 

designed and sponsored a series of trainings in 

Texas to introduce specific populations to tobacco 

control: the National African American Tobacco 

Prevention Network (NAATPN), the National Latino 

Tobacco Control Network (NLTCN), and the Asian 

Pacific Partners for Empowerment, Advocacy and 

Leadership (APPEAL). Participants with long-term 

involvement in their communities were identified 

and recruited to attend these training opportunities. 

The trainings sought to increase specific population 

leadership, collaboration, and civic engagement at 

a grassroots level to address disparities in health 

that result from tobacco use and secondhand 

smoke exposure. The trainings addressed the 

importance of: building organizational capacity 

by connecting participants with local coalitions, 

including Community Transformation Grantees, or 

building a local coalition; mobilizing communities 

to address health disparities and implement tobacco 

control and health promotion policies; facilitating 

cross cultural collaboration among Latino, African 

American, and Asian American, Native Hawaiian, 

and Pacific Islander communities; increasing 

leadership knowledge and skills on health 

disparities among community advocates; increasing 

knowledge of the impact of tobacco use on chronic 

disease disparities; creating emerging promising 

practices on engaging priority populations; 

and developing materials and approaches, 

such as workers’ rights and social justice, that 

make secondhand smoke exposure relevant to 

populations with a high burden of exposure.
26

Section A: State and Community Interventions

Budget 

Linking state and community interventions creates 

synergistic effects, greatly increasing the effects 

of each comprehensive tobacco control component. Effective actions are those that reinforce one 

another, including: raising community awareness 

and mobilization efforts; developing health communication interventions; collecting, analyzing, 

and disseminating data; and providing cessation 

interventions. Evidence indicates that interventions 

that promote changes in social norms appear to 

be the most effective approach for sustained 

behavior change.9

Best Practices dictates allocating funds for 

establishing and sustaining internal capacity with 

experienced staff and developing an infrastructure 

with partner organizations and other programs to 

oversee and implement evidence-based programs. 

Most states fund local health departments, boards 

of health, or health-related nonprofit community 

organizations representing each county, multicounty 

region, or major metropolitan areas to develop 

and maintain local infrastructure and implement 

jurisdiction-wide and targeted programs. Best 

Practices recommends that funds be awarded 

directly to tribal health departments and tribalserving organizations to deliver tobacco control 

programming to tribes and tribal members, as 

well as to other organizations that serve specific 

populations, in order to implement evidence-based 

programs and activities with that population. Funds 

may also be distributed to different agencies to 

ensure compliance with tobacco prevention and 

control laws. These varied efforts remain integrated 

through effective communication, coalitions, and 

networks. It is important that states also take into 

account the special issues of different communities 

within their state, such as large variations in 

population size, differences in the prevalence of 

smoking among various populations, access to 

cessation services, and reach of the interventions. 

Recommendations for funding state and 

community interventions are based on the 1999 

funding formulas, which were updated in 2007 to 

include the following major components: statewide 

programs, community programs to reduce tobacco 

use, chronic disease programs to reduce the burden 

of tobacco-related diseases, school programs, 

and enforcement.47,53

The minimum and recommended funding levels 

are derived from the 2007 funding formulas and 

adjusted for population changes and inflation. The 

specific state-recommended level of investment 

is based on the relative complexity and cost of 

doing business in that state. Drawing from the 

experience of states that have implemented robust 

state and community interventions, funding levels 

were determined for each state. The minimum 

and recommended levels of investment were 

based primarily on each state’s current smoking 

prevalence, while also taking into account other 

factors such as the proportion of individuals within 

the state living at or below 200% of the poverty 

level, the proportion of the population that is 

a racial/ethnic minority, average wage rates for 

implementing public health programs, geographic 

size, and the state’s infrastructure as reflected by 

the number of local governmental health units.

For the 2014 update of Best Practices, the 

state and community interventions formula 

does not specifically include chronic disease 

programs to reduce the burden of tobacco-related 

diseases, school programs, and enforcement as 

major components. However, activities in these 

three areas may still be undertaken within the 

framework of state and community interventions. 

For example, chronic disease prevention and 

control programs are stakeholders and partners in 

tobacco control. Using evidence-based interventions 

and strategies to address state tobacco control 

priorities, as described in the state chronic disease 

plan, can support achieving the four National 

Tobacco Control Program goals. Similarly, there 

is little evidence of the long-term effectiveness 

of school-based programs to prevent smoking.7,54

However, they can be more efficacious when part 

of a comprehensive, multicomponent approach to 

tobacco use prevention that includes school policies, 

community-wide strategies, and mass media. 

Finally, active enforcement of youth access laws 

is part of broader community mobilization efforts 

that combine additional interventions, including 

stronger retailer laws and retailer education, with 

reinforcement. The FSPTCA authorizes FDA to 

contract with states, territories, and tribes for 

the purposes of conducting compliance check 

inspections of tobacco retailers. Some states have 

contracted with local public health organizations 

to assist with FDA’s rigorous enforcement efforts. 

For the last 15 years, states have implemented 

CDC’s recommendations, focusing their efforts 

on proven activities that have the greatest 

impact, while also expanding the evidencebase of effective tobacco control interventions 

and building on each other’s successes.7,9,10,33
27

Section A: State and Community Interventions

References

1. Green LW, Kreuter M. Health Promotion 

Planning: An Educational and Ecological 

Approach. New York: McGraw-Hill, 2000.

2. Institute of Medicine. The Future of Public’s 

Health in the 21st Century. Washington: 

National Academies Press, 2002.

3. Eriksen, M. Lessons learned from public health efforts 

and their relevance to preventing childhood obesity. 

In: Koplan JP, Liverman CT, Kraak VA, editors. Preventing 

Childhood Obesity: Health in the Balance. Washington: 

National Academy of Sciences, 2005:343–75.

4. National Cancer Institute. ASSIST: Shaping the Future 

of Tobacco Prevention and Control. Tobacco Control

Monograph No. 16. Bethesda (MD): U.S. Department 

of Health and Human Services, Public Health Service, 

National Institutes of Health, National Cancer 

Institute, 2005. NIH Publication No. 05-5645.

5. Cummings KM, Sciandra R, Carol J, Burgess S, Tye 

JB, Flewelling R. Approaches directed to the social 

environment. In: Strategies to Control Tobacco Use 

in the United States: A Blueprint for Public Health 

in the 1990’s. Tobacco Control Monograph No. 1. 

Bethesda (MD): U.S. Department of Health and 

Human Services, Public Health Service, National 

Institutes of Health, National Cancer Institute, 

1991. NIH Publication 92-3316. Pages 203–65.

6. Frieden, TR. A framework for public health 

action: the health impact pyramid. American 

Journal of Public Health 2010;100(4):590–5.

7. U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Youth and Young 

Adults: A Report of the Surgeon General. Atlanta: 

U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2012.

8. U.S. Department of Health and Human 

Services. Principles of Community Engagement: 

Second Edition. National Institutes of Health, 

Centers for Disease Control and Prevention, 

and Agency for Toxic Substances and Disease 

Registry, 2011. NIH Publication No. 11-7782. 

9. Zaza S, Briss PA, Harris KW, editors. The Guide to 

Community Preventive Services: What Works to Promote 

Health? New York: Oxford University Press, 2005.

10. U.S. Department of Health and Human Services. 

Reducing Tobacco Use: A Report of the Surgeon 

General. Atlanta: U.S. Department of Health and 

Human Services, Centers for Disease Control 

and Prevention, National Center for Chronic 

Disease Prevention and Health Promotion, 

Office on Smoking and Health, 2000.

11. U.S. Department of Health and Human Services. 

The Health Consequences of Involuntary Exposure 

to Tobacco Smoke: A Report of the Surgeon General.

Atlanta: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, 

Coordinating Center for Health Promotion, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2006. 

12. National Cancer Institute. Community-Based 

Interventions for Smokers: The COMMIT Field 

Experience. Tobacco Control Monograph No. 

6. Bethesda (MD): U.S. Department of Health 

and Human Services, Public Health Service, 

National Institutes of Health, National Cancer 

Institute, 1995. NIH Publication No. 95-4028.

13. National Prevention Council. National 

Prevention Council Action Plan: Implementing 

the National Prevention Strategy. Washington: 

National Prevention Council, 2012.

14. California Department of Health Services. A 

Model for Change: The California Experience in 

Tobacco Control. Sacramento, CA: California 

Department of Health Services, 1998.

15. National Cancer Institute. Evaluating ASSIST: A Blueprint 

for Understanding State-Level Tobacco Control. Tobacco 

Control Monograph No. 17. Bethesda (MD): U.S. 

Department of Health and Human Services, Public 

Health Service, National Institutes of Health, National 

Cancer Institute, 2006. NIH Publication No. 06-6058.

16. Mueller NB, Luke DA, Herbers SH, Montgomery 

TP. The best practices: use of the guidelines by 

ten state tobacco control programs. American 

Journal of Preventive Medicine 2006;31:300–6.

17. California Department of Public Health. State Health 

Officer’s Report on Tobacco Use and Promotion in 

California. California Tobacco Control Program, 2012.

18. Lightwood J, Glantz SA. The effect of the 

California tobacco control program on smoking 

prevalence, cigarette consumption, and healthcare 

costs: 1989–2008. PLoS One 2013;8(2):e47145
28

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19. Roeseler A, Hagaman T, Kurtz C. The use of training 

and technical assistance to drive and improve 

performance of California’s Tobacco Control Program. 

Health Promotion Practice 2011;12(6 Suppl2):130S–143S.

20. Frieden, TR. Government’s role in protecting 

health and safety. New England Journal 

of Medicine 2013;368(20):1857–9. 

21. Federal Trade Commission. Federal Trade 

Commission Cigarette Report for 2011; <http://

www.ftc.gov/os/2013/05/130521cigarettere

port.pdf>; accessed: December 2, 2013.

22. U.S. Department of Health and Human Services. 

Preventing Tobacco Use Among Young People: A Report 

of the Surgeon General. Atlanta: U.S. Department of 

Health and Human Services, Public Health Service, 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1994. 

23. Charlesworth A, Glantz SA. Tobacco and the 

movie industry. Clinics in Occupational and 

Environmental Medicine 2006;5(1):73–84. 

24. Cummings KM, Morley CP, Horan JK, 

Leavell NR. Marketing to America’s youth: 

evidence from corporate documents. 

Tobacco Control 2002;11(Suppl 1):i5–i17.

25. Sargent JD, Stoolmiller M, Worth KA, Dal Cin S, 

Wills TA, Gibbons FX, et al. Exposure to smoking 

depictions in movies: its association with 

established adolescent smoking. Archives of 

Pediatric Adolescent Medicine 2007;161(9):849–56. 

26. Dube, SR, Arrazola RA, Lee J, Engstrom M, Malarcher 

A. Pro-tobacco influences and susceptibility to 

smoking cigarettes among middle and high 

school students—United States, 2011. Journal 

of Adolescent Health 2013;52(5 Suppl):45S–51S. 

27. King BA, Alam S, Promoff G, Arrazola R, Dube 

SR. Awareness and ever use of electronic 

cigarettes among U.S. adults, 2010–2011. 

Nicotine & Tobacco Research 2013;15(9):1623–7. 

28. Centers for Disease Control and Prevention. Notes 

from the field: electronic cigarette use among 

middle and high school students—United 

States, 2011–2012. Morbidity and Mortality 

Weekly Report 2013;62(35);729–30. 

29. California Department of Health Services. 

Communities of Excellence in Tobacco Control.

Sacramento, CA: California Department of Health 

Services, Tobacco Control Section, 2006.

30. Tobacco Technical Assistance Consortium. 

Communities of Excellence Plus; <http://www.

tacenters.emory.edu/documents/communities_

excellence_plus.pdf>; accessed: December 2, 2013.

31. National Association of County and City Health 

Officials. Program and Funding Guidelines for 

Comprehensive Local Tobacco Control Programs 

(2010). Washington: National Association of 

County and City Health Officials, 2010. 

32. Farrelly MC, Loomis BR, Han B, Gfroerer J, Kuiper N, 

Couzens GL, Dube S, Caraballo RS. A comprehensive 

examination of the influences of state tobacco 

control programs and policies on youth smoking. 

American Journal of Public Health 2013;103(3):549–55.

33. Institute of Medicine. Ending the Tobacco 

Problem: A Blueprint for the Nation. Washington: 

National Academies Press, 2007. 

34. Task Force on Community Preventive Services. 

Recommendations regarding interventions 

to reduce tobacco use and exposure to 

environmental tobacco smoke. American Journal 

of Preventive Medicine 2001;20(2S):10–5.

35. RTI International. 2010 Independent Evaluation Report 

for the New York Tobacco Control Program. Albany, 

NY: New York State Department of Health, 2010.

36. Centers for Disease Control and Prevention. Chronic 

Disease Prevention and Health Promotion Domains; 

<http://www.cdc.gov/chronicdisease/pdf/FourDomains-Nov2012.pdf>; accessed: December 2, 2013.

37. Family Smoking Prevention and Tobacco Control Act,

Public Law 111-31, U.S. Statutes at Large 123 (2009):1776.

38. Minkler M, editor. Community Organizing and 

Community Building for Health. 2nd edition. New 

Brunswick, NJ: Rutgers University Press, 2005. 

39. Ahmed SM, Palermo AG. Community engagement in 

research: frameworks for education and peer review. 

American Journal of Public Health 2010;100(8):1380–7.

40. Minkler M, Wallerstein N. The growing support for 

CPBR. In Minkler M, Wallerstein N, editors. CommunityBased Participatory Research for Health: From Process to 

Outcomes. 2nd ed. San Francisco: Jossey-Bass, 2008. 
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41. U.S. Department of Health and Human Services. 

Tobacco Use Among U.S. Racial/Ethnic Minority 

Groups—African Americans, American Indians 

and Alaska Natives, Asian Americans and Pacific 

Islanders, and Hispanics: A Report of the Surgeon 

General. Atlanta: U.S. Department of Health and 

Human Services, Centers for Disease Control and 

Prevention, Office on Smoking and Health, 1998.

42. Fagan P, King G, Lawrence D, Petrucci SA, Robinson 

RG, Banks D, et al. Eliminating tobacco-related 

health disparities: directions for future research. 

American Journal of Public Health 2004;94(2):211–7. 

43. Garrett BE, Dube SR, Trosclair A, Caraballo RS, 

Pechacek TF. Cigarette smoking—United 

States, 1965–2008. Morbidity and Mortality 

Weekly Report 2011;60(01):109–3.

44. King BA, Dube SR, Tynan MA. Current tobacco 

use among adults in the United States: findings 

from the National Adult Tobacco Survey. American 

Journal of Public Health 2012;102(11):e93–e100.

45. Starr G, Rogers T, Schooley M, Porter S, Wiesen E, 

Jamison N. Key Outcome Indicators for Evaluating 

Comprehensive Tobacco Control Programs. Atlanta: 

Centers for Disease Control and Prevention, 2005.

46. MacDonald G, Starr G, Schooley M, Yee SL, Klimowski 

K, Turner K. Introduction to Program Evaluation for 

Comprehensive Tobacco Control Programs. Atlanta: 

Centers for Disease Control and Prevention, 2001. 

47. Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control 

Programs—October 2007. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2007. 

48. U.S. Department of Health and Human Services. 

Ending the Tobacco Epidemic: A Tobacco Control 

Strategic Action Plan for the U.S. Department of 

Health and Human Services. Washington: Office 

of the Assistant Secretary for Health, 2010.

49. Land T, Rigotti N, Levy D, Paskowsky M, Warner D, 

Kwass J, Wetherell L, Keithly L. A longitudinal study 

of Medicaid coverage for tobacco dependence 

treatments in Massachusetts and associated 

decreases in hospitalizations for cardiovascular 

disease. PLoS Medicine 2010;7(12):e1000375.

50. California Department of Health Services. 

California Releases New Data and Anti-Smoking 

Ads Targeting Diverse Populations. News Release 

No. 06-82, 2006; accessed: December 2, 2013.

51. Centers for Disease Control and Prevention. Vital signs: 

current cigarette smoking among adults aged ≥18 

years with mental illness—United States, 2009–2011. 

Morbidity and Mortality Weekly Report 2013;62(05);81–7.

52. New York State Department of Health. 

Cooperative Agreement Interim Progress Report. 

Unpublished report submitted to CDC, 2007. 

53. Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control 

Programs—August 1999. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 1999. 

54. Thomas R, Perera R. School-based programmes 

for preventing smoking. Cochrane Database of 

Systematic Reviews 2006, Issue 3. Art. No.: CD001293. 

DOI: 10.1002/14651858.CD001293.pub3. 
30

II. Mass-Reach Health 

Communication Interventions 

Justification 

Mass-reach health communication interventions 

can be powerful tools for preventing the initiation 

of tobacco use, promoting and facilitating cessation, and shaping social norms related to tobacco 

use.1,2 The Community Preventive Services Task 

Force recommends mass-reach health communication interventions on the basis of strong evidence 

of effectiveness in: decreasing the prevalence 

of tobacco use; increasing cessation and use of 

available cessation services such as quitlines; 

and decreasing initiation of tobacco use among 

young people.3

Mass-reach health communication refers 

to the various means by which public health 

information reaches large numbers of people. 

The term “mass-reach” has been added to the 

description of health communication interventions 

in this edition of Best Practices because the 

available evidence suggests that the use of massreach vehicles, in particular television, is required 

to make meaningful changes in population-level 

awareness, knowledge, attitudes, and behaviors.3

Impact of Tobacco Advertising and 

Promotion

Billions of dollars are spent annually by tobacco 

companies to make tobacco use more affordable 

and attractive, as well as an accepted and established part of American culture.4,5 Young people 

are particularly vulnerable to social and environmental influences to use tobacco. Messages 

and images that make tobacco use appealing to 

them are everywhere.2,6 For example, youth and 

young adults see smoking in movies, video games, 

Web sites, in their social circles, and throughout 

the communities where they live. Tobacco marketing portrays smoking as a social norm, and 

young people exposed to these images are more 

likely to smoke. Nonsmoking adolescents exposed 

to tobacco advertising and promotional campaigns are significantly more likely to become 

young adult smokers.2,7,8 Youth who are exposed 

to images of smoking in movies are more likely to 

smoke. Those with the most exposure to onscreen 

smoking imagery are about twice as likely to begin 

smoking as those with the least exposure.2

 Evidence also indicates that tobacco purchase and 

cessation behaviors among adult smokers are influenced by tobacco promotion, particularly at the 

point of purchase.9–11 Because youth and adults 

continue to be heavily exposed to pro-tobacco 

media, advertising, and promotion, public education campaigns are needed to prevent tobacco use 

initiation and to promote cessation.

Despite the 1998 Master Settlement Agreement 

(MSA) between 46 states and several major 

tobacco companies that established restrictions 

on tobacco marketing and some types of outdoor 

advertising, tobacco product promotion remains 

prevalent. In 2011, tobacco companies spent more 

than $8.3 billion, or approximately $23 million 

per day, to market cigarettes in the United States;4

this level of spending exceeded spending on 

tobacco prevention and control efforts by all of the 

states and territories by a ratio of approximately 

18 to 1.4,12 In addition, marketing expenditures 

for smokeless tobacco exceeded $452 million 

in 2011—more than double the spending in 

2000.5 Although the majority of current tobacco 

marketing comprises price discounts, which 

offset the impact of excise taxes on tobacco use, 

traditional tobacco company advertising and 

marketing spending, at more than $700 million in 

2011, still far exceeds the $175 million spent on 

public health-sponsored antitobacco campaigns 

by the states and CDC.4,5,13 Since the MSA, tobacco 

promotions have shifted away from traditional 

media (e.g., billboards and magazines) and 

moved toward digital media and retail outlets,2,14–17

and tobacco companies are increasingly using 

tobacco product packages (e.g., shapes, colors, 

text) as a form of marketing.18,19 In addition, 

tobacco companies are re-entering the television 

market as they acquire or introduce electronic 

cigarette (e-cigarette) products and advertise these 

products.20 For example, Lorillard, Inc. acquired 

the e-cigarette manufacturer blu eCig® in 2012 

and was among the first companies to advertise 

an e-cigarette product nationally on television.21
31

Section A: Mass-Reach Health Communication Interventions

Tobacco advertising and promotion are 

real threats to public health. The 2012 Surgeon 

General’s report stated, “The evidence is sufficient 

to conclude that there is a causal relationship 

between advertising and promotional efforts of 

the tobacco companies and the initiation and 

progression of tobacco use among young people.”2

The National Cancer Institute’s (NCI’s) Monograph 

19 concluded that a causal relationship exists 

between tobacco advertising and promotion and 

increased tobacco use, including both increased 

smoking initiation and increased per capita 

tobacco consumption in the population.19 Evidencebased strategies, including mass-reach health 

communication interventions, are needed to 

counter the negative impact of tobacco industry 

marketing efforts and protect public health.19

Effectiveness of Tobacco 

Countermarketing

The research literature provides ample evidence 

that tobacco countermarketing, which is the use of 

commercial marketing tactics to reduce the prevalence of tobacco use, can be a valuable tool in 

reducing smoking.19,22 The NCI Monograph 19

reviewed the available literature from 1970 through 

2007 and found extensive evidence that tobacco 

countermarketing campaigns curbed smoking initiation in youth and promoted smoking cessation in 

adults, particularly in the context of comprehensive 

tobacco control programs.19 A 2012 review further 

confirmed the efficacy of mass-media campaigns 

in reducing smoking among adults.23 In addition, a 

2013 study found that greater exposure to tobacco 

control mass-media campaigns may reduce the 

likelihood of relapse among quitters.24

Media campaign research and evaluations 

have shown that advertising that elicits negative 

emotions through graphic and personal portrayals 

of the health consequences of tobacco use is 

especially effective in motivating smokers to 

quit.19,23,25 There is also evidence that this kind of 

approach to advertising messages reduces tobacco 

use among youth and young adults.2,26 CDC’s 

Tips From Former Smokers (Tips) campaign, the 

first federally funded, nationwide, paid-media 

tobacco education campaign in the United States, 

is an example of this approach. The first Tips

campaign was conducted during March–June 2012 

and featured former smokers talking about their 

experiences and their families’ experiences living 

with diseases caused by smoking and secondhand 

smoke exposure.27 In addition to a comprehensive 

earned media component, the Tips campaign 

included advertising on national and local television, 

local radio, online media, and billboards as well 

as in movie theaters, transit venues, and print 

media. A subsequent evaluation of Tips found that 

an estimated 1.6 million smokers attempted to quit 

smoking because of the campaign and that more 

than 100,000 of them would likely quit smoking 

permanently.26 Additionally, the 2012 Tips campaign 

and a subsequent 2013 Tips campaign resulted in 

immediate and significant increases in state quitline 

call volumes, which rapidly declined to baseline 

levels upon completion of these campaigns.26,27

There have been fewer studies examining 

the effectiveness of tobacco countermarketing 

campaigns among population subgroups that 

bear a disproportionate burden of tobaccorelated disease and death. However, some studies 

have assessed the potential differential impact 

of mass-media campaigns by socioeconomic 

status (SES). A 2012 review found evidence to 

suggest that general-population campaigns may 

be effective for encouraging quitting in low 

SES smokers if the campaigns have sufficient 

reach, frequency, and duration.23 A 2012 study 

in New York state found increased quit attempts 

among both the general population and low-SES 

groups who were exposed to strongly emotional 

and graphic antismoking advertisements.25

Over the past decade, states have 

remained an important source of innovative 

countermarketing content; however, many have 

also found that they can save time, money, and 

the risks associated with new advertisement 

development by adapting existing advertisements 

from other states, cities, national governmental 

agencies, or other countries. For example, 

New York City has used advertisements from 

Australia, England, Massachusetts, California, 

and Minnesota; Florida has used advertisements 

from Australia, California, Washington State, 

and New York City; and Minnesota has used 

advertisements from Canada, California, 

Vermont, Ohio, Arizona, and CDC.28 Many of 

the advertisements were found in CDC’s Media 

Campaign Resource Center (MCRC) database.28

In addition to the importance of effective 

messaging strategies, research from many sources 

shows that tobacco countermarketing campaigns 

must have sufficient reach, frequency, and 
32

Section A: Mass-Reach Health Communication Interventions

duration to be successful.24,27,29–31 A key goal for 

tobacco control campaigns is to reach a defined 

target audience with attention-getting messages 

in the most efficient and effective way possible. 

Media buying, which typically includes how 

placements are purchased, the channels selected, 

and how the budget is allocated across channels, 

is an integral part of an overall strategy.

Evidence also suggests that earned media, 

which is the process of securing free news 

placements in a variety of media outlets through 

dedicated efforts to communicate key messages, 

can contribute to tobacco countermarketing 

campaign effectiveness. Local and statewide 

earned media campaigns have been shown to 

effectively support key tobacco control goals, 

including increasing calls to a state quitline, 

influencing smoking knowledge, attitudes, 

and behavior among youth, and implementing 

changes in local tobacco control policy.32–35

Digital media, including electronic delivery 

of information via Web sites, mobile applications, 

and social networking sites, are emerging and 

promising vehicles for reaching and influencing key 

target audiences. However, there is not yet sufficient 

evidence to draw conclusions or to make formal 

recommendations on the efficacy or ideal use of 

these media at this time. The measurement and 

evaluation of digital media interventions are critical 

to help build an evidence base, to gauge their 

effectiveness, and to optimize future digital media 

interventions. Given that the tobacco industry is 

allocating significant funding to these media,4,5

use of digital media is likely a promising 

area for states to consider.

Recommendations

An effective state mass-reach health communication intervention delivers strategic, 

culturally appropriate, and high-impact messages via sustained and adequately funded 

campaigns that are integrated into a comprehensive state tobacco control program effort. 

Typically, effective health communication interventions and countermarketing strategies 

employ a wide range of efforts, including:22

 Paid television, radio, out-of-home (e.g., 

billboards, transit), print, and digital 

advertising at the state and local levels

 Media advocacy through public relations/

earned media efforts (e.g., press releases/

conferences, social media, and local events), 

which are often timed to coincide with holidays, 

heritage months, and health observances 

 Health promotion activities, such as working 

with health care professionals and other 

partners and promoting quitlines 

 Efforts to reduce or replace tobacco industry 

sponsorship and promotions as well as 

to decrease movie smoking imagery

Innovations in health communication 

interventions include the ability to target and engage 

specific audiences through multiple communication 

channels, such as online video, mobile Web, and 

smartphone and tablet applications (apps). Social 

media platforms, such as Twitter and Facebook, 

have facilitated improvements in how messages 

are developed, fostered, and disseminated in order 

to better communicate with target audiences and 

allow for relevant, credible messages to be shared 

more broadly within the target audiences’ social 

circles. However, these platforms are complements 

to, not substitutes for, traditional mass media. 

Because data on the contribution of digital media 

efforts to reaching tobacco countermarketing 

campaign goals are still emerging, evaluation 

of digital media efforts can help determine 

effectiveness and establish an evidence base.22

Behavior theory, audience insight research, pretesting of campaign materials, and surveillance and 

evaluation are grounded in communication science 

and are used to develop interventions that target 

specific audiences with messages that can change 

awareness, knowledge, attitudes, and behaviors. 

Examples of these audiences include adult tobacco 

users, youth, and high-risk populations such 

as members of the lesbian, gay, bisexual, and 

transgender (LGBT) communities, those with lower 

socioeconomic status, and certain races such as 

American Indians. These methods are often used 

to identify key strategies, influential messages, and 

the most effective communication channels and 

media options to reach specific audiences. However, 

ensuring that messages resonate with specific 

population subgroups does not require that unique 

materials be developed for each audience. Evidence 

has confirmed that strong ads, such as those that 

graphically or emotionally portray the serious 

consequences of smoking, resonate well with a 
33

Section A: Mass-Reach Health Communication Interventions

wide variety of audiences.19,23 Advertising concepts 

and advertisements can be tested among specific 

target audiences to ensure that they communicate 

persuasively, and media buying can be tailored, 

when feasible, to ensure appropriate reach of 

those audiences.

Effective media planning works within the total 

framework of a mass-reach health communication 

campaign’s goals. For an overall campaign, it is 

estimated that advertisements should reach 75% 

to 85% of the target audience each quarter of the 

year, with a minimum average per quarter of 1,200 

gross rating points (GRPs) during the introduction 

of a campaign and a minimum average of 800 

GRPs per quarter thereafter.22,23,29,36 GRPs track 

the total reach and frequency of the campaign. A 

campaign is expected to run at least 3 to 6 months 

to achieve awareness of the issue, 6 to 12 months to 

influence attitudes, and 12 to 18 months to influence 

behavior,22,29 although some campaigns, including 

CDC’s Tips campaign, have influenced behavior 

within a 3-month time frame.26,27 Campaigns need to 

overcome pro-tobacco marketing influences; thus, 

it is important to set reasonable expectations of 

effectiveness. In addition, campaigns must run as 

continuously as possible because their impact can 

diminish over a relatively short time period.26,27,37–39

For more information regarding the media 

planning process, consult CDC’s countermarketing 

manual, Designing and Implementing an Effective 

Tobacco Countermarketing Campaign.22

The experiences of many states, including 

New York, California, Florida, Massachusetts, 

and Minnesota; the national organization Legacy 

(formerly the American Legacy Foundation); and 

CDC emphasize that message content of tobacco 

control campaigns is very important. Messages that 

elicit strong emotional response, such as personal 

testimonials and viscerally negative content, 

produce stronger and more consistent effects on 

audience recall, knowledge, beliefs and quitting 

behaviors.2,22,25,26,40 Aggressive state and national 

countermarketing campaigns that have more 

directly confronted the tobacco industry’s marketing 

tactics have also demonstrated effectiveness, but 

have often become targets for budget cuts.41–43

Resources such as CDC’s countermarketing 

manual and the MCRC database can be used to 

develop effective communications plans and to 

acquire effective advertisements cost efficiently.22,28 

The countermarketing manual is a toolkit with 

chapters on all major aspects of campaign 

development, and MCRC is a clearinghouse of 

tobacco-related media campaign materials produced 

by states and other organizations that other states 

can adapt and reuse. Evidence suggests that it 

is not necessary to develop new advertising,44–46

particularly considering the availability of existing 

advertisements in the MCRC—many of which have 

been used with very effective results.28 Typically, 

new advertising should be developed only when a 

campaign objective is unique enough that existing 

advertisements may not address it, when a campaign 

needs to publicize a local event (e.g., a quitting 

program or implementation of a new smokefree 

law), or when another unique situation arises.

Comprehensive earned media efforts are an 

essential part of the strategic plan, regardless of 

the size of one’s media campaign budget, but 

especially when funds are limited. Additionally, 

each major campaign element and activity should 

have an earned media component. Although 

paid media benefits from the ability to control 

the message and the placement, news media 

coverage is important because it can help set the 

public agenda, influence what people are talking 

about, and further broaden and add credibility to 

paid messages. Examples of earned media tactics 

include: establishing relationships with journalists to 

become a trusted, responsive, and knowledgeable 

resource; issuing press releases; scheduling editorial 

board briefings; holding events to generated 

media coverage; writing letters to the editor; and 

training spokespeople for interviews.22,28,32–34

In addition to providing sufficient reach, frequency, and duration, effective media and mass-reach 

health communication intervention efforts will benefit from the activities identified in the following box. 
34

Section A: Mass-Reach Health Communication Interventions

 Audience insight research to determine the 

current knowledge, attitudes, and behaviors 

of target audiences, as well as the motivations 

and behavioral theory that can best influence 

change among specific audiences.

 Formative research to identify promising 

messages and concepts.

 Formative evaluation to pretest campaign 

materials to ensure that they are clear, credible, and 

persuasive and that they motivate the audience 

to change their attitudes and behaviors.

 Surveillance to understand pro-tobacco messaging, 

media placements, and marketing tactics.

 Local media promotion, event sponsorships, and 

other community collaboration tie-ins to support 

and reinforce the statewide campaign, increase 

awareness about policies that protect and promote 

health, and shift social norms related to tobacco use.

 Digital technologies, such as text/SMS 

messaging, social media, Web sites, and blogs 

to generate messages that can be further 

disseminated by the target audience.

 Process and outcome evaluation of a 

comprehensive communication effort, as well 

as specific evaluations of new and innovative 

approaches, including the use of digital media.

 Promotion of available services, including the state’s 

telephone cessation quitline number or the quitline 

portal numbers (1-800-QUIT-NOW, 1-855-DÉJELO-YA), 

as well as quitting Web sites and social media pages. 

Beneficial Activities for Effective Media and Mass-Reach 

Health Communication Intervention Efforts 

Achieving Equity to Reduce 

Tobacco-Related Disparities

Recognition of, and sensitivity to, diverse 

audiences is critically important in tobacco control 

mass-reach health communications campaigns, 

particularly to address disparities in tobacco use 

and corresponding inequities in tobacco-related 

health outcomes across population groups. The 

experiences of multiple states and CDC have 

shown that mass-reach health communication 

campaign funds can be efficiently and effectively 

used to reach and influence populations with the 

greatest tobacco-related burden through carefullyplanned formative research that determines which 

messages and approaches resonate powerfully 

across diverse audiences, as well as thoughtful 

media placement that reaches key audiences where 

and when they are most receptive to the messages. 

Television advertisements that are not tailored 

by audience segment are frequently used by state 

tobacco control programs in an effort to ensure 

the broad and consistent delivery of key messages. 

This approach is supported by evidence suggesting 

that there are some universally strong messages for 

tobacco prevention education advertisements, such 

as the serious negative effects of smoking on the 

body and the emotional impact on family members, 

and that these types of messages are effective across 

a broad spectrum of geographies and populations 

without requiring significant tailoring.19,23,47

However, it is still important to consider and 

address audience diversity when developing or 

selecting advertisements. For example, testimonial 

advertisements could feature individuals of varied 

sexes, ages, race/ethnicities, sexual orientations, 

gender identities, or other population characteristics. 

At the national level, CDC’s Tips campaign featured 

testimonials of former smokers from multiple 

population groups with high rates of tobacco use.27

Some state tobacco control programs also tailor 

media buys to reach specific audience segments 

within general-population campaigns. For example, 

certain population subgroups may be more likely to 

listen to radio, while others may be more likely to 

read language-specific print materials or to engage 

in social media. States can use these media channels 

to cost efficiently supplement television placements. 

For example, to reach low-SES male audiences, 

North Carolina placed an advertisement in a 

NASCAR publication and distributed earplugs with 

the state’s quitline number at the race. Similarly, 

New York purchased placement on a sports cable 

network and used baseball-themed advertisements 

from Florida and Massachusetts. To reach American 

Indians and Alaska Natives, CDC purchased 

placements on radio networks and regional 

print publications targeted to these audiences.
35

Section A: Mass-Reach Health Communication Interventions

When planning and developing a mass-reach 

health communication campaign, the most critical 

considerations are that the messages resonate 

effectively with each priority audience and that the 

tailored media placements help ensure that each key 

audience notices and internalizes those messages. 

Taking into account these considerations should 

ultimately help increase the likelihood that the 

messages lead to meaningful changes in tobaccorelated knowledge, attitudes, and behaviors.

Budget

Mass-reach health communication efforts 

must be adequately funded, sustained over time, 

and integrated with other program activities in 

order to counter tobacco industry marketing, 

reduce tobacco use initiation, increase cessation, 

and reduce exposure to secondhand smoke. 

Campaigns of longer duration and higher 

reach and frequency are associated with greater 

declines in smoking rates.2,22,23,48 Future funding for 

national campaigns sponsored by CDC, Legacy, 

and other organizations remains uncertain, and 

even if federal mass-media campaign efforts 

are conducted during some years, they are not 

sufficient alone and should not take the place 

of state-level media campaigns. Therefore, 

states may want to plan to provide the primary 

budget for mass-reach health communication 

interventions to ensure broad population-level 

exposure to messages that address the goals of a 

comprehensive tobacco control program. The three 

major content areas of these messages include:

 Motivating tobacco users to quit 

 Protecting people from the harms 

of secondhand smoke 

 Transforming social norms to 

prevent tobacco use initiation 

Budget recommendations should be sufficient 

to conduct mass-reach health communication 

campaigns in the state’s major media markets 

addressing these three key content areas. Evidence 

suggests that if proven message strategies are used, 

such as personal and graphic portrayals of the 

negative health consequences of tobacco use, the 

same advertisements can be effective among both 

youth and adults,2,19 thus maximizing the impact 

of limited funds. Funds can be competitively 

awarded to firms that understand a state’s media 

markets, have experience in reaching culturally 

diverse audiences, have the ability to conduct 

market research and surveillance of countermarketing efforts, and exhibit a willingness to 

review existing advertising before recommending 

that new advertising be developed. Additional 

guidance on selecting contractors for health 

communication interventions is available in 

Designing and Implementing an Effective 

Tobacco Countermarketing Campaign.22

Budget estimates for funding mass-reach health 

communication interventions are generally based 

on the Best Practices—2007 funding formula, 

but the estimates have been revised based upon 

more recent state and national experiences. These 

evidence-based levels of media presence were used 

to calculate the minimum and recommended levels 

of spending (see Appendix A for more details).

The minimum budget level assumes that three 

campaigns are conducted each year to address the 

following goals: 1) motivating smokers to quit; 2) 

protecting people from the harms of secondhand 

smoke exposure; and 3) transforming social 

norms to prevent tobacco use initiation, with a 

delivery of an average of 1,200 GRPs per quarter 

for either one of the cessation or secondhand 

smoke campaigns (assumes it is an introductory 

campaign and, thus, requires higher levels) and 

a delivery of an average of 800 GRPs for each of 

the other two campaigns. The minimum budget 

level also assumes a 20% reduction in costs to 

account for efficiencies in message communication 

and media negotiation (reduced rates or bonus 

placements) that would be expected when 

conducting three campaigns simultaneously. The 

recommended budget level assumes delivery of 

campaigns with the same overall goals, with an 

average of 1,600 GRPs per quarter for one of 

the cessation or secondhand smoke campaigns 

and 1,200 GRPs per quarter for the other two 

campaigns, and a 20% reduction in costs based 

on message and media negotiation efficiencies. 

This range of funding was applied to states 

according to the cost and complexity of their media 

markets, in part measured by the coverage provided 

by a state’s designated market areas (DMAs). Statelevel cost estimates for buying televised air time 

in all 210 U.S. DMAs in 2014 were acquired by 

CDC in May 2013. States with counties that fall 

outside their primary DMAs may need to consider 

purchasing media in a neighboring state or using 

other vehicles, such as digital, in order to reach 

75% to 85% of the target audience. Also, budgeting 

for cost-effective media campaigns is more 
36

Section A: Mass-Reach Health Communication Interventions

complicated for states having media markets that 

share major metropolitan areas with neighboring 

states, so such states may need to rely more on 

local vehicles (digital, out-of-home, newsprint, 

radio) and less on broadcast television to limit 

spending to reasonable levels. However, those 

placements may not easily translate to GRP levels.

It is important to note that the recommended 

level of media investment is for media placement 

only. Because they vary significantly across 

states, the following costs were not included 

in the budget estimates: advertising agency 

and media planning firm fees; audience insight 

research; pretesting of materials; advertising 

development and production; and talent fees. 

In addition, the more campaigns a state 

conducts, the more staffing will be required. 

Although the Infrastructure, Administrative, and 

Management chapter of this report provides 

general funding levels for staffing, additional 

funds will be needed to support three unique 

multimedia campaigns. Also, additional funds 

may be needed to tailor the campaign to specific 

population groups, especially to ensure language 

appropriateness, through the use of unique 

messages, materials, or media vehicles. However, 

states can lower advertising development costs by 

using existing television, radio, print, and outdoor 

advertisements from CDC’s MCRC.28 Also, alternative 

forms of communication—such as direct mail, 

Web sites, blogs, social media and text messaging, 

and working through health care providers, 

other government organizations, and the news 

media—can extend the reach and frequency of 

messages, as can recruiting audiences to produce 

or adapt, place, and promote messages themselves 

through social media and other digital technologies. 

In the event that available funding for massreach health communication interventions exceeds 

minimum levels and approaches recommended 

levels, state programs may want to consider 

allocating resources for elements related to the 

creation of their own advertisements, including 

audience insight research and advertisement 

development and production. It is important to 

note that these funding levels are general; thus, 

states may have to tailor certain factors—such 

as number of goals, campaigns conducted, and 

target audiences—to their unique situations.
37

Section A: Mass-Reach Health Communication Interventions

References

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9. Carter OB, Mills BW, Donovan RJ. The effect 

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10. Clattenburg EJ, Elff JL, Apelberg BJ. 

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11. Germain D, McCarthy M. Smoker sensitivity 

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FJ, Barker DC, Slater SJ, Clark PI, Giovino GA. Tobacco 

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T, Unger JB. An examination of trends in 

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2005. Tobacco Control 2008;17(2):93–8.

17. Loomis BR, Farrelly MC, Nonnemaker 

JM, Mann NH. Point of purchase cigarette 

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21. Internet Movie Database. Demo Reel (Blu 

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Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2003.

23. Durkin S, Brennan E, Wakefield M. Mass 

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24. Wakefield MA, Bowe SJ, Durkin SJ, Yong 

HH, Spittal MJ, Simpson JA, Borland R. Does 

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prevent relapse among recent quitters? Nicotine 

& Tobacco Research 2013;15(2):385–92.

25. Farrelly MC, Duke JC, Davis KC, Nonnemaker 

JM, Kamyab K, Willett JG, Juster HR. Promotion 

of smoking cessation with emotional and/

or graphic antismoking advertising. American 

Journal of Preventive Medicine 2012;43(5):475–82.

26. McAfee T, Davis KC, Alexander RL, 

Pechacek TF, Bunnel R. Effect of the first 

federally funded US antismoking national media 

campaign. Lancet 2013;382(9909):2003-11. 

27. Centers for Disease Control and Prevention. 

Increases in quitline calls and smoking cessation 

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campaign—March 19–June10, 2012. Morbidity 

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28. Centers for Disease Control and Prevention. 

Media Campaign Resource Center Online Database; 

< http://www.cdc.gov/tobacco/media_campaigns/

index.htm>; accessed: December 2, 2013.

29. Schar E, Gutierrez K, Murphy-Hoefer R, Nelson 

DE. Tobacco Use Prevention Media Campaigns: 

Lessons Learned from Youth in Nine Countries. Atlanta: 

U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2006.

30. Terry-McElrath Y, Wakefield M, Ruel E, Balch GI, 

Emery S, Szczypka G, et al. The effect of antismoking 

advertisement executional characteristics on youth 

comprehension, appraisal, recall, and engagement. 

Journal of Health Communication 2005;10:127–43.

31. Terry-McElrath YM, Emery S, Wakefield MA, 

O’Malley PM, Szczypka G, Johnston LD. Effects of 

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among 20-30-year-old adults: longitudinal data 

from the USA. Tobacco Control 2013;22(1):38–45.

32. Sheffer MA, Redmond LA, Kobinsky 

KH, Keller PA, McAfee T, Fiore MC. Creating a 

perfect storm to increase consumer demand for 

Wisconsin’s Tobacco Quitline. American Journal of 

Preventive Medicine 2010;38(3 Suppl):343S–346S.

33. Smith KC, Wakefield MA, Terry-McElrath Y, 

Chaloupka FJ, Flay B, Johnston L, Saba A, Siebel C. 

Relation between newspaper coverage of tobacco 

issues and smoking attitudes and behaviour among 

American teens. Tobacco Control 2008;17(1):17–24.

34. Dunlop SM, Romer D. Relation between 

newspaper coverage of ‘light’ cigarette litigation and 

beliefs about ‘lights’ among American adolescents 

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quitting intentions. Tobacco Control 2010;19(4):267–73.

35. Niederdeppe J, Farrelly MC, Wenter D. Media 

advocacy, tobacco control policy change and teen 

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MA. What is the role of tobacco control advertising 

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M, Scollo M, Simpson JA, Chapman S, White V, Hill D. 

Impact of tobacco control policies and mass media 

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38. Dietz NA, Westphal L, Arheart KL, Lee 

DJ, Huang Y, Sly DF, Davila E. Changes in youth 

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Preventing Chronic Disease 2010;7(3):A65.

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Effect of ending an antitobacco youth campaign 

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40. Wakefield M, Loken B, Hornik R. Use of 

mass media campaigns to change health 

behavior. Lancet 2010;376:1261–71.

41. Ibrahim JK, Glantz SA. The rise and fall of 

tobacco control media campaigns, 1967–2006. 

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42. Farrelly MC, Nonnemaker J, Davis KC, 

Hussin A. The influence of the national truth 

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43. Holtgrave DR, Wunderink KA, Vallone DM, 

Healton CG. Cost–utility analysis of the national 

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Dessaix A, Bishop JF. The case for recycling 

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Warne C, International Anti-Tobacco Advertisement 

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Promotion, Office on Smoking and Health, 2007. 
40

III. Cessation Interventions 

Justification 

Rationale

Promoting cessation is a core component of a 

comprehensive state tobacco control program’s 

efforts to reduce tobacco use.1,2 Encouraging 

and helping tobacco users to quit is the quickest approach to reducing tobacco-related disease, 

death, and health care costs.3 Quitting smoking has immediate and long-term health benefits.4

Although quitting smoking at any age is beneficial, smokers who quit by the time they are 

35 to 44 years of age avoid most of the risk 

of dying from a smoking-related disease.5

Population-wide interventions that change 

societal environments and norms related to 

tobacco use—including increases in the unit 

price of tobacco products, comprehensive 

smokefree policies, and hard-hitting media 

campaigns—increase tobacco cessation by 

motivating tobacco users to quit and making it 

easier for them to do so.1-3,6,7 Offering cessation 

assistance to smokers who attempt to quit in 

response to these interventions maximizes the 

impact of these interventions on cessation, while 

countering the perception that they are punitive.1-3,6-8

Guiding Principles

Population-wide cessation efforts—specifically, 

policy, systems, or environmental changes—are 

most efficient and effective at reaching many 

people.1,2,6,8 Systems changes within health care 

organizations complement interventions in state 

and community settings by institutionalizing sustainable approaches that support individual 

behavior change.1,6,8 As in other areas of tobacco 

control, policy and/or systems approaches support 

healthy behaviors at both the individual and the 

societal or institutional levels.1,6,8

Although it is appropriate and necessary for 

comprehensive state tobacco control programs 

to fund and provide certain cessation treatment 

services (i.e., to directly deliver cessation 

counseling and medications through populationbased approaches such as state quitlines) to 

certain populations, particularly groups that would 

otherwise not have access to these services (e.g. 

the uninsured), the programs’ focus should remain 

on population-level, strategic efforts to reconfigure 

policies and systems in ways that normalize 

quitting and that institutionalize tobacco use 

screening and intervention within medical care.1,6,8

State tobacco control programs can educate 

private and public health care systems, health 

insurers, and employers on the importance of 

assuming responsibility for, and covering the costs 

of, providing cessation services to their members 

and employees.1

 States can also monitor and 

leverage provisions in the Affordable Care Act that 

require new private health plans and state Medicaid 

programs to expand coverage of evidence-based 

tobacco use cessation treatments.9 The Affordable 

Care Act and the Health Information Technology 

for Economic and Clinical Health Act, which gave 

rise to the Meaningful Use of Electronic Health 

Records Incentive Program, provide states with a 

unique opportunity to focus cessation efforts on 

promoting and supporting the implementation 

of policies and systems within health care 

organizations and health insurers that support 

cessation, and also offer eligible providers and 

hospitals federal funding to adopt electronic health 

records and use them in ways that can support 

improvements in the delivery of clinical preventive 

services, including tobacco dependence treatment. 

Such policies and systems have the potential 

to dramatically increase the delivery of evidencebased cessation interventions, thus making them 

more widely available and accessible. Cessation 

services directly provided or funded by a 

comprehensive state tobacco control program are 

best focused on populations that lack access to 
41

Section A: Cessation Interventions

these services through other channels, such as 

the uninsured and the underinsured.10 In addition, 

state programs may perform some functions that 

are most efficiently handled at a centralized level, 

such as tagging mass-media advertisements with a 

phone number or Web site where individuals can 

obtain or be referred to basic cessation services.

Population quit rates are determined by two 

factors: (1) the number of quit attempts, which 

includes the number of smokers who try to quit, 

and the number of times they make a quit attempt; 

and (2) the odds that smokers who try to quit will 

succeed in doing so.11 It is important that state 

efforts to increase population quit rates strive to 

increase both quit attempts and quit success, and 

attempt to strike a balance between the reach and 

intensity of interventions.1,11 State tobacco control 

programs play an important role in implementing 

interventions such as hard-hitting media campaigns 

that motivate smokers to quit, as well as ensuring 

that smokers who want help quitting, but who lack 

adequate cessation coverage, have access to effective 

cessation assistance and know how to obtain it.

Two-thirds to three-quarters of smokers who 

try to quit do not use any evidence-based cessation 

counseling or medications.12,13 Smokers improve 

their odds of successfully quitting when they use 

these treatments.14 It is important for state cessation 

initiatives to make smokers aware of this fact and 

to ensure that cessation treatments are readily 

available through health care systems and providers, 

state telephone quitlines, and other communitybased cessation resources.1

 This message can be 

communicated without implying that smokers 

cannot quit successfully without using cessation 

treatments, so as not to lessen the impact of tobacco 

education campaigns on increasing quit attempts.15,16

An Altered Landscape

The cessation landscape has changed considerably 

since Best Practices—2007 as a result of the following developments: 

 Publication of an updated version of the Public 

Health Services Clinical Practice Guideline, 

Treating Tobacco Use and Dependence, in 2008

 Enactment of the Patient Protection 

and Affordable Care Act

 Implementation of the Meaningful Use initiative

 Widespread adoption of electronic 

health records

 Creation of the Centers for Medicare 

and Medicaid Innovation

 Introduction of new voluntary Joint Commission 

hospital cessation performance measures 

 Increasing shift to managed care 

plans in state Medicaid programs 

 Changes in the organization of private 

health care

 Increased emphasis on establishing 

linkages between public health 

interventions and clinical interventions

 Introduction of the national tobacco 

education media campaign, Tips From 

Former Smokers, conducted by CDC 

These changes have presented significant 

new opportunities to expand cessation coverage, 

institutionalize tobacco use screening and 

interventions within health care systems, 

and increase the availability and use of 

evidence-based cessation treatments. 

Three Major Goals

Comprehensive state tobacco control program cessation activities should focus on three broad goals:

 Promoting health systems change

 Expanding insurance coverage and 

utilization of proven cessation treatments

 Supporting state quitline capacity 
42

Section A: Cessation Interventions

Promoting Health Systems Change 

The health care system provides multiple opportunities 

for motivating and helping smokers to quit.6,8,14,17 More 

than 80% of smokers see a physician every year,18 and 

most smokers want and expect their physicians to talk to 

them about quitting smoking and are receptive to their 

physicians’ advice.14 Tobacco dependence treatment 

is both clinically effective and highly cost-effective, 

and results in reduced health care costs, increased 

productivity, and reduced absenteeism.14

Effective tobacco cessation interventions advance 

the goals of national and state health care reform efforts 

to improve health care, to improve health, and to reduce 

health care costs. Health systems change involves 

institutionalizing cessation interventions in health care 

systems and integrating these interventions into routine 

clinical care.6,8,14,17 This increases the likelihood that 

health care providers will consistently screen patients 

for tobacco use and intervene with patients who use 

tobacco, thus increasing cessation and making evidencebased tobacco dependence treatment the standard of 

care.14,17,19 When a health system seeks to intervene with 

every tobacco user at every visit,14 it can substantially and 

rapidly increase cessation.14,17,19

State efforts to promote health systems change 

involve working with health care systems and 

organizations to fully integrate tobacco dependence treatment into the clinical workflow.6,8, 

14,17,19 The goal is to ensure that every patient is 

screened for tobacco use, their tobacco use status 

is documented, and patients who use tobacco are 

advised to quit.6,8,14,17,19 This is followed by offering 

the patient cessation medication (unless contraindicated), counseling, and assistance, as well 

as arranging follow-up contact either on-site or 

through referrals to the state quitline or other community resources.6,8,14,17,19,20 This approach has been 

summarized as the “5 A’s”: (1) ask about tobacco 

use; (2) advise to quit; (3) assess willingness to 

make a quit attempt; (4) assist in the quit attempt; 

and (5) arrange follow-up.14

One way to increase the use of this approach 

is through provider reminder systems, which 

prompt health care providers to screen and 

intervene with patients around tobacco use and 

increase provider delivery of cessation advice.6,14

Consistent screening and delivery of cessation 

interventions are also facilitated by assigning 

multiple members of the health care team (e.g., 

medical assistants, physician assistants, nurses, and 

physicians) clearly identified roles in this area.14

State tobacco control programs can promote 

health systems change in multiple ways. For 

example, state governments provide health care 

coverage to Medicaid enrollees and state employees. 

States also regulate or otherwise interact with 

the health insurance market. These roles provide 

opportunities to improve health systems approaches 

to tobacco use prevention and cessation. In addition, 

state tobacco control programs can educate health 

care decision makers about the health and economic 

burden imposed by tobacco use and the evidence 

base for clinical cessation interventions, including 

the cost-effectiveness and return on investment 

of these interventions.1,21,22 State tobacco control 

programs can also offer technical assistance to help 

health care organizations and providers measure 

the implementation of health systems changes and 

the impact of these changes on outcomes in their 

patient populations using data from electronic 

health records, insurance claims, and other sources.

State programs can further support health 

systems change by carrying out academic 

detailing initiatives.21,22 This involves providing 

technical assistance to health care organizations 

and providers in implementing health systems 

changes that institutionalize tobacco use screening 

and intervention, including referrals to the state 

quitline.20-24 The technical assistance is typically 

provided in-person in the health care setting by 

trained personnel.21,22 Studies of academic detailing 

initiatives have found that they have the potential to 

increase: use of the “5 As”;25,26 frequency of tobacco 

cessation counseling;27 appropriate use of cessation 

medications;27 and fax referrals to quitlines.20–24
43

Section A: Cessation Interventions

Under the Meaningful Use initiative, the Centers 

for Medicare and Medicaid Services is making 

substantial financial incentives available to eligible 

providers and hospitals to migrate from paper 

to electronic health records in order to improve 

health care and health care outcomes.28 When 

electronic health records are implemented in a way 

that explicitly incorporates tobacco dependence 

treatment as part of a broader process of health 

systems change, they can serve as a powerful 

provider reminder system, prompting providers 

to screen their patients for, and intervene on, 

tobacco use by embedding prompts, language, 

and documentation within the records themselves, 

and helping to seamlessly integrate these steps 

into the clinical workflow.29-33 The implementation 

of electronic health records with a cessation 

component can have an even greater impact if it 

is coupled with training and technical assistance 

to all members of the health care team.32,33

Electronic health records can also make it easier 

for providers to refer patients to state quitlines, 

counseling within the health organization, and 

community-based cessation programs, especially 

when these referrals can be made electronically.20,30-32

Several provisions of the initial stages of Meaningful 

Use require electronic health records to capture 

identification of and intervention with patients who 

use tobacco and require providers to report on these 

measures in order to receive financial rewards.8,20

Health care organizations that have 

implemented electronic health records in 

combination with other health systems changes 

are able to achieve levels of 80% or higher for 

both screening and intervention, with additional 

improvement possible.19 State tobacco control 

programs can seek opportunities to leverage 

the implementation of electronic health records 

by working with large health care systems to 

integrate tobacco dependence treatment into their 

workflows.33 Electronic health records can also be 

used to monitor provider performance for purposes 

of feedback, recognition, and rewards at the 

organization and/or provider levels, as well as to 

conduct surveillance of tobacco-related measures.19,30

Finally, new hospital performance measures 

implemented by the Joint Commission in January 

2012 expand and strengthen previous Joint 

Commission measures by calling on hospitals 

to provide cessation interventions to all tobacco 

users, not just those with specific diagnoses, and 

by expanding the scope of these interventions.34-36 

State tobacco control programs can work with 

the health care sector to encourage hospitals to 

adopt these voluntary cessation measures and can 

provide technical assistance with implementation.36

Sample State Activities: Promoting Health Systems Change 

 Build and maintain relationships with large health 

care systems and key stakeholders in the health care 

sector, and educate them about the feasibility and 

health and economic benefits of integrating tobacco 

dependence treatment into their clinical workflows.

 Conduct academic detailing initiatives to provide 

technical assistance to health care organizations and 

providers in implementing health systems changes 

that institutionalize tobacco use screening and 

intervention, including promoting referrals to the 

state quitline.

 Collaborate with health care systems, regional 

extension centers, and other stakeholders to integrate 

tobacco dependence treatment into electronic health 

records and workflows.

 Leverage data from electronic health records, 

insurance claims, and other sources for surveillance/

evaluation of the implementation and outcomes of 

health systems change cessation interventions. 
44

Section A: Cessation Interventions

Expanding Insurance Coverage and 

Utilization of Proven Cessation Treatments 

Expanding cessation insurance coverage increases the 

number of smokers who attempt to quit, use evidencebased cessation treatments, and successfully quit by 

removing cost and administrative barriers that prevent 

smokers from accessing cessation counseling and 

medications. 6,14,17,37

Expanding cessation insurance coverage also has 

the potential to reduce tobacco-related population 

disparities.6,14,17,37 Comprehensive cessation coverage can 

also support providers in their efforts to offer patients 

effective cessation treatments.14,17 Finally, health systems 

cessation interventions can increase patients’ use of 

available coverage.14,17

One important function of state tobacco control 

programs is to educate key stakeholders—including private and public health care systems, health 

insurers, the state Medicaid program, and employers—on the meaning of comprehensive cessation 

coverage and the importance and benefits of 

implementing such coverage. Educating employers on these topics is important because employers 

can play a key role in expanding cessation coverage by demanding such coverage and because 

self-insured employers are in a position to directly 

provide such coverage.14,17

For cessation insurance coverage to be 

effective in increasing cessation, it is important for 

it to be comprehensive in scope. Comprehensive 

coverage includes all evidence-based cessation 

treatments—including individual, group, and 

telephone counseling—and all seven Food and 

Drug Administration (FDA) approved cessation 

medications (bupropion, varenicline, and five forms 

of nicotine replacement therapy (NRT), including 

the patch, gum, lozenge, inhaler, and nasal spray). 

Comprehensive cessation coverage also eliminates 

or minimizes cost sharing and other barriers to 

accessing this coverage.38 Finally, comprehensive 

cessation coverage includes proactively promoting 

the coverage to ensure that smokers and their health 

care providers are aware of it, thus increasing the 

chances that they will use it, and documenting 

and reporting utilization of the coverage.14,38–41

In January 2011, the Office of Personnel 

Management (OPM) implemented a cessation benefit 

for federal employees through the Federal Employees 

Health Benefits Program.42 Highlights of that benefit, 

which is a model of comprehensive, evidencebased coverage, are listed in the following box. 

Components of the Cessation Benefit Available to Federal Employees 

through the Federal Employees Health Benefits Program42

 Individual, group, and telephone counseling.

 All seven FDA-approved cessation 

medications, including both prescription 

and over-the-counter medications.

 Coverage for two quit attempts per year, with 

four counseling sessions per attempt.

 No copays, coinsurance, or deductibles.

 No annual or lifetime limits.
45

Section A: Cessation Interventions

Once comprehensive cessation coverage has been 

achieved, state tobacco control programs may 

want to consider working with private and public health care systems, health insurers, employers, 

and other partners to publicize this coverage to 

smokers and their health care providers and to 

monitor its utilization.39–41 High utilization is essential for a cessation benefit to be effective, because 

even the most comprehensive cessation coverage 

will have little impact if smokers and providers 

are not aware of it or don’t use it.39–41 In assessing 

the quality of cessation coverage, it is important to 

take into account barriers to access and utilization, 

as well as the cessation treatments covered. 

In addition to working with the state 

Medicaid program to expand Medicaid cessation 

coverage, state programs can also seek to 

expand cessation coverage for state employees.37

These employees typically make up a significant 

proportion of the state workforce, and the 

cessation coverage offered to this group can 

serve as a model for private employers and 

health plans.37 Another approach taken by several 

states is to mandate private health insurers to 

provide some level of cessation coverage.37

Results of Massachusetts’ Medicaid Cessation Benefit Implemented in 2006 

 The benefit was utilized by about 37% of Medicaid 

recipients who smoked, or more than 70,000 

individuals in its first 21⁄2 years.43

 The smoking rate among Medicaid enrollees fell from 

38.3% to 28.3%.43

 Annual hospital admissions for heart attacks and 

other acute heart disease diagnoses among Medicaid 

enrollees who used the benefit fell by 46% 

and 49%, respectively.44

 The benefit was found to generate a return on 

investment of $3.12 in cost savings from averted 

hospitalizations for acute cardiovascular events for 

every dollar spent on it.45

Several provisions in the Affordable Care Act 

expand private and Medicaid cessation coverage.9,37,46 The legislation requires non-grandfathered 

private plans to cover, with no cost-sharing, preventive services that receive an ‘A’ or ‘B’ rating 

from the U.S. Preventive Services Task Force, 

which includes tobacco cessation treatments.9,37,46

This requirement also applies to the insurance 

plans available to the individual and small group 

health insurance markets through each state’s 

Health Insurance Marketplace.9,37 Neither the Task 

Force recommendations nor the U.S. Department 

of Health and Human Services rules implementing the relevant provisions of the Act clearly 

define the specifics of the required tobacco cessation coverage; thus, these specifics remain 

somewhat open to interpretation.37,47,48 To the 

extent possible, it is important for state tobacco 

control programs to work with large health insurers to ensure that they realize the full potential 

of these provisions by implementing comprehensive, evidence-based cessation coverage.

As of October 2010, the Affordable Care Act 

requires state Medicaid programs to cover cessation 

counseling for pregnant women.9,37,46 Effective 

January 2014, the legislation bars these programs 

from excluding FDA-approved cessation medications 

from their coverage for all Medicaid enrollees.9,37,46

In addition, states that choose to expand Medicaid 

eligibility must provide tobacco cessation coverage 

to newly eligible adults through a benchmark 

benefit package.9,37 State Medicaid programs are also 

eligible for an increased federal medical assistance 

percentage if they provide recommended clinical 

preventive services, including tobacco cessation 

treatment, to traditional Medicaid recipients without 

cost sharing.9,46 State tobacco control programs 

can work with state Medicaid programs to ensure 

that the potential of these provisions is fully 

realized. Medicaid enrollees smoke at higher rates 

than the general population, and smoking-related 

diseases in this population are a major driver of 

increasing state and federal Medicaid costs.37,49

Another provision of the Affordable Care Act 

allows health insurers in the individual and small 
46

Section A: Cessation Interventions

group markets to charge tobacco users higher 

premiums than nontobacco users, up to a ratio 

of 1.5 to 1.0.9,37,46 States retain the ability to reduce 

the ratio or to prohibit this practice entirely,9,37 and 

several states have reportedly done so.37 Although 

imposing higher premiums on tobacco users could 

motivate them to quit, it could also lead them to 

misrepresent their tobacco use status, avoid seeking 

cessation assistance, or forego health insurance, 

and could impose a prohibitive cost burden on lowincome tobacco users.37,50 The rule implementing 

this provision seeks to avert such outcomes by 

requiring health insurers in the small group market 

to allow tobacco users the opportunity to avoid 

paying the full amount of the tobacco rating 

factor by participating in a wellness program.51,52

It is important for state tobacco control programs 

to monitor the implementation of this provision, 

and states may choose to restrict or prohibit 

the practice of charging tobacco users higher 

premiums if negative effects become apparent.

Separate from the Affordable Care Act, the 

Centers for Medicare and Medicaid Services has 

in recent years taken several steps to expand 

cessation coverage for Medicare enrollees, 

who comprise another potentially vulnerable 

population.37 This coverage now includes individual 

counseling and prescription cessation medications, 

but not comprehensive cessation coverage.37

There are opportunities to promote Medicare 

cessation benefits to increase their utilization.37

Sample State Activities: Expanding Insurance Coverage of 

Proven Cessation Treatments 

 Build and maintain a relationship with private health 

insurers, the state Medicaid program, the state 

employee health plan, and large employers and 

educate them about the definition of comprehensive 

cessation coverage and about the health and 

economic benefits of providing such coverage.

 Work with the state Medicaid program to ensure that 

both fee-for-service and managed-care Medicaid 

plans provide comprehensive cessation coverage.

 Promote and monitor utilization of the 

state Medicaid cessation benefit.

 Work with state government to ensure that state 

employees have comprehensive cessation coverage.

 Implement a state mandate requiring 

private health insurers to provide 

comprehensive cessation coverage.

 Monitor implementation and effects of the 

provisions of the Affordable Care Act that have 

the potential to expand cessation coverage, as 

well as the provision that allows health insurers 

to charge tobacco users higher premiums.
47

Section A: Cessation Interventions

Supporting State Quitline Capacity 

Quitlines are telephone-based services that help 

tobacco users quit by providing callers with counseling, 

practical information on how to quit, referral to other 

cessation resources, and, in some states and for certain 

populations, FDA-approved cessation medications.16

Quitlines potentially have broad reach, are effective with 

diverse populations, and increase quit rates.14

State quitlines are one of the most accessible 

cessation resources and can efficiently reach large 

numbers of smokers.14,16 In addition, quitlines are effective 

in reaching certain racial/ethnic populations, including 

African Americans; persons who predominantly speak 

Asian languages; and low-income smokers.53-56

Quitlines are highly cost-effective relative to other 

commonly used disease prevention interventions.14,57–59

State quitlines are also typically the most visible 

component of state cessation efforts and frequently serve 

as a hub or centerpiece of these efforts.16 State quitlines 

can also serve as clearinghouses and referral/triage 

centers, educating callers about the cessation coverage 

available from their health insurer and referring callers to 

community cessation services1,16

State quitlines can play an important role 

in supporting and increasing provider cessation 

interventions by offering a resource for additional, more 

intensive cessation counseling.20,60,61 Having the option 

of referring patients to state quitlines for follow-up 

assistance increases the likelihood that providers will 

intervene with patients who smoke.20,60,61 Most state 

quitlines have established fax referral programs,20 and 

many state quitlines are developing the capacity to 

accept e-referrals directly from patients’ electronic health 

records and to electronically send patient reports to the 

referring provider/health care organization. 

Notwithstanding their many advantages and potentially broad reach, state quitlines on average reach 

only about 1% of smokers annually.62,63 This situation is largely a function of modest state funding 

for providing and promoting state quitline services.62,63 Some states, employers, and health 

plans have attained quitline reach levels of 6% or 

more.64,65 State quitlines should seek to reach 8% of 

their state’s tobacco users annually, with a target of 

90% of these callers accepting counseling services. 

These guidelines take into account the experiences 

of state quitlines that have achieved higher levels 

of reach for limited periods.1,64,65 These guidelines 

are also based on expectations that more health 

care providers will refer patients to quitlines as a 

result of Meaningful Use and the adoption of electronic health records, that more health plans will 

refer their members to quitlines in response to 

the Affordable Care Act, and that CDC’s National 

tobacco education campaigns will continue to 

drive more callers to 1-800-QUIT-NOW. 

In developing funding and service models, 

it is crucial to balance reach and intensity. It is 

important for state quitlines to seek to ensure that 

all callers have access to a basic level of service 

while providing higher levels of service to certain 

populations that would otherwise lack access 

to such services. Ensuring that a basic level of 

quitline service is in place is important to support 

interventions that are likely to increase interest 

in quitting and calls to quitlines, such as national 

or state media campaigns and implementation 

of smokefree laws or tobacco price increases. 

State tobacco control programs can use several 

approaches to increase quitline reach, including 

paid media campaigns, promotion of cessation 

medicine giveaways, and outreach efforts to 

generate fax or electronic referrals from health 

care organizations and providers.1,6,23,24,66,67

It is also important for state tobacco control 

programs to consider the level of funding for 

quitline operations and promotion that can 

realistically be sustained over time and to explore 

long-term funding sources. For example, programs 

can establish public-private partnerships, in which 

health plans or employers reimburse the state 

quitline for services provided to their members/

employees, or contract directly with a quitline 

vendor to provide these services.67,68 The Colorado 

and Minnesota tobacco control programs worked 

with their states’ major private health plans to 

implement the first and second models, respectively; 

both these partnerships have been successful and 

have remained in place for a number of years.67,68

State tobacco control programs can also work with 

their state Medicaid programs to secure the 50% 

federal match for quitline counseling provided to 
48

Section A: Cessation Interventions

Medicaid enrollees, who typically account for a 

substantial proportion of state quitline callers.69

State quitlines should consider providing 

some form of cessation assistance to all callers, 

including ensuring that all callers who want to talk 

to a quitline coach receive at least one ten-minute 

reactive call (i.e., a call initiated by the caller in 

which brief counseling is offered). Beyond this 

initial call, state quitlines can offer an additional 

three proactive counseling calls (i.e., calls initiated 

by the quitline in which counseling is offered) to 

the uninsured and underinsured, persons enrolled 

in a plan through the state Health Insurance 

Marketplace, Medicaid enrollees, and members 

of health plans and employees of companies that 

have contracted with the state to receive quitline 

services. Callers with private health insurance 

that provides adequate cessation coverage can be 

directed to their insurer or employer for cessation 

services after receiving an initial counseling call, 

or alternatively, the cost of additional calls can 

be reimbursed by their insurer or employer.67,68

State quitlines can also provide a free 2-week 

starter supply of NRT patches or gum to: uninsured 

and underinsured callers, persons in state insurance 

marketplace plans, and Medicaid enrollees.1 This can 

increase calls to the quitline from these populations 

and these callers’ success rates.6,66,70–72 Another 

priority activity is to conduct targeted outreach to 

increase the state quitline’s reach to underserved 

populations with high smoking rates. Longer-term 

efforts include: developing the capacity to accept 

e-referrals from patient electronic health records; 

integrating telephone cessation services with text 

messaging interventions and cessation services 

provided through other technologies, such as the 

Web and social media; and re-engaging previous 

quitline callers who agree to be re-contacted in quit 

attempts.6,73 Text messaging, Web, and social media 

interventions could potentially extend the reach 

and impact of quitlines, particularly among younger 

individuals.14

State quitlines may also consider revisiting their 

eligibility protocols and service offerings in light 

of changes in health insurance coverage resulting 

from the implementation of the Affordable Care 

Act, including changes in the proportion of adults 

covered by different types of health insurance and 

in the cessation coverage provided. For example, 

several studies have documented the beneficial 

impact of providing brief introductory courses of 

NRT through quitlines.6,66,70–72 However, most of 

these studies were conducted at a time when overthe-counter NRT was not generally available as a 

covered medication through health insurance plans. 

Accordingly, it is important for state tobacco control 

programs to monitor the situation in their states as 

it evolves and to consider limiting state quitlines’ 

provision of longer (e.g., 8 week) courses of NRT 

to the uninsured, as appropriate. State quitlines 

can also revise the information they provide on 

NRT on the basis of recent FDA changes to the 

warnings on labeling of over-the-counter NRT 

products regarding long-term use and combined 

use with other NRT products or cigarettes.74
49

Section A: Cessation Interventions

Sample State Activities: Supporting State Quitline Capacity 

 Ensure that all callers receive some form of cessation 

assistance and that all callers who want to talk to a 

quitline coach receive at least one 10-minute reactive call.

 Ensure that all uninsured and underinsured callers 

and callers enrolled in state insurance marketplaces 

and Medicaid are offered three proactive counseling 

calls in addition to the reactive call and a free 2-week 

starter supply of NRT patches or gum.

 Ensure that all members of health plans and 

employees of companies that have contracted with 

the state quitline to receive quitline services are 

offered three proactive counseling calls in addition to 

the reactive call and a free 2-week starter supply of 

NRT patches or gum.

 Establish public-private partnerships under 

which health plans and employers either 

reimburse the state quitline for services provided 

to their members/employees or provide their 

own quitline services to these groups.

 Secure the federal Medicaid quitline match.

 Conduct targeted outreach to increase the state 

quitline’s reach to underserved populations with 

high smoking rates, including promoting the national 

Spanish-language quitline portal 1-855-DÉJELO-YA 

(1-855-335-3569) and the national Asian-language 

quitline.

 Develop the capacity to accept e-referrals from 

patient electronic health records.

 Integrate quitline services with text messaging by 

referring callers to NCI’s text messaging program.

 Re-engage previous quitline callers who agree to be 

re-contacted in quit attempts. 

Achieving Equity to Eliminate 

Tobacco-Related Disparities 

Significant population disparities exist with regard 

to tobacco cessation.12,14 For example, recent data 

suggest that African American adults are more 

likely to express interest in quitting and more 

likely to have tried to quit in the past year than 

white adults, but are less likely to use proven 

treatments and are less likely to succeed in quitting.12 Similarly, adults of lower socio-economic 

status express significant interest in quitting, but 

are more likely to be uninsured or on Medicaid 

and are less likely to receive cessation assistance.14

Medicaid enrollees smoke at higher rates than the 

general population37,49 and also express similar 

interest in quitting smoking as smokers with private insurance but are less likely to succeed.12 One 

likely reason for this population’s lower quit rates 

is that few state Medicaid programs provide comprehensive coverage of cessation treatments.37

Adults with mental illness have a much higher 

smoking prevalence than adults without mental 

illness, smoke more cigarettes per month, and are 

less likely to quit smoking.14,75 Potential reasons 

that smokers with mental illness are less likely to 

quit include higher levels of nicotine addiction 

among this population and less access to cessation 

treatment, which may result from a lack of financial 

resources, a lack of health insurance, or a general 

reluctance of mental health care providers and 

facilities to address tobacco use in their patients.14,75

Lower quit rates in certain populations may 

result in part from environments and social norms 

that are less supportive of cessation and more 

supportive of tobacco use.1,6,76,77 For example, blue 

collar and service workers have traditionally been 

less likely to be protected by smokefree workplace 

policies than white collar workers, and African 

Americans are less likely to live under smokefree 

home rules and are more likely to be exposed to 

secondhand smoke at work.7,78,79 Similarly, until 

recently, many mental illness and substance abuse 

treatment facilities have not implemented tobaccofree or smokefree policies.75 Comprehensive 

smokefree policies have been shown to effectively 

reduce population-level smoking, irrespective of 

socioeconomic status or race/ethnicity.80 Because 

environments that are smokefree and norms that 

reduce the social acceptability of smoking motivate 

smokers to quit and make it easier for them to do 

so,7,76,77 the lack of such environments and norms 

poses a barrier to cessation. State tobacco control 

programs can also increase cessation among 

population subgroups that make fewer quit attempts 

or are less likely to quit successfully by ensuring 

that settings where they spend time are smokefree. 

For example, state programs can seek to ensure 
50

Section A: Cessation Interventions

that comprehensive state and local smokefree 

policies are fully implemented in all workplaces, 

and can work with primary and behavioral health 

care organizations serving these populations 

to implement tobacco-free campus policies. 

In jurisdictions where comprehensive smokefree 

policies have already been implemented, other 

efforts can be made to encourage cessation, 

including the establishment of smokefree private 

settings, such as homes (including multiunit 

housing) and vehicles; and tobacco price 

increases, which motivate smokers to quit, and 

which low-income populations are especially 

responsive to. Increasing tax rates on tobacco 

products and dedicating a portion of the resulting 

revenue to fund cessation services for lowincome populations can be an effective way to 

increase cessation in these populations.6,81

As illustrated in some of the examples cited 

above, lower quit rates in certain populations are 

often driven in part by reduced access to and use 

of evidence-based cessation treatments, which 

in turn results in less success in quitting.12,14 One 

important way to improve cessation outcomes in 

populations with lower quit rates is to provide 

these populations with comprehensive cessation 

coverage.6,14,37 Reducing barriers to accessing 

proven cessation treatments, including language 

and cost barriers, would be expected to increase 

quit attempts, use of effective cessation treatments, 

and success in quitting in these populations.6,14,37

Providing comprehensive state Medicaid coverage 

would have a substantial impact, and is one 

of the most important steps a state can take to 

increase cessation and reduce tobacco use.37,43–45

Another effective approach is to conduct 

outreach and education to ensure that health care 

organizations serving these vulnerable populations 

with high smoking rates, such as federally qualified 

health centers, mental health care facilities, and 

substance abuse treatment facilities, integrate 

tobacco dependence treatment into routine health 

care delivery. Additionally, state tobacco control 

programs can address population disparities by 

conducting targeted outreach to increase the state 

quitline’s reach to underserved populations with 

high smoking rates. This can include promoting 

national quitline resources developed to assist these 

populations, such as the national Spanish-language 

quitline portal 1-855-DÉJELO-YA (1-855-335-

3569) and the national Asian-language quitline.

Budget

Promoting Health Systems 

Change/Expanding Cessation 

Insurance Coverage

The tobacco control goal of health systems 

change is to increase health care providers’ identification of and intervention with patients who 

smoke. Because more than 80% of smokers see 

a physician each year, the clinical setting is an 

important channel for motivating smokers to 

quit and for delivering evidence-based cessation treatments. In addition, as noted previously, 

by removing barriers to accessing effective cessation treatments, expanding cessation insurance 

coverage increases the number of smokers who 

attempt to quit, who use effective treatments, and 

who successfully quit. As a result, it is important for state tobacco control programs to work 

with health systems as part of a comprehensive 

approach to encourage and help smokers to quit.

The budget recommendation for the state 

program for this component includes $150,000 

per state, in addition to $17,850,000 allocated 

across states in proportion to total population, for 

grants to selected health care organizations, health 

insurers, and employers to evaluate cessation 

interventions, document the results, including 

cost-effectiveness and return on investment, and 

develop and disseminate reports on the findings.

Efforts to promote health systems change and 

expand cessation insurance coverage are demanding 

and time-intensive, requiring a sophisticated 

understanding of tobacco cessation and health care 

systems and sustained relationship-building with 

health care organizations, health insurers, and the 

state Medicaid program. Therefore, it is important 

to ensure that the tobacco control program’s 

staff includes a dedicated, full-time cessation 

coordinator to oversee its cessation efforts, as well 

as additional staff and/or contractual personnel 

to conduct academic detailing and outreach to 

health care systems and insurers and to conduct 

data collection and analysis around cessation 

interventions and outcomes, including examining 

data from electronic health records and claims data.
51

Section A: Cessation Interventions

Supporting State Quitline Capacity

The goal of state quitlines is to provide a convenient, readily accessible, evidence-based 

cessation service for smokers who want help 

quitting, a referral option for health care organizations and providers, and a clearinghouse for 

other cessation resources. Budget recommendations for this component are based on the percent 

of a state’s smokers calling the state quitline (or 

other quitlines that health plans or employers 

have contracted with) for assistance each year, 

with a lower bound of 8% (minimum level) and 

an upper bound of 13% (recommended level).

These parameters are based on the level of reach 

recommended in Best Practices—2007, combined with the updated assumption that 90% 

of callers will accept counseling and NRT.

These budget recommendations are based 

on offering all callers a single 10-minute reactive 

call and offering callers who are uninsured, 

underinsured, or enrolled in state insurance 

marketplaces or Medicaid three additional proactive 

counseling calls. The recommendations assume 

that callers who accept counseling will be provided 

with a total of four calls at a cost of $45.60 per 

call and that callers who accept medication will 

be provided with 2 weeks of NRT patches or gum 

at a cost of $38.00 per caller, with these estimates 

being based on state experience. In order to 

support population-based interventions such as 

smokefree policies and mass-media campaigns, state 

tobacco control programs may want to consider 

covering the cost of providing the initial reactive 

call during periods when such interventions are 

being implemented. During periods when such 

interventions are not being implemented, state 

quitlines can shift the cost of the initial call to other 

payers, except for uninsured and underinsured 

callers and callers enrolled in insurance through 

the state marketplaces and Medicaid. 

It is assumed that the state program will cover 

100% of the cost of providing the three proactive 

counseling calls to uninsured callers, underinsured 

callers, and callers who are enrolled in state 

insurance marketplaces and 50% of the cost of 

providing counseling to Medicaid callers, on the 

basis of the state quitline securing the 50% federal 

match for quitline counseling provided to Medicaid 

enrollees. In addition, it is assumed that the state 

tobacco control program will cover 100% of the 

cost of providing 2 weeks of NRT (patches or gum) 

to callers who are uninsured, underinsured, or 

enrolled in insurance through state marketplaces 

or Medicaid. Finally, it is assumed that other callers 

will have the costs of the three proactive quitline 

counseling calls and the 2 weeks of NRT borne 

by their payers. The payer will vary depending on 

the callers’ insurance coverage, the quitline they 

call, and whether the state quitline has developed 

public-private partnerships with health plans and/

or employers and secured the federal match for 

quitline counseling provided to Medicaid enrollees. 

Providing Cessation Services Via 

Other Technologies

Emerging technologies, such as text messaging, 

Web, and social media interventions, could potentially extend the reach and increase the impact of 

quitlines by complementing telephone cessation 

assistance with quitting motivation and support 

delivered through other modalities.14 These interventions are in some ways more convenient and 

readily accessible than quitlines and might engage 

young adult smokers, who may be especially 

likely to use these technologies and may prefer 

receiving cessation support through these familiar channels.6,14 Budget recommendations for this 

component of the report are based on a fixed cost 

of $135,000 per state. Because these communication channels may continue to evolve and expand 

over time, it is important for state tobacco control programs to annually assess whether it may be 

cost-effective to increase this funding level to meet 

their goals. 
52

Section A: Cessation Interventions

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31. Linder JA, Rigotti NA, Schneider LI, Kelley JHK, 

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39. McMenamin SB, Halpin HA, Ibrahim 

JK, Orleans CT. Physician and enrollee 

knowledge of Medicaid coverage for tobacco 

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40. McMenamin SB, Halpin HA, Bellows NM. 

Knowledge of Medicaid coverage and effectiveness 

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Preventive Medicine 2006;31(5):369–74.

41. Keller PA, Christiansen B, Kim SY, Piper ME, 

Redmond L, Adsit R, Fiore MC. Increasing 

consumer demand among Medicaid enrollees for 

tobacco dependence treatment: the Wisconsin 

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Wetherell L, Kaufmann R, Zhang L, Malarcher 

A, Pechacek T, Keithly L. Medicaid coverage 

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Massachusetts and associated decreases in 

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44. Land T, Rigotti NA, Levy DE, Paskowsky M, Warner 

D, Kwass JA, Wetherell L, Keithly L. A longitudinal 

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treatments in Massachusetts and associated 

decreases in hospitalizations for cardiovascular 

disease. PLoS Med 2010;7(12):e1000375. 

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of a Medicaid tobacco cessation program in 

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46. University of Wisconsin Center for Tobacco 

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Selected Tobacco, Prevention, and Public Health 

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Care and Education Reconciliation Act of 2010, 

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49. Armour BS, Finkelstein EA, Fiebelkorn IC. Statelevel Medicaid expenditures attributable to 

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Wong S, Cowling D, Gamst A. Quitline utilization 

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54. Rabius V, Wiatrek D, McAlister AL. African 

American participation and success in telephone 

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55. Zhu SH, Wong S, Stevens C, Nakashima D, Gamst 

A. Use of smokers’ quitline by Asian language 

speakers: results from 15 years of operation in 

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56. Miller CL, Sedivy V. Using a quitline plus low-cost 

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57. Hollis JF, McAfee TA, Fellows JL, et al. The effectiveness 

and cost effectiveness of telephone counseling 

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SK, Villars P, Rabius V, McAfee T. Promoting primary 
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J, Baker T, Fiore MC. Changes in tobacco 

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JL, McClure J, Cushing C. Impact of a free nicotine 

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67. Schillo BA, Wendling A, Saul J, Luxenberg MG, Lachter 

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56

IV. Surveillance and Evaluation 

Justification 

Publicly financed programs need to have accountability and demonstrate effectiveness, as well 

as have access to timely data that can be used 

for program improvement and decision making. 

Therefore, a critical infrastructure component of 

any comprehensive tobacco control program is a 

surveillance and evaluation system that can monitor and document key short-term, intermediate, 

and long-term outcomes within populations.1,2 Data 

obtained from surveillance and evaluation systems 

can be used to inform program and policy direction, demonstrate program effectiveness, ensure 

accountability to those with fiscal oversight, and 

engage stakeholders.2-6

Surveillance and evaluation planning may 

be integrated into the overall strategic plan of 

a comprehensive tobacco control program and 

be compatible and comparable with systems in 

other states and nationally.2 A strategic plan, with 

well-defined goals, objectives, and outcomes, 

requires appropriate data collection methods that 

can monitor the program, as well as evaluate 

key outcome indicators in a valid manner.7

Additionally, the collection of baseline data 

related to each objective and outcome indicator 

is critical to ensuring that program-related effects 

can be clearly measured.3,5 For this reason, 

surveillance and evaluation systems must have 

priority in the strategic planning process.

Surveillance 

Surveillance is the process of continuously monitoring attitudes, behaviors, and health outcomes 

over time.8 Although data gathered by surveillance 

systems can be useful for evaluation, they serve 

other purposes besides evaluation. For example, 

data collection for the purposes of evaluation is 

more flexible than for surveillance and may allow 

program areas to be assessed in greater depth. 

Statewide tobacco control surveillance programs 

should consider monitoring the achievement of the 

four overarching goals of comprehensive tobacco 

control programs:

 Preventing initiation among youth and 

young adults 

 Promoting quitting among adults and youth

 Eliminating exposure to secondhand smoke

 Identifying and eliminating tobacco-related 

disparities among population groups

Implementing state surveillance systems, 

such as the Behavioral Risk Factor Surveillance 

System (BRFSS), Youth Risk Behavior Surveillance 

System (YRBSS), Pregnancy Risk Assessment 

Monitoring System (PRAMS), and the Adult or 

Youth Tobacco Surveys (ATS, YTS), affords each 

state the opportunity to collect data on tobacco 

use behaviors and other important risk factors and 

health outcomes.9–11 Data from these systems also 

allow a state to compare its individual program 

impact and long-term tobacco indicators with other 

states as well as with national benchmarks from 

national surveillance systems. In addition to the 

standard core questions included in these surveys, 

there is flexibility to add state-specific questions 

and modules. States also have the flexibility to 

increase sample size in order to capture local 

and specific population data or to provide more 

data on intermediate performance outcomes. 

Evaluation 

Evaluation has been defined as the systematic 

collection of information about the activities, 

characteristics, and results of programs to make 

judgments about the program, improve or further 

develop program effectiveness, inform decisions 

about future programming, and/or increase 

understanding.12 Evaluation data can be used for 

assessing the effectiveness of individual program 

activities, program improvement, decision making, 

and to engage stakeholders. However, in order to 

do all these things, a written evaluation plan must 

first be integrated with the overall strategic plan. 

An effective evaluation plan:13

 Is collaboratively developed with a 

stakeholder workgroup

 Is responsive to program changes and priorities

 Covers multiple years if projects are ongoing
57

Section A: Surveillance and Evaluation

 Addresses the entire program rather 

than focusing on a single funding 

source, objective, or activity 

States can also consider publishing their 

evaluation results in order to contribute to 

the scientific literature on best practices 

for tobacco control programs.7

A typical approach to evaluation in public 

health is to design data-collection systems that 

monitor progress toward meeting a program’s 

process and outcome objectives.8 Process 

evaluations are used to document how well a 

program has been implemented and are conducted 

periodically during a program.8 This type of an 

evaluation is used to examine the program’s 

operations, including which activities are taking 

place, who is conducting the activities, and who 

is reached through the activities. In contrast, 

outcome evaluations are used to assess the 

effectiveness of a program on the stated shortterm, intermediate, and long-term objectives.8

This type of evaluation assesses what has 

occurred because of the program and whether 

the program has achieved its objectives. 

The program’s stages of development must be 

considered in the evaluation plan, particularly when 

determining the appropriate evaluation questions. 

Outcome evaluations are best conducted only 

when the program is mature enough to produce 

the intended outcome. However, consideration 

for future evaluations can be included in the 

evaluation plan so that programs can prepare 

datasets and baseline information for evaluations 

that consider more distal impacts and outcomes.14

An evaluation plan can include both process 

and outcome evaluation questions at the same 

time.14 Program evaluation also requires that a wide 

range of short-term, intermediate, and long-term 

indicators of program effectiveness be measured, 

including changes in policies, social norms, and 

exposure of individuals and communities to 

statewide and local program efforts. For example, 

evaluation efforts might include countermarketing 

surveillance to track new products and examine 

the impact of pro-tobacco influences, including 

tobacco product marketing, pricing, and promotion. 

Additional indicators for program evaluation 

can include, but need not be limited to, vital 

statistics, quitline utilization, policy compliance 

and enforcement, air quality, or media related 

measures. Practice-based criteria to be considered 

in the selection of indicators for monitoring and 

evaluation have previously been listed elsewhere.15

Qualities of Effective Program Evaluations2,13,16

 Ongoing and include a written evaluation plan that is 

integrated with the program’s overall strategic plan.

 Flexible, adaptive, transparent, and designed to inform 

and engage stakeholders at each step, including 

implementation, interpretation, dissemination, and 

utilization of results.

 Focus on priority evaluation questions and not special 

research interests or what is easiest to implement.

 Confirm that the methods align with the evaluation 

questions and objectives.

 Identify credible evidence and verify its accuracy and 

appropriateness with stakeholders.

 Make effective use of surveillance data by linking 

statewide and local program efforts to monitor progress 

toward program objectives.

 Plan for dissemination and sharing of lessons learned 

throughout the evaluation process. 

 Include technical assistance to disseminate information 

on how to implement effective evaluations to funded 

sites, partners, stakeholders, and local programs. 
58

Section A: Surveillance and Evaluation

Selected Surveillance and 

Evaluation Resources

Surveillance and evaluation can be conducted 

simultaneously.8 To assess tobacco-use prevention 

and control efforts adequately, states will usually 

need to supplement surveillance data with data 

collected to answer specific evaluation questions. 

States can collect data on, for example, knowledge, 

attitudes, behaviors, and environmental indicators. 

They can also collect information on infrastructure, 

program planning, and implementation to 

document and measure the effectiveness of a 

program, including its policy and media efforts. 

Some existing tools for both surveillance and 

evaluation at the state and national levels include: 

Adult Tobacco Survey (ATS): ATS is a state level 

landline and cellular telephone survey of adults 

aged 18 years or older.17 Core questions assess 

adults’ knowledge, attitudes, and behaviors related 

to tobacco use, secondhand smoke exposure, use 

of cessation assistance, and their awareness of and 

support for evidence-based policy interventions. 

In addition to these core questions, ATS 

allows for the inclusion of questions addressing 

state-specific program activities. CDC’s Key 

Outcome Indicators for Evaluating Comprehensive 

Tobacco Control Programs was used to inform the 

development of the ATS survey.1 CDC’s Office on 

Smoking and Health can provide technical assistance 

to states regarding the administration of ATS.

Behavioral Risk Factor Surveillance System (BRFSS):

BRFSS is a state-based telephone survey of noninstitutionalized U.S. adults aged 18 years or older 

that CDC initiated in 1984.9 Data are currently collected annually in all 50 states, the District of 

Columbia, and five U.S. territories. With assistance 

from CDC, state health departments contract with 

telephone call centers to conduct BRFSS surveys 

continuously throughout the year using a standardized core questionnaire and optional modules 

plus additional state-added questions. Beginning in 

2011, several enhancements were made to BRFSS 

to ensure optimal survey coverage and validity, 

including the addition of cellular telephone households and improvements to the sampling methods 

and statistical weighting.18

National Adult Tobacco Survey (NATS): NATS is a 

landline and cellular phone survey of U.S. adults 

aged 18 years or older.19 NATS was first conducted 

during 2009–2010, and the sample was designed 

to provide data representative at both national 

and state levels.19 Additional waves of NATS were 

fielded in 2012-2013 and 2013-2014 in collaboration 

with FDA; however state-level estimates will only 

be obtainable during 2009-2010.

National Youth Tobacco Survey (NYTS): NYTS is 

a nationally representative school-based survey 

of youth in middle school (grades 6–8) and high 

school (9–12).20 NYTS cannot be used to obtain 

state-level estimates, but estimates from the survey can serve as a national benchmark for those 

obtained from state YTS surveys. NYTS is a multitopic survey that includes measures that assess 

tobacco use, cessation, knowledge and attitudes, 

access, media and advertising, and secondhand 

smoke exposure.1

 Survey years include 2000, 2002, 

2004, 2006, 2009, 2011, and 2012. As of 2012, 

NYTS will be fielded annually until 2017 in collaboration with FDA.

Pregnancy Risk Assessment Monitoring System 

(PRAMS): PRAMS is a surveillance system that 

CDC and state health departments have conducted 

in multiple phases since 1987; PRAMS data were 

most recently collected in 2011.11 PRAMS collects 

state-specific, population-based data on maternal attitudes and experiences before, during, and 

shortly after pregnancy. The PRAMS questionnaire 

comprises two parts, including core questions 

that are asked by all states and a pretested list of 

standard questions that CDC or individual states 

develop. The core PRAMS questionnaire includes 

questions on maternal tobacco consumption. 

Quitline Minimum Data Set (MDS): The quitline 

MDS identifies a recommended set of indicators to 

assist in assessing telephone quitline performance, 

improving the quality of telephone quitlines, 

identifying knowledge gaps, and designing new 

strategies to fill the identified gaps.21

State Tobacco Activities Tracking and Evaluation 

(STATE) System: The STATE System is an online 

data warehouse that includes epidemiologic data 

on many long-term key outcome indicators, as 

well as economic data and tobacco-related state 

legislation.22

Tobacco Use Supplement to the Current Population Survey (TUS-CPS): TUS-CPS is an in-person 

and telephone survey of U.S. adults aged 18 

years and older that was administered during 

1992–1993, 1995–1996, 1998–1999, 2002–2003, 
59

Section A: Surveillance and Evaluation

2006–2007, and 2010–2011; the next wave is 

slated for 2014–2015.23 These tobacco-use modules provide national and state-specific estimates 

on factors such as tobacco use, quit attempts, 

secondhand smoke exposure, smokefree policies, and clinician cessation counseling.

Youth Risk Behavior Surveillance System (YRBSS):

YRBSS is a national school-based survey of middle 

and high school students conducted biennially by 

CDC.10 YRBSS also includes state, territorial, tribal,

and local surveys conducted by state, territorial,

and local education and health agencies and tribal

governments. YRBSS monitors six types of healthrisk behaviors that contribute to leading causes

of death and disability among youth and adults,

including tobacco use.

Youth Tobacco Survey (YTS): YTS is a schoolbased, state-level survey of students in grades 

6–12.24 Core questions assess students’ knowledge, 

attitudes, and behaviors related to tobacco use and 

exposure to secondhand smoke, as well as their 

exposure to prevention curricula, community programs, and media messages aimed at preventing 

and reducing youth tobacco use. In addition to 

the core set of questions, YTS allows for the inclusion of questions addressing state-specific program 

activities. CDC’s Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs 

was used to inform the development of the YTS 

survey.1

 CDC’s Office on Smoking and Health can 

provide technical assistance to states regarding the 

administration of YTS.

In addition to the previously described 

surveillance and evaluation tools, several resources 

are available to provide guidance and support 

to states on the selection and implementation of 

appropriate surveillance and evaluation data systems. 

Surveillance and Evaluation Resources 

 Surveillance and Data Resources for Comprehensive 

Tobacco Control Programs provides a summary 

of tobacco-related measures, sampling frames, and 

methodology for multiple national and state surveys 

as well as tools for use in conducting surveillance and 

evaluation efforts.25

 Introduction to Program Evaluation for 

Comprehensive Tobacco Control Programs is 

a “how-to” guide for planning and implementing 

evaluation activities.8

 Key Outcomes Indicators for Evaluating 

Comprehensive Tobacco Control Programs provides 

information on selecting evidence-based indicators and 

linking them to program outcomes.1

 Introduction to Process Evaluation in Tobacco Use 

Prevention and Control provides guidance to states 

on how to evaluate inputs, activities, and outputs of a 

tobacco control logic model.26

 Developing an Effective Evaluation Plan can help 

public health program managers, administrators, and 

evaluators develop an effective evaluation plan in the 

context of the planning process. It is intended to be 

used along with other evaluation resources and is not 

a complete resource on how to implement program 

evaluation.13 For example, disseminating surveillance 

and evaluation findings in brief updates or newsletters 

to key stakeholders may also be beneficial. 

 Developing an Effective Evaluation Reportcan help 

public health program managers, administrators, and 

evaluators develop an effective evaluation report. It is 

intended to be used along with other evaluation resources 

and is not a complete resource on how to write reports or 

communicate and use your evaluation results.14

 Impact and Value: Telling Your Program’s 

Story offers public health program managers 

practical steps for creating success stories 

that highlight their achievements.27
60

Section A: Surveillance and Evaluation

State-Level Examples

Surveillance and evaluation data can be used by 

states in multiple ways to help inform and sustain 

comprehensive state tobacco control programs. For 

example, states can collect their own state-level 

surveillance and evaluation data using previously 

developed instruments and resources, supplement existing surveillance systems with indicators 

related to specific state tobacco control program 

objectives, or utilize secondary data sources to 

assess key indicators and make comparisons with 

other states or national benchmarks. Examples of 

some recent state-level surveillance and evaluation 

activities are described below. 

The New York Tobacco Control Program 

has fielded variations of the ATS and YTS 

questionnaires regularly for more than a decade. 

The program utilizes these data to provide 

a comprehensive summary of multiple key 

outcomes indicators in its annual Independent 

Evaluation Report.28 These reports help to 

clearly and objectively illustrate the impact that 

the state tobacco control program has had on 

key outcome indicators, as well as to highlight 

gaps that need to be addressed in the future. 

Multiple states supplement the core BRFSS 

questionnaire with optional modules to inform 

state-level tobacco control program efforts.9

For example, in 2011, two optional modules 

pertaining to smoking cessation and secondhand 

smoke were proposed and ratified. The 

smoking cessation module was administered 

by Arizona, Guam, Kentucky, Louisiana, 

Maryland, and Nebraska; the secondhand 

smoke module was administered by Guam, 

Indiana, Kentucky, Louisiana, and Mississippi. 

The Public Health Division of the Wyoming 

Department of Health recently utilized statelevel data from the 2009–2010 NATS to measure 

progress toward attaining the objectives of 

Wyoming’s Tobacco Prevention and Control 

Program. A summary of the findings were 

described in a comprehensive report organized 

according to CDC’s four overarching goals for 

comprehensive tobacco control programs.7,29

Achieving Equity to Eliminate 

Tobacco-Related Disparities 

Dissemination of surveillance and evaluation 

data that show disparities can be very effective 

in mobilizing community involvement. In order 

to develop effective interventions and monitor 

progress, most states need more information on 

populations disproportionately affected by tobacco 

use.7 Many of the surveillance and evaluation 

resources described in this report include 

questions related to population characteristics 

for which tobacco-related disparities have been 

shown to exist, including but not limited to: 

race/ethnicity, educational attainment, income, 

occupation, geographic location, sex, age, sexual 

orientation and gender identity, veteran and 

military status, disability status, mental health 

status, and substance abuse conditions. 

However, it is important to note that existing 

surveillance and evaluation methods may 

not provide adequate sample size or enough 

information to fully characterize health disparities 

related to tobacco use. Therefore, additional data 

collection systems or approaches may be needed. 

For example, the use of oversampling, combining 

multiple years of data, and qualitative methods 

are often necessary to adequately assess these 

outcomes among some population groups. 
61

Section A: Surveillance and Evaluation

Budget

All federally funded tobacco prevention and control programs are expected to engage in strategic 

surveillance and program evaluation activities. To 

accomplish this, best practices dictate that 10% 

of total annual tobacco control program funds be 

allocated for surveillance and evaluation. 

It is important that tobacco control programs 

develop and maintain the appropriate infrastructure 

to enhance their surveillance and evaluation 

resources as needed. For example, conducting a 

detailed evaluation of a specific intervention, such 

as a cohort study to assess the effectiveness of 

a media campaign, can be resource intensive.7,30

Similarly, additional resources beyond the 

standard 10% of tobacco control program funds 

may also be required for developing increased 

technical capacity of local programs to perform 

process and outcome evaluation.7,30 For example, 

in California, every grantee was required to 

spend 10% of its budget on evaluating its own 

activities. To aid this activity, the state program 

published a directory of evaluation consultants 

and funded a local program evaluation center that 

provides technical assistance to contractors.31

In addition, programs may need to be flexible 

in shifting funding to address new and emerging 

products or trends of public health concern. 

For example, recent increases in electronic 

cigarette marketing and use warrant targeted 

surveillance, monitoring, and evaluation that 

may not have been recognized if a program’s 

plan was developed several years ago.

Realizing the national goal of eliminating 

tobacco-related disparities will require improved 

collection and use of standardized data to correctly 

identify disparities in both health outcomes and 

interventional efficacy.7 Accordingly, additional 

resources may also be required to fund data 

collection mechanisms and standardized systems 

to better characterize health disparities related 

to tobacco use among special populations 

and to effectively measure progress.
62

Section A: Surveillance and Evaluation

References

1. Starr G, Rogers T, Schooley M, Porter S, Wiesen E, 

Jamison N. Key Outcome Indicators for Evaluating 

Comprehensive Tobacco Control Programs. Atlanta: 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2005.

2. Lavinghouze R, Snyder K. Developing your 

evaluation plans: a critical component of public 

health program infrastructure. American Journal 

of Health Education 2013;44(4):237–43.

3. Giovino GA, Biener L, Hartman AM, Marcus 

SE, Schooley MW, Pechacek TF, Vallone D. 

Monitoring the tobacco use epidemic. I. Overview: 

optimizing measurement to facilitate change. 

Preventive Medicine 2009;48(1 Suppl):4S–10S.

4. Institute of Medicine. Ending the Tobacco 

Problem: A Blueprint for the Nation. Washington: 

National Academies Press, 2007.

5. World Health Organization (WHO). WHO Report on 

the Global Tobacco Epidemic, 2008: The MPOWER 

Package. Geneva, Switzerland: WHO, 2008. 

6. Lavinghouze R, Snyder K, Rieker P, Ottoson J. 

Consideration of an applied model of public 

health program infrastructure. Journal of Public 

Health Management and Practice 2013;19(6):E28–

E37. DOI: 10.1097/PHH.0b013e31828554c8. 

7. Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control 

Programs—October 2007. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2007.

8. MacDonald G, Starr G, Schooley M, Yee SL, Klimowski 

K, Turner K. Introduction to Program Evaluation for 

Comprehensive Tobacco Control Programs. Atlanta: 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2001.

9. Centers for Disease Control and Prevention. Behavioral 

Risk Factor Surveillance System; <http://www.

cdc.gov/brfss/>; accessed: December 2, 2013.

10. Centers for Disease Control and Prevention. 

Youth Risk Behavior Surveillance System; 

<http://www.cdc.gov/HealthyYouth/yrbs/

index.htm>; accessed: December 2, 2013.

11. Centers for Disease Control and Prevention. Pregnancy 

Risk Assessment Monitoring System; <http://www.

cdc.gov/PRAMS/>; accessed: December 2, 2013.

12. Patton, MQ. Utilization-Focused Evaluation. 4th 

ed. Los Angeles: Sage Publications, 2008.

13. Centers for Disease Control and Prevention. 

Developing an Effective Evaluation Plan. Atlanta: 

U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, Division 

of Nutrition, Physical Activity, and Obesity, 2011.

14. Centers for Disease Control and Prevention. 

Developing an Effective Evaluation Report. Atlanta: 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, Division 

of Nutrition, Physical Activity and Obesity, 2013.

15. MacDonald, G. Criteria for Selection of HighPerforming Indicators: A Checklist to Inform 

Monitoring and Evaluation; <http://www.wmich.edu/

evalctr/checklists/>; accessed: December 2, 2013. 

16. Lavinghouze SR, Price AW, Smith KA. The program 

success story: a valuable tool for program evaluation. 

Health Promotion Practice 2007;8(4):323–31.

17. McClave AK, Whitney N, Thorne SL, Mariolis P, 

Dube SR, Engstrom M. Adult Tobacco Survey—19 

states, 2003–2007. Morbidity and Mortality Weekly 

Report Surveillance Summary 2010;59(SS3):1–75.

18. Centers for Disease Control and Prevention. 

Methodologic changes in the Behavioral Risk 

Factor Surveillance System in 2011 and potential 

effects on prevalence estimates. Morbidity and 

Mortality Weekly Report 2012;61(22):410–3.

19. King BA, Dube SR, Tynan MA. Current tobacco 

use among adults in the United States: findings 

from the National Adult Tobacco Survey. American 

Journal of Public Health 2012;102(11):e93–e100. 

20. Centers for Disease Control and Prevention. 

National Youth Tobacco Survey; <http://www.

cdc.gov/tobacco/data_statistics/surveys/

nyts/>; accessed: December 2, 2013.

21. North American Quitline Consortium. 

Quitline Minimal Data Set; <http://www.naquitline.

org/?page=mds>; accessed: December 2, 2013.

22. Centers for Disease Control and Prevention. 

State Tobacco Activities Tracking and Evaluation 
63

Section A: Surveillance and Evaluation

(STATE) System; <http://www.cdc.gov/tobacco/

statesystem>; accessed: December 2, 2013.

23. National Cancer Institute. Tobacco 

Use Supplement to the Current Population 

Survey; <http://riskfactor.cancer.gov/studies/

tus-cps/>; accessed: December 2, 2013.

24. Centers for Disease Control and Prevention. 

Youth Tobacco Survey; <http://www.cdc.

gov/tobacco/data_statistics/surveys/YTS/

index.htm>; accessed: December 2, 2013.

25. Yee SL, Schooley M. Surveillance and 

Evaluation Data Resources for Comprehensive 

Tobacco Control Programs. Atlanta: Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2001.

26. Centers for Disease Control and Prevention. 

Introduction to Process Evaluation in Tobacco Use 

Prevention and Control. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2008.

27. Centers for Disease Control and Prevention. 

Impact and Value: Telling Your Program’s Story. 

Atlanta: Centers for Disease Control and Prevention, 

National Center for Chronic Disease Prevention and 

Health Promotion, Division of Oral Health, 2007.

28. New York State Department of Health. 

Reports, Brochures, and Fact Sheets; <http://

www.health.ny.gov/prevention/tobacco_

control/reports_brochures_fact-sheets.

htm>; accessed: December 2, 2013.

29. Wyoming Survey and Analytic Center. 2010 

Wyoming National Adult Tobacco Survey Report; 

< http://wysac1.uwyo.edu/wysac/ReportView.

aspx?DocId=529&A=1>; accessed: December 2, 2013. 

30. World Health Organization European Working Group 

on Health Promotion Evaluation. Health Promotion 

Evaluation: Recommendations to Policy-makers: 

Report of the WHO European Working Group on Health 

Promotion Evaluation. Copenhagen, Denmark: World 

Health Organization, Regional Office for Europe, 1998.

31. Roeseler A, Hagaman T, Kurtz C. The 

use of training and technical assistance to 

drive and improve performance of California’s 

Tobacco Control Program. Health Promotion 

and Practice 2011;12(6 Suppl 2):130S–143S. 
64

V. Infrastructure, Administration, 

and Management 

Justification 

A comprehensive tobacco control program requires 

considerable funding to implement; therefore, a 

fully functioning infrastructure must be in place in 

order to achieve the capacity to implement effective interventions.1–6 Sufficient capacity is essential 

for program sustainability, efficacy, and efficiency, 

and enables programs to plan their strategic 

efforts, provide strong leadership, and foster collaboration among the state and local tobacco control 

communities. An adequate number of skilled 

staff is also necessary to provide or facilitate program oversight, technical assistance, and training. 

Staff resources dedicated to administration 

and management of infrastructure development 

and maintenance activities include:1

 Engaging in strategic planning to guide program 

efforts and resources to accomplish their goals

 Recruiting and developing qualified and diverse 

technical, program, and administrative staff

 Awarding and monitoring program contracts 

and grants, coordinating implementation 

across program areas, and assessing 

grantee program performance 

 Developing and maintaining a realtime fiscal management system

 Increasing capacity at the local 

level by providing ongoing training 

and technical assistance 

 Coordinating across chronic disease programs 

and with local coalitions and partners

 Educating the public and decision 

makers on the health effects of 

tobacco and effective, evidence-based 

program and policy interventions 

In part due to rising fiscal challenges, an 

increasing number of state health departments 

have taken steps to combine efforts and 

increase efficiency by realigning diseasespecific programs into a coordinated chronic 

disease infrastructure. These steps often 

include developing and implementing crosscutting policies, conducting integrated chronic 

disease surveillance and evaluation, targeting 

interventions toward areas of the state with the 

greatest burden, and developing coordinated 

messaging to reach people with comorbidities. 

Addressing tobacco control strategies in 

the broader context of chronic diseases can 

be beneficial from the standpoint of enhanced 

coordination and efficiencies related to basic 

administrative functions, as well as the potential to 

synergistically increase the reach and efficacy 

of interventions. 

However, the realignment of disease-specific 

programs may also result in the dismantling of 

dedicated staff and resources for state tobacco 

control programs. Potential strategies to reduce 

any adverse impact of infrastructural changes 

on state tobacco control programs include: 

 Establishing or maintaining a full-time 

tobacco control program manager 

 Retaining core staff positions necessary and 

unique to tobacco control interventions

 Developing and sustaining collaborations 

with external partners 

 Expanding staff and partner capacity through 

trainings for state and community staff

 Exploring alternative funding opportunities 

to support staffing for a broad chronic 

disease infrastructure that includes a highly 

functioning tobacco control program
65

Section A: Infrastructure, Administration, and Management

Figure 2. Component Model of Infrastructure (CMI) 

Functioning Infrastructure

Program infrastructure is the foundation that supports program capacity, implementation, and 

sustainability.2–7 The Component Model of Infrastructure (CMI) defines infrastructure in a practical, 

actionable, and evaluable manner so that grant 

planners, evaluators, and program implementers can link infrastructure to capacity, measure 

success, and increase the likelihood for sustainable 

health achievements (See Figure 2). According to 

CMI, functioning program infrastructure includes 

five core components: networked partnerships, 

multilevel leadership, engaged data, managed 

resources, and responsive plans/planning.2-5
66

Section A: Infrastructure, Administration, and Management

Networked Partnerships: Strategic collaboration 

is crucial at the national, state, and local levels. These 

partnerships can be made between multiple types of 

organizations and content areas to promote progress 

toward health goals. Although many partners are 

working towards a common mission, they may fill 

different roles. In this way, networked partnerships 

can work to ensure the accomplishment of all 

activities necessary to achieve public health goals.

Multi-level Leadership: Leaders and champions can 

be identified and nurtured at all levels. This includes 

leadership above the tobacco control program 

in the health department or other organizational 

unit where the program is located; leadership 

within the program beyond the program manager; 

leadership among partners and other chronic 

disease areas; and leadership in local programs. 

Leadership at all levels is necessary to develop 

relationships and to ensure functioning program 

infrastructure and progress toward health goals. 

Engaged Data: Data can be used in a manner 

that engages staff, partners, decision makers, and 

local programs to act. Data should not merely be 

collected and displayed but also used to promote 

public health goals. Therefore, training, technical 

assistance, and follow-through are necessary 

to ensure the proper utilization of data.

Managed Resources: A functional infrastructure 

requires resources beyond financing, including 

an adequate number of staff and partners 

who are qualified and have diverse technical, 

program, and administrative skills. Staff, 

partners, and local programs must also have 

the necessary training and skills to effectively 

implement the tobacco control program.

Responsive Plans/ Planning: Responsive 

strategic plans are dynamic and evolve in response 

to contextual influences, such as changes in 

scientific evidence, priorities, funding levels, 

and external support. In addition, the planning 

process is collaborative and includes viewpoints 

from multiple stakeholders.8 This process 

fosters shared ownership and responsibility 

for the goals and objectives between the state 

program, partners, and local programs.

Multiple states have successfully realized the core 

components of the CMI. For example, Oregon has 

three levels of Networked Partnerships, including local community partners, chronic disease 

areas, and other agencies such as substance abuse 

and mental health treatment facilities. In 2011, 

networked partnerships were instrumental in successfully producing Oregon’s first-ever report on 

how managed care organizations serving Medicaid clients identify tobacco users and provide 

tobacco cessation services, and determine whether 

those services met evidence-based standards. 

Similarly, Utah utilized Multi-level Leadership 

to address cessation via a project addressing the 

health burden of tobacco use among those suffering 

from substance abuse or mental health issues. 

The program developed a leadership team for the 

project that included leaders from the substance 

abuse and mental health programs, as well as local 

health departments, non-profits, clinical directors, 

and clients. They worked with every leader to 

ensure that each felt ownership of the project. 

For Engaged Data, New York developed 

a surveillance and evaluation system using 

program logic models that included evaluation 

data from locally funded programs. Data have 

been used to evaluate the state’s comprehensive 

smokefree law using multiple indicators, including 

hospitality venue sales, indoor air quality, 

biomarkers of secondhand smoke exposure 

in employees, and long term measures such 

as hospital admissions for heart attacks. 

For Managed Resources, Massachusetts 

adheres to a model in which core capabilities 

are kept in house and the rest are outsourced. 

This model includes cross-training and preparing 

staff to move into leadership roles, as well as 

maintaining a robust training program that 

ensures staff and partners’ capabilities grow and 

keep pace with technological advancement. 

Finally, for Responsive Plans/Planning,

Colorado created a flexible, budget- and 

evidence-based, strategic plan that enabled 

their staff to respond to changes, including 

funding reductions. Key components of the plan 

comprised evaluation as well as infrastructure 

development and maintenance, which 

included training and technical assistance.

However, CMI goes beyond the core 

components in its depiction of functioning 

program infrastructure. The five core components 

of the CMI model are enveloped in contextual 

influences as well as supporting components, 
67

Section A: Infrastructure, Administration, and Management

including Strategic Understanding and 

Operations.2–7 This type of framework enables 

a tobacco control program to quickly align 

with strategic plans and partners, irrespective 

of what opportunities or challenges emerge.

The Strategic Understanding component 

encompasses the ideas, guidelines, and thinking 

that initiate, nurture, and sustain infrastructure. 

Core concepts include perception of the problem 

as a public health issue—both among the public 

and decision makers—as well as planning 

for program sustainability at the beginning 

rather than at the end of a funding cycle. A 

sustainability plan can be one of the critical plans 

included under the Responsive Plans/Planning 

component, along with the strategic plan.

The Operations component comprises the 

day-to-day work structures, communications, 

and procedures associated with implementing 

a comprehensive tobacco control program. 

Operations can include roles and responsibilities 

of staff, partners, and local programs, as well as 

a formal and effective communications system. 

This communication system needs to include 

methods for communicating data, evaluation results, 

program operations, funding guidelines, and goals 

and objectives, not only among staff, but also 

within the health department, across connected 

programs and chronic disease areas, and with 

partners, local programs, and decision makers.

Capacity

Capacity is the ability to implement evidencebased interventions.2–4 Once infrastructure is 

built and properly supported, it facilitates the 

capacity to take advantage of opportunities, 

create opportunities, and to defend against 

threats to the achievement of the program goals. 

Building and maintaining the infrastructure to 

support capacity to provide guidance, technical 

assistance, and coordination among programs and 

partners are critical, foundational activities for 

comprehensive tobacco control programs.1–4,9,10

State experience has shown the importance 

of having all of the program’s components 

coordinated and working together. Program 

management and coordination present a 

challenge in that a comprehensive program 

involves multiple state agencies (e.g. public 

health, education, and law enforcement) and 

levels of local government, other public health 

programs, and numerous health-related voluntary 

organizations, coalitions, and community groups. 

Administration and management staff 

provide the stable foundation on which any 

program is built and maintained. Accordingly, 

an adequate number of skilled staff is required 

to fully implement and sustain a comprehensive 

tobacco control program. The exact percentage 

of full time equivalent positions required 

will depend on the state population, current 

tobacco control progress, and program needs. 

However, all programs should consider having 

staff to cover the necessary components of a 

comprehensive tobacco control program.

Ideal Staffing Plan for a 

Comprehensive Tobacco 

Control Program

 Program director.

 Policy coordinator. 

 Communications specialist.

 Cessation coordinator.

 Surveillance and evaluation staff.

 Fiscal management systems staff.

 Administrative staff.

Continued Support

Once a strong, functioning program 

infrastructure is in place, the cumulative 

effect of funding on program effectiveness 

becomes evident. Research shows that the 

longer states invest in comprehensive tobacco 

control programs, the greater and quicker the 

impact.11–13 Because a significant amount of time 

and resources may be required to establish a 

functional infrastructure capable of implementing 

effective tobacco control interventions, it is 

critical to maintain that infrastructure. 

CMI depicts the critical nature of continued 

support and the cyclical nature of maintaining 

functioning program infrastructure and its impact 

on outcomes and sustainability. Sustainability 

has been defined as the “existence of structures 

and processes that allow a program to leverage 

resources to effectively implement and maintain 

evidence-based policies and activities.”10 These 

structures and processes are embodied in the 

core and enveloping components of CMI.
68

Section A: Infrastructure, Administration, and Management

Achieving Equity to Reduce 

Tobacco-Related Disparities

In order to adequately identify and effectively eliminate tobacco-related disparities, 

state tobacco control programs must implement a number of tobacco prevention and 

control strategies, including establishing infrastructure and building capacity.14 These 

strategies help guide the development of policies and practices that reflect the principles of 

inclusion, cultural competency, and equity.

To support achieving equity and reaching 

the goal of identifying and eliminating tobaccorelated disparities, it is crucial that state tobacco 

control programs work to achieve the infrastructure 

and capacity necessary to: conduct surveillance to 

identify populations disproportionately affected by 

tobacco use and disseminate the data; partner with 

population groups disproportionately affected by 

tobacco and the community organizations that serve 

them; ensure that disparity issues are an integral part 

of state and community tobacco control strategic 

plans, fund organizations that can effectively 

reach, involve, and mobilize these populations; 

and provide culturally competent technical 

assistance and training to grantees and partners. 

This guidance highlights the minimum 

infrastructure and capacity needed by state 

tobacco control programs to pursue a strategic 

plan with initiatives that will most effectively 

achieve equity in tobacco prevention and 

control through the identification and 

elimination of tobacco-related disparities.

Budget

Best practices dictate that 5% of total annual 

tobacco control program funds be allocated for 

administration and management of infrastructure development and maintenance activities. This 

budget is for the administration and management 

of infrastructure, not for all infrastructure activities. This might include costs pertaining to office 

expenses, postage and shipping, printing and 

duplication, occupancy expenses, equipment and 

maintenance, training and travel, planning, coordination activities, as well as staff time directly 

related to core planning and program oversight 

functions. 

Because of the importance of maintaining 

functioning infrastructure and the capacity to 

provide guidance, technical assistance, and 

coordination among programs and other key 

partners, the suggested target for administration 

and management of infrastructure activities should 

generally be 5% of a state’s total CDC-recommended 

program budget, even if actual program funding 

is below the CDC-recommended level. 
69

Section A: Infrastructure, Administration, and Management

References

1. Centers for Disease Control and Prevention. 

Best Practices for Comprehensive Tobacco Control 

Programs—October 2007. Atlanta: U.S. Department 

of Health and Human Services, Centers for 

Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, 2007.

2. Lavinghouze SR, Snyder K, Rieker P, Ottsoson 

J. Consideration of an applied model of public 

health program infrastructure. Journal of Public 

Health Management and Practice 2013;19(6):E28–

E37. DOI: 10.1097/PHH.0b013e31828554c8. 

3. Lavinghouze SR. The difficulties and complexities of 

evaluating “inputs”: the forgotten box of the logic 

model. Panel presentation #406 at the TwentyFifth Annual American Evaluation Association 

Conference; November 2011; Anaheim, CA. 

4. Lavinghouze SR. The components of infrastructure: 

A model in progress. Panel presentation #576 at the 

Twenty-Fifth Annual American Evaluation Association 

Conference; November 2011; Anaheim, CA.

5. Lavinghouze, SR, Rieker P, Snyder K. The Component 

Model of Infrastructure (CMI): an infrastructure model 

for evaluating tobacco control programs. Evaluation 

ancillary meeting at the National Conference on 

Tobacco or Health; August 2012; Kansas City, MO.

6. Lavinghouze SR, Snyder K. Developing your 

evaluation plans: a critical component of public 

health program infrastructure. American Journal 

of Health Education 2013;44(4):237–43. 

7. Centers for Disease Control and Prevention. 

Developing an Effective Evaluation Report. Atlanta: 

Centers for Disease Control and Prevention, National 

Center for Chronic Disease Prevention and Health 

Promotion, Office on Smoking and Health, Division 

of Nutrition, Physical Activity and Obesity, 2013.

8. Institute of Medicine. Living Well with Chronic 

Illness: A Call for Public Health Action. Washington: 

The National Academies Press, 2012. 

9. Chapman R. Organization development in 

public health: A foundation for growth. 2010.

10. Schell SF, Luke DA, Schooley MW, Elliott MB, 

Herbers SH, Mueller NB, Bunger AC. Public 

health program capacity for sustainability: 

A new framework. Implementation Science 

2013;8(15). DOI: 10.1186/1748-5908-8-15.

11. Farrelly MC, Pechacek TF, Chaloupka FJ. The 

impact of tobacco control program expenditures 

on aggregate cigarette sales: 1981–2000. Journal 

of Health Economics 2003;22(5):843–59.

12. Farrelly MC, Pechacek TF, Thomas KY, 

Nelson D. The impact of tobacco control 

programs on adult smoking. American 

Journal of Public Health 2008;98(2):304–9. 

13. Farrelly MC, Loomis BR, Han B, Gfroerer J, Kuiper N, 

Couzens GL, Dube SR, Caraballo RS. A comprehensive 

examination of the influence of state tobacco 

control programs and policies on youth smoking. 

American Journal of Public Health 2013;103(3):549–55.

14. Fagan P, King G, Lawrence D, Petrucci SA, Robinson 

RG, Banks D, et al. Eliminating tobacco-related 

health disparities: directions for future research. 

American Journal of Public Health 2004;94(2):211–7. 
70
Section B

Recommended Funding Levels for All 

50 States and the District Of Columbia 
72

Annual Total Funding Levels for State Programs

Total 

Program Costs

State and Community 

Interventions

Mass-Reach Health 

Communication Interventions

Minimum 

(millions)

Recommended 

(millions)

Minimum 

(millions)

Recommended 

(millions)

Minimum 

(millions)

Recommended 

(millions)

United States 2,325.3 3,306.3 856.7 1,071.0 370.1 532.0 

Alabama 39.1 55.9 14.4 18.0 4.2 6.0 

Alaska 7.5 10.2 3.3 4.1 1.0 1.4 

Arizona 45.5 64.4 16.8 20.9 7.9 11.4 

Arkansas 25.9 36.7 10.1 12.7 2.5 3.5 

California 248.6 347.9 99.9 124.9 52.8 76.0 

Colorado 37.4 52.9 13.2 16.4 6.9 9.9 

Connecticut 22.7 32.0 9.1 11.4 2.6 3.7 

Delaware 9.3 13.0 3.4 4.3 2.0 2.8 

District of Columbia 7.8 10.7 3.4 4.2 1.4 2.0 

Florida 135.5 194.2 44.9 56.2 25.9 37.2 

Georgia 74.4 106.0 28.0 35.0 10.4 14.9 

Hawaii 9.9 13.7 4.5 5.6 1.1 1.6 

Idaho 11.3 15.6 4.7 5.8 1.5 2.1 

Illinois 96.3 136.7 36.1 45.2 15.9 22.8 

Indiana 51.2 73.5 18.8 23.5 5.1 7.3 

Iowa 21.3 30.1 8.4 10.5 2.5 3.6 

Kansas 19.8 27.9 8.4 10.5 1.3 1.9 

Kentucky 39.2 56.4 15.2 19.0 2.4 3.5 

Louisiana 41.8 59.6 15.6 19.5 5.7 8.1 

Maine 11.2 15.9 4.1 5.2 1.6 2.3 

Maryland 33.7 48.0 12.8 16.0 3.5 5.0 

Massachusetts 47.0 66.9 16.9 21.2 8.9 12.8 

Michigan 76.9 110.6 28.3 35.4 7.9 11.4 

Minnesota 37.1 52.9 13.5 16.8 5.2 7.5 

Mississippi 25.7 36.5 10.0 12.5 2.9 4.1 

Missouri 50.7 72.9 17.4 21.8 7.5 10.8 

Montana 10.5 14.6 4.0 5.0 2.2 3.1 

Nebraska 14.7 20.8 5.3 6.6 2.5 3.6 

Nevada 21.3 30.0 8.3 10.4 3.4 4.9 

New Hampshire 11.7 16.5 4.0 5.0 2.8 4.1 

New Jersey 72.7 103.3 23.4 29.2 19.1 27.5 

New Mexico 16.3 22.8 7.4 9.3 1.3 1.8 

New York 142.8 203.0 49.3 61.6 31.8 45.7 

North Carolina 69.3 99.3 26.4 33.1 6.8 9.8 

North Dakota 7.0 9.8 2.9 3.7 0.9 1.3 

Ohio 92.0 132.0 34.3 42.9 10.0 14.4 

Oklahoma 29.8 42.3 11.7 14.6 2.4 3.4 

Oregon 27.7 39.3 10.3 12.9 4.1 5.9 

Pennsylvania 97.3 140.0 32.7 40.8 14.8 21.3 

Rhode Island 9.3 12.8 3.8 4.7 1.5 2.1 

South Carolina 35.5 51.0 13.4 16.7 3.2 4.7 

South Dakota 8.5 11.7 3.5 4.4 1.2 1.7 

Tennessee 52.5 75.6 18.7 23.4 5.5 7.9 

Texas 185.8 264.1 68.0 85.0 33.3 47.9 

Utah 13.9 19.3 5.8 7.3 2.3 3.4 

Vermont 6.1 8.4 2.5 3.1 1.1 1.6 

Virginia 63.9 91.6 19.1 23.8 15.4 22.2 

Washington 44.5 63.6 16.4 20.5 6.3 9.1 

West Virginia 19.2 27.4 6.7 8.4 2.6 3.7 

Wisconsin 40.0 57.5 14.7 18.4 4.4 6.4 

Wyoming 6.2 8.5 2.9 3.6 0.6 0.9 
73

Annual Total Funding Levels for State Programs

Cessation 

Interventions

Surveillance 

and Evaluation

Infrastructure, Administration, 

and Management

Minimum 

(millions)

Recommended 

(millions)

Minimum 

(millions)

Recommended 

(millions)

Minimum 

(millions)

Recommended 

(millions)

United States 795.1 1,271.9 202.6 287.7 100.8 143.7 

Alabama 15.4 24.6 3.4 4.9 1.7 2.4 

Alaska 2.2 3.4 0.7 0.9 0.3 0.4 

Arizona 14.8 23.7 4.0 5.6 2.0 2.8 

Arkansas 9.9 15.7 2.3 3.2 1.1 1.6 

California 63.5 101.6 21.6 30.3 10.8 15.1 

Colorado 12.4 19.7 3.3 4.6 1.6 2.3 

Connecticut 8.0 12.7 2.0 2.8 1.0 1.4 

Delaware 2.7 4.2 0.8 1.1 0.4 0.6 

District of Columbia 2.0 3.1 0.7 0.9 0.3 0.5 

Florida 47.0 75.5 11.8 16.9 5.9 8.4 

Georgia 26.3 42.3 6.5 9.2 3.2 4.6 

Hawaii 3.0 4.7 0.9 1.2 0.4 0.6 

Idaho 3.6 5.6 1.0 1.4 0.5 0.7 

Illinois 31.7 50.9 8.4 11.9 4.2 5.9 

Indiana 20.6 33.1 4.5 6.4 2.2 3.2 

Iowa 7.6 12.1 1.9 2.6 0.9 1.3 

Kansas 7.5 11.9 1.7 2.4 0.9 1.2 

Kentucky 16.5 26.5 3.4 4.9 1.7 2.5 

Louisiana 15.1 24.2 3.6 5.2 1.8 2.6 

Maine 4.0 6.3 1.0 1.4 0.5 0.7 

Maryland 13.0 20.7 2.9 4.2 1.5 2.1 

Massachusetts 15.1 24.2 4.1 5.8 2.0 2.9 

Michigan 30.7 49.4 6.7 9.6 3.3 4.8 

Minnesota 13.6 21.7 3.2 4.6 1.6 2.3 

Mississippi 9.5 15.1 2.2 3.2 1.1 1.6 

Missouri 19.2 30.8 4.4 6.3 2.2 3.2 

Montana 2.9 4.6 0.9 1.3 0.5 0.6 

Nebraska 5.0 7.9 1.3 1.8 0.6 0.9 

Nevada 6.8 10.8 1.9 2.6 0.9 1.3 

New Hampshire 3.4 5.3 1.0 1.4 0.5 0.7 

New Jersey 20.7 33.1 6.3 9.0 3.2 4.5 

New Mexico 5.5 8.7 1.4 2.0 0.7 1.0 

New York 43.1 69.2 12.4 17.7 6.2 8.8 

North Carolina 27.1 43.5 6.0 8.6 3.0 4.3 

North Dakota 2.3 3.5 0.6 0.9 0.3 0.4 

Ohio 35.7 57.5 8.0 11.5 4.0 5.7 

Oklahoma 11.8 18.8 2.6 3.7 1.3 1.8 

Oregon 9.7 15.4 2.4 3.4 1.2 1.7 

Pennsylvania 37.1 59.6 8.5 12.2 4.2 6.1 

Rhode Island 2.8 4.3 0.8 1.1 0.4 0.6 

South Carolina 14.3 23.0 3.1 4.4 1.5 2.2 

South Dakota 2.7 4.1 0.7 1.0 0.4 0.5 

Tennessee 21.4 34.4 4.6 6.6 2.3 3.3 

Texas 60.2 96.7 16.2 23.0 8.1 11.5 

Utah 4.0 6.1 1.2 1.7 0.6 0.8 

Vermont 1.7 2.6 0.5 0.7 0.3 0.4 

Virginia 21.0 33.6 5.6 8.0 2.8 4.0 

Washington 16.0 25.7 3.9 5.5 1.9 2.8 

West Virginia 7.4 11.7 1.7 2.4 0.8 1.2 

Wisconsin 15.7 25.2 3.5 5.0 1.7 2.5 

Wyoming 1.9 2.9 0.5 0.7 0.3 0.4 
74

Annual Per Capita Funding Levels for State Programs

Total 

Program Costs

State and Community 

Interventions

Mass-Reach Health 

Communication Interventions

Minimum Recommended Minimum Recommended Minimum Recommended

United States 7.41 10.53 2.73 3.41 1.18 1.69 

Alabama 8.11 11.58 2.99 3.73 0.87 1.24 

Alaska 10.22 14.00 4.51 5.61 1.37 1.91 

Arizona 6.93 9.84 2.56 3.19 1.21 1.74 

Arkansas 8.77 12.44 3.42 4.31 0.85 1.19 

California 6.54 9.15 2.63 3.28 1.39 2.00 

Colorado 7.20 10.20 2.54 3.16 1.33 1.91 

Connecticut 6.30 8.92 2.53 3.18 0.72 1.03 

Delaware 10.15 14.17 3.71 4.69 2.18 3.05 

District of Columbia 12.37 16.91 5.38 6.64 2.21 3.16 

Florida 7.00 10.07 2.32 2.91 1.34 1.93 

Georgia 7.50 10.68 2.82 3.53 1.05 1.50 

Hawaii 7.10 9.84 3.23 4.02 0.79 1.15 

Idaho 7.08 9.73 2.95 3.63 0.94 1.32 

Illinois 7.46 10.61 2.80 3.51 1.23 1.77 

Indiana 7.83 11.24 2.88 3.59 0.78 1.12 

Iowa 6.91 9.81 2.73 3.42 0.81 1.17 

Kansas 6.86 9.68 2.91 3.64 0.45 0.66 

Kentucky 8.96 12.87 3.47 4.34 0.55 0.80 

Louisiana 9.10 12.95 3.39 4.24 1.24 1.76 

Maine 8.38 11.94 3.08 3.91 1.20 1.73 

Maryland 5.73 8.15 2.18 2.72 0.59 0.85 

Massachusetts 7.08 10.08 2.54 3.19 1.34 1.93 

Michigan 7.79 11.19 2.86 3.58 0.80 1.15 

Minnesota 6.91 9.82 2.51 3.12 0.97 1.39 

Mississippi 8.63 12.21 3.35 4.19 0.97 1.37 

Missouri 8.43 12.10 2.89 3.62 1.25 1.79 

Montana 10.42 14.52 3.98 4.97 2.19 3.08 

Nebraska 7.94 11.23 2.86 3.56 1.35 1.94 

Nevada 7.71 10.88 3.01 3.77 1.23 1.78 

New Hampshire 8.88 12.54 3.03 3.79 2.12 3.10 

New Jersey 8.20 11.64 2.64 3.29 2.15 3.10 

New Mexico 7.83 10.91 3.55 4.46 0.62 0.86 

New York 7.29 10.38 2.52 3.15 1.62 2.34 

North Carolina 7.12 10.18 2.71 3.39 0.70 1.00 

North Dakota 10.04 13.98 4.15 5.29 1.29 1.86 

Ohio 7.97 11.45 2.97 3.72 0.87 1.25 

Oklahoma 7.81 11.10 3.07 3.83 0.63 0.89 

Oregon 7.11 10.09 2.64 3.31 1.05 1.51 

Pennsylvania 7.62 10.97 2.56 3.20 1.16 1.67 

Rhode Island 8.88 12.15 3.62 4.47 1.43 2.00 

South Carolina 7.54 10.81 2.84 3.54 0.68 0.99 

South Dakota 10.21 14.07 4.20 5.28 1.44 2.04 

Tennessee 8.12 11.70 2.90 3.62 0.85 1.22 

Texas 7.13 10.13 2.61 3.26 1.28 1.84 

Utah 4.87 6.77 2.03 2.56 0.81 1.19 

Vermont 9.74 13.41 3.99 4.95 1.76 2.56 

Virginia 7.80 11.18 2.33 2.91 1.88 2.71 

Washington 6.45 9.22 2.38 2.97 0.91 1.32 

West Virginia 10.35 14.75 3.61 4.53 1.40 1.99 

Wisconsin 6.99 10.04 2.57 3.21 0.77 1.12 

Wyoming 10.78 14.76 5.03 6.25 1.04 1.56 
75

Annual Per Capita Funding Levels for State Programs

Cessation 

Interventions

Surveillance 

and Evaluation

Infrastructure, Administration, 

and Management

Minimum Recommended Minimum Recommended Minimum Recommended

United States 2.53 4.05 0.65 0.92 0.32 0.46

Alabama 3.19 5.10 0.71 1.01 0.35 0.50

Alaska 3.01 4.65 0.89 1.22 0.44 0.61

Arizona 2.26 3.62 0.60 0.86 0.30 0.43

Arkansas 3.36 5.32 0.76 1.08 0.38 0.54

California 1.67 2.67 0.57 0.80 0.28 0.40

Colorado 2.39 3.80 0.63 0.89 0.31 0.44

Connecticut 2.23 3.54 0.55 0.78 0.27 0.39

Delaware 2.94 4.58 0.88 1.23 0.44 0.62

District of Columbia 3.16 4.90 1.08 1.47 0.54 0.74

Florida 2.43 3.91 0.61 0.88 0.30 0.44

Georgia 2.65 4.26 0.65 0.93 0.33 0.46

Hawaii 2.15 3.38 0.62 0.86 0.31 0.43

Idaho 2.26 3.51 0.62 0.85 0.31 0.42

Illinois 2.46 3.95 0.65 0.92 0.32 0.46

Indiana 3.15 5.06 0.68 0.98 0.34 0.49

Iowa 2.47 3.94 0.60 0.85 0.30 0.43

Kansas 2.60 4.12 0.60 0.84 0.30 0.42

Kentucky 3.77 6.05 0.78 1.12 0.39 0.56

Louisiana 3.28 5.26 0.79 1.13 0.40 0.56

Maine 3.01 4.74 0.73 1.04 0.36 0.52

Maryland 2.21 3.52 0.50 0.71 0.25 0.35

Massachusetts 2.27 3.64 0.62 0.88 0.31 0.44

Michigan 3.11 5.00 0.68 0.97 0.34 0.49

Minnesota 2.53 4.03 0.60 0.85 0.30 0.43

Mississippi 3.18 5.06 0.75 1.06 0.38 0.53

Missouri 3.19 5.11 0.73 1.05 0.37 0.53

Montana 2.89 4.58 0.91 1.26 0.45 0.63

Nebraska 2.69 4.26 0.69 0.98 0.35 0.49

Nevada 2.46 3.91 0.67 0.95 0.34 0.47

New Hampshire 2.57 4.01 0.77 1.09 0.39 0.55

New Jersey 2.34 3.73 0.71 1.01 0.36 0.51

New Mexico 2.64 4.17 0.68 0.95 0.34 0.47

New York 2.20 3.54 0.63 0.90 0.32 0.45

North Carolina 2.78 4.46 0.62 0.89 0.31 0.44

North Dakota 3.29 5.00 0.87 1.22 0.44 0.61

Ohio 3.09 4.98 0.69 1.00 0.35 0.50

Oklahoma 3.09 4.93 0.68 0.97 0.34 0.48

Oregon 2.49 3.95 0.62 0.88 0.31 0.44

Pennsylvania 2.91 4.67 0.66 0.95 0.33 0.48

Rhode Island 2.67 4.09 0.77 1.06 0.39 0.53

South Carolina 3.03 4.87 0.66 0.94 0.33 0.47

South Dakota 3.24 4.92 0.89 1.22 0.44 0.61

Tennessee 3.31 5.33 0.71 1.02 0.35 0.51

Texas 2.31 3.71 0.62 0.88 0.31 0.44

Utah 1.40 2.14 0.42 0.59 0.21 0.29

Vermont 2.72 4.15 0.85 1.17 0.42 0.58

Virginia 2.57 4.10 0.68 0.97 0.34 0.49

Washington 2.32 3.73 0.56 0.80 0.28 0.40

West Virginia 3.99 6.31 0.90 1.28 0.45 0.64

Wisconsin 2.74 4.40 0.61 0.87 0.30 0.44

Wyoming 3.30 5.03 0.94 1.28 0.47 0.64

Section C

Recommended Funding Levels, 

by State 
78

Section C: Recommended Funding Levels, by State

Alabama

Program Intervention Budgets: 2014

Recommended Annual Investment $55.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 8,600

Youth aged 0-17 projected to die from smoking 107,600

Annual Costs Incurred in State from Smoking

Total medical $1,886 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $134.6 million

FY 2012 tobacco settlement payment $93.8 million

Total state revenue from tobacco sales and settlement $228.4 million

Percent Tobacco Revenue to Fund at Recommended Level 24%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$14.4 $18.0 $2.99 $3.73

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$4.2 $6.0 $0.87 $1.24

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $15.4 $24.6 $3.19 $5.10

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.4 $4.9 $0.71 $1.01

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.7 $2.4 $0.35 $0.50

TOTAL $39.1 $55.9 $8.11 $11.58

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
79

Section C: Recommended Funding Levels, by State

Alaska

Program Intervention Budgets: 2014

Recommended Annual Investment $10.2 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 600

Youth aged 0-17 projected to die from smoking 14,000

Annual Costs Incurred in State from Smoking

Total medical $ 438 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $ 71.3 million

FY 2012 tobacco settlement payment $30.0 million

Total state revenue from tobacco sales and settlement $101.3 million

Percent Tobacco Revenue to Fund at Recommended Level 10%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$3.3 $4.1 $4.51 $5.61

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.0 $1.4 $1.37 $1.91

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.2 $3.4 $3.01 $4.65

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.7 $0.9 $0.89 $1.22

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.3 $0.4 $0.44 $0.61

TOTAL $7.5 $10.2 $10.22 $14.00

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
80

Section C: Recommended Funding Levels, by State

Arizona

Program Intervention Budgets: 2014

Recommended Annual Investment $64.4 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 8,300

Youth aged 0-17 projected to die from smoking 115,100

Annual Costs Incurred in State from Smoking

Total medical $2,383 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $337.8 million

FY 2012 tobacco settlement payment $101.1 million

Total state revenue from tobacco sales and settlement $438.9 million

Percent Tobacco Revenue to Fund at Recommended Level 15%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$16.8 $20.9 $2.56 $3.19

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$7.9 $11.4 $1.21 $1.74

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $14.8 $23.7 $2.26 $3.62

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$4.0 $5.6 $0.60 $0.86

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$2.0 $2.8 $0.30 $0.43

TOTAL $45.5 $64.4 $6.93 $9.84

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
81

Section C: Recommended Funding Levels, by State

Arkansas

Program Intervention Budgets: 2014

Recommended Annual Investment $36.7 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 5,800

Youth aged 0-17 projected to die from smoking 68,700

Annual Costs Incurred in State from Smoking

Total medical $1,215 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $245.4 million

FY 2012 tobacco settlement payment $50.5 million

Total state revenue from tobacco sales and settlement $295.9 million

Percent Tobacco Revenue to Fund at Recommended Level 12%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$10.1 $12.7 $3.42 $4.31

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.5 $3.5 $0.85 $1.19

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $9.9 $15.7 $3.36 $5.32

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$2.3 $3.2 $0.76 $1.08

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.1 $1.6 $0.38 $0.54

TOTAL $25.9 $36.7 $8.77 $12.44

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
82

Section C: Recommended Funding Levels, by State

California

Program Intervention Budgets: 2014

Recommended Annual Investment $347.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 40,000

Youth aged 0-17 projected to die from smoking 440,600

Annual Costs Incurred in State from Smoking

Total medical $13,292 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $891.1 million

FY 2012 tobacco settlement payment $735.8 million

Total state revenue from tobacco sales and settlement $1,626.9 million

Percent Tobacco Revenue to Fund at Recommended Level 21%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$99.9 $124.9 $2.63 $3.28

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$52.8 $76.0 $1.39 $2.00

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $63.5 $101.6 $1.67 $2.67

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$21.6 $30.3 $0.57 $0.80

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$10.8 $15.1 $0.28 $0.40

TOTAL $248.6 $347.9 $6.54 $9.15

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
83

Section C: Recommended Funding Levels, by State

Colorado

Program Intervention Budgets: 2014

Recommended Annual Investment $52.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 5,100

Youth aged 0-17 projected to die from smoking 90,600

Annual Costs Incurred in State from Smoking

Total medical $1,891 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $203.4 million

FY 2012 tobacco settlement payment $90.8 million

Total state revenue from tobacco sales and settlement $294.2 million

Percent Tobacco Revenue to Fund at Recommended Level 18%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$13.2 $16.4 $2.54 $3.16

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$6.9 $9.9 $1.33 $1.91

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $12.4 $19.7 $2.39 $3.80

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.3 $4.6 $0.63 $0.89

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.6 $2.3 $0.31 $0.44

TOTAL $37.4 $52.9 $7.20 $10.20

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
84

Section C: Recommended Funding Levels, by State

Connecticut

Program Intervention Budgets: 2014

Recommended Annual Investment $32.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 4,900

Youth aged 0-17 projected to die from smoking 56,100

Annual Costs Incurred in State from Smoking

Total medical $2,039 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $418.2 million

FY 2012 tobacco settlement payment $123.8 million

Total state revenue from tobacco sales and settlement $542.0 million

Percent Tobacco Revenue to Fund at Recommended Level 6%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$9.1 $11.4 $2.53 $3.18

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.6 $3.7 $0.72 $1.03

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $8.0 $12.7 $2.23 $3.54

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$2.0 $2.8 $0.55 $0.78

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.0 $1.4 $0.27 $0.39

TOTAL $22.7 $32.0 $6.30 $8.92

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
85

Section C: Recommended Funding Levels, by State

Delaware

Program Intervention Budgets: 2014

Recommended Annual Investment $13.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,400

Youth aged 0-17 projected to die from smoking 17,200

Annual Costs Incurred in State from Smoking

Total medical $532 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $126.0 million

FY 2012 tobacco settlement payment $26.7 million

Total state revenue from tobacco sales and settlement $152.7 million

Percent Tobacco Revenue to Fund at Recommended Level 9%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$3.4 $4.3 $3.71 $4.69

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.0 $2.8 $2.18 $3.05

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.7 $4.2 $2.94 $4.58

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.8 $1.1 $0.88 $1.23

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.4 $0.6 $0.44 $0.62

TOTAL $9.3 $13.0 $10.15 $14.17

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
86

Section C: Recommended Funding Levels, by State

District of Columbia

Program Intervention Budgets: 2014

Recommended Annual Investment $10.7 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 800

Youth aged 0-17 projected to die from smoking 7,100

Annual Costs Incurred in State from Smoking

Total medical $391 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $34.1 million

FY 2012 tobacco settlement payment $38.3 million

Total state revenue from tobacco sales and settlement $72.4 million

Percent Tobacco Revenue to Fund at Recommended Level 15%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$3.4 $4.2 $5.38 $6.64

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.4 $2.0 $2.21 $3.16

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.0 $3.1 $3.16 $4.90

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.7 $0.9 $1.08 $1.47

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.3 $0.5 $0.54 $0.74

TOTAL $7.8 $10.7 $12.37 $16.91

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
87

Section C: Recommended Funding Levels, by State

Florida

Program Intervention Budgets: 2014

Recommended Annual Investment $194.2 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 32,300

Youth aged 0-17 projected to die from smoking 270,200

Annual Costs Incurred in State from Smoking

Total medical $8,644 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $1,238.0 million

FY 2012 tobacco settlement payment $383.0 million

Total state revenue from tobacco sales and settlement $1,621.0 million

Percent Tobacco Revenue to Fund at Recommended Level 12%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$44.9 $56.2 $2.32 $2.91

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$25.9 $37.2 $1.34 $1.93

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $47.0 $75.5 $2.43 $3.91

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$11.8 $16.9 $0.61 $0.88

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$5.9 $8.4 $0.30 $0.44

TOTAL $135.5 $194.2 $7.00 $10.07

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
88

Section C: Recommended Funding Levels, by State

Georgia

Program Intervention Budgets: 2014

Recommended Annual Investment $106.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 11,700

Youth aged 0-17 projected to die from smoking 204,000

Annual Costs Incurred in State from Smoking

Total medical $3,183 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $225.0 million

FY 2012 tobacco settlement payment $141.1 million

Total state revenue from tobacco sales and settlement $366.1 million

Percent Tobacco Revenue to Fund at Recommended Level 29%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$28.0 $35.0 $2.82 $3.53

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$10.4 $14.9 $1.05 $1.50

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $26.3 $42.3 $2.65 $4.26

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$6.5 $9.2 $0.65 $0.93

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$3.2 $4.6 $0.33 $0.46

TOTAL $74.4 $106.0 $7.50 $10.68

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
89

Section C: Recommended Funding Levels, by State

Hawaii

Program Intervention Budgets: 2014

Recommended Annual Investment $13.7 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,400

Youth aged 0-17 projected to die from smoking 21,400

Annual Costs Incurred in State from Smoking

Total medical $526 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $138.8 million

FY 2012 tobacco settlement payment $48.6 million

Total state revenue from tobacco sales and settlement $187.4 million

Percent Tobacco Revenue to Fund at Recommended Level 7%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$4.5 $5.6 $3.23 $4.02

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.1 $1.6 $0.79 $1.15

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $3.0 $4.7 $2.15 $3.38

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.9 $1.2 $0.62 $0.86

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.4 $0.6 $0.31 $0.43

TOTAL $9.9 $13.7 $7.10 $9.84

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
90

Section C: Recommended Funding Levels, by State

Idaho

Program Intervention Budgets: 2014

Recommended Annual Investment $15.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,800

Youth aged 0-17 projected to die from smoking 30,200

Annual Costs Incurred in State from Smoking

Total medical $508 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $48.3 million

FY 2012 tobacco settlement payment $24.9 million

Total state revenue from tobacco sales and settlement $73.2 million

Percent Tobacco Revenue to Fund at Recommended Level 21%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$4.7 $5.8 $2.95 $3.63

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.5 $2.1 $0.94 $1.32

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $3.6 $5.6 $2.26 $3.51

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.0 $1.4 $0.62 $0.85

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.5 $0.7 $0.31 $0.42

TOTAL $11.3 $15.6 $7.08 $9.73

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
91

Section C: Recommended Funding Levels, by State

Illinois

Program Intervention Budgets: 2014

Recommended Annual Investment $136.7 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 18,300

Youth aged 0-17 projected to die from smoking 230,400

Annual Costs Incurred in State from Smoking

Total medical $5,496 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $608.8 million

FY 2012 tobacco settlement payment $273.7 million

Total state revenue from tobacco sales and settlement $882.5 million

Percent Tobacco Revenue to Fund at Recommended Level 15%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$36.1 $45.2 $2.80 $3.51

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$15.9 $22.8 $1.23 $1.77

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $31.7 $50.9 $2.46 $3.95

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$8.4 $11.9 $0.65 $0.92

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$4.2 $5.9 $0.32 $0.46

TOTAL $96.3 $136.7 $7.46 $10.61

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
92

Section C: Recommended Funding Levels, by State

Indiana

Program Intervention Budgets: 2014

Recommended Annual Investment $73.5 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 11,100

Youth aged 0-17 projected to die from smoking 150,700

Annual Costs Incurred in State from Smoking

Total medical $2,930 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $457.2 million

FY 2012 tobacco settlement payment $129.5 million

Total state revenue from tobacco sales and settlement $586.7 million

Percent Tobacco Revenue to Fund at Recommended Level 13%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$18.8 $23.5 $2.88 $3.59

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$5.1 $7.3 $0.78 $1.12

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $20.6 $33.1 $3.15 $5.06

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$4.5 $6.4 $0.68 $0.98

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$2.2 $3.2 $0.34 $0.49

TOTAL $51.2 $73.5 $7.83 $11.24

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
93

Section C: Recommended Funding Levels, by State

Iowa

Program Intervention Budgets: 2014

Recommended Annual Investment $30.1 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 5,100

Youth aged 0-17 projected to die from smoking 55,100

Annual Costs Incurred in State from Smoking

Total medical $1,285 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $225.4 million

FY 2012 tobacco settlement payment $65.7 million

Total state revenue from tobacco sales and settlement $291.1 million

Percent Tobacco Revenue to Fund at Recommended Level 10%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$8.4 $10.5 $2.73 $3.42

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.5 $3.6 $0.81 $1.17

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $7.6 $12.1 $2.47 $3.94

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.9 $2.6 $0.60 $0.85

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.9 $1.3 $0.30 $0.43

TOTAL $21.3 $30.1 $6.91 $9.81

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
94

Section C: Recommended Funding Levels, by State

Kansas

Program Intervention Budgets: 2014

Recommended Annual Investment $27.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 4,400

Youth aged 0-17 projected to die from smoking 61,200

Annual Costs Incurred in State from Smoking

Total medical $1,128 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $103.9 million

FY 2012 tobacco settlement payment $58.0 million

Total state revenue from tobacco sales and settlement $161.9 million

Percent Tobacco Revenue to Fund at Recommended Level 17%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$8.4 $10.5 $2.91 $3.64

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.3 $1.9 $0.45 $0.66

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $7.5 $11.9 $2.60 $4.12

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.7 $2.4 $0.60 $0.84

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.9 $1.2 $0.30 $0.42

TOTAL $19.8 $27.9 $6.86 $9.68

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
95

Section C: Recommended Funding Levels, by State

Kentucky

Program Intervention Budgets: 2014

8,900 $56.4 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 8,900

Youth aged 0-17 projected to die from smoking 118,900

Annual Costs Incurred in State from Smoking

Total medical $1,927 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $282.9 million

FY 2012 tobacco settlement payment $101.8 million

Total state revenue from tobacco sales and settlement $384.7 million

Percent Tobacco Revenue to Fund at Recommended Level 15%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$15.2 $19.0 $3.47 $4.34

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.4 $3.5 $0.55 $0.80

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $16.5 $26.5 $3.77 $6.05

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.4 $4.9 $0.78 $1.12

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.7 $2.5 $0.39 $0.56

TOTAL $39.2 $56.4 $8.96 $12.87

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
96

Section C: Recommended Funding Levels, by State

Louisiana

Program Intervention Budgets: 2014

Recommended Annual Investment $59.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 7,200

Youth aged 0-17 projected to die from smoking 98,400

Annual Costs Incurred in State from Smoking

Total medical $1,892 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $140.0 million

FY 2012 tobacco settlement payment $141.2 million

Total state revenue from tobacco sales and settlement $281.2 million

Percent Tobacco Revenue to Fund at Recommended Level 21%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$15.6 $19.5 $3.39 $4.24

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$5.7 $8.1 $1.24 $1.76

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $15.1 $24.2 $3.28 $5.26

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.6 $5.2 $0.79 $1.13

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.8 $2.6 $0.40 $0.56

TOTAL $41.8 $59.6 $9.10 $12.95

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
97

Section C: Recommended Funding Levels, by State

Maine

Program Intervention Budgets: 2014

Recommended Annual Investment $15.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 2,400

Youth aged 0-17 projected to die from smoking 27,000

Annual Costs Incurred in State from Smoking

Total medical $811 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $139.7 million

FY 2012 tobacco settlement payment $51.0 million

Total state revenue from tobacco sales and settlement $190.7 million

Percent Tobacco Revenue to Fund at Recommended Level 8%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$4.1 $5.2 $3.08 $3.91

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.6 $2.3 $1.20 $1.73

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $4.0 $6.3 $3.01 $4.74

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.0 $1.4 $0.73 $1.04

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.5 $0.7 $0.36 $0.52

TOTAL $11.2 $15.9 $8.38 $11.94

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
98

Section C: Recommended Funding Levels, by State

Maryland

Program Intervention Budgets: 2014

Recommended Annual Investment $48.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 7,500

Youth aged 0-17 projected to die from smoking 92,500

Annual Costs Incurred in State from Smoking

Total medical $2,710 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $410.7 million

FY 2012 tobacco settlement payment $145.8 million

Total state revenue from tobacco sales and settlement $556.5 million

Percent Tobacco Revenue to Fund at Recommended Level 9%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$12.8 $16.0 $2.18 $2.72

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$3.5 $5.0 $0.59 $0.85

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $13.0 $20.7 $2.21 $3.52

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$2.9 $4.2 $0.50 $0.71

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.5 $2.1 $0.25 $0.35

TOTAL $33.7 $48.0 $5.73 $8.15

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
99

Section C: Recommended Funding Levels, by State

Massachusetts

Program Intervention Budgets: 2014

Recommended Annual Investment $66.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 9,300

Youth aged 0-17 projected to die from smoking 103,100

Annual Costs Incurred in State from Smoking

Total medical $4,081 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $571.9 million

FY 2012 tobacco settlement payment $253.6 million

Total state revenue from tobacco sales and settlement $825.5 million

Percent Tobacco Revenue to Fund at Recommended Level 8%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$16.9 $21.2 $2.54 $3.19

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$8.9 $12.8 $1.34 $1.93

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $15.1 $24.2 $2.27 $3.64

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$4.1 $5.8 $0.62 $0.88

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$2.0 $2.9 $0.31 $0.44

TOTAL $47.0 $66.9 $7.08 $10.08

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
100

Section C: Recommended Funding Levels, by State

Michigan

Program Intervention Budgets: 2014

Recommended Annual Investment $110.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 16,200

Youth aged 0-17 projected to die from smoking 213,300

Annual Costs Incurred in State from Smoking

Total medical $4,590 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $972.3 million

FY 2012 tobacco settlement payment $256.2 million

Total state revenue from tobacco sales and settlement $1,228.5 million

Percent Tobacco Revenue to Fund at Recommended Level 9%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$28.3 $35.4 $2.86 $3.58

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$7.9 $11.4 $0.80 $1.15

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $30.7 $49.4 $3.11 $5.00

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$6.7 $9.6 $0.68 $0.97

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$3.3 $4.8 $0.34 $0.49

TOTAL $76.9 $110.6 $7.79 $11.19

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
101

Section C: Recommended Funding Levels, by State

Minnesota

Program Intervention Budgets: 2014

Recommended Annual Investment $52.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 5,900

Youth aged 0-17 projected to die from smoking 102,100

Annual Costs Incurred in State from Smoking

Total medical $2,519 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $375.6 million

FY 2012 tobacco settlement payment $166.9 million

Total state revenue from tobacco sales and settlement $542.5 million

Percent Tobacco Revenue to Fund at Recommended Level 10%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$13.5 $16.8 $2.51 $3.12

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$5.2 $7.5 $0.97 $1.39

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $13.6 $21.7 $2.53 $4.03

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.2 $4.6 $0.60 $0.85

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.6 $2.3 $0.30 $0.43

TOTAL $37.1 $52.9 $6.91 $9.82

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
102

Section C: Recommended Funding Levels, by State

Mississippi

Program Intervention Budgets: 2014

Recommended Annual Investment $36.5 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 5,400

Youth aged 0-17 projected to die from smoking 68,500

Annual Costs Incurred in State from Smoking

Total medical $1,237 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $151.6 million

FY 2012 tobacco settlement payment $113.0 million

Total state revenue from tobacco sales and settlement $264.6 million

Percent Tobacco Revenue to Fund at Recommended Level 14%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$10.0 $12.5 $3.35 $4.19

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.9 $4.1 $0.97 $1.37

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $9.5 $15.1 $3.18 $5.06

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$2.2 $3.2 $0.75 $1.06

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.1 $1.6 $0.38 $0.53

TOTAL $25.7 $36.5 $8.63 $12.21

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
103

Section C: Recommended Funding Levels, by State

Missouri

Program Intervention Budgets: 2014

Recommended Annual Investment $72.9 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 11,000

Youth aged 0-17 projected to die from smoking 127,500

Annual Costs Incurred in State from Smoking

Total medical $3,032 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $104.9 million

FY 2012 tobacco settlement payment $135.2 million

Total state revenue from tobacco sales and settlement $240.1 million

Percent Tobacco Revenue to Fund at Recommended Level 30%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$17.4 $21.8 $2.89 $3.62

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$7.5 $10.8 $1.25 $1.79

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $19.2 $30.8 $3.19 $5.11

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$4.4 $6.3 $0.73 $1.05

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$2.2 $3.2 $0.37 $0.53

TOTAL $50.7 $72.9 $8.43 $12.10

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
104

Section C: Recommended Funding Levels, by State

Montana

Program Intervention Budgets: 2014

Recommended Annual Investment $14.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,600

Youth aged 0-17 projected to die from smoking 18,900

Annual Costs Incurred in State from Smoking

Total medical $440 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $90.0 million

FY 2012 tobacco settlement payment $30.2 million

Total state revenue from tobacco sales and settlement $120.2 million

Percent Tobacco Revenue to Fund at Recommended Level 12%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$4.0 $5.0 $3.98 $4.97

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.2 $3.1 $2.19 $3.08

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.9 $4.6 $2.89 $4.58

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.9 $1.3 $0.91 $1.26

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.5 $0.6 $0.45 $0.63

TOTAL $10.5 $14.6 $10.42 $14.52

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
105

Section C: Recommended Funding Levels, by State

Nebraska

Program Intervention Budgets: 2014

Recommended Annual Investment $20.8 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 2,500

Youth aged 0-17 projected to die from smoking 38,000

Annual Costs Incurred in State from Smoking

Total medical $795 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $69.0 million

FY 2012 tobacco settlement payment $37.7 million

Total state revenue from tobacco sales and settlement $106.7 million

Percent Tobacco Revenue to Fund at Recommended Level 19%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$5.3 $6.6 $2.86 $3.56

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.5 $3.6 $1.35 $1.94

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $5.0 $7.9 $2.69 $4.26

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.3 $1.8 $0.69 $0.98

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.6 $0.9 $0.35 $0.49

TOTAL $14.7 $20.8 $7.94 $11.23

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
106

Section C: Recommended Funding Levels, by State

Nevada

Program Intervention Budgets: 2014

Recommended Annual Investment $30.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 4,100

Youth aged 0-17 projected to die from smoking 41,200

Annual Costs Incurred in State from Smoking

Total medical $1,080 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $102.4 million

FY 2012 tobacco settlement payment $40.3 million

Total state revenue from tobacco sales and settlement $142.7 million

Percent Tobacco Revenue to Fund at Recommended Level 21%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$8.3 $10.4 $3.01 $3.77

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$3.4 $4.9 $1.23 $1.78

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $6.8 $10.8 $2.46 $3.91

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.9 $2.6 $0.67 $0.95

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.9 $1.3 $0.34 $0.47

TOTAL $21.3 $30.0 $7.71 $10.88

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
107

Section C: Recommended Funding Levels, by State

New Hampshire

Program Intervention Budgets: 2014

Recommended Annual Investment $16.5 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,900

Youth aged 0-17 projected to die from smoking 21,700

Annual Costs Incurred in State from Smoking

Total medical $729 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $215.1 million

FY 2012 tobacco settlement payment $42.5 million

Total state revenue from tobacco sales and settlement $257.6 million

Percent Tobacco Revenue to Fund at Recommended Level 6%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$4.0 $5.0 $3.03 $3.79

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.8 $4.1 $2.12 $3.10

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $3.4 $5.3 $2.57 $4.01

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.0 $1.4 $0.77 $1.09

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.5 $0.7 $0.39 $0.55

TOTAL $11.7 $16.5 $8.88 $12.54

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
108

Section C: Recommended Funding Levels, by State

New Jersey

Program Intervention Budgets: 2014

Recommended Annual Investment $103.3 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 11,800

Youth aged 0-17 projected to die from smoking 142,700

Annual Costs Incurred in State from Smoking

Total medical $4,066 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $772.8 million

FY 2012 tobacco settlement payment $231.3 million

Total state revenue from tobacco sales and settlement $1,004.1 million

Percent Tobacco Revenue to Fund at Recommended Level 10%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$23.4 $29.2 $2.64 $3.29

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$19.1 $27.5 $2.15 $3.10

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $20.7 $33.1 $2.34 $3.73

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$6.3 $9.0 $0.71 $1.01

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$3.2 $4.5 $0.36 $0.51

TOTAL $72.7 $103.3 $8.20 $11.64

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
109

Section C: Recommended Funding Levels, by State

New Mexico

Program Intervention Budgets: 2014

Recommended Annual Investment $22.8 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 2,600

Youth aged 0-17 projected to die from smoking 39,800

Annual Costs Incurred in State from Smoking

Total medical $844 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $99.4 million

FY 2012 tobacco settlement payment $39.3 million

Total state revenue from tobacco sales and settlement $138.7 million

Percent Tobacco Revenue to Fund at Recommended Level 16%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$7.4 $9.3 $3.55 $4.46

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.3 $1.8 $0.62 $0.86

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $5.5 $8.7 $2.64 $4.17

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.4 $2.0 $0.68 $0.95

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.7 $1.0 $0.34 $0.47

TOTAL $16.3 $22.8 $7.83 $10.91

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
110

Section C: Recommended Funding Levels, by State

New York

Program Intervention Budgets: 2014

Recommended Annual Investment $203.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 28,200

Youth aged 0-17 projected to die from smoking 279,700

Annual Costs Incurred in State from Smoking

Total medical $10,390 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $1,630.5 million

FY 2012 tobacco settlement payment $737.7 million

Total state revenue from tobacco sales and settlement $2,368.2 million

Percent Tobacco Revenue to Fund at Recommended Level 9%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$49.3 $61.6 $2.52 $3.15

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$31.8 $45.7 $1.62 $2.34

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $43.1 $69.2 $2.20 $3.54

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$12.4 $17.7 $0.63 $0.90

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$6.2 $8.8 $0.32 $0.45

TOTAL $142.8 $203.0 $7.29 $10.38

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
111

Section C: Recommended Funding Levels, by State

North Carolina

Program Intervention Budgets: 2014

Recommended Annual Investment $99.3 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 14,200

Youth aged 0-17 projected to die from smoking 180,000

Annual Costs Incurred in State from Smoking

Total medical $3,810 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $294.8 million

FY 2012 tobacco settlement payment $141.0 million

Total state revenue from tobacco sales and settlement $435.8 million

Percent Tobacco Revenue to Fund at Recommended Level 23%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$26.4 $33.1 $2.71 $3.39

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$6.8 $9.8 $0.70 $1.00

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $27.1 $43.5 $2.78 $4.46

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$6.0 $8.6 $0.62 $0.89

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$3.0 $4.3 $0.31 $0.44

TOTAL $69.3 $99.3 $7.12 $10.18

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
112

Section C: Recommended Funding Levels, by State

North Dakota

Program Intervention Budgets: 2014

Recommended Annual Investment $9.8 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,000

Youth aged 0-17 projected to die from smoking 13,900

Annual Costs Incurred in State from Smoking

Total medical $326 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $28.2 million

FY 2012 tobacco settlement payment $31.5 million

Total state revenue from tobacco sales and settlement $59.7 million

Percent Tobacco Revenue to Fund at Recommended Level 16%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$2.9 $3.7 $4.15 $5.29

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$0.9 $1.3 $1.29 $1.86

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.3 $3.5 $3.29 $5.00

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.6 $0.9 $0.87 $1.22

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.3 $0.4 $0.44 $0.61

TOTAL $7.0 $9.8 $10.04 $13.98

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
113

Section C: Recommended Funding Levels, by State

Ohio

Program Intervention Budgets: 2014

Recommended Annual Investment $132.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 20,200

Youth aged 0-17 projected to die from smoking 259,100

Annual Costs Incurred in State from Smoking

Total medical $5,647 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $841.8 million

FY 2012 tobacco settlement payment $295.2 million

Total state revenue from tobacco sales and settlement $1,137.0 million

Percent Tobacco Revenue to Fund at Recommended Level 12%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$34.3 $42.9 $2.97 $3.72

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$10.0 $14.4 $0.87 $1.25

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $35.7 $57.5 $3.09 $4.98

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$8.0 $11.5 $0.69 $1.00

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$4.0 $5.7 $0.35 $0.50

TOTAL $92.0 $132.0 $7.97 $11.45

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
114

Section C: Recommended Funding Levels, by State

Oklahoma

Program Intervention Budgets: 2014

Recommended Annual Investment $42.3 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 7,500

Youth aged 0-17 projected to die from smoking 88,200

Annual Costs Incurred in State from Smoking

Total medical $1,622 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $291.3 million

FY 2012 tobacco settlement payment $77.4 million

Total state revenue from tobacco sales and settlement $368.7 million

Percent Tobacco Revenue to Fund at Recommended Level 11%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$11.7 $14.6 $3.07 $3.83

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.4 $3.4 $0.63 $0.89

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $11.8 $18.8 $3.09 $4.93

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$2.6 $3.7 $0.68 $0.97

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.3 $1.8 $0.34 $0.48

TOTAL $29.8 $42.3 $7.81 $11.10

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
115

Section C: Recommended Funding Levels, by State

Oregon

Program Intervention Budgets: 2014

Recommended Annual Investment $39.3 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 5,500

Youth aged 0-17 projected to die from smoking 68,300

Annual Costs Incurred in State from Smoking

Total medical $1,548 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $255.7 million

FY 2012 tobacco settlement payment $78.9 million

Total state revenue from tobacco sales and settlement $334.6 million

Percent Tobacco Revenue to Fund at Recommended Level 12%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$10.3 $12.9 $2.64 $3.31

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$4.1 $5.9 $1.05 $1.51

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $9.7 $15.4 $2.49 $3.95

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$2.4 $3.4 $0.62 $0.88

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.2 $1.7 $0.31 $0.44

TOTAL $27.7 $39.3 $7.11 $10.09

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
116

Section C: Recommended Funding Levels, by State

Pennsylvania

Program Intervention Budgets: 2014

Recommended Annual Investment $140.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 22,000

Youth aged 0-17 projected to die from smoking 243,700

Annual Costs Incurred in State from Smoking

Total medical $6,383 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $1,116.7 million

FY 2012 tobacco settlement payment $337.4 million

Total state revenue from tobacco sales and settlement $1,454.1 million

Percent Tobacco Revenue to Fund at Recommended Level 10%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$32.7 $40.8 $2.56 $3.20

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$14.8 $21.3 $1.16 $1.67

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $37.1 $59.6 $2.91 $4.67

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$8.5 $12.2 $0.66 $0.95

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$4.2 $6.1 $0.33 $0.48

TOTAL $97.3 $140.0 $7.62 $10.97

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
117

Section C: Recommended Funding Levels, by State

Rhode Island

Program Intervention Budgets: 2014

Recommended Annual Investment $12.8 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,800

Youth aged 0-17 projected to die from smoking 15,600

Annual Costs Incurred in State from Smoking

Total medical $640 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $132.1 million

FY 2012 tobacco settlement payment $46.7 million

Total state revenue from tobacco sales and settlement $178.8 million

Percent Tobacco Revenue to Fund at Recommended Level 7%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$3.8 $4.7 $3.62 $4.47

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.5 $2.1 $1.43 $2.00

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.8 $4.3 $2.67 $4.09

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.8 $1.1 $0.77 $1.06

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.4 $0.6 $0.39 $0.53

TOTAL $9.3 $12.8 $8.88 $12.15

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
118

Section C: Recommended Funding Levels, by State

South Carolina

Program Intervention Budgets: 2014

Recommended Annual Investment $51.0 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 7,200

Youth aged 0-17 projected to die from smoking 103,300

Annual Costs Incurred in State from Smoking

Total medical $1,907 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $165.7 million

FY 2012 tobacco settlement payment $73.4 million

Total state revenue from tobacco sales and settlement $239.1 million

Percent Tobacco Revenue to Fund at Recommended Level 21%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$13.4 $16.7 $2.84 $3.54

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$3.2 $4.7 $0.68 $0.99

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $14.3 $23.0 $3.03 $4.87

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.1 $4.4 $0.66 $0.94

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.5 $2.2 $0.33 $0.47

TOTAL $35.5 $51.0 $7.54 $10.81

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
119

Section C: Recommended Funding Levels, by State

South Dakota

Program Intervention Budgets: 2014

Recommended Annual Investment $11.7 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,300

Youth aged 0-17 projected to die from smoking 21,000

Annual Costs Incurred in State from Smoking

Total medical $373 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $60.1 million

FY 2012 tobacco settlement payment $24.1 million

Total state revenue from tobacco sales and settlement $84.2 million

Percent Tobacco Revenue to Fund at Recommended Level 14%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$3.5 $4.4 $4.20 $5.28

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.2 $1.7 $1.44 $2.04

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $2.7 $4.1 $3.24 $4.92

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.7 $1.0 $0.89 $1.22

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.4 $0.5 $0.44 $0.61

TOTAL $8.5 $11.7 $10.21 $14.07

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
120

Section C: Recommended Funding Levels, by State

Tennessee

Program Intervention Budgets: 2014

Recommended Annual Investment $75.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 11,400

Youth aged 0-17 projected to die from smoking 125,300

Annual Costs Incurred in State from Smoking

Total medical $2,673 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $278.6 million

FY 2012 tobacco settlement payment $139.2 million

Total state revenue from tobacco sales and settlement $417.8 million

Percent Tobacco Revenue to Fund at Recommended Level 18%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$18.7 $23.4 $2.90 $3.62

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$5.5 $7.9 $0.85 $1.22

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $21.4 $34.4 $3.31 $5.33

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$4.6 $6.6 $0.71 $1.02

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$2.3 $3.3 $0.35 $0.51

TOTAL $52.5 $75.6 $8.12 $11.70

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
121

Section C: Recommended Funding Levels, by State

Texas

Program Intervention Budgets: 2014

Recommended Annual Investment $264.1 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 28,000

Youth aged 0-17 projected to die from smoking 498,500

Annual Costs Incurred in State from Smoking

Total medical $8,856 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $1,484.0 million

FY 2012 tobacco settlement payment $474.6 million

Total state revenue from tobacco sales and settlement $1,958.6 million

Percent Tobacco Revenue to Fund at Recommended Level 13%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$68.0 $85.0 $2.61 $3.26

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$33.3 $47.9 $1.28 $1.84

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $60.2 $96.7 $2.31 $3.71

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$16.2 $23.0 $0.62 $0.88

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$8.1 $11.5 $0.31 $0.44

TOTAL $185.8 $264.1 $7.13 $10.13

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
122

Section C: Recommended Funding Levels, by State

Utah

Program Intervention Budgets: 2014

Recommended Annual Investment $19.3 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,300

Youth aged 0-17 projected to die from smoking 38,600

Annual Costs Incurred in State from Smoking

Total medical $542 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $132.0 million

FY 2012 tobacco settlement payment $36.4 million

Total state revenue from tobacco sales and settlement $168.4 million

Percent Tobacco Revenue to Fund at Recommended Level 11%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$5.8 $7.3 $2.03 $2.56

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.3 $3.4 $0.81 $1.19

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $4.0 $6.1 $1.40 $2.14

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.2 $1.7 $0.42 $0.59

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.6 $0.8 $0.21 $0.29

TOTAL $13.9 $19.3 $4.87 $6.77

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
123

Section C: Recommended Funding Levels, by State

Vermont

Program Intervention Budgets: 2014

Recommended Annual Investment $8.4 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 1,000

Youth aged 0-17 projected to die from smoking 10,100

Annual Costs Incurred in State from Smoking

Total medical $348 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $80.1 million

FY 2012 tobacco settlement payment $34.5 million

Total state revenue from tobacco sales and settlement $114.6 million

Percent Tobacco Revenue to Fund at Recommended Level 7%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$2.5 $3.1 $3.99 $4.95

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$1.1 $1.6 $1.76 $2.56

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $1.7 $2.6 $2.72 $4.15

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.5 $0.7 $0.85 $1.17

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.3 $0.4 $0.42 $0.58

TOTAL $6.1 $8.4 $9.74 $13.41

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
124

Section C: Recommended Funding Levels, by State

Virginia

Program Intervention Budgets: 2014

Recommended Annual Investment $91.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 10,300

Youth aged 0-17 projected to die from smoking 150,300

Annual Costs Incurred in State from Smoking

Total medical $3,113 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $187.4 million

FY 2012 tobacco settlement payment $117.4 million

Total state revenue from tobacco sales and settlement $304.8 million

Percent Tobacco Revenue to Fund at Recommended Level 30%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$19.1 $23.8 $2.33 $2.91

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$15.4 $22.2 $1.88 $2.71

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $21.0 $33.6 $2.57 $4.10

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$5.6 $8.0 $0.68 $0.97

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$2.8 $4.0 $0.34 $0.49

TOTAL $63.9 $91.6 $7.80 $11.18

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
125

Section C: Recommended Funding Levels, by State

Washington

Program Intervention Budgets: 2014

Recommended Annual Investment $63.6 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 8,300

Youth aged 0-17 projected to die from smoking 104,000

Annual Costs Incurred in State from Smoking

Total medical $2,812 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $471.4 million

FY 2012 tobacco settlement payment $150.7 million

Total state revenue from tobacco sales and settlement $622.1 million

Percent Tobacco Revenue to Fund at Recommended Level 10%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$16.4 $20.5 $2.38 $2.97

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$6.3 $9.1 $0.91 $1.32

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $16.0 $25.7 $2.32 $3.73

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.9 $5.5 $0.56 $0.80

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.9 $2.8 $0.28 $0.40

TOTAL $44.5 $63.6 $6.45 $9.22

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
126

Section C: Recommended Funding Levels, by State

West Virginia

Program Intervention Budgets: 2014

Recommended Annual Investment $27.4 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 4,300

Youth aged 0-17 projected to die from smoking 47,300

Annual Costs Incurred in State from Smoking

Total medical $1,008 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $109.6 million

FY 2012 tobacco settlement payment $63.7 million

Total state revenue from tobacco sales and settlement $173.3 million

Percent Tobacco Revenue to Fund at Recommended Level 16%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$6.7 $8.4 $3.61 $4.53

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$2.6 $3.7 $1.40 $1.99

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $7.4 $11.7 $3.99 $6.31

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$1.7 $2.4 $0.90 $1.28

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.8 $1.2 $0.45 $0.64

TOTAL $19.2 $27.4 $10.35 $14.75

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
127

Section C: Recommended Funding Levels, by State

Wisconsin

Program Intervention Budgets: 2014

Recommended Annual Investment $57.5 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 7,900

Youth aged 0-17 projected to die from smoking 106,200

Annual Costs Incurred in State from Smoking

Total medical $2,663 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $653.3 million

FY 2012 tobacco settlement payment $131.1 million

Total state revenue from tobacco sales and settlement $784.4 million

Percent Tobacco Revenue to Fund at Recommended Level 7%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$14.7 $18.4 $2.57 $3.21

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$4.4 $6.4 $0.77 $1.12

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $15.7 $25.2 $2.74 $4.40

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$3.5 $5.0 $0.61 $0.87

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$1.7 $2.5 $0.30 $0.44

TOTAL $40.0 $57.5 $6.99 $10.04

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
128

Section C: Recommended Funding Levels, by State

Wyoming

Program Intervention Budgets: 2014

Recommended Annual Investment $8.5 million

Deaths in State Caused by Smoking

Annual average smoking-attributable deaths 800

Youth aged 0-17 projected to die from smoking 12,100

Annual Costs Incurred in State from Smoking

Total medical $258 million

State Revenue from Tobacco Sales and Settlement

FY 2012 tobacco tax revenue $24.8 million

FY 2012 tobacco settlement payment $18.6 million

Total state revenue from tobacco sales and settlement $43.4 million

Percent Tobacco Revenue to Fund at Recommended Level 20%

Annual Total (Millions) Annual Per Capita

Minimum Recommended Minimum Recommended

I. State and Community Interventions 

Multiple social resources working together will 

have the greatest long-term population impact.

$2.9 $3.6 $5.03 $6.25

II. Mass-Reach Health Communication Interventions 

Media interventions work to prevent smoking initiation, 

promote cessation, and shape social norms.

$0.6 $0.9 $1.04 $1.56

III. Cessation Interventions 

Tobacco use treatment is effective and highly cost-effective. $1.9 $2.9 $3.30 $5.03

IV. Surveillance and Evaluation 

Publicly funded programs should be accountable and 

demonstrate effectiveness.

$0.5 $0.7 $0.94 $1.28

V. Infrastructure, Administration, and Management 

Complex, integrated programs require experienced 

staff to provide fiscal management, accountability, 

and coordination.

$0.3 $0.4 $0.47 $0.64

TOTAL $6.2 $8.5 $10.78 $14.76

Note: A justification for each program element and the rationale for the budget estimates are provided in Section A. The funding estimates presented are based on adjustments for changes in population and cost-of-living increases since Best Practices—2007 was published. The actual 

funding required for implementing programs will vary depending on state characteristics, such as prevalence of tobacco use, sociodemographic 

factors, and other factors. See Appendix E for data sources on deaths, costs, revenue, and state-specific factors. 

Centers for Disease Control and Prevention • Office on Smoking and Health

www.cdc.gov/tobacco • tobaccoinfo@cdc.gov • 1 (800) CDC-INFO or 1 (800) 232-4636 

2014
Appendices
130

Appendix A: 

Funding Recommendation Formulations 

The funding recommendations in this publication are based on the funding formulas presented 

in Best Practices for Comprehensive Tobacco Control Programs—2007. However, Best Practices for 

Comprehensive Tobacco Control Programs—2014

updates the guidance provided in 2007, reflecting additional state experiences in implementing 

comprehensive tobacco control programs, new 

scientific literature, and changes in state populations, inflation, and the national tobacco control 

landscape since its previous release. The recommended levels of investment (per capita 

and total) are presented in 2013 dollars using 

2012 population estimates. To account for inflation and changes in the U.S. population over 

time, these estimates can be updated using 

data from the U.S. Department of Labor Consumer Price Index and U.S. Census Bureau.

Best Practices for Comprehensive Tobacco 

Control Programs—2014 provides a streamlined 

two-tier funding-level framework for each state: 

minimum and recommended. These minimum 

and recommended funding levels reflect the 

annual investment that each state should make 

in order to fund and sustain a comprehensive 

tobacco control program. However, it is 

important to note that additional investments 

are also required at the societal level in order 

to most effectively reduce tobacco use. 

State and Community 

Interventions

The budget formula and state-by-state calculations 

for the state and community interventions component of the report were generally based on the 

Best Practices—2007 funding formulas, adjusted 

for population changes and inflation. However, 

for the 2014 update of Best Practices, the state and 

community interventions formula includes only 

two major components: state interventions and 

community interventions. The 2014 formula does 

not specifically include chronic disease programs 

to reduce the burden of tobacco-related diseases, school programs, and enforcement as major 

components. However, activities in these three 

areas may still be undertaken within the framework of state and community interventions. 

Minimum and recommended funding 

levels were established for each state on the 

basis of the following budget items, which 

in turn are based on the experiences of 

comprehensive tobacco control programs with 

robust state and community programs, as 

previously outlined in Best Practices—2007.

Minimum level: The minimum funding level was 

equal to the sum of minimum statewide and 

community intervention costs. The minimum 

statewide intervention cost was equal to the total 

population in each state, multiplied by a variable statewide cost per person (state range: $0.58 

to $1.46) that was adjusted for six state-specific 

factors and inflation. The minimum community intervention cost was equal to the total 

population in each state, multiplied by a variable community cost per person (state range: 

$1.02 to $1.61), adjusted for six state-specific factors and inflation, and added to a community 

base (state range in millions: $1.24 to $1.75).

Recommended level: The recommended funding level was equal to the sum of recommended 

statewide and community intervention costs. The 

recommended statewide intervention cost was 

equal to the minimum statewide intervention cost 

(which was adjusted for six state-specific factors 

and inflation) multiplied by a ratio of 1.25. The recommended community intervention cost was equal 

to the minimum community intervention cost 

(which was adjusted for six state-specific factors 

and inflation) multiplied by a ratio of 1.25. 

The six state-specific factors that were used for 

adjustment included:

 Prevalence of smoking among adults

 Average wage rates for implementing 

public health programs

 The proportion of individuals within the state 

living at or below 200% of the poverty level
131

Appendix A: Funding Recommendation Formulations

 The proportion of the population that 

is a racial/ethnic minority (i.e., race/

ethnicity other than non-Hispanic White)

 The state’s geographic size

 The state’s infrastructure as reflected by the 

number of local governmental health units

Mass-Reach Health 

Communication Interventions

The budget formula and state-by-state calculations 

for the mass-reach health communication interventions component of the report were obtained using 

SQAD® 2014 cost projections for three campaign 

types: 1) motivating smokers to quit; 2) protecting people from the harms of secondhand smoke 

exposure; and 3) transforming social norms to 

prevent tobacco use initiation. Television media 

exposure was chosen because television is the primary mass-reach health communication vehicle 

used by most states.

Minimum level: The minimum level comprises 

delivery of an average of 1,200 GRPs per quarter for four quarters for an introductory campaign 

addressing either motivating smokers to quit 

(media buying target: adults 25–54 years of age) 

or protecting people from the harms of secondhand smoke exposure (media buying target: adults 

25–54 years of age); and delivery of an average of 800 GRPs per quarter for four quarters for 

each of two ongoing campaigns: one to address 

transforming social norms to prevent tobacco use 

initiation (media buying target: youth and young 

adults 12–24 years of age) and one to address the 

campaign type not addressed in the introductory 

campaign (i.e. motivating smokers to quit or protecting people from the harms of secondhand 

smoke exposure). 

Also, a 20% discount in each state’s costs was 

made on the basis of assumed efficiencies gained 

from media negotiation and message synergies 

when three campaigns are run simultaneously. 

Some states receive the majority of their television 

exposure from stations in out-of-state markets. In 

these cases, a statistical approach was used to cap 

per capita funding at $2.16 with the assumption 

that media plans would be developed on the 

basis of cost-efficient media, such as digital.

Recommended level: The recommended level comprises delivery of an average of 1,600 GRPs per 

quarter for four quarters for an introductory campaign addressing either motivating smokers to 

quit (media buying target: adults 25–54 years of 

age) or protecting people from the harms of secondhand smoke exposure (media buying target: 

adults 25–54 years of age); and delivery of an average of 1,200 GRPs per quarter for four quarters for 

each of two ongoing campaigns: one to address 

transforming social norms to prevent tobacco use 

initiation (media buying target: youth and young 

adults 12–24 years of age) and one to address the 

campaign type not addressed in the introductory 

campaign (i.e. motivating smokers to quit or protecting people from the harms of secondhand 

smoke exposure).

Also, a 20% discount in each state’s costs was 

made on the basis of assumed efficiencies gained 

from media negotiation and message synergies 

when three campaigns are run simultaneously. 

Some states receive the majority of their television 

exposure from stations in out-of-state markets. In 

these cases, a statistical approach was used to cap 

per capita funding at $3.10 with the assumption 

that media plans would be developed on the 

basis of cost-efficient media, such as digital.

Cessation Interventions

The budget formula and state-by-state calculations 

for the cessations interventions component of the 

report were based on four primary components: 

(1) promoting health systems changes; (2) providing quitline counseling; (3) providing nicotine 

replacement therapy through quitlines; and (4) providing cessation services via other technologies.

Minimum level: The minimum funding level was 

equal to the sum of costs associated with promoting health systems changes, providing quitline 

counseling, providing nicotine replacement therapy 

through quitlines, and providing cessation services 

via other technologies. 

The costs of promoting health systems changes 

were determined using a fixed cost per state 

($150,000) added to a variable cost allocated in 

proportion to a state’s total population ($17,850,000 

total). The costs of providing quitline counseling 

were determined using the number of quitline 

counseling sessions received by adult smokers per 

state (assumed percent of adult smokers calling 
132

Appendix A: Funding Recommendation Formulations

quitline for assistance = 8% and percent who 

receive quitline counseling = 90%) multiplied 

by cost per call ($45.60). The costs of providing 

nicotine replacement therapy through quitlines were 

determined using the number of quitline nicotine 

replacement therapy treatments received by adult 

smokers per state (assumed percent of adult smokers 

calling quitline for assistance = 8%) multiplied by 

the estimated cost of providing 2 weeks of quitline 

nicotine replacement therapy ($38.00). The costs of 

providing cessation services via other technologies 

were set at a fixed value of $135,000 per state. 

Recommended level: The recommended funding 

level was equal to the sum of costs associated with 

promoting health systems changes, providing quitline counseling, providing nicotine replacement 

therapy through quitlines, and providing cessation 

services via other technologies. 

The costs of promoting health systems changes 

were determined using a fixed cost per state 

($150,000) added to a variable cost allocated in 

proportion to a state’s total population ($17,850,000 

total). The costs of providing quitline counseling 

were determined using the number of quitline 

counseling sessions received by adult smokers per 

state (assumed percent of adult smokers calling 

quitline for assistance = 13% and percent who 

receive quitline counseling = 90%) multiplied 

by cost per call ($45.60). The costs of providing 

nicotine replacement therapy through quitlines were 

determined using the number of quitline nicotine 

replacement therapy treatments received by adult 

smokers per state (assumed percent of adult smokers 

calling quitline for assistance = 13%) multiplied by 

the estimated cost of providing 2 weeks of quitline 

nicotine replacement therapy ($38.00). The costs of 

providing cessation services via other technologies 

were set at a fixed value of $135,000 per state. 

Surveillance and Evaluation

The budget formula and state-by-state calculations 

for the surveillance and evaluation component of 

the report were obtained by calculating 10% of 

the combined funding recommendation for state 

and community interventions, mass-reach health 

communication interventions, and cessation interventions in each state. 

Infrastructure, Administration, 

and Management

The budget formula and state-by-state calculations 

for the infrastructure, administration and management component of the report were obtained by 

calculating 5% of the combined funding recommendation for state and community interventions, 

mass-reach health communication interventions, 

and cessation interventions in each state. 
133

Appendix B: 

Program and Policy Recommendations for 

Comprehensive Tobacco Control Programs 

Guide to Community 

Preventive Services: What 

Works to Promote Health? 

The Task Force on Community Preventive Service’s report, The Guide to Community Preventive 

Services: What Works to Promote Health?, provides a list of effective tobacco prevention and 

control interventions that states and communities can implement to reduce tobacco use 

and exposure to secondhand smoke.1 Tobacco 

control programs and their partners can 

compare their existing activities with these recommendations, take steps to ensure that these 

interventions are adequately implemented and 

funded, and consider additional interventions, 

with the ultimate goal of building and sustaining a comprehensive tobacco control program. 

On the basis of evidence of effectiveness 

documented in the scientific literature, the Task 

Force’s report supports the following populationbased tobacco prevention and control interventions. 

Population-Based Tobacco Prevention and Control Interventions 

 Clean indoor air legislation prohibiting tobacco 

use in indoor public and private workplaces.

 Federal, state, and local efforts to increase tobacco 

product excise taxes as an effective public health 

intervention to promote tobacco use cessation and 

to reduce the initiation of tobacco use among youth.

 Funding and implementing long-term, highintensity, mass-media campaigns using 

paid broadcast times and media messages 

developed through formative research.

 Proactive telephone cessation support 

services (quitlines).

 Reduced or eliminated copayments 

for effective cessation therapies.

 Reminder systems for health care providers. 

 Combinations of efforts to mobilize communities 

to identify and reduce the commercial 

availability of tobacco products to youth. 

The recommendations from the Task Force 

confirm the importance of coordinated or combined 

interventions for tobacco control and prevention. 

The evidence supporting the effectiveness of 

efforts to reduce tobacco use among youth through 

access restrictions, to institute mass-reach health 

communication campaigns, and to assist tobacco 

users to quit via telephone quitlines comes 

primarily from studies that implemented these 

interventions in combination with other strategies. 
134

Appendix B: Program and Policy Recommendations

Healthy People 2020

The Healthy People initiative provides sciencebased, national objectives for improving the 

health of all Americans.2 For three decades, 

Healthy People has established benchmarks 

and monitored progress over time in order to 

encourage collaborations across communities 

and sectors, empower individuals toward 

making informed health decisions, and measure the impact of prevention activities. 

Healthy People 2020 was launched in 2010 

and includes an ambitious, yet achievable, 10-year 

agenda for improving the nation’s health. The 

national health objectives related to tobacco 

prevention and control are noted below.3

Tobacco Use 

 TU-1—Reduce tobacco use by adults.

 TU-2—Reduce tobacco use by adolescents.

 TU-3—Reduce the initiation of tobacco use among children, adolescents, and young adults.

 TU-4—Increase smoking cessation attempts by adult smokers.

 TU-5—Increase recent smoking cessation success by adult smokers.

 TU-6—Increase smoking cessation during pregnancy.

 TU-7—Increase smoking cessation attempts by adolescent smokers. 

Health Systems Change 

 TU-8—Increase comprehensive Medicaid insurance coverage of evidence-based treatment for nicotine 

dependency in states and the District of Columbia.

 TU-9—Increase tobacco screening in health care settings. 

 TU-10—Increase tobacco cessation counseling in health care settings. 

Social and Environmental Changes 

 TU-11—Reduce the proportion of nonsmokers exposed to secondhand smoke.

 TU-12—Increase the proportion of persons covered by indoor worksite policies that prohibit smoking.

 TU-13—Establish laws in states, the District of Columbia, territories, and tribes on smokefree indoor air that 

prohibit smoking in public places and worksites.

 TU-14—Increase the proportion of smokefree homes.

 TU-15—Increase tobacco-free environments in schools, including all school facilities, property, vehicles, 

and school events.

 TU-16—Eliminate state laws that preempt stronger local tobacco control laws.

 TU-17—Increase the Federal and State tax on tobacco products.

 TU-18—Reduce the proportion of adolescents and young adults in grades 6–12 who are exposed to 

tobacco marketing.

 TU-19—Reduce the illegal sales rate to minors through enforcement of laws prohibiting 

the sale of tobacco products to minors.

 TU-20—(Developmental) Increase the number of states and the District of Columbia, territories, and tribes with 

sustainable and comprehensive evidence-based tobacco control programs.
135

Appendix B: Program and Policy Recommendations

References

1. Zaza S, Briss PA, Harris KW, editors. The Guide to 

Community Preventive Services: What Works to Promote 

Health? New York: Oxford University Press, 2005. 

2. U.S. Department of Health and Human 

Services. About Healthy People; <http://

www.healthypeople.gov/2020/about/default.

aspx>; accessed: December 2, 2013.

3. U.S. Department of Health and Human Services. 

Healthy People 2020 Objectives; <http://www.

healthypeople.gov/2020/topicsobjectives2020/

default.aspx>; accessed December 2, 2013.
136

Appendix C: 

National Prevention Strategy 

Recommendations 

(National Prevention Council1)

National Prevention Strategy Recommendations 

 Support comprehensive tobacco-free and other evidence-based tobacco control policies.

 Support full implementation of the 2009 Family Smoking Prevention and Tobacco Control Act.

 Expand use of tobacco cessation services.

 Use media to educate and encourage people to live tobacco-free.

National Prevention Strategy 

Federal Actions

National Prevention Council 

Department Actions

Support states, tribes, and communities 

to implement tobacco control 

interventions and policies.

 HHS will continue to enforce tobacco advertising and 

youth promotion restrictions as well as work with 

states to enforce age compliance checks.

 HHS will continue to support states, tribes, and communities 

through the National Tobacco Control Program, which works 

to prevent initiation, promote quitting, eliminate disparities 

among population groups, and eliminate exposure to 

secondhand smoke through population-based community 

interventions, countermarketing, and data collection.

 HUD is partnering with HHS to encourage the adoption and 

implementation of smoke free multi-unit housing policies among 

Public Housing Agencies by developing toolkits with information 

about smoke free living and identifying and disseminating 

best practices in the creation of smoke free housing.

Promote comprehensive tobacco-free 

worksite, campus, and conference/

meeting policies.

 DOD will implement a comprehensive tobacco control program with 

special emphasis on environmental and primary prevention activities 

to promote health and mission readiness and to lead by example.

 DOD is working to reduce tobacco use on DOD installations 

to promote health and mission readiness, help tobacco users 

to abstain/quit, and lead by example for all workplaces. 

Promote utilization of smoking cessation 

benefits by federal employees, Medicare 

and Medicaid beneficiaries, and active 

duty and military retirees.

 HHS will launch a tobacco Web site that provides users with 

a single source of information on how to access available 

cessation resources to increase the use of such resources.

CONTINUED
137

Appendix C: National Prevention Strategy Recommendations

National Prevention Strategy 

Federal Actions

National Prevention Council 

Department Actions

Make cessation services more accessible 

and available by implementing applicable 

provisions of the Affordable Care Act, 

including in government health care 

delivery sites.

 HHS is working with partners to implement the expanded 

tobacco screening and cessation services now covered under 

the Affordable Care Act, including screening and cessation 

interventions for adults, expanded counseling for pregnant 

tobacco users, and full coverage for tobacco cessation services 

for pregnant women in states’ Medicaid programs. 

 HHS will continue to match 50% of the states’ cost of providing 

tobacco cessation telephone quitline services for Medicaid 

patients to support convenient delivery of such services 

and maximize successful tobacco cessation rates.

 VA will support the delivery of evidence-based, effective 

tobacco cessation counseling to tobacco users through 

training health care providers, screening patients for tobacco 

use, offering a variety of cessation services, and monitoring 

tobacco cessation processes to encourage and support smoking 

cessation efforts of veterans who use tobacco products.

Implement the warning mandated to 

appear on cigarette packages and in 

cigarette advertisements to include 

new textual warning statements and 

color graphics depicting the negative 

health consequences of tobacco use, 

as required by FSPTCA.*

 HHS announced the final rules requiring larger, more 

prominent cigarette health warning labels with 

accompanying color graphics in June 2011. 

*The FDA’s final rule on cigarette graphic warnings that was required under 

the FSPTCA was found unconstitutional on first amendment grounds. The 

US Court of Appeals remanded the matter to FDA, which will undertake 

research to support a new rulemaking consistent with the FSPTCA. 

Research tobacco use and 

the effectiveness of tobacco 

control interventions.

 DOD will consider how the availability of tobacco in military 

exchanges is contributing to tobacco consumption and how 

strategies outlined in Best Practices for Comprehensive 

Tobacco Control Programs can improve the health of Military 

Health System beneficiaries and the civilian workforce. 

Encourage clinicians and health care 

facilities to record smoking status 

for patients aged 13 years or older 

and to report on the clinical quality 

measure for smoking cessation 

counseling, in accordance with the 

Medicare and Medicaid Electronic 

Health Records Incentive Program.

 HHS will continue to include measures in its quality 

reporting programs that promote the assessment and 

treatment of smoking in adolescents and adults.

Abbreviations: 

DOD: Department of Defense 

FDA: Food and Drug Administration

FSPTCA: Family Smoking Prevention and Tobacco Control Act

HHS: Department of Health and Human Services

HUD: Department of Housing and Urban Development

VA: Department of Veterans Affairs

Reference

4. National Prevention Council. National Prevention

Council Action Plan: Implementing the National

Prevention Strategy; < http://www.surgeongeneral.

gov/initiatives/prevention/2012-npc-actionplan.pdf >; accessed: December 2, 2013.
138

Appendix D: 

Guidelines for Comprehensive 

Local Tobacco Control Programs 

(National Association of County and City Health Officials1)

1. Community Interventions: 

$3.99 to $6.75 per person, per year

For meaningful change to occur in the way 

tobacco products are marketed, sold, and used, 

community involvement is essential. For example, promoting smokefree environments and 

enforcing policies that restrict tobacco advertising help to change social norms about tobacco 

use. Raising taxes on tobacco is among the most 

effective ways to reduce use, especially among 

young people and the poor. Restricting access 

to tobacco products discourages youth from initiating tobacco use, and with the new Food and 

Drug Administration legislation, localities will have 

more opportunity to influence where, when, and 

how tobacco products are displayed and sold.

2. Health Communications: 

$0.65 to $1.95 per person, per year

There is considerable evidence that communication campaigns are effective at reducing tobacco 

consumption. A well-coordinated mass-media 

campaign that reaches a wide market and warns 

individuals about the dangers of tobacco use can 

promote cessation and prevent initiation in the 

general population and hard-to-reach groups. 

Media messages can have a powerful influence 

on public support for tobacco control policies and 

help reinforce school and community efforts.

3. Cessation Interventions: 

$2.04 to $5.94 per adult, per year

More than two-thirds of adult smokers report a 

desire to quit. Cessation interventions offer the 

quickest and largest short-term public health 

benefit compared with any other component 

of the comprehensive tobacco control program. Many effective treatments for tobacco 

dependence now exist but are underused. 

Health care systems must better identify, treat, 

and refer patients addicted to tobacco use.

4. Program Administration 

and Management: The larger 

of 5% of program budget or 

one-quarter to one full-time 

equivalent (FTE) dedicated staff

Each local health department requires dedicated personnel who can perform strategic 

planning, staffing, and fiscal management functions, and a well-trained work force that has the 

skills required to carry out program activities. For 

even the smallest of populations, at least onequarter full-time equivalent (FTE) staff member 

should be dedicated to tobacco control programming and oversight and can also serve as 

chronic disease lead. As the size of the population and the program increases, staff resources 

beyond one FTE to implement tobacco interventions should be derived from the recommended 

budgets of the other program components.

5. Surveillance and Evaluation: 

10% of program budget

Surveillance and evaluation are essential 

elements of a comprehensive tobacco control program. A successful program should 

assess the use of tobacco, local factors contributing to tobacco use, and progress toward 

planned outcomes and should report data that 

are useful to policymakers and the public.

Reference

5. National Association of County & City Health 

Officials. 2010 Program and Funding Guidelines 

for Local Comprehensive Tobacco Control 

Program; <http://www.naccho.org/toolbox/tool.

cfm?id=1994>; accessed: December 2, 2013. 
139

Appendix E: 

Data Sources 

Deaths Caused by Smoking

Annual Average Smoking-Attributable Deaths:

Data were obtained from the Adult SmokingAttributable Mortality, Morbidity, and Economic 

Costs (SAMMEC) system. Data are annual averages among adults aged 35 years and older 

from 2005–2009. The estimates were calculated using the smoking-attributable outcomes 

and general approach outlined in the 2014 

Surgeon General’s Report on Smoking and 

Health. These estimates do not include deaths 

related to burns or secondhand smoke. All figures were rounded to the nearest hundred.2

Youth Projected to Die from Smoking: This measure is calculated using estimates of youth 

projected to start smoking as well as estimates of 

premature deaths attributable to smoking among 

continuing smokers and among those who quit 

after 35 years of age.2 Data on the number of 

youth projected to start smoking were obtained 

using the number of persons aged 0–17 years in 

each state from the U.S. Census Bureau (July 1, 

2012 estimates).3 The average prevalence of smoking among adults aged 18–30 years for each state 

was obtained from the 2011–2012 Behavioral Risk 

Factor Surveillance System.4 Data on premature 

deaths attributable to smoking were obtained from 

the Adult Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) system.1

 All 

figures were rounded to the nearest hundred. 

Annual Costs Incurred 

from Smoking

Annual Costs Incurred from Smoking: Estimates 

were obtained on the basis of smoking-attributable 

fractions obtained from the Smoking-Attributable Mortality, Morbidity, and Economic Costs 

(SAMMEC) system,1 and state-specific health care 

expenditure data were obtained from the Centers for Medicare and Medicaid Services.5

 All 

figures were rounded to the nearest million.

State Revenue from Tobacco 

Sales and Settlement

Tobacco Tax Revenue: Data for fiscal year 

2012 were obtained from The Tax Burden on 

Tobacco, 2012.6 Figures were rounded to the 

nearest hundred thousand.

Tobacco Settlement Payment: Data for fiscal year 

2012 were obtained from the State Tobacco Activities Tracking and Evaluation (STATE) System.7

Data were provided to the STATE System by the 

National Association of Attorneys General for the 

46 states and District of Columbia that participated in the Master Settlement Agreement (MSA). 

Payments for four non-MSA states were obtained 

by direct contact with those states. All figures 

were rounded to the nearest hundred thousand.

State Revenue from Tobacco Sales and Settlement:

Total figures were obtained by adding the total 

tobacco tax revenue and tobacco settlement payment figures above. All figures were rounded to 

the nearest hundred thousand.

State-Specific 

Factors Used in Funding 

Recommendation Formulas

Total Population Size, Population of Adults Aged 

18 years and Older, and Population Estimates by 

Race: Data were obtained from the U.S. Census 

Bureau for total state populations (July 1, 2012 

estimates).3

 The estimates are based on the 2010 

Census and reflect changes to the April 1, 2010 

population due to the Count Question Resolution program and geographic program revisions.

Cigarette Smoking Prevalence: Data were 

obtained from the 2012 Behavioral Risk 

Factor Surveillance System (BRFSS).4 

Poverty Status: Data were obtained from the 

2012 Annual Social and Economic Supplement 

(ASEC) of the Current Population Survey (CPS).8
140

Appendix E: Data Sources

Average Annual Salary to Implement Public Health Programs: Data were obtained from 

the 2012 Quarterly Census of Employment 

and Wages, U.S. Bureau of Labor Statistics.9 

Number of Local Health Units: Data were 

obtained from the National Association 

of County and City Health Officials.10

Designated Market Area Cost and Reach of Targeted 

Audience: Data for the year 2013 were obtained 

from AC Nielsen through PlowShare Group Inc.11

Land Area: Data were obtained from the 2010 

State Area Measurements and Internal Point Coordinates report of the U.S. Census Bureau.12

Consumer Price Index: Data were obtained 

from the U.S. Bureau of Labor Statistics.13
141

References

1. Centers for Disease Control and Prevention. 

Smoking-Attributable Mortality, Morbidity, and 

Economic Costs (SAMMEC); <http://apps.nccd.cdc.

gov/sammec/>; accessed: December 2, 2013. 

2. Centers for Disease Control and Prevention. 

Smoking-Attributable Mortality, Years of Potential 

Life Lost, and Productivity Losses—United 

States, 2000–2004. Morbidity and Mortality 

Weekly Report. 2008;57(45):1226–8. 

3. U.S. Census Bureau. Population Estimates; <http://

www.census.gov/>; accessed: December 2, 2013. 

4. Centers for Disease Control and Prevention. Behavioral 

Risk Factor Surveillance System; <http://www.

cdc.gov/brfss/>; accessed: December 2, 2013. 

5. Centers for Medicaid and Medicare Services. National 

Health Expenditure Date; <http://www.cms.gov/

Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/NationalHealthExpendData/

index.html>; accessed: December 2, 2013.

6. Orzechowski W, Walker RC. The Tax Burden on 

Tobacco, 2012. Tables 9, 12, and 19. Arlington, 

VA: Orzechowski and Walker, 2013. 

7. Centers for Disease Control and Prevention. 

State Tobacco Activities Tracking and Evaluation 

(STATE) System; <http://www.cdc.gov/tobacco/

statesystem>; accessed: December 2, 2013.

8. U.S. Census Bureau. Annual Social and Economic 

Supplement (ASEC) of the Current Population 

Survey (CPS); <http://www.census.gov/cps/data/

cpstablecreator.html>; accessed: December 2, 2013. 

9. United States Department of Labor. Quarterly 

Census of Employment and Wages; <http://

data.bls.gov/>; accessed: December 2, 2013. 

10. National Association of County and City 

Health Officials. Local Health Units, by 

State. Unpublished data. 2012. 

11. PlowShare Group Inc. Unpublished data. 2013. 

12. U.S. Census Bureau. State Area Measurements 

and Internal Point Coordinates; <http://

www.census.gov/geo/reference/state-area.

html>; accessed: December 2, 2013. 

13. U.S. Department of Labor. Consumer Price 

Index; <http://www.bls.gov/cpi/tables.

htm>; accessed: December 2, 2013. 
Notes:
Notes:
For more information please contact:

Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov

Web: www.atsdr.cdc.gov

Publication date: 2014