Report to the Honorable Bill Frist, U.S. 

Senate 

United States General Accounting Office 

GAO 

November 2003 TOBACCO USE AND 

PUBLIC HEALTH 

Federal Efforts to 

Prevent and Reduce 

Tobacco Use among 

Youth 

GAO-04-41 
Some federal programs, research, and activities that aim to address tobacco 

use among youth focus only on tobacco while others aim to address tobacco 

use as part of broader efforts to address unhealthy behaviors such as 

substance abuse and violence. Two federal programs within the Department 

of Health and Human Services (HHS) focus only on tobacco use. CDC’s 

National Tobacco Control Program (NTCP) focuses on preventing and 

reducing tobacco use among the general population and explicitly targets 

youth. The Substance Abuse and Mental Health Services Administration’s 

program to oversee implementation of a provision of federal law, commonly 

referred as the Synar Amendment, focuses only on tobacco use among 

youth. The Synar Amendment requires states to enact and enforce laws 

prohibiting the sale of tobacco products to minors. In addition to these 

tobacco-focused programs, HHS, and the Departments of Defense (DOD), 

Justice (DOJ), and Education sponsor programs that include tobacco use as 

part of broader efforts to address unhealthy behaviors among youth, such as 

substance abuse and violence. For example, Education’s Safe and Drug-Free 

Schools and Communities program is designed to prevent substance abuse 

and violence. HHS agencies, such as the National Institutes of Health, 

conduct research on tobacco use and nicotine addiction among youth and its 

health effects on youth. HHS agencies and other federal departments also 

support activities to prevent and reduce tobacco use among youth, such as 

education and outreach efforts. HHS and its component agencies coordinate 

tobacco-related efforts with other federal, state, and local government 

agencies and nongovernmental entities. 

Federal departments and agencies collect a variety of information to monitor 

how programs that aim to address tobacco use among youth are being 

implemented by grantees and the effectiveness of grantee efforts in meeting 

program goals. The information is collected through various means, 

including grant applications, progress reports, periodic site visits, and 

program evaluations. For example, to monitor NTCP, CDC requires states to 

submit biannual reports on the implementation of state NTCP-supported 

tobacco control programs. The information that federal departments and 

agencies collect on these programs is also used to provide training and 

technical assistance to grantees on topics such as conducting program 

evaluation. 

In commenting on a draft of this report, HHS stated that the report was very 

informative but it did not include programs like Medicaid that are a 

substantial element of HHS tobacco prevention efforts. Including programs 

that finance health insurance such as Medicaid, however, was beyond the 

scope of our review. Also, HHS noted that we did not include information 

about the challenges other federal agencies face in coordinating tobaccorelated issues but DOD, DOJ, and Education did not describe such 

challenges. DOD and DOJ had no comments on the report and HHS and 

Education provided technical comments that we incorporated as 

appropriate. 

Tobacco use is the leading cause of 

preventable death in the United 

States. The Centers for Disease 

Control and Prevention (CDC) 

reported that, on average, over 

440,000 deaths and $76 billion in 

medical expenditures were 

attributable to cigarette smoking 

each year from 1995 through 1999. 

Reducing tobacco-related deaths 

and the incidence of disease, along 

with the associated costs, 

represents a significant public 

health challenge for the federal 

government. Most adults who use 

tobacco started using it between 

the ages of 10 and 18. According to 

a Surgeon General’s report, if 

children and adolescents can be 

prevented from using tobacco 

products before they become 

adults, they are likely to remain 

tobacco-free for the rest of their 

lives. 

GAO was asked to provide 

information on federal efforts to 

prevent and reduce youth smoking. 

Specifically, this report describes 

(1) federal programs, research, and 

activities that aim to prevent and 

reduce tobacco use among youth, 

(2) the efforts of federal 

departments and agencies to 

monitor their programs, and (3) the 

coordination among federal 

departments and agencies in efforts

to prevent and reduce tobacco use 

among youth. 

www.gao.gov/cgi-bin/getrpt?GAO-04-41.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marjorie E. 

Kanof at (202) 512-7101. 

Highlights of GAO-04-41, a report to the 

Honorable Bill Frist, U.S. Senate 

November 2003

TOBACCO USE AND PUBLIC HEALTH 

Federal Efforts to Prevent and Reduce 

Tobacco Use among Youth 
Page i GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Letter 1

Results in Brief 3

Background 5

Some Federal Programs, Research, and Activities Focus Only on 

Tobacco Use, While Others Address Tobacco Use Along with 

Other Unhealthy Behaviors 7

Federal Departments and Agencies Collect a Variety of Information 

on Their Programs That Aim to Prevent Tobacco Use among 

Youth 14

Federal Departments and Agencies Coordinate in Various Ways to 

Address Tobacco Use among Youth 18

Agency Comments 22

Appendix I Scope and Methodology 24 

Appendix II Selected Federal Programs That Address or Can 

Address Tobacco Prevention and Reduction among 

Youth 26 

Appendix III Comments from the Department of Health and 

Human Services 30 

Appendix IV GAO Contact and Acknowledgments 32 

GAO Contact 32

Acknowledgments 32

Tables 

Table 1: Examples of Federal Collaborative Education and 

Outreach Activities to Address Tobacco Use among Youth 21

Table 2: Selected Federal Programs That Address or Can Address 

Tobacco Prevention and Reduction among Youth 26

Contents 
Page ii GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Figure 

Figure 1: Estimated Rate of Current Smoking among 8th, 10th, and 

12th Grade Students, 1991-2002 5

Abbreviations 

AHRQ Agency for Healthcare Research and Quality 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare & Medicaid Services 

DEFY Drug Education for Youth Program 

DOD Department of Defense 

DOJ Department of Justice 

EPA Environmental Protection Agency 

HHS Department of Health and Human Services 

HRSA Health Resources and Services Administration 

IHS Indian Health Service 

NCI National Cancer Institute 

NHLBI National Heart, Lung, and Blood Institute 

NICHD National Institute of Child Health and Human Development 

NIDCR National Institute of Dental and Craniofacial Research 

NIDA National Institute on Drug Abuse 

NIH National Institutes of Health 

NTCP National Tobacco Control Program 

ONDCP Office of National Drug Control Policy 

SAMHSA Substance Abuse and Mental Health Services 

 Administration 

TTURCs Transdisciplinary Tobacco Use Research Centers 

This is a work of the U.S. government and is not subject to copyright protection in the 

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permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 
Page 1 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

November 21, 2003 

The Honorable Bill Frist 

United States Senate 

Dear Senator Frist: 

Tobacco use is the leading cause of preventable death in the United States. 

In its most recent estimates of selected health consequences of cigarette 

smoking, the Centers for Disease Control and Prevention (CDC) reported 

that, on average, over 440,000 deaths and $76 billion in medical 

expenditures were attributable to cigarette smoking each year from 1995 

through 1999.1

 Reducing the number of tobacco-related deaths, along with 

the associated costs, represents a significant public health challenge for 

the federal government. The first Surgeon General’s report to the Congress 

that specifically focused on tobacco use among youth concluded that 

preventing youth from starting to use tobacco is key to reducing the 

deaths and incidence of disease attributable to tobacco use.2

 Most adults 

who use tobacco started using it between the ages of 10 and 18. According 

to the report, if children and adolescents can be encouraged to abstain 

from using tobacco before they become adults, they are less likely to use 

tobacco for the rest of their lives. Although smoking rates (defined as 

smoking one or more cigarettes in the previous 30 days) among 12th grade 

students have declined from a rate of about 37 percent in 1997, in 2002, 

about 27 percent of 12th grade students reported that they smoked. In 

1992, the Congress passed legislation, commonly referred to as the Synar 

Amendment, designed to prohibit the sale and distribution of tobacco 

products to minors.3

 1

Centers for Disease Control and Prevention, “Annual Smoking-Attributable Mortality, 

Years of Potential Life Lost, and Economic Costs – United States, 1995-1999,” Morbidity 

and Mortality Weekly Report, vol. 51, no. 14 (2002) 300-303. The Morbidity and Mortality 

Weekly Report disseminates information about the public health issues in which CDC is 

involved. 

2

U.S. Department of Health and Human Services, Preventing Tobacco Use Among Young 

People: A Report of the Surgeon General (Atlanta, Ga.: Centers for Disease Control and 

Prevention, 1994). 

3

The Synar Amendment is found in §1926 of the Public Health Service Act as added by the 

Drug Abuse and Mental Health Administration Reorganization Act, Pub. L. No. 102-321 § 

202, 106 Stat. 394 (1992) (classified to 42 U.S.C. § 300x-26 (2000)). 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Given the harmful effects of tobacco use and the rates of smoking among 

youth,4

 you asked us to provide information on federal efforts to prevent 

and reduce youth smoking. We focused our review on describing 

(1) programs, research, and activities that aim to prevent and reduce 

tobacco use among youth, (2) the efforts of federal departments and 

agencies to monitor their programs, and (3) the coordination among 

federal departments and agencies in their efforts to prevent and reduce 

tobacco use among youth. 

To identify federal programs, research, and activities5

 that aim to address 

tobacco use among youth, we reviewed the Catalog of Federal Domestic 

Assistance, which is a database of federal grant programs, 6 and other 

pertinent documents. In addition, we interviewed program officials in 

multiple federal agencies.7

 As a result, we focused on four federal 

departments that support programs and other efforts to prevent and 

reduce tobacco use among youth: the Department of Health and Human 

Services (HHS) and its component agencies—CDC, Substance Abuse and 

Mental Health and Services Administration (SAMHSA), National Institutes 

of Health (NIH), and Health Resources and Services Administration 

(HRSA); the Department of Defense (DOD); the Department of Justice 

(DOJ); and the Department of Education (Education). Where available, we 

also obtained fiscal year 2002 funding information on the federal programs 

and research that we identified. To identify how federal departments and 

agencies monitor their programs, we reviewed agency strategic plans, 

annual performance plans and reports, program guidance documents, and 

program evaluations. To determine how federal departments and agencies 

coordinate their efforts, we reviewed their strategic plans and annual 

performance plans and reports and also descriptions of coordination 

efforts. In addition, we interviewed agency officials about their program 

monitoring and coordination efforts and asked them to describe any 

coordination challenges they faced. (For additional information on our 

methodology, see app. I.) We conducted our work from January 2003 

 4

For the purposes of this report, youth refers to children and adolescents under the age of 

18. 

5

In this report, the term “activities” refers to federal efforts to prevent and reduce tobacco 

use among youth, such as education and outreach and training and technical assistance. 

6

The General Services Administration maintains this database. 

7

The scope of our work did not include programs that finance health insurance such as 

Medicaid. 
Page 3 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

through October 2003 in accordance with generally accepted government 

auditing standards. 

Some federal programs, research, and activities that address tobacco use 

among youth focus only on tobacco use, while others aim to prevent and 

reduce tobacco use as part of broader efforts to address unhealthy 

behaviors like substance abuse and violence. We identified two federal 

programs that focus only on tobacco use. These programs are within HHS, 

the lead federal department for addressing public health issues related to 

tobacco. The first program, CDC’s National Tobacco Control Program 

(NTCP), provides funds through cooperative agreements to state tobacco 

control programs to prevent and reduce tobacco use among youth and 

adults. The second tobacco program, SAMHSA’s program to oversee 

implementation of the Synar Amendment, is the only federal program we 

identified that focuses only on tobacco use among youth. The Synar 

Amendment requires states to enact and enforce tobacco control laws to 

prevent individuals under the age of 18 from purchasing tobacco products. 

In addition to these tobacco-focused programs, HHS, Education, DOJ, and 

DOD sponsor programs that aim to address tobacco use among youth as 

part of broader efforts to prevent unhealthy behaviors, such as substance 

abuse and violence. For example, Education’s Safe and Drug-Free Schools 

and Communities program supports state efforts to create learning 

environments in the nation’s schools that are free of violence and drug 

use, including tobacco. HHS agencies also conduct research on tobacco 

use among youth. For example, NIH supports research projects to 

examine the factors influencing both tobacco use and nicotine addiction 

among youth and assesses interventions designed to prevent and help 

youth quit tobacco use. HHS agencies and other federal departments also 

support activities to prevent and reduce tobacco use among youth, such as 

education and outreach efforts. 

To monitor their programs that aim to prevent and reduce tobacco use 

among youth, federal departments and agencies collect a variety of 

information on how their programs are being implemented by grantees 

and the effectiveness of grantees’ efforts in meeting national program 

goals. This information is obtained from such sources as grant 

applications, grantee progress reports, periodic site visits, and program 

evaluations. In fiscal year 2003, CDC took steps to obtain additional 

information on the design, implementation, and effects of state tobacco 

control programs. For example, CDC now requires that states submit more 

detailed information in their biannual reports and dedicate staff to 

evaluate their individual tobacco control programs. Other federal 

Results in Brief 
Page 4 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

departments and agencies obtain information on the efforts and 

effectiveness of their programs that aim to prevent and reduce smoking 

among youth. For example, SAMHSA annually collects information from 

states to determine their compliance with the Synar Amendment and its 

implementing regulation regarding the sale and distribution of tobacco 

products to minors. Similarly, DOJ is conducting a national evaluation of 

the Drug-Free Communities Support program to determine the effects the 

program is having on preventing and reducing unhealthy behaviors among 

youth, such as the use of tobacco, alcohol, or other drugs. 

Federal departments coordinate their efforts to prevent and reduce 

tobacco use among youth by participating on various committees and 

work groups and collaborating on programs, research, and other 

activities—with HHS leading many of these efforts. HHS brings together 

representatives from federal, state, and local government agencies and 

nongovernmental entities to participate in various interagency committees 

and work groups that address tobacco prevention, cessation, and 

treatment of nicotine addiction. In addition, HHS and other federal 

departments share responsibility for administering programs, conducting 

and disseminating information on research, and engaging in education and 

outreach activities. Some HHS officials described challenges to 

coordination among HHS agencies. Several officials explained that, 

although multiple HHS agencies have programs and other efforts that aim 

to prevent and reduce tobacco use, coordination can be challenging 

because the missions and priorities of these agencies differ. 

We provided a draft of this report to HHS, DOD, DOJ, and Education for 

comment. In written comments, HHS stated that the report provides a 

thorough and informative overview of the federal effort to prevent and 

reduce youth smoking. HHS noted that the report does not include the 

Centers for Medicare & Medicaid Services programs that are a substantial 

element of HHS tobacco prevention, particularly Medicaid. Including joint 

federal-state programs that finance health insurance such Medicaid and 

the State Children’s Health Insurance Program, was beyond the scope of 

our review. HHS also noted that the report does not include information 

about the challenges federal agencies other than HHS experienced in 

coordinating tobacco-related issues. Officials from DOD, DOJ, and 

Education did not provide information on challenges they experienced in 

coordinating their tobacco-related efforts. DOD concurred with the report 

as written and DOJ officials said they had no comments. HHS and 

Education provided technical clarifications which we made, as 

appropriate. 
Page 5 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

From 1991 through 2002, smoking rates among youth fluctuated and 

reached their highest points around 1997. The estimated rate of current 

smoking among youth (defined as smoking one or more cigarettes during 

the previous 30 days) varied according to grade level8

 (see fig.1). For 

example, the rate among 8th grade students peaked at about 21 percent in 

1996 before declining to about 11 percent in 2002. For 10th grade students, 

the smoking rate peaked at 30 percent in 1996 before declining to 18 

percent in 2002. Similarly, smoking among 12th grade students peaked at 

about 37 percent in 1997, before declining to about 27 percent in 2002. 

Figure 1: Estimated Rate of Current Smoking among 8th, 10th, and 12th Grade 

Students, 1991-2002 

Note: Based on data from the Monitoring the Future survey, 2002. 

HHS serves as the lead federal department for addressing the nation’s 

public health issues, including tobacco use. HHS is responsible for 

informing the public of the dangers of tobacco use and coordinating 

 8

L.D. Johnston, P.M. O’Malley, and J.G. Bachman, Monitoring the Future: National Results 

on Adolescent Drug Use: Overview of Key Findings, 2002, NIH Publication No. 03-5374 

(Bethesda, Md.: National Institute on Drug Abuse, 2002). 

Background 

Percentage

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

12th grade

10th grade

8th grade

Source: NIDA.

0

20

40

100
Page 6 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

federal efforts to address tobacco use issues. Within HHS, CDC’s Office on 

Smoking and Health has been delegated the lead for all policy and 

programmatic issues related to the prevention and reduction of tobacco 

use and has primary responsibility within the federal government for 

tobacco use prevention efforts.9

 Also within HHS, the Surgeon General 

serves as the nation’s spokesperson on matters of public health and 

reports on issues such as the health effects of tobacco use. Other HHS 

agencies, such as SAMHSA, NIH, and HRSA, support efforts to prevent and 

reduce tobacco use. Education, DOD, and DOJ also support programs and 

activities that aim to address tobacco use among youth. 

Several studies have highlighted the importance of addressing tobacco use 

among youth. In 1994, the Surgeon General released a report that focused 

on the use of tobacco among youth. The report highlighted several factors 

that increase the likelihood that youth will begin using tobacco. These 

factors include engaging in other unhealthy behaviors, like substance 

abuse and violence; peer pressure to smoke; and cigarette advertising and 

promotion. In addition, the Surgeon General, CDC, NIH, and the Institute 

of Medicine have reported on approaches that can help prevent youth 

from starting to use tobacco and help existing users quit. For instance, 

they have reported on the demonstrated benefits of interventions such as 

implementing counter-marketing campaigns, using school-based 

educational programs in combination with providing youth with 

alternatives to the illicit use of tobacco, deglamorizing tobacco use, and 

restricting minors’ access to tobacco. According to the Surgeon General’s 

1994 report, strategies for preventing and reducing tobacco use among 

youth should be multifaceted and involve collaborations among those that 

can influence the behavior and attitudes of youth, such as family members 

and educators. 

HHS led federal, state, and local agencies and nongovernmental 

organizations in developing a 10-year national plan, the Healthy People 

2010 initiative, that includes goals for addressing tobacco use. The Healthy 

People 2010 initiative has identified tobacco use as one of 10 leading 

health indicators for the nation.10 Healthy People 2010 objectives related to 

 9

The Office on Smoking and Health is a division of the National Center for Chronic Disease 

Prevention and Health Promotion. 

10The Healthy People 2010 leading health indicators are physical activity, overweight and 

obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury 

and violence, environmental quality, immunization, and access to health care. 
Page 7 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

tobacco use among youth include, among other objectives, reducing the 

percentage of adolescents who smoked cigarettes in the past month and 

increasing the percentage of adolescents who try to quit smoking. 

Two HHS agencies, CDC and SAMHSA, administer programs that focus 

only on tobacco use. CDC’s NTCP targets youth within a broader mission 

of preventing and reducing tobacco use among the general population. 

SAMHSA oversees implementation of the Synar Amendment that requires 

states to enact and enforce tobacco control laws prohibiting the sale of 

tobacco products to minors. Other programs and activities administered 

by HHS, DOD, DOJ, Education, and the Office of National Drug Control 

Policy (ONDCP) address tobacco use as part of a broader focus on 

unhealthy behaviors, such as substance abuse and violence. (See app. II 

for examples of federal programs that can address tobacco prevention and 

reduction among youth.) 

We identified two federal programs that focus only on tobacco use. The 

first, CDC’s NTCP,11 focuses on preventing and reducing tobacco use 

among the general population, but it also explicitly targets tobacco use 

among youth. NTCP provides funds through cooperative agreements to all 

states.12 In fiscal year 2002, NTCP provided about $58 million to states to 

address NTCP’s four goals.13 NTCP’s four goals are to (1) prevent youth 

from starting to smoke, (2) help youth and adults quit smoking, (3) 

minimize the public’s exposure to secondhand smoke, and (4) identify and 

mitigate the factors that make some populations more likely to use 

tobacco than others. NTCP cooperative agreements specify the terms 

under which federal funds are provided to the states. 

 11In 1999, two HHS demonstration projects—the American Stop Smoking Intervention 

Study for Cancer Prevention and the Initiatives to Mobilize for the Prevention and Control 

of Tobacco Use—were combined to form NTCP. 

12In our discussion of NTCP, the term “states” refers to the 50 states, the District of 

Columbia, and American Samoa, Guam, the Federated States of Micronesia, the 

Commonwealth of the Northern Mariana Islands, the Republic of Palau, Puerto Rico, and 

the U.S. Virgin Islands. 

13In addition to NTCP funds, states use funds from other sources, such as other federal 

programs and initiatives, state taxes and state settlements with tobacco companies, and 

competitive grants from private foundations to finance their tobacco control programs and 

activities. 

Some Federal 

Programs, Research, 

and Activities Focus 

Only on Tobacco Use, 

While Others Address 

Tobacco Use Along 

with Other Unhealthy 

Behaviors 

Some Federal Programs 

Only Address Tobacco Use 
Page 8 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Under NTCP, CDC encourages states to use multiple types of interventions 

in their efforts to prevent and reduce tobacco use. CDC has developed 

guidance intended to assist states in designing, implementing, and 

evaluating their individual tobacco control programs.14 For instance, CDC 

recommends that states establish comprehensive tobacco control 

programs that include certain components, such as 

• community-based programs to reduce tobacco use that include a wide 

range of prevention activities, such as engaging youth in developing and 

implementing tobacco control interventions, conducting educational 

programs for young people, parents, school personnel, and others, and 

restricting access to tobacco products; 

• school programs to implement school health policies that consist of 

tobacco-free policies, evidence-based curricula, teacher training, parental 

involvement, cessation services, and links between school and other 

community efforts and state media and educational campaigns; 

• marketing campaigns to counter protobacco influences and increase 

prohealth messages and influences, including paid television, radio, 

billboard, and print media campaigns; 

• cessation services to help people quit smoking; 

• enforcement of tobacco control policies by restricting minors’ access to 

tobacco and restricting smoking in public places; and 

• statewide efforts to provide localities with technical assistance on how to 

evaluate tobacco programs, promote media advocacy, implement smokefree policies, and reduce minors’ access to tobacco. 

CDC officials told us that CDC also provides training and technical 

assistance to states in designing, implementing, and evaluating their 

tobacco control programs. For example, in fiscal year 2000, CDC 

conducted three regional workshops for state health departments and 

education agencies aimed at helping such agencies develop coordinated 

plans to prevent youth from starting to use tobacco. According to CDC, 

representatives from 33 states participated in these workshops. 

The second federal program that focuses only on tobacco and aims to 

prevent tobacco use among youth is SAMHSA’s program to oversee state 

implementation of legislation commonly referred to as the Synar 

Amendment. This program is the only one we identified that focuses solely 

on tobacco use among youth. The Synar Amendment and its implementing 

 14Centers for Disease Control and Prevention, Best Practices for Comprehensive Tobacco 

Control Programs, August 1999 (Atlanta Ga.: 1999). 
Page 9 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

regulation require states to enact and enforce laws that prohibit the sale of 

tobacco products to minors, conduct random inspections of tobacco retail 

or distribution outlets and estimate the percentage of retailers that illegally 

sell tobacco to minors, and report the results of their efforts to the 

Secretary of HHS.15 States are also required to report enforcement actions 

taken against those who violate state laws in order to receive certain 

federal grants.16 By the end of fiscal year 2003, states may have no more 

than 20 percent of retail tobacco outlets in violation of state laws that 

prohibit the sale of tobacco products to minors. To oversee states’ efforts 

to accomplish this, SAMHSA and the states negotiated interim annual 

target rates that states should meet. States may use a portion of their 

Substance Abuse Prevention and Treatment block grant to help fund the 

design and implementation of their inspection programs. For fiscal year 

2002, the states reported that they planned to expend more than $5.4 

million in block grant funds on Synar-related activities. 

Other federal programs aim to address tobacco use among youth as part of 

a broader focus on unhealthy behaviors. For example, CDC’s Coordinated 

School Health program provides grants to states to implement school 

health programs to prevent a range of unhealthy behaviors or conditions, 

such as drug, alcohol, and tobacco use; physical inactivity; poor nutrition, 

and obesity. In fiscal year 2002, CDC awarded grants to 22 states, with 

each state receiving approximately $400,000. CDC helps state education 

and health departments identify and implement health education curricula 

to provide youth with information and the decision-making, 

communication, and peer-resistance skills needed to avoid unhealthy 

 1542 U.S.C. § 300x 26 (2002) Synar Amendment: 45 C.F.R. § 96.130 (2002) implementing 

regulation. SAMHSA requires states to develop and implement a consistent sample design 

and a standardized inspection procedure. SAMHSA provides guidance to states on effective 

ways to conduct unannounced inspections and to estimate statewide violation rates. See 

U.S. General Accounting Office, Synar Amendment Implementation: Quality of State 

Data on Reducing Youth Access to Tobacco Could Be Improved, GAO-02-74 (Washington, 

D.C.: Nov. 7, 2001). 

1642 U.S.C. § 300x-26(b)(2)(B)(i) (2000). States must comply with the Synar Amendment 

and its implementing regulation to obtain federal Substance Abuse Prevention and 

Treatment block grants. The Synar Amendment provides for a 40 percent reduction in a 

state’s Substance Abuse Prevention and Treatment block grant for noncompliance with 

Synar requirements. However, provisions contained in the HHS annual appropriations acts 

since fiscal year 2000 have prohibited the Secretary of HHS from withholding grant funds 

from noncompliant states that pledge to commit state funds to ensure compliance with 

state laws prohibiting tobacco sales to minors. (See, e.g., Consolidated Appropriations 

Resolution, 2003, Pub. L. No. 108-7, Div. G, § 214, 117 Stat. 11, 324.) 

Other Federal Programs 

Address Tobacco Use 

Along with Other 

Unhealthy Behaviors 
Page 10 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

behaviors. In addition, CDC provides guidance to state and local health 

education agencies on tobacco prevention programs in schools that covers 

policies, programs, and a tobacco-free environment. CDC periodically 

surveys the states, school districts, and schools on the health curricula 

they offer and on school health policies relating to tobacco prevention and 

reduction efforts. According to CDC, the information obtained through 

these survey efforts is used to assess trends in school health education 

programs. 

Education’s Safe and Drug-Free Schools and Communities program aims 

to prevent violence and drug, alcohol, and tobacco use in the nation’s 

schools.17 Under this program in fiscal year 2002, Education awarded more 

than $472 million in grants to state education departments and governors’ 

offices.18 Similarly, the Safe Schools/Healthy Students program, which is 

funded by Education, HHS, and DOJ, provides local education agencies 

with grants that support a variety of services designed to promote healthy 

childhood development and prevent substance abuse (which can include 

the use of tobacco) and violence. These services target preschoolers, 

school-aged children, and adolescents. The Safe Schools/Healthy Students 

program’s activities totaled about $172 million for fiscal year 2002. 

DOJ and DOD support drug prevention programs that also aim to prevent 

tobacco use among youth. For example, the Drug-Free Communities 

Support program,19 which is administered by ONDCP and DOJ, is designed 

to support the efforts of community coalitions that aim to prevent and 

reduce young people’s use of drugs, alcohol, and tobacco. These coalitions 

consist of youth, parents, health care professionals, educators, law 

enforcement officials, and other community partners. In fiscal year 2002, 

 17This program was authorized under the Safe and Drug-Free Schools and Communities 

Act, Title IV, Part A of the Elementary and Secondary Education Act of 1965 as amended by 

the No Child Left Behind Act of 2001, Pub. L. No. 107-110, §401, 115 Stat.1425, 1734-1765 

(classified to 20 U.S.C. § 7101-7165 (Supp. I 2002)). The program has two main components, 

a state grant program and a national program. The national program provides discretionary 

funding for demonstration projects, special initiatives, technical assistance to states and 

districts, evaluation, and other efforts to improve drug and violence prevention. 

18These grants afford grantees significant discretion in implementing the federal program. 

In general, the Safe and Drug-Free Schools and Communities Act State Grants program 

funds a variety of violence, drug, alcohol, and tobacco prevention activities, including 

prevention instruction for students; and teacher and staff training and support services for 

students. 

19This program was authorized by the Drug-Free Communities Act of 1997, Pub. L. No. 105-

20, § 2, 111 Stat. 224, 226 (classified to 21 U.S.C. § 1531(2000)). 
Page 11 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

DOJ awarded about $46 million to community coalitions located in 50 

states. Approximately $7 million was given in new awards to 70 

community coalitions, and $39 million was given in renewed funding to 

462 existing community coalitions. Another program, the Drug Education 

for Youth program (DEFY), which is sponsored by DOD and DOJ, targets 

youth aged 9 to 12 to improve awareness of the harmful effects of alcohol 

and other drugs, including tobacco. According to agency officials, the 

program aims to promote positive self-images and lifestyles. In fiscal year 

2002, DOD funding totaled over $1 million for 55 local DEFY programs. 

DOJ provided approximately $850,000 in funding to implement 111 local 

DEFY programs. 

In addition to supporting programs that aim to address tobacco use among 

youth, HHS agencies conduct research on tobacco use and its health 

effects. NIH’s National Cancer Institute (NCI) has identified tobacco use 

among youth as one of its research priorities.20 In fiscal year 2002, NCI 

funded more than 40 grants, totaling almost $30 million, for research on 

ways to understand, prevent, reduce, and treat tobacco use among youth. 

Similarly, NIH’s National Institute on Drug Abuse (NIDA) supports 

research on effective tobacco use prevention and reduction interventions 

for youth. For example, NIDA established and funds a teen tobacco 

addiction treatment research center to examine methods of eliminating 

dependence on nicotine and assess the effectiveness of these strategies. 

The center is assessing the safe use and effectiveness of nicotine patches 

and gum for adolescents. According to NIDA, in fiscal year 2002, funding 

for its research projects that focused on substance abuse, including 

tobacco use among youth, totaled about $124 million. 

In fiscal year 1999, NCI and NIDA jointly established seven 

Transdisciplinary Tobacco Use Research Centers (TTURCs) at academic 

institutions in an effort to identify effective ways to prevent and reduce 

tobacco use.21 According to HHS officials, additional information on ways 

to reduce tobacco use among youth is needed because of the limited 

knowledge available about cessation interventions that work best for 

young people. The 5-year TTURCs research effort is designed to study new 

 20Other NIH institutes, such as the National Institute of Child Health and Human 

Development (NICHD) and the National Institute of Dental and Craniofacial Research 

(NIDCR) also conduct research on tobacco use among youth. 

21The Robert Wood Johnson Foundation also provides funding for TTURCs. 

HHS Agencies Support 

Research to Address 

Tobacco Use among Youth 
Page 12 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

ways of preventing tobacco use and nicotine addiction. According to HHS 

officials, in fiscal year 2002, NCI and NIDA provided over $15 million to 

TTURCs, which included funding for research on youth and adolescent 

tobacco use and nicotine addiction at four of the seven centers. These four 

centers are conducting studies on adolescent smoking.22 According to NCI, 

one study found that students with high academic performance, perceived 

academic competence, and involvement in school-related clubs and sports 

teams were less likely to smoke.23

CDC also supports research on health promotion and disease prevention 

including research on tobacco use among youth, through its network of 28 

research centers that are affiliated with schools of public health, medicine, 

or osteopathy located throughout the country. According to CDC officials, 

these research centers focus on identifying effective prevention strategies 

that can be applied at the community level. One center is examining 

factors that can influence youth and young adults to start using tobacco 

and two other centers are conducting research that examines youth 

cessation programs, according to CDC. HRSA is working with certain 

federally supported community health centers on a multiyear initiative to 

address health disparities among youth. HRSA officials said that the effort 

would involve developing interventions to address the needs of high-risk 

medical subpopulations, such as young people with asthma or 

cardiovascular conditions for whom tobacco use can pose especially high 

risks. 

In addition to research, HHS and other federal departments conduct a 

variety of tobacco-focused activities that aim to prevent and reduce 

tobacco use among youth. For example, officials from HHS, Education, 

and other federal departments, along with experts from national 

organizations and professional associations, developed guidance to help 

schools identify and implement strategies for preventing tobacco use 

 22These four centers are located at Brown University, the University of 

Pennsylvania/Georgetown University, the University of Southern California, and the 

University of California at Irvine. The other funded research centers are located at the 

University of Minnesota, University of Wisconsin Medical School, and Yale University. 

23The Nation’s Investment in Cancer Research for Fiscal Year 2003, National Cancer 

Institute, National Institutes of Health (http:/plan2003.cancer.gov/scipri/tobacco.htm). 

Federal Activities Also Aim 

to Address Tobacco Use 

among Youth 
Page 13 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

among youth.24 For example, the guidelines recommend that schools 

develop and enforce a school policy on tobacco use, provide tobacco-use 

prevention education from kindergarten through 12th grade, provide 

instructions about the short- and long-term consequences of tobacco use, 

and provide training for teachers. Similarly, in 1997, SAMHSA issued 

guidance that describes strategies that communities can use to prevent 

and reduce tobacco use among youth.25

In other activities, HHS agencies develop and promote educational 

materials to prevent and reduce a range of unhealthy behaviors among 

adolescents, including tobacco use. For example, Girl Power!, a national 

public education campaign, is designed to prevent 9- to 13-year-old girls 

from using tobacco, alcohol, and illegal drugs and includes a Web site that 

offers articles, games, and quizzes that teach girls about the dangers of 

tobacco use. Similarly, CDC’s Tobacco Information and Prevention Source 

Web site offers a variety of educational materials for youth, such as tips on 

how to quit using tobacco and information on the health consequences of 

using tobacco. CDC also disseminates information for parents, such as a 

kit that offers advice on ways to increase parental involvement in their 

children’s lives and incorporate tobacco prevention messages into daily 

activities. In addition, DOD sponsors Web sites that include information on 

preventing and reducing tobacco use among youth and supports various 

youth activities that address unhealthy behaviors, including tobacco use. 

For example, one project identified was Smart Moves,26 which aims to 

prevent tobacco, alcohol, and drug use by bolstering youths’ self-esteem 

and their resistance to unhealthy behaviors. 

HHS agencies also support activities that use various media, such as print, 

radio, television, and videotapes, to counteract the impact of tobacco 

product marketing. For example, CDC supports a variety of entertainmentrelated outreach activities that enlist celebrities as spokespersons to 

deliver antismoking messages and to increase prohealth messages in 

 24Centers for Disease Control and Prevention, Guidelines for School Health Programs to 

Prevent Tobacco Use and Addiction, Morbidity and Mortality Weekly Report, vol. 43, no. 

RR-2, 1-18 1994 (Atlanta, Ga.: 1994), 43. 

25U.S. Department of Health and Human Services, Reducing Tobacco Use Among Youth: 

Community-Based Approaches, Prevention Enhancement Protocol, 1997, DHHS 

Publication No. 97-3146 (Rockville, Md., Substance Abuse and Mental Health 

Administration: 1997). 

26This program was developed by the Boys and Girls Club of America. 
Page 14 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

entertainment programming. CDC also supports the Media Campaign 

Resource Center, a clearinghouse offering antitobacco media products 

developed for television, radio, print, and outdoor advertising. In addition, 

CDC and SAMHSA developed Media Sharp, a media literacy guide for 

educators and community leaders who work with middle school and high 

school age youth to dissuade youth from using tobacco. 

To monitor federal programs that aim to prevent and reduce tobacco use 

among youth, federal departments and agencies collect information on 

how their programs are being implemented by grantees and the 

effectiveness of grantees’ efforts in meeting national program goals. 

Federal departments and agencies obtain this information from various 

sources, such as grantee applications for federal funding, progress reports, 

site visits, and program evaluations. According to federal officials, the 

information is used to assist grantees in managing and evaluating their 

programs. 

To monitor the NTCP, CDC collects information on the design, 

implementation, and effectiveness of state tobacco control programs. CDC 

obtains this information through various sources, such as states’ 

applications for NTCP funding, state progress reports, periodic site visits, 

surveys, and program evaluations conducted by various states. For 

instance, the applications that states submit when applying for NTCP 

funding must include strategic plans that provide information on the 

design and implementation of their tobacco control programs. The plans 

must also include information on how states will achieve NTCP’s goals. 

According to CDC officials, other important sources of information are the 

biannual reports that the agency requires states to submit on the progress 

of their tobacco control programs. These reports provide CDC with 

additional information, such as enforcement strategies used to prevent the 

sale of tobacco products to minors, information campaigns to increase the 

public’s awareness of the health consequences of using tobacco, and 

efforts to promote tobacco-free schools and positive role models for 

youth. 

Federal Departments 

and Agencies Collect 

a Variety of 

Information on Their 

Programs That Aim to 

Prevent Tobacco Use 

among Youth 

CDC Collects Information 

on the States’ NTCPSupported Tobacco 

Control Programs 
Page 15 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

CDC also obtains information on state tobacco control programs through 

other sources. For example, CDC officials said that NTCP project officers, 

who are responsible for monitoring state tobacco control programs, visit 

each of their assigned states approximately every 12 to 18 months. CDC 

officials said that through these visits they obtain more in-depth 

information about the design and implementation of the states’ programs, 

and they gain a better understanding of the challenges that states may face 

in achieving NTCP’s goals. In addition, these officials said that they 

monitor the effects of state tobacco control programs through periodic 

national and state youth tobacco surveys. Through these surveys, CDC 

obtains information on changes in tobacco use among youth and their 

knowledge, attitudes, and behaviors towards tobacco use. CDC officials 

said that they work with the states to design the state surveys and to help 

states interpret and use the survey data. CDC officials also said that they 

have obtained useful information from evaluations that several states 

completed on the effectiveness of their tobacco control programs.27

According to CDC officials, the information they obtain has been used in 

various ways. For example, in developing its best practice guidance for 

comprehensive tobacco control programs, CDC used information from 

analyses of tobacco control programs in California and Massachusetts and 

CDC officials’ experience in providing technical assistance in other states. 

CDC officials also said that the agency has provided a variety of training 

and technical assistance to help states, among other things, adopt 

evidence-based interventions for preventing tobacco use. In addition, CDC 

developed guidance in 2001 on how states could evaluate their individual 

tobacco control programs.28 The guidance includes information on 

approaches for designing evaluations; measuring outcomes of specific 

program components; and analyzing, interpreting, and using evaluation 

results to improve operations and enhance the impact of tobacco control 

programs. 

 27According to CDC officials, evaluations of state tobacco control programs have been 

completed by Arizona, California, Florida, Maine, Massachusetts, Mississippi, Oregon, and 

Texas. 

28Goldie MacDonald and others, Introduction to Program Evaluation for Comprehensive 

Tobacco Control Programs (Atlanta, Ga.: Centers for Disease Control and Prevention, 

November 2001) and Centers for Disease Control and Prevention, Surveillance and 

Evaluation Data Sources for Comprehensive Tobacco Control Programs (Atlanta, Ga.: 

November 2001). 
Page 16 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

In fiscal year 2003, CDC took action to collect additional information on 

the design, implementation, and effectiveness of state tobacco control 

programs. For instance, CDC now requires that states submit additional 

information in their biannual reports. These officials said that the 

expanded NTCP data collection effort should enable CDC to obtain a more 

comprehensive picture of state tobacco control programs and the extent 

to which program activities are consistent with NTCP’s goals. CDC 

officials said that they anticipate that these changes, along with the 

redesign of the NTCP information system, will facilitate more 

comprehensive comparisons within and across states and regions on 

progress towards reducing tobacco use. The changes should also enable 

CDC to better identify state-specific or systemic issues, according to these 

officials. 

In fiscal year 2003, CDC began requiring that each state dedicate staff to 

evaluate the state’s tobacco control program. Each state was required to 

submit detailed information with its NTCP funding application that 

described how it intended to evaluate the program’s effectiveness. The 

application had to include information on the specific performance 

indicators the state intends to use and its methodologies for collecting and 

analyzing data, projected time lines for completing evaluation efforts, and 

plans for using evaluation results to improve its program. CDC officials 

told us that they recognize that conducting program evaluations can 

present financial and methodological challenges for state tobacco control 

programs, but that CDC had instituted this requirement because evidence 

on the impact of individual state programs has been generally limited. 

These officials noted that while evaluations have been completed by eight 

states, the results of these evaluations and other studies provide only a 

limited picture of the impact of all states’ programs in achieving NTCP’s 

goals. 

To monitor state compliance with the requirements of the Synar 

Amendment and its implementing regulation, SAMHSA collects data on 

the design and implementation of state compliance efforts. The regulation 

requires that each state report to SAMHSA information on the state’s 

efforts to inspect retail tobacco outlets, including the state’s sampling 

methodology, inspection protocol, and inspection results. SAMSHA 

reviews the information to determine whether states have complied with 

requirements for enforcing state laws and conducting random inspections 

of retail tobacco outlets. In reviewing these data, SAMHSA determines 

whether a state’s estimated retailer violation rate meets negotiated annual 

targets and shows progress toward the 20 percent goal. Based on the latest 

SAMHSA Collects 

Information on States’ 

Progress in Prohibiting the 

Sale of Tobacco Products 

to Minors 
Page 17 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

data available at the time of our review, 49 states met their negotiated 

retailer violation rate targets for 2002. 

Federal agencies with programs that address tobacco use, along with 

other unhealthy behaviors among youth, obtain information on grantees’ 

efforts to design and implement their programs. They obtain this 

information by various means, such as periodic reports and visits to 

grantee sites. For example, DOJ requires community antidrug coalitions 

that participate in the Drug-Free Communities Support program to submit 

annual progress reports on their programs. As part of this reporting 

requirement, coalitions must report on certain measures of youth 

behavior, such as the age youth first started to use tobacco, the frequency 

of tobacco use in the past 30 days, and youths’ perceptions of tobaccorelated risks. According to DOJ officials, the information obtained from 

reports and site visits is used to provide grantees with training and 

technical assistance. DOJ is also overseeing a 5-year evaluation of the 

effectiveness of this federal grant program. The evaluation, which is 

scheduled for completion in 2004, is designed to take into consideration 

both the similarities and differences among the coalitions and their 

communities and aims to assess the effectiveness of the coalitions’ efforts 

to reduce the use of tobacco, alcohol, and illicit drugs among youth. 

Similarly, to monitor their programs, DOJ and DOD contracted for 

evaluations of the effectiveness of some DEFY components. For instance, 

one study examined the effectiveness of the summer camp component in 

1997 at 18 DOJ DEFY camps and 28 military DEFY camps. The study 

included the use of pre- and postcamp questionnaires to assess youths’ 

attitudes towards smoking cigarettes and to determine how often they 

smoked.29

 29We did not review the methodology used in the evaluation of DEFY. 

Federal Departments and 

Agencies Collect 

Information on Their 

Programs That Address 

Unhealthy Behaviors 

among Youth 
Page 18 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

HHS and other federal departments coordinate their efforts to prevent, 

treat, and reduce tobacco use among youth by participating on various 

committees and work groups and by collaborating on various programs, 

research projects, and activities. Although HHS has the lead responsibility 

for coordinating these efforts, some HHS officials stated that coordination 

among HHS agencies presents challenges. 

HHS leads efforts among its agencies and others to develop strategies for 

addressing tobacco use among youth in support of the Healthy People 

initiative, which includes objectives to reduce tobacco use among youth. 

As part of this initiative, representatives from various federal departments 

and nongovernmental organizations participate in work groups that focus 

on tobacco use objectives. For example, the Healthy People 2010 Tobacco 

Use Work Group, chaired by CDC, includes representatives from other 

HHS agencies as well as the Environmental Protection Agency (EPA), the 

Federal Trade Commission, and nonfederal organizations. The work group 

meets periodically to discuss strategies and challenges in addressing 

issues related to tobacco use.30

HHS also plays a leadership role in the Youth Tobacco Cessation 

Collaborative. Established in 1998, the collaborative brings together CDC, 

NCI, NICHD, NIDA, the National Heart, Lung, and Blood Institute (NHLBI), 

and several nonfederal organizations to help ensure young tobacco users’ 

access to cessation interventions.31 In 2000, the collaborative published an 

action plan to facilitate planning and priority-setting on the need for 

tobacco cessation for youth.32 In addition, three members of the 

 30Other HHS agencies represented on the Tobacco Use Work Group are the Administration 

for Children and Families, the Agency for Healthcare Research and Quality (AHRQ), the 

Centers for Medicare & Medicaid Services (CMS), HRSA, the Indian Health Service (IHS), 

NIH, and SAMHSA. 

31Nonfederal members involved in the collaborative include the American Cancer Society, 

the American Legacy Foundation, the American Lung Association, the Canadian Tobacco 

Research Initiative, the National Cancer Institute of Canada, and the Robert Wood Johnson 

Foundation. 

32Center for the Advancement of Health for the Youth Tobacco Cessation Collaborative, 

National Blueprint for Action: Youth and Young Adult Tobacco-Use Cessation 

(Washington, D.C.: 2000). 

Federal Departments 

and Agencies 

Coordinate in Various 

Ways to Address 

Tobacco Use among 

Youth 

HHS Leads Coordination 

Efforts to Address 

Tobacco Use 
Page 19 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

collaborative—CDC, NCI, and the Robert Wood Johnson Foundation—are 

working together on the Helping Young Smokers Quit initiative, a 4-year 

project that aims to identify, characterize, and evaluate the effectiveness 

of various youth cessation programs. 

Other work groups focus on broader adolescent health issues that include 

tobacco use among youth. For example, both the Healthy People 2010 

Adolescent Health Work Group, cochaired by CDC and HRSA, and the 

related National Initiative to Improve Adolescent Health by 2010 aim to 

foster greater involvement by various professions to improve the overall 

health of adolescents, in part by reducing their use of tobacco. According 

to HRSA officials, members of the national initiative are trying to educate 

health care and other professionals on the importance of screening for 

tobacco use and other unhealthy behaviors during routine health care 

visits, providing counseling on the benefits of quitting tobacco use, and 

providing referrals for youth, their parents, and other family members to 

tobacco cessation services. As part of the national initiative, CDC, HRSA, 

and the American Academy of Pediatrics are collaborating on the 

development of a prevention guide to help pediatricians address unhealthy 

behaviors among youth, including tobacco use. 

In 1984, the Congress passed legislation requiring, among other things, that 

HHS establish an interagency committee to coordinate the department’s 

research, educational programs, and other smoking and health efforts with 

similar efforts of other federal departments and nonfederal organizations.33

As a result, in 1985, HHS established the Interagency Committee on 

Smoking and Health. According to CDC officials, the committee brings 

together representatives of federal agencies and nonfederal organizations 

involved in tobacco use issues34 and serves as a forum for committee 

members and the public to share information and discuss a variety of 

tobacco-related issues and efforts. Committee meetings that have 

specifically focused on tobacco use among youth have covered such 

 33Comprehensive Smoking Education Act of 1984, Pub. L. No. 98-474 § 3, 98 Stat. 2200-2201 

(classified to 15 U.S.C. §1341(b) (2000)). 

34As of October 2003, other federal entities represented on the Interagency Committee on 

Smoking and Health are HHS’s AHRQ, CDC, CMS, HRSA, IHS, NCI, NICHD, NIDA, NHLBI, 

and SAMHSA; the Departments of Labor and Transportation; EPA; and the Federal Trade 

Commission. 

HHS Established the 

Interagency Committee on 

Smoking and Health to 

Coordinate Federal Efforts 
Page 20 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

topics as the health effects of smoking on young people, the sale of 

cigarettes to minors, and strategies for preventing tobacco use. 

Federal departments also collaborate on efforts to prevent and reduce 

tobacco use among youth by jointly administering programs, conducting 

research, and supporting education and outreach activities. For example, 

Education, DOJ, and HHS jointly administer the Safe Schools/Healthy 

Students program. Through interagency agreements, Education handles 

grants management activities, HHS provides technical advice and financial 

assistance, and DOJ oversees program evaluation efforts. Similarly, for the 

Drug-Free Communities Support program, ONDCP directs the program 

and through an interagency agreement transfers funds to DOJ to cover 

grant awards, grants management, and evaluation activities. Both ONDCP 

and DOJ provide technical assistance to program grantees. 

HHS agencies also coordinate on efforts to jointly support research on 

tobacco use prevention and cessation. For example, in addition to the NCIand NIDA-supported TTURCs initiative, NCI led the creation of an NIHwide Tobacco and Nicotine Research Interest Group in January 2003. 

According to NCI officials, the group was established to leverage expertise 

and resources across NIH for tobacco research. In addition to NCI, 

representatives from other NIH institutes, such as NICHD, NIDA, NHLBI, 

and the National Institute of Dental and Craniofacial Research (NIDCR) 

have participated in the group. Representatives from CDC are also 

participating in the group’s meetings. 

Furthermore, HHS agencies, Education, ONDCP, and nonfederal 

organizations collaborate on education and outreach activities aimed at 

discouraging youth from starting to use tobacco and encouraging existing 

users to quit. For example, CDC and Education collaborated on the 

development and dissemination of a guide for parents on how to address 

their children’s health needs, including preventing and reducing tobacco 

use. Table 1 highlights various education and outreach activities aimed at 

preventing and reducing tobacco use among youth that HHS and other 

federal departments and agencies work on together. 

HHS and Other Federal 

Departments Coordinate 

Their Efforts by Jointly 

Administering Programs 

and Supporting Research 

and Activities 
Page 21 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Table 1: Examples of Federal Collaborative Education and Outreach Activities to 

Address Tobacco Use among Youth 

Activity or 

project 

Federal 

departments 

or agencies Description 

Tobacco-Free 

Sports 

CDC, NCI, 

SAMHSA, and 

ONDCP 

An initiative that involves sports stars, sport leagues, 

and youth organizations helping to deliver tobaccofree messages. The initiative is intended to depict 

positive role models and provide information about 

how to make positive health choices related to 

tobacco use, physical activity, and nutrition. 

Entertainment 

Industry 

Outreach 

CDC, NIDA 

SAMHSA, and 

ONDCP 

A multifaceted outreach effort to, among other things, 

enlist celebrities to serve as national spokespersons 

to deliver antismoking messages and to educate 

young people on how to interpret depictions of 

tobacco use in entertainment media. As part of this 

effort, federal agencies have collaborated on 

promoting a video-based media literacy program, 

Scene Smoking: Cigarettes, Cinema, and the Myth of 

Cool, aimed at high school and college students. 

Pathways to 

Freedom 

CDC and NCI A self-help guide intended to motivate and assist 

African American adults and youth to stop smoking. 

The guide is intended to prevent young children from 

developing the smoking behaviors of their parents 

who use tobacco and to prevent exposure to 

secondhand smoke. 

Got a Minute? 

Give It to Your 

Kids 

CDC, 

SAMHSA, 

Education, 

and ONDCP 

A guide to educate parents on how to 

comprehensively address their children’s health 

needs, including information on how to prevent their 

children from using tobacco. Education is assisting 

CDC in disseminating the guide to schools 

nationwide. 

Source: HHS agencies, Education, and ONDCP. 
Page 22 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

HHS officials said that coordinating on tobacco-related issues within HHS 

presents challenges. They pointed out that, although multiple HHS 

agencies have programs and other efforts to address the prevention and 

reduction of tobacco use, the missions and funding priorities of the 

agencies differ. For example, CDC officials told us that they had initiated 

discussions in fiscal year 2003 with HRSA to collaborate on offering 

tobacco prevention and cessation services to underserved populations 

that obtain health care through HRSA’s network of community health 

centers. However, this effort has been delayed largely due to HRSA’s 

competing funding priorities and limited resources. In another instance, 

NCI officials noted that NIDA and NIDCR decided to fund a proposal to 

translate research findings on alcohol, tobacco, and other drug prevention 

and treatment research to clinical dental practice settings. However, 

according to an NCI official, NCI did not learn about the proposal in time 

to consider it for fiscal year 2003 funding. 

We provided a draft of this report to HHS, DOD, DOJ, and Education for 

comment. DOD concurred with the report as written and DOJ did not have 

comments. HHS and Education provided technical comments that we 

incorporated as appropriate. 

In written comments, HHS stated that the report was very informative and 

provided a thorough overview of nicotine and tobacco activities related to 

youth, but did not include programs within CMS that are a substantial 

element of HHS tobacco prevention. Specifically, HHS stated that under 

Medicaid, states are required to cover certain smoking cessation services 

for children and adolescents. Including joint federal-state programs that 

finance health insurance such Medicaid and the State Children’s Health 

Insurance Program, was beyond the scope of our review. HHS also noted 

that the report did not include information about the challenges other 

federal agencies experienced in coordinating tobacco-related issues. We 

discussed coordination of tobacco-related issues with officials from DOD, 

DOJ, and Education. However, these officials did not cite any challenges 

they had experienced with coordinating their tobacco-related efforts. 

HHS Officials Identified 

Several Challenges to 

Coordination within the 

Department 

Agency Comments 
Page 23 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

As agreed with your office, unless you release its contents earlier, we plan 

no further distribution of this report until 30 days after the issue date. At 

that time, we will send copies of this report to the Secretary of Health and 

Human Services, the Secretary of Defense, the Attorney General, the 

Secretary of Education, appropriate congressional committees, and other 

interested parties. We will also make copies available to others upon 

request. In addition, the report is available at no charge on the GAO Web 

site at http://www.gao.gov. If you or your staff have questions about this 

report, please contact me at (202) 512-7101. An additional contact and staff 

acknowledgments are provided in appendix III. 

Sincerely yours, 

Marjorie E. Kanof 

Director, Health Care—Clinical Health Care Issues 
Appendix I: Scope and Methodology 

Page 24 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

To do our work, we obtained and reviewed program documents, strategic 

and performance plans, pertinent program reports and special studies, 

surveillance and other data, and federal Web sites from the Department of 

Health and Human Services (HHS) including the Office of the Secretary, 

the Office of the Assistant Secretary for Planning and Evaluation, Office of 

Public Health and Science, Agency for Healthcare Research and Quality, 

Centers for Disease Control and Prevention (CDC), Centers for Medicare 

& Medicaid Services, Health Resources and Services Administration 

(HRSA), Indian Health Service, National Institutes of Health (NIH), and 

Substance Abuse and Mental Health Services Administration (SAMHSA); 

the Departments of Defense (DOD), Justice (DOJ), and Education; the 

Environmental Protection Agency; the Federal Trade Commission; and the 

Office of National Drug Control Policy (ONDCP). We also reviewed the 

relevant literature and documents prepared by federal interagency 

committees and work groups that focused on the prevention and 

reduction of tobacco use among youth and adults. 

To identify federal programs that aim to prevent and reduce tobacco use 

among youth (defined as children and adolescents under age 18), we 

reviewed the Catalog of Federal Domestic Assistance, a database of 

federal grant programs.1

 We also reviewed pertinent documents and 

federal Web sites. After identifying federal programs, we interviewed and 

collected information from federal program officials to confirm that these 

programs supported efforts to prevent and reduce tobacco use among 

youth.2

 As a result, we focused on four federal departments: HHS and its 

component agencies—CDC, SAMHSA, NIH, and HRSA; Education; DOJ; 

and DOD. We then obtained more detailed information on the programs 

they fund. We interviewed officials in HHS, DOD, DOJ, and Education and 

obtained information on program characteristics, including the purpose, 

target audience, and program and financial requirements. We also 

obtained information on research and activities that involve federal 

departments and agencies, such as education and outreach efforts 

intended to prevent the initiation of tobacco use among youth and help 

youth quit tobacco use. In conducting this work, we also reviewed 

strategic and annual performance plans, along with budgetary and other 

pertinent documents, including national action plans and tobacco use 

prevention and cessation guidance. Where available, we obtained fiscal 

 1

The General Services Administration maintains this database. 

2

The scope of our work did not include programs that finance health insurance such as 

Medicaid. 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 25 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

year 2002 funding information on the federal programs and research that 

we identified. However, we were unable to determine the extent of 

spending by federal agencies on efforts to prevent and reduce tobacco use 

among youth because, in many instances, funding information covers 

more than the prevention and reduction of tobacco use among youth. The 

programs, research, and activities that we discuss in this report do not 

represent an exhaustive list of all federal efforts to prevent and reduce 

tobacco use among youth, but highlight a range of such efforts. 

To determine how federal departments and agencies monitor programs 

that aim to prevent and reduce tobacco use among youth and the types of 

monitoring information that departments and agencies collect, we 

obtained and reviewed descriptive information on federal departments 

and agencies’ monitoring efforts. Specifically, we reviewed strategic plans, 

annual performance plans and reports, performance monitoring reports, 

program evaluation guidance, and copies of federal and state program 

evaluation reports. We also interviewed program officials to obtain a more 

detailed understanding of their monitoring efforts. 

To determine how federal departments and agencies coordinate their 

efforts to address youth tobacco use, we focused our attention on 

identifying the key coordination mechanisms and the results of such 

coordination. Specifically, we reviewed strategic and annual performance 

plans and reports, interagency agreements, memorandums of 

understanding, minutes of interagency meetings, and other pertinent 

documents. We also interviewed federal program officials and obtained 

information from these officials describing the characteristics of various 

federal efforts, including information on purpose, federal agencies 

involved, and the target audience. We also obtained their perspectives on 

any factors presenting coordination challenges related to addressing youth 

tobacco use. 

We conducted our work from January 2003 through October 2003 in 

accordance with generally accepted government auditing standards. Our 

findings are limited to the select examples identified and thus do not 

necessarily reflect the full scope of federal programs and other activities 

related to preventing and reducing tobacco use among youth. We did not 

assess the effectiveness of federal programs, monitoring efforts, or 

coordination activities. 
Appendix II: Selected Federal Programs That 

Address or Can Address Tobacco Prevention 

and Reduction among Youth 

Page 26 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Table 2 lists selected federal grant programs that may be used to address 

tobacco use among youth. The list includes programs from four 

departments. 

Table 2: Selected Federal Programs That Address or Can Address Tobacco Prevention and Reduction among Youth 

Program 

Funding fiscal 

year 2002a

Eligible applicantsb

Targeted 

beneficiaries 

Grant program 

description 

Department of Health and Human Services 

Centers for Disease Control and Prevention 

National Tobacco Control $58,000,000 States General population To support state 

tobacco control 

programs to prevent 

and reduce tobacco 

use, including 

preventing youth from 

starting to smoke. 

Tribal Support Centers $1,600,000 Tribes and tribal 

organizations 

American 

Indian/Alaskan 

Natives 

To support seven 

tribal centers in 

developing tobacco 

control programs to 

prevent and reduce 

tobacco use, including 

preventing youth from 

starting to smoke. 

Coordinated School Health $11,000,000 State and local education 

agencies 

Students in grades 9 

through 12 

To support school 

health programs in 

discouraging 

unhealthy behaviors, 

such as poor eating 

habits, physical 

inactivity, and tobacco 

use. 

Preventive Services Block Grant 

to States 

$408,450c States General population To carry out public 

health activities, 

including preventing 

tobacco sales to 

minors. 

Health Resources and Services Administration 

Healthy Schools, 

Healthy Communities 

$19,500,000 Public and nonprofit 

private entities, including 

faith-based and 

community-based 

organizations 

Students attending 

schools (kindergarten 

through grade 12) that 

serve low-income or 

high-risk children 

To increase access to 

comprehensive 

primary and 

preventive health care 

for underserved 

children, adolescents, 

and their families, 

including tobacco 

prevention and 

reduction programs. 

Appendix II: Selected Federal Programs That 

Address or Can Address Tobacco Prevention 

and Reduction among Youth 
Appendix II: Selected Federal Programs That 

Address or Can Address Tobacco Prevention 

and Reduction among Youth 

Page 27 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Program 

Funding fiscal 

year 2002a

Eligible applicantsb

Targeted 

beneficiaries 

Grant program 

description 

Community Health Centers $1,077,578,000 Public and nonprofit 

private entities, including 

faith-based and 

community-based 

organizations 

People in medically 

underserved areas 

To develop and 

operate community 

health centers that 

provide preventive and 

primary health care 

services, and link 

clients with Medicaid 

and mental health and 

substance abuse 

treatment, including 

that for tobacco use. 

Maternal and Child Health 

Services Block Grant to States 

$595,727,279 States Pregnant women, 

mothers, infants and 

children, and children 

with special health 

care needs, 

particularly those of 

low-income families 

To maintain and 

strengthen state 

leadership in planning, 

promoting, 

coordinating, and 

evaluating health care 

services. Funds can 

be used for tobacco 

prevention programs 

and activities. 

Substance Abuse and Mental Health Services Administration 

Synar Amendment $5,448,273dStates Children under age 18 To enable states to 

implement the Synar 

survey requirements 

to assess state 

compliance and 

enforcement of 

tobacco access 

control laws that 

prohibit the sale and 

distribution of tobacco 

products to individuals 

under age 18. 

Substance Abuse Prevention and 

Treatment Block Grant 

$1,725,000,000 States General population To provide financial 

assistance to states 

for the purpose of 

planning, carrying out, 

and evaluating 

activities to prevent 

and treat substance 

abuse, including youth 

tobacco use. 

State Incentive Grants $58,480,885 States Adolescents To prevent and reduce 

alcohol, tobacco, and 

illicit drug use by 

adolescents ages 

12-17. 
Appendix II: Selected Federal Programs That 

Address or Can Address Tobacco Prevention 

and Reduction among Youth 

Page 28 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Program 

Funding fiscal 

year 2002a

Eligible applicantsb

Targeted 

beneficiaries 

Grant program 

description 

Department of Education 

Office of Elementary and Secondary Education 

Safe and Drug-Free Schools and 

Communities: State Grants 

$472,017,000 State departments 

of education 

Children and youth 

who are enrolled and 

attending school 

(primarily kindergarten 

through grade 12) 

To support programs 

that seek to prevent 

violence in and around 

schools; prevent illegal 

use of alcohol, 

tobacco, and drugs; 

and coordinate with 

federal, state, school, 

and community efforts 

to foster a safe and 

drug-free learning 

environment. 

 Governors Children and youth not 

normally served by 

state or local 

educational agencies, 

or populations that 

need special services 

or additional resources 

(for example, youth in 

detention facilities and 

runaway and 

homeless youth) 

To support programs 

of drug use (including 

tobacco) and violence 

prevention. 

Multiagency programs 

Drug-Free Communities Support 

(DOJ and ONDCP) 

$46,000,000 Community coalitions Youth To support coalitions 

engaged in efforts to 

prevent youth alcohol, 

tobacco, illicit drug, 

and inhalant abuse. 

Drug Education for Youth (DOJ 

and DOD) 

$1,869,136 Community coalitions Youth ages 9 to 12 To support a 

multiphased program 

for 9- to 12-year-olds 

to reduce risk factors 

that scientific research 

has linked to 

adolescent substance 

abuse, including 

tobacco use, school 

failure, delinquency, 

and violence. 
Appendix II: Selected Federal Programs That 

Address or Can Address Tobacco Prevention 

and Reduction among Youth 

Page 29 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Program 

Funding fiscal 

year 2002a

Eligible applicantsb

Targeted 

beneficiaries 

Grant program 

description 

Safe Schools/Healthy Students 

(Education, HHS and DOJ) 

$171,588,449 Local education agencies 

in partnership with local 

public mental health 

authorities, and law 

enforcement agencies 

Preschool and schoolage children, 

adolescents, and their 

families who are at 

risk of being involved 

in drug abuse, or 

violence as 

perpetrators, victims, 

or witnesses 

To assist school 

districts in developing 

comprehensive 

services to promote 

healthy childhood 

development and 

prevent violence and 

alcohol and other drug 

abuse, including 

tobacco use. 

Sources: Agency program officials, agency documents, and the Catalog of Federal Domestic Assistance. 

a

All funding is amount appropriated or allocated. 

b

In this column, the term “state” includes the District of Columbia and some or all of the following: the 

Commonwealth of Puerto Rico, the U.S. Virgin Islands, the Republic of Palau, the Federated States 

of Micronesia, and other territories or possessions of the United States unless otherwise noted. 

c

Total block grant funding for chronic disease programs was $49,601,321. 

d

State-reported planned expenditures for fiscal year 2002. 
Appendix III: Comments from the Department 

of Health and Human Services 

 Page 30 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

Appendix III: Comments from the 

Department of Health and Human Services 
Appendix III: Comments from the Department 

of Health and Human Services 

 Page 31 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 
Appendix IV: GAO Contact and 

Acknowledgments 

Page 32 GAO-04-41 Preventing and Reducing Tobacco Use among Youth 

James O. McClyde, (202) 512-7152 

In addition to the person named above, contributors to this report were 

Alice London, Donna Bulvin, Krister Friday, and Lawrence Solomon. 

Appendix IV: GAO Contact and 

Acknowledgments 

GAO Contact 

Acknowledgments 

(290239) 
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